Coral Rehabilitation and Nursing of Arlington

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances residents had and ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for two months (December 2024 and January 2025) of two months reviewed of resident council meetings and facility-received grievances.<BR/>1. The facility failed to document any attempts to resolve Resident #2's grievance when he expressed concern there was no hot or warm water available in his room. <BR/>2. The facility failed to document show evidence of attempts to resolve all grievances from the Resident Council for December 2024 and January 2025. <BR/>This failure could place residents at risk with unresolved grievances and unmet care needs. <BR/>Findings included:<BR/>1. Record review of Resident #2's Face Sheet reflected dated 01/30/25 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2's active diagnoses included paraplegia (a condition that causes paralysis or loss of muscle function in both legs), neuromuscular dysfunction of bladder (impaired bladder control due to disrupted communication between the brain and the bladder muscles), Stage 4 pressure ulcer of right heel and Stage 4 pressure ulcer of right lower back.<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 15 which indicated no cognitive impairment. Resident #2 had range of motion impairment on both sides of his lower extremities and used a wheelchair for mobility. Resident #2 required partial/moderate assistance from staff for bathing and personal hygiene. He had an indwelling and external catheter (a flexible tube inserted into the body to drain or deliver fluids) and ostomy (a surgical procedure that creates an opening in the abdomen to allow waste to exit the body).<BR/>An interview with Resident #2 on 01/30/25 at 1:49 PM revealed he had been moved to the room he was in several days prior and there was no hot or warm water available in his bathroom to use. Resident #2 stated he had let the water run in his bathroom sink for over an hour when he first got moved to the room but there was nothing but cold water. He said the shower at the end of his hall also did not have any hot or warm water. Resident #2 said he had not received a shower the past two scheduled times (01/27/25 and 01/29/25). Resident #2 stated he felt not having hot or warm water available in his room made him feel very dirty, he said he could not wash his face well and it was starting to breakout and his skin was starting to get itchy all over. <BR/>An observation of Resident #2's bathroom sink faucet on 01/30/25 at 1:50 PM revealed it did not have hot or warm water. <BR/>An observation of Resident #2' shower room at the end of Hall 400 on 01/30/25 at 1:56 PM revealed there was no hot or warm water coming from the shower faucet. <BR/>Review of a grievance from Resident #2 dated 01/28/25 reflected he communicated to the SW a concern there was no hot water in his bathroom. The grievance form noted the maintenance director was assigned responsibility to follow up on the concern on 01/29/25. The grievance's sections for 1) Documentation of the Investigation (which included findings, plan to resolve, results of action taken, reportable to state agency), 2) Resolution (which included if the complaint/grievance was resolved, was complainant satisfied, complainant remarks and how was the investigation results communicated to the person-verbal or written, and 3) Signatures of Resident/Department Head and Dates were all blank. <BR/>Review of the SW's Monthly Grievance Log provided by the ADM reflected an entry for Resident #2's concern about not hot/warm water on 01/28/25 and showed it was sent to the maintenance director for follow up. <BR/>An interview with the ADM on 01/30/25 at 9:30 AM revealed the DON was out sick on leave.<BR/>An interview with the Maintenance Director on 01/30/25 at 2:30 PM revealed he knew the hot water heater was broken on hall 400 and he thought it had been broken for about two weeks. He stated Resident #2 did not have any hot water in his room and had been moved to that room over the past weekend and was upset about it. The Maintenance Director stated he had seen a grievance filed for Resident #2 on 01/28/25 related to the lack of hot water and stated he was just waiting for the owner of the facility to approve the repairs. He stated. I kind of wish it wasn't out of my hands because I would not have let it last that long. <BR/>2. Record review of the facility's Resident Council Meeting Minutes for December 2024 reflected concerns related to:<BR/>- A resident was not getting enough portions to eat and would like double portions.<BR/>- A resident asked for more food and was denied <BR/>-Nobody listens to the residents and they do not get any help from the staff. <BR/>-A CNA (identified by name) was lazy and refused to assist residents, did not listen to them, or answer the call lights and refused to do the residents' smoke breaks. <BR/>-Residents complained of sleep deprivation due to loud TVs and music playing at night <BR/>Additionally, the resident council meeting minutes form documented the grievances related to food were sent to the dietary manager and the DON was routed the rest of them. <BR/>Record review of the facility's Resident Council Meeting Minutes for January 2025 reflected concerns related to:<BR/>- The weekend staff do not answer call lights<BR/>- Facility nurses did not help when needed<BR/>- There was no staff assistance available at night to help residents<BR/>- Rat! Rats are eating up food. Rats are in rooms, holes in ceiling.<BR/>- Heat complaints that it was too cold in the facility and residents were freezing at night. <BR/>- A staff member (identified by name) was refusing to assist the residents<BR/>- The fried food served was too hard and residents could not chew it.<BR/>- Dialysis residents continued to be served food they were not supposed to have. <BR/>- There was no coffee available at the facility. <BR/>Record review of the facility grievances provided by the ADM on 01/30/25 revealed only three resident specific issues (not listed above) had written grievances that had been resolved. None of the other concerns voiced by the residents during the two resident council meetings had been addressed. <BR/>3. An interview with the SW on 01/30/25 at 2:45 PM revealed in general the facility grievances came to her, but not always. When she received them, she would log them in a binder. The SW stated when concerns were voiced during a resident council meeting, the activity director was supposed to document it on a grievance form and then give it to whatever department head was in charge of the issue. The SW stated if the activity director did not make a copy for the SW, then the SW did not have a record of it and could not log it and track it to its conclusion. The SW stated she did not know why the activity director was not writing up the concerns voiced by the residents during their resident council and making sure they got to the SW. Regarding Resident #2, the SW revealed Resident #2 had voiced a concern during the past few days related to not having any hot water in his room. The SW stated she logged the grievance for him on the form and put it in the maintenance director's box. The SW stated Resident #2 wanted to have hot water in his room so she told him she would let the maintenance department know. The SW stated with grievances, she tried to identify who was responsible for the resolution of the grievances and then forward them the form to complete. The SW stated she had not been getting them back from the persons responsible and that the DON had been out on leave. The SW stated completing a grievance form in its entirety was important because, We are supposed to resolve them and it is hard if no one is investigating and no one is speaking to the resident or family. The SW stated in the morning meetings, she had not developed a good system yet for going over the grievances. She said she would remind the staff during those meetings if they had any grievance forms completed, to give them to her. The SW said when she first started working at the facility, she saw the grievance system needed to be addressed and she wanted to be able to talk more about them during the morning meetings. However, she was told by other staff the meetings were long enough as it was. The SW stated at the end of December 2024, she tried to bring up grievances again when she saw that the resident council concerns were not being addressed and there were numerous complaints with no resolution. The SW said she wanted to know what happened and the staff in those meetings told her, Oh, they are all psychotic and Shut me down in wanting to discuss concerns of the residents.<BR/>An interview with the AD on 01/31/25 at 11:08 AM revealed she was the scribe for the resident council meetings and when the residents in the meetings voiced complaints, she wrote them up on grievance forms. Once those forms were started, the AD sent them to the SW and the SW handed the form(s) out to the department head responsible for the issue the resident had. The AD stated sometimes she (AD) also gave the resident council concerns directly to the ADM who would say to hold onto them until the next morning meeting when the department heads would be present. The AD stated the SW was responsible to go to the resident council members and let them know about the resolution of their concerns, but the AD also let the resident council know that she had sent them in and they would be notified about results. The AD stated she rarely knew what the resolution was of a grievance from the resident council except for dietary. She said with dietary issues, the dietary manager was on top of it and would let the AD know what was done about any complaints. The AD stated if the resident council brought up an issue that was general in nature and not resident specific, she would still complete a grievance and give it to the DON to follow up, not the SW, but the SW would still get a copy to log. The AD stated she had received numerous complaints that the SW was not doing her job and was putting grievances to the side and did not see them as a priority. The AD stated the residents were frustrated their concerns were not being addressed and felt they were not being heard. The AD stated, That is why I talked to the Administrator and he said let's start passing them out in stand-up as well as give a copy to the social worker so everyone is on the same page. <BR/>An interview with the ADM on 01/31/25 at 1:54 PM revealed his expectation was when a grievance was made, it was written on a grievance form, dated, a copy made and turned into the SW or ADM. Typically, the ADM then would see the concern before it got routed to the specific department head and he would tell that department head they had 72 business hours to look into the issue. Then the department head was supposed to fill out the outcome portion of the form and let the person know who made the grievance what the outcome was and then give it to the SW to track and trend. The ADM stated grievances were important to address because it was a resident right, and the residents had the right to ensure the facility was tracking their concerns and showing what they did to resolve them in a timely manner. <BR/>4. Review of the facility's policy titled, Filing Grievances/Complaints, revised August 2008, reflected, Our facility will help residents, their representatives (sponsors) other interested family members, or resident advocated file grievances or complaints when such requests are made .4. The Administrator has designated the responsibility of grievance and/or complaint investigation to [blank]; 5. Upon receipt of a grievance and/or complaint, [blank] will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint; 6. The Administrator will review the findings with the person investigation the complaint to determine what corrective actions, if any, need to be taken; 7. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The Administrator, or his or her designee, will make such reports orally within [blank] working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 3 (Resident #5, #14, and #62) of 7 residents reviewed for respiratory care, in that:<BR/>The facility failed to:<BR/>A.) Label and date the oxygen tubing and concentrator water bottle for Resident #5 and Resident #62.<BR/>B) Label and date Resident # 14 oxygen tubing<BR/>These deficient practices could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. <BR/>Findings Included:<BR/>Resident #5<BR/>Record review of Resident #5 face sheet dated 1/24/24 reflected a [AGE] year-old female admitted on [DATE], diagnosis include Chronic Respiratory failure with Hypoxia (low oxygen). <BR/>Record review of Resident #5's MDS dated [DATE], reflected a BIMS score of 14 indicating she was cognitively in tack. Functional level impaired on both sides and needs staff supervision for mobility, incontinent, eating set up or clean up assistance. MDS Section O - Special Treatments, Procedures, and Programs was left blank.<BR/>Record review of Resident #5's Care plan dated 12/07/23 Continuously on oxygen. via n/c. Administer medications as ordered. Monitor/document for side effects and effectiveness. The resident has shortness of breath (SOB) r/t chronic respiratory failure with hypoxia 02 at 2 LPM continuous via nasal to keep oxygen level above 92% every shift for SOB. Resident # 5 will have no complications related to SOB though the review date .Monitor/document breathing patterns. Report abnormalities to MD: Use universal precautions as appropriate. The care plan did not address changing oxygen tubing.<BR/>Record review of Resident #5's MD orders dated 09/27/23 reflected 02 at 2 LPM continuous via nasal to keep oxygen level above 92% every shift for SOB. There was no order for tubing change.<BR/>Observation on 01/24/25 at 12:00 PM of Resident #5's oxygen tubing and oxygen concentrator bottle was not dated and labeled.<BR/>In an interview on 01/24/24 at 12:00 PM with Resident #5 revealed she was on oxygen, and she does not know when the tubing was changed, however staff does change the tubing. She did not know which shift.<BR/>Resident #14<BR/>Record review of Resident #14 face sheet dated 01/24/24 reflected a [AGE] year-old male admitted on admission 6/23/23 with diagnosis: Paroxysmal Atrial Fibrillation (irregular heartbeats), Cardiovascular and Coagulations (heart attack, Chronic Obstructive Pulmonary Disease (inflammatory of lungs); Intermittent Asthma chronic lung disease, <BR/>Record review of resident # 14's MDS dated [DATE] reflected a BIMS score of 15 cognitively intact. Independent, uses a walker or manual wheelchair and has oxygen treatments.<BR/>Record review of Resident #14's care plan dated 01/09/24 reflected. The resident has Oxygen Therapy r/t . The resident will have no s/sx of poor oxygen absorption through the review date .Oxygen Settings: The resident has O2 via nasal cannula prn Oxygen @ 2L via NC . Resident will have no complications related to SOB. The care plan did not address changing oxygen tubing.<BR/>Observation on 01/24/25 at 12:05 PM of Resident #14's he was lying in bed with his NC positioned in his nose and concentrator on with oxygen flowing and his oxygen tubing was not dated and labeled.<BR/>In an interview on 01/24/24 at 12:10 PM with Resident #14 revealed he was a little confused and could not articulate responses to questions about tubing change. he said his oxygen was flowing well. <BR/>Resident #62<BR/>Record Review of resident #62 reflected a [AGE] year-old male with an admission date of 06/08/22, Dx Disorganized Schizophrenia, Pan lobular Emphysema condition effecting the whole acinus of the lungs permanently damaging the air sacs. Schizoaffective Disorder (mental illness), Chronic Obstructive Pulmonary Disease (inflammatory of lungs), Unspecified, chronic diastolic congestive heart failure. <BR/>Record review of Resident #62's quarterly MDS dated [DATE] reflected he had a BIMS score of 15, indicating he was cognitively intact. Resident is independent, uses a walker or manual wheelchair, has mood and behaviors. MDS Section O - Special Treatments, Procedures, and Programs was left blank <BR/>Record review of Resident #62's care plan dated 01/9/24 indicated the resident received O2 at 2 L per as needed to keep sat above 90%Resident will have no reports of unrelieved shortness of breath through next review date .Observe for SOB, respiratory distress, wheezing, fatigue, increased anxiety and implement appropriate ordered interventions and notify MD if interventions are not effective Provide medication as ordered. The care plan did not address changing oxygen tubing.<BR/>Record review of Resident #62's MD orders dated 08/12/22 reflected O2 at 2 L per (NC/FM/Non-rebreather) as <BR/>needed to keep sat above 90% as needed for SOB.<BR/>Observation and interview with Resident #62 on 01/24/25 at 12:50 PM revealed his oxygen tubing and oxygen concentrator bottle was not dated and labeled, the tubing was lying across the nightstand and inside the trash can. Resident #62 said the tubing was changed this morning by LVN D He does not recall staff dating tubing. <BR/>In an interview on 01/24/24 at 2:-10 PM with LVN D, the charge nurse for Resident #5, Resident #14, and Resident #62. LVN D said she assess resident's oxygen treatment and tubing during rounds and check for date the tubing was change in the nurse notes. LVN D said she had conducted rounds every 2 hours and had observed that the water bottle and tubing for Resident #5, Resident #14, and Resident #62 were not dated. LVN D said she would change the tubing at this time. LVN D said it was the assigned nurse for each shift to check for dates on all oxygen equipment and assess oxygen flow during resident rounds. LVN D said concentrator water bottles should be changed every 24 hours and she observe water bottle levels every 2 hours. LVN D said oxygen tubing should be changed, dated, and documented PRN and every Sunday by night shift. LVN D said failing to change the tubing, label, and date tubing and water bottle cold lead to overuse, kinks in hose, bacteria, respiratory infection, poor air flow, sepsis, and death.<BR/>In an interview with DON on 01/25/24 at 12:12 PM revealed oxygen tubing should be changed, dated, and labeled weekly by the overnight night nursing staff. He said the concentrator water bottles should be changed as needed and assessed during nursing rounds for accurate flow, tubing kinks, dates, and labels. The DON stated that facility protocols would develop and implement protocol for documentation moving forward. The DON said failing to change oxygen tubing for resident could lead to bacterial infection, or respiratory infection. He stated that the facility protocol does not mandate that oxygen tubing and treatment be documented, however he has educated nursing staff today on documentation, changing and dated. The DON said the facility does not use the TAR to document treatment at this time, however it was his plan to educate the nursing staff to document the change in tubing, dating, and labeling. The DON said it was the nursing staff responsibility to monitor oxygen for change and date. The DON the facility plan moving forward would include all nursing staff being in-serviced to change resident tubing weekly on Sunday 10AM-6PM shift. The DON said the morning charge nurses will check documentation, labels, and dates to assure nursing task was completed, and the ADON and DON will then monitor charge nursing task to assure accuracy. The DON expects the nursing staff to monitor for dates.<BR/>In an interview with the ADM on 01/25/24 at 1:30 PM wtih the ADM, and AIT, she expected staff to change the tubing, if visibly soiled. She was not sure of complications related to respiratory treatment task and maintenance as she does not have a clinical background. She said ADON, DON, and charge nurse are responsible for monitoring nursing and treatment procedures. <BR/>Review of facility's in-service dated 10/15/2022 and titled with topic: O2 therapy - weekly and PRN changing of O2 tubing (must date) revealed staff was in-serviced on changing and dating oxygen tubing.<BR/>Record review of facility policy Titled Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, 5 .Other infection control measures include: Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated .Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. Use only sterile water for humidification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide activities based on the comprehensive assessment and care plan, designed to meet the interests of and support the physical, mental and psychosocial well-being of one resident (Resident #4) out of five who were reviewed for activities. The facility failed to consistently provide encouragement and assistance to participate in facility provided activities for Resident #4. This failure could place residents at risk for social isolation, depression, and a decline in psychosocial well-being.Findings included: Review of Resident #4's annual Minimum Data Set, dated [DATE] reflected the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a condition caused by damage to the developing brain that affects a person's ability to control their muscles, problems with movement, coordination) kidney failure (kidneys are no longer able to properly filter waste and extra fluid from the blood), contracture (a muscle, tendon, or joint becomes permanently stiff or tight), and dysphagia (trouble swallowing). Review of Resident #4's annual Minimum Data Set assessment dated [DATE] reflected he had no speech, rarely/never made himself-understood, and sometimes was able to understand others. His Brief Interview for Mental Status was not completed. He was totally dependent on two staff for dressing, transferring, bathing and toilet use. He was totally dependent on staff for locomotion, eating, and personal hygiene. He was not ambulatory and had functional limitations in range of motion for upper extremity and lower extremity on both sides. He was indicated as always incontinent of bowel and bladder. He had a physical therapy start date of 03/29/25 with an end date of 04/21/25 with no minutes of treatment recorded during that duration. Review of Resident #4's Care Plan, initiated on 4/11/2018 and revised on 5/27/25 reflected Resident #4 would have 1:1 activity to Resident #4's likes/abilities. Activity Director to individualize activities for Resident #4 and work on getting Resident #4 to socialize with others in a group setting. The goal stated that Resident #4 would continue to participate in activities of choice to his likes/abilities through the next review date and to provide 1:1 assistance as needed to participate in activities. The Care Plan also stated that Resident #4 would have involvement related to music, therapy, and fitness each week at an unspecified number of times a week. The tasks/interventions stated Resident #4 needed a variety of activity types and locations to maintain interests. The tasks/interventions stated that Resident #4 would need assistance/escort to activity functions. The Care Plan included a Focus that stated Resident #4 was high risk for decreased quality of life related to little interest in activities. The goal stated that Resident #4 would maintain his highest practical quality of life as evidenced by attending activities of choice. The intervention/task stated that the facility would encourage Resident #4 to attend group activities as it appeared Resident #4 enjoyed singing and sports where he could participate passively. The facility would assist to/monitor individual/small group activities which included restorative exercise, watching TV, staff talking and laughing with him. Review of Resident #4's Individual Profile - Nursing Facility, dated 6/18/25 under section 4 titled These are my preferences and what is important to me reflected in part It is important for me to maintain a sense of pride and dignity.Please don't leave me in bed all day, I want to be dressed and out of bed in my chair.I love to be taken to musicals or listening to sing a longs and CD's.Sometimes the social workers pull me into their office and turn up the music where I can bounce to the tunes.I can watch TV up until dinner time.I especially like to watch all the action in sport programs.[Resident #4] likes to be out of room on a daily basis.[Resident] #4 enjoys people watch in the hallways or in the lobby of the nursing facility.It is important for [Resident #4] to be around other people. The plan went on to list activities Resident #4 enjoyed: [Resident #4] likes listening to music, instrument sounds, spending time outside, instrumentals, and being around others. Review of Resident #4's Individual Profile - Nursing Facility, dated 6/18/25 under section Communication stated Resident #4 did not communicate verbally, he would follow people with his eyes and watch what was going on, at times he would say ya, most of the time when someone would ask him a question he would not respond, he would show emotion in body language, make gestures and point or look toward things, and yell out. Review of Resident #4's Habilitative Service Plan, dated 6/18/25 reflected that Resident #4 wanted to listen to music, attend musicals when the facility offered them, TV/movies, music videos, music therapy, music exercise group, and go outside. Review of Resident #4's most recent Activity Evaluation, dated 6/24/24, reflected that Resident #4 required reminders/cues, extensive verbal cuing, and could not comprehend instructions. The evaluation indicated that Resident #4 used a wheelchair with max assist. The evaluation also indicated Resident #4 had a cooperative and cheerful attitude, needed assistance to and from activities, enjoyed 1 on 1 in room, bible study, and watching TV. Review of Resident #4's Progress Notes dated 4/5/25 at 4:30PM entered by Nutrition/Dietary stated in part .patient continues to want to be in his chair more sitting out.Even though patient is nonverbal he cries when he has to return to bed. Review of Resident #4's Progress Notes dated 5/18/25 at 10:19PM stated in part .[Resident] has been sitting up during the day for activities. Review of Resident #4's Progress Notes revealed no further notes that reflected Resident #4 participating in activities since 5/18/25 as indicated by the note entered for that day. Review of the most recent Activities Quarterly Note dated 2/9/24 at 1:01PM stated, Staff will continue to provide Resident #4 with 1:1 visit. Resident also enjoyed sitting in the TV room watching. Staff will continue to provide various activities. Review of the facility's activity calendar, dated July 2025, reflected the following scheduled activities for: 07/01/25 9:00AM - Coffee & Convo10:00AM - Daily Devotional 10:30AM - Nail Time & Chit Chat1:30PM - Arts N Craft3:00PM - In room visits6:00PM - Nightly Cinema Review of the facility's activity calendar, dated July 2025, reflected the following scheduled activities for: 07/02/25 9:00AM - Coffee & Convo10:00AM - Words for Life10:30AM - Fitness for Life1:00PM - Popcorn Social1:30PM - Bingo6:00PM - Nightly Cinema Review of the facility's activity calendar, dated July 2025, reflected the following scheduled activities for: 07/06/25 (Sunday) Activity of Your ChoiceReadingWriting - DrawingWord SearchesChurch Service on TV at 11amFamily Visits During interview and observation with Resident #4 on 7/1/25 at 10:09AM, he was observed to be lying in his bed. Resident #4 was non-verbal but made eye contact at times when spoken to. He was not able to answer questions by gesturing or nodding. Resident #4 was observed in a hospital gown. The TV was not on and no music was playing. During an observation of Resident #4 on 7/1/25 at 1:45PM, Resident #4 was observed to be lying in his bed in the same hospital gown. The TV was not on and no music playing. Resident was not participating in the scheduled activity of Arts N Crafts at 1:30PM. During an observation of Resident #4 on 7/1/25 at 3:00PM, Resident #4 was with his hospice nurse being bathed. During an observation of Resident #4 on 7/2/25 at 3:00PM, Resident #4 was observed to be lying in bed in hospital gown. His TV was on showing a reality court show. During an interview of Resident #4's family member/legal representative on 7/1/25 at 4:45PM, he stated Resident #4's hospice nurse was supposed to be getting him out of bed every day to change clothes. He stated Resident #4 liked watching sports and action shows. He stated the former social worker at the facility would take Resident #4 into her office and play music. He stated Resident #4 would also attend church services at the facility and enjoyed being in the halls around other people. During an interview with LVN J on 7/1/25 at 1:20PM, he stated Resident #4 communicated by facial expressions and he would smile to show emotion. He stated Resident #4 did not participate in activities. He stated Resident #4 received a haircut last week. During an interview with the Activity Director on 7/2/25 at 10:30AM, she reported she would meet one-on-one with Resident #4 twice a week to provide daily devotional which she would do with every resident or bring a music box. She reported she would record these interactions in her activity logbook. She stated Resident #4 liked to watch TV, he would listen to the daily devotional, and enjoyed music when she would bring a radio. The Activity Director stated she had spoken to Resident #4's family about what he was interested in. She stated she was told that he liked music, church, and TV. She stated at times she would leave the radio in Resident #4's room over the weekend. She stated the nurses or aides would turn his TV on. She stated she had never gotten Resident #4 out of bed to participate in activities. She stated before an activity on Monday's, Wednesday's and Friday's, she would go into Resident #4's room and ask him if he wanted to participate. She stated Resident #4 would not show any interest. She stated she knew he was not interested by him having a blank stare on his face. The Activity Director reported she believed that Resident #4 had been out of his bed twice for activities since she began employment there in March 2025. She stated she was unaware that Resident #4 enjoyed being around people and people watching because no one told her. To determine what residents liked to do, she stated she would talk to the family members. When asked about church services, she stated they no longer had someone come to the facility to facilitate church service. She stated the residents would watch services on TV. The Activity Director was asked to provide her one-on-one activity logbook, and it was never provided. She stated she could not locate her book. She stated she was out on leave last week so she is not sure who moved it. When asked who covered activities while she was on leave, she stated no one did. During an interview with Director of Nursing on 7/2/25 at 10:50AM, she stated Resident #4 would communicate by making sounds and if annoyed he would scream. She stated staff would anticipate his needs. She stated he couldn't nod for yes or no. Review of the Facility's Quality of Life - Resident Self Determination and Participation Policy dated December 2016 stated in part: Our Facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life.Each resident is allowed to choose activities, schedules, and health care that are consistent with his or her interest, values, assessments and plans of care including: (a) daily routine, such as sleeping and waking, exercise and bathing schedules; (b) personal care needs, such as bathing methods, grooming styles, and dress; (e) Activities, hobbies and interests; and (f) Religious affiliations and worship preferences. In order to facilitate resident choices, the administration and staff: (a) inform the residents and family members of the residents' right to self-determination and participation in preferred activities; (b) Gather information about the residents' personal preferences on initial assessment and periodically thereafter, and document these preferences in the medical record; (d) Document and communicate any medical conditions or limitations that may inhibit or interfere with participation in preferred activities. Residents are encouraged to make choices about aspects of their lives in the facility, including: (b) organizing and participating in resident groups; (c) interacting with other residents, family and members of the community. Residents are provided assistance as needed to engage in their preferred activities on a routine bases.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to coordinate the assessment with the pre-admission screening and resident review (PASRR) program for one (Resident #10) of five resident assessments reviewed for PASRR evaluations.<BR/>The facility did not correctly identify Resident #10 as having a mental illness diagnosis, failed to correct his PASARR Level One screen accurately to reflect the information, and failed to appropriately complete Form 1012, Mental Illness/Dementia Resident Review, in a timely manner to be signed by the attending physician for Resident #10.<BR/>This failure could place residents with psychiatric diagnoses with Dementia as their primary diagnosis at risk for missed assessments, interventions and services.<BR/>The findings were:<BR/>Review of Resident #10's Annual MDS assessment dated [DATE] reflected he was a [AGE] year-old male, re-admitted to the facility on [DATE]. He had a BIMS score of 15/15 indicating no cognitive impairment. The MDS revealed that Resident #10 had an active diagnoses of bipolar disorder (mental illness characterized by mood swings)<BR/>Review of Resident #10's care plan, no date indicated, did not reflect residents current or active diagnoses of bipolar disorder.<BR/>Review of Resident #10's current physician orders reflected an order for Seroquel Oral Tablet 100mg (Quetiapine Fumarate). Directions for the medication indicate that the medication was to be given one tablet by mouth at bedtime related to bipolar disorder.<BR/>Surveyor requested from the facility Resident #10's most recent PASRR Level One submission as related to his most recent re-admission date of 08/09/23. Surveyor was provided a PASRR Level One, dated 09/20/22 for Resident #10. Review of PASRR Level One, dated for 09/20/22, reflected Resident #10 did not have a mental illness. <BR/>Review of resident's form titled Mental Illness/Dementia Resident Review Form 1012 of Texas Health and Human Services. Form 1012 revealed that this form was to be completed only for nursing facility residents with a current Negative PASRR Level 1 (PL1) Screening for Mental Illness to determine whether to submit a new Positive PL1 screening form on the long-term care portal before further evaluation is needed. <BR/>Section A. Resident Nursing and Facility Identifying Information revealed to be for Resident #11<BR/>Section B. Dementia Review states that if the individual has a primary diagnosis of dementia as defined above. The physician signs and dates the form attesting to the dementia diagnosis, form is circled yes, the individual has a primary diagnosis of dementia as defined above, but it is not signed by the physician attesting to the dementia diagnosis. <BR/>Section B.1 Physical Attestation of Form 1012 revealed to be blank and not signed by the physician.<BR/>Section C Mental Illness (MI) Indication revealed to be blank<BR/>Record review of Form 1012 revealed to be signed by facility MDS nurse, dated for 7/17/24.<BR/>An interview with the DON on 07/17/24 at 12:50 PM revealed that the MDS Nurse was responsible for ensuring that all PASRR Level 1 Screenings and related forms were accurate and reflected the residents current and active diagnoses. <BR/>An interview with the MDS nurse on 07/17/24 at 2:19 PM revealed that she was responsible for ensuring that residents PL1's was coded appropriately and uploaded for review along with all necessary forms. The MDS nurses revealed that she was the only one in the facility responsible for PASRR submissions on new admissions or updated diagnoses as well as completion of Form 1012 timely and ensuring they were signed by the physician. MDS nurse revealed that she was in the process of auditing all PL1's and completing Form 1012 as indicated and was working on Resident #10's Form 1012. When asked about risks associated for not ensuring that residents have an appropriate PL1 coded or Form 1012 signed by the physician or submitted in a timely manner, MDS nurse stated it could place residents at risks for not receiving the services they need. <BR/>An interview with the Administrator on 07/18/24 at 3:55 PM revealed that it was the MDS Nurse's responsibility for ensuring that the PASRR's were accurate and reflected the resident's current diagnosis and needs as well as completing all necessary forms. Interview with the administrator revealed that this process should be completed on admission. <BR/>Review of the facility policy titled, PASRR (Pre-admission Screening and Resident Review), revised February 2018, revealed that it is the purpose of this procedure to ensure that any resident with a PASRR need is identified. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admissions Screening and Resident Review (PASRR) process. If the Level 1 screen indicates that the individual may meet the criteria for MD, ID, or RD he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process. The admitting nurse or designee notified the social services department, when a resident is identified as having a possible (or evident) MD, ID or RD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that baseline care plans were completed within 48 hours of the resident's admission for 3 out of 5 residents (Resident #6, Resident #7, Resident #8) whose care was reviewed for baseline care plans.<BR/>The facility failed to ensure that baseline care plans were completed within 48 hours for Resident #6, Resident #7, and Resident #8.<BR/>This failure could place the resident at risk for not having continuity of care among nursing home staff to safeguard against adverse events that are most likely to occur right after admission.<BR/>The findings included:<BR/>Record Review of Resident #6's admission MDS assessment dated [DATE] reflected she was an [AGE] year-old female, admitted to the facility on [DATE]. She had a BIMS scoring of 14/15 indicating no cognitive impairment. Her diagnoses included: Muscle weakness, chronic respiratory failure with hypoxia (Condition where your body is not getting enough oxygen to your blood) and cognitive communication deficit (condition that refers to difficulties with communications that are affected by disruptions in cognition).<BR/>Record Review of Resident #6's Care Plans on 07/15/24 reflected no baseline care plan was completed. <BR/>Record Review of Resident #7's admission MDS assessment dated [DATE] reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. He had a BIMS scoring of 14/15 indicating no cognitive impairment. His diagnosis included: Malignant neoplasm of bladder (abnormal growth or cancerous tissue found in the bladder), muscle weakness and urinary tract infections. <BR/>Record Review of Resident #7's Care Plans on 07/15/24 reflected no baseline care plan completed. <BR/>Record Review of Resident #8's admission MDS assessment dated [DATE] reflected a [AGE] year-old female, re-admitted to the facility on [DATE]. He had a BIMS scoring of 9/15 indicating moderately impaired cognition. Her diagnoses included: Cerebral infarction (condition where the blood flow to the brain is disrupted) , Edema (condition that causes excess fluid accumulation in the body tissues) and Cognitive Communication Deficit (condition that refers to difficulties with communications that are affected by disruptions in cognition). <BR/>Record Review of Resident #8's Care Plans on 07/15/24 reflected no baseline care plan completed.<BR/>An interview on 07/16/24 with the DON at 9:35 AM revealed that he was unsure of what the baseline care plan was. The DON said the MDS Nurse was responsible for completing the baseline care plan on admission. The DON revealed that risks to the residents without baseline care plans could include missing care for the resident.