WHISPERING PINES NURSING AND REHAB

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to ensure residents were free from abuse for 2 of 6 residents (Resident #5 and Resident #2) reviewed for resident abuse. <BR/>1. The facility did not ensure Resident #5 was free from abuse when Resident #6 attempted to choke and struck Resident #5 on the middle of his back on 12/25/24. <BR/>2. The facility did not ensure Resident #2 was free from abuse when Resident #3 slapped Resident #2 on his left upper arm on 12/20/24. <BR/>The noncompliance was identified as PNC. The noncompliance began on 12/20/24 and ended on 12/26/24. The facility had corrected the noncompliance before the survey began.<BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings included: <BR/>1.Record review of Resident #5's face sheet dated 03/06/25 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses Schizophrenia (mental health condition that affects everything from how you think to how you feel and behave), mild cognitive impairment, high blood pressure, and depression (common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy that interferes with daily life).<BR/>Record review of Resident #5's annual MDS dated [DATE] indicated he rarely made himself understood and he sometimes understood others. The MDS also indicated he did not have a BIMS score, he had short-term and long-term memory problems, and moderately impaired cognition and no behaviors. <BR/>Record review of Resident #5's care plan dated 02/21/25 indicated Resident #5 had cognitive loss/dementia and required staff to monitor for cognition or confusion, remind resident of scheduled activities, and staff to assist in decision making as needed. <BR/>Record review of Resident #5's skin assessment dated [DATE] indicated he had no skin issues. <BR/>2.Record review of Resident #6's face sheet dated 03/06/25 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), anxiety (an intense and excessive and persistent worry and fear about daily situations), high blood pressure, and parkinsonism (disorder of the central nervous system that affects movement and often causes tremors). <BR/>Record review of Resident #6's EMR indicated he did not have a MDS because he was a respite care (temporary relief stay for caregivers to have a break, usually lasts 5 days) resident.<BR/>Record review of Resident #6's care plan dated 11/13/24 did not indicate any behaviors. <BR/>Record review of Resident's #6's baseline care plan dated 12/20/24 did not indicate any behaviors. <BR/>Record review of Resident #6's safety monitoring dated 12/25/24-12/26/24 indicated monitoring was completed until Resident #6 discharged on 12/26.24. <BR/>Record review of the facility PIR dated 12/31/24 indicated on 12/25/24 LVN E observed Resident #6 to have hands on Resident #5's throat in their bathroom and Resident #6 hit Resident #5 in his back. The were immediately separated and Resident #6 was placed on 1 on 1 observation. The facility was noted to have contacted the families of both residents, the Medical Director, and the Veteran's Affairs. LVN E contacted the abuse coordinator, and an abuse and neglect in-service were provided to the secured unit as well as in-service on proper rounding of the unit. The Social Worker conducted safe surveys and resident interviews and head to toe assessments were completed for both residents. <BR/>During an interview on 03/03/25 at LVN E said close to 10PM on 12/25/24 herself, CNA E, and CNA CC were talking, standing at the nurse station and they heard a loud noise, so they all ran into the Resident #5's room. When they entered the bathroom Resident #6 had Resident #5 by the throat. LVN E said she then separated the residents, and she took Resident #5 to the nurse station and left Resident #6 to be accompanied by CNA C. LVN E said when she turned around, she noticed Resident #6 coming and he hit Resident #5 in his back with a cup. She said CNA CC had walked out with Resident #6 and CNA C went with her to accompany Resident #5. LVN E said when he hit Resident #5, they placed him on 1 on 1 observation, and she notified the Administrator and the DON immediately. LVN E said Abuse and neglect in-servicing were completed by the Administrator. LVN E said Resident #6 had never been aggressive, and he had stayed at the facility for a respite stay a month before that incident. She said Resident #6 was discharged on 12/26/25. <BR/>During an interview on 03/03/25 at 5:14 PM CNA CC said she was not working on the unit on the day that Resident #5 and Resident #6 had the incident. <BR/>During an interview on 03/06/25 2:25 PM CNA C said she was working on the unit on that evening, and she could not remember what CNA was working with her but her and LVN E and other CNA ran to the room to find Resident #6 with his hands on the throat of Resident #5 and they were separated. She said she went to the Nurse station with Resident #5 and some how Resident #6 got away from the other CNA and came to the nurse station and hit Resident #5 in his back with a cup. CNA C said they placed Resident #6 on 1 on 1 observation with the other CNA.<BR/>During an interview on 03/06/25 at 2:46PM the DON said she remembers that LVN E called her and said they had to separate Resident #5, and Resident #6 related to a resident-to-resident altercation that occurred. The DON said Resident #6 was placed on 1 on 1 observation and skin assessments for both residents were performed. The DON said she did not recall Resident #6 hitting Resident #5 in the back. She said she expected all residents to be separated and kept safe and she expected the aggressor to had immediately be placed on 1 on 1 until the aggressor was cleared by psychological evaluation or sent to the Emergency Room. The DON said the failure placed other residents at risk for abuse and that all staff were responsible for ensuring residents were not abused and any allegations should be reported to the administrator immediately if suspected. The DON said she expected any resident-on-resident abuse to reported to the administrator immediately. <BR/>During an interview on 03/06/25 at 3:12 PM The Administrator said she understood LVN E heard commotion and the LVN E and CNAs went to Resident #5's room and found Resident #6 with his hands on Resident #5's throat and the two residents were separated. She said Resident #6 was placed under 1 on 1 care to prevent any other abuse. The Administrator said her expectation was separating the residents to ensure safety, placing the resident who harmed the other on 1 on 1 observation, and ensuring the safety of all residents. She said education to the staff of what to do when a resident-to-resident altercation occurred, what was expected of them, and monitoring of residents was provided on 12/26/24. The Administrator said she expected any resident who had aggressive behaviors to have an evaluation by Psychology after any incident of behaviors of abuse upon another resident. She said the incident was surprise to her and all other staff because Resident #6 had no prior behaviors of that nature. <BR/>3. Record review of Resident #2's face sheet dated 03/06/25, indicated an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included dementia (memory loss), mood disorder, hypertension (high blood pressure), cerebrovascular disease (condition that affects blood flow to the brain), and encephalopathy (brain disease that alters brain function or structure). <BR/>Record review of Resident #2's quarterly assessment dated [DATE], indicated Resident #2 was usually understood and usually understood others. Resident #2 had a BIMS score of 7, which indicated his cognition was severely impaired. Resident #2 did not have any behaviors.<BR/>Record review of Resident 2's comprehensive care plan dated 02/20/25 indicated Resident #2 resided in the secure unit related to at risk for elopement. The care plan interventions included to keep environment free of possible hazards and to monitor to assure resident safety. <BR/>Record review of Resident #2's physician order report dated 03/01/25-03/31/25 indicated Resident #2 had an order for may resident on secure unit with an order start date of 01/24/25. <BR/>Record review of Resident #2's progress note dated 12/20/24 at 4:08 PM, indicated . SW met with resident to discuss incident that happened around 1545 (3:45 PM). Resident was visiting with family in the common area of [secure unit]. Resident was singing, laughing and praising Jesus. SW notified family of incident that occurred with another resident. RP wanted to know who it was, SW stated she could not tell them but that we were addressing situation and would keep resident away from said resident. SW asked resident if someone had been mean to resident. He stated no, that he was just 'praising the Lord and happy to be alive.' SW asked resident if he was upset and he stated no. Resident has no recollection of incident and shows no sign of distress. SW will continue to assist as needed.<BR/>Record review of Resident #2's weekly skin assessment dated [DATE], did not any skin issues. <BR/>Record review of Resident #2's safety one on one monitoring dated 12/20/24, indicated Resident #2's monitoring was initiated at 4:00 PM and completed until Resident #2 left to the hospital at 4:45 PM.<BR/>4. Record review of Resident #3's face sheet dated 03/06/25, indicated an [AGE] year-old female who readmitted to the facility on [DATE] with diagnoses which included dementia (memory loss ) with behaviors, hypertension (high blood pressure), anxiety (intense, excessive, and persistent worry and fear about everyday situations), chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe) and osteoarthritis (joint disease that causes pain, stiffness, and swelling in the joints).<BR/>Record review of Resident #3's quarterly MDS assessment dated [DATE], indicated she was usually understood and usually understood others. Resident #3 had a BIMS score of 07, which indicated her cognition was severely impaired. Resident #3 did not have any behaviors. <BR/>Record review of Resident #3's physician order report dated 03/01/25-03/31/25, indicated Resident #3 had an order for may reside on secure unit with an order start date of 07/24/24.<BR/>Record review of Resident #3's comprehensive care plan dated 12/20/24, indicated Resident #3 had exhibited aggressive behavior toward others with interventions to attempt to find out reason for behavior, notify physician and family as needed regarding any concerns and refer to psychiatric services. <BR/>Record review of the facility's PIR dated 12/20/24 with an incident category of resident to resident indicated Resident #2 was the alleged victim and Resident #3 was the alleged perpetrator. The report indicated Resident #3 was witnessed to open slap [Resident #2] on upper right arm. [Resident #3] was agitated by [Resident #2] repetitive noise and asked him to stop. The report indicated LVN E was the witness to the incident. The report indicated the provider response was Residents separated immediately. [Resident #3] was placed on 1:1 immediately. Families, medical director, VA notified. Abuse Coordinator notified; abuse in-service conducted. Social services conducted safe survey and resident interviews. Head to toe assessment completed. The PIR indicated investigation findings were confirmed. The PIR reflected staff was in-serviced promptly on abuse, reportable events policy, and examples of abuse on 12/20/24. The PIR included Resident #2's and Resident #3's skin assessments completed on 12/20/24, Resident #3's one on one monitoring completed on 12/20/24 until she was sent to the hospital , Resident #2's and Resident #3's progress notes dated 12/20/24, Resident #3's updated care plan regarding aggressive behaviors, resident safe surveys completed on 12/20/24, and monitoring completed on staff interviews on abuse on neglect. <BR/>Record review of Resident #3's progress noted dated 12/20/24 at 4:05 PM, indicated . SW met with resident to discuss incident that happened about 15:45 (3:45 PM) Resident was laughing with another female resident. SW asked resident how she was doing and she stated that she was great. SW asked resident if something had happened to upset her and she stated no, she was visiting with her friend. Resident has no recollection of incident and shows no sign of agitation or aggression. SW will assist as needed.<BR/>Record review of Resident #3's progress note dated 12/20/24 at 4:47 pm and signed by LVN E, indicated . Resident taken to [local hospital] for evaluation. Resident was transported via facility van accompanied by two facility staff members.<BR/>Record review of Resident #3's weekly skin assessment dated [DATE], did not any skin issues. <BR/>Record review of the in-service training report dated 12/20/24, indicated staff was in-serviced on abuse/reportable events, immediately notifying the administrator for any abuse allegations, and the types of abuse. <BR/>Record review of 9 resident safe surveys completed on 12/20/24 with no concerns of abuse. <BR/>Record review of Resident #3's hospital physician Discharge summary dated [DATE], indicated . She was admitted on [DATE] with concern regarding agitation combined with dementia .<BR/>During an interview on 03/04/25 at 3:29 PM, LVN E said on the day of the incident Resident #2 was making his normal noises for him, Resident #3 came up to him and hit him on his arm. LVN E said she immediately separated them and reported it to the Administrator and DON. She said she had been across the room at the nurse's station when she saw the incident happen. LVN E said when a resident-to-resident incident occurred, the residents were immediately separated, the Administrator and DON were notified, one on one behavior monitoring initiated, incident documented, and skin assessments completed. LVN E said Resident #3 was on one on one until she left to the hospital that day. LVN E was able to answer questions regarding abuse and neglect in-service, separating the perpetrator, notifying the abuse coordinator immediately for any abuse allegations and types of abuse. <BR/>During an interview on 03/06/25 at 2:30 PM, the DON said Resident #2 was making a noise and Resident #3 told him to stop and then slapped him. She said the residents were immediately separated and residents were assessed. She said when a resident to resident occurred, she expected all residents to be separated and kept safe and she expected the aggressor to had immediately be placed on 1 on 1 until the aggressor was cleared by psychological evaluation or sent to the Emergency Room. The DON said she expected any resident-on-resident abuse to reported to the administrator immediately. <BR/>During an interview on 03/06/25 at 3:00 PM, the Administrator said Resident #2 had been making repetitive noises, Resident #3 was frustrated and with open hand hit him. She said there were no injuries to either resident. The Administrator said she was the abuse coordinator and when a resident-to-resident altercations occurred she expected staff to make sure both residents were safe, to immediately notify her, assess residents and see if there were any concerns of what prompted the behavior. <BR/>Record review of the facility policy for Abuse/Reportable Events effective 1-10-2017 indicated:<BR/>Policy: All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.<BR/>The noncompliance was identified as PNC. The noncompliance began on 12/20/24 and ended on 12/26/24. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 6 residents reviewed for misappropriation of resident property. (Resident #4)<BR/>The failed to ensure CNA/Van Driver K did not take Resident #4's debit/credit card and use it for her personal use.<BR/>The noncompliance was identified as PNC. The noncompliance began on 08/12/24 and ended on 08/12/24. The facility had corrected the noncompliance before the survey began.<BR/>This failure could place residents at risk for decreased quality of life, misappropriation of property, misappropriation of physician ordered medications and dignity.<BR/>Findings included: <BR/>1.Record review of Resident #4's face sheet dated 03/06/25 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnosis of dementia (memory loss), depression, and anxiety.<BR/>Record review of Resident #4's quarterly MDS dated [DATE] indicated he had clear speech, understood others, and was understood by others. The MDS also indicated Resident #4 had a BIMS score of 10 and had moderately cognitive impairment. <BR/>Record review of Resident #4's care plan dated 04/29/24 indicated he had cognitive loss/dementia and required staff to assist him with decision making as needed throughout the day. <BR/>Record review of the PIR dated 12/14/24 indicated misappropriation of funds from Resident #4 by CNA/Van Driver K was confirmed. <BR/>Record review of the police report emailed 03/06/25 and dated 08/08/24 indicated police had photos and camera footage of CNA/[NAME] Driver K getting money from the bank ATM with #4's debit/credit card. Per the police report the transactions were: <BR/>07/28/2024 11:49 for $300.00<BR/>07/29/2024 10:56 for $150.00<BR/>07/30/2024 06:48 for $60.00<BR/>Total amount stolen (all days): $510.00<BR/>The police report further indicated:<BR/>The first initial fraudulent transaction was on 12/29/2023. The most recent documented fraudulent transaction was to be 07/30/2024. It was determined through the investigation and the records provided that there was a total of 59 fraudulent transactions completed without the effective consent of the cardholder or the fiduciary of the account.<BR/>The investigation was completed and forwarded Criminal Investigation Department for further investigation.<BR/>During a telephone interview on 03/06/25 at 12:21 PM CNA/Van Driver K said she had an attorney that can talk to the surveyor about what was needed to be known. She said she refused to talk. <BR/>During an interview on 03/06/25 at 1:35 PM the Social Worker said CNA/Van Driver K had been noticed by her being very attentive to Resident #4's needs on several occasions. She said she [NAME] gone to speak to Resident #4's Fiduciary of his financials and asked for her to look at his records because the aide seemed suspicious. The Social Worker said the allegation was reported to the state on 08/12/24 as well as the police. The police officer had sent a photo that was confirmed to be CNA/Van Driver K that showed she had gone to the ATM on several occasions and had taken money from Resident #4's account. She said CNA/Van Driver had taken Resident #4 to the bank at some point and replaced his card and obtained a new PIN number to have access to the money. The Social Worker said when the facility realized the problem the Fiduciary and Social Worker closed Resident #4's account. She said CNA/Van Driver K was then terminated from the facility. <BR/>During an interview on 03/06/25 at 2:46 PM The DON said she saw CNA/Van Driver K and Resident #4 behind a closed door on an unrecalled date and the Social Worker investigated Resident #4's financial information starting on 08/12/24 and found several charges on his card at locations the facility staff knew Resident #4 could not have completed. The police were notified on 08/12/24 and CNA/Van Driver K was terminated. The expectation was for no staff to steal from residents. The DON said the facility staff were educated endlessly on abuse neglect and misappropriation. The DON said the failure placed a risk for negative outcomes and loss of money for all residents. <BR/>During an interview on 03/06/25 at the Administrator said she reported the incident on 08/12/24 and the CNA/Van Driver K was found to have taken Resident #4's card and used it. She said she had completed follow up calls with the local police department and they were working on a federal warrant to get the CNA. The Administrator said she was unsure how CNA/Van Driver K got Resident #4's card but they found the unusual transactions and had access, then the facility called the police and worked together to figure it all out. She said she did not refer CNA/Van Driver K because she thought the state completed referrals. The Administrator said the failure placed a risk of the longevity of the misappropriation for Resident #4 and any other resident. <BR/>Record review of CNA/Van Driver K's personnel file indicated she was hired on 02/08/23 and had a background check performed on 02/06/23 with no negative results. The personnel also indicted CNA/Van Driver K had an employee disciplinary report dated 08/12/24 with the disciplinary action of termination related to the misappropriation of resident funds confirmed by police officers.<BR/>Record review of the facility policy for Abuse/Reportable Events effective 1-10-2017 indicated:<BR/>Policy: All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.<BR/>The noncompliance was identified as PNC. The noncompliance began on 08/12/24 and ended on 08/12/24. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident and hazards for 2 of 7 residents (Residents #1 and #2) reviewed for accident hazards.<BR/>CNA B and CNA C failed to ensure Resident #2's Hoyer lift (an assistive lift device that allows for transfer using electrical power) transfer was performed correctly. <BR/>CNA D did not lock Resident #1's bed during incontinent care. <BR/>These failures could place dependent residents at risk for falls, significant injuries and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 1/9/24 indicated Resident #2 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, dementia, high blood pressure and COPD (chronic obstructive pulmonary disease - group of lung diseases that block airflow and make it difficult to breathe). <BR/>Record review of the MDS dated [DATE] indicated Resident #2 had unclear speech, rarely made herself understood and rarely understood others. The MDS indicated Resident #2 cognitive skills for decision making was severely impaired and she had both long-term and short-term memory problems. The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #2 was completely dependent on staff for toileting, oral hygiene, eating, bathing, dressing, and personal hygiene. The MDS indicated Resident #2 was completely dependent on staff for rolling side to side and all transfers. The MDS indicated Resident #2 had no impairment to the upper and lower extremities. The MDS indicated Resident #2 was always incontinent of bowel and bladder.<BR/>Record review of the care plan dated on 10/19/23 indicated Resident #2 had a self-care deficit due to her impaired cognition and impaired mobility. The care plan interventions included staff to assist resident with transfers as needed. The care plan also indicated Resident #2 was at risk for falls due to factors including decreased activity, confusion, and poor safety awareness. <BR/>During an observation on 1/9/24 at 1:20 p.m., CNA B and CNA C began to transfer Resident #2 from her wheelchair to her bed using a Hoyer lift. Resident #2 was initially combative with the CNAs, swinging her arms at them as they worked to attach the Hoyer sling to the Hoyer lift. After hooking the sling to the Hoyer lift, without locking the brakes (on the wheels) of the Hoyer lift, CNA B and CNA C lifted Resident #2 from her wheelchair. They (CNA B and CNA C) then guided the Hoyer lift to Resident #2's bed. Without locking the brakes of the Hoyer lift, they (CNA B and CNA C) lowered Resident #2 into the bed. <BR/>During an interview on 1/9/24 at 1:34 p.m., CNA B said she should have ensured the brakes were locked on the Hoyer lift wheels before Resident #2 was lifted from her wheelchair and before they (CNA B and CNA C) lowered Resident #2 into the bed. CNA B said she just forgot to double check and ensure the lift brakes (on the wheels of the Hoyer) were locked during the transfer. CNA B said the lift could have slid when they lifted/lowered Resident #2 and fallen over, especially since she (Resident #2) could be combative. CNA B said Resident #2 could have fallen out of the lift and gotten hurt. <BR/>During an interview on 1/9/24 at 1:37 p.m., CNA C said she should have ensured the brakes (on the wheels of the Hoyer) were locked on the Hoyer lift before Resident #2 was lifted from her wheelchair and before they (CNA B and CNA C) lowered Resident #2 into the bed. CNA C said she was just busy and forgot to ensure the Hoyer lift brakes were locked. CNA C said the lift could have tipped over and Resident #2 could have fallen into the floor. <BR/>2.Record review of the face sheet dated 1/9/24 indicated Resident #1 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, high blood pressure and heart disease. <BR/>Record review of the MDS dated [DATE] indicated Resident #1 had clear speech, usually made herself understood and usually understood others. The MDS indicated Resident #1 had mild cognitive impairment (BIMS of 9). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #1 required substantial/maximal assistance with personal hygiene, putting on/taking off footwear, dressing, and bathing. The MDS indicated Resident #1 required substantial/maximal assistance with rolling left to right and tub/shower transfer. The MDS indicated she required partial/moderate assistance with sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, and toilet transfer. The MDS indicated she required partial/moderate assistance with toileting and oral hygiene. The MDS indicated Resident #1 required setup or clean-up assistance with eating. The MDS indicated Resident #1 required extensive assistance of 2 persons to complete bed mobility, transfers, bathing and toilet use. The MDS indicated she had no impairment to the upper and lower extremities. The MDS indicated Resident #1 was frequently incontinent of bowel and bladder.<BR/>Record review of the care plan dated on 12/25/23 indicated Resident #1 had a self-care deficit due to her impaired cognition and impaired mobility. The care plan interventions included staff to assist resident with turning/repositioning while in bed, and staff will assist bathroom. The care plan also indicated Resident #1 was at risk for falls due to factors including decreased mobility.<BR/>During an observation on 1/9/24 at 1:00 p.m., CNA D provided incontinent care to Resident #1. CNA D did not check the brakes on the wheels of the bed before she started the incontinent care. During the incontinent care, CNA D moved the bed away from the wall and went to the left side of the bed (the side that was against the wall). CNA D did not lock the brakes on the wheels of the bed. CNA D then rolled Resident #1 to her (Resident #1's) right side (the side not against the wall). CNA D completed the care, returned the bed to the original position and did not lock the brakes on the wheels of the bed. <BR/>During an interview on 1/9/24 at 1:10 p.m., CNA D said she should have locked Resident #1's bed before starting the incontinent care, after she moved the bed, and after returning the bed to its original position. CNA D said Resident #1 could have fallen out the bed and sustained an injury. <BR/>During an interview on 1/9/24 at 1:40 p.m., LVN A said the CNAs should have ensured the brakes on the wheels on the Hoyer lift were locked before Resident #2 was lifted/lowered with the Hoyer lift. LVN A said CNA D should have double checked to ensure Resident #1's bed was locked before care was started. LVN A said Resident #1's bed should have been locked, before Resident #1 was repositioned in the bed and after CNA D completed Resident #1's care. LVN A said these things (the Hoyer lift brakes on the wheels left unlocked during the lift/descent of a resident and not ensuring bed brakes (on the wheels) were locked when a resident was repositioned in the bed) were safety issues. LVN A said Resident #2 could have been dropped from the Hoyer lift and Resident #1 could have fallen out of the bed.<BR/>During an interview on 1/9/24 at 1:57 p.m., the ADON said the CNA B and CNA C should have ensured the brakes on the wheels on the Hoyer lift were locked before Resident #2 was lifted/lowered with the Hoyer lift. The ADON said CNA D should have ensured Resident #1's bed was locked before care was started, before Resident #1 was repositioned and after the care was completed. The ADON said these things (the Hoyer lift brakes on the wheels left unlocked during the lift/descent of a resident and not ensuring bed brakes (on the wheels of the bed) were locked when a resident was repositioned in the bed) were posed a risk of injury. She said the system in place to ensure staff performed Hoyer lift transfers safely was the annual skills check off which included Hoyer lift transfers and ensuring brakes were locked on beds before repositioning a resident. The ADON said going forward a system would be put in place to perform spot checks on CNAs to ensure they were safely repositioning and transferring residents. <BR/>During an interview on 1/9/24 at 3:00 p.m., the Administrator said he expected staff to take appropriate measures to ensure residents safety during Hoyer lift transfers and incontinent care. The Administrator said leaving the bed unlocked and the Hoyer lift unlocked while a resident was lifted/lowered were not practices that would ensure resident safety. <BR/>During an interview on 1/9/24 at 2:30 p.m., the ADON said the facility did not have a policy and procedure specifically related to ensuring bed brakes (on the wheels of the bed) were locked. <BR/>Record review of the facility policy and procedure titled Lifting and movement of Resident-safe, dated December of 2017 stated, Policy: In order to protect the safety and well-being of staff and residents and to promote quality care, this home uses appropriate techniques and devices to lift and move residents . The policy and procedure did not specifically address the use of bed brakes (on the wheels of the bed or mechanical lift brakes (on the wheels of the mechanical lift). <BR/>Record review of the facility policy and procedure titled Mechanical Lift, dated December of 2017 reveled it did not specifically address the use of mechanical lift brakes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 4 of 6 (Resident #40, Resident #33, Resident #4 and Resident #23) residents reviewed for the care plan.<BR/>1. The facility failed to care plan Resident #40 needs to be in the secure unit <BR/>2. The facility failed to care plan or write an order for Resident #33's to be in the secure unit. The facility failed to care plan Resident #33 was a smoker.<BR/>3. The facility failed to ensure Resident #4's comprehensive care plan addressed she received a prophylactic antibiotic.<BR/>4. The facility failed to ensure Resident #23's comprehensive care plan was person-centered to include his diagnosis of PTSD and any triggers he had.<BR/>These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.<BR/>The findings included:<BR/>1.Record review of Resident #40's face sheet, dated 05/07/24, indicated Resident #40 was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #40 had diagnoses which included Dementia (loss of memory), Depression (sadness), and Paranoid Schizophrenia (a kind of psychosis, which means your mind does not agree with reality). <BR/>Record review of Resident #40's quarterly MDS assessment, dated 03/14/24, indicated Resident #40 was sometimes understood and sometimes understood by others. Resident #40's BIMS score was 07, which indicated he was moderately cognitively impaired. Resident #40 required extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, and supervision with eating. <BR/>Record review of Resident #40's Elopement/Wandering Observation dated 02/27/24 indicated Resident #40 was at high risk of elopement.<BR/>Record review of Resident #40's physician orders dated 12/19/22, indicated resident to reside in the secure unit related to wandering and elopement risk. <BR/>Record review of Resident #40's comprehensive care plan dated 09/22/21 did not indicate any plan of care or interventions for the secure unit. <BR/>During an observation on 05/06/24 at 10:00 a.m., Resident #40 was sitting at the dining room table in the secure unit.<BR/>2. Record review of Resident #33's face sheet, dated 05/07/24, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included stroke, Parkinson's (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), and Paranoid Schizophrenia (a kind of psychosis, which means your mind doesn't agree with reality).<BR/>Record review of Resident #33's quarterly MDS assessment, dated 03/22/24, indicated Resident #33 was rarely understood and sometimes understood by others and his BIMS was a 04, indicating severe cognition impairment. The MDS assessment indicated he had short and long-term memory problems. Resident #33 required assistance with bathing, dressing, bed mobility, personal hygiene, toileting, and setting up for eating. <BR/>Record review of Resident #33's Elopement/Wandering Observation dated 02/26/24 indicated Resident was at a low risk of elopement.<BR/>Record review of Resident #33's Smoking assessment dated [DATE] indicated Resident #33 was a smoker. <BR/>Record review of Resident #33's physician orders dated 05/07/24, did not indicate an order for the secure unit.<BR/>Record review of Resident #33's comprehensive care plan, dated 03/24/24, did not indicate any plan of care or interventions for the secure unit. <BR/>Record review of Resident #33's comprehensive care plan, dated 03/24/24, did not indicate any plan of care or interventions for smoking.<BR/>During an observation on 05/06/24 at 10:31 a.m., Resident #33 was outside smoking with staff.<BR/>During an observation on 05/06/24 at 12:15 p.m., Resident #33 was walking down the hallway in the secure unit.<BR/>During an interview on 05/09/24 at 9:49 a.m., RN G said Resident #33 was a resident who smoked and resided in the unit. RN G said if a resident was on the secure unit, they should have an order indicating they needed to be in the unit and it should be care planned. RN G said the nurses were responsible for writing an order to admit to the secure unit. He said the MDS nurse or nurse management did the care plans. <BR/>During an observation and interview on 05/09/24 at 6:06 p.m., the MDS nurse said she was responsible for the comprehensive care plans, but all the department heads did their acute care plans. The surveyor observed the MDS nurse look in the electronic records for Resident #40 and Resident #33. She said she did not see a care plan for the secure unit on Resident #40 or Resident #33. She said she did not see a smoking care plan for Resident #33. The MDS nurse said the reason for being in the secure unit and interventions should have been listed on Resident #40's and Resident #33's care plan. She said Resident #33 should have had a smoking care plan because he smoked. The MDS nurse said they discussed orders, changes in the resident's condition in the morning meetings, and any changes that should have been made to their care plan. She said she did not know how she failed to care plan for both residents. She said care plans were done to address concerns, she said it was like a road map for their care. <BR/>During an interview on 05/09/24 at 6:39 p.m., the DON said the MDS nurse was responsible for completing the care plans but all department heads did care plans. She said during morning meetings she would review orders, progress notes, 24-hour reports, and incidents to ensure things had been added or discontinued from the care plan. She said she was the overseer. She said Resident #40 and Resident #33's nurses should have written orders for the secure unit when they were admitted to the unit. The DON said she was not aware that Resident #40 and Resident #33 had missed care plans. She said care plans were done to ensure the residents were getting the appropriate care.<BR/>3. Record review of Resident #4's face sheet dated 05/07/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4's diagnoses included dementia (memory loss), depression (persistent depressed mood), and urinary tract infection (an infection in any part of the urinary system).<BR/>Record review of Resident #4's quarterly MDS assessment dated [DATE], indicated she was sometimes understood and sometimes understood others. The MDS assessment indicated Resident #4 had a BIMS score of 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #4 had taking antibiotic within the last 7 days of the look back period. <BR/>Record review of Resident #4's comprehensive care plan dated 03/20/24 did not indicate Resident #4 was taking Macrodantin or a prophylactic antibiotic daily. <BR/>Record review of Resident #4's physician order report dated 05/01/24- 05/07/24, indicated Resident #4 had an order for Macrodantin (antibiotic to treat and prevent urinary tract infections) 50mg one tablet daily for prophylaxis (preventative) with a start date of 01/04/23. <BR/>Record review of Resident #4's medication administration history dated 05/01/24-05/09/24, indicated she had been receiving macrodantin 50mg one capsule daily.<BR/>4. Record review of Resident #23's face sheet dated 05/08/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugars and using it for energy), post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), hypertensive heart disease (heart condition due to untreated high blood pressure) and paraplegia (leg paralysis).<BR/>Record review of Resident #23's admission MDS assessment dated [DATE], indicated was usually understood and was able to understand others. The MDS assessment indicated Resident #23's BIMS score was a 9, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #23 had diagnoses of post-traumatic stress disorder. <BR/>Record review of Resident #23's comprehensive care plan dated 04/05/24, did not indicate Resident #23 had a diagnosis of PTSD or if he had any triggers.<BR/>During an interview on 05/07/24 at 10:59 AM Resident #23 said he had PTSD from Vietnam and Kuwait wars. Resident #23 said loud noises was his trigger.<BR/>During an interview on 05/09/24 at 3:50 PM, the DON said Resident #4's prophylactic antibiotic and Resident #23's diagnoses of PTSD should have had been care planned. The DON said they should have been care planned so staff would know Resident #4 was taking an antibiotic long term and Resident #23 had a diagnosis of PTSD with any triggers he had. The DON said the nurse leadership was responsible for ensuring the care plans were updated. The DON said since Resident #4's antibiotic and Resident #23's PTSD diagnoses were not care planned, the care plan was not accurate. <BR/>During an interview on 05/09/24 at 04:36 PM the Regional Clinical Consultant said Resident #4 care plan should reflect Resident #4 was receiving antibiotics as ordered as they do not name the medication. The Regional Clinical Consultant said Resident #23's diagnoses of PTSD should have been on his care plan with any triggers he had. The Regional Clinical Consultant said she expected the care plans to be updated timely. The Regional Clinical Consultant said nursing leadership was responsible for updating the care plans.<BR/>Record review of the facility's policy titled Care Plan dated 12/2018, indicated . It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident . 4. Concerns and Problems . 1. The specific problem as well as the underlying cause should be listed .b. sources are but are not limited to: 1. problems relating to diagnoses .8. Problems related to preventative care .10. All problems identified on all assessments .the resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate and planned to meet the individual needs of the resident consistent with the physician's plan of care for the resident .the resident care plan must be kept current at all times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 residents reviewed for respiratory care (Residents #1).The facility failed to ensure Resident #1's oxygen filter was in the back of the concentrator.This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease.Findings Included:Findings Included:Record review of Resident #1's face sheet dated 06/25/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses heart failure, personal history of COVID, altered mental status, anxiety, and high blood pressure. Record review of Resident #1's quarterly MDS dated [DATE] indicated she made herself understood and was able to understand others. The MDS also indicated she had a BIMS score of 3 which indicated she had severely impaired cognition. The MDS also indicated she used oxygen while she was a resident. Record review of Resident #1's care plan dated 11/12/24 indicated she had and ADL selfcare deficit related to impaired cognition and impaired mobility with interventions for staff to provide supervision and assist resident to the bathroom when needed, provide supervision ad assist with transfers as needed, and provide moderate assistance with showers 3 times a week. The care plan also indicated Resident #1 had oxygen therapy with a goal for resident to have no signs and symptoms of poor oxygen absorption and interventions to provide oxygen per MD orders and monitor for signs and symptoms of respiratory distress. Record review of Resident #1's physician order report dated 05/25/2025-06/25/2025 indicated she had an order for:Oxygen: Change oxygen tubing, bubble humidification, and clean filters in use Q week. Once a day on Sunday night shift 22:00-06:00(10:00pm-6:00 am) with a start date 08/15/2022 and no end date. Record review of Resident #1's respiratory administration history dated 06/01/2025-06/25/2025 indicated LVN K signed off as completing the order:Oxygen: Change oxygen tubing, bubble humidification, and clean filters in use Q week. Once a day on Sunday night shift 22:00-06:00(10:00pm-6:00 am) on 06/22/25. During an observation and interview on 06/23/25 at 11:25 AM Resident #1 was sitting in her room and had an oxygen concentrator beside her bed that did not have a filter in it. Resident #1 said she used her oxygen every night. During an observation on 06/24/25 at 08:40 AM Resident #1's oxygen concentrator in her room had no filter. During an observation on 06/25/25 at 08:15 AM Resident #1's oxygen concentrator in her room had no filter. During an observation and interview on 06/25/25 at 03:39 PM Resident #1's oxygen concentrator in her room had no filter and LVN L said the oxygen filters and the tubing were changed out by night shift nurse on Sundays. LVN L said there should have been a filter in the concentrator. She said the failure placed Resident #1 at risk infection because the filter was used to block dirt, bacteria, and trash from going into her nasal cavity. During an interview on 06/25/25 at 03:53 PM the DON said her expectation was for the oxygen concentrator filter to be in place and clean. The DON said the night shift nurses were responsible for changing the tubing and cleaning the filters on Sundays. The DON said the failure placed a risk is for the oxygen concentrator not working properly and placed a risk for infection. During an interview on 06/25/25 at 04:03 PM the Administrator said he expected the staff to be properly trained and for nurses to inspect and change the oxygen concentrator tubing and filters He said the floor nurses should ensure the filters were replaced correctly and working properly. The Administrator said the DON as well as the floor nurses were responsible for ensuring the oxygen concentrators were clean and operating properly. The Administrator said the failure placed Resident #1 at risk of contamination. During an attempted call on 06/25/25 at 04:19 PM LVN K (the night nurse who signed the order for cleaning the oxygen filter as completed) did not answer.Record review of the facility policy Respiratory Therapy Equipment dated 12/2017 indicated:POLICYIt is the policy of this home that residents on respiratory therapy will have appropriate treatment. Only trained licensed staff will administer respiratory therapy. Respiratory equipment used to provide therapy will be maintained appropriately.PROCEDUREOxygen Administration1. Obtain equipment (i.e., oxygen tubing, reservoir, and distilled water) .9. Wash filters from oxygen concentrators every 7 days in soapy water. Rinse and squeeze dry .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 22 residents (Resident #23) reviewed for quality of care.<BR/>The facility did not ensure Resident #23's trauma screening was completed upon admission to the facility. <BR/>This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. <BR/>The findings included:<BR/>Record review of Resident #23's face sheet dated 05/08/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugars and using it for energy), post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), hypertensive heart disease (heart condition due to untreated high blood pressure) and paraplegia (leg paralysis).<BR/>Record review of Resident #23's admission MDS assessment dated [DATE], indicated was usually understood and was able to understand others. The MDS assessment indicated Resident #23's BIMS score was a 9, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #23 had diagnoses of post-traumatic stress disorder. <BR/>Record review of Resident #23's comprehensive care plan dated 04/05/24, did not indicate Resident #23 had a diagnosis of PTSD or if he had any triggers.<BR/>Record review of Resident #23's trauma informed care observation dated 04/12/24 indicated the observation was recorded and completed on 05/08/24 by the SW. The assessment indicated Resident #23 had personally experienced a natural disaster, a serious accident, life-threatening illness or injury and physical assault. The assessment indicated Resident #23 had personally experienced and witnessed a combat or war-one. The assessment indicated yes when asked if any of these events bothered him. The assessment under comments indicated years of therapy have helped him cope with PTSD. VA assists as well. The assessment under triggers that remind you of the event indicated loud noises and water. The assessment indicated, under the question how do you react when you are reminded of the event, sometimes anxious. The assessment indicated breathing and thinking about other things helped Resident #23 refocus when he reacted to the events. <BR/>During an interview on 05/07/24 at 10:59 AM Resident #23 said he had PTSD from Vietnam and Kuwait wars. Resident #23 said loud noises was his trigger.<BR/>During an interview on 05/09/24 at 09:03 AM, the SW provided Resident #23's completed trauma assessment. The SW said she did not complete Resident #23's trauma assessment until yesterday, 05/08/24, when it was requested. The SW said she had completed the trauma assessment prior but had only documented it her notes and not in Resident #23's electronic medical record.<BR/>During an interview on 05/09/24 at 3:50 PM, the DON said Resident #23 should have had his trauma assessment completed upon admission. The DON said she knew the SW had completed the trauma assessment but did not have an answer as to why she did not input that information in Resident #23's medical record. The DON said it was important for the trauma assessment to be completed to have access to that information so they could accurately meet Resident #23's needs. The DON said the SW was responsible for completing the trauma assessments. <BR/>During an interview on 05/09/24 at 04:36 PM, the Regional Director said nurse management was responsible for completing the trauma assessments. The Regional Director said he was unsure of the risks for not completing the trauma assessment or when it should have been completed.<BR/>During an interview on 05/09/24 at 05:23 PM, the SW said she was responsible for completing the trauma assessments within the first 14 days of admission. The SW said by not completing the trauma assessment timely the staff will not know of any triggers Resident #23 could have. The SW said she educated staff regarding Resident #23's triggers which included loud noises, engine backfire, and water. <BR/>During an interview on 05/09/24 at 05:27 PM, RN B said she was not aware of Resident #23 having a diagnosis of PTSD or if he had any triggers. RN B said if a resident had the diagnosis of PTSD, the staff should be aware of any triggers the resident had to be able to care for the resident. <BR/>During an interview on 05/09/24 at 05:33 PM, CNA D said she was unsure if Resident #23 had PTSD or if he had any triggers. CNA D said it was important for staff to be aware so they could properly care for Resident #23. CNA D said Resident #23 triggers should have been documented on his care plan. <BR/>During an interview on 05/09/24 at 10:16 AM, the DON said they did not have a policy on trauma informed care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** BASED on interview and record review, the facility failed to ensure the drug regimen was free from unnecessary drugs for 1 of 21 residents reviewed for medications. (Resident #30)The facility failed to ensure Resident #30's Remeron (mirtazapine) (antidepressant medication) was decreased on 04/10/25 when the medical director signed the pharmacy recommendation and agreed to decrease the Remeron (mirtazapine) from 22.5mg to 15mg every night. This failure could place residents who received antipsychotic medications at risk of receiving unnecessary medication.Findings include:Record review of Resident #30's face sheet dated 06/25/25 indicated he was an [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses Alzheimer's disease, diabetes mellitus, heart disease, depression, and anxiety. Record review of Resident #30's significant change MDS dated [DATE] indicated he usually makes himself understood and usually understood others. The MDS also indicated he had a BIMS score of 5 which indicated severely impaired cognition. The MDS also indicated Resident #30 was dependent on staff for transfers, bed mobility, bathing and eating. Record review of Resident #30's care plan dated 04/17/25 indicated he had potential for side effects related to psychotropic medication use (antipsychotic, antidepressant) with interventions in place for the pharmacy consultant to review medications periodically for possible reduction, and for the staff to administer medications for conditions as ordered.Record review of Resident #30's physician order report dated 05/25/25-06/25/25 indicated he had and order for:1.Remeron (mirtazapine) 15mg tablet oral to give with 7.5mg tablet to=22.5mg once a day at 18:00-22:00(6:00 PM-6:00 AM) with a start date of 06/11/24 and no end date.2.Mirtazapine 7.5mg tablet oral to give with 15mg tablet to=22.5mg once a day at 18:00-22:00(6:00 PM-6:00 AM) with a start date of 06/11/24 and no end date.Record review of Resident #30's note to attending physician/prescriber dated 03/30/25 indicated Resident #30 had been taking the antidepressant REMERON 22.5MG QD since 5/2024. The note to the attending physician/prescriber was signed in agreement by the MD with a rationale to decrease the Remeron (mirtazapine) from 22.5mg to 15mg every night. Record review of Resident #30's medication administration record dated 06/01/25-07/01/25 indicated Resident #30 continued to receive the Remeron (mirtazapine) 22.5mg dose every night until 06/25/25 after surveyor intervention. During an interview on 06/25/25 at 03:30 PM LVN M said she was not taking care of Resident #30 in April 2025, she was working in the locked unit. She said that by reading the order noted by the physician on the note to attending physician/prescriber dated 03/30/25 she would have changed the order for the Remeron (mirtazapine). During an interview on 06/25/25 at 03:51 PM the DON said she oversaw the process for the pharmacy recommendations. She said the charge nurses gets the signed orders and the nurse would be responsible for changing the orders and provide the signed note to the attending physician/prescriber to the DON for follow up to ensure the orders were completed. She said she just missed Resident #30's note to the attending physician/prescriber. The DON said the charge nurse possibly did not give the note to her after completing it to verify and ensure order was carried out. The DON gave Resident #30's signed note to attending physician/prescriber dated 03/30/25 to the ADON for the orders to be updated in the computer and told the ADON to notify the MD. The DON said the failure placed a risk for Resident #30 having improper doses of medication and unnecessary medications. During an interview on 06/25/25 at 04:07 PM the Administrator said his expectation was for the nursing staff to ensure gradual dose reductions from the pharmacy and nursing orders were followed. The Administrator said the failure placed a risk for Resident #30 but he was not exactly sure about what risk, but he said he expected the medication to be decreased as ordered. Record review of the facility policy Behavior Management-Psychoactive Medication-Antipsychotic Drug Therapy dated 12/2017 indicated:POLICYIt is the policy of this home to use antipsychotic medications per CMS guidelines and to perform dose reductions and monitoring as required by regulation, to promote the highest level of resident care and safety.DEFINITIONS1. A gradual dose reduction is a tapering of the resident's daily dose to determine if the resident's symptoms can be controlled by a lower dose or to determine if the dose can be eliminated altogether .

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 6 medication carts (main street medication cart) reviewed for medication storage.<BR/>The facility failed to ensure the main street hall medication cart was locked when the ADON left the floor and left the cart unattended. <BR/>This failure could place residents at risk of taking medications not intended for them with adverse outcomes; risk of loss/interruption in receiving medications.<BR/>Findings included:<BR/>During an observation on 04/03/23 from 11:46 a.m. to 11:57 a.m., the main street hall medication cart was left on the main street hall unlocked and unattended while nurse had left it to go to the dining room. <BR/>During an observation and interview on 04/03/23 at 11:57 AM, the Corporate Clinical Nurse walked up to the cart and tried to hide her hand while she locked the medication cart. The Corporate Clinical Nurse said anything could happen with the cart being unlocked. The Corporate Clinical Nurse said anyone could have accessed the cart and ingested the medications. She said the nurse was responsible to ensure the carts were locked.<BR/>During an interview on 04/03/23 at 12:07 PM, the ADON said she was responsible for the medication cart and had forgotten to lock the cart. The ADON said with the cart being unlocked any resident, staff, or visitor could have opened the cart and took the medications out of the cart. The ADON said she was busy and did not lock the cart prior to her leaving the cart. The ADON said the facility performed proficiency checkoffs to ensure the nurses and medication aides were aware of the need to lock the medication carts on the hallways when the carts were not in use. She said the DON was responsible for completing proficiency checkoffs. <BR/>During an interview on 04/05/23 at 03:21 PM, the DON said the medication carts should always be locked if the nurse or aide was not working out of the cart. The failure to lock the medication cart could place a staff or visitor, who was unauthorized to access the medications, capability of getting in the cart. The DON said any resident in the facility could get into the cart and take the medications. The policy and procedures upon hire instructed all nurses or med aides to always keep the cart locked. She said it was a part off the skills checkoff<BR/>During an interview on 04/05/23 at 03:38 PM, the administrator said if the medication carts were not being used, they should be closed and locked. He said the failure to lock the medication carts provided risks of residents taking medications that they did not need, as well as other staff and visitors. The administrator said the nursing staff were responsible for ensuring the carts were locked.<BR/>Record review of the policy for Medication Storage, dated 1-2023, indicated<BR/>Policy<BR/>It is the policy of this home that the medications will be stored appropriately as to be secure from tampering, exposure, or misuse. <BR/>Procedure<BR/>1. <BR/>The provider pharmacy dispenses medications .<BR/>2. <BR/>Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (i.e., medication aides, etc.) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.<BR/>1. The facility failed to ensure 3 sheet pans were free from a brown colored grease like build up on the inside corners of the sheet pans.<BR/>2. The facility failed to ensure 2 cast iron skillets were free from a carbon build up not covering the inside walls and the outside of the skillet.<BR/>3. The facility failed to ensure the juice machine was free from dusty like material on the front and sides.<BR/>These failures could place residents at risk for food borne illness.<BR/>Findings included:<BR/>During observations on initial tour on 5/06/2024 at 9:28 a.m., the following was found:<BR/>*2 cast iron skillets with a large amount of black encrusted carbon buildup on the inside and the outside.<BR/>*3-1/4 sheet pans with dark brown build up appears to be caked on grease material was on the inside corners of each pan.<BR/>*Juice machine had dust buildup on the two sides and the front of the machine.<BR/>During an interview with the on 5/06/2024 at 9:30 a.m., the cook said she used the sheet pans to cook the breakfast meats, and the cast iron skillets were used to fry fish on Fridays. The [NAME] said the pans should be cleaned better, to remove the brown material. The [NAME] said the pans were not considered clean enough to cook food.<BR/>Record review of the Daily Cleaning Schedule dated May 2024 the sheet pans, the cast iron skillets, and the juice machine was not listed on the cleaning schedule duties. <BR/>During an interview on 5/09/2024 at 11:48 a.m., the DON said she expected the dietary department to be clean according to basic kitchen standards. The DON said unsanitary cleaning practices could lead to undesirable events including food borne illnesses. The DON said the Dietary Manager and staff were responsible for ensuring kitchen sanitation.<BR/>During an interview on 5/09/2024 at 12:57 p.m., the RDO indicated he expected the dietary department to be clean including the machines, and pans. The RDO said the Dietary Manager was responsible for ensuring kitchen sanitation.<BR/>During an interview on 5/09/2024 at 2:40 p.m., the Dietary Manager said she would have to remove and replace the iron skillets after the Friday menu items of fish. The Dietary Manager said the pans could not be cleaned and could make someone ill. The Dietary Manager said she would have to ensure the juice machine was clean to prevent dust from getting in the drinks.<BR/>Record review of the General Kitchen Sanitation policy dated October 1, 2018 indicated the facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition and Food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness 3. Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil.<BR/>Record review of the Food Code dated 01/18/23 and accessed online at www.fda.gov/[NAME]/164194 on 5/13/2024 revealed:<BR/>4-101.11 Characteristics <BR/>Material that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: A). Safe, B). Durable, corrosion-resistant, and non-absorbent . D). Finished to have a smooth, easily cleanable surface <BR/>4-101.12 Cast Iron, Use Limitation. (A) Except as specified in (B) and (C) of this section, cast iron may not be used for UTENSILS or FOOD-CONTACT SURFACES of EQUIPMENT. (B) Cast iron may be used as a surface for cooking. (C) Cast iron may be used in UTENSILS for serving FOOD if the UTENSILS are used only as part of an uninterrupted process from cooking through service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident and hazards for 2 of 7 residents (Residents #1 and #2) reviewed for accident hazards.<BR/>CNA B and CNA C failed to ensure Resident #2's Hoyer lift (an assistive lift device that allows for transfer using electrical power) transfer was performed correctly. <BR/>CNA D did not lock Resident #1's bed during incontinent care. <BR/>These failures could place dependent residents at risk for falls, significant injuries and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 1/9/24 indicated Resident #2 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, dementia, high blood pressure and COPD (chronic obstructive pulmonary disease - group of lung diseases that block airflow and make it difficult to breathe). <BR/>Record review of the MDS dated [DATE] indicated Resident #2 had unclear speech, rarely made herself understood and rarely understood others. The MDS indicated Resident #2 cognitive skills for decision making was severely impaired and she had both long-term and short-term memory problems. The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #2 was completely dependent on staff for toileting, oral hygiene, eating, bathing, dressing, and personal hygiene. The MDS indicated Resident #2 was completely dependent on staff for rolling side to side and all transfers. The MDS indicated Resident #2 had no impairment to the upper and lower extremities. The MDS indicated Resident #2 was always incontinent of bowel and bladder.<BR/>Record review of the care plan dated on 10/19/23 indicated Resident #2 had a self-care deficit due to her impaired cognition and impaired mobility. The care plan interventions included staff to assist resident with transfers as needed. The care plan also indicated Resident #2 was at risk for falls due to factors including decreased activity, confusion, and poor safety awareness. <BR/>During an observation on 1/9/24 at 1:20 p.m., CNA B and CNA C began to transfer Resident #2 from her wheelchair to her bed using a Hoyer lift. Resident #2 was initially combative with the CNAs, swinging her arms at them as they worked to attach the Hoyer sling to the Hoyer lift. After hooking the sling to the Hoyer lift, without locking the brakes (on the wheels) of the Hoyer lift, CNA B and CNA C lifted Resident #2 from her wheelchair. They (CNA B and CNA C) then guided the Hoyer lift to Resident #2's bed. Without locking the brakes of the Hoyer lift, they (CNA B and CNA C) lowered Resident #2 into the bed. <BR/>During an interview on 1/9/24 at 1:34 p.m., CNA B said she should have ensured the brakes were locked on the Hoyer lift wheels before Resident #2 was lifted from her wheelchair and before they (CNA B and CNA C) lowered Resident #2 into the bed. CNA B said she just forgot to double check and ensure the lift brakes (on the wheels of the Hoyer) were locked during the transfer. CNA B said the lift could have slid when they lifted/lowered Resident #2 and fallen over, especially since she (Resident #2) could be combative. CNA B said Resident #2 could have fallen out of the lift and gotten hurt. <BR/>During an interview on 1/9/24 at 1:37 p.m., CNA C said she should have ensured the brakes (on the wheels of the Hoyer) were locked on the Hoyer lift before Resident #2 was lifted from her wheelchair and before they (CNA B and CNA C) lowered Resident #2 into the bed. CNA C said she was just busy and forgot to ensure the Hoyer lift brakes were locked. CNA C said the lift could have tipped over and Resident #2 could have fallen into the floor. <BR/>2.Record review of the face sheet dated 1/9/24 indicated Resident #1 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, high blood pressure and heart disease. <BR/>Record review of the MDS dated [DATE] indicated Resident #1 had clear speech, usually made herself understood and usually understood others. The MDS indicated Resident #1 had mild cognitive impairment (BIMS of 9). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #1 required substantial/maximal assistance with personal hygiene, putting on/taking off footwear, dressing, and bathing. The MDS indicated Resident #1 required substantial/maximal assistance with rolling left to right and tub/shower transfer. The MDS indicated she required partial/moderate assistance with sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, and toilet transfer. The MDS indicated she required partial/moderate assistance with toileting and oral hygiene. The MDS indicated Resident #1 required setup or clean-up assistance with eating. The MDS indicated Resident #1 required extensive assistance of 2 persons to complete bed mobility, transfers, bathing and toilet use. The MDS indicated she had no impairment to the upper and lower extremities. The MDS indicated Resident #1 was frequently incontinent of bowel and bladder.<BR/>Record review of the care plan dated on 12/25/23 indicated Resident #1 had a self-care deficit due to her impaired cognition and impaired mobility. The care plan interventions included staff to assist resident with turning/repositioning while in bed, and staff will assist bathroom. The care plan also indicated Resident #1 was at risk for falls due to factors including decreased mobility.<BR/>During an observation on 1/9/24 at 1:00 p.m., CNA D provided incontinent care to Resident #1. CNA D did not check the brakes on the wheels of the bed before she started the incontinent care. During the incontinent care, CNA D moved the bed away from the wall and went to the left side of the bed (the side that was against the wall). CNA D did not lock the brakes on the wheels of the bed. CNA D then rolled Resident #1 to her (Resident #1's) right side (the side not against the wall). CNA D completed the care, returned the bed to the original position and did not lock the brakes on the wheels of the bed. <BR/>During an interview on 1/9/24 at 1:10 p.m., CNA D said she should have locked Resident #1's bed before starting the incontinent care, after she moved the bed, and after returning the bed to its original position. CNA D said Resident #1 could have fallen out the bed and sustained an injury. <BR/>During an interview on 1/9/24 at 1:40 p.m., LVN A said the CNAs should have ensured the brakes on the wheels on the Hoyer lift were locked before Resident #2 was lifted/lowered with the Hoyer lift. LVN A said CNA D should have double checked to ensure Resident #1's bed was locked before care was started. LVN A said Resident #1's bed should have been locked, before Resident #1 was repositioned in the bed and after CNA D completed Resident #1's care. LVN A said these things (the Hoyer lift brakes on the wheels left unlocked during the lift/descent of a resident and not ensuring bed brakes (on the wheels) were locked when a resident was repositioned in the bed) were safety issues. LVN A said Resident #2 could have been dropped from the Hoyer lift and Resident #1 could have fallen out of the bed.<BR/>During an interview on 1/9/24 at 1:57 p.m., the ADON said the CNA B and CNA C should have ensured the brakes on the wheels on the Hoyer lift were locked before Resident #2 was lifted/lowered with the Hoyer lift. The ADON said CNA D should have ensured Resident #1's bed was locked before care was started, before Resident #1 was repositioned and after the care was completed. The ADON said these things (the Hoyer lift brakes on the wheels left unlocked during the lift/descent of a resident and not ensuring bed brakes (on the wheels of the bed) were locked when a resident was repositioned in the bed) were posed a risk of injury. She said the system in place to ensure staff performed Hoyer lift transfers safely was the annual skills check off which included Hoyer lift transfers and ensuring brakes were locked on beds before repositioning a resident. The ADON said going forward a system would be put in place to perform spot checks on CNAs to ensure they were safely repositioning and transferring residents. <BR/>During an interview on 1/9/24 at 3:00 p.m., the Administrator said he expected staff to take appropriate measures to ensure residents safety during Hoyer lift transfers and incontinent care. The Administrator said leaving the bed unlocked and the Hoyer lift unlocked while a resident was lifted/lowered were not practices that would ensure resident safety. <BR/>During an interview on 1/9/24 at 2:30 p.m., the ADON said the facility did not have a policy and procedure specifically related to ensuring bed brakes (on the wheels of the bed) were locked. <BR/>Record review of the facility policy and procedure titled Lifting and movement of Resident-safe, dated December of 2017 stated, Policy: In order to protect the safety and well-being of staff and residents and to promote quality care, this home uses appropriate techniques and devices to lift and move residents . The policy and procedure did not specifically address the use of bed brakes (on the wheels of the bed or mechanical lift brakes (on the wheels of the mechanical lift). <BR/>Record review of the facility policy and procedure titled Mechanical Lift, dated December of 2017 reveled it did not specifically address the use of mechanical lift brakes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident and hazards for 2 of 7 residents (Residents #1 and #2) reviewed for accident hazards.<BR/>CNA B and CNA C failed to ensure Resident #2's Hoyer lift (an assistive lift device that allows for transfer using electrical power) transfer was performed correctly. <BR/>CNA D did not lock Resident #1's bed during incontinent care. <BR/>These failures could place dependent residents at risk for falls, significant injuries and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 1/9/24 indicated Resident #2 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, dementia, high blood pressure and COPD (chronic obstructive pulmonary disease - group of lung diseases that block airflow and make it difficult to breathe). <BR/>Record review of the MDS dated [DATE] indicated Resident #2 had unclear speech, rarely made herself understood and rarely understood others. The MDS indicated Resident #2 cognitive skills for decision making was severely impaired and she had both long-term and short-term memory problems. The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #2 was completely dependent on staff for toileting, oral hygiene, eating, bathing, dressing, and personal hygiene. The MDS indicated Resident #2 was completely dependent on staff for rolling side to side and all transfers. The MDS indicated Resident #2 had no impairment to the upper and lower extremities. The MDS indicated Resident #2 was always incontinent of bowel and bladder.<BR/>Record review of the care plan dated on 10/19/23 indicated Resident #2 had a self-care deficit due to her impaired cognition and impaired mobility. The care plan interventions included staff to assist resident with transfers as needed. The care plan also indicated Resident #2 was at risk for falls due to factors including decreased activity, confusion, and poor safety awareness. <BR/>During an observation on 1/9/24 at 1:20 p.m., CNA B and CNA C began to transfer Resident #2 from her wheelchair to her bed using a Hoyer lift. Resident #2 was initially combative with the CNAs, swinging her arms at them as they worked to attach the Hoyer sling to the Hoyer lift. After hooking the sling to the Hoyer lift, without locking the brakes (on the wheels) of the Hoyer lift, CNA B and CNA C lifted Resident #2 from her wheelchair. They (CNA B and CNA C) then guided the Hoyer lift to Resident #2's bed. Without locking the brakes of the Hoyer lift, they (CNA B and CNA C) lowered Resident #2 into the bed. <BR/>During an interview on 1/9/24 at 1:34 p.m., CNA B said she should have ensured the brakes were locked on the Hoyer lift wheels before Resident #2 was lifted from her wheelchair and before they (CNA B and CNA C) lowered Resident #2 into the bed. CNA B said she just forgot to double check and ensure the lift brakes (on the wheels of the Hoyer) were locked during the transfer. CNA B said the lift could have slid when they lifted/lowered Resident #2 and fallen over, especially since she (Resident #2) could be combative. CNA B said Resident #2 could have fallen out of the lift and gotten hurt. <BR/>During an interview on 1/9/24 at 1:37 p.m., CNA C said she should have ensured the brakes (on the wheels of the Hoyer) were locked on the Hoyer lift before Resident #2 was lifted from her wheelchair and before they (CNA B and CNA C) lowered Resident #2 into the bed. CNA C said she was just busy and forgot to ensure the Hoyer lift brakes were locked. CNA C said the lift could have tipped over and Resident #2 could have fallen into the floor. <BR/>2.Record review of the face sheet dated 1/9/24 indicated Resident #1 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, high blood pressure and heart disease. <BR/>Record review of the MDS dated [DATE] indicated Resident #1 had clear speech, usually made herself understood and usually understood others. The MDS indicated Resident #1 had mild cognitive impairment (BIMS of 9). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #1 required substantial/maximal assistance with personal hygiene, putting on/taking off footwear, dressing, and bathing. The MDS indicated Resident #1 required substantial/maximal assistance with rolling left to right and tub/shower transfer. The MDS indicated she required partial/moderate assistance with sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, and toilet transfer. The MDS indicated she required partial/moderate assistance with toileting and oral hygiene. The MDS indicated Resident #1 required setup or clean-up assistance with eating. The MDS indicated Resident #1 required extensive assistance of 2 persons to complete bed mobility, transfers, bathing and toilet use. The MDS indicated she had no impairment to the upper and lower extremities. The MDS indicated Resident #1 was frequently incontinent of bowel and bladder.<BR/>Record review of the care plan dated on 12/25/23 indicated Resident #1 had a self-care deficit due to her impaired cognition and impaired mobility. The care plan interventions included staff to assist resident with turning/repositioning while in bed, and staff will assist bathroom. The care plan also indicated Resident #1 was at risk for falls due to factors including decreased mobility.<BR/>During an observation on 1/9/24 at 1:00 p.m., CNA D provided incontinent care to Resident #1. CNA D did not check the brakes on the wheels of the bed before she started the incontinent care. During the incontinent care, CNA D moved the bed away from the wall and went to the left side of the bed (the side that was against the wall). CNA D did not lock the brakes on the wheels of the bed. CNA D then rolled Resident #1 to her (Resident #1's) right side (the side not against the wall). CNA D completed the care, returned the bed to the original position and did not lock the brakes on the wheels of the bed. <BR/>During an interview on 1/9/24 at 1:10 p.m., CNA D said she should have locked Resident #1's bed before starting the incontinent care, after she moved the bed, and after returning the bed to its original position. CNA D said Resident #1 could have fallen out the bed and sustained an injury. <BR/>During an interview on 1/9/24 at 1:40 p.m., LVN A said the CNAs should have ensured the brakes on the wheels on the Hoyer lift were locked before Resident #2 was lifted/lowered with the Hoyer lift. LVN A said CNA D should have double checked to ensure Resident #1's bed was locked before care was started. LVN A said Resident #1's bed should have been locked, before Resident #1 was repositioned in the bed and after CNA D completed Resident #1's care. LVN A said these things (the Hoyer lift brakes on the wheels left unlocked during the lift/descent of a resident and not ensuring bed brakes (on the wheels) were locked when a resident was repositioned in the bed) were safety issues. LVN A said Resident #2 could have been dropped from the Hoyer lift and Resident #1 could have fallen out of the bed.<BR/>During an interview on 1/9/24 at 1:57 p.m., the ADON said the CNA B and CNA C should have ensured the brakes on the wheels on the Hoyer lift were locked before Resident #2 was lifted/lowered with the Hoyer lift. The ADON said CNA D should have ensured Resident #1's bed was locked before care was started, before Resident #1 was repositioned and after the care was completed. The ADON said these things (the Hoyer lift brakes on the wheels left unlocked during the lift/descent of a resident and not ensuring bed brakes (on the wheels of the bed) were locked when a resident was repositioned in the bed) were posed a risk of injury. She said the system in place to ensure staff performed Hoyer lift transfers safely was the annual skills check off which included Hoyer lift transfers and ensuring brakes were locked on beds before repositioning a resident. The ADON said going forward a system would be put in place to perform spot checks on CNAs to ensure they were safely repositioning and transferring residents. <BR/>During an interview on 1/9/24 at 3:00 p.m., the Administrator said he expected staff to take appropriate measures to ensure residents safety during Hoyer lift transfers and incontinent care. The Administrator said leaving the bed unlocked and the Hoyer lift unlocked while a resident was lifted/lowered were not practices that would ensure resident safety. <BR/>During an interview on 1/9/24 at 2:30 p.m., the ADON said the facility did not have a policy and procedure specifically related to ensuring bed brakes (on the wheels of the bed) were locked. <BR/>Record review of the facility policy and procedure titled Lifting and movement of Resident-safe, dated December of 2017 stated, Policy: In order to protect the safety and well-being of staff and residents and to promote quality care, this home uses appropriate techniques and devices to lift and move residents . The policy and procedure did not specifically address the use of bed brakes (on the wheels of the bed or mechanical lift brakes (on the wheels of the mechanical lift). <BR/>Record review of the facility policy and procedure titled Mechanical Lift, dated December of 2017 reveled it did not specifically address the use of mechanical lift brakes .

**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 2 of 22 residents reviewed for dignity. (Residents #14 and #36).<BR/>The facility did not ensure Resident #14's catheter drainage bag was covered for one day. <BR/>The facility failed to ensure CNA C did not feed Resident #36 while standing. <BR/>These failures could place residents at risk of a diminished quality of life, loss of dignity and self-worth.<BR/>Findings included:<BR/>1.Record review of a face sheet dated 05/09/2024 indicated Resident #14 was [AGE] years old, re-admitted on [DATE] with diagnoses including encounter for surgical aftercare - surgery on skin and subcutaneous tissue (deepest layer of the skin), urinary tract infection, schizoaffective disorder(mental health disorder that is marked by a combination of schizophrenia symptoms such as hallucinations and delusions) , gastro reflux, dysphagia (difficulty swallowing), gastrostomy status (artificial entrance for the stomach), parkinsonism (disorder of the central nervous system that affects movements, often resulting in tremors), hypertension (condition in which the force of the blood against the artery walls is too high), dementia, mild cognitive impairment (a group of thinking and social symptoms that interferes with daily functioning).<BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #14 usually made herself understood and usually understands. Resident #14 had a BIMS (brief interview for mental status) score of 9 which indicated Resident #14 was moderately cognitively impaired. The assessment indicated Resident #14 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS indicated Resident #14 required total dependence with bed mobility, transfers, dressing, toileting, personal hygiene, bathing and eating. <BR/>Record review of the care plan revised on 05/07/2024 indicated Resident #14 required an indwelling urinary catheter with interventions of assess drainage - record the amount, type, color, and odor. Avoid lying on tubing. Do not allow drainage tube to touch the floor. Position bag below the bladder. Store the collection bag inside a protective dignity cover.<BR/>Record review of the physician order dated 02/02/2024 indicated Resident #14 has a foley catheter for urinary retention as follows: <BR/>During an observation on 05/06/2024 at 9:57 a.m., Resident #14 was lying in bed asleep. Resident #14's indwelling catheter did not have a cover over the urinary bag. Resident #14 urinary bag was visible from the hallway. <BR/>During an observation on 05/06/20241 at 12:00 p.m., Resident #14's indwelling catheter did not have a cover over the urinary bag. Resident #14 urinary bag was visible from hallway.<BR/>During an observation on 05/06/2024 at 1:47 p.m., Resident #14's indwelling catheter did not have a cover over the urinary bag. Resident #14 urinary bag was visible from the hallway.<BR/>During an observation on 05/06/2024 at 3:15 p.m., Resident #14's indwelling catheter did not have a cover over the urinary bag. Resident #14 urinary bag was visible from the hallway.<BR/>During an interview on 05/07/2024 at 2:02 p.m., LVN F said Resident #14 should have had a cover over the urinary bag to preserve dignity. LVN F said Resident #14 was under her care and hall and she had not placed the cover over the urinary bag earlier because she had not noticed.<BR/>During an interview on 05/07/2024 at 2:15 p.m., LVN A said Resident #14 should have had a cover over the urinary bag for privacy and dignity reasons.<BR/>2.Record review of a face sheet dated 05/09/2024 indicated Resident #36 was [AGE] years old, re-admitted on [DATE] with diagnoses including complete traumatic amputation at level between knee and ankle, left lower leg, acute respiratory infection, hypertension (high blood pressure), psychotic disorder with hallucinations (a mental disorder characterized with a disconnect from reality), major depressive disorder (persistently low or depressed mood, decreased interest in pleasurable activities, feelings of guilt or worthlessness), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), lack of coordination, dysphagia (difficulty swallowing), vitamin deficiency, anxiety disorder, muscle weakness.<BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #36 usually made himself understood and usually understands. Resident #36 had a BIMS (brief interview for mental status) score of 5 which indicated Resident #36 was severely cognitively impaired. The assessment indicated Resident #36 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS indicated Resident #36 required total dependence with bed mobility, transfers, toileting, bathing and maximal assistance with dressing, personal hygiene, and eating. <BR/>Record review of the care plan revised on 05/06/2024 indicated Resident #36 required assistance with ADL's related to impaired cognition and impaired mobility with the intervention for setup help provided during meals.<BR/>During an observation on 05/06/2024 at 12:16 p.m., CNA C was standing in front Resident #36's<BR/>chair in the dining room while feeding his lunch.<BR/>During an interview on 05/06/2024 at 02:24 p.m., CNA N said she sits down to feed the residents at eye level to make the resident feel better.<BR/>During an interview on 05/06/2024 at 02:39 p.m., CNA H said she sits with the residents while feeding because she should.<BR/>Unable to reach CNA C after three attempted telephone calls with requested call back on 05/08/2024 at 12:15 p.m., 05/09/2024 at 10:32 a.m., 05/09/2024 at 04:35 p.m.<BR/>During an interview 05/09/2024 at 4:07 p.m., the DON said residents' urinary bag to be covered to preserve dignity. The DON said Resident #14 should have had a privacy bag over his urinary drainage bag and she expected staff to ensure it was always covered. The DON said the appropriate thing to do when feeding a resident was to sit at eye level facing the resident. The DON said these failures could be a dignity issue.<BR/>During an interview on 05/09/2024 at 02:22 PM, the Regional Director said Residents with foley catheters should have had a privacy bag over the urinary drainage bag. The Regional Director said staff should not stand towering over the residents while feeding for dignity purposes. The Regional Director said he expected the Administrator and DON to ensure the staff is educated on the rights of the residents. <BR/>Record review of a Resident Rights policy dated November of 2021 indicated, be treated with dignity, courtesy, consideration and respect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 22 residents (Residents #4) reviewed for reasonable accommodations. <BR/>The facility failed to ensure Resident #4's call light was accessible.<BR/>This failure could place residents at risk of injuries, health complications and decreased quality of life. <BR/>Findings included:<BR/>Record review of Resident #4's face sheet dated 05/07/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4's diagnoses included dementia (memory loss), depression (persistent depressed mood), and urinary tract infection (an infection in any part of the urinary system).<BR/>Record review of Resident #4's comprehensive care plan dated 03/18/24, indicated Resident #4 has had an actual fall and has potential for injury related to falls due to unsteady gait, history of previous fall impulsiveness, and decreased safety awareness. The care plan interventions included to place call light within reach. <BR/>Record review of Resident #4's quarterly MDS assessment dated [DATE], indicated she was sometimes understood and sometimes understood others. The MDS assessment indicated Resident #4 had a BIMS score of 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #4 was dependent on staff with oral hygiene, toileting hygiene, showers, dressing, personal hygiene, and chair to bed transfer. The MDS assessment indicated Resident #4 had 2 falls with no injury since the prior MDS assessment.<BR/>During an observation on 05/06/24 at 10:12 AM, Resident #4 was laying in her bed and her call light was noted to be under the bed and unable to be reached by resident. <BR/>During an observation on 05/06/24 at 2:44 PM, Resident #4 was sitting on the side of the bed. Resident #4's call light continued to be under her bed and unable to reached by Resident #4.<BR/>During an interview on 05/06/24 at 3:43 PM, Resident #4's family member was in her room and said she had noted Resident #4's call light not within reach and reported it to the DON. Resident #4's family member said the DON dug it from under her bed. Resident #4's family member said she has had issues with Resident #4's call light not being in reach before. Resident #4's family member said Resident #4 forgets to use it, but she still wanted the call light within reach of Resident #4. Resident #4's family member said she has had to dig it up before but today I went to tell. <BR/>During an interview on 05/09/24 at 3:23 PM, CNA D said it was everyone's responsibility to ensure the call lights were within reach. CNA D said failure to have the call lights within reach of the resident could cause them to get up and fall trying to get assistance. CNA D said she had never seen Resident #4 remove her call light once it was placed within reach. <BR/>During an interview on 05/09/24 at 3:26 PM, RN B said the call lights were to be within reach of the resident. RN B said the nurses and aides were responsible of ensuring the call lights were within reach during their rounds. RN B said not having the call light within reach could cause residents to not be able to call for assistance or they could fall.<BR/>During an interview on 05/09/24 at 3:50 PM, the DON said she expected the call lights to be in place and answered timely. The DON said everyone was responsible for ensuring the call lights were within reach. The DON said not having the call lights within reach could cause resident to not receive the care they needed. The DON said she obtained Resident #4's call light from the floor on 05/06/24, after Resident #4's family member notified her, it was not within reach. The DON said she was 100% sure Resident #4's call light had fallen to the floor. <BR/>During an interview on 05/09/24 at 04:36 PM, the Regional Director said he expected the call lights to be answered timely and be within reach. The Regional Director said by not having their call light within reach the resident would not be able to call for assistance. The Regional Director said all staff was responsible for ensuring the call lights were within reach. <BR/>During an interview on 05/09/24 at 09:24 AM, the DON said they did not have a policy on call lights.