<BR/>An interview on 07/16/24 at 9:50 AM with the MDS nurse revealed that the admitting nurses were responsible for completing the baseline care plans. The MDS Nurse revealed that the nursing management including the ADON, DON and MDS Nurse audited the residents clinical record daily to ensure compliance of baseline care plans. The MDS Nurse revealed that risks to the residents without base care plans could include missing items in the resident's comprehensive plan of care. <BR/>An interview on 0 7/17/24 at 3:46 PM with LVN B revealed that it would be the admitting nurse's responsibility to complete the baseline care plan. LVN B revealed that the baseline care plan should be completed within 24 hours admission. <BR/>Interview on o7/18/24 at 4:08 PM with the Administrator revealed that the admitting nursing staff was responsible for ensuring all admitting assessments and documentation was completed. The administrator stated that the resident could face service delays if baseline care plans were not completed. <BR/>A review of the facility policy titled, Care plans Preliminary, revised on August 2006, reflected that a preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission. Per the facility policy, the preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop the interdisciplinary plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 9 residents (Resident #1) reviewed for care plans. <BR/>The facility failed to ensure Resident #1, who resided in the memory care unit, had a comprehensive care plan identifying reasons for aggression, appropriate supervision, interventions to prevent Resident #1 from eating non-edible items in order to attain and maintain the highest practicable physical, mental, and psychosocial well-being and safety. <BR/>An Immediate Jeopardy situation was identified on 06/08/2023 at 9:45 AM. The Immediate Jeopardy was removed on 06/09/2023 at 4:18 PM. The facility remained out of compliance at a scope of Isolated and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. <BR/>This failure could place residents at risk for not being provided necessary care and services. <BR/>Findings Included:<BR/>Record review of Resident #1's electronic face sheet, dated 06/07/2023, revealed Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's diagnoses included dementia with agitation (walk up and down, move objects around or fixate on tasks such as tidying), major depressive disorder (mood disorder that interferes with daily life), anxiety disorder (involves persistent and excessive worry that interferes with daily activities), and delusional disorders (type of mental health condition in which a person can't tell what's real from what's imagined).<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 04/21/2023, revealed Resident #1's BIMS score was 00 which indicated severe cognitive impairment. Review of behaviors reflected physical behavioral symptoms directed toward others and self, wandering occured daily. <BR/>Record review of Resident #1's care plan, initiated on 05/30/2023, reflected Resident #1 was at risk of elopement / non-goal directed wandering, interventions included Disguise exits .identify pattern of wandering. Is it purposeful? Further review revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes and impaired decision-making skill. Resident #1 exhibited verbal and physical aggression, exhibited hitting and biting during ADL care and interventions included Provide physical and verbal cues to alleviate anxiety .give the resident as many choices as possible about care and activities. The care plan also reflected a diagnosis of dementia and need for a secure environment due to risk of elopement, exit seeking and wandering. Interventions included Assess for reasons for wandering and provide redirection as needed. Resident #1 had a history of resisting or refusing care and became aggressive during care. <BR/>Record review of Resident #1's Progress Notes dated 04/13/2023, RN A documented, Resident came out from her room and was holding pull up full of feces and writer tried to take it away from her and resident pushed nurse and nurse landed on the floor and hit her right leg on double door. Nurse was assisted off from the floor by two staff members. Resident was then attended by two staff members. Family, Md, and ADON notified. Progress notes dated 05/15/2023, 05/16/2023, 05/16/2023, 05/22/2023, and 05/24/2023 reflected LVN E documented the following on each date, Resident is up wandering up and down the hallway, checked V/S and gave all medications as ordered, tolerated well, resident is at high risk for elopement, requires constant redirection by staff members. Resident requires 2 to 3 staff members to provide cares, resident has a very aggressive behavior, such as kicking and biting. Resident is developing a new habit, messing with her own poop, staff members has to help her thoroughly cleaned her and sanitize all the places she touched. Will continue to monitor. Progress notes dated 06/06/2023 reflected LVN E documented, Resident was seen be states surveyor possibly eating and notified first nurse aide and next the nurse who was told by the DON immediately notified the MD at 12:33PM, that was 3 minutes after this nurse was notified, MD immediately responded and ordered to call poison control center and checked resident's V/S, BP .poison control advised us to rinse resident's mouth and provide more fluids, we did as ordered, no S/S of nausea or vomiting noted at this time. Will continue to monitor resident and continue to encourage fluids. Called poison control regarding possible ingestion of deodorant. Poison control indicated that a possible adverse effect would b, mild GI upset, limited diarrhea, and upset stomach. Was told to monitor for upset stomach and encourage fluids. Case #75554424. <BR/>Observation and interview on 06/07/2023 at 11:45AM revealed Resident #1, in the hall facing the patio, eating a stick of deodorant with a plastic spoon. Resident #1 turned the deodorant stick up and used the spoon to scoop chunks of the deodorant from the container and then ate it. CNA B and LVN C were observed around the corner on the room hall passing lunch trays. The surveyor called down the hall to notify LVN C and CNA B that Resident #1 was eating the deodorant stick. CNA B came to the hall where Resident #1 was and stated she could not take the deodorant from Resident #1 without assistance because Resident #1 had bitten her in the past when she took something away from her. CNA B called for LVN C to assist. During the time LVN C came to assist, Resident #1 was observed placing the deodorant container in a sock she was holding. LVN C was observed trying to get the sock that contained the deodorant stick from Resident #1. Resident #1 refused to give it and LVN C then distracted Resident #1 from her left side while CNA B took the sock from Residnet#1's grip. Resident #1 still had the plastic spoon in her hand and walked down the hall to the rear door exit area where she began taking items from the trash can. Resident #1 used the spoon to scrape particles of deodorant from her arms and licked the spoon. <BR/>An observation and interview on 06/07/2023 at 11:50AM, with LVN C and CNA B, revealed the deodorant container was empty. LVN C said Resident #1 could get very aggressive when staff took items from her that she should not have. LVN C said Resident #1 constantly wandered from room to room taking any items she could find. LVN C stated the deodorant stick was not from the facility and may have been brought into the secured unit by another resident's family members. He said there was one resident in the secured unit who did have personal care items in her room because she was only diagnosed with schizophrenia and able to do her own personal care. He said each room had child covers on the doorknob which prevented residents from entering rooms, however, Resident #1 was able to open doors with the child cover on. CNA B stated Resident #1 needed constant supervision because she wandered from room to room taking anything she could find. She stated when staff attempted to redirect Resident #1 or take something from her she would be aggressive. <BR/>An interview on 06/07/2023 at 12:16PM with the Administrator revealed she was informed that Resident #1 had eaten the deodorant. She stated she did not know where Resident #1 could have gotten the deodorant from because all personal care items should have been secured in the shower room. She said family members often brought items into the secured unit for residents and left the items in their room. She said she directed staff to do a sweep of the secured unit to ensure there were no more hazardous items accessible to residents; she stated they did find additional personal care items in resident rooms and removed them. She said she was not aware of any resident in the secured unit who kept personal care items in their room but the DON may have told her about such a resident but was not sure. She said there were child covers on the doorknobs in the secured unit to prevent residents from entering rooms. She said she had not been informed Resident #1 could open the doors with the child covers on. She stated typically one nurse and two CNAs worked in the secured unit to ensure appropriate supervision of the 17 residents. She stated the facility's policy stated that all personal and hazardous items should be locked to prevent a risk of harm to residents. She said she understood Resident #1's eating deodorant posed an immediate concern for a risk of harm to all the residents in the secured unit. <BR/>An observation and interview on 06/07/2023 at 12:23PM, in the secured unit, with the Administrator and DON revealed Resident #1 in the room hall with a small can of shaving cream. Resident #1 was trying to push the button at the top of the can and held the can to her mouth but was unsuccessful in getting the contents to come out. The DON was observed taking the can of shaving cream from Resident #1. When asked if they had removed all the hazardous items from the secured unit, The Administrator stated staff had already done that and stated she did not know where Resident #1 got the can of shaving cream from. <BR/>An observation and interview on 06/07/2023 at 12:25PM with Resident #2 revealed she recently came to the facility. She stated she had her own room and was allowed to keep her personal care items in her room. She stated she hid the items in her dresser drawers as residents often came inter her room and took them. She said she hid her purse under a chair for the same reason. Resident #2's purse was observed stuffed under a chair in her room and personal care items (toothpaste, shampoo, and deodorant) were observed in the top drawer of the dresser in her room. <BR/>An interview on 06/07/2023 at 12:40PM with LVN C revealed Resident #1 was hard to redirect and constantly wandered from room to room. He said Resident #1 likely got the deodorant from another resident's room. He stated staff do not check rooms regularly for items that may be hazardous to residents. He said residents' family often bring items and leave them in the residents' rooms. He stated he noted Resident #1 started to mess with her poop and said he had never seen her eat anything non-edible before. He stated his note referred to her taking her adult diaper off and smearing poop all over. <BR/>An interview on 06/07/2023 at 12:52PM with CNA B revealed Resident #1 would get into anything she could including briefs, wipes, and deodorant. She said she had not seen her eat anything hazardous but Resident #1 had to be supervised all the time to ensure her safety. She said she thought Resident #1 may have taken the deodorant from the shower room because she had found the lid to the deodorant stick in the locked shower room when she completed the sweep. She stated the shower room was always locked but this morning a hospice aide was in the secured unit caring for a resident and Resident #1 could have gotten the deodorant while the aide was showering another resident. CNA B stated during her sweep of the secured unit, she found five deodorants in five different rooms, soap, two large bottles of lotion, and three large bottles of shampoo. She said the items were labeled Keep out of reach of children. CNA B stated Resident #1 bit her on her breast, on 04/19/2023, when she tried to take lotion from Resident #1. She stated she informed the DON and Administrator. She stated Human Resources had her go to the hospital for treatment. She stated she had not receive any in-service related to handling Resident #1's aggressive behavior.<BR/>An interview on 06/07/2023 at 1:41PM with the Administrator revealed when CNA B was bit by Resident #1 she was primarily concerned with ensuring CNA B was taken care of and followed up with human resources. She said she did not follow up with any behaviors that may have led to why Resident #1 bit CNA B and ultimately kept Resident #1 safe. She said in reviewing progress notes, the staff knew Resident #1 wandered and got into any items she could find; all staff could assume Resident #1 could possibly consume them as well. She stated she should have followed up to ensure the safety of Resident #1. She stated the DON and ADON were responsible for reviewing the progress notes to ensure information was brought to her. She stated she was not made aware of an incident where Resident #1 pushed RN A to the ground on 4/13/2023. She said the incident may have been reported to human resources. She said it should have been brought to her attention by staff or the DON because it was documented in the progress notes. She said she expected the DON and ADON to review the progress notes and bring any concerns to her attention. She stated she expected staff to ensure residents, who did not have the cognitive ability to understand their actions, were safe and any hazards were secured to prevent residents from any harm. <BR/>An interview on 06/07/2023 at 2:25PM with RN A revealed she was pushed to the ground on 4/13/2023, when she tried to take a soiled adult brief from Resident #1. RN A said Resident #1 came out of her room with the soiled brief in her hand. She said the brief was tore and Resident #1 had feces on her hands, face and inside her mouth. She stated she believed Resident #1 was eating the brief. RN A stated she had never seen Resident #1 eat deodorant but was not surprised as she wandered from room to room looking for anything she could find. RN A stated she told the DON, ADON, Administrator and Human Resources about the incident. She stated Human Resources directed her to get medical attention. RN A stated there were no care plan changes, in-services, or direction from the DON or ADON to address Resident #1's behaviors. <BR/>In an interview on 06/07/2023 at 3:00PM the Social Worker stated she and the MDS Coordinator held a care plan meeting for Resident #1 on 05/23/2023. She stated there was no information about Resident #1 eating poop or any other non-consumable items. She stated she gained resident information from the DON or ADON regarding issues or concerns and concerns of the resident's specific behaviors should have been relayed to her and the MDS Coordinator for care planning. She said Resident #1's aggressiveness was discussed in the care plan but no specific details regarding when aggression occurred or why. <BR/>An interview on 06/07/2023 at 3:30PM with the DON revealed she had not seen any of the progress notes related to Resident #1. She said it was her and the ADON's responsibility to review the notes and care plans to ensure any concerns were addressed. She said she held a stand-up meeting every morning at 10:00AM where issues would be discussed. She said she was working with staff to ensure they brought concerns to the stand-up meetings but realized they had not always done that. She said she was aware Resident #1 had aggressive behaviors but did not know why. She stated she knew Resident #1 had bitten CNA B but did not why. She said she did not know Resident #1 pushed RN A to the ground when she tried to take a soiled adult diaper from her. The DON said Resident #1's aggressive behaviors that occurred when staff tried to take things from her should have been in the care plan. She stated there should not be any potentially hazardous items accessible to any resident in the secured because they did not have the mental capacity to know what could be consumed. She said Resident #1 eating deodorant posed a potential risk of harm and could have been avoided. <BR/>An interview on 06/07/2023 at 4:22PM with CNA D revealed Resident #1 was aggressive when staff tried to redirect her or take something she should not have away. She said she had seen Resident #1 eat feces from her adult diaper and told the nursing staff but did not know what was done from there. She stated she did not recall the nurse she told or the time she observed Resident #1 eat feces from her adult diaper. She said Resident #1 needed constant supervision because she constantly looked for anything she could get into. <BR/>An interview on 06/07/2023 at 4:35PM with MDS Coordinator/LVN revealed she and the SW conducted a care plan meeting for Resident #1 on 05/23/2023. She said information for Resident #1's care plan would be communicated to her by the ADON or the DON during morning meetings. She said she was aware of Resident #1 biting a staff member but was not sure why it occurred. She said she was not informed of specific circumstances that may have caused Resident's #1's behavior. She stated those circumstances should be communicated from nursing staff and reflected in the care plan. <BR/>An interview on 06/07/2023 at 5:03PM with the ADON revealed she had not reviewed Resident #1's progress notes. She said it was the DON and her responsibility to review them for any concerns related to residents. She said that information would be passed on to the MDS Coordinator to be addressed in care plans. The ADON said she was not aware Resident #1 was messing with her poop and did not know RN A was pushed to the ground by Resident #1 when she took a soiled adult diaper from her. She stated specific interventions should have been reflected in the care plan to ensure Resident #1's safety. She said the facility did not have a system in place to ensure rooms were checked for hazardous items. She said since Resident #1 wandered and got into things, the facility needed to ensure her safety by making sure all potentially hazardous items were secured. <BR/>In an interview on 06/07/2023 at 5:15PM, the Administrator stated she dropped the ball. She said in hindsight, she should have followed up with the DON regarding Resident #1's aggression. She said she should have investigated as to the circumstances of Resident #1's aggression. She stated there was not an incident report done when Resident #1 bit CNA E or pushed RN A. She said she and the DON should have known about Resident #1 eating a solid adult diaper. She said she felt like she needed to have better communication with nursing staff to ensure all resident's safety. She said the facility should have a system in place to ensure resident did not have access to non-consumable items and ensure their safety. <BR/>An interview on 06/07/2023 at 5:57PM with the COO revealed he expected staff to ensure all residents were safe. He stated the DON and ADON should have known about the context of Resident #1's behaviors and ensured the care plan reflected specific issues. He stated there seemed to be a breakdown in communication between the front-line staff, nurse management, and the Administrator. <BR/>Record review of the facility's incident / accident report between 03/01/2023 to 06/07/2023 revealed no record of incidents involving Resident #1, CNA B, or RN A. <BR/>Record review of the MSDS for the deodorant consumed on 06/07/2023 by Resident #1 revealed Hazards Identification: Eye: Classification Eye Contact may cause mild, transient irritation. Some redness and/or stinging may occur. Ingestion: Product used as intended is not expected to cause gastrointestinal irritation. Accidental ingestion of undiluted product may cause mild gastrointestinal irritation with nausea, vomiting and diarrhea.<BR/>Record review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, dated 12/2009 reflected, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.including time and date .nature .circumstances .name of witnesses .complete report sent to the DON within 24 hours .DON shall ensure that the Administrator receives a copy of the Report .<BR/>Record review of the facility's policy titled, Safety and Supervision of Residents, dated 12/2008 reflected, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA and A reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. Staff shall use various sources to identify risk factors for residents, including information obtained from the medical history, physical exam, observation of the resident, and the MDS. Implementing interventions to reduce accident risk and hazards shall include the following: communicating specific interventions to all relevant staff, providing training .documenting interventions .