Based on observation, interview, and record review, the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response 3 of 3 groups.<BR/>There was no documentation of the facility's effort to resolve grievances concerning beds not being made daily and cold food collected at Resident Council meetings on 2/29/2024, 3/27/2024, and 4/18/2024.<BR/>This failure placed residents at risk of not having grievances addressed or provided a rational for facility decisions for issues identified <BR/>Findings included:<BR/>Record review of a Resident Council Meeting Form dated 2/29/2024 indicated the group council voiced their beds were not made daily and hot foods should be hot. The form failed to address how the grievances would be managed. The AD signed the Resident Council meeting form on 2/29/2024. <BR/>Record review of a Resident Council Meeting Form dated 3/27/2024 indicated the group council voiced their beds were still not getting made. The form failed to address how the grievance would be managed. The AD signed the Resident Council meeting form on 3/27/2024.<BR/>Record review of a Resident Council Meeting Form dated 4/18/2024 indicated the group council voiced their beds were not getting made. The response portion of the Resident Council Meeting Form indicated the DON wrote on 4/24/2024 the department heads would make frequent rounds to ensure beds were made.<BR/>During an observation of medication administration on 5/06/2024 at 10:00 a.m.- 10:45 a.m., 1 confidential resident's bed was not made. The confidential resident had made this concern to management in resident council meetings.<BR/>During an interview on initial tour on 5/06/2024 9:28 a.m. - 4:00 p.m., 2 confidential residents voiced their meal trays when received were cold. These confidential residents had made these concerns known during resident council meetings.<BR/>During a confidential group interview on 5/07/2024 at 2:00 p.m., 5 of 5 residents said the food trays served on the halls were cold, and they have had problems for months with their beds not being made.<BR/>During an observation, and interview, on 5/08/2024 at 12:10 p.m., the Dietary Manager voiced agreeance the test trays chicken taco was cold, and the Mexican corn was warm at best.<BR/>During an interview on 5/09/2024 at 12:09 p.m., the DON said she expected the grievances to be resolved in its entirety. The DON said the grievance officer was the Administrator, but each department would address the grievance in their area. The DON said she expected beds to be made, and food to be served palatable. The DON said management completed rounds as part of the monitoring process.<BR/>During an interview on 5/09/2024 at 1:12 p.m., the RDO said he expected grievances to be resolved. The RDO said the Administrator was responsible for ensuring grievances were resolved by delegating to the individual departments to manage a resolution. The RDO said the Administrator was out of town and was not able to be reached for interview.<BR/>During an interview on 5/09/2024 at 3:20 p.m., the Activity Director said during resident council she writes down the concerns of the residents, then she distributes them to the indicated department to form a resolution within 72 hours. The Activity Director said she had been in her position since February 2024 and had just recently learned how to handle the resident council grievances/concerns.<BR/>Record review of a Grievance-Voicing and Resolution policy dated 12/2017 indicated the policy of this home was that staff would promptly attempt to resolve grievances the resident may have, including those which involve the behavior of others. They will be able to voice grievances without fear of reprisal or discrimination. Such grievances included those with respect of care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents and other concerns regarding their stay. <BR/>Record review of the Resident Rights from the Texas Department of Aging and Disability Services dated April 2008 found in the resident council minutes binder revealed in the section, Complaints revealed: a resident had the right to complain about the care or treatment and receive prompt response to resolve the complaint without fear of reprisal or discrimination .<BR/>Procedure:<BR/>1. The home will inform each resident upon admission and at least annually of their right to voice grievances .<BR/>2. The Grievance Official will be the Administrator .issuing written grievance decisions to the resident and coordinating with state and federal agencies as necessary .<BR/>4. The home will address each grievance in a reasonable time frame and as necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation was being investigated .<BR/>7. The home will provide acknowledgment of grievances to the person who filed the complaint. <BR/>8. Home will upon resolution of grievance, follow-up in a timely manner to assure that resolution has been successful.<BR/>Record review of the HUMAN RESOURCES CODE CHAPTER 102. RIGHTS OF THE ELDERLY (texas.gov) accessed on 5/13/2024 revealed:<BR/>Sec. 102.003. RIGHTS OF THE ELDERLY. (a) An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights.<BR/>(b) An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual: .<BR/>(f) An elderly individual may complain about the individual's care or treatment. The complaint may be made anonymously or communicated by a person designated by the elderly individual. The person providing service shall promptly respond to resolve the complaint. The person providing services may not discriminate or take other punitive action against an elderly individual who makes a complaint.

Based on interview, and record review, the facility failed to ensure residents received mail delivered to the facility for 5 of 5 confidential residents reviewed for right to communication <BR/>The facility failed to ensure residents received their mail on the weekend.<BR/>This failure could affect residents in the facility who receive mail at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life.<BR/>Findings included:<BR/>Record review of a Resident Council Meeting Form dated 2/29/2024 indicated the council was asked, Do you receive mail timely and on weekends?. The resident council answered no.<BR/>Record review of a Resident Council Meeting Form dated 3/27/2024 indicated the council was asked, Do you receive mail timely and on weekends?. The resident council answered no.<BR/>Record review of a Resident Council Meeting Form dated 4/18/2024 indicated the council was asked, Do you receive mail timely and on weekends?. The resident council answered no.<BR/>During a confidential group interview on 5/07/2024 at 2:00 p.m., 5 of 5 residents said mail was not being distributed on Saturdays. They indicated they were unsure why mail was not delivered by the weekend staff.<BR/>During an interview on 5/09/2024 at 12:06 p.m., the DON said she was new in the facility, but she indicated she believed the Activity Director would be responsible for the delivery of mail. The DON said a resident could get upset if they did not receive their mail timely.<BR/>During an interview on 5/09/2024 at 1:10 p.m., the RDO said the Administrator was not available during the survey, but he indicated he expected the residents to receive their mail if the mail ran on Saturdays. The RDO said the Administrator was responsible for ensuring the residents received their mail timely. <BR/>During an interview on 5/09/2024 at 3:00 p.m., RN B said she works the weekends. RN B indicated she had not delivered any weekend mail and was unsure about the mail process.<BR/>During an interview on 5/09/2024 at 3:13 p.m., the local Postmaster indicated the facility did not receive mail on the weekends. The Postmaster said the business stopped their mail. The Postmaster said the resident mail was included in the mail held for delivery due to the delivery site was considered a business. The Postmaster failed to respond when asked why the individuals residing in the facility mail was stopped.<BR/>During an interview on 5/09/2024 at 3:30 p.m., the Clinical Director indicated there was not a facility policy regarding mail.<BR/>Record review of the Resident Rights from the Texas Department of Aging and Disability Services dated April 2008 found in the resident council minutes binder revealed in the section Privacy and Confidentiality that a resident had the right to send and receive unopened mail and to receive help in reading or writing correspondences. <BR/>Record review of the HUMAN RESOURCES CODE CHAPTER 102. RIGHTS OF THE ELDERLY (texas.gov) accessed on 5/13/2024 revealed:<BR/>An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights.<BR/>(b) An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual: .<BR/>(g) An elderly individual is entitled to privacy while attending to personal needs and a private place for receiving visitors or associating with other individuals unless providing privacy would infringe on the rights of other individuals. This right applies to medical treatment, written communications, telephone conversations, meeting with family, and access to resident councils. An elderly person may send and receive unopened mail, and the person providing services shall ensure that the individual's mail is sent and delivered promptly. If an elderly individual is married and the spouse is receiving similar services, the couple may share a room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents had the right to formulate an advanced directive for 1 of 22 residents (Resident #10) reviewed for advance directives. <BR/>The facility failed to accurately update Resident #10's comprehensive care plan with her code status.<BR/>This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, psychosocial outcome and inaccurate medical records.<BR/>Findings included:<BR/>Record review of Resident #10's face sheet dated [DATE], indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Alzheimer's (a progress disease that destroys memory and other important mental functions), atrial fibrillation (irregular often rapid heart rate that commonly causes poor blood flow), depression (persistent depressed mood), and anxiety.<BR/>Record review of Resident #10's significant change in status MDS assessment dated [DATE], indicated Resident #10 was usually understood and usually understood others. The MDS assessment indicated Resident #10's BIMS score was a 5, which indicated her cognition was severely impaired.<BR/>Record review of Resident #10's comprehensive care plan dated [DATE], indicated Resident #10 was a full code CPR order in place. The care plan interventions indicated to review medical record to ensure that proper documents were signed. <BR/>Record review of Resident #10's physician order report dated [DATE]-[DATE], indicated Resident #10 had an order for code status DNR (do not resuscitate) with a start date of [DATE] . <BR/>Record review of Resident #10's Out of Hospital Do-Not-Resuscitate (OOH-DNR) order indicated Resident #10's family member had signed the order on [DATE] and was notarized. The OOH-DNR order indicated the physician had signed the order on [DATE].<BR/>During an interview on [DATE] at 3:50 PM, the DON said Resident #10 comprehensive care plan should have been updated to indicate her code status had changed from full code to DNR whenever they received the order for DNR. The DON said nurse leadership was responsible for updating the care plans. The DON said failure to update Resident #10's care plan could place Resident #10 at risk for receiving CPR. The DON said that was not something they would have want to happen since Resident #10 had a DNR.<BR/>During an interview on [DATE] at 05:23 PM, the Regional Clinical Consultant said she expected the care plans to updated timely. The Regional Clinical Consultant said Resident #10's care plan should have reflected the updated code status so plan of care was appropriate. The Regional Clinical Consultant said nursing leadership was responsible for updating the care plans. <BR/>Record review of the facility's policy titled Care Plan dated 12/2018, indicated . It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident .10. To update the resident care plan . changes and dated on problems per home policy . if the entry must be changed significantly, the plan will look neater if the entry is lined out and reference made to the new entry .the resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate and planned to meet the individual needs of the resident consistent with the physicians plan of care for the resident .the resident care plan must be kept current at all times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident rights of confidentiality of medical records for 2 of 23 residents (Resident #'s 1 and 35) reviewed for medical record confidentiality. <BR/>The facility failed to ensure MA E closed the EMR of Resident #'s 1 and 35's medication regimen prior to her walking away from the medication cart during the passing of medications.<BR/>This failure could place residents at risk of their medical information being provided to unauthorized personnel, other residents, or visitors.<BR/>Findings included:<BR/>1)Record review of a face sheet dated 5/08/2024 indicated Resident #1 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, and keratoconjunctivitis (inflammation of both the cornea and the conjunctiva, which can be infectious or non-infectious causing ocular dryness, burning, and foreign-body sensation and grittiness).<BR/>Record review of the comprehensive care plan dated 1/19/2024 indicated Resident #1 had a visual function problem with the goal of Resident #1 would maintain current level of visual function. The care plan interventions indicated to administer medications as ordered. The comprehensive care plan also indicated Resident #1 had anxiety with the goal of the care plan being Resident #1 would not have signs or symptoms of anxiety. The interventions of the care plan included to administer medications as ordered and monitor and record abnormal behaviors.<BR/>Record review of the Quarterly MDS dated [DATE] indicated Resident #1 was usually understood, and usually understood others. The MDS indicated Resident #1 had difficulties with recall and she was severely cognitively impaired with a BIMS of 4.<BR/>Record review of the consolidated physician's orders dated 5/01/2024 - 5/08/2024 indicated Resident #1 received Systane balance eye drops one drop to each eye at 9:30 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m.<BR/>During an observation and interview on 5/07/2024 at 9:47 a.m., MA E walked away from the medication cart parked in front of room [ROOM NUMBER], walked down the hall to the dayroom/nurse station area looking for Resident #1 while leaving Resident #1's medication regimen open and viewable to others. MA E said leaving Resident #1's EMR open and visible could allow others to view her information and break privacy.<BR/>2) Record review of a face sheet dated 5/08/2024 indicated Resident #35 was a [AGE] year-old female who admitted on [DATE] with the diagnosis of major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normal enjoyable activities) and weakness.<BR/>Record review of the comprehensive care plan dated 3/15/2024 indicated Resident #35 had a diagnosis of depression. The goal of the care plan was Resident #35 would remain free of distress and anxiety. The interventions for Resident #35's care plan included to administer medications as ordered, and discuss any fears, issues regarding her health.<BR/>Record review of the Annual MDS dated [DATE] indicated Resident #35 was usually understood, and usually understood others. The MDS indicated Resident #35 had problems with recall and had severely impaired cognition.<BR/>Record review of the consolidated physician's orders dated 5/01/2024- 5/08/2024 indicated Resident #35 received aspirin 81 milligrams daily, buspirone 10 milligrams one three times daily, and Claritin 10 milligrams daily. <BR/>During an observation and interview on 5/07/2024 at 9:50 a.m., MA E prepared Resident #35's medications, walked away from her medication cart parked in front of room [ROOM NUMBER], to enter room [ROOM NUMBER]. MA E left Resident #35's medication regimen open and viewable to others. MA E said she should have not left Resident #35's medication regimen open and visible. MA E said leaving the computer open to Resident #35's medications could allow for others to view her information. MA E said she was unsure of the last training regarding privacy of records.<BR/>During an interview on 5/09/2024 at 11:40 a.m., the DON said she expected the staff to protect the resident's personal information. The DON said by leaving the EMR visible it could allow others to have information regarding the resident that was not needed. The DON said everyone was responsible for ensuring resident privacy was protected. The DON said the facility monitors for breach of privacy by observation with walking rounds called scout rounds. <BR/>During an interview on 5/09/2024 at 1:08 p.m., the RDO said he expected confidentiality to be protected. The RDO said the Administrator was responsible for ensuring privacy was protected. <BR/>During an interview on 5/09/2024 at 3:00 p.m., RN B said she expected the computer screens to be closed to protect a resident's privacy.<BR/>Record review of a Resident Rights posting dated April 2008 indicated in the section Privacy and Confidentiality indicated a resident had the right to have facility information about them maintained as confidential.<BR/>Record review of the HUMAN RESOURCES CODE CHAPTER 102. RIGHTS OF THE ELDERLY (texas.gov) accessed on 5/13/2024 revealed:<BR/>An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights.<BR/>(b) An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual: .<BR/>(g) An elderly individual is entitled to privacy while attending to personal needs and a private place for receiving visitors or associating with other individuals unless providing privacy would infringe on the rights of other individuals. This right applies to medical treatment, written communications, telephone conversations, meeting with family, and access to resident councils. An elderly person may send and receive unopened mail, and the person providing services shall ensure that the individual's mail is sent and delivered promptly. If an elderly individual is married and the spouse is receiving similar services, the couple may share a room.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.Record review of Resident #36's face sheet dated 05/09/2024 indicated he was an [AGE] year-old male who re-admitted to the facility on [DATE] with diagnosis including complete traumatic amputation at level between knee and ankle, left lower leg, acute respiratory infection, hypertension (high blood pressure), psychotic disorder with hallucinations (a mental disorder characterized with a disconnect from reality), major depressive disorder (persistently low or depressed mood, decreased interest in pleasurable activities, feelings of guilt or worthlessness), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), lack of coordination, dysphagia (difficulty swallowing), vitamin deficiency, anxiety disorder, muscle weakness.<BR/>Record review of Resident #36's most recent comprehensive MDS dated [DATE] indicated he usually made himself understood and usually understands. Resident #36 had a BIMS (brief interview for mental status) score of 5 which indicated Resident #36 was severely cognitively impaired. The assessment indicated Resident #36 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS indicated Resident #36 required total dependence with bed mobility, transfers, toileting, bathing and maximal assistance with dressing, personal hygiene, and eating. <BR/>Record review of Resident #36's care plan revised on 05/06/2024 indicated he required assistance with ADL's related to impaired cognition and impaired mobility. The care plan also indicated he was at risk for falls related to decreased mobility and use of anti-depressant medication use with no actual falls noted. <BR/>Record review of Resident #36's event report dated 11/29/23 indicated he had bruising of unknown origin to his bilateral buttocks and his left breast. <BR/>Record review of Resident #36's progress note dated 11/29/23 at 6:30 PM completed by LVN P indicated the resident was given a shower with family present due to refusal or behaviors and during the shower the bruising was noted to left buttock approximately 12CM X5CM blue discoloration, right buttock 3CM X3CM dark purple/blue discoloration, and left breast 2CM X 2CM greenish/yellow discoloration. The progress note also indicated Resident #36 denied having fallen or any pain. <BR/>During an interview on 05/09/24 at 5:13 PM, the DON said typically bruises of unknown origins should have been reported but she was not the DON at that time. She said after reviewing the final summary she did not think the bruising was suspicious but would have expected it to be reported due to it having an unknown cause and it was not up to the facility to determine if the incident was reported or not. <BR/>During an attempt to call the previous DON on 05/09/24 at 5:20 PM there was no answer. <BR/>Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to follow their policy on abuse for 2 of 22 residents (Resident #'s 10 and 36) reviewed for abuse.<BR/>The facility failed to report Resident #10's injury of unknown to HHSC when bruising was found to her perineum.<BR/>The facility failed to report Resident #36's injury of unknown to HHSC when bruising was found to his bilateral buttocks and left chest.<BR/>These failures could place residents at risk of being abused and neglected. <BR/>Findings included:<BR/>Record review of the facility's policy titled, Abuse/Reportable Events dated 12/1/2018, indicated . All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . The facility will provide and ensure the promotion and protection of resident rights. It is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . Injury of Unknown Source: any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because the extent of the injury or the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidents of injuries over time .Identification: The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, and state. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist and/or designee will be called .The facility administrator or designee will report the allegation to HHSC. If the allegations involve abuse or result in serious bodily injury, the report is made within 2 hours of the allegation. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation . <BR/>1. Record review of Resident #10's face sheet dated 05/07/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Alzheimer's (a progress disease that destroys memory and other important mental functions), atrial fibrillation (irregular often rapid heart rate that commonly causes poor blood flow), depression (persistent depressed mood), and anxiety.<BR/>Record review of Resident #10's significant change in status MDS assessment dated [DATE], indicated Resident #10 was usually understood and usually understood others. The MDS assessment indicated Resident #10's BIMS score was a 5, which indicated her cognition was severely impaired. The MDS indicated Resident #10 required substantial/maximal assistance with toileting and toilet transfer and was dependent on staff with personal hygiene and chair to bed transfers. The MDS assessment indicated Resident #10 had 2 falls with no injuries and one fall with injury within since the prior MDS assessment.<BR/>Record review of Resident #10's physician order report dated 03/01/24-05/07/24, indicated Resident #10 had the following orders with a start date of 03/14/24:<BR/>*Monitor dry scabbed scratches to the left knee every day until resolved<BR/>*Monitor daily mid upper back red blanchable area until resolved. <BR/>The order summary report did not indicate any orders to monitor areas for the bruising noted to the perineum. <BR/>Record review of Resident #10's comprehensive care plan dated 03/14/24, indicated Resident #10 has had an actual fall and potential for injury related to falls due to history of previous fall. The care plan interventions included to offer to toilet resident upon rising, before and after means, at bedtime and as needed through night. The care plan also indicated to remind/encourage resident to use call light to gain assistance. The care plan indicated Resident #10 was at risk for self-inflicting injury such as skin tears and bruising related to poor safety awareness with interventions for weekly skin assessments.<BR/>Record review of Resident #10's progress note dated 03/14/24 at 07:38 AM completed by LVN A, indicated . Resident was observed sitting on the floor next to her bed, leaning against the bed. She was sitting in urine and the trash can was turned over and she was leaning back on the trash can. She stated she had gotten up to use the restroom. She denied hitting her head, there were no injuries to the scale (sic). She has a red/blue mark approximately 6 inches in length on the mid back that appears from where she was leaning against the trash can. This was on the only area noted at this time. It was not open, and she denied any pain. She was assisted back to bed, legs were weak, arms strong, neuros started and were normal for resident's ability .<BR/>Record review of Resident #10's event report dated 03/14/24 completed by LVN A, indicated an unwitnessed fall and Resident # 10 said she had gotten up to go to restroom. The event report under location of injury indicated has a mark on mid back, from where she was resting against her trash can. The event report under evaluation notes indicated . Resident was noted attempting to utilize the restroom and fell to the floor. IDT feels most appropriate to offer scheduling toileting. Care plan reviewed and updated.<BR/>Record review of Resident #10's progress note dated at 03/15/24 at 07:11 AM, indicated . no delayed injuries noted, the mark on her mid back has diminished. She does have bruising at the top of shoulders. No complaints of pain or discomfort noted to any area .<BR/>Record review of Resident #10's progress note dated 03/16/24 at 01:30 AM, indicated . no delayed injuries noted from fall .<BR/>Record review of Resident #10's progress note dated 03/17/24 at 01:38 PM, indicated . no delayed injuries from fall . <BR/>Record review of Resident #10's progress note dated 03/18/24 at 12:08 AM, indicated . no delayed injuries from fall .<BR/>Record review of Resident #10's event report dated 03/19/24, indicated bruise to perineum and purplish black checked. The event report indicated under activity during bruise occurrence had fall marked. <BR/>Record review of Resident #10's progress note dated 03/20/24 at 02:40 AM, indicated monitoring bruise to perineum area. Resident is in her bed sleeping at this time and shows no signs or symptoms of distress or discomfort . <BR/>During an interview on 05/07/24 at 09:55 AM, LVN A said, regarding the bruising to Resident #10's perineum, the prior week they had found Resident #10 on the floor next to her bed, sitting next to the trash can. There was a line to her back and there was urine all over the floor. LVN A said when the aides had found the bruising, they figured Resident #10 had sat down on the trash can the day she fell and then sat on the floor. LVN A said Resident #10 never complained of pain. LVN A said Resident #10's bruise was large and was found on her perineum area towards the back. LVN A said Resident #10 had been going to the bathroom by herself at times and had a bedside commode in her room. LVN A said any signs of abuse or neglect should be reported to the Administrator and DON immediately. LVN A said the Administrator was the abuse coordinator for the facility. <BR/>During an interview on 05/07/24 at 10:04 AM, CNA C said Resident #10 used to be able to walk to the bathroom by herself. CNA C said the day Resident #10 fell she was trying to pee in the trash can, since Resident #10 was not used to wearing a brief. CNA C said the bruising to Resident #10's perineum was very black and believed it was caused by the trash can. CNA C said she believes she noticed the bruising the day after the fall and reported it to LVN A and the Treatment Nurse. CNA C said Resident #10 did not voice any complaints of someone hurting her. <BR/>During an interview on 05/07/24 at 10:13 AM, the Treatment Nurse said they had noticed the bruising to Resident #10's perineum a few days after the fall. The Treatment Nurse said they suspected the bruising had been from her fall on 03/14/24. The Treatment Nurse said Resident #10 had not complained of pain or anyone hurting her. The Treatment Nurse said they had gotten Resident #10 a bedside commode after the fall since she tried to get up by herself to use the restroom. The Treatment Nurse said any signs of abuse or neglect should be reported to the Administrator immediately, since he was the abuse coordinator at the facility. <BR/>During an interview on 05/09/24 at 3:50 PM, the DON said they felt confident that Resident #10's bruising to the perineum was from the fall she had on 03/14/24. The DON said if they had felt it was suspicious, they should have reported and investigated but based on staff present and the staff that found the bruising it did not seem suspicious. The DON said since the nurse had reported to her when Resident #10 fell, she was hovering over the trash can and was trying to pee they related the bruising to that. The DON read Resident #10's progress notes and it did not specify Resident #10 fell on the trash can . The DON said the Administrator was responsible for reporting suspicious bruising to the HHSC . The DON said if Resident #10 had not had a fall previously then it would have been different where they should have had reported the bruising then. The DON said if it had been an abuse allegation and it was not reported the residents could have been at risk for harm. The DON said the Administrator was out of the country and was not available for interview.<BR/>During an interview on 05/09/24 at 4:36 PM, the Regional Director said without knowing about the case thoroughly he chose not to comment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the State Survey Agency immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for 1 of 6 (Resident #1) residents reviewed for abuse and neglect.<BR/>On 04/28/23 at 6:30 p.m., Resident #1 sustained redness and blistering to his face when RN A lit a cigarette while Resident #1 was using Oxygen. The incident was not reported until 04/29/23 at 11:17 a.m.<BR/>This failure could place residents at risk of emotional, physical, and mental abuse.<BR/>Findings included:<BR/>During an observation and interview on 04/29/23 at 10:25 a.m. Resident #1 had a large fluid fill blister, white in color, on his right cheek that extended to the top of his upper lip. There was another fluid filled blister on the right side of his nose that extended to the tip of his nose. Facial hair on his right upper lip appeared to be shorter than the left side of his lip. Resident #1 said he was not in pain. He said he was smoking the night before (04/28/23) and did not realize that Oxygen was flammable. He said he was wearing his Oxygen while smoking. He said he normally does not have his Oxygen on while smoking and does not use Oxygen all the time. He said while smoking the Oxygen caught fire. He said it was storming and he thought at first it was a lightning flash. He said RN A was there and quickly put out the flame. (Within a few seconds) He said he went to the doctor the next day. (04/29/23). He said he did not feel he was abused or neglected.<BR/>Record review of face sheet dated 04/30/23, indicated Resident #1 was a [AGE] year-old male, last admitted on [DATE] and his diagnoses included Transient cerebral ischemic attack, (a stroke that lasts only a few minutes), hypertension, Dyspnea (Shortness of Breath), dementia, cognitive communication deficit, muscle weakness, Bipolar disorder, Chronic obstructive pulmonary disease (COPD), schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms), and Pulmonary hypertension (A type of high blood pressure that affects the arteries in the lungs and the right side of the heart? <BR/>Record review of MDS dated [DATE] indicated Resident #1 was able to express ideas and wants, alert to person, place, and time, was able to understand others, and was cognitively intact. Resident #1 required supervision and set-up assistance of 1 person for all ADLs other than hygiene where he required assistance of 2 persons. He was able to transfer independently and used a wheelchair. <BR/>Record review of Resident #1's care plan initiated 12/19/22 and revised on 04/30/23 indicated he was a smoker and at risk of injury. He was to wear a smoking apron during smoke breaks. Staff were to supervise during smoking. Care plan was updated on 04/29/23 to show staff are to ensure that resident is not in the smoking area with Oxygen tank or tubing/nasal canula. <BR/>Record review of consolidated physician orders dated 02/26/23, Resident #1 may have Oxygen (O2) 2L/min via Nasal Canula (NC) as needed (PRN) for oxygen sat below 92%. Every shift Days 6:00 AM - 2:00 PM, Evenings 2:00 PM - 10:00 PM, and Nights 10:00 PM - 6:00 AM.<BR/>Record review of an incident report dated 04/29/23, completed by administrator indicated on 04/28/23 at 6:30 p.m., Resident #1 was smoking in the designated smoke area when RN A lit his cigarette while he was wearing oxygen. The Oxygen flashed causing his beard to singe. The next morning at 10:00 a.m. redness and blistering was discovered to Resident #1 face. Doctor notified and new orders for Silvadene (silver sulfadiazine) cream 1% was to be applied to the affected area once a day. Resident #1 was sent to the hospital on [DATE] for evaluation and returned the same day with no new orders.<BR/>Record review of progress note dated 04/28/23 at 06:40 p.m., RN A recorded he went to the smoking area to observe resident smoke break. Resident #1 was already outside with his smoking apron on. Cigarettes were handed out and lit. RN A did not recognize Resident #1 had Oxygen on. A small flame extinguished, and Oxygen turned off. Resident #1 was assessed for injuries with left cheek and nose light pink with no open areas or blisters noted. Resident #1 denied pain. Resident sitting up at nurse's station with no signs of distress. Responsible party and physician was notified. No new orders from physician.<BR/>During an interview on 04/30/23 at 9:45 a.m., the Administrator said on 04/29/23 at 6:30 p.m., RN A was taking residents out for a smoke break. Resident #1 was already in the smoking area with his apron on when RN A arrived with 2 other residents. The Administrator said RN A lit Resident #1's cigarette without noticing he had his Oxygen on. The Administrator said RN A was assisting the two other residents when Resident #1's Oxygen ignited and singed Resident #1's facial hair. The Administrator said RN A immediately responded and assessed Resident #1 for injury. The Administrator said there was some redness to Resident #1's cheek and nose. There were no other injuries found at that time. The Administrator said he asked questions about the incident, and it was determined that the incident was not a reportable incident at the time, because there was no major injury to Resident #1. The Administrator said the next morning (04/30/23) around 10:00 a.m. during an assessment LVN A, found blisters to Resident #1's face. The Administrator said he did not report the incident until 04/30/23 at 11:17 a.m. after the blistering was discovered.<BR/>Record review of progress note dated 04/29/23 at 11:30 a.m. LVN A recorded she contacted with physician to report need for wound care orders to Resident #1's face after smoking incident last evening. Nurse reported areas of burns and appearance of areas of concern. New orders received of Silvadene (silver sulfadiazine) cream 1% once a day. Resident reports no pain/discomfort in area currently. <BR/>Record review of progress note dated 04/29/23 at 3:16 p.m. DON recorded she noticed Resident #1 to have newly onset and slight difficulty breathing. Upon further assessment, swelling noted to Resident #1's right inner nare. (Opening of the nose). Physician contacted with orders to send to hospital for evaluation. <BR/>Record review of hospital records dated 04/2923 indicated Resident #1 was seen at the hospital for facial burn. Diagnosis Facial burn, second degree. (Involves the top two layers of the skin, might have blisters over the burn area. The burn may leave a scar). New orders gently clean with soap and water and apply bacitracin (topical antibiotic ointment). Follow-up to be scheduled by facility staff. <BR/>Review of progress note dated 04/29/23 at 4:58 p.m. Resident #1 returned from the emergency room with new orders for bacitracin ointment, apply BID. (Twice daily) Physician was contacted and ordered to discontinue bacitracin and continue with Silvadene as previously ordered. Resident continues to have difficulty breathing through nose. No distress noted. Resident at nurses' station currently. Resident #1 states he can breathe though his nose and that is does not hurt to breath.<BR/>During an observation and interview on 04/29/23 at 10:45 a.m. six residents was observed in the smoking area including Resident #1. Three of the residents were wearing smoking aprons including Resident #1. There were no Oxygen tanks in the smoking area. The fire extinguisher was available and last serviced April 2023. Ash trays were appropriate for safety. Residents were being supervised by a nurse. Resident #2 said she was present when Resident #1's Oxygen ignited on 04/28/23 around 6:30 p.m. She said RN A was helping her to her table and Resident #1 was already in the smoking area with his safety apron on when she arrived. She said after RN A assisted her to her normal table and Resident #1 was sitting behind her. She said it was storming and darker than usual. Resident #1 asked RN A to light his cigarette. She said RN A turned around, lit Resident #1's cigarette and turned and lit hers. She said the next thing she knew, there was a flash. She said she thought it was a lighting flash, but she saw there was a flame at Resident #1's face. She said RN A quickly turned and extinguished the flame. She said they all went back inside the building and RN A took Resident #1 to his room.<BR/>During an interview on 05/01/23 at 4:10 p.m., RN A he was working as a charge nurse on 04/28/23 2:00 PM to 10:00 PM shift. RN said at 6:30 PM, he took residents out for a smoke break. He said when he arrived at the smoking area, Resident #1 was already outside in the smoking area with his safety apron on. He said Resident #1 asked him to light his cigarette. He said he turned around and lit the cigarette for Resident #1. RN A said he did not notice the Resident #1 had his nasal canula under his nose and did not know his Oxygen was on. RN A said he should have checked before lighting the cigarette, but he did not. He said it was only a few seconds when he saw a flame and turned around and put out the fire. RN A said she assessed resident [NAME] #1 and Resident #1 said he was not in pain. RN A said he immediately ended the smoke break. RN A said he took Resident #1 to his room so he would assess him better in the light. RN A said he observed some pink areas to Resident #1's nose and cheek, but there was no blistering. RN A said he notified the Assistant Director of Nursing (ADON) April, who said she would notify the Administrator and DON.<BR/>During an interview on 04/30/23 at 9:45 a.m., the Administrator said on 04/29/23 at 6:30 p.m., RN A was taking residents out for a smoke break. Resident #1 was already in the smoking area with his apron on when RN A arrived with 2 other residents. The Administrator said RN A lit Resident #1's cigarette without noticing he had his Oxygen on. The Administrator said RN A was assisting the two other residents when Resident #1's Oxygen ignited and singed Resident #1's facial hair. The Administrator said RN A immediately responded and assessed Resident #1 for injury. The Administrator said there was some redness to Resident #1's cheek and nose. There were no other injuries found at that time. Physician, family, and Administrator was notified of the incident. The Administrator said he asked questions about the incident, and it was determined that the incident was not a reportable incident at the time, because there was no major injury to Resident #1. The Administrator said the next morning (04/30/23) around 10:00 a.m. during an assessment LVN A, found blisters to Resident #1's face. Administrator said all residents were re-assessed for Smoking Safety and RN A was suspended pending investigation. Administrator said RN A should have monitored to ensure there was no Oxygen in the area prior to lighting a cigarette. Administrator said it is the policy of the facility that Oxygen should not be within 50 feet of the smoking area. The Administrator said he did not report the incident until 04/30/23 at 11:17 a.m. after the blistering was discovered.<BR/>During an interview on 04/30/23 at 9:45 a.m. the DON said RN-A should have noticed that Resident #1 was using Oxygen and should have not lit any cigarettes before making sure there was no Oxygen in or near the area. The DON said it is the facility policy that Oxygen should not be within 50 feet of the smoking area. The DON said Residents are not allowed to have Oxygen in the smoking area whether it is on or off. The DON said all Oxygen should be left inside the building or in the resident's rooms. DON said there are ten residents who smoke and out of those ten residents, six use Oxygen.<BR/>Review of an undated facility policy provided by Administrator on 04/30/23 showed: Reporting: Facility employees [NAME] must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. * If the allegation involves abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. * If the allegation does not involve abuse or serious bodily injury, the report must be made with 24 hours of the allegation . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure assessments accurately reflected the resident status for 1 of 22 residents (Resident #41) reviewed for MDS assessment accuracy. <BR/>The facility inaccurately coded Resident #41 as having had a weight loss on his quarterly MDS assessment dated [DATE].<BR/>This failure could place residents at risk for not receiving care and services to meet their needs.<BR/>Findings included:<BR/>Record review of Resident #41's face sheet dated 05/08/24, indicated a [AGE] year old male who admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis that affects all limbs and body from the neck down), dysphagia (difficulty swallowing), anemia (a condition in which the blood does not have enough healthy red blood cells, to carry oxygen all through the body), and neurofibromatosis (a condition that causes tumors to form in the brain, spinal cord, and nerves).<BR/>Record review of Resident #41's comprehensive care plan dated 01/10/24, indicated Resident #41 had a significant unplanned/unexpected weight gain of 9.3% in the last 60 days. The care plan interventions included to monitor and record food intake at each meal and notify the dietician of the weight gain upon their next visit. <BR/>Record review of Resident #41's registered dietician progress note dated 01/11/24 indicated . resident has good appetite and PO intake . Resident is underweight but 9.2 lbs weight gain noted since last 30 days-desired .<BR/>Record review of Resident #41's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated Resident #41 had a BIMS score of 13, indicating his cognition was intact. The MDS assessment indicated Resident #41 was dependent on facility staff for all ADLs. The MDS assessment indicated Resident #41 had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a physician prescribed weight regimen.