<BR/>Record review of the facility's policy titled, Care Plans - Comprehensive, dated 12/2010 reflected, An individualized comprehensive care plan that includes measurable objectives and timetables to meet resident's medical, nursing, mental, and psychosocial needs is developed for each resident. Each resident's comprehensive care plan is designed to: .incorporate identified problems .incorporate risk factors associated with identified problems <BR/>The Administrator was notified on 06/08/2023 at 9:30AM, that an Immediate Jeopardy had been identified due to the above failures. The IJ Template was provided to the Administrator on 06/08/2023 at 9:45AM and she was informed the POR was due to HHSC by 12:00PM on 06/08/2023. <BR/>The Plan of Removal (POR) was accepted on 06/08/2023 at 4:20PM. <BR/>The Plan of Removal reflected the following:<BR/>Immediate Corrective Action for residents affected by the alleged deficient practice:<BR/>The resident who allegedly ingested deodorant was assessed, all vital signs within normal limits. Despite finding no evidence of deodorant within her mouth, the resident's mouth was rinsed, fluids encouraged. Medical director, poison control, and family were notified. The medical director instructed facility to continue to monitor for signs of GI distress. <BR/>This deficient practice had the potential to affect 17 residents residing on the secure unit, however, no other resident was found to be affected.<BR/>The secure unit was swept for personal care items on 06/07/23 and again on 06/08/23. All personal care items found were removed from resident rooms and given to the charge nurse to be secured behind locked doors, including items from resident who was previously reluctant to let them go. <BR/>All family members were called on 06/07/2023 and informed that personal care items must be labeled and turned into management staff or nursing to be locked for the safety of all residents. Signs were also posted at the front of the building to turn in personal care items which will be made available for use at the appropriate time. <BR/>Care plans updated to reflect the residents wandering and aggression being further agitated by attempts to remove items or redirect resident. The care plan updated to reflect the residents alleged tendency to ingest non-food items. <BR/>Staff members in-serviced on the need to lock personal care items out of reach of residents, particularly those who tend to become confused or exhibit behaviors related to wandering and picking up items found in other rooms. Education occurred on 06/07/23 and again on 06/08/23 and will continue.<BR/>Actions taken to prevent a serious adverse outcome from recurring:<BR/>Management staff swept the rest of the facility on 06/08/2023 and ensured personal care items were secured appropriately. Anything found not stored appropriately was labeled by resident name and given to charge nurses to secure in locked room on 300 hall. <BR/>Additional checks were conducted of locked supply, shower, and utility rooms. The facility will continue to monitor to ensure the security of these areas. Additional education completed on the need to keep personal care items away from residents who might become confused or exhibit behaviors.<BR/>Ad Hoc QAPI Meeting was held on 06/08/2023 to discuss the incident, make staff members aware of the new policy on personal care items. MD and management staff present, corporate staff available by phone. <BR/>Additional sweeps of the area daily by staff members x 2 weeks, then weekly for 2 weeks, and monthly thereafter. <BR/>The facility will utilize a daily behavior monitoring sheet for changes in behavior/condition. This sheet will be reviewed weekly and as necessary, changes in behavior or condition will be discussed and care planned appropriately. <BR/>When will actions be complete:<BR/>Coral Nursing and Rehabilitation of Arlington requests the removal of the immediate jeopardy on 06/08/2023<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>An interview on 06/09/2023 at 1:30PM with the Administrator revealed 57 of 110 staff have been in-serviced regarding the Behavior monitoring log and Securing personal care items. She stated the management team had been completed to ensure any hazardous items were secured for the safety of residents. She stated sweeps will be completed daily by the management team for two weeks and then weekly. She said she would be completing the sweeps on weekends until a weekend supervisor was hired. She stated she would be addressing progress notes, the results of sweeps, and any aggressive incidents daily stand-up meetings. She stated the management team participated in an Ad Hoc QUPI meeting on 06/08/2023 wiht the medical director, Corporate RN, DON, ADON, and MDS Coordinator present. She said she had implemented a behavioral log to be completed by staff daily and monitored by the DON in an effort to catch any changes in resident behaviors. She said the DON was expected to report any changes in resident behavior to her, daily. She stated the families of all Secured Unit residents were contacted and instructed that any items they bring to the facility must be secured by staff. <BR/>A record review of the medical record for Resident #1 revealed she was assessed for complications and ongoing monitoring of adverse effects. Resident #1's care plan was updated to reflect the residents wandering and aggression, further agitated by attempts to remove items or redirect the resident and resident's tendency to ingest non-food items. <BR/>Observations on 06/09/2023 from 3:00PM to 3:10PM revealed all rooms and areas in the memory care unit were free from hazardous products.<BR/>Interviews were conducted on 06/09/2023 from 12:40 PM to 3:00 PM with 18 staff members (6 CNAs, 2 RNs, 4 LVNs, 2 MAs, 1 Restorative Aide, and 3 Housekeeping staff) from multiple shifts. The staff all indicated they had been in-serviced on safety awareness, which included a list of prohibited items in memory care, how hazardous items should be stored, the procedures on storing prohibited items that family members might bring for resident use, ongoing sweeps for hazardous items and their security, and procedures in case they were not sure if an item was hazardous.<BR/>In a telephone interview on 06/09/2023 at 2:55PM, the Corporate RN said he understood the components of the IJ and was not aware the DON and ADON had not been reviewing the progress notes. He said it was impossible to complete a comprehensive care plan without considering behaviors. He said he expected the Administrator to ensure residents were safe from hazardous items. He said he expected the DON to ensure behaviors were monitored and communicated to staff for appropriate care planning. He said he provided a behavior log to the Administrator to assist with this. He said he in-serviced the Administrator, DON, ADON, and MDS Coordinator on the need to address changes in resident behavior in care planning, reviewing progress notes to ensure behaviors are addressed and care planed appropriately, and ensuring resident were cared for in a safe environment. <BR/>Record review of in-service dated 06/07/2023, 06/08/2023, and 06/09/2023 on Personal Care Items .Inform family members that all personal care items must be labeled and turned into management staff or nursing staff to be locked for the safety of all residents .Personal care items include but are not limited to the following: Soap, shampoo, conditioner, deodorant, lotions, mouthwash, toothpaste, hand sanitizer, and other potentially hazardous chemical items .In continuing sweeps, if such items are found please remove them from the room. Make sure they are labeled and give it to the nursing staff to be secured revealed 57 signatures from multiple shifts and multiple departments (RNs, LVNs, CNAs, MAs, Housekeeping, Laundry, and Maintenance) had received in-services which covered all aspects of the POR. <BR/>Record review of in-service dated 06/07/2023, 06/08/2023, and 06/09/2023 on Behavior Monitoring Log .the facility will distribute behaviors monitoring sheets to the nursing staff to be filled out daily. The DON will collect the sheets weekly or as necessary to be discussed at the Standards of Care meeting. Any changes will be communicated to management staff in the meeting and care planned appropriately. Changes will also be discussed in the morning IDT meeting so all staff can be aware of changes, revealed 57 signatures from multiple shifts and multiple departments (RNs, LVNs, CNAs, MAs, Housekeeping, Laundry, and Maintenance) had received in-services which covered all aspects of the POR. <BR/>Record review of signed in-service dated 06/09/2023 and conducted by the Corporate RN revealed the Administrator, DON, ADON, and MDS Coordinator were educated on their .responsibility that every resident within my facility receives quality, appropriate care .understand that changes in resident's behavior must be discussed promptly, with the DON, ADON, and IDT team for intervention and appropriate care planning .understand that it is my responsibility to periodically read and review the charts of my residents with behaviors, to ensure completeness and that all behaviors are addressed and care planned appropriately. <BR/>Record review of the Behavior Monitoring Log reflected behavior, intervention and outcome codes with a monthly calendar noting day, evening, and night shifts. <BR/>The Administrator was informed the Immediate Jeopardy was removed on 06/09/2023 at 4:18PM; however, the facility remained out of compliance at a scope of Pattern and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide activities based on the comprehensive assessment and care plan, designed to meet the interests of and support the physical, mental and psychosocial well-being of one resident (Resident #4) out of five who were reviewed for activities. The facility failed to consistently provide encouragement and assistance to participate in facility provided activities for Resident #4. This failure could place residents at risk for social isolation, depression, and a decline in psychosocial well-being.Findings included: Review of Resident #4's annual Minimum Data Set, dated [DATE] reflected the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a condition caused by damage to the developing brain that affects a person's ability to control their muscles, problems with movement, coordination) kidney failure (kidneys are no longer able to properly filter waste and extra fluid from the blood), contracture (a muscle, tendon, or joint becomes permanently stiff or tight), and dysphagia (trouble swallowing). Review of Resident #4's annual Minimum Data Set assessment dated [DATE] reflected he had no speech, rarely/never made himself-understood, and sometimes was able to understand others. His Brief Interview for Mental Status was not completed. He was totally dependent on two staff for dressing, transferring, bathing and toilet use. He was totally dependent on staff for locomotion, eating, and personal hygiene. He was not ambulatory and had functional limitations in range of motion for upper extremity and lower extremity on both sides. He was indicated as always incontinent of bowel and bladder. He had a physical therapy start date of 03/29/25 with an end date of 04/21/25 with no minutes of treatment recorded during that duration. Review of Resident #4's Care Plan, initiated on 4/11/2018 and revised on 5/27/25 reflected Resident #4 would have 1:1 activity to Resident #4's likes/abilities. Activity Director to individualize activities for Resident #4 and work on getting Resident #4 to socialize with others in a group setting. The goal stated that Resident #4 would continue to participate in activities of choice to his likes/abilities through the next review date and to provide 1:1 assistance as needed to participate in activities. The Care Plan also stated that Resident #4 would have involvement related to music, therapy, and fitness each week at an unspecified number of times a week. The tasks/interventions stated Resident #4 needed a variety of activity types and locations to maintain interests. The tasks/interventions stated that Resident #4 would need assistance/escort to activity functions. The Care Plan included a Focus that stated Resident #4 was high risk for decreased quality of life related to little interest in activities. The goal stated that Resident #4 would maintain his highest practical quality of life as evidenced by attending activities of choice. The intervention/task stated that the facility would encourage Resident #4 to attend group activities as it appeared Resident #4 enjoyed singing and sports where he could participate passively. The facility would assist to/monitor individual/small group activities which included restorative exercise, watching TV, staff talking and laughing with him. Review of Resident #4's Individual Profile - Nursing Facility, dated 6/18/25 under section 4 titled These are my preferences and what is important to me reflected in part It is important for me to maintain a sense of pride and dignity.Please don't leave me in bed all day, I want to be dressed and out of bed in my chair.I love to be taken to musicals or listening to sing a longs and CD's.Sometimes the social workers pull me into their office and turn up the music where I can bounce to the tunes.I can watch TV up until dinner time.I especially like to watch all the action in sport programs.[Resident #4] likes to be out of room on a daily basis.[Resident] #4 enjoys people watch in the hallways or in the lobby of the nursing facility.It is important for [Resident #4] to be around other people. The plan went on to list activities Resident #4 enjoyed: [Resident #4] likes listening to music, instrument sounds, spending time outside, instrumentals, and being around others. Review of Resident #4's Individual Profile - Nursing Facility, dated 6/18/25 under section Communication stated Resident #4 did not communicate verbally, he would follow people with his eyes and watch what was going on, at times he would say ya, most of the time when someone would ask him a question he would not respond, he would show emotion in body language, make gestures and point or look toward things, and yell out. Review of Resident #4's Habilitative Service Plan, dated 6/18/25 reflected that Resident #4 wanted to listen to music, attend musicals when the facility offered them, TV/movies, music videos, music therapy, music exercise group, and go outside. Review of Resident #4's most recent Activity Evaluation, dated 6/24/24, reflected that Resident #4 required reminders/cues, extensive verbal cuing, and could not comprehend instructions. The evaluation indicated that Resident #4 used a wheelchair with max assist. The evaluation also indicated Resident #4 had a cooperative and cheerful attitude, needed assistance to and from activities, enjoyed 1 on 1 in room, bible study, and watching TV. Review of Resident #4's Progress Notes dated 4/5/25 at 4:30PM entered by Nutrition/Dietary stated in part .patient continues to want to be in his chair more sitting out.Even though patient is nonverbal he cries when he has to return to bed. Review of Resident #4's Progress Notes dated 5/18/25 at 10:19PM stated in part .[Resident] has been sitting up during the day for activities. Review of Resident #4's Progress Notes revealed no further notes that reflected Resident #4 participating in activities since 5/18/25 as indicated by the note entered for that day. Review of the most recent Activities Quarterly Note dated 2/9/24 at 1:01PM stated, Staff will continue to provide Resident #4 with 1:1 visit. Resident also enjoyed sitting in the TV room watching. Staff will continue to provide various activities. Review of the facility's activity calendar, dated July 2025, reflected the following scheduled activities for: 07/01/25 9:00AM - Coffee & Convo10:00AM - Daily Devotional 10:30AM - Nail Time & Chit Chat1:30PM - Arts N Craft3:00PM - In room visits6:00PM - Nightly Cinema Review of the facility's activity calendar, dated July 2025, reflected the following scheduled activities for: 07/02/25 9:00AM - Coffee & Convo10:00AM - Words for Life10:30AM - Fitness for Life1:00PM - Popcorn Social1:30PM - Bingo6:00PM - Nightly Cinema Review of the facility's activity calendar, dated July 2025, reflected the following scheduled activities for: 07/06/25 (Sunday) Activity of Your ChoiceReadingWriting - DrawingWord SearchesChurch Service on TV at 11amFamily Visits During interview and observation with Resident #4 on 7/1/25 at 10:09AM, he was observed to be lying in his bed. Resident #4 was non-verbal but made eye contact at times when spoken to. He was not able to answer questions by gesturing or nodding. Resident #4 was observed in a hospital gown. The TV was not on and no music was playing. During an observation of Resident #4 on 7/1/25 at 1:45PM, Resident #4 was observed to be lying in his bed in the same hospital gown. The TV was not on and no music playing. Resident was not participating in the scheduled activity of Arts N Crafts at 1:30PM. During an observation of Resident #4 on 7/1/25 at 3:00PM, Resident #4 was with his hospice nurse being bathed. During an observation of Resident #4 on 7/2/25 at 3:00PM, Resident #4 was observed to be lying in bed in hospital gown. His TV was on showing a reality court show. During an interview of Resident #4's family member/legal representative on 7/1/25 at 4:45PM, he stated Resident #4's hospice nurse was supposed to be getting him out of bed every day to change clothes. He stated Resident #4 liked watching sports and action shows. He stated the former social worker at the facility would take Resident #4 into her office and play music. He stated Resident #4 would also attend church services at the facility and enjoyed being in the halls around other people. During an interview with LVN J on 7/1/25 at 1:20PM, he stated Resident #4 communicated by facial expressions and he would smile to show emotion. He stated Resident #4 did not participate in activities. He stated Resident #4 received a haircut last week. During an interview with the Activity Director on 7/2/25 at 10:30AM, she reported she would meet one-on-one with Resident #4 twice a week to provide daily devotional which she would do with every resident or bring a music box. She reported she would record these interactions in her activity logbook. She stated Resident #4 liked to watch TV, he would listen to the daily devotional, and enjoyed music when she would bring a radio. The Activity Director stated she had spoken to Resident #4's family about what he was interested in. She stated she was told that he liked music, church, and TV. She stated at times she would leave the radio in Resident #4's room over the weekend. She stated the nurses or aides would turn his TV on. She stated she had never gotten Resident #4 out of bed to participate in activities. She stated before an activity on Monday's, Wednesday's and Friday's, she would go into Resident #4's room and ask him if he wanted to participate. She stated Resident #4 would not show any interest. She stated she knew he was not interested by him having a blank stare on his face. The Activity Director reported she believed that Resident #4 had been out of his bed twice for activities since she began employment there in March 2025. She stated she was unaware that Resident #4 enjoyed being around people and people watching because no one told her. To determine what residents liked to do, she stated she would talk to the family members. When asked about church services, she stated they no longer had someone come to the facility to facilitate church service. She stated the residents would watch services on TV. The Activity Director was asked to provide her one-on-one activity logbook, and it was never provided. She stated she could not locate her book. She stated she was out on leave last week so she is not sure who moved it. When asked who covered activities while she was on leave, she stated no one did. During an interview with Director of Nursing on 7/2/25 at 10:50AM, she stated Resident #4 would communicate by making sounds and if annoyed he would scream. She stated staff would anticipate his needs. She stated he couldn't nod for yes or no. Review of the Facility's Quality of Life - Resident Self Determination and Participation Policy dated December 2016 stated in part: Our Facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life.Each resident is allowed to choose activities, schedules, and health care that are consistent with his or her interest, values, assessments and plans of care including: (a) daily routine, such as sleeping and waking, exercise and bathing schedules; (b) personal care needs, such as bathing methods, grooming styles, and dress; (e) Activities, hobbies and interests; and (f) Religious affiliations and worship preferences. In order to facilitate resident choices, the administration and staff: (a) inform the residents and family members of the residents' right to self-determination and participation in preferred activities; (b) Gather information about the residents' personal preferences on initial assessment and periodically thereafter, and document these preferences in the medical record; (d) Document and communicate any medical conditions or limitations that may inhibit or interfere with participation in preferred activities. Residents are encouraged to make choices about aspects of their lives in the facility, including: (b) organizing and participating in resident groups; (c) interacting with other residents, family and members of the community. Residents are provided assistance as needed to engage in their preferred activities on a routine bases.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide activities based on the comprehensive assessment and care plan, designed to meet the interests of and support the physical, mental and psychosocial well-being of one resident (Resident #4) out of five who were reviewed for activities. The facility failed to consistently provide encouragement and assistance to participate in facility provided activities for Resident #4. This failure could place residents at risk for social isolation, depression, and a decline in psychosocial well-being.Findings included: Review of Resident #4's annual Minimum Data Set, dated [DATE] reflected the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a condition caused by damage to the developing brain that affects a person's ability to control their muscles, problems with movement, coordination) kidney failure (kidneys are no longer able to properly filter waste and extra fluid from the blood), contracture (a muscle, tendon, or joint becomes permanently stiff or tight), and dysphagia (trouble swallowing). Review of Resident #4's annual Minimum Data Set assessment dated [DATE] reflected he had no speech, rarely/never made himself-understood, and sometimes was able to understand others. His Brief Interview for Mental Status was not completed. He was totally dependent on two staff for dressing, transferring, bathing and toilet use. He was totally dependent on staff for locomotion, eating, and personal hygiene. He was not ambulatory and had functional limitations in range of motion for upper extremity and lower extremity on both sides. He was indicated as always incontinent of bowel and bladder. He had a physical therapy start date of 03/29/25 with an end date of 04/21/25 with no minutes of treatment recorded during that duration. Review of Resident #4's Care Plan, initiated on 4/11/2018 and revised on 5/27/25 reflected Resident #4 would have 1:1 activity to Resident #4's likes/abilities. Activity Director to individualize activities for Resident #4 and work on getting Resident #4 to socialize with others in a group setting. The goal stated that Resident #4 would continue to participate in activities of choice to his likes/abilities through the next review date and to provide 1:1 assistance as needed to participate in activities. The Care Plan also stated that Resident #4 would have involvement related to music, therapy, and fitness each week at an unspecified number of times a week. The tasks/interventions stated Resident #4 needed a variety of activity types and locations to maintain interests. The tasks/interventions stated that Resident #4 would need assistance/escort to activity functions. The Care Plan included a Focus that stated Resident #4 was high risk for decreased quality of life related to little interest in activities. The goal stated that Resident #4 would maintain his highest practical quality of life as evidenced by attending activities of choice. The intervention/task stated that the facility would encourage Resident #4 to attend group activities as it appeared Resident #4 enjoyed singing and sports where he could participate passively. The facility would assist to/monitor individual/small group activities which included restorative exercise, watching TV, staff talking and laughing with him. Review of Resident #4's Individual Profile - Nursing Facility, dated 6/18/25 under section 4 titled These are my preferences and what is important to me reflected in part It is important for me to maintain a sense of pride and dignity.Please don't leave me in bed all day, I want to be dressed and out of bed in my chair.I love to be taken to musicals or listening to sing a longs and CD's.Sometimes the social workers pull me into their office and turn up the music where I can bounce to the tunes.I can watch TV up until dinner time.I especially like to watch all the action in sport programs.[Resident #4] likes to be out of room on a daily basis.[Resident] #4 enjoys people watch in the hallways or in the lobby of the nursing facility.It is important for [Resident #4] to be around other people. The plan went on to list activities Resident #4 enjoyed: [Resident #4] likes listening to music, instrument sounds, spending time outside, instrumentals, and being around others. Review of Resident #4's Individual Profile - Nursing Facility, dated 6/18/25 under section Communication stated Resident #4 did not communicate verbally, he would follow people with his eyes and watch what was going on, at times he would say ya, most of the time when someone would ask him a question he would not respond, he would show emotion in body language, make gestures and point or look toward things, and yell out. Review of Resident #4's Habilitative Service Plan, dated 6/18/25 reflected that Resident #4 wanted to listen to music, attend musicals when the facility offered them, TV/movies, music videos, music therapy, music exercise group, and go outside. Review of Resident #4's most recent Activity Evaluation, dated 6/24/24, reflected that Resident #4 required reminders/cues, extensive verbal cuing, and could not comprehend instructions. The evaluation indicated that Resident #4 used a wheelchair with max assist. The evaluation also indicated Resident #4 had a cooperative and cheerful attitude, needed assistance to and from activities, enjoyed 1 on 1 in room, bible study, and watching TV. Review of Resident #4's Progress Notes dated 4/5/25 at 4:30PM entered by Nutrition/Dietary stated in part .patient continues to want to be in his chair more sitting out.Even though patient is nonverbal he cries when he has to return to bed. Review of Resident #4's Progress Notes dated 5/18/25 at 10:19PM stated in part .[Resident] has been sitting up during the day for activities. Review of Resident #4's Progress Notes revealed no further notes that reflected Resident #4 participating in activities since 5/18/25 as indicated by the note entered for that day. Review of the most recent Activities Quarterly Note dated 2/9/24 at 1:01PM stated, Staff will continue to provide Resident #4 with 1:1 visit. Resident also enjoyed sitting in the TV room watching. Staff will continue to provide various activities. Review of the facility's activity calendar, dated July 2025, reflected the following scheduled activities for: 07/01/25 9:00AM - Coffee & Convo10:00AM - Daily Devotional 10:30AM - Nail Time & Chit Chat1:30PM - Arts N Craft3:00PM - In room visits6:00PM - Nightly Cinema Review of the facility's activity calendar, dated July 2025, reflected the following scheduled activities for: 07/02/25 9:00AM - Coffee & Convo10:00AM - Words for Life10:30AM - Fitness for Life1:00PM - Popcorn Social1:30PM - Bingo6:00PM - Nightly Cinema Review of the facility's activity calendar, dated July 2025, reflected the following scheduled activities for: 07/06/25 (Sunday) Activity of Your ChoiceReadingWriting - DrawingWord SearchesChurch Service on TV at 11amFamily Visits During interview and observation with Resident #4 on 7/1/25 at 10:09AM, he was observed to be lying in his bed. Resident #4 was non-verbal but made eye contact at times when spoken to. He was not able to answer questions by gesturing or nodding. Resident #4 was observed in a hospital gown. The TV was not on and no music was playing. During an observation of Resident #4 on 7/1/25 at 1:45PM, Resident #4 was observed to be lying in his bed in the same hospital gown. The TV was not on and no music playing. Resident was not participating in the scheduled activity of Arts N Crafts at 1:30PM. During an observation of Resident #4 on 7/1/25 at 3:00PM, Resident #4 was with his hospice nurse being bathed. During an observation of Resident #4 on 7/2/25 at 3:00PM, Resident #4 was observed to be lying in bed in hospital gown. His TV was on showing a reality court show. During an interview of Resident #4's family member/legal representative on 7/1/25 at 4:45PM, he stated Resident #4's hospice nurse was supposed to be getting him out of bed every day to change clothes. He stated Resident #4 liked watching sports and action shows. He stated the former social worker at the facility would take Resident #4 into her office and play music. He stated Resident #4 would also attend church services at the facility and enjoyed being in the halls around other people. During an interview with LVN J on 7/1/25 at 1:20PM, he stated Resident #4 communicated by facial expressions and he would smile to show emotion. He stated Resident #4 did not participate in activities. He stated Resident #4 received a haircut last week. During an interview with the Activity Director on 7/2/25 at 10:30AM, she reported she would meet one-on-one with Resident #4 twice a week to provide daily devotional which she would do with every resident or bring a music box. She reported she would record these interactions in her activity logbook. She stated Resident #4 liked to watch TV, he would listen to the daily devotional, and enjoyed music when she would bring a radio. The Activity Director stated she had spoken to Resident #4's family about what he was interested in. She stated she was told that he liked music, church, and TV. She stated at times she would leave the radio in Resident #4's room over the weekend. She stated the nurses or aides would turn his TV on. She stated she had never gotten Resident #4 out of bed to participate in activities. She stated before an activity on Monday's, Wednesday's and Friday's, she would go into Resident #4's room and ask him if he wanted to participate. She stated Resident #4 would not show any interest. She stated she knew he was not interested by him having a blank stare on his face. The Activity Director reported she believed that Resident #4 had been out of his bed twice for activities since she began employment there in March 2025. She stated she was unaware that Resident #4 enjoyed being around people and people watching because no one told her. To determine what residents liked to do, she stated she would talk to the family members. When asked about church services, she stated they no longer had someone come to the facility to facilitate church service. She stated the residents would watch services on TV. The Activity Director was asked to provide her one-on-one activity logbook, and it was never provided. She stated she could not locate her book. She stated she was out on leave last week so she is not sure who moved it. When asked who covered activities while she was on leave, she stated no one did. During an interview with Director of Nursing on 7/2/25 at 10:50AM, she stated Resident #4 would communicate by making sounds and if annoyed he would scream. She stated staff would anticipate his needs. She stated he couldn't nod for yes or no. Review of the Facility's Quality of Life - Resident Self Determination and Participation Policy dated December 2016 stated in part: Our Facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life.Each resident is allowed to choose activities, schedules, and health care that are consistent with his or her interest, values, assessments and plans of care including: (a) daily routine, such as sleeping and waking, exercise and bathing schedules; (b) personal care needs, such as bathing methods, grooming styles, and dress; (e) Activities, hobbies and interests; and (f) Religious affiliations and worship preferences. In order to facilitate resident choices, the administration and staff: (a) inform the residents and family members of the residents' right to self-determination and participation in preferred activities; (b) Gather information about the residents' personal preferences on initial assessment and periodically thereafter, and document these preferences in the medical record; (d) Document and communicate any medical conditions or limitations that may inhibit or interfere with participation in preferred activities. Residents are encouraged to make choices about aspects of their lives in the facility, including: (b) organizing and participating in resident groups; (c) interacting with other residents, family and members of the community. Residents are provided assistance as needed to engage in their preferred activities on a routine bases.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of five residents reviewed for pressure ulcers.<BR/>1. <BR/>The facility failed to ensure Resident #1 received all physician ordered wound care 10 out of 31 days in December 2024. <BR/>2. <BR/>The facility failed to ensure Resident #1 received all physician ordered wound care 5 out of 30 days in January 2025. <BR/>This facility failure could place residents at risk of developing infections or worsening of their wounds.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 01/30/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included paraplegia (a condition that causes paralysis or loss of muscle function in the lower half of the body, including both legs), pressure ulcer of sacral region-stage 4, pressure ulcer of right heel-stage 3, pressure ulcer of left heel-stage 3, non-pressure chronic ulcer of back, neuromuscular dysfunction of bladder (impaired bladder control due to disrupted communication between the brain and the bladder muscles), colostomy status(a surgical procedure that creates an opening in the abdomen through which waste from the large intestine can be expelled into a bag) and chronic pain syndrome (a condition characterized by persistent pain that lasts for at least three to six months). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 13, which indicated intact cognition. Resident #1 had no rejection of care issues and no verbal or physical behaviors. Resident #1 had range of motion impairment on both sides of his lower body and was dependent on staff for transfers, bed mobility and ADLs that included dressing, showering, personal hygiene and incontinent care. Resident #1 had an indwelling catheter and an ostomy appliance. Resident #1's assessment reflected he was at risk of developing pressure ulcers/injuries and had four unhealed pressure ulcers and one unstageable deep tissue injury that were present upon admission to the facility. Skin and ulcer/injury treatments included pressure ulcer/injury care, application of nonsurgical dressings and applications of ointments/medications. <BR/>Record review of Resident #1's care plan dated 10/02/24 and last revised on 01/29/25 reflected the following focus areas:<BR/>-Wound Management-Skin tear to the left instep of his foot due to hitting the bedrail during a spasm episode (Initiated12/02/2024); Intervention: Wound will show signs of improvement, provide wound care per treatment order. <BR/>-Resident is at risk for pain related to wound; Site #1: Stage 4 pressure wound sacrum full thickness, wound size: 13.5 x 21.8 x 0.2cm; Site #5: Stage 4 pressure wound of left heel full thickness, wound size: 2.1 x 1.5 x 0.1cm; Site #6: Stage 4 pressure wound of right lateral foot full thickness, wound size: 1.1 x 0.7 x Non measurable cm; Site #12: Non-pressure wound of the left buttock full thickness, wound size: Resolved- 01/22/25. Interventions included to provide wound treatment per MD order, Site #1: Stage 4 pressure wound sacrum full thickness: clean surrounding skin with skin prep, clean wound with NS or wound cleanser, pat dry, apply collagen powder and calcium alginate to wound bed, island dressing or ABD pad and paper tape daily. Site #5- skin prep surround skin, clean wound with NS, pat dry, apply Xeroform to wound, apply island border dressing daily. Site #6- Skin prep three times a week.<BR/>Record review of Resident #1's care plan also reflected a revision on 01/02/25 reflected he was resistent to wound care and skin assessments. The intervention reflected, Give one on one care as needed.<BR/>Record review of Resident #1's physician's order summary for December 2024 and January 2025 reflected the following treatments were ordered:<BR/>1) Cleansed open area on top of left foot, apply triple antibiotic ointment, cover with dry gauze dressing one time a day for open wound on top of left foot (start date 11/30/24, discontinued 01/02/25)<BR/>2) Non-pressure wound right medial heel, skin prep three times per week on Monday, Wednesday and Friday for preventative measure (start date 01/03/25, discontinued 01/15/25)<BR/>3) Non-pressure wound to left lateral ankle - apply skin prep daily (start date 01/02/25, discontinued 01/15/25)<BR/>4) Non-pressure wound left 2nd toe apply skin prep three times per week every day shift every Mon, Wed, Friday for Preventative Measure (start date 01/03/2025, discontinued 01/15/25)<BR/>5) Non-pressure wound of the left 2nd toe partial thickness, once a day every Monday, Wednesday and Friday for 23 days, Apply skin prep; Off-load wound; Pressure off-loading boot (start 12/05/24, discontinued 12/28/24)<BR/>6) Non-pressure wound of the left buttock full thickness, skin prep skin around wound, clean wound with NS, apply xeroform to wound bed, island border dressing or ABD pad daily x23 days. one time a day (start 01/16/25, discontinued 01/22/2025)<BR/>7) Non-pressure wound of the right toe of undetermined thickness once a day for 30 days, apply skin prep, off-load wound with pressure offloading boot (start 12/05/24, discontinued 01/02/25)<BR/>8) Non-pressure wound of the right medial heel partial thickness once a day on Monday, Wednesday and Friday for 16 days, apply skin prep, offload wound with offloading boot (start 12/05/25, discontinued 12/21/24)<BR/>9) Non-pressure wound to left superior lateral ankle-apply skin prep daily for preventative measure (start 01/03/25, discontinued 01/15/25) <BR/>10) Right Lateral Foot: cleanse with NS, pat dry. Apply [NAME] and leave open to air Tuesdays/Thursdays. every day shift for Wound Treatment (start 01/05/25, discontinued 01/15/25)<BR/>11) Stage 4 pressure wound of right lateral foot full thickness: skin prep three times a week x16 days once a day on Monday, Wednesday and Friday (start date 01/17/25 to present)<BR/>12) Stage 4 pressure wound of the left heel full thickness once a day for 30 days apply skin prep, use Xeroform gauze to wound bed and cover with island bordered dressing (start date 12/05/24 through present)<BR/>13) Stage 4 pressure wound of the left heel full thickness: clean with NS, pat dry apply xeroform to wound bed and island border dressing daily x16 days once a day (start date 01/16/25, discontinued 01/29/25). <BR/>14) Stage 4 pressure wound of the left heel full thickness, skin prep surround skin of wound, clean with NS, pat dry apply xeroform to wound bed and island border dressing daily for 30 days once a day (start 01/30/25)<BR/>15) Stage 4 pressure wound of the right lateral foot thickness once a day on Monday, Wednesday, Friday for 30 days (start date 12/05/24, discontinued 01/04/25).<BR/>16) Stage 4 pressure wound sacrum full thickness-apply xeroform gauze to wound bed and cover with ABD pads, use tape/island bordered gauze for retention every day (start 12/31/24, discontinued 01/02/25)<BR/>17) Stage 4 pressure wound sacrum full thickness, once a day on Monday, Wednesday, Friday for 30 days, apply xeroform gauze to wound bed and cover with ABD pads, use tape/island bordered gauze for retention (start date 12/04/24, discontinued 12/20/24)<BR/>18) Stage 4 pressure wound sacrum full thickness, skin prep around wound, clean with NS, Pat dry, apply collagen powder and calcium alginate to wound bed, island dressing or ABD pad and paper tap daily, and as needed. Monitor for s/s of infection once a day (start date 01/16/25 through present)<BR/>19) Stage 4 pressure wound sacrum full thickness, one time a day every Monday, Wednesday, Friday for 30 days apply xeroform guaze to wound bed and cover with ABD pads, use tape/island border gauze for retention (start date 12/05/24, discontinued 12/30/24)<BR/>20) Stage 4 pressure wound sacrum full thickness, apply peri-wound skin prep, aliginate calcium gauze to wound bed and cover with ABD pads, use tape/island border gauze for retention as needed (start date 01/02/25, discontine 01/15/25)<BR/>Record review of Resident #1's December 2024 TAR reflected he did not receive wound care to his sacrum and heel as ordered by his physician on 12/03/24, 12/05/24, 12/12/24, 12/16/24, 12/19/24, 12/20/24, 12/23/24, 12/24/24, 12/25/24 and 12/27/24.