<BR/>During an interview on 05/07/24 at 10:40 AM, Resident #41 said he has had a weight gain. <BR/>Record review of Resident #41's weights from 09/01/23-05/07/24, indicated the following recorded weights:<BR/>*11/02/24- 91.2lbs- admission weight<BR/>*12/05/23- 99 lbs<BR/>*01/05/24- 108.2 lbs<BR/>*01/18/24- 110 lbs<BR/>*02/05/24- 110.4 lbs<BR/>During an interview on 05/09/24 at 2:08 PM, the MDS Coordinator reviewed Resident #41's MDS assessment dated [DATE] and said Resident #41 did not have a weight loss and that he had actually had a weight gain. The MDS Coordinator said she must have clicked the wrong one by mistake and unsure as to why she did that. The MDS Coordinator said the MDS was inaccurate, and it was a human error. The MDS Coordinator said it was her responsibility to ensure the MDS were accurate. <BR/>During an interview on 05/09/24 at 3:50 PM, the DON said she expected the MDS assessments to be accurate. The DON said the MDS Coordinator was responsible for ensuring the MDS were accurate. The DON said not having an accurate MDS could place the resident at risk for inappropriate interventions. <BR/>During an interview on 05/09/24 at 04:36 PM, the Regional Director said he expected the MDS assessments to be accurate. The Regional Director said the MDS Coordinator was responsible for ensuring the MDS assessments were accurate. The Regional Director said an inaccurate MDS assessments could affect their quality measures and reimbursement but as far as clinical practice he was unsure. <BR/>During an interview on 05/09/24 at 09:24 AM, the DON said they did not have a policy on MDS accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 4 of 6 (Resident #40, Resident #33, Resident #4 and Resident #23) residents reviewed for the care plan.<BR/>1. The facility failed to care plan Resident #40 needs to be in the secure unit <BR/>2. The facility failed to care plan or write an order for Resident #33's to be in the secure unit. The facility failed to care plan Resident #33 was a smoker.<BR/>3. The facility failed to ensure Resident #4's comprehensive care plan addressed she received a prophylactic antibiotic.<BR/>4. The facility failed to ensure Resident #23's comprehensive care plan was person-centered to include his diagnosis of PTSD and any triggers he had.<BR/>These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.<BR/>The findings included:<BR/>1.Record review of Resident #40's face sheet, dated 05/07/24, indicated Resident #40 was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #40 had diagnoses which included Dementia (loss of memory), Depression (sadness), and Paranoid Schizophrenia (a kind of psychosis, which means your mind does not agree with reality). <BR/>Record review of Resident #40's quarterly MDS assessment, dated 03/14/24, indicated Resident #40 was sometimes understood and sometimes understood by others. Resident #40's BIMS score was 07, which indicated he was moderately cognitively impaired. Resident #40 required extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, and supervision with eating. <BR/>Record review of Resident #40's Elopement/Wandering Observation dated 02/27/24 indicated Resident #40 was at high risk of elopement.<BR/>Record review of Resident #40's physician orders dated 12/19/22, indicated resident to reside in the secure unit related to wandering and elopement risk. <BR/>Record review of Resident #40's comprehensive care plan dated 09/22/21 did not indicate any plan of care or interventions for the secure unit. <BR/>During an observation on 05/06/24 at 10:00 a.m., Resident #40 was sitting at the dining room table in the secure unit.<BR/>2. Record review of Resident #33's face sheet, dated 05/07/24, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included stroke, Parkinson's (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), and Paranoid Schizophrenia (a kind of psychosis, which means your mind doesn't agree with reality).<BR/>Record review of Resident #33's quarterly MDS assessment, dated 03/22/24, indicated Resident #33 was rarely understood and sometimes understood by others and his BIMS was a 04, indicating severe cognition impairment. The MDS assessment indicated he had short and long-term memory problems. Resident #33 required assistance with bathing, dressing, bed mobility, personal hygiene, toileting, and setting up for eating. <BR/>Record review of Resident #33's Elopement/Wandering Observation dated 02/26/24 indicated Resident was at a low risk of elopement.<BR/>Record review of Resident #33's Smoking assessment dated [DATE] indicated Resident #33 was a smoker. <BR/>Record review of Resident #33's physician orders dated 05/07/24, did not indicate an order for the secure unit.<BR/>Record review of Resident #33's comprehensive care plan, dated 03/24/24, did not indicate any plan of care or interventions for the secure unit. <BR/>Record review of Resident #33's comprehensive care plan, dated 03/24/24, did not indicate any plan of care or interventions for smoking.<BR/>During an observation on 05/06/24 at 10:31 a.m., Resident #33 was outside smoking with staff.<BR/>During an observation on 05/06/24 at 12:15 p.m., Resident #33 was walking down the hallway in the secure unit.<BR/>During an interview on 05/09/24 at 9:49 a.m., RN G said Resident #33 was a resident who smoked and resided in the unit. RN G said if a resident was on the secure unit, they should have an order indicating they needed to be in the unit and it should be care planned. RN G said the nurses were responsible for writing an order to admit to the secure unit. He said the MDS nurse or nurse management did the care plans. <BR/>During an observation and interview on 05/09/24 at 6:06 p.m., the MDS nurse said she was responsible for the comprehensive care plans, but all the department heads did their acute care plans. The surveyor observed the MDS nurse look in the electronic records for Resident #40 and Resident #33. She said she did not see a care plan for the secure unit on Resident #40 or Resident #33. She said she did not see a smoking care plan for Resident #33. The MDS nurse said the reason for being in the secure unit and interventions should have been listed on Resident #40's and Resident #33's care plan. She said Resident #33 should have had a smoking care plan because he smoked. The MDS nurse said they discussed orders, changes in the resident's condition in the morning meetings, and any changes that should have been made to their care plan. She said she did not know how she failed to care plan for both residents. She said care plans were done to address concerns, she said it was like a road map for their care. <BR/>During an interview on 05/09/24 at 6:39 p.m., the DON said the MDS nurse was responsible for completing the care plans but all department heads did care plans. She said during morning meetings she would review orders, progress notes, 24-hour reports, and incidents to ensure things had been added or discontinued from the care plan. She said she was the overseer. She said Resident #40 and Resident #33's nurses should have written orders for the secure unit when they were admitted to the unit. The DON said she was not aware that Resident #40 and Resident #33 had missed care plans. She said care plans were done to ensure the residents were getting the appropriate care.<BR/>3. Record review of Resident #4's face sheet dated 05/07/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4's diagnoses included dementia (memory loss), depression (persistent depressed mood), and urinary tract infection (an infection in any part of the urinary system).<BR/>Record review of Resident #4's quarterly MDS assessment dated [DATE], indicated she was sometimes understood and sometimes understood others. The MDS assessment indicated Resident #4 had a BIMS score of 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #4 had taking antibiotic within the last 7 days of the look back period. <BR/>Record review of Resident #4's comprehensive care plan dated 03/20/24 did not indicate Resident #4 was taking Macrodantin or a prophylactic antibiotic daily. <BR/>Record review of Resident #4's physician order report dated 05/01/24- 05/07/24, indicated Resident #4 had an order for Macrodantin (antibiotic to treat and prevent urinary tract infections) 50mg one tablet daily for prophylaxis (preventative) with a start date of 01/04/23. <BR/>Record review of Resident #4's medication administration history dated 05/01/24-05/09/24, indicated she had been receiving macrodantin 50mg one capsule daily.<BR/>4. Record review of Resident #23's face sheet dated 05/08/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugars and using it for energy), post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), hypertensive heart disease (heart condition due to untreated high blood pressure) and paraplegia (leg paralysis).<BR/>Record review of Resident #23's admission MDS assessment dated [DATE], indicated was usually understood and was able to understand others. The MDS assessment indicated Resident #23's BIMS score was a 9, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #23 had diagnoses of post-traumatic stress disorder. <BR/>Record review of Resident #23's comprehensive care plan dated 04/05/24, did not indicate Resident #23 had a diagnosis of PTSD or if he had any triggers.<BR/>During an interview on 05/07/24 at 10:59 AM Resident #23 said he had PTSD from Vietnam and Kuwait wars. Resident #23 said loud noises was his trigger.<BR/>During an interview on 05/09/24 at 3:50 PM, the DON said Resident #4's prophylactic antibiotic and Resident #23's diagnoses of PTSD should have had been care planned. The DON said they should have been care planned so staff would know Resident #4 was taking an antibiotic long term and Resident #23 had a diagnosis of PTSD with any triggers he had. The DON said the nurse leadership was responsible for ensuring the care plans were updated. The DON said since Resident #4's antibiotic and Resident #23's PTSD diagnoses were not care planned, the care plan was not accurate. <BR/>During an interview on 05/09/24 at 04:36 PM the Regional Clinical Consultant said Resident #4 care plan should reflect Resident #4 was receiving antibiotics as ordered as they do not name the medication. The Regional Clinical Consultant said Resident #23's diagnoses of PTSD should have been on his care plan with any triggers he had. The Regional Clinical Consultant said she expected the care plans to be updated timely. The Regional Clinical Consultant said nursing leadership was responsible for updating the care plans.<BR/>Record review of the facility's policy titled Care Plan dated 12/2018, indicated . It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident . 4. Concerns and Problems . 1. The specific problem as well as the underlying cause should be listed .b. sources are but are not limited to: 1. problems relating to diagnoses .8. Problems related to preventative care .10. All problems identified on all assessments .the resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate and planned to meet the individual needs of the resident consistent with the physician's plan of care for the resident .the resident care plan must be kept current at all times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 6 (Resident #44) residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #44's diabetic wound was being monitored for improvement or worsening. <BR/>This failure could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection. <BR/>Findings included:<BR/>Record review of Resident #44's face sheet dated 05/08/24, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #44 had diagnoses of metabolic encephalopathy (problems with the metabolism that causes brain dysfunction), dementia (memory loss), history of diabetic foot ulcer (an open sore or wound on the foot that develop in patients type 1 or type 2 diabetes), and type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugars and using it for energy). <BR/>Record review of Resident #44's annual MDS assessment dated [DATE], indicated he was usually understood and understood others. The MDS assessment indicated Resident #44 had a BIMS score of 10, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #44 had a diabetic foot ulcer. <BR/>Record review of Resident #44's comprehensive care plan dated 02/05/24, indicated Resident #44 had a diabetic ulcer to right foot. The care plan interventions included to monitor/document wound: size, depth, margins: peri wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene, and to document progress in wound healing on an ongoing basis.<BR/>Record review of Resident #44's physician orders report dated 05/01/24-05/08/24, indicated Resident #44 had an order for diabetic ulcer to right foot with calcium alginate follow with dry dressing and Coban daily with a start date of 04/16/24.<BR/>Record review of Resident #44's podiatrist routine foot care note dated 12/14/23, did not indicate any measurements for Resident #44's diabetic wound to his right foot.<BR/>Record review of Resident #44's podiatrist routine foot care note dated 03/25/24, did not indicate any measurements for Resident #44's diabetic wound to his right foot. <BR/>Record review of Resident #44's weekly skin assessment dated [DATE], indicated yes marked under the question does the resident have a pressure injury, venous, arterial, diabetic ulcer, or surgical wound? If yes complete a wound assessment. The skin assessment under description of findings resolving s/p diabetic ulcer left foot. The weekly skin assessment did not include Resident #44's measurements for the diabetic ulcer to his left foot.<BR/>Record review of Resident #44's weekly skin assessment dated [DATE], indicated yes marked under the question does the resident have a pressure injury, venous, arterial, diabetic ulcer, or surgical wound? If yes complete a wound assessment. The skin assessment under description of findings resolving s/p diabetic ulcer left foot. The weekly skin assessment did not include Resident #44's measurements for the diabetic ulcer to his left foot.<BR/>Record review of Resident #44's weekly skin assessment dated [DATE], indicated yes marked under the question does the resident have a pressure injury, venous, arterial, diabetic ulcer, or surgical wound? If yes complete a wound assessment. The skin assessment under description of findings resolving s/p diabetic ulcer left foot. The weekly skin assessment did not include Resident #44's measurements for the diabetic ulcer to his left foot.<BR/>Record review of Resident #44's electronic medical record on 05/09/24, did not reveal a wound assessment had been completed.<BR/>During an observation on 05/08/24 at 09:43 am, the Treatment Nurse entered Resident #44's room to provide wound care to his diabetic ulcer. Resident #44's diabetic ulcer was observed to the bottom of his left foot. <BR/>During an interview on 05/08/24 at 09:55 AM, the Treatment Nurse said the Resident #44 was being seen by the podiatrist regarding his diabetic ulcer and they were keeping up with the wound measurements. The Treatment Nurse said she had not been keeping up with Resident #44 measurements lately since Resident #44 was going to the podiatrist and were monitoring the progression of Resident #44's wound. <BR/>During an interview on 05/09/24 at 03:50 PM, the DON said she expected the wound assessment to be completed appropriately with wound measurements. The DON said by not documenting wound measurements, they were running a risk for not tracking progression or worsening of the wound. The DON said the treatment nurse was responsible for ensuring the skin assessments were completed with wound measurements. <BR/>During an interview on 05/09/24 at 4:36 PM, the Regional Director said he expected the treatment nurse to document wound measurements on the skin assessments. The Regional Director said documenting wound measurements allowed them to know if the wound was improving or worsening. The Regional Director said the DON was responsible for ensuring the treatment nurse was completing the skin assessments or wound assessments accurately. <BR/>Record review of the facility's policy titled Skin Integrity Monitoring System dated 12/2017, indicated . 1. A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown .3. A system will be in place to assure any type of skin conditions that do not constitute pressure injuries, will be monitored closely for any type of complications . assessment of the skin area is documented in the clinical software .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident and hazards for 2 of 7 residents (Residents #1 and #2) reviewed for accident hazards.<BR/>CNA B and CNA C failed to ensure Resident #2's Hoyer lift (an assistive lift device that allows for transfer using electrical power) transfer was performed correctly. <BR/>CNA D did not lock Resident #1's bed during incontinent care. <BR/>These failures could place dependent residents at risk for falls, significant injuries and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 1/9/24 indicated Resident #2 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, dementia, high blood pressure and COPD (chronic obstructive pulmonary disease - group of lung diseases that block airflow and make it difficult to breathe). <BR/>Record review of the MDS dated [DATE] indicated Resident #2 had unclear speech, rarely made herself understood and rarely understood others. The MDS indicated Resident #2 cognitive skills for decision making was severely impaired and she had both long-term and short-term memory problems. The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #2 was completely dependent on staff for toileting, oral hygiene, eating, bathing, dressing, and personal hygiene. The MDS indicated Resident #2 was completely dependent on staff for rolling side to side and all transfers. The MDS indicated Resident #2 had no impairment to the upper and lower extremities. The MDS indicated Resident #2 was always incontinent of bowel and bladder.<BR/>Record review of the care plan dated on 10/19/23 indicated Resident #2 had a self-care deficit due to her impaired cognition and impaired mobility. The care plan interventions included staff to assist resident with transfers as needed. The care plan also indicated Resident #2 was at risk for falls due to factors including decreased activity, confusion, and poor safety awareness. <BR/>During an observation on 1/9/24 at 1:20 p.m., CNA B and CNA C began to transfer Resident #2 from her wheelchair to her bed using a Hoyer lift. Resident #2 was initially combative with the CNAs, swinging her arms at them as they worked to attach the Hoyer sling to the Hoyer lift. After hooking the sling to the Hoyer lift, without locking the brakes (on the wheels) of the Hoyer lift, CNA B and CNA C lifted Resident #2 from her wheelchair. They (CNA B and CNA C) then guided the Hoyer lift to Resident #2's bed. Without locking the brakes of the Hoyer lift, they (CNA B and CNA C) lowered Resident #2 into the bed. <BR/>During an interview on 1/9/24 at 1:34 p.m., CNA B said she should have ensured the brakes were locked on the Hoyer lift wheels before Resident #2 was lifted from her wheelchair and before they (CNA B and CNA C) lowered Resident #2 into the bed. CNA B said she just forgot to double check and ensure the lift brakes (on the wheels of the Hoyer) were locked during the transfer. CNA B said the lift could have slid when they lifted/lowered Resident #2 and fallen over, especially since she (Resident #2) could be combative. CNA B said Resident #2 could have fallen out of the lift and gotten hurt. <BR/>During an interview on 1/9/24 at 1:37 p.m., CNA C said she should have ensured the brakes (on the wheels of the Hoyer) were locked on the Hoyer lift before Resident #2 was lifted from her wheelchair and before they (CNA B and CNA C) lowered Resident #2 into the bed. CNA C said she was just busy and forgot to ensure the Hoyer lift brakes were locked. CNA C said the lift could have tipped over and Resident #2 could have fallen into the floor. <BR/>2.Record review of the face sheet dated 1/9/24 indicated Resident #1 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, high blood pressure and heart disease. <BR/>Record review of the MDS dated [DATE] indicated Resident #1 had clear speech, usually made herself understood and usually understood others. The MDS indicated Resident #1 had mild cognitive impairment (BIMS of 9). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #1 required substantial/maximal assistance with personal hygiene, putting on/taking off footwear, dressing, and bathing. The MDS indicated Resident #1 required substantial/maximal assistance with rolling left to right and tub/shower transfer. The MDS indicated she required partial/moderate assistance with sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, and toilet transfer. The MDS indicated she required partial/moderate assistance with toileting and oral hygiene. The MDS indicated Resident #1 required setup or clean-up assistance with eating. The MDS indicated Resident #1 required extensive assistance of 2 persons to complete bed mobility, transfers, bathing and toilet use. The MDS indicated she had no impairment to the upper and lower extremities. The MDS indicated Resident #1 was frequently incontinent of bowel and bladder.<BR/>Record review of the care plan dated on 12/25/23 indicated Resident #1 had a self-care deficit due to her impaired cognition and impaired mobility. The care plan interventions included staff to assist resident with turning/repositioning while in bed, and staff will assist bathroom. The care plan also indicated Resident #1 was at risk for falls due to factors including decreased mobility.<BR/>During an observation on 1/9/24 at 1:00 p.m., CNA D provided incontinent care to Resident #1. CNA D did not check the brakes on the wheels of the bed before she started the incontinent care. During the incontinent care, CNA D moved the bed away from the wall and went to the left side of the bed (the side that was against the wall). CNA D did not lock the brakes on the wheels of the bed. CNA D then rolled Resident #1 to her (Resident #1's) right side (the side not against the wall). CNA D completed the care, returned the bed to the original position and did not lock the brakes on the wheels of the bed. <BR/>During an interview on 1/9/24 at 1:10 p.m., CNA D said she should have locked Resident #1's bed before starting the incontinent care, after she moved the bed, and after returning the bed to its original position. CNA D said Resident #1 could have fallen out the bed and sustained an injury. <BR/>During an interview on 1/9/24 at 1:40 p.m., LVN A said the CNAs should have ensured the brakes on the wheels on the Hoyer lift were locked before Resident #2 was lifted/lowered with the Hoyer lift. LVN A said CNA D should have double checked to ensure Resident #1's bed was locked before care was started. LVN A said Resident #1's bed should have been locked, before Resident #1 was repositioned in the bed and after CNA D completed Resident #1's care. LVN A said these things (the Hoyer lift brakes on the wheels left unlocked during the lift/descent of a resident and not ensuring bed brakes (on the wheels) were locked when a resident was repositioned in the bed) were safety issues. LVN A said Resident #2 could have been dropped from the Hoyer lift and Resident #1 could have fallen out of the bed.<BR/>During an interview on 1/9/24 at 1:57 p.m., the ADON said the CNA B and CNA C should have ensured the brakes on the wheels on the Hoyer lift were locked before Resident #2 was lifted/lowered with the Hoyer lift. The ADON said CNA D should have ensured Resident #1's bed was locked before care was started, before Resident #1 was repositioned and after the care was completed. The ADON said these things (the Hoyer lift brakes on the wheels left unlocked during the lift/descent of a resident and not ensuring bed brakes (on the wheels of the bed) were locked when a resident was repositioned in the bed) were posed a risk of injury. She said the system in place to ensure staff performed Hoyer lift transfers safely was the annual skills check off which included Hoyer lift transfers and ensuring brakes were locked on beds before repositioning a resident. The ADON said going forward a system would be put in place to perform spot checks on CNAs to ensure they were safely repositioning and transferring residents. <BR/>During an interview on 1/9/24 at 3:00 p.m., the Administrator said he expected staff to take appropriate measures to ensure residents safety during Hoyer lift transfers and incontinent care. The Administrator said leaving the bed unlocked and the Hoyer lift unlocked while a resident was lifted/lowered were not practices that would ensure resident safety. <BR/>During an interview on 1/9/24 at 2:30 p.m., the ADON said the facility did not have a policy and procedure specifically related to ensuring bed brakes (on the wheels of the bed) were locked. <BR/>Record review of the facility policy and procedure titled Lifting and movement of Resident-safe, dated December of 2017 stated, Policy: In order to protect the safety and well-being of staff and residents and to promote quality care, this home uses appropriate techniques and devices to lift and move residents . The policy and procedure did not specifically address the use of bed brakes (on the wheels of the bed or mechanical lift brakes (on the wheels of the mechanical lift). <BR/>Record review of the facility policy and procedure titled Mechanical Lift, dated December of 2017 reveled it did not specifically address the use of mechanical lift brakes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 22 residents (Resident #23) reviewed for quality of care.<BR/>The facility did not ensure Resident #23's trauma screening was completed upon admission to the facility. <BR/>This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. <BR/>The findings included:<BR/>Record review of Resident #23's face sheet dated 05/08/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugars and using it for energy), post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), hypertensive heart disease (heart condition due to untreated high blood pressure) and paraplegia (leg paralysis).<BR/>Record review of Resident #23's admission MDS assessment dated [DATE], indicated was usually understood and was able to understand others. The MDS assessment indicated Resident #23's BIMS score was a 9, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #23 had diagnoses of post-traumatic stress disorder. <BR/>Record review of Resident #23's comprehensive care plan dated 04/05/24, did not indicate Resident #23 had a diagnosis of PTSD or if he had any triggers.<BR/>Record review of Resident #23's trauma informed care observation dated 04/12/24 indicated the observation was recorded and completed on 05/08/24 by the SW. The assessment indicated Resident #23 had personally experienced a natural disaster, a serious accident, life-threatening illness or injury and physical assault. The assessment indicated Resident #23 had personally experienced and witnessed a combat or war-one. The assessment indicated yes when asked if any of these events bothered him. The assessment under comments indicated years of therapy have helped him cope with PTSD. VA assists as well. The assessment under triggers that remind you of the event indicated loud noises and water. The assessment indicated, under the question how do you react when you are reminded of the event, sometimes anxious. The assessment indicated breathing and thinking about other things helped Resident #23 refocus when he reacted to the events. <BR/>During an interview on 05/07/24 at 10:59 AM Resident #23 said he had PTSD from Vietnam and Kuwait wars. Resident #23 said loud noises was his trigger.<BR/>During an interview on 05/09/24 at 09:03 AM, the SW provided Resident #23's completed trauma assessment. The SW said she did not complete Resident #23's trauma assessment until yesterday, 05/08/24, when it was requested. The SW said she had completed the trauma assessment prior but had only documented it her notes and not in Resident #23's electronic medical record.<BR/>During an interview on 05/09/24 at 3:50 PM, the DON said Resident #23 should have had his trauma assessment completed upon admission. The DON said she knew the SW had completed the trauma assessment but did not have an answer as to why she did not input that information in Resident #23's medical record. The DON said it was important for the trauma assessment to be completed to have access to that information so they could accurately meet Resident #23's needs. The DON said the SW was responsible for completing the trauma assessments. <BR/>During an interview on 05/09/24 at 04:36 PM, the Regional Director said nurse management was responsible for completing the trauma assessments. The Regional Director said he was unsure of the risks for not completing the trauma assessment or when it should have been completed.<BR/>During an interview on 05/09/24 at 05:23 PM, the SW said she was responsible for completing the trauma assessments within the first 14 days of admission. The SW said by not completing the trauma assessment timely the staff will not know of any triggers Resident #23 could have. The SW said she educated staff regarding Resident #23's triggers which included loud noises, engine backfire, and water. <BR/>During an interview on 05/09/24 at 05:27 PM, RN B said she was not aware of Resident #23 having a diagnosis of PTSD or if he had any triggers. RN B said if a resident had the diagnosis of PTSD, the staff should be aware of any triggers the resident had to be able to care for the resident. <BR/>During an interview on 05/09/24 at 05:33 PM, CNA D said she was unsure if Resident #23 had PTSD or if he had any triggers. CNA D said it was important for staff to be aware so they could properly care for Resident #23. CNA D said Resident #23 triggers should have been documented on his care plan. <BR/>During an interview on 05/09/24 at 10:16 AM, the DON said they did not have a policy on trauma informed care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 4 of 8 residents (Residents #11, #54, #50, and #55) reviewed for pharmacy services.<BR/>1. The facility failed to ensure MA K administered Resident #11's Clindamycin (antibiotic), Eliquis (anticoagulant), Keppra (antiseizure), and Vimpat (antiseizure) timely as ordered at 8:30 a.m.<BR/>2. The facility failed to ensure MA K administered Resident #54's Tylenol (pain medication), Coreg (blood pressure), Gabapentin (used to treat pain), and Isosorbide (blood pressure) timely as ordered at 8:30 a.m.<BR/>3. The facility failed to ensure MA K administered Resident #50's Tylenol (pain reliever), timely as ordered at 8:30 a.m.<BR/>4. The facility failed to ensure MA K administered Resident #55's oxcarbazepine (antiseizure) timely as ordered at 9:00 a.m. <BR/>This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.<BR/>Findings included:<BR/>1) Record review of a face sheet dated 5/08/2024 indicated Resident #11 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of seizures, anxiety, high blood pressure and depression.<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #11 was sometimes understood and usually understands. Resident #11's BIMs score was a 5 indicating she had severe cognitive impairment.<BR/>Record review of the comprehensive care plan dated 10/06/2023 indicated Resident #11 was on anticoagulant therapy for a diagnosis of a blood clot. The goal of the care plan was Resident #11 would be free from discomfort. The care plan interventions included Resident #11 would receive her medication as ordered. Resident #11 was care planned for a seizure disorder. The care plan goal indicated Resident #11 would be from injury from seizure activity. The care plan intervention included to give the medications as ordered. The care plan indicated Resident #11 had a potential for side effects related to use of anti-depressants. The goal of the care plan indicated Resident #11 would not have any signs and symptoms of depression. The interventions for the care plan included to administer the medication for the condition.<BR/>During an observation on 5/06/2024 at 10:00 a.m., MA K prepared and administered Resident #11's medications for administration.<BR/>Clindamycin (antibiotic) 300 milligrams one, <BR/>Eliquis (anti-coagulant) 5 milligrams one, <BR/>Keppra (anti-seizure) 500 milligrams one, and<BR/>Vimpat (anti-seizure). <BR/>Record review of the consolidated physician's orders dated 5/01/2024 - 5/08/2024 indicated Resident #11 was ordered:<BR/>Clindamycin(antibiotic) capsules 300 milligrams one capsule three times a day 8:30 a.m., 2:00 p.m., and 8:00 p.m.<BR/>Eliquis (anti-coagulant) 5 milligrams one tablet twice a day at 8:30 a.m. and 8:00 p.m.<BR/>Keppra (anti-seizure) 500 milligrams one tablet at 8:30 a.m.<BR/>Vimpat (anti-seizure) 150 milligrams one tablet daily at 9:00 a.m.<BR/>Record review of the Medication Administration History Report dated 5/06/2024 indicated Resident #11 received her medications as listed:<BR/>Clindamycin 300 milligrams one capsule at 10:31 a.m.<BR/>Eliquis 5 milligrams one tablet at 10:31 a.m.<BR/>Keppra 500 milligrams one tablet at 10:31 a.m.<BR/>Vimpat 150 milligrams one tablet at 10:31 a.m.<BR/>2) Record review of a face sheet dated 5/08/2024 indicated Resident #54 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of chronic pain, and high blood pressure.<BR/>Record review of an admission MDS dated [DATE] indicated Resident #54 was usually understood and understands. The MDS indicated Resident #54's BIMs score was a 9 indicating moderately impaired cognition. <BR/>Record review of a comprehensive care plan indicated Resident #54had a diagnosis of high blood pressure with a goal of the blood pressure would remain within normal limits. The care plan interventions included administer medications as ordered. The comprehensive care plan indicated Resident #54 requires pain management. The goal of the care plan was Resident #54 would have her pain controlled. The interventions included to administer the medications for the condition as ordered. The comprehensive care plan indicated Resident #54 used an anti-depressant. The goal was Resident #54 would not have any signs of depression. The interventions included to administer the medication for the condition as ordered.<BR/>Record review of the consolidated physician's orders date 5/01/2024 - 5/08/2024 indicated Resident #54 was ordered:<BR/>Tylenol (pain medication) 650 milligrams one tablet three times a day at 8:30 a.m., 2:00 p.m., and 8:00 p.m.<BR/>Coreg (high blood pressure) 12.5 milligrams one tablet twice daily at 8:30 a.m., and 8:00 p.m.<BR/>Gabapentin (pain medication) 300 milligrams one capsule 4 times daily at 8:30 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m.<BR/>Isosorbide ER (high blood pressure) 30 milligrams one tablet daily at 8:30 a.m.<BR/>During an observation on 5/06/2024 at 10:22 a.m., MA K prepared and administered Resident #54's medications as follows: <BR/>Tylenol (mild pain reliever) 650 milligrams one<BR/>Coreg (high blood pressure) 12.5 milligrams one<BR/>Gabapentin (pain medication) 300 milligrams one<BR/>Isosorbide ER (high blood pressure) 30 milligrams one<BR/>Record review of the Medications Administration History dated 5/06/2024 indicated Resident #54 received her medications as listed:<BR/>Tylenol 650 milligrams one tablet administered at 10:31 a.m.<BR/>Coreg 12.5 mg one tablet administered at 10:31 a.m.<BR/>Gabapentin 300 milligrams one capsule administered 10:32 a.m.<BR/>Isosorbide ER 30 milligrams one tablet administered at 10:31 a.m.<BR/>3) Record review of a face sheet dated 5/08/2024 indicated Resident #50 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of stroke, kidney disease, and anxiety.<BR/>Record review of the admission MDS dated [DATE] indicated Resident #50 was usually understood and usually understands. The MDS indicated Resident #50 had moderate cognitive impairment.<BR/>Record review of the comprehensive care plan dated 3/08/2024 indicated Resident #50 had occasional generalized discomfort and the goal of the care plan was Resident #50's pain would be controlled. The intervention of the care plan included to administer the medication for the condition. <BR/>During an observation and interview on 5/06/2024 at 10:34 a.m., MA K prepared Resident #50's medications for administration as indicated:<BR/>Tylenol (mild pain reliever) 500 milligrams two caps<BR/>Record review of the consolidated physician's orders dated 5/01/2024 - 5/08/2024 indicated Resident #50 was ordered:<BR/>Tylenol (mild pain reliever) 500 milligrams 2 tablets twice a day at 8:30 a.m. and 8:00 p.m.<BR/>Record review of the Medication Administration History dated 5/06/2024 indicated Resident #50 received:<BR/>Tylenol 500 milligrams 2 tablets at 10:44 a.m.<BR/>4) Record review of a face sheet dated 5/08/2024 indicated Resident #55 was an [AGE] year-old-male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), Bi-polar disorder (mental illness), and pain.<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #50 was usually understood and usually understands. The MDS indicated Resident #50 had moderate cognitive impairment.<BR/>Record review of the comprehensive care plan dated 9/25/2023 indicated Resident #50 had a diagnosis of depression and the goal of the care plan was he would remain free of symptoms of depression. The interventions included to administer the medications as ordered. <BR/>Record review of the consolidated physician's orders dated 5/01/2024 - 5/08/2024 indicated Resident #50 was ordered:<BR/>Oxcarbazepine 150 milligrams one tablet twice a day at 9:00 a.m. and 9:00 p.m.<BR/>During an observation on 5/06/2024 at 10:50 a.m., MA K prepared and administered Resident #55's medications as follows:<BR/>Oxcarbazepine (anti-seizure) 150 milligrams one<BR/>Record review of the medications Administration History dated 5/06/2024 indicated Resident #50 received:<BR/>Oxcarbazepine 150 milligrams one tablet administered at 10:53 a.m.<BR/>MA K said Resident #55's medications were late for administration because she was called in to work and arrived around 6:35 a.m., instead of 6:00 a.m. MA K said 6:00 a.m. - 2:00 p.m. was not her normal shift to work.<BR/>During an interview on 5/09/2024 at 11:51 a.m., the DON said she expected the medications to be administered as scheduled. The DON said residents could suffer adverse effects when the medications were not administered timely. The DON said she was new to the facility and was not aware there was a report to monitor the timeliness of medication administration until the surveyor asked for such a report. The DON said she was responsible for monitoring to ensure medications were passed timely along with the nurses. <BR/>During an interview on 5/09/2024 at 1:00 p.m., the RDO said he expected the medications to be administered within the time allotted and based on the physician's orders. The RDO said when medications were not administered timely the effectiveness of the medication could be affected. The RDO said the DON and nursing was responsible for ensuring the medications were passed timely. The RDO said random checks was a way medications administration could be monitored. <BR/>During an interview on 5/09/2024 at 2:42 p.m., MA K said the medications were passed late due to her arriving late to cover the open shift. MA K said this was a usual occurrence and has happened often. MA K said late administration of medications could cause symptoms to increase. <BR/>During an interview on 5/09/2024 at 2:52 p.m., RN B said she expected the medications to be administered according to the schedule to ensure effectiveness. RN B said someone's pain level or blood pressure in particularly could be affected.<BR/>Record review of a Medication-Administration policy dated 12/2017 indicated it was the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations .8. Medications are administered within 60 minutes of the scheduled time, unless otherwise specified by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviewss, the facility failed to ensure residents who used psychotropic drugs were not given those drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #62) reviewed for unnecessary psychotropic drugs. <BR/>The facility failed to follow the pharmacy recommendation to discontinue Resident #62's Seroquel/quetiapine (antipsychotic medication) on 04/25/24 therefore Resident #62 received 13 more doses of Seroquel. <BR/>This failure could place residents at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status.<BR/>Findings included:<BR/>Record review of Resident #62's face sheet dated 05/08/24, indicated an [AGE] year-old male who admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), insomnia (problems with falling and staying asleep), left femur fracture (left thighbone break), and weakness.<BR/>Record review of Resident #62's admission MDS assessment dated [DATE], indicated he was usually understood and usually understood others. The MDS assessment indicated he had a BIMS score of 6, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #62 had taken antipsychotic medications within the last 7 days of the look back period. <BR/>Record review of Resident #62's comprehensive care plan dated 04/02/24, indicated Resident #62 had a potential for side effects related to psychotropic med use of anti-psychotic meds. The care plan intervention included to administer medication for condition as ordered and pharmacy consultant to review meds periodically for possible reduction. <BR/>Record review of Resident #62's physician order report dated 04/08/24-05/08/24, indicated he had an order for quetiapine 25mg give 3 tablets to equal 75mg at bedtime with a start date of 03/17/24. <BR/>Record review of Resident #62's medication administration record dated 04/01/24-04/30/24 indicated he had been receiving quetiapine 75mg daily. <BR/>Record review of Resident #62's pharmacy recommendation dated 03/23/24, indicated federal guidelines for long-term care facilities require an evaluation of antipsychotic usage upon admission. This resident was recently admitted with an order for quetiapine 75mg HS to treat DX NEEDED . The pharmacy recommendation indicated under physician's response had agree checked with d/c quetiapine signed by Resident #62's physician and dated 04/25/24.<BR/>During an interview on 05/09/23 at 03:03 PM, the DON said the ADON and herself were responsible for ensuring the pharmacy recommendations were completed. The DON said she received the recommendations via email. She said after she received them she gave the medical director the recommendations he had to review. The DON said any new orders on the recommendations were given to her or the ADON. The DON said Resident #62 should have had his Seroquel discontinued on 04/25/24 when the medical director signed the pharmacy recommendation. The DON said she was unsure of how it was missed. The DON said the medical director usually referred the residents to psych services, so she was unsure what happened. The DON said the pharmacy recommendation clearly stated to discontinue the quetiapine and failure to not complete the order could cause negative effects of antipsychotic medications. <BR/>During an interview on 05/09/24 at 4:36 PM, the Regional Director said he expected the pharmacy recommendations to be followed through. The Regional Director said nursing should have had implemented the physician's order. The Regional Director said nurse management was responsible for ensuring the pharmacy recommendations were completed. <BR/>Record review of the facility's policy titled Behavior Management - Psychoactive Medication - Antipsychotic Drug Therapy dated 12/2018, indicated . It is the policy of this home to use antipsychotic medications per CMS guidelines and to perform dose reductions and monitoring as required by regulation, to promote the highest level of resident care and safety. A gradual dose reduction is a tapering of the resident's daily dose to determine if the resident's symptoms can be controlled by a lower dose or to determine if the dose can be eliminated altogether . b. The physician can order the dose reduction suggested, order an alternative dosage reduction schedule, or state that it is clinically contraindicated to adjust the dosage, with justification for this determination .