<BR/>Record review of Resident #1's January 2025 TAR reflected he did not receive wound care to his sacrum and heel as ordered by his physician on 01/06/25, 01/09/25, 01/14/25, 01/21/25 and 01/29/25.<BR/>Record review of Resident #1's nursing progress notes reflected no entries on the dates of the missed wound care in December 2024 and January 2025 to explain why it was not provided. <BR/>Record review of Resident #1's Wound Evaluation and Management Summaries dated 12/11/24 and 01/29/25 reflected in each visit under the Expanded Evaluation Performed that Resident #1 was a current smoker which was known to affect wound healing and healing progression. Continued interventions for wound healing ordered and implemented included a multivitamin once a day, vitamin C twice a day, low air loss mattress, off-loading wound, repositioning per facility protocol and offloading chair cushion. The following measurements were reflected for his current wounds:<BR/>1) 11/06/24- Stage 4 pressure wound to sacrum over 675 days: The measurements were 20.3 x 14.5 x 0.2 cm with a surface area: 294.35 cm, Cluster Wound open ulceration area of 88.31 cm, Sharp selective debridement procedure was used to remove biofilm over the wound surface area of 88.305 cm, Wound progress: At Goal. (Note: A cluster wound is a grouping of multiple wounds that are close to one another and documenting them as a single wound 'clustered wound' could simplify assessment, when appropriate.)<BR/>-12/11/24- Stage 4 pressure wound to sacrum over 710 days: The measurements were 16x 6x 0.2cm with a surface area of 96 cm with noted improvement, Cluster Wound open ulceration of 19.2 cm, Wound progress: Improved-evidenced by decreased surface area. A sharp selective debridement procedure was used to remove biofilm over the wound surface area of 19.2 cm. Goal of treatment is healing as evidenced by a 61.5 % decrease in surface area within the wound bed in comparison to the last wound visit. <BR/>-01/01/25-Stage 4 pressure wound to sacrum over 731 days: The measurements were 16.5 x22.5 x 0.2 cm with a surface area of 371.25 cm&sup2; and a Cluster Wound open ulceration area of 111.38 cm, Wound progress: Exacerbated due to multifactorial. A surgical excisional debridement procedure was used to surgically excise 37.12 cm of devitalized tissue and necrotic muscle tissue along with slough and biofilm were removed at a depth of 0.3cm and healthy bleeding tissue was observed. As a result of the procedure, the nonviable tissue in the wound bed decreased form 20 percent to 10 percent. Hemostasis was achieved and a clean dressing was applied. <BR/>-01/15/25- Stage 4 pressure wound to sacrum over 745 days: The measurements were 13.4 x22.5 x 0.2 cm with a surface area: of 301.50 cm&sup2; and a Cluster Wound open ulceration area of 90.45 cm, Wound progress: Improved evidence by decreased surface area. A surgical excisional debridement procedure was used to surgically excise 30.15 cm of devitalized tissue including slough, biofilm and non-viable muscle tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of the procedure, the nonviable tissue in the wound bed decreased form 10 percent to 0 percent. Hemostasis was achieved and a clean dressing was applied.<BR/>-01/29/25-Stage 4 pressure wound to sacrum over over 758 days: The measurements were 13.5 x21.9 x0.2cm with a surface area of 294.30 cm with the wound progress noted to be at goal. <BR/>2) Stage 4 pressure wound to the left heel: On 12/11/24, the measurements were 3.5x 3.5x 0.1 cm with a surface area of 12.25 and was not at goal. On 01/29/25, the measurements were 2.1x 5.0x 0.1 cm with a surface area of 3.15cm and was not at goal. <BR/>3) Stage 4 pressure wound of the right lateral foot: On 12/11/24, the measurements were 1.1x 0.5x not measurable cm with a surface area of .55 cm. On 01/29/25, the measurements were 1.1x 0.7x not measurable cm with a with a surface area of .77 cm with noted wound improvement. <BR/>An interview with Resident #1 on 01/30/25 at 1:07 PM revealed he had a very large wound that he admitted to the facility with on his bottom and it had almost gotten healed up by the previous ADON, but when he left employment at the end of November 2024, Resident #1's wounds got worse. Resident #1 said the floor nurses were providing the wound care during December 2024 because there was no wound care nurse designated for the facility. He said the floor nurse would tell him they would get to the wound care, but no one was coming into his room to do it consistently. Resident #1 said he told the ADM, who ended up getting a nurse to start coming in [ADON A] to do the wound care, but he was not sure when she started. Resident #1 stated since ADON A started working on his wounds during the weekdays they had gotten better. However, when ADON A was not at the facility, the floor nurses doing the wound care were not always knowledgeable on the required supplies, technique and application of dressings. Resident #1 stated there had never been a consistent wound care nurse until recently and there had been numerous times when ADON A was not working that his wound care did not get provided. Resident #1 felt that the lack of wound care being done consistently in December 2024 set him back two months on his healing. <BR/>An interview with Resident #1's RP on 01/31/25 at 10:11 AM revealed she had been having concerns about his wound care not being done as well as the nurses not coming to check on him. The RP stated she had seen Resident #1's wounds via photos and they had almost healed around Thanksgiving 2024, but within a few weeks after that, the one on his bottom started going downhill and getting bad. The RP stated Resident #1 could not feel his feet and the wounds on them were chronic and always recurring. As a result, they were not as much of an issue as the one on his bottom. The RP stated, But the bottom wound, they weren't doing right. The RP stated she had tried to get in touch the DON with no success as well as the ADON. <BR/>Record review of a grievance form for Resident #1 dated 12/30/24 reflected a concern that Resident #1 was not getting his wound care done daily. The grievance resolution reflected the DON educated the Resident #1 that his wound care was not done daily and a documented he was told a majority of his wound care was done on Mondays, Wednesdays and Fridays and that the resident should speak with the doctor regarding any order changes. The grievance also reflected Resident #1 then stated, Well they are not doing it on Mondays, Wednesdays and Fridays either and showed me [DON] pictures of his wounds and said they are getting worse. I asked if I could do a full head to toe assessment and the resident refused.<BR/>An interview with the ADM on 01/30/25 at 9:30 AM revealed the DON was out sick on leave. <BR/>An interview with the SW on 01/30/25 at 2:45 PM revealed Resident #1 did make a complaint about his wounds and said he was going to contact the State [HHSC] because he was not getting wound care every day. The SW said, however, the doctor did not order wound care every day and Resident #1 wanted to know why. The SW stated, I think the nurse talked to him and helped him understand that we are only following doctor's orders .He gets worked up sometimes. <BR/>An interview with the wound care nurse, ADON A on 01/31/25 at 11:23 AM revealed she started as the wound care nurse on 01/08/25 and prior to that she was a PRN floor nurse at the facility. ADON A said any wounds from 01/08/25 to present were wounds she had done wound care for, unless she was working on the floor. ADON A stated that she could not speak for anyone else, but if there were blanks on the TAR during January 2025 when she was doing wound care, it may have been due to updating orders in the system, but she was not sure. ADON A stated she was at the facility during the weekdays and the only time she delegated wound care to the charge nurses was if she was working on the floor She stated, Sometimes I try to do wounds before the floor shift starts; sometimes I don't and will delegate to the nurses who are capable of doing treatments. ADON A stated the weekend charge nurses were responsible for doing wound care on the weekends. Regarding Resident #1, ADON A stated he had told her the nurses were not doing the wound care correctly but she did not know what he meant. She said Resident #1's wound drained a lot and she taped them up very well and they did not come undone, so she thinks when other nurses did it, Resident #1 may feel that the bandages were falling off. ADON A stated residents' wounds in the facility were tracked by herself. She said she would know if wound care was not getting done because of how the bandages were dated when came in for her next shift.<BR/>An interview with the ADM on 01/31/25 at 1:54 PM revealed ADON A was in charge of monitoring wound care and sometimes the DON did weekly random audits of wounds. <BR/>Record review of the facility's policy titled Wound Care revised October 2010 reflected, Purpose: The purpose of this procedure is to provider guidelines for the care of wounds to promote healing .Steps in the Procedure .12. Apply treatments as indicated, 13. Dress wound .Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given, 2. The date and time the wound care was given .4. The name of the individual performing the wound care, 5. Any change in the resident's condition .10. The signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Residents #15) of 4 residents reviewed for quality of care. <BR/>1. Resident #15 did not receive care on the overnight shift (10PM-6AM) on 08/05/24. Resident #15's entire, right leg hung from the bed throughout the night and was observed swollen. Resident #15 was in distress, discomfort, pain, shed tears and had a flushed face (blood vessels below the skin dilate and fill with more blood, making the skin appear pink, red.) Resident #15 call light and bathroom call light did not work properly. Resident #15 yelled and cried out for help continuously for thirty minutes at 7:00 AM on 08/06/24.<BR/>On 08/07/24 at 3:46 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/12/24, the facility remained out of compliance at a severity level of - no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. <BR/>These failures could place all residents at risk for abuse that could lead to serious injury, harm, impairment, or death. <BR/>Findings included: <BR/>Record review of Resident #15's face sheet, dated 08/12/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: paraplegia (the loss of muscle function in the lower half of the body, including both legs), abnormalities of gait and mobility, intervertebral disc degeneration (a condition that occurs when the spinal discs break down and lose function), lumbar region (spinal disks wear down), post-traumatic stress disorder (a mental health condition that caused by extremely stressful or terrifying event), pain unspecified, and retention of urine. <BR/>Record review of Resident #15's initial MDS assessment, dated 06/28/24, reflected her BIMS score was 13, which indicated she was cognitively intact. <BR/>Record review of Resident #15's care plan, revised on 08/02/24, reflected Resident #15 required skilled nursing care related to paraplegia. Resident #15 will safely transition to long term care. Resident #15 will continue to improve. Resident #15 has limited physical mobility/ADL deficit related to paraplegia, Chronic Obstructive Pulmonary Disease, anxiety, and bipolar disorder. Resident #15 were on skilled services and decided she wanted long term care instead of short stay. Resident #15 had rails on bed for positioning and turning. Resident #15 required bed mobility with 1 staff, transfers with 2 staff with a sliding board and a Hoyer lift with showers, toileting with 1 staff, and dressing/grooming with 1 staff. Goals: free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, and fall related injury through the next review date. Interventions: Monitor/document/report to MD PRN s/sx of immobility: contractures forming or worsening, thrombus formation, skin break down, and fall related injury .Provide supportive care, assistance with mobility as needed. Document assistance as needed.<BR/>Record review of Resident #15's progress note, late entry dated 08/08/24 by the social worker, reflected the following: [Resident #15] asked if she had to move rooms. SS explained to the resident that once a resident transition to long-term, they get a roommate. The resident then stated a staff member said she could stay in a private room if her family could pay the difference. When asked who told her that, resident said she could not remember. SS told the resident that they would ask the administrator and see what he says. The [Resident #15] then said she plans on leaving the facility September 1st and will move in with her.<BR/>Observation on 08/06/24 at 7:00 AM revealed Resident #15 yelled for help from her bedroom. Observed Resident #15 right entire leg hanging out of the bed and appeared to be red and swollen. Observed Resident #15 face was red, in distress and she was crying. <BR/>Observation on 08/06/24 at 7:30 AM of the social worker went into the room and then walked out. Observed Resident #15 call out for help again.<BR/>Observation on 08/06/24 at 7:40 AM revealed LVN H and CNA N lifted Resident #15's leg back in the bed and gave her pain medication. LVN H stated to Resident #15 that they will assist her after breakfast with getting dressed and changed.<BR/>Observation on 08/06/24 at 7:45 AM revealed Resident #15's call light in the room and in the bathroom did not work. <BR/>Observation on 08/06/24 at 4:30 PM revealed Resident #15's call light worked properly. <BR/>Interview and observation on 08/06/24 at 7:21 AM with Resident #15 who stated she was not checked on by the overnight shift. Resident #15 stated she had been calling out for help for a while and no one had been by to help her. Resident #15 was distressed and crying. Resident #15 stated that she felt alone and abandoned. Resident #15 stated the last time she saw staff was when she moved into the room.<BR/>In an interview on 08/06/24 at 7:45 AM Resident #15 stated she did not know why she was moved to hallway 500, she was moved yesterday and was the only resident on that hall. Resident #15 stated her call light in the room and bathroom did not work. Resident #15 stated she had told the DON and other staff that her call light did not work on 08/05/24 around dinner time at 4:30 PM.<BR/>In an interview on 08/06/24 at 8:10 AM with the social worker revealed Resident #15 was moved to the 500 hall because she wanted to be transferred to long term care and have a single room.<BR/>In an interview on 08/06/24 at 9:00 AM LVN H stated Resident #15 was transferred to the 500 hall on 08/05/24 between first and second shift. LVN H stated that she was responsible for 300 and 500 hall. LVN H stated the facility had problems in the past with the call lights not working. LVN H stated that if residents were not checked on every 2 hours and as needed, they were in danger of falls and skin break down.<BR/>In an interview on 08/06/24 at 9:10 AM CNA F revealed she did not know there was a resident on hallway 500. CNA F revealed residents were to be checked on every 2 hours. <BR/>In an interview over the phone on 08/06/24 at 9:15 AM CNA N (overnight shift) stated she did not know a resident was on 500 hall.<BR/>In an interview on 08/06/24 at 3:00 PM the DON stated that staff knew Resident #15 was on 500 hall and she had a history of lying, drinking, and smoking in the room and that was part of the reason why she was put on the hall by herself. The DON revealed that Resident #15 was transferring to long term care and wanted to stay in a room by herself. The DON stated the call light system just started to act up on 08/05/24. The DON stated the call light company would be out to repair the system. The DON stated residents are checked on every 2 hours and the residents who call lights did not work then bells would be provided. The DON stated residents are in danger of skin break down or falls if they are not checked every 2 hours. <BR/>In an interview on 08/06/24 at 3:08 PM with Resident #15 stated that her entire left leg hung out of the bed all night and she did not know until she started to feel pain. Resident #15 stated her pain level this morning was at a ten and now she was down to an 8. Resident #15 stated she expected staff to answer the call light and help her as soon as they could. Resident #15 stated she understood the staff were busy but when they tell her they will come back staff don't. Resident #15 stated the social worker told her she was moved because she wanted to move to long term care and stay in a single room. Resident #15 stated the DON asked her if she wanted to move back to hall 100 and she told him no because she had too much stuff too.<BR/>In an interview on 08/07/24 at 5:15 AM with LVN R (Overnight shift) stated she was responsible for hall 300, 400, and 500. LVN R revealed she changed Resident #15 once overnight the night before. LVN R stated since Resident #15's call light was not working she was checked on every 2 hours.<BR/>In an interview on 08/07/24 at 5:20 AM with CNA N (Overnight shift) revealed she worked halls 100, 300, and 500. CNA N revealed that Resident #15 was checked on once.<BR/>In an interview on 08/07/24 at 7:00 AM with the Maintenance Director stated the facility was in the process of updating the call light system and the owner would know more information about that. The Maintenance Director stated when the call light system did not work resident rounds should be every 30 minutes. The Maintenance Director stated residents could be at risk of not getting care when needed. The Maintenance Director stated the facility had on and off issues with the call lights. The Maintenance Director stated the call light company would be out on 08/07/24 after 12:00 PM to work on the system. <BR/>Record review of facility in-service dated 08/06/24 titled: call light and resident care reflected: <BR/>Resident should be up in a WC and back to bed as needed and requested. If a resident wants to get up, we need to do all we can to get him/her up. If they want to go back to bed, assist them back in bed as need. Let us work with our residents to meet their needs. We should always encourage residents to get out if bed; not discourage them. We should also empower residents by allowing them to participate in the decision-making process. For example, we can ask: What time would you like to get up: What time would you like to go back to bed? I know you want to get up at 5 PM. At that time, we are passing dinner on the floor. Is it possible for you to get up earlier or later than 5pm? Make residents feel in control of daily lives. We need to do round on residents all the time and provide incontinent care as needed without delays to all halls INCLUDING 500 HALL Do not delay care or wait for the end of the shift when we know that a resident is wet and needs assistance. We cannot let our residents lie in urine and feces: placing them at remarkably high risks of all types of infection. We should always treat our residents with dignity and respect. DO not display a behavior or attitude that may be misinterpreted or make residents uncomfortable. Do not make fun at residents. When they need something, please take time to explain and answer all their questions to the best of your ability. <BR/>Call lights should be answered in a timely manner without delays by all departments. When answering the call light, please refer to the service resident is requesting. Make sure to return and update resident. Leave the call light on until residents' needs have been met.<BR/>No staff signatures included with in services.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 08/07/24 at 3:46 PM. The Administrator and DON was notified. The Administrator was provided with the IJ template on 08/07/24 at 4:00 PM. <BR/>The following Plan of Removal was submitted by the facility and was accepted on 08/09/24 at 3:11 PM and reflected: <BR/>Immediate Corrective Action for residents affected by the alleged deficient practice: <BR/>Identified Immediate Jeopardy (IJ) Issues: Policy and procedure have and will be reviewed and will be re-in-serviced if change is required. <BR/>1. <BR/>Noncompliance with &sect;483.12 (F 600) Freedom from Abuse, Neglect, and Exploitation<BR/>o <BR/>Resident #1 was not checked on the overnight shift.