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a policy identifying those cirumstances when the loss or damage of dentures was the facility's responsibility and failed to provide or obtain dental services to meet the needs of each resident for 1 of 9 (Resident #30) residents reviewed for dental services. <BR/>The facility failed to provide dental services when Resident #30 lost his dentures.<BR/>The facility failed to have policies and procedures for lost dentures. <BR/>This failure could affect residents by placing them at risk for oral complications and diminished quality of life. <BR/>Findings included:<BR/>Record review of the face sheet dated 05/08/2024 indicated Resident #30 was an [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including encounter for surgical aftercare following surgery of genitourinary system (organs of the reproductive and urinary system), colitis (inflammation of the colon), calculus (stone) of kidney, hematuria(blood in urine), weakness, astigmatism (a curvature in the lens of the eye), intermittent explosive disorder (mental health disorder marked by frequent impulsive anger and/or outburst of aggression), muscle wasting, insomnia (inability to sleep), chronic pain, flaccid hemiplegia (lack of voluntary moment in a limb) affecting left dominant side.<BR/>Record review of the Quarterly MDS assessments dated 03/08/2024 indicated Resident #30 understood others and was understood by others. The MDS indicated Resident #30 had a BIMS score of 10 and was moderately cognitively impaired. The MDS indicated Resident #30 did not have any mouth or facial pain, discomfort, or difficulty swallowing. <BR/>Record review of the physician orders dated 10/26/2023 indicated Resident #30 had an order dated 01/26/2021 which indicated may have dental consults and treatment if indicated as needed.<BR/>Record review of Resident #30's electronic data record indicated no dental referral had been made. <BR/>During an interview on 05/07/2024 at 10:13 a.m., Resident #30's family member said the facility lost his top dentures right after he was admitted . Resident #30's family member voiced concerns regarding a referral for dental services to be provided at the facility. <BR/>During an interview on 05/07/2024 at 10:40 a.m., Resident #30 said he had no dentures. Resident #30 said he could eat but he would like to get his teeth back. Resident #30 said his family member was trying to get him an appointment to get dentures at the facility. <BR/>During an interview on 05/07/2024 at 12:13 p.m., the Social Worker said she had reached out to the corporate office regarding Resident #30's lost dentures and was told the facility was not responsible for dentures. The Social Worker said the corporate office informed her there was no policy regarding lost dentures. The Social Worker said corporate had told her the facility was not Resident #30's representative payee on his insurance and therefore she did not make any type of referral. The Social Worker was not able to provide any documentation of communication with the corporate office. The Social Worker said she had not followed up because Resident #30's family member had not mentioned it to her since that time back in January. The Social Worker said it was important to make dental referrals appropriately and timely to prevent weight loss and ensure the residents' needs were being met. <BR/>During an interview on 05/08/2024 at 4:00 p.m., the DON said she was not aware of Resident #30's lost dentures. The DON said she expected the Social Worker to ensure and handle those types of dental referrals appropriately and timely, so the residents did not have any type of deficits such as weight loss. The DON said she had started at the facility approximately 2 months ago and this was the first time she heard of any incidents involving Resident #30 and missing dentures. The DON said she was not familiar with the dental/denture procedures. <BR/>During an interview on 05/09/2024 at 09:24 a.m., the DON said the facility did not have a policy regarding dental/dentures care/referrals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.<BR/>1. The facility failed to ensure 3 sheet pans were free from a brown colored grease like build up on the inside corners of the sheet pans.<BR/>2. The facility failed to ensure 2 cast iron skillets were free from a carbon build up not covering the inside walls and the outside of the skillet.<BR/>3. The facility failed to ensure the juice machine was free from dusty like material on the front and sides.<BR/>These failures could place residents at risk for food borne illness.<BR/>Findings included:<BR/>During observations on initial tour on 5/06/2024 at 9:28 a.m., the following was found:<BR/>*2 cast iron skillets with a large amount of black encrusted carbon buildup on the inside and the outside.<BR/>*3-1/4 sheet pans with dark brown build up appears to be caked on grease material was on the inside corners of each pan.<BR/>*Juice machine had dust buildup on the two sides and the front of the machine.<BR/>During an interview with the on 5/06/2024 at 9:30 a.m., the cook said she used the sheet pans to cook the breakfast meats, and the cast iron skillets were used to fry fish on Fridays. The [NAME] said the pans should be cleaned better, to remove the brown material. The [NAME] said the pans were not considered clean enough to cook food.<BR/>Record review of the Daily Cleaning Schedule dated May 2024 the sheet pans, the cast iron skillets, and the juice machine was not listed on the cleaning schedule duties. <BR/>During an interview on 5/09/2024 at 11:48 a.m., the DON said she expected the dietary department to be clean according to basic kitchen standards. The DON said unsanitary cleaning practices could lead to undesirable events including food borne illnesses. The DON said the Dietary Manager and staff were responsible for ensuring kitchen sanitation.<BR/>During an interview on 5/09/2024 at 12:57 p.m., the RDO indicated he expected the dietary department to be clean including the machines, and pans. The RDO said the Dietary Manager was responsible for ensuring kitchen sanitation.<BR/>During an interview on 5/09/2024 at 2:40 p.m., the Dietary Manager said she would have to remove and replace the iron skillets after the Friday menu items of fish. The Dietary Manager said the pans could not be cleaned and could make someone ill. The Dietary Manager said she would have to ensure the juice machine was clean to prevent dust from getting in the drinks.<BR/>Record review of the General Kitchen Sanitation policy dated October 1, 2018 indicated the facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition and Food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness 3. Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil.<BR/>Record review of the Food Code dated 01/18/23 and accessed online at www.fda.gov/[NAME]/164194 on 5/13/2024 revealed:<BR/>4-101.11 Characteristics <BR/>Material that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: A). Safe, B). Durable, corrosion-resistant, and non-absorbent . D). Finished to have a smooth, easily cleanable surface <BR/>4-101.12 Cast Iron, Use Limitation. (A) Except as specified in (B) and (C) of this section, cast iron may not be used for UTENSILS or FOOD-CONTACT SURFACES of EQUIPMENT. (B) Cast iron may be used as a surface for cooking. (C) Cast iron may be used in UTENSILS for serving FOOD if the UTENSILS are used only as part of an uninterrupted process from cooking through service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 22 residents (Resident #10) reviewed for resident records. <BR/>The facility failed to accurately update Resident #10's comprehensive care plan with her code status.<BR/>This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, psychosocial outcome and inaccurate medical records.<BR/>Findings included:<BR/>Record review of Resident #10's face sheet dated [DATE], indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Alzheimer's (a progress disease that destroys memory and other important mental functions), atrial fibrillation (irregular often rapid heart rate that commonly causes poor blood flow), depression (persistent depressed mood), and anxiety.<BR/>Record review of Resident #10's significant change in status MDS assessment dated [DATE], indicated Resident #10 was usually understood and usually understood others. The MDS assessment indicated Resident #10's BIMS score was a 5, which indicated her cognition was severely impaired.<BR/>Record review of Resident #10's comprehensive care plan dated [DATE], indicated Resident #10 was a full code CPR order in place. The care plan interventions indicated to review medical record to ensure that proper documents were signed. <BR/>Record review of Resident #10's physician order report dated [DATE]-[DATE], indicated Resident #10 had an order for code status DNR (do not resuscitate) with a start date of [DATE] . <BR/>Record review of Resident #10's Out of Hospital Do-Not-Resuscitate (OOH-DNR) order indicated Resident #10's family member had signed the order on [DATE] and was notarized. The OOH-DNR order indicated the physician had signed the order on [DATE].<BR/>During an interview on [DATE] at 3:50 PM, the DON said Resident #10 comprehensive care plan should have been updated to indicate her code status had changed from full code to DNR whenever they received the order for DNR. The DON said nurse leadership was responsible for updating the care plans. The DON said failure to update Resident #10's care plan could place Resident #10 at risk for receiving CPR. The DON said that was not something they would have want to happen since Resident #10 had a DNR.<BR/>During an interview on [DATE] at 05:23 PM, the Regional Clinical Consultant said she expected the care plans to updated timely. The Regional Clinical Consultant said Resident #10's care plan should have reflected the updated code status so plan of care was appropriate. The Regional Clinical Consultant said nursing leadership was responsible for updating the care plans. <BR/>Record review of the facility's policy titled Care Plan dated 12/2018, indicated . It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident .10. To update the resident care plan . changes and dated on problems per home policy . if the entry must be changed significantly, the plan will look neater if the entry is lined out and reference made to the new entry .the resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate and planned to meet the individual needs of the resident consistent with the physicians plan of care for the resident .the resident care plan must be kept current at all times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 3 residents (Resident #40 and Resident # 18) reviewed for hospice services.<BR/>The facility failed to maintain Resident #40's hospice binder containing information related to hospice services provided for the resident. <BR/>The facility failed to obtain Resident #18's most recent hospice plan of care.<BR/>These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. <BR/>The findings included:<BR/>1. Record review of Resident #40's face sheet, dated 05/07/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease {COPD}( a chronic inflammatory lung disease that causes obstructed airflow from the lungs), Congestive heart failure(CHF), or heart failure, (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), hypertension (high blood pressure), and Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar (glucose).<BR/>Record review of Resident 40's admission MDS assessment, dated 03/22/24, indicated Resident #40 was usually understood and usually understood by others. Resident #40 BIMs score was a 05 indicating he was cognitively moderately impaired. The MDS indicated Resident #40 required assistance with his ADLs. The MDS indicated he was receiving hospice service.<BR/>Record review of Resident 48's Physician order dated 03/15/24 revealed Resident #40 was admitted to hospice with a diagnosis of COPD. <BR/>Record review of Resident #40's comprehensive care plan, dated 03/18/24, revealed Resident #40 was admitted to hospice for a diagnosis of COPD. The intervention was staff would notify the hospice of any changes, the staff would coordinate care with the hospice, staff would monitor for signs or symptoms and the effectiveness of medication/ and monitor for relief.<BR/>Record review of Resident #40's hospice binder could not be located.<BR/>During an interview on 05/09/24 at 2:00 p.m., RN G said he could not locate Resident #40's binder. He said he would reach out to hospice for them to bring him a binder. He said the hospice book was a way of communication between the hospice and the facility to manage Resident #40's care. He said the book contained his diagnosis, care plan, and medication list. He said it was also important for documentation if the nurses or aides had concerns during their visits.<BR/>During a phone interview on 05/09/24 at 4:19 p.m., Hospice RN J said it was the responsibility of the nurses to drop off the hospice updates when they visited the residents. She said she could not say why Resident #40 book was not at the facility. She said Resident #40 had a hospice aide three times a week and a nurse once a week. She said Resident #40 was due to have his recertification on 05/22/24. She said Resident #40 had his last hospice bi-weekly meeting on 05/06/24. She said it was important to have the hospice binder in the facility to help correlate with care. She said she would bring him a binder today (05/09/24).<BR/>During an interview on 05/09/24 at 6:39 p.m., the DON said the hospice company was responsible for ensuring the hospice book was in the facility and updated. She said the books were utilized for communication between the hospice company and the facility on Resident #40's care. She said she was made aware the hospice book for Resident #40 could not be located. She said it was important to have the hospice binder at the facility for continuity of care.<BR/>2. Record review of Resident #18's face sheet dated 05/09/24, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #18 diagnoses included senile degeneration of brain (mental deterioration), dysphagia (difficulty swallowing), protein calorie malnutrition (inadequate protein and calorie intake), anxiety and depression (persistent depressed mood).<BR/>Record review of Resident #18's quarterly MDS assessment dated [DATE], indicated she was able to sometimes understand others and sometimes made herself understood. The MDS assessment indicated Resident #18 had a BIMS score of 2, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #18 received hospice care within 14 days of the look back period while a resident at the facility. <BR/>Record review of Resident 18's comprehensive care plan last reviewed/revised on 03/18/24, indicated Resident #18 required hospice services as evidenced by terminal illness. The care plan interventions indicated to communicate with hospice when any changes were indicated in the resident's plan of care.<BR/>Record review of Resident #18's hospice binder indicated the last hospice plan of care update report was dated 03/15/24. The hospice plan of care did not indicate Resident #18 had orders for Xanax or acetaminophen as it indicated on Resident #18's facility physician order report. <BR/>Record review of Resident #18's physician order report dated 05/01/24-05/09/24, indicated she had the following orders: <BR/>*Admit to [hospice company] services for end-of-life care for senile degeneration of the brain with a start date of 03/19/24. <BR/>*Xanax (antianxiety medication) 0.5mg twice a day with a start date of 03/26/24.<BR/>*Acetaminophen 500mg give 2 tablets every 4 hours as needed for pain/fever 100.9 or greater with a start date of 03/07/24.<BR/>During an interview on 05/09/24 at 11:53 AM, the Hospice DON said they tried to send updated hospice care plans after every IDG meeting or monthly. The Hospice DON said Resident #23's last plan of care should have been updated at the end of March 2024. The Hospice DON the Hospice Case Manager was responsible for ensuring Resident #18 had the most recent plan of care at the facility. The Hospice DON said it was important for the most recent hospice plan of care to be at the facility so facility staff could see if there has been any medication changes or updates to the plan of care. The Hospice DON said the office manager printed the current hospice plans of care so the hospice staff could deliver to the facility and update the hospice binder. The Hospice DON said it was ultimately the responsibility of the Hospice Case Manager to ensure that was being done.<BR/>During an interview on 05/09/24 at 12:05 PM, the Hospice Case Manager said they had IDG meetings every 2 weeks, and they usually updated the hospice binder after the IDG meeting or at the end of the month. The Hospice Case Manager said they had been pretty behind in getting those updated care plans to the facility. The Hospice Case Manager said she was responsible for ensuring the hospice binders at the facility were kept up to date. The Hospice Case Manager said it was important for keeping the updated plans of care so facility could be aware of any changes to the plan of care. <BR/>During an interview on 05/09/24 at 3:50 PM, the DON said she expected the hospice to keep their binders or paperwork to be up to date. The DON said the plan of care changes all the time and there needs to be updated documentation in the resident's medical record for coordination of care. The DON said not having the updated plan of care Resident #18 was at risk for not receiving the right meds or the right care. The DON said the hospice company was responsible for ensuring the hospice paperwork is up to date.<BR/>During an interview on 05/09/24 at 4:36 PM, the Regional Director said he expected the hospice provider to be updating notes, status updates, and any order changes in the resident's hospice binder. The Regional Director said he was unsure of when the hospice plan of care should be updated but not keeping them updated was lack of coordination of care. <BR/>During an interview on 05/09/24 at 10:16 AM, the DON said they did not have a policy on hospice services .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Record review of Resident #12's face sheet indicated an [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses which included Alzheimer's disease (memory loss), and atrioventricular block (heart beats more slowly) and dry eye syndrome (little moisture in the eye).<BR/>Record review of Resident #12's consolidated physician's orders, dated 03/04/2023 - 04/04/2024, indicated she was prescribed Restasis (dry eye medication) one drop to each eye twice daily for dry eye syndrome. <BR/>During an observation on 04/03/2023 at 10:45 a.m., the ADON provided Resident #12 with a tissue, and she wiped her nose. The ADON held Resident #12's right eye lid open with an ungloved hand and administered the Restasis eye medication in the resident's right eye. The ADON did not sanitize or perform hand hygiene before or after administering the eye drop with ungloved hands . The ADON held Resident #12's left eye open with an ungloved hand and administered the Restasis eye medication in the resident's left eye. The ADON used the same tissue Resident #12 used to clean her nose to dab around each of Resident #12's eyes with ungloved hands. <BR/>During an interview on 04/05/2023 at 3:14 p.m., the ADON said she should have used gloves during the administration of eye medications. The ADON said she was the infection preventionist. The ADON said touching Resident #12's eye lids barehanded could spread infection . The ADON said she should have sanitized her hands before applying gloves, and after removing gloves. <BR/>During an interview on 04/05/2023 at 3:30 p.m., the administrator said he expected eye drops to be administered with gloves to prevent any type of infection. <BR/>Record review of the facility's nursing policy and procedure Medication Administration, dated 01/2023, indicated the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. Eye Drops Procedure .3. Cleanse hands 4. Prevent tip of the eyedropper from touching the resident 6. While holding the bottle or tube in a vertical position and slightly to the side of the eye and about one-half inches above the eye, instill the ordered number of drops into the conjunctiva sac, or a ribbon of ointment along the lower conjunctiva from the inner to outer canthus. 7. Wipe excess medications from around the eye with tissue if needed.<BR/>Record review of the facility's policy Hand Washing, dated 01/2023, indicated . hand hygiene is the primary means to prevent the spread of infection . Employees must wash their hands for at least 20 seconds using antimicrobial or nonmicrobial soap and water under the following conditions .before and after assisting a resident with personal care after removing gloves .<BR/>Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 16 residents (Residents #5 and #23) reviewed for infection control practices.<BR/>1. CNA A failed to wash or sanitize her hands before, in between glove changes, and after performing peri care to Resident #5.<BR/>2. The facility failed to ensure the ADON used gloves when she administered Resident #23's eye medication.<BR/>3. The facility failed to ensure the ADON did not dry Resident #23's eyes with the same tissue used to clean Resident #23's nose.<BR/>These failures could place residents at risk for infections. <BR/>Findings included:<BR/>1. Record review of Resident #5's face sheet, dated 04/04/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia with behavioral disturbance (memory loss with behaviors), essential hypertension (high blood pressure), hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction affecting left non-dominant side (stroke affecting left side), and diabetes (a chronic condition that affects the way the body process blood sugar).<BR/>Record review of Resident #5's comprehensive care plan, dated 07/08/22, indicated Resident #5 was occasionally incontinent of bowel and bladder. The care plan interventions included incontinent checks to be performed approximately every 2-3 hours and perineal care to be given as needed.<BR/>Record review of Resident #5's quarterly MDS assessment, dated 02/23/23, indicated Resident #5 was usually understood and usually understood others. Resident #5 had a BIMS score of 6, which indicated he had severe cognitive impairment. Resident #5 required extensive assistance with two-person physical assist for bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Resident #5 was totally dependent with bathing. Resident #5 was always incontinent of urine and frequently incontinent of bowel. <BR/>During an observation on 04/03/23 at 09:26 a.m. revealed CNA A entered Resident #5's room to provide incontinent care. CNA A put on gloves and did not wash her hands prior to the start of care. CNA A obtained a package of disposable wipes, removed multiple wipes from the package, and placed them directly on the linen of Resident #5's bed. CNA A removed the soiled brief from Resident #5, removed her gloves and put on a new pair of gloves. CNA A failed to perform hand hygiene prior to putting on clean gloves. CNA A removed multiple wipes from the package and placed them directly on Resident #5's bed linen. CNA A continued to provide incontinent care to Resident #5. CNA A placed a clean brief on Resident #5 with same gloves. CNA A removed her gloves and put on clean gloves. CNA A did not perform hand hygiene in between glove changes and did not perform hand hygiene after the completion of care. <BR/>During an interview on 04/03/23 at 09:46 a.m., CNA A said she should have had performed hand hygiene before and after incontinent care and in between glove changes. CNA A said failure to perform hand hygiene could place Resident #5 at risk for infections. CNA A said she was responsible for performing hand hygiene. CNA A said she had been checked off on incontinent care and hand hygiene by the DON by return demonstration . <BR/>During an interview on 04/05/23 at 1:40 p.m., LVN C said she expected hand hygiene to be performed before and after care, before meals, after removing gloves and in between glove changes. LVN C said failure to perform hand hygiene placed residents at risk for infection. LVN C said everyone was responsible for ensuring hand hygiene was performed. LVN C said staff had hand hygiene and incontinent care competencies completed upon hire and yearly. <BR/>During an interview on 04/05/23 at 3:11 p.m., the ADON said she expected staff to perform hand hygiene before, after, in between care, and after changing gloves. The ADON said failure to perform hand hygiene placed the residents at risk for infection. <BR/>During an interview on 04/05/23 at 3:18 p.m., the administrator said he expected the staff to wash their hands before, after, and in between care. The administrator said he expected the staff to perform hand hygiene in between glove changes. The administrator said failure to perform hand hygiene between glove changes could place residents at risk for infection. <BR/>During an interview on 04/05/23 at 3:35 p.m., the DON said staff should wash their hands between soiled and clean tasks, and before and after completion of incontinent care. The DON said not performing hand hygiene could cause a break in infection control. The DON said everyone was responsible for ensuring hand hygiene was performed. <BR/>Record review of the CNA A's CNA Proficiency, dated 12/21/22, indicated skill for male perineal care was satisfactory. <BR/>Record review of the facility's policy Incontinent care/Perineal care with or without a catheter, dated 01/2023, indicated . It is the policy of this home to provide incontinent care to residents in a manner which provides privacy, promotes dignity and ensures no cross contamination .Beginning steps a. wash hands .Discard soiled gloves along with the soiled brief and/or wipes . wash hands with soap and water .sanitize hands and put on gloves .Re-glove prior to touching clean linens/adult brief .If gloved, remove and discard gloves following home guideline at the appropriate time to avoid environmental contamination. Sanitize hands

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic Zithromax was used despite criteria, to determine the appropriate use of an antibiotic for 1 of 6 residents (Residents #44) reviewed for antibiotic use. <BR/>The facility failed to ensure Resident #44 had documented signs and symptoms and diagnosis to support the use of prescribed antibiotic Zithromax.<BR/>This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections.<BR/>Findings included:<BR/>Record review of Resident #44's face sheet dated 05/08/24, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #44 had diagnoses of metabolic encephalopathy (problems with the metabolism that causes brain dysfunction), dementia (memory loss), history of diabetic foot ulcer (an open sore or wound on the foot that develop in patients type 1 or type 2 diabetes), and type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugars and using it for energy). <BR/>Record review of Resident #44's annual MDS assessment dated [DATE], indicated he was usually understood and understood others. The MDS assessment indicated Resident #44 had a BIMS score of 10, indicating his cognition was moderately impaired.<BR/>Record review of Resident #44's physician order report dated 05/01/24-05/08/24 did not indicate the order for the antibiotic Zithromax since medication had been completed.<BR/>Record review of Resident #44's comprehensive care plan on 05/09/23, did not address the antibiotic Zithromax since Resident #44 was no longer taking it.<BR/>Record review of Resident #44's skilled nurses note dated 04/25/24, indicated Resident #44 did not have a fever, cough, or an upper respiratory infection. The nurses note indicated . New order: Zpak (Zithromax) + Medrol pack. The note did not indicate the signs or symptoms Resident #44 was having to warrant the use of the antibiotic. <BR/>Record review of Resident #44's progress note dated 04/26/24 at 01:57 PM, indicated . the resident has not had any cough today. Lungs are clear to auscultation .<BR/>Record review of Resident #44's progress note dated 04/27/24 at 12:20 AM, indicated . no cough or congestion heard at this time.<BR/>Record review of Resident #44's progress note dated 04/28/24 at 12:21 AM, indicated . no cough or congestion heard at this time.<BR/>Record review of Resident #44's medication administration history dated 04/01/24- 04/30/24, indicated he had received Zithromax 250mg 2 tablets on 04/26/24 and Zithromax 250mg one tablet from 04/27/24-04/30/24 . <BR/>During an interview on 05/09/24 at 3:26 PM, RN B said Resident #44 started a Zpak on 4/25/24 because he was having a cough, congested and symptoms of respiratory infection. RN B reviewed Resident #44's progress notes and she said Resident #44's progress notes did not indicate he was having symptoms of URI and said it should have been documented. RN B said the nurse that spoke with the physician and obtained the order was responsible for documenting findings that warranted the use of the antibiotic Zithromax. <BR/>During an interview on 05/09/24 at 3:50 PM, the DON said Resident #44 should have had documentation in the progress notes if he was having any symptoms that warranted the use of the antibiotic Zithromax. The DON reviewed Resident #44's order and said Resident #44 started the antibiotic for a cough but there was no other solid documentation Resident #44 as to why Resident #44 started the antibiotic Zithromax. The DON said they should have documented signs and symptoms along with MD notification and follow up orders. The DON said the nurse who notified the MD was responsible for ensuring documentation for the antibiotic use. The DON said since there was no documentation regarding the need for antibiotic Resident #44 was a risk for receiving an unnecessary medication. The DON said they followed the antibiotic stewardship process. The DON said the ADON was the infection preventionist and was responsible for monitoring the antibiotic stewardship program at the facility. The DON said the ADON was on leave.<BR/>During an interview on 05/09/24 at 04:36 PM, the Regional Director said if a resident was having signs and symptoms that warranted an antibiotic, a call to the physician should be made and an assessment completed. The Regional Director said not having proper documentation could place the resident at risk of an unwarranted order. The Regional Director said nurse management was responsible for ensuring proper documentation was in place and monitoring the antibiotic stewardship program at the facility. <BR/>Record review of the facility's policy titled, Antibiotic Stewardship, dated 12/01/18, indicated . The facility will establish a multidisciplinary antimicrobial stewardship program (ASP) that defines and provides guidance for optimal antimicrobial use 5. When facility staff suspects a resident has an infection, the nurse should perform and document a complete assessment of the resident using established and accepted assessment protocol to determine if the resident status meets minimum criteria for initiating antibiotics. This facility uses McGreers Criteria for Initiation of Antibiotics in Long-Term Care Residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's representative immediately when there was an accident or significant change in the resident's physical, mental, or psychosocial status that is, a deterioration of health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 2 of 9 residents (Resident #9 and Resident #39) reviewed for notification of changes.<BR/>The facility failed to notify Resident #9's representative when Resident #9 sustained a fall on 02/18/2024.<BR/>The facility failed to notify Resident #39's representative when Resident #39 sustained a fall on 03/31/2024.<BR/>This failure placed residents' at risk of not having their representative being aware of any changes in their conditions and could result in delay in treatment and decline in residents' health and well-being.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 05/07/2024 indicated, Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia with other behavioral disturbance (a condition in which a person loses the ability to think, remember, learn and make decisions and solve problems), weakness, vitamin D deficiency, major depressive disorder (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities), urinary tract infection, acute respiratory disease (occurs when your lungs cannot release enough oxygen into your blood), hypertension (high blood pressure). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #9 was understood and was able to understand others. The MDS assessment indicated Resident #9 had a BIMS score of 04, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #9 required maximal assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. <BR/>Record review of the care plan with a target date of 07/31/2024 indicated, Resident #9 required staff assistance with ADL's.<BR/>Record review of Resident #9's progress note dated 02/18/2024 at 05:15 PM and signed by RN B indicated Resident #9 had an unwitnessed fall and noted a scratched eyebrow and applied hydrocolloid dressing and neurological checks started . Neurological checks was completed for 72 hours. The Skin Assessment was completed. The progress note did not indicate Resident #9's family member had been notified of the fall or new areas of injuries. <BR/>Record review of a face sheet dated 05/08/2024 indicated, Resident #39 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia with other behavioral disturbance (a condition in which a person loses the ability to think, remember, learn and make decisions and solve problems), hypertension (high blood pressure), major depressive disorder (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities), insomnia (a sleep disorder), cognitive communication deficit (difficulty with thinking and how someone uses language), Alzheimer's disease (a progress disease that destroys memory and other important mental function) with late onset. <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #39 was understood and was able to understand others. The MDS assessment indicated Resident #39 had a BIMS score of 05, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #39 required supervision or touching assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and maximal assistance for bathing. <BR/>Record review of the care plan with a target date of 07/31/2024 indicated, Resident #39 had an actual fall had potential for injury related to falls with interventions for physical therapy, occupational therapy, encourage exercise, well-fitting shoes and placing call light in reach. <BR/>Record review of Resident #39's progress note dated 03/31/2024 at 6:30 AM and signed by RN B indicated Resident #39 had an unwitnessed fall and noted a small bump to left forehead and bruising under eyes with neurological checks started. The Skin Assessment was completed. Neurological checks was completed for 72 hours. The progress note did not indicate Resident #39's family member had been notified of the fall or new areas of injuries. <BR/>During an interview on 05/06/2024 at 03:43 PM, Resident #9's family member said they were not notified by the facility regarding the unwitnessed fall on 02/18/2024.<BR/>During an interview on 05/07/2024 at 01:10 PM, Resident #39's family member said they were not notified by the facility regarding the unwitnessed fall on 03/31/2024.<BR/>During an interview on 05/07/2024 at 3:05 PM, RN B said she failed to notify the family members of Resident #9 and Resident #39 because there was so much to be done with all the paperwork and she forgot. RN B said family should be notified to prevent any issues, delays in treatments and serve as coordination of care.<BR/>During an interview on 05/08/2024 at 04:00 PM, the DON said Resident #9 and Resident #39's family should have been notified regarding the falls at the time of the occurrence. The DON said the progress note did not indicate Resident #9's family was notified of the fall on 2/18/2024. The DON said the progress note did not indicate Resident #39's family was notified of the fall on 3/31/2024. The DON said the family members of both Residents #9 and #39 should have been notified of the falls because it was a change in condition, and they should have been made aware of new areas of concerns, orders, etc. The DON said it was the responsibility of the charge nurse to notify the family of any changes of condition of the residents. The DON said she gave an inservice regarding notifications to physicians and families when there has been an accident/change in condition.<BR/>During an interview on 05/09/2024 at 04:22 PM, the Regional Director said he expected the resident's representatives to be notified of any changes in the resident's care. The Regional Director said he expected the staff to document the notification of the family. The Regional Director said Resident #9 and Resident #39's family should have been notified of the fall and orders because the residents' family could come in, see, and suspect the residents were being abused. The Regional Director said the charge nurse was responsible for notifying the resident's representative. The Regional Director said he was unsure if there was a system in place to monitor if resident's representatives where being notified of any changes in condition or new orders.<BR/>Record review of the facility's policy Change of Condition - Observing, Reporting and Recording effective December 2018 indicated . 5. Notify resident's responsible party . 3. Document in the clinical software who was notified and when.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 1 of 9 residents (Resident #9's) and 1 of 1 dining rooms reviewed for a homelike environment.<BR/>The facility failed to ensure Resident #9's bathroom was free of offensive odors and unbroken and misshaped tiles around the base of the toilet. <BR/>The facility failed to ensure the dining room did not have plastic, folding tables used as dining tables.<BR/>This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 05/07/2024 indicated, Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia with other behavioral disturbance (a condition in which a person loses the ability to think, remember, learn and make decisions and solve problems), weakness, vitamin D deficiency, major depressive disorder (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities), urinary tract infection, acute respiratory disease , hypertension (high blood pressure). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #9 was understood and was able to understand others. The MDS assessment indicated Resident #9 had a BIMS score of 04, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #9 required maximal assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. <BR/>Record review of the care plan with a target date of 07/31/2024 indicated, Resident #9 required staff assistance with ADL's. <BR/>During an observation on 05/06/2024 at 09:20 AM, upon entrance of Resident #9's room a strong odor of urine was detected in the bathroom area. The floor tiles around the base of the toilet were broken and misshaped and exposed large areas of grout. <BR/>During an observation on 05/06/2024 at 11:30 AM, there was a strong odor of urine in Resident # 9's bathroom.<BR/>During an observation on 05/06/2024 at 2:35 PM, there was a strong odor of urine in Resident # 9's bathroom . Resident #9 was in the room asleep at this time.<BR/>During an interview on 05/07/2024 at 1:32 PM., RN G said on occasion he had noticed the urine odor in Resident #9's bathroom. RN G said there had been water leaks around the toilets in a couple of the rooms recently and he had noticed the tile had peeled up and was exposing areas of grout. In Resident #9's bathroom, RN G said the maintenance supervisor was aware of broken and peeled up tiles because they had discussed this on different occasions over the last month or so when there was some plumbing issues in the unit. RN G said he was not aware of the status of repairs. RN G said the urine odor could be absorbed in the exposed grout. RN G said the smell of urine and the broken tiles was not a welcoming environment for the resident's family. <BR/>During an interview on 05/08/24 at 9:23 AM., Housekeeping Aide O said she smelled urine odor in Resident #9's room. Housekeeping Aide O said she usually cleans the rooms once daily for a deep clean then does a walk through in the evenings. She said she used the chemicals she was able to use when cleaning Resident #9's bathroom. She said she saw the bathroom floor tiles peeling from around the toilet in Resident #9's bathroom. She said she had not placed a work order for maintenance but said she thought the maintenance supervisor was aware . She said she would clean Resident #9's room next. Housekeeping Aide O said she told the Maintenance Supervisor in person at some point weeks ago but she could also put the needed repair in the maintenance work order book. <BR/>During an interview on 05/08/2024 at 2:24 PM., the Maintenance Supervisor said he was aware of the tiles in Resident #9's bathroom that were broken, misshaped and revealed areas of grout. The Maintenance Supervisor said the facility had experienced some plumbing issues that had been caused by wipes and briefs being flushed and had clogged in the system. The Maintenance Supervisor said all the plumbing repairs had been completed and he did not feel like there was any type of leakage currently that had caused the strong urine odor in Resident #9's bathroom unless it had absorbed in the grout during the recent plumbing issues. The Maintenance Supervisor said there is a written plan to complete the renovation for the peeled-up tiles in the bathroom, but he was awaiting the approval to proceed. The Maintenance Supervisor said it was his responsibility to ensure the facility created a home like environment for the residents. <BR/>During an interview on 05/08/2024 at 04:00 PM, the DON said she had not noticed the offensive odors or the broken/peeled-up tiles in Resident #9's bathroom and she did not recall being in Resident #9's room lately. The DON said she expected the housekeeping staff to fully clean all resident's bathrooms daily to alleviate odors. The DON said all the staff should be making sure the facility did not have offensive odors. The DON said she expected the Maintenance Supervisor to maintain the facility to create a home-like environment. The DON said she felt like there was a plan of renovation for the flooring repairs, but she would need to verify that with the Maintenance Supervisor and Administrator. The DON said it was important to keep the facility free of offensive odors and it was important to provide the residents with a clean and safe environment. <BR/>During an interview on 05/09/2024 at 04:22 PM, the Regional Director said all the staff were responsible for making sure there were no offensive odors in the facility. The Regional Director said he expected for the staff to provide a homelike environment for the residents. <BR/>2. During an observation on 05/06/2024 at 12:15 PM, approximately 17 residents were seated at the plastic, folding tables in the dining room. The arms of the wheelchair were unable to fit appropriately under the table to allow proper positioning for eating comfortably. <BR/>During an observation on 05/07/2024 at 12:15 PM, approximately 17 residents were seated at plastic, folding tables in the dining room. The arms of the wheelchair were unable to fit appropriately under the table to allow the resident proper positioning for eating comfortably. <BR/>During an observation on 05/08/2024 at 12:15 PM, approximately 17 residents were seated at plastic, folding tables in the dining room. The arms of the wheelchair were unable to fit appropriately under the table to allow the resident proper positioning for eating comfortably. <BR/>During an observation on 05/09/2024 at 12:15 PM, approximately 17 residents were seated at plastic, folding tables in the dining room. The arms of the wheelchair were unable to fit appropriately under the table to allow the residents proper positioning for eating comfortably. <BR/>During an interview on 05/09/2024 at 1:30 PM, LVN A said it had been several months that the dining room was provided with the plastic, folding tables and the other wooden tables had been removed. LVN A said the plastic, folding tables were institutional like and did not enhance the dining experience for the residents due to the cumbersome fit of the wheelchairs at the tables. <BR/>During an interview on 05/09/2024 at 04:30 PM, the Regional Director said the plastic, folding tables were not homelike. The Regional Director said he had intentions of purchasing better tables for the dining area and the more homelike tables were in his basket of things to do. <BR/>During an interview on 05/09/2024 at 09:24 AM, the DON said the facility does not have a policy regarding homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's representative immediately when there was an accident or significant change in the resident's physical, mental, or psychosocial status that is, a deterioration of health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 2 of 9 residents (Resident #9 and Resident #39) reviewed for notification of changes.<BR/>The facility failed to notify Resident #9's representative when Resident #9 sustained a fall on 02/18/2024.<BR/>The facility failed to notify Resident #39's representative when Resident #39 sustained a fall on 03/31/2024.<BR/>This failure placed residents' at risk of not having their representative being aware of any changes in their conditions and could result in delay in treatment and decline in residents' health and well-being.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 05/07/2024 indicated, Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia with other behavioral disturbance (a condition in which a person loses the ability to think, remember, learn and make decisions and solve problems), weakness, vitamin D deficiency, major depressive disorder (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities), urinary tract infection, acute respiratory disease (occurs when your lungs cannot release enough oxygen into your blood), hypertension (high blood pressure). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #9 was understood and was able to understand others. The MDS assessment indicated Resident #9 had a BIMS score of 04, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #9 required maximal assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. <BR/>Record review of the care plan with a target date of 07/31/2024 indicated, Resident #9 required staff assistance with ADL's.<BR/>Record review of Resident #9's progress note dated 02/18/2024 at 05:15 PM and signed by RN B indicated Resident #9 had an unwitnessed fall and noted a scratched eyebrow and applied hydrocolloid dressing and neurological checks started . Neurological checks was completed for 72 hours. The Skin Assessment was completed. The progress note did not indicate Resident #9's family member had been notified of the fall or new areas of injuries. <BR/>Record review of a face sheet dated 05/08/2024 indicated, Resident #39 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia with other behavioral disturbance (a condition in which a person loses the ability to think, remember, learn and make decisions and solve problems), hypertension (high blood pressure), major depressive disorder (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities), insomnia (a sleep disorder), cognitive communication deficit (difficulty with thinking and how someone uses language), Alzheimer's disease (a progress disease that destroys memory and other important mental function) with late onset. <BR/>Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #39 was understood and was able to understand others. The MDS assessment indicated Resident #39 had a BIMS score of 05, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #39 required supervision or touching assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and maximal assistance for bathing. <BR/>Record review of the care plan with a target date of 07/31/2024 indicated, Resident #39 had an actual fall had potential for injury related to falls with interventions for physical therapy, occupational therapy, encourage exercise, well-fitting shoes and placing call light in reach. <BR/>Record review of Resident #39's progress note dated 03/31/2024 at 6:30 AM and signed by RN B indicated Resident #39 had an unwitnessed fall and noted a small bump to left forehead and bruising under eyes with neurological checks started. The Skin Assessment was completed. Neurological checks was completed for 72 hours. The progress note did not indicate Resident #39's family member had been notified of the fall or new areas of injuries. <BR/>During an interview on 05/06/2024 at 03:43 PM, Resident #9's family member said they were not notified by the facility regarding the unwitnessed fall on 02/18/2024.<BR/>During an interview on 05/07/2024 at 01:10 PM, Resident #39's family member said they were not notified by the facility regarding the unwitnessed fall on 03/31/2024.<BR/>During an interview on 05/07/2024 at 3:05 PM, RN B said she failed to notify the family members of Resident #9 and Resident #39 because there was so much to be done with all the paperwork and she forgot. RN B said family should be notified to prevent any issues, delays in treatments and serve as coordination of care.<BR/>During an interview on 05/08/2024 at 04:00 PM, the DON said Resident #9 and Resident #39's family should have been notified regarding the falls at the time of the occurrence. The DON said the progress note did not indicate Resident #9's family was notified of the fall on 2/18/2024. The DON said the progress note did not indicate Resident #39's family was notified of the fall on 3/31/2024. The DON said the family members of both Residents #9 and #39 should have been notified of the falls because it was a change in condition, and they should have been made aware of new areas of concerns, orders, etc. The DON said it was the responsibility of the charge nurse to notify the family of any changes of condition of the residents. The DON said she gave an inservice regarding notifications to physicians and families when there has been an accident/change in condition.<BR/>During an interview on 05/09/2024 at 04:22 PM, the Regional Director said he expected the resident's representatives to be notified of any changes in the resident's care. The Regional Director said he expected the staff to document the notification of the family. The Regional Director said Resident #9 and Resident #39's family should have been notified of the fall and orders because the residents' family could come in, see, and suspect the residents were being abused. The Regional Director said the charge nurse was responsible for notifying the resident's representative. The Regional Director said he was unsure if there was a system in place to monitor if resident's representatives where being notified of any changes in condition or new orders.<BR/>Record review of the facility's policy Change of Condition - Observing, Reporting and Recording effective December 2018 indicated . 5. Notify resident's responsible party . 3. Document in the clinical software who was notified and when.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 4 of 6 (Resident #40, Resident #33, Resident #4 and Resident #23) residents reviewed for the care plan.<BR/>1. The facility failed to care plan Resident #40 needs to be in the secure unit <BR/>2. The facility failed to care plan or write an order for Resident #33's to be in the secure unit. The facility failed to care plan Resident #33 was a smoker.<BR/>3. The facility failed to ensure Resident #4's comprehensive care plan addressed she received a prophylactic antibiotic.<BR/>4. The facility failed to ensure Resident #23's comprehensive care plan was person-centered to include his diagnosis of PTSD and any triggers he had.<BR/>These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.<BR/>The findings included:<BR/>1.Record review of Resident #40's face sheet, dated 05/07/24, indicated Resident #40 was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #40 had diagnoses which included Dementia (loss of memory), Depression (sadness), and Paranoid Schizophrenia (a kind of psychosis, which means your mind does not agree with reality). <BR/>Record review of Resident #40's quarterly MDS assessment, dated 03/14/24, indicated Resident #40 was sometimes understood and sometimes understood by others. Resident #40's BIMS score was 07, which indicated he was moderately cognitively impaired. Resident #40 required extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, and supervision with eating. <BR/>Record review of Resident #40's Elopement/Wandering Observation dated 02/27/24 indicated Resident #40 was at high risk of elopement.<BR/>Record review of Resident #40's physician orders dated 12/19/22, indicated resident to reside in the secure unit related to wandering and elopement risk. <BR/>Record review of Resident #40's comprehensive care plan dated 09/22/21 did not indicate any plan of care or interventions for the secure unit. <BR/>During an observation on 05/06/24 at 10:00 a.m., Resident #40 was sitting at the dining room table in the secure unit.<BR/>2. Record review of Resident #33's face sheet, dated 05/07/24, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included stroke, Parkinson's (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), and Paranoid Schizophrenia (a kind of psychosis, which means your mind doesn't agree with reality).<BR/>Record review of Resident #33's quarterly MDS assessment, dated 03/22/24, indicated Resident #33 was rarely understood and sometimes understood by others and his BIMS was a 04, indicating severe cognition impairment. The MDS assessment indicated he had short and long-term memory problems. Resident #33 required assistance with bathing, dressing, bed mobility, personal hygiene, toileting, and setting up for eating. <BR/>Record review of Resident #33's Elopement/Wandering Observation dated 02/26/24 indicated Resident was at a low risk of elopement.<BR/>Record review of Resident #33's Smoking assessment dated [DATE] indicated Resident #33 was a smoker. <BR/>Record review of Resident #33's physician orders dated 05/07/24, did not indicate an order for the secure unit.<BR/>Record review of Resident #33's comprehensive care plan, dated 03/24/24, did not indicate any plan of care or interventions for the secure unit. <BR/>Record review of Resident #33's comprehensive care plan, dated 03/24/24, did not indicate any plan of care or interventions for smoking.<BR/>During an observation on 05/06/24 at 10:31 a.m., Resident #33 was outside smoking with staff.<BR/>During an observation on 05/06/24 at 12:15 p.m., Resident #33 was walking down the hallway in the secure unit.<BR/>During an interview on 05/09/24 at 9:49 a.m., RN G said Resident #33 was a resident who smoked and resided in the unit. RN G said if a resident was on the secure unit, they should have an order indicating they needed to be in the unit and it should be care planned. RN G said the nurses were responsible for writing an order to admit to the secure unit. He said the MDS nurse or nurse management did the care plans. <BR/>During an observation and interview on 05/09/24 at 6:06 p.m., the MDS nurse said she was responsible for the comprehensive care plans, but all the department heads did their acute care plans. The surveyor observed the MDS nurse look in the electronic records for Resident #40 and Resident #33. She said she did not see a care plan for the secure unit on Resident #40 or Resident #33. She said she did not see a smoking care plan for Resident #33. The MDS nurse said the reason for being in the secure unit and interventions should have been listed on Resident #40's and Resident #33's care plan. She said Resident #33 should have had a smoking care plan because he smoked. The MDS nurse said they discussed orders, changes in the resident's condition in the morning meetings, and any changes that should have been made to their care plan. She said she did not know how she failed to care plan for both residents. She said care plans were done to address concerns, she said it was like a road map for their care. <BR/>During an interview on 05/09/24 at 6:39 p.m., the DON said the MDS nurse was responsible for completing the care plans but all department heads did care plans. She said during morning meetings she would review orders, progress notes, 24-hour reports, and incidents to ensure things had been added or discontinued from the care plan. She said she was the overseer. She said Resident #40 and Resident #33's nurses should have written orders for the secure unit when they were admitted to the unit. The DON said she was not aware that Resident #40 and Resident #33 had missed care plans. She said care plans were done to ensure the residents were getting the appropriate care.<BR/>3. Record review of Resident #4's face sheet dated 05/07/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4's diagnoses included dementia (memory loss), depression (persistent depressed mood), and urinary tract infection (an infection in any part of the urinary system).<BR/>Record review of Resident #4's quarterly MDS assessment dated [DATE], indicated she was sometimes understood and sometimes understood others. The MDS assessment indicated Resident #4 had a BIMS score of 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #4 had taking antibiotic within the last 7 days of the look back period. <BR/>Record review of Resident #4's comprehensive care plan dated 03/20/24 did not indicate Resident #4 was taking Macrodantin or a prophylactic antibiotic daily. <BR/>Record review of Resident #4's physician order report dated 05/01/24- 05/07/24, indicated Resident #4 had an order for Macrodantin (antibiotic to treat and prevent urinary tract infections) 50mg one tablet daily for prophylaxis (preventative) with a start date of 01/04/23. <BR/>Record review of Resident #4's medication administration history dated 05/01/24-05/09/24, indicated she had been receiving macrodantin 50mg one capsule daily.<BR/>4. Record review of Resident #23's face sheet dated 05/08/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugars and using it for energy), post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), hypertensive heart disease (heart condition due to untreated high blood pressure) and paraplegia (leg paralysis).<BR/>Record review of Resident #23's admission MDS assessment dated [DATE], indicated was usually understood and was able to understand others. The MDS assessment indicated Resident #23's BIMS score was a 9, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #23 had diagnoses of post-traumatic stress disorder. <BR/>Record review of Resident #23's comprehensive care plan dated 04/05/24, did not indicate Resident #23 had a diagnosis of PTSD or if he had any triggers.<BR/>During an interview on 05/07/24 at 10:59 AM Resident #23 said he had PTSD from Vietnam and Kuwait wars. Resident #23 said loud noises was his trigger.<BR/>During an interview on 05/09/24 at 3:50 PM, the DON said Resident #4's prophylactic antibiotic and Resident #23's diagnoses of PTSD should have had been care planned. The DON said they should have been care planned so staff would know Resident #4 was taking an antibiotic long term and Resident #23 had a diagnosis of PTSD with any triggers he had. The DON said the nurse leadership was responsible for ensuring the care plans were updated. The DON said since Resident #4's antibiotic and Resident #23's PTSD diagnoses were not care planned, the care plan was not accurate. <BR/>During an interview on 05/09/24 at 04:36 PM the Regional Clinical Consultant said Resident #4 care plan should reflect Resident #4 was receiving antibiotics as ordered as they do not name the medication. The Regional Clinical Consultant said Resident #23's diagnoses of PTSD should have been on his care plan with any triggers he had. The Regional Clinical Consultant said she expected the care plans to be updated timely. The Regional Clinical Consultant said nursing leadership was responsible for updating the care plans.<BR/>Record review of the facility's policy titled Care Plan dated 12/2018, indicated . It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident . 4. Concerns and Problems . 1. The specific problem as well as the underlying cause should be listed .b. sources are but are not limited to: 1. problems relating to diagnoses .8. Problems related to preventative care .10. All problems identified on all assessments .the resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate and planned to meet the individual needs of the resident consistent with the physician's plan of care for the resident .the resident care plan must be kept current at all times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 4 of 8 residents (Residents #11, #54, #50, and #55) reviewed for pharmacy services.<BR/>1. The facility failed to ensure MA K administered Resident #11's Clindamycin (antibiotic), Eliquis (anticoagulant), Keppra (antiseizure), and Vimpat (antiseizure) timely as ordered at 8:30 a.m.<BR/>2. The facility failed to ensure MA K administered Resident #54's Tylenol (pain medication), Coreg (blood pressure), Gabapentin (used to treat pain), and Isosorbide (blood pressure) timely as ordered at 8:30 a.m.<BR/>3. The facility failed to ensure MA K administered Resident #50's Tylenol (pain reliever), timely as ordered at 8:30 a.m.<BR/>4. The facility failed to ensure MA K administered Resident #55's oxcarbazepine (antiseizure) timely as ordered at 9:00 a.m. <BR/>This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.<BR/>Findings included:<BR/>1) Record review of a face sheet dated 5/08/2024 indicated Resident #11 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of seizures, anxiety, high blood pressure and depression.<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #11 was sometimes understood and usually understands. Resident #11's BIMs score was a 5 indicating she had severe cognitive impairment.<BR/>Record review of the comprehensive care plan dated 10/06/2023 indicated Resident #11 was on anticoagulant therapy for a diagnosis of a blood clot. The goal of the care plan was Resident #11 would be free from discomfort. The care plan interventions included Resident #11 would receive her medication as ordered. Resident #11 was care planned for a seizure disorder. The care plan goal indicated Resident #11 would be from injury from seizure activity. The care plan intervention included to give the medications as ordered. The care plan indicated Resident #11 had a potential for side effects related to use of anti-depressants. The goal of the care plan indicated Resident #11 would not have any signs and symptoms of depression. The interventions for the care plan included to administer the medication for the condition.<BR/>During an observation on 5/06/2024 at 10:00 a.m., MA K prepared and administered Resident #11's medications for administration.<BR/>Clindamycin (antibiotic) 300 milligrams one, <BR/>Eliquis (anti-coagulant) 5 milligrams one, <BR/>Keppra (anti-seizure) 500 milligrams one, and<BR/>Vimpat (anti-seizure). <BR/>Record review of the consolidated physician's orders dated 5/01/2024 - 5/08/2024 indicated Resident #11 was ordered:<BR/>Clindamycin(antibiotic) capsules 300 milligrams one capsule three times a day 8:30 a.m., 2:00 p.m., and 8:00 p.m.<BR/>Eliquis (anti-coagulant) 5 milligrams one tablet twice a day at 8:30 a.m. and 8:00 p.m.<BR/>Keppra (anti-seizure) 500 milligrams one tablet at 8:30 a.m.<BR/>Vimpat (anti-seizure) 150 milligrams one tablet daily at 9:00 a.m.<BR/>Record review of the Medication Administration History Report dated 5/06/2024 indicated Resident #11 received her medications as listed:<BR/>Clindamycin 300 milligrams one capsule at 10:31 a.m.<BR/>Eliquis 5 milligrams one tablet at 10:31 a.m.<BR/>Keppra 500 milligrams one tablet at 10:31 a.m.<BR/>Vimpat 150 milligrams one tablet at 10:31 a.m.<BR/>2) Record review of a face sheet dated 5/08/2024 indicated Resident #54 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of chronic pain, and high blood pressure.<BR/>Record review of an admission MDS dated [DATE] indicated Resident #54 was usually understood and understands. The MDS indicated Resident #54's BIMs score was a 9 indicating moderately impaired cognition. <BR/>Record review of a comprehensive care plan indicated Resident #54had a diagnosis of high blood pressure with a goal of the blood pressure would remain within normal limits. The care plan interventions included administer medications as ordered. The comprehensive care plan indicated Resident #54 requires pain management. The goal of the care plan was Resident #54 would have her pain controlled. The interventions included to administer the medications for the condition as ordered. The comprehensive care plan indicated Resident #54 used an anti-depressant. The goal was Resident #54 would not have any signs of depression. The interventions included to administer the medication for the condition as ordered.<BR/>Record review of the consolidated physician's orders date 5/01/2024 - 5/08/2024 indicated Resident #54 was ordered:<BR/>Tylenol (pain medication) 650 milligrams one tablet three times a day at 8:30 a.m., 2:00 p.m., and 8:00 p.m.<BR/>Coreg (high blood pressure) 12.5 milligrams one tablet twice daily at 8:30 a.m., and 8:00 p.m.<BR/>Gabapentin (pain medication) 300 milligrams one capsule 4 times daily at 8:30 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m.<BR/>Isosorbide ER (high blood pressure) 30 milligrams one tablet daily at 8:30 a.m.<BR/>During an observation on 5/06/2024 at 10:22 a.m., MA K prepared and administered Resident #54's medications as follows: <BR/>Tylenol (mild pain reliever) 650 milligrams one<BR/>Coreg (high blood pressure) 12.5 milligrams one<BR/>Gabapentin (pain medication) 300 milligrams one<BR/>Isosorbide ER (high blood pressure) 30 milligrams one<BR/>Record review of the Medications Administration History dated 5/06/2024 indicated Resident #54 received her medications as listed:<BR/>Tylenol 650 milligrams one tablet administered at 10:31 a.m.<BR/>Coreg 12.5 mg one tablet administered at 10:31 a.m.<BR/>Gabapentin 300 milligrams one capsule administered 10:32 a.m.<BR/>Isosorbide ER 30 milligrams one tablet administered at 10:31 a.m.<BR/>3) Record review of a face sheet dated 5/08/2024 indicated Resident #50 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of stroke, kidney disease, and anxiety.<BR/>Record review of the admission MDS dated [DATE] indicated Resident #50 was usually understood and usually understands. The MDS indicated Resident #50 had moderate cognitive impairment.<BR/>Record review of the comprehensive care plan dated 3/08/2024 indicated Resident #50 had occasional generalized discomfort and the goal of the care plan was Resident #50's pain would be controlled. The intervention of the care plan included to administer the medication for the condition. <BR/>During an observation and interview on 5/06/2024 at 10:34 a.m., MA K prepared Resident #50's medications for administration as indicated:<BR/>Tylenol (mild pain reliever) 500 milligrams two caps<BR/>Record review of the consolidated physician's orders dated 5/01/2024 - 5/08/2024 indicated Resident #50 was ordered:<BR/>Tylenol (mild pain reliever) 500 milligrams 2 tablets twice a day at 8:30 a.m. and 8:00 p.m.<BR/>Record review of the Medication Administration History dated 5/06/2024 indicated Resident #50 received:<BR/>Tylenol 500 milligrams 2 tablets at 10:44 a.m.<BR/>4) Record review of a face sheet dated 5/08/2024 indicated Resident #55 was an [AGE] year-old-male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), Bi-polar disorder (mental illness), and pain.<BR/>Record review of a Quarterly MDS dated [DATE] indicated Resident #50 was usually understood and usually understands. The MDS indicated Resident #50 had moderate cognitive impairment.<BR/>Record review of the comprehensive care plan dated 9/25/2023 indicated Resident #50 had a diagnosis of depression and the goal of the care plan was he would remain free of symptoms of depression. The interventions included to administer the medications as ordered. <BR/>Record review of the consolidated physician's orders dated 5/01/2024 - 5/08/2024 indicated Resident #50 was ordered:<BR/>Oxcarbazepine 150 milligrams one tablet twice a day at 9:00 a.m. and 9:00 p.m.<BR/>During an observation on 5/06/2024 at 10:50 a.m., MA K prepared and administered Resident #55's medications as follows:<BR/>Oxcarbazepine (anti-seizure) 150 milligrams one<BR/>Record review of the medications Administration History dated 5/06/2024 indicated Resident #50 received:<BR/>Oxcarbazepine 150 milligrams one tablet administered at 10:53 a.m.<BR/>MA K said Resident #55's medications were late for administration because she was called in to work and arrived around 6:35 a.m., instead of 6:00 a.m. MA K said 6:00 a.m. - 2:00 p.m. was not her normal shift to work.<BR/>During an interview on 5/09/2024 at 11:51 a.m., the DON said she expected the medications to be administered as scheduled. The DON said residents could suffer adverse effects when the medications were not administered timely. The DON said she was new to the facility and was not aware there was a report to monitor the timeliness of medication administration until the surveyor asked for such a report. The DON said she was responsible for monitoring to ensure medications were passed timely along with the nurses. <BR/>During an interview on 5/09/2024 at 1:00 p.m., the RDO said he expected the medications to be administered within the time allotted and based on the physician's orders. The RDO said when medications were not administered timely the effectiveness of the medication could be affected. The RDO said the DON and nursing was responsible for ensuring the medications were passed timely. The RDO said random checks was a way medications administration could be monitored. <BR/>During an interview on 5/09/2024 at 2:42 p.m., MA K said the medications were passed late due to her arriving late to cover the open shift. MA K said this was a usual occurrence and has happened often. MA K said late administration of medications could cause symptoms to increase. <BR/>During an interview on 5/09/2024 at 2:52 p.m., RN B said she expected the medications to be administered according to the schedule to ensure effectiveness. RN B said someone's pain level or blood pressure in particularly could be affected.<BR/>Record review of a Medication-Administration policy dated 12/2017 indicated it was the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations .8. Medications are administered within 60 minutes of the scheduled time, unless otherwise specified by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 22 residents (Resident #10) reviewed for resident records. <BR/>The facility failed to accurately update Resident #10's comprehensive care plan with her code status.<BR/>This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, psychosocial outcome and inaccurate medical records.<BR/>Findings included:<BR/>Record review of Resident #10's face sheet dated [DATE], indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Alzheimer's (a progress disease that destroys memory and other important mental functions), atrial fibrillation (irregular often rapid heart rate that commonly causes poor blood flow), depression (persistent depressed mood), and anxiety.<BR/>Record review of Resident #10's significant change in status MDS assessment dated [DATE], indicated Resident #10 was usually understood and usually understood others. The MDS assessment indicated Resident #10's BIMS score was a 5, which indicated her cognition was severely impaired.<BR/>Record review of Resident #10's comprehensive care plan dated [DATE], indicated Resident #10 was a full code CPR order in place. The care plan interventions indicated to review medical record to ensure that proper documents were signed. <BR/>Record review of Resident #10's physician order report dated [DATE]-[DATE], indicated Resident #10 had an order for code status DNR (do not resuscitate) with a start date of [DATE] . <BR/>Record review of Resident #10's Out of Hospital Do-Not-Resuscitate (OOH-DNR) order indicated Resident #10's family member had signed the order on [DATE] and was notarized. The OOH-DNR order indicated the physician had signed the order on [DATE].<BR/>During an interview on [DATE] at 3:50 PM, the DON said Resident #10 comprehensive care plan should have been updated to indicate her code status had changed from full code to DNR whenever they received the order for DNR. The DON said nurse leadership was responsible for updating the care plans. The DON said failure to update Resident #10's care plan could place Resident #10 at risk for receiving CPR. The DON said that was not something they would have want to happen since Resident #10 had a DNR.<BR/>During an interview on [DATE] at 05:23 PM, the Regional Clinical Consultant said she expected the care plans to updated timely. The Regional Clinical Consultant said Resident #10's care plan should have reflected the updated code status so plan of care was appropriate. The Regional Clinical Consultant said nursing leadership was responsible for updating the care plans. <BR/>Record review of the facility's policy titled Care Plan dated 12/2018, indicated . It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident .10. To update the resident care plan . changes and dated on problems per home policy . if the entry must be changed significantly, the plan will look neater if the entry is lined out and reference made to the new entry .the resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate and planned to meet the individual needs of the resident consistent with the physicians plan of care for the resident .the resident care plan must be kept current at all times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 1 of 9 residents (Resident #9's) and 1 of 1 dining rooms reviewed for a homelike environment.<BR/>The facility failed to ensure Resident #9's bathroom was free of offensive odors and unbroken and misshaped tiles around the base of the toilet. <BR/>The facility failed to ensure the dining room did not have plastic, folding tables used as dining tables.<BR/>This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 05/07/2024 indicated, Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia with other behavioral disturbance (a condition in which a person loses the ability to think, remember, learn and make decisions and solve problems), weakness, vitamin D deficiency, major depressive disorder (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities), urinary tract infection, acute respiratory disease , hypertension (high blood pressure). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #9 was understood and was able to understand others. The MDS assessment indicated Resident #9 had a BIMS score of 04, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #9 required maximal assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. <BR/>Record review of the care plan with a target date of 07/31/2024 indicated, Resident #9 required staff assistance with ADL's. <BR/>During an observation on 05/06/2024 at 09:20 AM, upon entrance of Resident #9's room a strong odor of urine was detected in the bathroom area. The floor tiles around the base of the toilet were broken and misshaped and exposed large areas of grout. <BR/>During an observation on 05/06/2024 at 11:30 AM, there was a strong odor of urine in Resident # 9's bathroom.<BR/>During an observation on 05/06/2024 at 2:35 PM, there was a strong odor of urine in Resident # 9's bathroom . Resident #9 was in the room asleep at this time.<BR/>During an interview on 05/07/2024 at 1:32 PM., RN G said on occasion he had noticed the urine odor in Resident #9's bathroom. RN G said there had been water leaks around the toilets in a couple of the rooms recently and he had noticed the tile had peeled up and was exposing areas of grout. In Resident #9's bathroom, RN G said the maintenance supervisor was aware of broken and peeled up tiles because they had discussed this on different occasions over the last month or so when there was some plumbing issues in the unit. RN G said he was not aware of the status of repairs. RN G said the urine odor could be absorbed in the exposed grout. RN G said the smell of urine and the broken tiles was not a welcoming environment for the resident's family. <BR/>During an interview on 05/08/24 at 9:23 AM., Housekeeping Aide O said she smelled urine odor in Resident #9's room. Housekeeping Aide O said she usually cleans the rooms once daily for a deep clean then does a walk through in the evenings. She said she used the chemicals she was able to use when cleaning Resident #9's bathroom. She said she saw the bathroom floor tiles peeling from around the toilet in Resident #9's bathroom. She said she had not placed a work order for maintenance but said she thought the maintenance supervisor was aware . She said she would clean Resident #9's room next. Housekeeping Aide O said she told the Maintenance Supervisor in person at some point weeks ago but she could also put the needed repair in the maintenance work order book. <BR/>During an interview on 05/08/2024 at 2:24 PM., the Maintenance Supervisor said he was aware of the tiles in Resident #9's bathroom that were broken, misshaped and revealed areas of grout. The Maintenance Supervisor said the facility had experienced some plumbing issues that had been caused by wipes and briefs being flushed and had clogged in the system. The Maintenance Supervisor said all the plumbing repairs had been completed and he did not feel like there was any type of leakage currently that had caused the strong urine odor in Resident #9's bathroom unless it had absorbed in the grout during the recent plumbing issues. The Maintenance Supervisor said there is a written plan to complete the renovation for the peeled-up tiles in the bathroom, but he was awaiting the approval to proceed. The Maintenance Supervisor said it was his responsibility to ensure the facility created a home like environment for the residents. <BR/>During an interview on 05/08/2024 at 04:00 PM, the DON said she had not noticed the offensive odors or the broken/peeled-up tiles in Resident #9's bathroom and she did not recall being in Resident #9's room lately. The DON said she expected the housekeeping staff to fully clean all resident's bathrooms daily to alleviate odors. The DON said all the staff should be making sure the facility did not have offensive odors. The DON said she expected the Maintenance Supervisor to maintain the facility to create a home-like environment. The DON said she felt like there was a plan of renovation for the flooring repairs, but she would need to verify that with the Maintenance Supervisor and Administrator. The DON said it was important to keep the facility free of offensive odors and it was important to provide the residents with a clean and safe environment. <BR/>During an interview on 05/09/2024 at 04:22 PM, the Regional Director said all the staff were responsible for making sure there were no offensive odors in the facility. The Regional Director said he expected for the staff to provide a homelike environment for the residents. <BR/>2. During an observation on 05/06/2024 at 12:15 PM, approximately 17 residents were seated at the plastic, folding tables in the dining room. The arms of the wheelchair were unable to fit appropriately under the table to allow proper positioning for eating comfortably. <BR/>During an observation on 05/07/2024 at 12:15 PM, approximately 17 residents were seated at plastic, folding tables in the dining room. The arms of the wheelchair were unable to fit appropriately under the table to allow the resident proper positioning for eating comfortably. <BR/>During an observation on 05/08/2024 at 12:15 PM, approximately 17 residents were seated at plastic, folding tables in the dining room. The arms of the wheelchair were unable to fit appropriately under the table to allow the resident proper positioning for eating comfortably. <BR/>During an observation on 05/09/2024 at 12:15 PM, approximately 17 residents were seated at plastic, folding tables in the dining room. The arms of the wheelchair were unable to fit appropriately under the table to allow the residents proper positioning for eating comfortably. <BR/>During an interview on 05/09/2024 at 1:30 PM, LVN A said it had been several months that the dining room was provided with the plastic, folding tables and the other wooden tables had been removed. LVN A said the plastic, folding tables were institutional like and did not enhance the dining experience for the residents due to the cumbersome fit of the wheelchairs at the tables. <BR/>During an interview on 05/09/2024 at 04:30 PM, the Regional Director said the plastic, folding tables were not homelike. The Regional Director said he had intentions of purchasing better tables for the dining area and the more homelike tables were in his basket of things to do. <BR/>During an interview on 05/09/2024 at 09:24 AM, the DON said the facility does not have a policy regarding homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to be administered in a manner that enables it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 4 of 5 residents( Resident #3, #4, #6, and #5) reviewed comfortable and safe temperatures and 5 of 6 zones (Zone 6, Zone 5, Zone 5/11, Zone 5/7 and Zone 10) reviewed for comfortable and safe temperatures. <BR/>The Facility Administrator failed to ensure temperatures in the building were adequately monitored after a power outage on 6/16/23. <BR/>The facility Administrator failed to accurately monitor the effectiveness of his action plans as additional equipment continued to fail to sustain appropriate temperatures.<BR/>These failures could place residents at risk of heat exposure and dehydration. <BR/>Findings included: <BR/>During an interview on 6/19/23 at 1:30 p.m., the Administrator said the facility lost power at approximately 1:00 a.m. on 6/16/23. The Administrator said the facility's backup generator had kicked on upon the outage. The administrator said he had chosen not to evacuate the building because additional resources were coming to keep the building cool and if the facility evacuated the residents, they would have had to evacuate to another city, as many of the sister facilities had also been affected by the outage. He said the facility had maintained temperatures in the building from 72-82 degrees Fahrenheit since the outage to his knowledge. The Administrator said the secure unit (zone 6) and the back hall (zone 5/11 and zone 5/7) were warmer, but Residents were being kept on the front lobby/activity area (zone 8) where the temperature had been between 72-82 degrees. The Administrator said some residents had refused to come to the cool area (zone 8). <BR/>During an interview on 6/19/23 at 1:40 p.m., the Maintenance Director said he had not kept any temperature logs for the facility since the power outage, so he could not accurately report what the temperatures in the facility had been since the outage. <BR/>During an interview on 6/20/23 at 12:10 p.m., the EMTFD (Emergency Management Task Force Director)-Region 4, said he came to the facility on 6/17/23. He said he offered evacuation on two occasions that day (6/17/23) because he was concerned about the well being of the residents. The EMTFD said the first time he came to the facility on 6/17/23, one of the thermostats read 88 degrees Fahrenheit. The EMTFD said the Administrator declined the evacuation offer and reassured him the facility had additional generators and portable HVAC units to cool the building on the way. The EMTFD said the second time he came to the facility on 6/17/23, the Administrator met him on the front porch of the facility. The EMTFD said he was not invited into the building at that time. The EMTFD said he thoroughly explained to the Administrator that the evacuation services offered would be at no cost to the facility and that there was already space for the facility's residents at a local hospital. The EMTFD said he explained to the Administrator the facility would not lose any money while the residents were evacuees at the local hospital and would be able to continue to bill for services as the facility's staff would continue to provide care for the residents. The EMTFD said the Administrator insisted the residents were doing just fine and they had a cool area in the facility for the residents. <BR/>During observations on 6/20/23 at 12:10 to 12:35 p.m., the facility temperatures on the Center Hall (zone 5) were 76 degrees F at the front of the hall and 85 degrees at the back of the hall.<BR/>During observations on 6/20/23 at 12:35 to 12:40 p.m. facility temperatures on the back hall (zones: 5/11 and 5/7) were 85-86 degrees Fahrenheit.<BR/>During observations on 6/20/23 at 12:50 p.m., in the front/ right hall (secured unit- zone 6) the facility temperature was 86 degrees Fahrenheit.<BR/>During an interview on 6/20/23 at 12:55 p.m., the Maintenance Director said the facility's current 150 kw generator was not big enough to run additional AC units for the whole building. The Maintenance Director said the Power went out at 1:00 a.m. in the morning on Friday (6/16/23). He said the emergency generator came on immediately and fans were gathered and plugged in to keep areas cool. The Maintenance Director said portable HVAC units arrived early afternoon on Friday (6/16/23). He said window units arrived Saturday morning around 10:00 a.m. The Maintenance director said the large generator arrived Sunday (6/18/23) evening around 11:00 p.m. The maintenance director said without the larger generator the temperatures had been between 82- and 84-degrees Fahrenheit. <BR/>Record review of the face sheet for Resident #3 dated 6/20/23 indicated she was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including heart failure, muscle wasting and atrophy, heart disease, and high blood pressure. <BR/>Record review of the MDS dated [DATE] indicated Resident #3 usually made herself understood and usually understood others. The MDS indicated she had severe cognitive deficit (BIMS of 4). The MDS indicated she required limited assistance with most ADLS (bed mobility, Transfers, dressing, toilet use, bathing and personal hygiene) but did require extensive assistance with locomotion in her wheelchair on the unit. <BR/>During an interview and observation on 6/20/23 at 1:00 p.m., Resident #3 laid in her bed on the back hall (zone5/7) with a cold washcloth on her face. Resident # 3 said she was hot. Resident #3 said she had been in the front of the building and wanted to go back up there. <BR/>Record review of Resident #4's face sheet indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including, history of hypertensive urgency muscle wasting and atrophy, muscle weakness, diabetes, high blood pressure, and history of stroke. The MDS indicated she required supervision only with ADLS except for bathing for which she required limited assistance. <BR/>Record review of the MDS dated [DATE] indicated Resident #4 understood others and made herself understood. The MDS indicated she had no cognitive impairment (BIMS of 13).