<BR/>o <BR/>Call lights and bathroom lights were not functional. <BR/>Corrective Actions and Steps for Removal of Immediate Jeopardy:<BR/>1. Ensuring Resident Safety and Dignity<BR/>Immediate Staff Training:<BR/>o <BR/>Action: Conduct immediate in-service training for all staff on the importance of resident checks, especially during night shifts, and proper use of the call light system. Review of Policy and Procedure for call light and ADL's.<BR/>o <BR/>Responsible Party: Director of Nursing (DON)<BR/>o <BR/>Completion Date: 08/09/2024<BR/>Immediate Resident Checks:<BR/>o <BR/>Action: Implement a system to ensure residents are checked every two hours, with documentation of each check. Review of Policy and Procedure ADL's.<BR/>o <BR/>Responsible Party: Nursing Staff<BR/>o <BR/>Completion Date: Ongoing with immediate effect<BR/>2. Functionality of Call Lights and Electrical Systems<BR/>Repair Call Lights and Electrical Issues:<BR/>o <BR/>Action: Ensure all call lights in resident rooms and bathrooms are fully functional. A certified electrician will repair any non-functional lights immediately. Review of Policy and Procedure for call light and ADL's.<BR/>o <BR/>Responsible Party: Maintenance Supervisor<BR/>o <BR/>Completion Date: 08/09/2024<BR/>Routine Maintenance Checks:<BR/>o <BR/>Action: Conduct daily checks of call light systems for two weeks, followed by weekly checks to ensure ongoing functionality.<BR/>o <BR/>Responsible Party: Maintenance Supervisor<BR/>o <BR/>Completion Date: Start immediately and continue weekly<BR/>4. Resident Assistance and ADL Care<BR/>Enhance ADL Care:<BR/>o <BR/>Action: Review and revise hall assignments to ensure adequate staffing on all halls, including hall 500. Ensure staff are aware of and meet residents' ADL needs promptly.<BR/>o <BR/>Responsible Party: DON and Nursing Supervisor<BR/>o <BR/>Completion Date: 08/09/2024<BR/>Frequent Monitoring and Assistance:<BR/>o <BR/>Action: Implement a policy requiring staff to respond to call lights within 5 minutes. Regularly audit compliance and address any delays promptly.<BR/>o <BR/>Responsible Party: Nursing Supervisor<BR/>o <BR/>Completion Date: Start immediately with ongoing monitoring<BR/>5. Family and Resident Communication<BR/>Communication with Residents and Families:<BR/>o <BR/>Action: Inform residents and their families about the steps being taken to address the identified issues and ensure their safety and well-being.<BR/>o <BR/>Responsible Party: Administrator and Social Worker<BR/>o <BR/>Completion Date: 08/09/2024<BR/>Monitoring and Verification<BR/>Regular Audits:<BR/>o <BR/>Action: Conduct weekly audits for compliance with the above actions for the next three months, then transition to monthly audits.<BR/>o <BR/>Responsible Party: Quality Assurance Team<BR/>o <BR/>Completion Date: Ongoing<BR/>Immediate Reporting:<BR/>o <BR/>Action: Any noncompliance or issues identified during audits must be reported to the DON and Administrator immediately for corrective action.<BR/>o <BR/>Responsible Party: Audit Team<BR/>o <BR/>Completion Date: Ongoing<BR/>Completion and Documentation<BR/>Document All Actions:<BR/>o <BR/>Action: Maintain thorough documentation of all corrective actions, training sessions, maintenance checks, and communication with residents and families.<BR/>o <BR/>Responsible Party: Administrator<BR/>o <BR/>Completion Date: On going<BR/>The facility's implementation of the Plan of Removal was verified through the following:<BR/>Record review of in-service record sheet dated 08/07/24 titled: Call light/check residents. Purpose: plan of correction. Ensure resident safety and dignity: Make sure to check all residents at least every two hours every shift and as needed, especially at night. Before leaving the room make sure call light is working in room and the bathroom and within patients reach.<BR/>Enhance ADL Care: Check residents in hall 500 at least every two hours every shift and throughout the night. Hall 500 assignments will be added to the staffing book. Check staffing book assignment daily to know who is assigned to hall 500. DO not ignore call light. Call light needs to be answered promptly. Even if you are not assigned to a resident, you must answer call light and address residents needs as much as you could. Provide showers to residents as scheduled and as needed. If a patient missed shower for more some reasons, we should provide it to them when requested even if it's not their shower day. When a patient refuses shower, notify the nurse immediately who will then inform family and document under PCC notes.<BR/>Frequent Monitoring and assistance: We need to respond to call light immediately; within 5 minutes or less. Any staff that delay care or call light response will face disciplinary action.<BR/>Record review of NMAR reflected: [ Resident #15] check on resident at least every two hours every shift initiated on 08/08/24.<BR/>Record review for in-services were initiated on 08/12/24 at 11:11 AM in a message to the team. Message reflected: Good morning, Team! Please see in-service regarding call lights/resident rooms from DON. We need to answer call light immediately. When we go to room, check to make sure call lights works in the room and bathroom. If it does not report it to charge nurse, DON and/or Maintenance. <BR/>There are patients on 500 hall that need to be monitored as well. Check on all patients including the ones on hall 500 at least every two hours. Hall 500 assignments will be in staffing book. Please check it at the beginning of each shift. Please respond to acknowledge the in-service. <BR/>An interview on 08/09/24 at 5:15 AM with RN P revealed residents were checked on every 2 hours and as needed. RN P revealed that checks were documented on the EMAR.<BR/>An interview on 08/09/24 at 5:20 AM with RN Q revealed she worked over night with Resident #15, and she was checked on every 2 hours and as needed. RN Q revealed that checks were documented on the EMAR.<BR/>An interview on 08/09/24 at 5:25 AM with CNA F revealed residents were checked on every 2 hours and as needed. CNA F revealed that checks were documented on the EMAR.<BR/>An interview on 08/09/24 at 5:30 AM with LVN A revealed residents were checked on every 2 hours and as needed. LVN A revealed that checks were documented on the EMAR.<BR/>An interview on 08/09/24 at 6:10 AM with LVN B revealed residents were checked on every 2 hours and as needed. LVN B revealed that checks were documented on the EMAR.<BR/>An interview on 08/09/24 at 6:20 AM with LVN D revealed she worked with Resident #15 overnight and she was checked on every 2 hours and as needed. LVN D revealed that checks were documented on the EMAR. <BR/>An interview on 08/10/24 at 1:30 PM with CNA X who stated residents are checked on every 2 hours. CNA X stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/10.24 at 1:37 PM with RN Y who stated residents are checked on every 2 hours. RN Y stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/11/24 at 5:45 AM with Med Aide S who stated residents are checked on every 2 hours. Med Aide S stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/11/24 at 5:58 AM with LVN R who stated residents are checked on every 2 hours. LVN R stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/11/24 at 6:00 AM with CNA T who stated residents are checked on every 2 hours. CNA T stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/11/24 at 6:00 AM with CNA V who stated residents are checked on every 2 hours. <BR/>An interview on 08/11/24 at 6:03 AM with CNA U who stated residents are checked on every 2 hours.<BR/>An interview on 08/11/24 at 6:03 AM with RN W who stated residents are checked on every 2 hours. RN W stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/11/24 at 8:41 AM with the DON stated the MAR needed to be updated to reflect every 2-hour check for residents. DON stated he needed to do in-services for residents on hall 500 and assigned task. DON stated he would send updated information before the end of the day. DON stated residents are checked on every 2 hours. DON stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/12/24 at 5:30 AM CNA J who stated residents are checked on every 2 hours. CNA J stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/12/24 at 6:00 AM LVN B stated who stated residents are checked on every 2 hours. LVN B stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/12/24 at 6:04 AM LVN H who stated she worked the day shift and is responsible for Resident #15 and she is checked on every 2 hours. LVN H stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>The Administrator was notified the IJ was removed on 08/12/24 at 12:15 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolation due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that the facility residents received proper treatment and care to maintain mobility and good foot health for 2 (Resident #11 and Resident #12) of 5 residents reviewed for foot care services.<BR/>1. The facility failed to provide podiatry services to Residents #11 and #12.<BR/>This failure could lead to increased potential negative outcomes related to foot health.<BR/>Findings Included:<BR/>Record Review of Resident #11's demographic sheet, dated 07/18/24, revealed he was a [AGE] year-old male with an initial admission date to the facility of 11/1/2023. Resident #11's active diagnoses included: Type 2 diabetes mellitus with hyperglycemia (person with a condition of diabetes that has high blood sugar levels), muscle weakness (generalized), peripheral vascular disease, unspecified (condition where the arteries narrow, causing reduced blood flow to the arms or legs). He had a BIMS score of 14/15 revealing no cognitive impairment.<BR/>Record Review of Resident #11's care plan, no date indicated, revealed the following:<BR/>Focus- Resident #11 has Diabetes Mellitus, Date Initiated- 1/18/24.<BR/>Goal- Resident #11 will have no complications related to diabetes through next review, Date Initiated- 1/8/24, Revision on 4/19/24.<BR/>Focus- Resident #11 has an ADL self-care performance deficit, Date initiated- 1/18/24.<BR/>Goal- Resident #11 will be clean, dry and neatly dressed daily through next 90 days, date initiated on 4/19/24. <BR/>Record Review of Resident #11's clinical record, progress notes, social work notes does not indicate a referral made for podiatry services.<BR/>An interview and observation with Resident #11 on 07/18/24 at 1:45 PM revealed the resident was lying in bed. Observation of resident's toenails revealed toenails to be discolored, broken and dry. Resident #11 stated he has been at the facility for some time and could not remember ever seeing a podiatrist. When asked if he could independently manage his own foot care, Resident #11 responded no. The resident revealed that he would like to see a podiatrist routinely but was unsure who to ask.<BR/>Record Review of Resident #12's, demographic sheet revealed he was a [AGE] year-old male with an initial admission date to the facility of 11/22/2019. Resident #12's active diagnoses included: Quadriplegia (paralysis of both the arms and legs), unspecified, Type 2 diabetes mellitus with foot ulcer and muscle weakness (generalized)<BR/>Record Review of Resident #12's MDS dated [DATE] revealed he had a BIMS score of 0/15 indicating a severe cognitive impairment.<BR/>Record Review of Resident #12's care plan, no date indicated revealed the following:<BR/>Focus- Resident #12 has Quadriplegia r/t LE of CVA with LE dysphagia and Aphasia. Date initiated- 5/3/23.<BR/>Goal- Resident #12 will remain free of complications or discomfort related to paraplegia through review date. Date initiated- 5/3/2023.<BR/>Focus- Resident #12 has an ADL self-care performance deficit r/t Quadriplegia.<BR/>Goal- Resident #12 will maintain current levels of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene mobility through next review date. Date initiated- 5/3/2023, revision date on 11/25/2023. <BR/>Focus- Resident #12 has Diabetes Mellitus- Date initiated on 5/3/2023, Revision on 11/25/2023.<BR/> Goal- Resident #12 will have no complications related to diabetes through review date. Date initiated on 5/3/2023, revision on 11/25/2023. <BR/>Interventions/Tasks- Elicit a verbal understanding from the resident/family/caregiver that nails should always be cut straight across, never cut corners, file rough edges with emery board. Date initiated on 5/3/2024, revision on 8/2/2023.<BR/>Record Review of Resident #12s clinical record document titled, Care plan Conference revealed the following:<BR/>Care Plan Meeting Date and Time: 6/11/24 at 1:44PM<BR/>Invitations: Family/Responsible Party, Invited and Attended.<BR/>Participants: Nurse, Social Worker, Occupational Therapist, Activities Director.<BR/>Social Services Summary: No changes, resident in a comatose state. Residents' family member attended the meeting over the phone.<BR/>Consults Needed (Podiatry, Dental, Opth, etc.): None requested.<BR/>Record review of Resident #12's clinical record document titled, Care Plan Conference revealed that the document was signed and locked by MDS nurse on 7/18/24 at 1:09 PM, date of record review during survey.<BR/>Record Review of the document, [Name of Podiatry] Podiatry Group revealed that resident #12 was last examined by Podiatry Group on 6/22/2022. Document was electronically signed by the Podiatrist on 6/22/22. Record Review of the document, [Name of Podiatry] Podiatry Group revealed that, recall to be as medically necessary, but no sooner than 60 days.<BR/>Record Review of document titled, [Name of Podiatry Group] Visit Summary revealed the visit date to be 7/3/24. Document revealed the following:<BR/>Treated Patients: Did not reveal resident #11 or resident #12 to be treated during the 7/3/24.<BR/>Non-treated patients: Did not reveal Resident #11 or Resident #12 to be under the non-treated patients' section.<BR/>Record Review of a facility document titled, [Name of Podiatry Group] Podiatry Group Schedule revealed a visit date of 8/9/2024. Record Review of the document did not reveal Resident #11 or Resident #12 to be scheduled for the 8/9/24 visit.<BR/>An observation of Resident #11 on 07/18/24 at 2:20 PM revealed he was in bed, woke to verbal stimuli, but was unable to verbalize or correspond with the surveyor. Physical observation revealed toenails to be broken, discolored and long.<BR/>An interview with Resident's Responsible Party on 07/18/24 at 2:41pm revealed they were the responsible party for Resident #12. He revealed that he had never been asked if he would like Resident #12 to be on routine podiatry services and could not recall the last time Resident #12 was seen at the facility by a podiatrist. Interview with the Resident's Responsibility Party revealed that he was unsure of who to ask at the facility if he would like the resident to be seen by the podiatrist.<BR/>An interview with RN Q on 07/18/24 at 3:28 PM revealed that she had been working on the 400 hall since November 2023 and has been the nurse for both Resident #11 and Resident #12 during that time and had not seen podiatrist services for those residents. RN Q said she would go to the attending physician for an order for podiatry services. When asked about the risk for residents not receiving podiatry services who have an increased risk to their foot health related to their diagnoses, RN Q revealed that a risk would be an increase in skin breakdown. <BR/>An attempt was made to interview the Social Worker on 7/18/24 at 3:40 PM via phone, no return call. Request made to administrator to have Social Worker call surveyor. <BR/>An interview with the MDS nurse on 07/18/24 at 3:45 PM revealed that the Social Worker was responsible for ancillary service coordination, including podiatry services. When asked about risks associated for not having residents seen, consulted or on routine podiatry services who have increased risk of negative foot health due to their diagnoses, the MDS nurse revealed risks to be further breakdown and missing care. The MDS nurse revealed that Resident #11 was referred to the podiatrist last week but could not locate the referral or consents. <BR/>An interview with the Administrator on 07/18/24 at 4:10 PM revealed that it was the responsibility of the social worker to ensure residents were referred to ancillary services including podiatry services.<BR/>Record Review of the facility's Social Worker Job Responsibilities titled, Job Description Facility Social Worker, no date indicated, revealed that the social worker is responsible for enabling each resident to function at the highest possible level of social and emotional well-being. The Social Service director also assures that the resident's continuing needs are met through the highest degree of quality resident care in accordance with state and federal regulations and facility policies and procedures. Responsibilities of the social worker include, assist and prepare residents to resume life in the community or long-term residence in the facility as appropriate to the resident's status and capability. Connect with resources appropriate to their needs, regardless of payment. <BR/>Record Review of the Foot care policy titled, Skin integrity- Foot Care, revised October 2022, revealed that it is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. Policy revealed that the facility will provide foot care and treatment in accordance with professional standards of practice, including the prevention of complications from the resident's medical condition.

**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 be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 4 residents (Resident #1, Resident #2) reviewed for abuse and/or neglect.The facility failed to ensure Resident #1 was free from abuse when the call device was not functioning and available to call for immediate assistance when she was physically abused by Resident #2. A manual bell had been placed at Resident#1's door and in her drawer, but Resident #1 had not been instructed on how/when to use the bells. On 07/24/25 at 5:20 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/26/25 the facility remained out of compliance at a scope of no actual harm with a potential for more than minimal harm and a scope of isolated that was not an immediate jeopardy due to the facility's need to monitor the implementation and the effectiveness of their Plan of Removal. This failure could place residents at risk of abuse, neglect, and psychosocial harm.Findings included: Record review of Resident #1's admission record, dated 07/24/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, cognitive communication deficit (communication disorder stemming from cognitive impairments that affect a person's ability to communicate effectively), bipolar disorder (associated with episode of mood swings ranging from depressive lows to manic highs), calculus of kidney (small, hard deposit that forms in the kidneys and is often painful when passed), morbid (severe) obesity (a disorder that involves having too much body fat, which increases the risk of health problems), and paraplegia (condition characterized by the loss or impairment of motor and sensory functions in the lower half of the body). Record review of Resident #1's care plan dated 6/13/25 reflected the resident had limited physical mobility, does not walk, used manual wheelchair for locomotion, was totally dependent on staff for repositioning and turning in bed, and totally dependent on (2) staff for transferring. The care plan addressed Resident #1's behavior problem of cursing out the staff when she did not get her way, the facility was to monitor her daily/weekly and administer medications as ordered. The resident's plan did not address her rooming with resident #2, the staff involved in the decision were no longer working at the facility. Record review of Resident #2's admission record, dated 07/24/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included, a diffuse traumatic brain injury (widespread damage to the brain's white matter), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life activities), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), chronic pain syndrome (persistent pain that last weeks to years by be caused by inflammation or dysfunctional nerves), bipolar disorder (associated with episode of mood swings ranging from depressive lows to manic highs), and antisocial personality disorder (a mental health disorder characterized by disregard for other people).Record review of Resident #2's care plan dated 6/13/25 reflected the resident required limited assistance by (1) staff tomove between surfaces, the resident did not walk, and resident used a manual wheelchair for locomotion. Resident #2's care plan addressed his psychiatric illness and refusing medications