<BR/>During an interview and observation on 6/20/23 at 1:10 p.m., Resident #4 was sitting in a wheelchair in her room on the back hall (zone 5/11). Resident #4 said she was about to go back to the front of building because it was a little cooler up there. Resident #4 said she slept up there on the couch (in the front lobby area zone 8) last night because it was just too hot in her room and said she was dripping with sweat. <BR/>Record review of Resident #6's face sheet dated 6/20/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including history of metabolic encephalopathy, back abscess (a swollen area within body tissue, containing an accumulation of pus.), history of GI hemorrhage (Gastrointestinal (GI) bleeding is any type of bleeding that starts in the GI tract, also called the digestive tract), high blood pressure, history of skull fracture, history of traumatic brain injury, Type II diabetes, and dysphasia after stroke. <BR/>Record review of the MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated he had moderate cognitive impairment (BIMS of 11 ). The MDS indicated he required supervision only with most ADLS except for bathing for which he was totally dependent on staff.<BR/>During an interview on 6/20/23 at 3:00 p.m. Resident #6 was sitting in his wheelchair in the front lobby area (zone 8). He said the temperature up here was not terrible and was much better than it was over the weekend. Resident #6 said he did not know what the actual temperature was over the weekend but said it was real hot. Resident #6 said he had not been able to sleep much because it was just too hot in his room on the back hall (zone 5/11). <BR/>Record review of Resident #5's face sheet dated 6/20/23 indicated he was [AGE] years old readmitted to the facility on [DATE] with diagnoses including COPD, Schizoaffective disorder, bradycardia, muscle wasting and atrophy, history of left knee replacement, and chest pain. <BR/>Record review of the MDS dated [DATE] indicated Resident #5 understood others and made himself understood. The MDS indicated he had moderate cognitive impairment (BIMS of 11). The MDS indicated he required supervision with ADLS except for bathing for which he was totally dependent on staff. <BR/>During an interview on 6/20/23 at 4:16 p.m., Resident #5 was sitting in the front lobby area (zone 8). Resident #5 said he has had increased trouble breathing with the heat and has not been able to sleep since the outage. He said it was just too hot to get any sleep. Resident #5 said it helped to sit up here (in the front [zone 8]) but at night, he said residents go back to the rooms to sleep and it's just too dang hot to sleep on the back hall (Zone 5/7). <BR/>During an interview on 6/20/23 at 11:56 a.m., CNA B said she worked at the facility Friday (6/16/23) morning from 6am to 2pm. She said the power had gone out sometime before her shift started but was not sure what time. CNA B said it was very hot in the building. CNA B said it was hotter in the back of the building than it was in the front of the building. CNA B said she could not say what the thermostats read on the resident halls during her shift. CNA B said she remembered looking at the thermostat in the dining room when the residents were eating lunch and it said 93 or 94 degrees Fahrenheit. She said it was very hot and the facility was gathering fans at that time. CNA B said there were no portable HVAC units in the building at the time (6/16/23 from 6am to 2pm). <BR/>During an interview on 6/20/23 at 12:09 pm MA C said she worked Friday (6/16/23) and it was awful. MA C said it was awful because it was so hot in the building. MA C said she did not recall what the thermostats said in the building. <BR/>During an interview on 6/20/23 at 12:12 p.m., CNA D said she worked in the facility on Saturday (6/17/23) and Sunday (6/18/23). CNA D said it was very hot in the building all weekend. CNA D said she did have some residents compliant to her about the heat but could not recall their names. CNA D explained she worked for a staffing agency and was not extremely familiar with the residents. CNA D said she was told an additional generator was coming to help cool the building. CNA D said she heard the nurses saying that a big generator was coming to help cool the building, so that was what she told residents. CNA D said the big generator did not come until Sunday night. CNA D said she heard there was some delay with getting the generator started on Sunday night due to some of the cords needed had not arrived. CNA D said she was not sure what time the big generator was up and running Sunday night. CNA D said the front of the building (zone 8) was just as hot as the rest of the building Saturday (6/17/23) and Sunday (6/18/23). CNA D said the thermostat to the immediate left when entering the back hall (zone 5) on Saturday between 4:00 p.m. and 5:00 p.m. read 92 degrees Fahrenheit. On Sunday (6/18/23) CNA D said the same thermostat read between 80-85 degrees Fahrenheit during her 2:00 p.m.-10:00 p.m. shift. <BR/> During an interview on 6/20/23 at 12:20 pm the ADON said she came home early from her vacation on Saturday (6/17/23) to help out at the facility. The ADON said she worked as the medication aide that day. The ADON said it was hot in the building but not unbearable. The ADON said there were fans up and running throughout the building but said she could not say if there were any portable HVAC systems in the building at that time. The ADON said she also came in Sunday to help out. The ADON said no residents complained to her about the heat. The ADON said she knew the idea of evacuation was mentioned but never heard any actual plan. The ADON said the DON was on vacation herself and could not be reached. <BR/>During observations on 6/20/23 at 3:40 p.m. the front cool area (zone 8) temperatures were 78-79 degrees Fahrenheit.<BR/>During observations on 6/20/23 at 3:40 to 3:41 p.m., facility temperatures on the Center Hall (zone 5) were 91-93 degrees Fahrenheit.<BR/>During observations on 6/20/23 at 3:44-3:47 p.m., facility temperatures on the back hall (zones: 5/11 and 5/7) were 90- 93 degrees Fahrenheit.<BR/>During observations on 6/20/23 at 3:45 pm the facility census 52 residents had all been moved to the front cool area of the building.<BR/>During an interview on 6/20/23 at 3:47 pm the Administrator said all Residents were currently being kept in the front lobby. The Administrator reported all residents had been sleeping in their rooms since the outage. <BR/>According to the website www.accuweather.com accessed on 6/20/23 the outside temperature on 6/20/23 at 4:16 p.m. was 99 degrees Fahrenheit with a heat index of 120 degrees. <BR/>During an interview on 6/23/23 at 10:50 a.m., the Administrator said hindsight being 20/20 he might have evacuated the Residents. He continued, but we just really thought when the first big generator got here Sunday night (6/18/23) it was going to fix our problems. <BR/>The facility Emergency preparedness plan reviewed on 7/22/21, Emergency Preparedness Plan Loss of Power Heat and Water, stated . (2) Loss of Comfort Heating/Cooling .(b) If loss is in the entire home due to interruption of public utilities (electrical /natural gas) and residents become uncomfortable, they will be placed in the beds and protected by an adequate supply of linen, or they will be moved to a central location that can be heated/cooled. (c) If loss is for extended period of time and the residents can no longer be protected in a comfortable manner, the residents will be evacuated to another location .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility for 4 of 4 residents ( Resident #1, #7, #4, and #3) reviewed for RP notification. <BR/>The facility did not notify Resident representatives of the facility's power outage that occurred 6/16/23, in compliance with its Emergency Preparedness Plan. <BR/>This failure could place residents at risk of decreased quality of services and unmet needs. <BR/>Findings included:<BR/>1.Record review of Resident #1's face sheet indicated he was [AGE] years old, re-admitted to the facility on [DATE] with diagnoses including history of heart attack, high blood pressure, history of urinary retention, muscle weakness, history of urinary tract infections, BPH (Benign prostatic hyperplasia is also called an enlarged prostate which can impede urine flow) Type II diabetes, and Alzheimer's disease. <BR/>Record review of Resident #1's MDS dated [DATE] indicated he understood others and made himself understood. The MDS indicated he had severe cognitive impairment (BIMS of 5). The MDS indicated Resident #1 had no behavior of rejecting care. The MDS indicated he required extensive assistance with bed mobility, transfers, locomotion in his wheelchair, dressing, eating, toilet use and personal hygiene. The MDS indicated he was totally dependent on staff for bathing. The MDS indicated he had an indwelling catheter and was frequently incontinent of bowel. <BR/>Record review of Resident #1's progress notes from 6/16/23 to 6/18/23 did not indicate his responsible party had been notified of the power outage at the facility. <BR/>During an interview on 6/22/23 at 10:12 a.m., Resident #1's responsible party said she was not notified by the facility in regard to the power outage. Resident #1's responsible party said she was not aware of the outage until after Resident #1 was in the hospital (admitted to the hospital on [DATE]) and said she had heard it through the grapevine.<BR/>2.Record review of Resident # 7's face sheet dated 6/20/23 indicated he was admitted to the facility on [DATE] with diagnoses including dysphasia (difficulty speaking) after stroke, hypothyroidism, high blood pressure, high cholesterol, History of stroke and Atrial fibrillation (an irregular and often very rapid heart rhythm). <BR/>Record review of the MDS dated [DATE] indicated Resident #7 sometimes made himself understood and understood others. The MDS indicated he had moderate cognitive impairment (BIMS of 11 ). The MDS indicated he required Supervision with bed mobility, transfers, locomotion in his wheelchair, eating, toilet use and personal hygiene. The MDS indicated he required limited assistance with dressing. The MDS indicated he was totally dependent on staff for bathing. <BR/>Record review of Resident #7's progress notes from 6/16/23 to 6/19/23 (on 6/19/23 Resident #7 went out on pass with his family) did not indicate his responsible party had been notified of the power outage at the facility. <BR/>During an interview on 6/22/23 at 10:15 a.m., Resident #7's responsible party said she had not been notified of the facility's power outage. Resident #7's responsible party said she had heard about the outage from her family member who went to visit Resident #7 days after the outage. Resident #7' responsible party said he was taken out of the facility on pass on 6/19/23. <BR/>3. Record review of Resident #4's face sheet indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including, history of hypertensive urgency muscle wasting and atrophy, muscle weakness, diabetes, high blood pressure, and history of stroke. <BR/>Record review of the MDS dated [DATE] indicated Resident #4 understood other and made herself understood. The MDS indicated she had no cognitive impairment (BIMS of 13). The MDS indicated she required supervision only with ADLS except for bathing for which she required limited assistance<BR/>Record review of Resident #4's progress note dated 6/20/23 at 6:14 p.m., stated Resident RP notified of power outage and current situation. No concerns at this time. This note was written by the Social Worker. <BR/>During an interview on 6/22/23 at 10:27 a.m. Resident #4's responsible party said the facility did not notify her of the power outage. Resident #4's responsible party said she had called up to the facility herself on Tuesday (6/20/23) and spoke with the Social Worker. Resident #4's responsible party said the Social Worker notified her at that time because she (Resident #4's representative) asked about the outage. Resident #4's responsible party said no one at the facility had any communication with her or attempted to call her before 6/20/23. <BR/>4.Record review of the face sheet for Resident #3 dated 6/20/23 indicated she was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including heart failure, muscle wasting and atrophy, heart disease, and high blood pressure. <BR/>Record review of the MDS dated [DATE] indicated Resident #3 usually made herself understood and usually understood others. The MDS indicated she had severe cognitive deficit (BIMS of 4). The MDS indicated she required limited assistance with most ADLS (bed mobility, Transfers, dressing, toilet use, bathing and personal hygiene) but did require extensive assistance with locomotion in her wheelchair on the unit. <BR/>Record review of the Resident # 3's progress note dated 6/20/23 at 6:02 p.m., stated Resident RP notified of power outage and current situation. No concerns at this time. This note was written by the Social Worker. <BR/>During an interview on 6/22/23 at 10:28 a.m., Resident #3's responsible party said the facility did not notify her of the outage at the facility. Resident #3's responsible party said she did not know the facility was without power until late Saturday (6/17/23) when she went to the facility herself. <BR/>During an interview on 6/22/23 at 11:25 a.m., the Social Worker said she had not notified any families of the power outage before Tuesday 6/20/23 . The Social Worker said she had not notified families because no one had told her to until Tuesday 6/20/23 (4 days after the outage). <BR/>During an interview on 6/22/23 at 11:32 a.m., the Administrator said it was the responsibility of the social worker to ensure that families / responsible parties were notified about the power outage at the facility. The Administrator said RPs and families should have been notified prior to 6/20/23. He said he was looking into putting in place an alert system that would notify families all at once via email or text. <BR/>The facility Emergency preparedness plan reviewed on 7/22/21, Amendment to Emergency Procedures for (Facility) Sheltering in Place, stated .Resident Family members will be notified by facility staff and may come to facility to be with residents for the duration of the emergency if they choose .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the State Survey Agency immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for 1 of 6 (Resident #1) residents reviewed for abuse and neglect.<BR/>On 04/28/23 at 6:30 p.m., Resident #1 sustained redness and blistering to his face when RN A lit a cigarette while Resident #1 was using Oxygen. The incident was not reported until 04/29/23 at 11:17 a.m.<BR/>This failure could place residents at risk of emotional, physical, and mental abuse.<BR/>Findings included:<BR/>During an observation and interview on 04/29/23 at 10:25 a.m. Resident #1 had a large fluid fill blister, white in color, on his right cheek that extended to the top of his upper lip. There was another fluid filled blister on the right side of his nose that extended to the tip of his nose. Facial hair on his right upper lip appeared to be shorter than the left side of his lip. Resident #1 said he was not in pain. He said he was smoking the night before (04/28/23) and did not realize that Oxygen was flammable. He said he was wearing his Oxygen while smoking. He said he normally does not have his Oxygen on while smoking and does not use Oxygen all the time. He said while smoking the Oxygen caught fire. He said it was storming and he thought at first it was a lightning flash. He said RN A was there and quickly put out the flame. (Within a few seconds) He said he went to the doctor the next day. (04/29/23). He said he did not feel he was abused or neglected.<BR/>Record review of face sheet dated 04/30/23, indicated Resident #1 was a [AGE] year-old male, last admitted on [DATE] and his diagnoses included Transient cerebral ischemic attack, (a stroke that lasts only a few minutes), hypertension, Dyspnea (Shortness of Breath), dementia, cognitive communication deficit, muscle weakness, Bipolar disorder, Chronic obstructive pulmonary disease (COPD), schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms), and Pulmonary hypertension (A type of high blood pressure that affects the arteries in the lungs and the right side of the heart? <BR/>Record review of MDS dated [DATE] indicated Resident #1 was able to express ideas and wants, alert to person, place, and time, was able to understand others, and was cognitively intact. Resident #1 required supervision and set-up assistance of 1 person for all ADLs other than hygiene where he required assistance of 2 persons. He was able to transfer independently and used a wheelchair. <BR/>Record review of Resident #1's care plan initiated 12/19/22 and revised on 04/30/23 indicated he was a smoker and at risk of injury. He was to wear a smoking apron during smoke breaks. Staff were to supervise during smoking. Care plan was updated on 04/29/23 to show staff are to ensure that resident is not in the smoking area with Oxygen tank or tubing/nasal canula. <BR/>Record review of consolidated physician orders dated 02/26/23, Resident #1 may have Oxygen (O2) 2L/min via Nasal Canula (NC) as needed (PRN) for oxygen sat below 92%. Every shift Days 6:00 AM - 2:00 PM, Evenings 2:00 PM - 10:00 PM, and Nights 10:00 PM - 6:00 AM.<BR/>Record review of an incident report dated 04/29/23, completed by administrator indicated on 04/28/23 at 6:30 p.m., Resident #1 was smoking in the designated smoke area when RN A lit his cigarette while he was wearing oxygen. The Oxygen flashed causing his beard to singe. The next morning at 10:00 a.m. redness and blistering was discovered to Resident #1 face. Doctor notified and new orders for Silvadene (silver sulfadiazine) cream 1% was to be applied to the affected area once a day. Resident #1 was sent to the hospital on [DATE] for evaluation and returned the same day with no new orders.<BR/>Record review of progress note dated 04/28/23 at 06:40 p.m., RN A recorded he went to the smoking area to observe resident smoke break. Resident #1 was already outside with his smoking apron on. Cigarettes were handed out and lit. RN A did not recognize Resident #1 had Oxygen on. A small flame extinguished, and Oxygen turned off. Resident #1 was assessed for injuries with left cheek and nose light pink with no open areas or blisters noted. Resident #1 denied pain. Resident sitting up at nurse's station with no signs of distress. Responsible party and physician was notified. No new orders from physician.<BR/>During an interview on 04/30/23 at 9:45 a.m., the Administrator said on 04/29/23 at 6:30 p.m., RN A was taking residents out for a smoke break. Resident #1 was already in the smoking area with his apron on when RN A arrived with 2 other residents. The Administrator said RN A lit Resident #1's cigarette without noticing he had his Oxygen on. The Administrator said RN A was assisting the two other residents when Resident #1's Oxygen ignited and singed Resident #1's facial hair. The Administrator said RN A immediately responded and assessed Resident #1 for injury. The Administrator said there was some redness to Resident #1's cheek and nose. There were no other injuries found at that time. The Administrator said he asked questions about the incident, and it was determined that the incident was not a reportable incident at the time, because there was no major injury to Resident #1. The Administrator said the next morning (04/30/23) around 10:00 a.m. during an assessment LVN A, found blisters to Resident #1's face. The Administrator said he did not report the incident until 04/30/23 at 11:17 a.m. after the blistering was discovered.<BR/>Record review of progress note dated 04/29/23 at 11:30 a.m. LVN A recorded she contacted with physician to report need for wound care orders to Resident #1's face after smoking incident last evening. Nurse reported areas of burns and appearance of areas of concern. New orders received of Silvadene (silver sulfadiazine) cream 1% once a day. Resident reports no pain/discomfort in area currently. <BR/>Record review of progress note dated 04/29/23 at 3:16 p.m. DON recorded she noticed Resident #1 to have newly onset and slight difficulty breathing. Upon further assessment, swelling noted to Resident #1's right inner nare. (Opening of the nose). Physician contacted with orders to send to hospital for evaluation. <BR/>Record review of hospital records dated 04/2923 indicated Resident #1 was seen at the hospital for facial burn. Diagnosis Facial burn, second degree. (Involves the top two layers of the skin, might have blisters over the burn area. The burn may leave a scar). New orders gently clean with soap and water and apply bacitracin (topical antibiotic ointment). Follow-up to be scheduled by facility staff. <BR/>Review of progress note dated 04/29/23 at 4:58 p.m. Resident #1 returned from the emergency room with new orders for bacitracin ointment, apply BID. (Twice daily) Physician was contacted and ordered to discontinue bacitracin and continue with Silvadene as previously ordered. Resident continues to have difficulty breathing through nose. No distress noted. Resident at nurses' station currently. Resident #1 states he can breathe though his nose and that is does not hurt to breath.<BR/>During an observation and interview on 04/29/23 at 10:45 a.m. six residents was observed in the smoking area including Resident #1. Three of the residents were wearing smoking aprons including Resident #1. There were no Oxygen tanks in the smoking area. The fire extinguisher was available and last serviced April 2023. Ash trays were appropriate for safety. Residents were being supervised by a nurse. Resident #2 said she was present when Resident #1's Oxygen ignited on 04/28/23 around 6:30 p.m. She said RN A was helping her to her table and Resident #1 was already in the smoking area with his safety apron on when she arrived. She said after RN A assisted her to her normal table and Resident #1 was sitting behind her. She said it was storming and darker than usual. Resident #1 asked RN A to light his cigarette. She said RN A turned around, lit Resident #1's cigarette and turned and lit hers. She said the next thing she knew, there was a flash. She said she thought it was a lighting flash, but she saw there was a flame at Resident #1's face. She said RN A quickly turned and extinguished the flame. She said they all went back inside the building and RN A took Resident #1 to his room.<BR/>During an interview on 05/01/23 at 4:10 p.m., RN A he was working as a charge nurse on 04/28/23 2:00 PM to 10:00 PM shift. RN said at 6:30 PM, he took residents out for a smoke break. He said when he arrived at the smoking area, Resident #1 was already outside in the smoking area with his safety apron on. He said Resident #1 asked him to light his cigarette. He said he turned around and lit the cigarette for Resident #1. RN A said he did not notice the Resident #1 had his nasal canula under his nose and did not know his Oxygen was on. RN A said he should have checked before lighting the cigarette, but he did not. He said it was only a few seconds when he saw a flame and turned around and put out the fire. RN A said she assessed resident [NAME] #1 and Resident #1 said he was not in pain. RN A said he immediately ended the smoke break. RN A said he took Resident #1 to his room so he would assess him better in the light. RN A said he observed some pink areas to Resident #1's nose and cheek, but there was no blistering. RN A said he notified the Assistant Director of Nursing (ADON) April, who said she would notify the Administrator and DON.<BR/>During an interview on 04/30/23 at 9:45 a.m., the Administrator said on 04/29/23 at 6:30 p.m., RN A was taking residents out for a smoke break. Resident #1 was already in the smoking area with his apron on when RN A arrived with 2 other residents. The Administrator said RN A lit Resident #1's cigarette without noticing he had his Oxygen on. The Administrator said RN A was assisting the two other residents when Resident #1's Oxygen ignited and singed Resident #1's facial hair. The Administrator said RN A immediately responded and assessed Resident #1 for injury. The Administrator said there was some redness to Resident #1's cheek and nose. There were no other injuries found at that time. Physician, family, and Administrator was notified of the incident. The Administrator said he asked questions about the incident, and it was determined that the incident was not a reportable incident at the time, because there was no major injury to Resident #1. The Administrator said the next morning (04/30/23) around 10:00 a.m. during an assessment LVN A, found blisters to Resident #1's face. Administrator said all residents were re-assessed for Smoking Safety and RN A was suspended pending investigation. Administrator said RN A should have monitored to ensure there was no Oxygen in the area prior to lighting a cigarette. Administrator said it is the policy of the facility that Oxygen should not be within 50 feet of the smoking area. The Administrator said he did not report the incident until 04/30/23 at 11:17 a.m. after the blistering was discovered.<BR/>During an interview on 04/30/23 at 9:45 a.m. the DON said RN-A should have noticed that Resident #1 was using Oxygen and should have not lit any cigarettes before making sure there was no Oxygen in or near the area. The DON said it is the facility policy that Oxygen should not be within 50 feet of the smoking area. The DON said Residents are not allowed to have Oxygen in the smoking area whether it is on or off. The DON said all Oxygen should be left inside the building or in the resident's rooms. DON said there are ten residents who smoke and out of those ten residents, six use Oxygen.<BR/>Review of an undated facility policy provided by Administrator on 04/30/23 showed: Reporting: Facility employees [NAME] must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. * If the allegation involves abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. * If the allegation does not involve abuse or serious bodily injury, the report must be made with 24 hours of the allegation . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident and hazards for 2 of 7 residents (Residents #1 and #2) reviewed for accident hazards.<BR/>CNA B and CNA C failed to ensure Resident #2's Hoyer lift (an assistive lift device that allows for transfer using electrical power) transfer was performed correctly. <BR/>CNA D did not lock Resident #1's bed during incontinent care. <BR/>These failures could place dependent residents at risk for falls, significant injuries and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 1/9/24 indicated Resident #2 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, dementia, high blood pressure and COPD (chronic obstructive pulmonary disease - group of lung diseases that block airflow and make it difficult to breathe). <BR/>Record review of the MDS dated [DATE] indicated Resident #2 had unclear speech, rarely made herself understood and rarely understood others. The MDS indicated Resident #2 cognitive skills for decision making was severely impaired and she had both long-term and short-term memory problems. The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #2 was completely dependent on staff for toileting, oral hygiene, eating, bathing, dressing, and personal hygiene. The MDS indicated Resident #2 was completely dependent on staff for rolling side to side and all transfers. The MDS indicated Resident #2 had no impairment to the upper and lower extremities. The MDS indicated Resident #2 was always incontinent of bowel and bladder.<BR/>Record review of the care plan dated on 10/19/23 indicated Resident #2 had a self-care deficit due to her impaired cognition and impaired mobility. The care plan interventions included staff to assist resident with transfers as needed. The care plan also indicated Resident #2 was at risk for falls due to factors including decreased activity, confusion, and poor safety awareness. <BR/>During an observation on 1/9/24 at 1:20 p.m., CNA B and CNA C began to transfer Resident #2 from her wheelchair to her bed using a Hoyer lift. Resident #2 was initially combative with the CNAs, swinging her arms at them as they worked to attach the Hoyer sling to the Hoyer lift. After hooking the sling to the Hoyer lift, without locking the brakes (on the wheels) of the Hoyer lift, CNA B and CNA C lifted Resident #2 from her wheelchair. They (CNA B and CNA C) then guided the Hoyer lift to Resident #2's bed. Without locking the brakes of the Hoyer lift, they (CNA B and CNA C) lowered Resident #2 into the bed. <BR/>During an interview on 1/9/24 at 1:34 p.m., CNA B said she should have ensured the brakes were locked on the Hoyer lift wheels before Resident #2 was lifted from her wheelchair and before they (CNA B and CNA C) lowered Resident #2 into the bed. CNA B said she just forgot to double check and ensure the lift brakes (on the wheels of the Hoyer) were locked during the transfer. CNA B said the lift could have slid when they lifted/lowered Resident #2 and fallen over, especially since she (Resident #2) could be combative. CNA B said Resident #2 could have fallen out of the lift and gotten hurt. <BR/>During an interview on 1/9/24 at 1:37 p.m., CNA C said she should have ensured the brakes (on the wheels of the Hoyer) were locked on the Hoyer lift before Resident #2 was lifted from her wheelchair and before they (CNA B and CNA C) lowered Resident #2 into the bed. CNA C said she was just busy and forgot to ensure the Hoyer lift brakes were locked. CNA C said the lift could have tipped over and Resident #2 could have fallen into the floor. <BR/>2.Record review of the face sheet dated 1/9/24 indicated Resident #1 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, high blood pressure and heart disease. <BR/>Record review of the MDS dated [DATE] indicated Resident #1 had clear speech, usually made herself understood and usually understood others. The MDS indicated Resident #1 had mild cognitive impairment (BIMS of 9). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #1 required substantial/maximal assistance with personal hygiene, putting on/taking off footwear, dressing, and bathing. The MDS indicated Resident #1 required substantial/maximal assistance with rolling left to right and tub/shower transfer. The MDS indicated she required partial/moderate assistance with sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, and toilet transfer. The MDS indicated she required partial/moderate assistance with toileting and oral hygiene. The MDS indicated Resident #1 required setup or clean-up assistance with eating. The MDS indicated Resident #1 required extensive assistance of 2 persons to complete bed mobility, transfers, bathing and toilet use. The MDS indicated she had no impairment to the upper and lower extremities. The MDS indicated Resident #1 was frequently incontinent of bowel and bladder.<BR/>Record review of the care plan dated on 12/25/23 indicated Resident #1 had a self-care deficit due to her impaired cognition and impaired mobility. The care plan interventions included staff to assist resident with turning/repositioning while in bed, and staff will assist bathroom. The care plan also indicated Resident #1 was at risk for falls due to factors including decreased mobility.<BR/>During an observation on 1/9/24 at 1:00 p.m., CNA D provided incontinent care to Resident #1. CNA D did not check the brakes on the wheels of the bed before she started the incontinent care. During the incontinent care, CNA D moved the bed away from the wall and went to the left side of the bed (the side that was against the wall). CNA D did not lock the brakes on the wheels of the bed. CNA D then rolled Resident #1 to her (Resident #1's) right side (the side not against the wall). CNA D completed the care, returned the bed to the original position and did not lock the brakes on the wheels of the bed. <BR/>During an interview on 1/9/24 at 1:10 p.m., CNA D said she should have locked Resident #1's bed before starting the incontinent care, after she moved the bed, and after returning the bed to its original position. CNA D said Resident #1 could have fallen out the bed and sustained an injury. <BR/>During an interview on 1/9/24 at 1:40 p.m., LVN A said the CNAs should have ensured the brakes on the wheels on the Hoyer lift were locked before Resident #2 was lifted/lowered with the Hoyer lift. LVN A said CNA D should have double checked to ensure Resident #1's bed was locked before care was started. LVN A said Resident #1's bed should have been locked, before Resident #1 was repositioned in the bed and after CNA D completed Resident #1's care. LVN A said these things (the Hoyer lift brakes on the wheels left unlocked during the lift/descent of a resident and not ensuring bed brakes (on the wheels) were locked when a resident was repositioned in the bed) were safety issues. LVN A said Resident #2 could have been dropped from the Hoyer lift and Resident #1 could have fallen out of the bed.<BR/>During an interview on 1/9/24 at 1:57 p.m., the ADON said the CNA B and CNA C should have ensured the brakes on the wheels on the Hoyer lift were locked before Resident #2 was lifted/lowered with the Hoyer lift. The ADON said CNA D should have ensured Resident #1's bed was locked before care was started, before Resident #1 was repositioned and after the care was completed. The ADON said these things (the Hoyer lift brakes on the wheels left unlocked during the lift/descent of a resident and not ensuring bed brakes (on the wheels of the bed) were locked when a resident was repositioned in the bed) were posed a risk of injury. She said the system in place to ensure staff performed Hoyer lift transfers safely was the annual skills check off which included Hoyer lift transfers and ensuring brakes were locked on beds before repositioning a resident. The ADON said going forward a system would be put in place to perform spot checks on CNAs to ensure they were safely repositioning and transferring residents. <BR/>During an interview on 1/9/24 at 3:00 p.m., the Administrator said he expected staff to take appropriate measures to ensure residents safety during Hoyer lift transfers and incontinent care. The Administrator said leaving the bed unlocked and the Hoyer lift unlocked while a resident was lifted/lowered were not practices that would ensure resident safety. <BR/>During an interview on 1/9/24 at 2:30 p.m., the ADON said the facility did not have a policy and procedure specifically related to ensuring bed brakes (on the wheels of the bed) were locked. <BR/>Record review of the facility policy and procedure titled Lifting and movement of Resident-safe, dated December of 2017 stated, Policy: In order to protect the safety and well-being of staff and residents and to promote quality care, this home uses appropriate techniques and devices to lift and move residents . The policy and procedure did not specifically address the use of bed brakes (on the wheels of the bed or mechanical lift brakes (on the wheels of the mechanical lift). <BR/>Record review of the facility policy and procedure titled Mechanical Lift, dated December of 2017 reveled it did not specifically address the use of mechanical lift brakes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 1 resident (Resident #12) reviewed for activities of daily living. <BR/>The facility failed to remove Resident #12's facial hair.<BR/>This failure could place residents at risk of embarrassment, decreased self-esteem, or decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #12's face sheet, dated 04/05/23, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia(symptoms affecting memory), respiratory failure(disease that makes it difficult to breathe), heart failure(the heart does not pump the way it should), osteoarthritis(cartilage at ends of bones wear down), and anxiety(excessive worrying causing increased heart rates and breathing). <BR/>Record review of Resident #12's quarterly MDS assessment, dated 01/08/23, indicated Resident #12 was understood by others, and she was able to understand. Resident #12 had a BIMS score of 06, which indicated severe cognitive impairment. Resident #12 had no behaviors or rejection of care. Resident #12 required an extensive assist with personal hygiene. <BR/>Record review of Resident #12's comprehensive care plan, initiated on 10/13/22, indicated Resident #12 had an ADL self-care deficit related to impaired cognition and impaired mobility. The interventions included staff to provide personal hygiene needs throughout the day as needed.<BR/>Record review of the Point of Care History, dated 03/27/23-04/05/23, indicated Resident #12 received bathing assistance during a shower and personal hygiene on 04/04/23. <BR/>During an observation on 04/03/23 at 11:04 AM, Resident #12 was sitting in the front lobby in her wheelchair. Resident #12 had multiple, white facial hairs over an area of approximately 4 inches on her chin and each hair was approximately 0.5 cm - 1 cm in length. <BR/>During an observation on 04/04/23 at 08:40 AM, Resident #12 was sitting up in her wheelchair and had multiple, white facial hairs over an area of approximately 4 inches on her chin and each hair was approximately 0.5 cm - 1 cm in length. <BR/>During an observation and interview on 04/04/23 at 09:16 AM, Resident #12 had multiple, white facial hairs on her chin that were approximately 0.5 cm - 1 cm in length. Resident #12 said she felt the facial hair on her chin and did not like it because it did not look good for a woman. Resident #12 said staff normally helped her remove it by shaving when she showered, but sometimes they did not. Resident #12 said she preferred to have her facial hair removed because it did not make her feel good. <BR/>During an observation and interview on 04/05/23 at 10:34 AM, Resident #12 was in the dining room. Resident #12 continued to have chin hairs that were approximately 0.5 cm - 1 cm in length. She said she did not recall having a shower but did want the hair removed from her face because it did not look good. <BR/>During an interview on 04/05/23 at 01:25 PM, CNA E said facial hair removal should have been performed during the resident showers for men and women. CNA E said she was unsure when Resident #12's scheduled showers were, but they provided showers according to the shower sheets. CNA E said facial hair for Resident #12 had not been removed because she did not notice the hair. CNA E said it was important to ensure facial hair was removed so Resident #12 felt comfortable with the way she looked. <BR/>During an interview on 04/05/23 at 03:18 PM, the DON said the CNAs were responsible for removing Resident #12's chin hairs. She said the CNAs should have been shaving the men and women when they completed their showers. The DON said the failure of not keeping the resident shaved could have caused dignity issues or caused the resident to not feel good about herself. <BR/>During an interview on 04/05/23 at 03:35 PM, the administrator said he expected the female residents with facial hairs to receive showers and have facial hair removed. The administrator said if any resident refused care, the staff should have returned or had another CNA attempt to ask the resident. The administrator said all CNAs should follow the shower schedule and remove residents' facial hair. He said he noticed Resident #12 had chin hairs on 04/04/23. The administrator said he was sure it did not make Resident #12 feel good having chin hairs, and it was considered an issue. <BR/>During an interview on 04/05/23 at 03:45 PM, the ADON said the nurses and the CNAs were responsible for ensuring all residents received baths or showers, and their facial hair was removed. She said they had to use so much agency that they had not been able to keep up with things of that nature. The ADON said she was responsible for looking at the bath assignment sheets and ensuring the residents were bathed, showered, and shaved but had been so busy that shower sheet monitoring may had been missed. The ADON said women with chin hairs not being trimmed could have caused the resident to feel bad or be embarrassed. <BR/>Record review of the facility's Activities of Daily Living Policy, dated 1-2023, indicated <BR/>Policy<BR/>It is the policy of this home to assure residents have their activities of daily living needs met

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 6 medication carts (main street medication cart) reviewed for medication storage.<BR/>The facility failed to ensure the main street hall medication cart was locked when the ADON left the floor and left the cart unattended. <BR/>This failure could place residents at risk of taking medications not intended for them with adverse outcomes; risk of loss/interruption in receiving medications.<BR/>Findings included:<BR/>During an observation on 04/03/23 from 11:46 a.m. to 11:57 a.m., the main street hall medication cart was left on the main street hall unlocked and unattended while nurse had left it to go to the dining room. <BR/>During an observation and interview on 04/03/23 at 11:57 AM, the Corporate Clinical Nurse walked up to the cart and tried to hide her hand while she locked the medication cart. The Corporate Clinical Nurse said anything could happen with the cart being unlocked. The Corporate Clinical Nurse said anyone could have accessed the cart and ingested the medications. She said the nurse was responsible to ensure the carts were locked.<BR/>During an interview on 04/03/23 at 12:07 PM, the ADON said she was responsible for the medication cart and had forgotten to lock the cart. The ADON said with the cart being unlocked any resident, staff, or visitor could have opened the cart and took the medications out of the cart. The ADON said she was busy and did not lock the cart prior to her leaving the cart. The ADON said the facility performed proficiency checkoffs to ensure the nurses and medication aides were aware of the need to lock the medication carts on the hallways when the carts were not in use. She said the DON was responsible for completing proficiency checkoffs. <BR/>During an interview on 04/05/23 at 03:21 PM, the DON said the medication carts should always be locked if the nurse or aide was not working out of the cart. The failure to lock the medication cart could place a staff or visitor, who was unauthorized to access the medications, capability of getting in the cart. The DON said any resident in the facility could get into the cart and take the medications. The policy and procedures upon hire instructed all nurses or med aides to always keep the cart locked. She said it was a part off the skills checkoff<BR/>During an interview on 04/05/23 at 03:38 PM, the administrator said if the medication carts were not being used, they should be closed and locked. He said the failure to lock the medication carts provided risks of residents taking medications that they did not need, as well as other staff and visitors. The administrator said the nursing staff were responsible for ensuring the carts were locked.<BR/>Record review of the policy for Medication Storage, dated 1-2023, indicated<BR/>Policy<BR/>It is the policy of this home that the medications will be stored appropriately as to be secure from tampering, exposure, or misuse. <BR/>Procedure<BR/>1. <BR/>The provider pharmacy dispenses medications .<BR/>2. <BR/>Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (i.e., medication aides, etc.) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Record review of Resident #12's face sheet indicated an [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses which included Alzheimer's disease (memory loss), and atrioventricular block (heart beats more slowly) and dry eye syndrome (little moisture in the eye).<BR/>Record review of Resident #12's consolidated physician's orders, dated 03/04/2023 - 04/04/2024, indicated she was prescribed Restasis (dry eye medication) one drop to each eye twice daily for dry eye syndrome. <BR/>During an observation on 04/03/2023 at 10:45 a.m., the ADON provided Resident #12 with a tissue, and she wiped her nose. The ADON held Resident #12's right eye lid open with an ungloved hand and administered the Restasis eye medication in the resident's right eye. The ADON did not sanitize or perform hand hygiene before or after administering the eye drop with ungloved hands . The ADON held Resident #12's left eye open with an ungloved hand and administered the Restasis eye medication in the resident's left eye. The ADON used the same tissue Resident #12 used to clean her nose to dab around each of Resident #12's eyes with ungloved hands. <BR/>During an interview on 04/05/2023 at 3:14 p.m., the ADON said she should have used gloves during the administration of eye medications. The ADON said she was the infection preventionist. The ADON said touching Resident #12's eye lids barehanded could spread infection . The ADON said she should have sanitized her hands before applying gloves, and after removing gloves. <BR/>During an interview on 04/05/2023 at 3:30 p.m., the administrator said he expected eye drops to be administered with gloves to prevent any type of infection. <BR/>Record review of the facility's nursing policy and procedure Medication Administration, dated 01/2023, indicated the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. Eye Drops Procedure .3. Cleanse hands 4. Prevent tip of the eyedropper from touching the resident 6. While holding the bottle or tube in a vertical position and slightly to the side of the eye and about one-half inches above the eye, instill the ordered number of drops into the conjunctiva sac, or a ribbon of ointment along the lower conjunctiva from the inner to outer canthus. 7. Wipe excess medications from around the eye with tissue if needed.<BR/>Record review of the facility's policy Hand Washing, dated 01/2023, indicated . hand hygiene is the primary means to prevent the spread of infection . Employees must wash their hands for at least 20 seconds using antimicrobial or nonmicrobial soap and water under the following conditions .before and after assisting a resident with personal care after removing gloves .<BR/>Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 16 residents (Residents #5 and #23) reviewed for infection control practices.<BR/>1. CNA A failed to wash or sanitize her hands before, in between glove changes, and after performing peri care to Resident #5.<BR/>2. The facility failed to ensure the ADON used gloves when she administered Resident #23's eye medication.<BR/>3. The facility failed to ensure the ADON did not dry Resident #23's eyes with the same tissue used to clean Resident #23's nose.<BR/>These failures could place residents at risk for infections. <BR/>Findings included:<BR/>1. Record review of Resident #5's face sheet, dated 04/04/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia with behavioral disturbance (memory loss with behaviors), essential hypertension (high blood pressure), hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction affecting left non-dominant side (stroke affecting left side), and diabetes (a chronic condition that affects the way the body process blood sugar).<BR/>Record review of Resident #5's comprehensive care plan, dated 07/08/22, indicated Resident #5 was occasionally incontinent of bowel and bladder. The care plan interventions included incontinent checks to be performed approximately every 2-3 hours and perineal care to be given as needed.<BR/>Record review of Resident #5's quarterly MDS assessment, dated 02/23/23, indicated Resident #5 was usually understood and usually understood others. Resident #5 had a BIMS score of 6, which indicated he had severe cognitive impairment. Resident #5 required extensive assistance with two-person physical assist for bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Resident #5 was totally dependent with bathing. Resident #5 was always incontinent of urine and frequently incontinent of bowel. <BR/>During an observation on 04/03/23 at 09:26 a.m. revealed CNA A entered Resident #5's room to provide incontinent care. CNA A put on gloves and did not wash her hands prior to the start of care. CNA A obtained a package of disposable wipes, removed multiple wipes from the package, and placed them directly on the linen of Resident #5's bed. CNA A removed the soiled brief from Resident #5, removed her gloves and put on a new pair of gloves. CNA A failed to perform hand hygiene prior to putting on clean gloves. CNA A removed multiple wipes from the package and placed them directly on Resident #5's bed linen. CNA A continued to provide incontinent care to Resident #5. CNA A placed a clean brief on Resident #5 with same gloves. CNA A removed her gloves and put on clean gloves. CNA A did not perform hand hygiene in between glove changes and did not perform hand hygiene after the completion of care. <BR/>During an interview on 04/03/23 at 09:46 a.m., CNA A said she should have had performed hand hygiene before and after incontinent care and in between glove changes. CNA A said failure to perform hand hygiene could place Resident #5 at risk for infections. CNA A said she was responsible for performing hand hygiene. CNA A said she had been checked off on incontinent care and hand hygiene by the DON by return demonstration . <BR/>During an interview on 04/05/23 at 1:40 p.m., LVN C said she expected hand hygiene to be performed before and after care, before meals, after removing gloves and in between glove changes. LVN C said failure to perform hand hygiene placed residents at risk for infection. LVN C said everyone was responsible for ensuring hand hygiene was performed. LVN C said staff had hand hygiene and incontinent care competencies completed upon hire and yearly. <BR/>During an interview on 04/05/23 at 3:11 p.m., the ADON said she expected staff to perform hand hygiene before, after, in between care, and after changing gloves. The ADON said failure to perform hand hygiene placed the residents at risk for infection. <BR/>During an interview on 04/05/23 at 3:18 p.m., the administrator said he expected the staff to wash their hands before, after, and in between care. The administrator said he expected the staff to perform hand hygiene in between glove changes. The administrator said failure to perform hand hygiene between glove changes could place residents at risk for infection. <BR/>During an interview on 04/05/23 at 3:35 p.m., the DON said staff should wash their hands between soiled and clean tasks, and before and after completion of incontinent care. The DON said not performing hand hygiene could cause a break in infection control. The DON said everyone was responsible for ensuring hand hygiene was performed. <BR/>Record review of the CNA A's CNA Proficiency, dated 12/21/22, indicated skill for male perineal care was satisfactory. <BR/>Record review of the facility's policy Incontinent care/Perineal care with or without a catheter, dated 01/2023, indicated . It is the policy of this home to provide incontinent care to residents in a manner which provides privacy, promotes dignity and ensures no cross contamination .Beginning steps a. wash hands .Discard soiled gloves along with the soiled brief and/or wipes . wash hands with soap and water .sanitize hands and put on gloves .Re-glove prior to touching clean linens/adult brief .If gloved, remove and discard gloves following home guideline at the appropriate time to avoid environmental contamination. Sanitize hands

Based on observations, and interviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 3 of 3 showers (Whispering Lane shower, Park Place shower, and Texas Boulevard shower), and 1 of 3 public restrooms (nursing station area public restroom) observed.<BR/>1. The facility failed to ensure the three common shower rooms were free of black and green substances growing in the grout, towels lying on the floor, and a pink slimy substance growing on the undersurface of the shower chairs.<BR/>2. The facility failed to ensure the bathtub in the public restroom was free of a black substance .<BR/>These failures could place residents at risk of infections and a loss of dignity.<BR/>Findings included:<BR/>During an observation on 04/04/2023 at 11:50 a.m., clean and folded towels and wash cloths were sitting exposed on the half wall petition in the communal shower room on Park Place Hall; used and un-labeled toothpaste was on the sink; and the dirty linen and trash barrels were stored in the shower. <BR/>During an observation and interview on 04/04/2023 at 12:10 p.m., the communal shower on Whisper Lane Hall (secured unit) had a black substance in the grout; the shower wall had missing tiles; the windowsill had dirt like material on it; the white window blind was covered in a dirt like material; the toilet had brown stains inside; and a bottle of degreaser and bathroom cleaner was sitting on top of the locked cabinet. CNA B said the housekeeper cleaned the shower every morning. <BR/>During an observation on 04/04/2023 at 12:20 p.m., the shower on Texas Boulevard Hall had a pink slimy substance on the undersurface of the shower chair. The grout in the shower stall had black in areas on the wall and green in areas around the space where the walls and floor met. The shower stall had a rusted and broken over the bed table with a stack of clean, folded towels, and wash cloths lying on top and sitting next to the towels was a spray bottle labeled bathroom cleaner. There was a gallon of liquid bath soap, two cans of shaving cream, a bottle of hair shampoo, conditioner, a handheld mirror, and a large pump bottle of lotion on the table. The shower stall had towels lying on the floor. The unlocked cabinet had Calmoseptine ointment, razors, and a bottle half full of mouth wash. <BR/>During an observation and interview on 04/04/2023 at 12:55 p.m., RN D said the shower on Texas Boulevard Hall and was not clean for residents to use. RN D said it was her responsibility to ensure the showers were clean. RN D said a resident could get an infection from an unclean shower. RN D said the showers were cleaned daily by housekeeping. RN D was unsure why the shower was not cleaned.<BR/>During an observation and interview on 04/04/2023 at 12:58 p.m., the DON and administrator, after viewing the showers, said the showers should be clean for the residents' use. The DON and administrator said the unsecured chemicals in the shower could be an accident especially sitting next to the bath linen. The DON said the showers should be cleaned daily by housekeeping .<BR/>During and observation and interview on 04/05/2023 at 1:30 p.m., the bathtub in the public restroom had a black substance growing. The DON said the black substance in the bathtub in the public bathroom should be cleaned daily by housekeeping .<BR/>During a confidential resident group meeting, 1 of 11 residents said they hated to shower in the resident communal showers because they were so filthy.<BR/>During an interview on 04/05/2023 at 1:16 p.m., the Housekeeping Supervisor said she was responsible for ensuring the communal showers and public restrooms were clean for use. The housekeeping supervisor said she had three open positions, and this played a role in some cleaning lapses . <BR/>During an interview on 04/05/2023 at 3:15 p.m., the ADON said the showers should be cleaned at least daily. The ADON said the CNAs were responsible for cleaning up after a communal shower was used. The ADON said a resident could acquire an infection from a dirty shower.<BR/>During an interview on 04/05/2023 at 3:30 p.m., the administrator said he was responsible for the oversight of the communal shower rooms and public restroom's cleanliness with the help of the Housekeeping Supervisor. The administrator said the Housekeeping Supervisor did not have a cleaning schedule at this time. The administrator said the showers and the public restroom should be cleaned daily by housekeeping.<BR/>During an interview on 04/05/2023 at 3:41 p.m., the DON said she believed the communal showers were being overlooked for cleaning. The DON said the nurse managers made morning rounds but had not implemented afternoon rounds to ensure rooms and showers were cleaned. The DON said no one would want to be bathed in an area that was not clean. The DON said a resident could get an infection from being bathed in an unclean area.<BR/>Record review of the facility's nursing policy and procedure, Infection Control-Environmental Rounds, dated 01/2023, indicated the policy of this home was that the administrator or other appropriate designee completes environmental rounds on a regular basis. Environmental rounds will be an integral part of the daily routine and will be performed regularly throughout the entire home, with detailed reporting to all units and departments as needed. (It is suggested that a selection of individual units as well as the dietary, laundry, and housekeeping departments be specifically identified for closer scrutiny each month.)

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 7 of 7 confidential residents reviewed for food and nutrition services. <BR/>The facility failed to ensure dietary staff provided food that was palatable and appetizing temperature on 5/08/2024 for confidential residents.<BR/>These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.<BR/>Findings included:<BR/>During an initial tour interview on 5/06/2024 between 9:28 a.m. - 4:00 p.m., 2 confidential residents voiced their meal trays, when received, were cold.<BR/>During a confidential group interview on 5/07/2024 at 2:00 p.m., 5 residents said the food trays served on the halls were cold.<BR/>Record review of the food temperature log dated May 8,2024 indicated the Regular meat's temperature at the time of serving was 188 degrees Fahrenheit, the cooked vegetables were 170- and 171-degrees Fahrenheit, and the dessert was 33 degrees Fahrenheit.<BR/>During an observation on 5/08/2024 at 11:50 a.m., the tray cart with the test tray left the kitchen preparation area. The tray cart was reviewed by nurses and left the dining room and went directly to the hall. The trays were passed starting from 11:53 a.m. and ending when the test tray arrived in the work room at 12:10 p.m. The resident trays nor the test tray were prepared on warmed plates using a plate warmer.<BR/>During a test tray interview with the Dietary Manager and State Surveyors on 5/08/2024 12:10 p.m., The Dietary Manager stated the following regarding the regular food diet for lunch served on 5/08/2024: chicken fajita taco tasted like chicken fajita taco but was cold; beans were hot and seasoned well, Mexican corn was warm at best, and gelatin was cold. The Surveyors stated chicken fajita was cold, the beans were hot, corn was warm at best, and gelatin was cold. <BR/>During an interview on 5/09/2024 at 11:44 a.m., the DON said she expected the meals to be served at the standard required temperatures. The DON said the food served at a palatable temperature would prevent decreased intake and prevent weight loss. The DON said the Dietary Manager was responsible for ensuring palatability. <BR/>During an interview on 5/09/2024 R 12:52 p.m., the RDO said he expected the meals to be palatable regarding temperature and taste. The RDO said he said palatability ensured enjoyable meals. The RDO said nursing and the dietary department was responsible for ensuring meals were palatable. <BR/>During an interview on 5/09/2024 at 2:37 p.m., the Dietary Manager said the test tray tasted good, but the temperature needed improvement. The Dietary Manager said the cold plate could have caused the food temperature to drop. The Dietary Manager said it was important the residents enjoyed their food and should be a priority.<BR/>During an interview on 5/09/2024 at 3:30 p.m., the RNC indicated there was no policy on the palatability of food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident and hazards for 2 of 7 residents (Residents #1 and #2) reviewed for accident hazards.<BR/>CNA B and CNA C failed to ensure Resident #2's Hoyer lift (an assistive lift device that allows for transfer using electrical power) transfer was performed correctly. <BR/>CNA D did not lock Resident #1's bed during incontinent care. <BR/>These failures could place dependent residents at risk for falls, significant injuries and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 1/9/24 indicated Resident #2 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, dementia, high blood pressure and COPD (chronic obstructive pulmonary disease - group of lung diseases that block airflow and make it difficult to breathe). <BR/>Record review of the MDS dated [DATE] indicated Resident #2 had unclear speech, rarely made herself understood and rarely understood others. The MDS indicated Resident #2 cognitive skills for decision making was severely impaired and she had both long-term and short-term memory problems. The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #2 was completely dependent on staff for toileting, oral hygiene, eating, bathing, dressing, and personal hygiene. The MDS indicated Resident #2 was completely dependent on staff for rolling side to side and all transfers. The MDS indicated Resident #2 had no impairment to the upper and lower extremities. The MDS indicated Resident #2 was always incontinent of bowel and bladder.<BR/>Record review of the care plan dated on 10/19/23 indicated Resident #2 had a self-care deficit due to her impaired cognition and impaired mobility. The care plan interventions included staff to assist resident with transfers as needed. The care plan also indicated Resident #2 was at risk for falls due to factors including decreased activity, confusion, and poor safety awareness. <BR/>During an observation on 1/9/24 at 1:20 p.m., CNA B and CNA C began to transfer Resident #2 from her wheelchair to her bed using a Hoyer lift. Resident #2 was initially combative with the CNAs, swinging her arms at them as they worked to attach the Hoyer sling to the Hoyer lift. After hooking the sling to the Hoyer lift, without locking the brakes (on the wheels) of the Hoyer lift, CNA B and CNA C lifted Resident #2 from her wheelchair. They (CNA B and CNA C) then guided the Hoyer lift to Resident #2's bed. Without locking the brakes of the Hoyer lift, they (CNA B and CNA C) lowered Resident #2 into the bed. <BR/>During an interview on 1/9/24 at 1:34 p.m., CNA B said she should have ensured the brakes were locked on the Hoyer lift wheels before Resident #2 was lifted from her wheelchair and before they (CNA B and CNA C) lowered Resident #2 into the bed. CNA B said she just forgot to double check and ensure the lift brakes (on the wheels of the Hoyer) were locked during the transfer. CNA B said the lift could have slid when they lifted/lowered Resident #2 and fallen over, especially since she (Resident #2) could be combative. CNA B said Resident #2 could have fallen out of the lift and gotten hurt. <BR/>During an interview on 1/9/24 at 1:37 p.m., CNA C said she should have ensured the brakes (on the wheels of the Hoyer) were locked on the Hoyer lift before Resident #2 was lifted from her wheelchair and before they (CNA B and CNA C) lowered Resident #2 into the bed. CNA C said she was just busy and forgot to ensure the Hoyer lift brakes were locked. CNA C said the lift could have tipped over and Resident #2 could have fallen into the floor. <BR/>2.Record review of the face sheet dated 1/9/24 indicated Resident #1 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, high blood pressure and heart disease. <BR/>Record review of the MDS dated [DATE] indicated Resident #1 had clear speech, usually made herself understood and usually understood others. The MDS indicated Resident #1 had mild cognitive impairment (BIMS of 9). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #1 required substantial/maximal assistance with personal hygiene, putting on/taking off footwear, dressing, and bathing. The MDS indicated Resident #1 required substantial/maximal assistance with rolling left to right and tub/shower transfer. The MDS indicated she required partial/moderate assistance with sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, and toilet transfer. The MDS indicated she required partial/moderate assistance with toileting and oral hygiene. The MDS indicated Resident #1 required setup or clean-up assistance with eating. The MDS indicated Resident #1 required extensive assistance of 2 persons to complete bed mobility, transfers, bathing and toilet use. The MDS indicated she had no impairment to the upper and lower extremities. The MDS indicated Resident #1 was frequently incontinent of bowel and bladder.<BR/>Record review of the care plan dated on 12/25/23 indicated Resident #1 had a self-care deficit due to her impaired cognition and impaired mobility. The care plan interventions included staff to assist resident with turning/repositioning while in bed, and staff will assist bathroom. The care plan also indicated Resident #1 was at risk for falls due to factors including decreased mobility.<BR/>During an observation on 1/9/24 at 1:00 p.m., CNA D provided incontinent care to Resident #1. CNA D did not check the brakes on the wheels of the bed before she started the incontinent care. During the incontinent care, CNA D moved the bed away from the wall and went to the left side of the bed (the side that was against the wall). CNA D did not lock the brakes on the wheels of the bed. CNA D then rolled Resident #1 to her (Resident #1's) right side (the side not against the wall). CNA D completed the care, returned the bed to the original position and did not lock the brakes on the wheels of the bed. <BR/>During an interview on 1/9/24 at 1:10 p.m., CNA D said she should have locked Resident #1's bed before starting the incontinent care, after she moved the bed, and after returning the bed to its original position. CNA D said Resident #1 could have fallen out the bed and sustained an injury. <BR/>During an interview on 1/9/24 at 1:40 p.m., LVN A said the CNAs should have ensured the brakes on the wheels on the Hoyer lift were locked before Resident #2 was lifted/lowered with the Hoyer lift. LVN A said CNA D should have double checked to ensure Resident #1's bed was locked before care was started. LVN A said Resident #1's bed should have been locked, before Resident #1 was repositioned in the bed and after CNA D completed Resident #1's care. LVN A said these things (the Hoyer lift brakes on the wheels left unlocked during the lift/descent of a resident and not ensuring bed brakes (on the wheels) were locked when a resident was repositioned in the bed) were safety issues. LVN A said Resident #2 could have been dropped from the Hoyer lift and Resident #1 could have fallen out of the bed.<BR/>During an interview on 1/9/24 at 1:57 p.m., the ADON said the CNA B and CNA C should have ensured the brakes on the wheels on the Hoyer lift were locked before Resident #2 was lifted/lowered with the Hoyer lift. The ADON said CNA D should have ensured Resident #1's bed was locked before care was started, before Resident #1 was repositioned and after the care was completed. The ADON said these things (the Hoyer lift brakes on the wheels left unlocked during the lift/descent of a resident and not ensuring bed brakes (on the wheels of the bed) were locked when a resident was repositioned in the bed) were posed a risk of injury. She said the system in place to ensure staff performed Hoyer lift transfers safely was the annual skills check off which included Hoyer lift transfers and ensuring brakes were locked on beds before repositioning a resident. The ADON said going forward a system would be put in place to perform spot checks on CNAs to ensure they were safely repositioning and transferring residents. <BR/>During an interview on 1/9/24 at 3:00 p.m., the Administrator said he expected staff to take appropriate measures to ensure residents safety during Hoyer lift transfers and incontinent care. The Administrator said leaving the bed unlocked and the Hoyer lift unlocked while a resident was lifted/lowered were not practices that would ensure resident safety. <BR/>During an interview on 1/9/24 at 2:30 p.m., the ADON said the facility did not have a policy and procedure specifically related to ensuring bed brakes (on the wheels of the bed) were locked. <BR/>Record review of the facility policy and procedure titled Lifting and movement of Resident-safe, dated December of 2017 stated, Policy: In order to protect the safety and well-being of staff and residents and to promote quality care, this home uses appropriate techniques and devices to lift and move residents . The policy and procedure did not specifically address the use of bed brakes (on the wheels of the bed or mechanical lift brakes (on the wheels of the mechanical lift). <BR/>Record review of the facility policy and procedure titled Mechanical Lift, dated December of 2017 reveled it did not specifically address the use of mechanical lift brakes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that medication error rates of 5 percent or greater. The facility had a medication error rate of 7.14 %, based on 2 errors out of 28 opportunities, which involved 1 of 7 residents (Resident #23) reviewed for medication administration .<BR/>The facility failed to ensure Resident #23 received aspirin (non-steroidal anti-inflammatory) and magnesium oxide (supplement) at the correct dosage.<BR/>This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.<BR/>Findings included:<BR/>Record review of Resident #23's face sheet indicated an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses which included Alzheimer's disease (memory loss), and atrioventricular block (heart beats more slowly).<BR/>Record review of Resident #23's consolidated physician's orders, dated 03/04/2023, indicated she was prescribed aspirin delayed release 325 milligrams by mouth daily for a slow heartbeat with a start date of 03/04/2023, and magnesium oxide 500 milligrams by mouth for osteoporosis (brittle bones) with a start date of 03/04/2023.<BR/>Record review of Resident #23's Annual MDS, dated [DATE], indicated she usually understood and was usually understood. Resident #23's BIMS score indicated she had a severe cognitive deficit. <BR/>Record review of Resident #23's comprehensive care plan, dated 03/23/2023, indicated she had a diagnosis of osteoporosis (brittle bones) and was at risk for fractures. The care plan indicated the goal was Resident #23 would remain free of any injuries. The intervention was to administer medications as ordered.<BR/>During an observation on 04/03/2023 at 10:45 a.m., the ADON administered aspirin 81 milligrams, and magnesium oxide 400 milligrams by mouth to Resident #23.<BR/>During an interview on 04/05/2023 at 10:40 a.m., the ADON said she should have administered aspirin 325 milligrams, and magnesium oxide 500 milligrams . The ADON said by not administering the ordered doses of these medications Resident #23 was not receiving the desired therapeutic effects. The ADON said the usual dose of magnesium oxide was 400 milligrams not realizing she misread the dosage.<BR/>During an interview on 04/05/2023 at 3:30 p.m., the administrator said medications should be administered by the right medication, right dose, the right person, and the right time. The administrator said the resident would not receive the same results with the inaccurate dosing. The administrator said the pharmacy consultant evaluated medication pass. The administrator said he expected the residents to receive the medications the physician ordered to have the therapeutic results.<BR/>During an interview on 04/05/2023 at 3:38 p.m., the DON said she expected the medications to be administered as prescribed. The DON said not receiving the prescribed medications in the correct doses could provide less of the desired effect. The DON said she and the ADON were responsible for ensuring medications were administered according to the 6 rights of medication administration. <BR/>Record review of the facility's policy titled, Medication-Administration, dated 01/2023 indicated, .It was the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations.13. Prior to administration, the medication and dosage schedule on the resident's medication administration record is compared with the medication label.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 6 medication carts (main street medication cart) reviewed for medication storage.<BR/>The facility failed to ensure the main street hall medication cart was locked when the ADON left the floor and left the cart unattended. <BR/>This failure could place residents at risk of taking medications not intended for them with adverse outcomes; risk of loss/interruption in receiving medications.<BR/>Findings included:<BR/>During an observation on 04/03/23 from 11:46 a.m. to 11:57 a.m., the main street hall medication cart was left on the main street hall unlocked and unattended while nurse had left it to go to the dining room. <BR/>During an observation and interview on 04/03/23 at 11:57 AM, the Corporate Clinical Nurse walked up to the cart and tried to hide her hand while she locked the medication cart. The Corporate Clinical Nurse said anything could happen with the cart being unlocked. The Corporate Clinical Nurse said anyone could have accessed the cart and ingested the medications. She said the nurse was responsible to ensure the carts were locked.<BR/>During an interview on 04/03/23 at 12:07 PM, the ADON said she was responsible for the medication cart and had forgotten to lock the cart. The ADON said with the cart being unlocked any resident, staff, or visitor could have opened the cart and took the medications out of the cart. The ADON said she was busy and did not lock the cart prior to her leaving the cart. The ADON said the facility performed proficiency checkoffs to ensure the nurses and medication aides were aware of the need to lock the medication carts on the hallways when the carts were not in use. She said the DON was responsible for completing proficiency checkoffs. <BR/>During an interview on 04/05/23 at 03:21 PM, the DON said the medication carts should always be locked if the nurse or aide was not working out of the cart. The failure to lock the medication cart could place a staff or visitor, who was unauthorized to access the medications, capability of getting in the cart. The DON said any resident in the facility could get into the cart and take the medications. The policy and procedures upon hire instructed all nurses or med aides to always keep the cart locked. She said it was a part off the skills checkoff<BR/>During an interview on 04/05/23 at 03:38 PM, the administrator said if the medication carts were not being used, they should be closed and locked. He said the failure to lock the medication carts provided risks of residents taking medications that they did not need, as well as other staff and visitors. The administrator said the nursing staff were responsible for ensuring the carts were locked.<BR/>Record review of the policy for Medication Storage, dated 1-2023, indicated<BR/>Policy<BR/>It is the policy of this home that the medications will be stored appropriately as to be secure from tampering, exposure, or misuse. <BR/>Procedure<BR/>1. <BR/>The provider pharmacy dispenses medications .<BR/>2. <BR/>Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (i.e., medication aides, etc.) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 7 of 7 confidential residents reviewed for food and nutrition services. <BR/>The facility failed to ensure dietary staff provided food that was palatable and appetizing temperature on 5/08/2024 for confidential residents.<BR/>These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.<BR/>Findings included:<BR/>During an initial tour interview on 5/06/2024 between 9:28 a.m. - 4:00 p.m., 2 confidential residents voiced their meal trays, when received, were cold.<BR/>During a confidential group interview on 5/07/2024 at 2:00 p.m., 5 residents said the food trays served on the halls were cold.<BR/>Record review of the food temperature log dated May 8,2024 indicated the Regular meat's temperature at the time of serving was 188 degrees Fahrenheit, the cooked vegetables were 170- and 171-degrees Fahrenheit, and the dessert was 33 degrees Fahrenheit.<BR/>During an observation on 5/08/2024 at 11:50 a.m., the tray cart with the test tray left the kitchen preparation area. The tray cart was reviewed by nurses and left the dining room and went directly to the hall. The trays were passed starting from 11:53 a.m. and ending when the test tray arrived in the work room at 12:10 p.m. The resident trays nor the test tray were prepared on warmed plates using a plate warmer.<BR/>During a test tray interview with the Dietary Manager and State Surveyors on 5/08/2024 12:10 p.m., The Dietary Manager stated the following regarding the regular food diet for lunch served on 5/08/2024: chicken fajita taco tasted like chicken fajita taco but was cold; beans were hot and seasoned well, Mexican corn was warm at best, and gelatin was cold. The Surveyors stated chicken fajita was cold, the beans were hot, corn was warm at best, and gelatin was cold. <BR/>During an interview on 5/09/2024 at 11:44 a.m., the DON said she expected the meals to be served at the standard required temperatures. The DON said the food served at a palatable temperature would prevent decreased intake and prevent weight loss. The DON said the Dietary Manager was responsible for ensuring palatability. <BR/>During an interview on 5/09/2024 R 12:52 p.m., the RDO said he expected the meals to be palatable regarding temperature and taste. The RDO said he said palatability ensured enjoyable meals. The RDO said nursing and the dietary department was responsible for ensuring meals were palatable. <BR/>During an interview on 5/09/2024 at 2:37 p.m., the Dietary Manager said the test tray tasted good, but the temperature needed improvement. The Dietary Manager said the cold plate could have caused the food temperature to drop. The Dietary Manager said it was important the residents enjoyed their food and should be a priority.<BR/>During an interview on 5/09/2024 at 3:30 p.m., the RNC indicated there was no policy on the palatability of food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that medication error rates of 5 percent or greater. The facility had a medication error rate of 7.14 %, based on 2 errors out of 28 opportunities, which involved 1 of 7 residents (Resident #23) reviewed for medication administration .<BR/>The facility failed to ensure Resident #23 received aspirin (non-steroidal anti-inflammatory) and magnesium oxide (supplement) at the correct dosage.<BR/>This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.<BR/>Findings included:<BR/>Record review of Resident #23's face sheet indicated an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses which included Alzheimer's disease (memory loss), and atrioventricular block (heart beats more slowly).<BR/>Record review of Resident #23's consolidated physician's orders, dated 03/04/2023, indicated she was prescribed aspirin delayed release 325 milligrams by mouth daily for a slow heartbeat with a start date of 03/04/2023, and magnesium oxide 500 milligrams by mouth for osteoporosis (brittle bones) with a start date of 03/04/2023.<BR/>Record review of Resident #23's Annual MDS, dated [DATE], indicated she usually understood and was usually understood. Resident #23's BIMS score indicated she had a severe cognitive deficit. <BR/>Record review of Resident #23's comprehensive care plan, dated 03/23/2023, indicated she had a diagnosis of osteoporosis (brittle bones) and was at risk for fractures. The care plan indicated the goal was Resident #23 would remain free of any injuries. The intervention was to administer medications as ordered.<BR/>During an observation on 04/03/2023 at 10:45 a.m., the ADON administered aspirin 81 milligrams, and magnesium oxide 400 milligrams by mouth to Resident #23.<BR/>During an interview on 04/05/2023 at 10:40 a.m., the ADON said she should have administered aspirin 325 milligrams, and magnesium oxide 500 milligrams . The ADON said by not administering the ordered doses of these medications Resident #23 was not receiving the desired therapeutic effects. The ADON said the usual dose of magnesium oxide was 400 milligrams not realizing she misread the dosage.<BR/>During an interview on 04/05/2023 at 3:30 p.m., the administrator said medications should be administered by the right medication, right dose, the right person, and the right time. The administrator said the resident would not receive the same results with the inaccurate dosing. The administrator said the pharmacy consultant evaluated medication pass. The administrator said he expected the residents to receive the medications the physician ordered to have the therapeutic results.<BR/>During an interview on 04/05/2023 at 3:38 p.m., the DON said she expected the medications to be administered as prescribed. The DON said not receiving the prescribed medications in the correct doses could provide less of the desired effect. The DON said she and the ADON were responsible for ensuring medications were administered according to the 6 rights of medication administration. <BR/>Record review of the facility's policy titled, Medication-Administration, dated 01/2023 indicated, .It was the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations.13. Prior to administration, the medication and dosage schedule on the resident's medication administration record is compared with the medication label.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that medication error rates of 5 percent or greater. The facility had a medication error rate of 7.14 %, based on 2 errors out of 28 opportunities, which involved 1 of 7 residents (Resident #23) reviewed for medication administration .<BR/>The facility failed to ensure Resident #23 received aspirin (non-steroidal anti-inflammatory) and magnesium oxide (supplement) at the correct dosage.<BR/>This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.<BR/>Findings included:<BR/>Record review of Resident #23's face sheet indicated an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses which included Alzheimer's disease (memory loss), and atrioventricular block (heart beats more slowly).<BR/>Record review of Resident #23's consolidated physician's orders, dated 03/04/2023, indicated she was prescribed aspirin delayed release 325 milligrams by mouth daily for a slow heartbeat with a start date of 03/04/2023, and magnesium oxide 500 milligrams by mouth for osteoporosis (brittle bones) with a start date of 03/04/2023.<BR/>Record review of Resident #23's Annual MDS, dated [DATE], indicated she usually understood and was usually understood. Resident #23's BIMS score indicated she had a severe cognitive deficit. <BR/>Record review of Resident #23's comprehensive care plan, dated 03/23/2023, indicated she had a diagnosis of osteoporosis (brittle bones) and was at risk for fractures. The care plan indicated the goal was Resident #23 would remain free of any injuries. The intervention was to administer medications as ordered.<BR/>During an observation on 04/03/2023 at 10:45 a.m., the ADON administered aspirin 81 milligrams, and magnesium oxide 400 milligrams by mouth to Resident #23.<BR/>During an interview on 04/05/2023 at 10:40 a.m., the ADON said she should have administered aspirin 325 milligrams, and magnesium oxide 500 milligrams . The ADON said by not administering the ordered doses of these medications Resident #23 was not receiving the desired therapeutic effects. The ADON said the usual dose of magnesium oxide was 400 milligrams not realizing she misread the dosage.<BR/>During an interview on 04/05/2023 at 3:30 p.m., the administrator said medications should be administered by the right medication, right dose, the right person, and the right time. The administrator said the resident would not receive the same results with the inaccurate dosing. The administrator said the pharmacy consultant evaluated medication pass. The administrator said he expected the residents to receive the medications the physician ordered to have the therapeutic results.<BR/>During an interview on 04/05/2023 at 3:38 p.m., the DON said she expected the medications to be administered as prescribed. The DON said not receiving the prescribed medications in the correct doses could provide less of the desired effect. The DON said she and the ADON were responsible for ensuring medications were administered according to the 6 rights of medication administration. <BR/>Record review of the facility's policy titled, Medication-Administration, dated 01/2023 indicated, .It was the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations.13. Prior to administration, the medication and dosage schedule on the resident's medication administration record is compared with the medication label.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to conduct and document a facility wide assessment to determine what resources were necessary to care for it's residents competently during both day-to-day operation, including nights and weekend, and emergencies for 1 of 1 facility assessment reviewed for administration and 1 resident who received dialysis (Resident #53).The facility failed to ensure the assessment accurately reflected dialysis patients.This deficient practice could place residents at risk for inadequate care or treatmentsThe findings include:Record review of the Facility assessment dated [DATE] (date of assessments or update) read in part: . Special Treatments and Conditions . dialysis. Number/Average or Range of Residents . 0 . Record review of Resident #53's face sheet, dated 06/25/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #53 had diagnoses which included Chronic kidney disease, also called chronic kidney failure (involves a gradual loss of kidney function), malignant neoplasm of kidney (a cancerous tumor in the kidney), diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and high blood pressure.Record review of Resident #53's admission MDS assessment, dated 04/21/25, indicated Resident #53 understood others and was understood by others. The Resident #53 had a BIMS score of 13, which indicated he was cognitively intact. Resident #53 required assistance with bathing, toileting, dressing, bed mobility, personal hygiene, and eating. Resident #53 received dialysis. Record review of Resident #53's care plan, dated 04/21/25, indicated he was scheduled for dialysis on Tuesday, Thursday, and Saturdays. Record review of Resident #53's orders indicated the resident's dialysis order was dated 04/21/25.During an observation and interview on 06/24/25 at 3:30 p.m., the Administrator said he had 1 resident, Resident #53, who received dialysis. He looked at the facility assessment and said Resident #53 should have been on the facility assessment. He said he reviewed the facility assessment on 06/19/25 but did not realize Resident #53 had not been added; he said it was an oversight. He said he just missed the dialysis being documented and it was important to have the facility assessment accurate because it reflected the care they provided to the residents in the facility.During an interview on 07/01/25 at 01:32 PM, the DON said the facility did not have a policy for facility assessment.