and services, staff were to monitor, encourage him to participate, inform him of the danger to his health if he did not participate, staff were to document his refusals. Resident #2's care plan did not address him rooming with Resident #1, the staff involved with that decision were no longer working at the facility. The plan addressed the facility educating Resident #2 on the dangers of sleeping in the bed with Resident #1. Resident #2's care plan did not address him leaving the facility, nor did it address any drug/alcohol use.Current MDS requested for Resident #1 and Resident #2 on 07/26/25 at 2:11 PM, and reminder sent on 07/28/25 at 5:16 PM. Received MDS for Resident #1 and Resident #2 on 07/29/25 at 5:04 PM the BIMS was blank.On 07/31/25 at 6:10 AM emailed Administrator-B and Director of Clinical Services and informed the MDS' for Resident's #1 and #2 had no BIMS and if the admission MDS could be provided. On 08/06/25 at 12:07 PM an email was sent to Administrator-B, the MDS for Residents #1 and #2 were requested and received, noting that Resident #1 and Resident #2 both had a BIMS of 15. Interview on 07/24/25 at 11:04 AM with Resident #1 revealed she and Resident #2 were roommates. She stated he was her fiance. She stated earlier in the day on 07/22/25, Resident #2 was upset with RN-A and called the police on him. She stated Resident #2 left to get some beer and brought it back to the room to drink. She stated another resident's friend gave Resident #2 drugs and when he came to the room to try to smoke it, she told him he could not smoke it and he got upset and began to beat on her. She stated she was yelling for help, she stated RN-B came into the room and screamed for Resident #2 to stop hitting her. She stated Resident #2 did stop hitting her then EMS arrived and took her to the hospital, and she was there for about two hours then she was brought back to the facility. She stated her injuries were a black right eye, a busted upper lip, bruised to both cheeks, and a large bruise to her left breast. She stated she did not feel safe at the facility because someone else could enter the room and she could not protect herself. She stated she and Resident #2 had not had any physical altercations in the past. She stated he had taken care of her he had never hurt her. When asked if she pushed the call light button, she stated the call light had not worked in four months. She stated she was given a bell to ring when she needed assistance, but they had put the bell on the door. She said she also had a bell in the drawer next to her bed. She stated no one had told her she needed to keep the bell out of the drawer. She stated she was given a bell to ring when she needed assistance, but they had put the bell on the door. She said she also had a bell in the drawer next to her bed. Observation on 07/24/25 at 11:30 AM revealed there were two call light cords plugged into the wall in the room of Residents #1 and #2. Observation of the call light cords revealed both cords on the floor. Further observation of the room revealed a bell hanging on a short rope/string on the back of the door to the room, out of reach of the Residents. Resident #1 was observed in her bed. A telephone interview with RN-A on 07/24/25 at 11:51 AM revealed he had worked the 2-10 shift on 07/22/25 when Resident #2 came to him at 6 PM and asked for his pain medication, Resident #2 was informed his pain medication was due at 7:30 PM. He stated 30 minutes later Resident #2 came to him and said that Resident #1 needed her wound dressing changed. He stated when he went to the room of Resident #1 and Resident #2, he started to do the dressing when Resident #2 yelled at him that he was not taking care of the wound. He stated he was treating Resident #1 for the sacrum area, when Resident #2 had informed him (RN-A) that the dressing needed to be changed. RN-A stated while he was changing dressing, Resident #2 informed him (the nurse) that there was another wound that had developed. He stated he informed Resident #2 that Resident #1 did not have another wound and Resident #2 attempted to touch the area the nurse was re-dressing, and RN-A pushed his hand away and became upset saying he (RN-A) had put his hands on him and he (Resident #2) was going to call the police. He stated the police did come to the facility and talked to him and Resident #2, then they left. He stated when he was in a room taking care of a resident who had a G-Tube, he heard noises coming from the room of Resident #1 and Resident #2, he stated when he heard the yelling, he was actively caring for another resident. He stated when he finished with the G-Tube resident he went into the hallway, and he saw RN-B with CNAs in the hallway. He stated he did not see Resident #2 hit Resident #1; the incident ended when RN-B called out Resident #2's name. He stated then RN-B went to the nurses station and called 911. He stated prior to the police arrival Resident #2 came after him and attacked him with a pocketknife and cut his hand. He stated he and Resident #1 went to the hospital for medical attention and Resident #2 was treated and taken to jail. He stated the residents were at risk because Resident #1 did not have a way to call for help other than to yell for help. Face to face interview with Maintenace Director on 07/24/25 at 3:15 PM revealed he had been employed since late February. He stated he knew there were some call lights that were not working throughout the building. He stated he would fix the call lights then they would go out again, because the system was old. He stated if the call light was not working the residents would be given a bell to ring for help until the light could be fixed. He stated he was not sure if the call lights were working in Resident #1 and Resident #2's room. He stated when an aide would report the light was not working, he would fix the light on the spot. He stated he did not believe the light situation got to a point that he needed to notify Administrator-A. He stated there was not any room that had to have the call light fixed more than one time. He stated the staff would come to him face to face to report a call light was not working. He stated the staff could always call him on his cell phone to report issues. He stated when the call light was not working it could delay or not allow a resident to receive help. Face to face interview with Administrator-B on 07/24/25 at 3:36 PM, revealed the day was her fourth day working at the facility. She stated she was not aware Resident #1 and Resident #2 did not have a call light in their room. She stated when she found out about the call light, she was trying to move Resident #1 to another room, but she had refused to move. She stated she did not know how long Resident #1 and Resident #2 had been without a call light or any way to communicate to staff the need for assistance. She stated she did not know how the residents were supposed to let staff know they needed assistance. She stated she did not know there was a bell in the room or that the bell was on the back of the door out of reach of the resident. She stated perhaps the resident put the bell on the back of the door herself. When advised the resident was unable to walk and could not get up without help of staff, she replied, the resident could have put the bell on the door when she was in her wheelchair. She stated she would assume the Maintenace director was responsible to ensure the call lights worked in the rooms. She stated the CNAs and nurses would be responsible to ensure the placement of the bell was in reach of the resident. She stated there was a severe risk of injury or a lack of care to the residents' when they did not have access to communication.A telephone interview with CNA-A on 07/25/25 at 12:09 PM reflected Resident #2 had told him he was upset with RN-A and took his anger out on Resident #1. He stated RN-A had disrespected Resident #1. He stated RN-B was with him when they went to the Resident #1 and #2's door. RN-B asked what was going on and why was Resident #2 hitting Resident #1. He stated Resident #1 said he was not hitting Resident #2, but he could see they were the only two people in the room. CNA-A stated he knew to go to the room because he heard Resident #1 screaming from the room. He stated he did not know the call light was out in the room of Resident #1 and Resident #2. He stated Resident #2 would come out of the room to let the nurse know that Resident #1 needed help. He stated after the incident he was told there was a bell in the room for them to use to let staff know they needed help, but he had never heard it used. He stated when a resident was not able to call for help, they could be at risk of injury. In a telephone interview with RN-B on 07/26/25 at 6:15 PM, reflected she was aware some of the call lights were not working but she was not sure how long the lights had been out. She stated she thought the administrator and Maintenace knew the light was not working but she had not checked with them. She stated the night of the incident between Resident #2 and #1 she was assigned to halls 300 and 500. She stated she was on hall 400 at the time of the incident to get supplies from the supply closet. She stated she heard Resident #1 screaming and went to see what was happening and when she got to the room, she saw Resident #2 hitting Resident #1 in the face. She stated she called the name of Resident #2, and he stopped hitting Resident #1 immediately and started calling her baby. She stated she called 911, Resident #2 came to the nurses station shouting and saying it was RN-A's fault and swung on RN-A and cut his hand with a knife. She stated the police and EMS arrived, and Resident #1 went to the hospital and Resident #2 was arrested. She stated she did not believe if the resident had a call light it would have kept Resident #2 from harming Resident #1.Record review of facility's incident report dated 07/22/25, reflected, [Resident #2's] roommate (Resident #1) screamed for help and when staff responded to the screams for help, [Resident #2] was seen standing over his roommate punching her in the face repeatedly. After his name was called, he (Resident #2) stopped attacking her (Resident #1) and tried to console her. [Resident #2] slit his own throat with a pocketknife and came to the nurses station and began shouting at the male nurse (RN-A) on duty and [he the jumped on top of the counter swung the knife at the nurse and cut the nurse's hand]. 911 was called when the resident (Resident #1) was beating on his roommate (Resident #2), and they were on the phone when he (Resident #2) cut the nurse's (RN-A) hand. The police came and removed the resident (Resident #2) from the building. DON notified via phone of the incident. [No further action taken at this time ].Record review of LE report dated 07/22/25, reflected, On Tuesday July 22nd, 2024, I Officer [#1] was dispatched to [Nursing & Rehab] room [Resident #1 and Resident #2] reference a cutting in progress call at 2359 hours (11:59 pm). Call text stated a residence of the rehab center got in a fight with the nurses and cut himself as well as a nurse with a knife. The complainant did advise both the resident and the nurse have injuries. EMS and Fire were added to the call for medical treatment on both parties. I was equipped with a functioning body worn camera, while wearing a distinct patrol uniform and driving in marked patrol vehicle [#].Upon arrival to the [Nursing & Rehab] center at 0002 hours (12:02 am) on 7/23/2025, I walked inside the main lobby area and was met by the nurse who had been cut by the resident. This nurse was identified as [RN-A]. While I spoke with [RN-A], Officer [#2], Officer [#3], and Sergeant all went to room [Resident #1 and #2] to[ make contact with] the suspect who had cut himself and nurse [RN-A]. As I remained with [RN-A], I could see he was utilizing gauze to tend to his wounds as he was actively bleeding from both his right and left thumbs. [RN-A] informed me that the resident who officers were going to, had cut him with a knife that was on a keychain lanyard. [RN-A] did show me the knife which was a small black knife that attached to a keychain. Officers confiscated the knife as evidence.Officer [#2] later came back to [RN-A] and gathered his statement and what transpired between him and the resident this evening. I took photographs of [RN-A] injuries with my BWC. EMS and Fire arrived on scene and [RN-A] did advise that he wanted to go to the hospital for further treatment on his lacerations. I followed [RN-A] out to the ambulance and later provided him with the report number.Once [RN-A] left in the ambulance, I went back inside the rehab center and to room [Resident 1 & 2]. As I walked into room [Resident 1 & 2], I observed officers on the ground fighting with the suspect. Ofc. [#3] informed me that they went to place the subject under arrest for aggravated assault and he resisted arrest. I observed Ofc. [#2] controlling the subjects legs and Ofc. [#3] controlling the subjects upper body. I asked Ofc. [#3] and Ofc. [#2] if they needed leg restraints to assist with taking the subject into custody. Ofc. [#3] did confirm to utilize leg restraints to which I then ran out to my patrol vehicle to gather the restraints. Once I gathered the leg restraints, I ran back to room [Resident #1 and #2] and assisted Ofc. [#2] with placing them on the subject. Once the subject was in leg restraints and handcuffs, Officers escorted the subject to my patrol vehicle where he was placed in the back seat.Ofc. [#2] informed me that the subject also cut his throat with the knife he used against [RN-A] and was needing to be medically cleared before being transported to the jail. Due to the subject needing medical clearance, I transported him to [Local] Hospital where he was further treated for his injuries. Once at [Local] Hospital, Ofc. [#2] completed a full search incident to arrest on the subject. In Ofc. [#2] search, she located a black circular container inside the subjects pant pockets. I retrieved this container from Ofc. [#2]as she finished searching the subject. I looked inside the container and observed multiple pills inside of it as a well as a [crystal like] substance that appeared to be methamphetamine based on my training and experience. I later called the Poison Control number and was able to identify some of the pills inside of the container. ID [#199] from the Texas Poison Control Center assisted me in identify the pills. 6 yellow circular pills with the lettering of 0.5 was later identified as Clonazepam (can cause paranoid or suicidal ideation and impair memory, judgment, and coordination.) is a benzodiazepine medication (depressants that produce sedation and hypnosis, relieve anxiety and muscle spasms, and reduce seizures). The second pill was a white circular pill with the lettering of 5.03. This was identified as Tizanidine (it can treat muscle spasms). ID [#199] informed me that this pill is a prescribed muscle relaxer. The third pill was unable to be identified due to no insignia or lettering on it. There were 2 of these pills which were half black and half red capsules. These pills were sent off for further testing. Lastly, I later tested the [crystal like] substance using a presumptive field test kit. The test kit did show to be positive for methamphetamine as it turned dark purple in color. I later booked in and weighed all the pills and methamphetamine into the North Station property room as seized property. The total weight for all pills were as follows: Tizanidine 0.5 grams, Clonazepam 1.0 grams, and the red and black pills weighed 1.7 grams. The total weight of the methamphetamine weighed 0.01 grams. On Tuesday 07-22-25, at approximately 2359 hours (11:59 p.m.), I, Officer [#2], was dispatched to a Cutting in Progress call at [Nursing & Rehab). The call text stated that the complainant advised residents go into a fight. The suspect is cursing in the background and cut both his neck and the nurse. Upon arrival, at approximately 0002 hours (00:02 a.m.), officers [entered into] the facility, and I saw a B/M who appeared to have a few lacerations to both his left and right hands. He later identified himself as [RN-A], and he is a nurse at the location. I was told that the suspect was back in his girlfriend's room and no longer had the knife but had cut himself in the neck with the knife. When I got back to the room and [made contact with] the suspect, he was very animated and irate. I also noticed that he had several lacerations to his neck which he told me were self-inflicted. He was identified to me as [Resident #2] When I tried to ask [Resident #2] what had happened, he would not tell me anything except that it was the nurse's fault, referring to [RN-A], and that he was the reason this happened. Also in the room with [Resident #2] was his girlfriend who was laying in the bed and later identified herself as [Resident #1]. Since [Resident #2] was being uncooperative and not telling me the story of what happened, I went to the front desk where [RN-A] was to ask him what had occurred. [RN-A] told me that the whole situation started at around 1800 hours (6:00 p.m.) this evening and police had been called out at that time too. [RN-A] said that he was changing the dressing on [Resident #1's] wounds when [Resident #2] kept touching the open wound with his bare hands. Since this was not sanitary, [RN-A] advised [Resident #2] to stop and then pushed his hand away. This made [Resident #2] extremely upset and [Resident #2] called the police to try and report an assault. When officers came out, they did not find that any offense occurred and cleared the scene. Still upset about this incident earlier, [Resident #2] ended up coming after [RN-A] with a small knife while he was standing at the nurse's station. [Resident #2] did this after having an altercation with [Resident #1] and then cutting his own neck with the knife. [RN-A] stated that he did want to press charges for the Aggravated Assault and was transported by ambulance to [Local] Hospital. Officer [#1] took pictures of [RN-A's] injuries with his body worn camera. There were two other hospital personnel that stated they were also at the nurse's station with [RN-A] and witnessed the incident. The first nurse identified herself to me as [LVN-A] stated that [Resident #2] came out of his girlfriend's room extremely irate and cussing. He approached [RN-A] and began trying to slice at his face with the knife that was in his hand. [RN-A] ended up putting his hands up to block the blade from striking his face which is how he got the lacerations to his hands. The second nurse identified herself to me as [not listed on employee roster] confirmed the statements from [LVN-A] and added that [Resident #2] was telling [RN-A] that he was going to kill him as he was slashing the knife towards him. I [Ofc. #2] was then informed that there was an additional nurse who had witnessed the beginning of the incident, so I went to talk to her at this time. This nurse identified herself to me as [RN-B]. [RN-B] told me that she heard [Resident #1] screaming so she went to go see what was going on. That's when she witnessed [Resident #2], who was standing beside her bed, punching her repeatedly in the face as she was laying in bed. [RN-B] told me that she began to yell at [Resident #2] to try and get him to stop and he eventually stopped. Once [RN-B] walked away, that is when [Resident #2] grabbed the knife that was attached to his key chain and began slicing his neck before going to the nurse's station, threatening and cutting [RN-A]. When I later spoke to [Resident #1], she confirmed what [RN-B] told me, and I also observed that her face was red and swollen in several spots. I took a picture of [Resident #1's] injuries with my body worn camera. She told me that her and [Resident #2] had gotten in an argument over him trying to bring methamphetamine in the room. [Resident #1] stated that she told [Resident #2] not to bring it in because she is on probation. He then got irate and began punching her in the face several times. She was later transported to [Local hospital] by ambulance for treatment. At this time, I went back to the room where [Resident #2] was being checked out by EMS and placed him under arrest for Aggravated Assault w/Deadly Weapon. Once [Resident #2] was in handcuffs, he began becoming extremely combative. We had him sitting down in chair, but he began trying to get up and at one point got up and attempted to head butt me in the face. This is when Officer [#3], who had hold of his right arm, took him to the ground and secured his upper body while I secured his legs with body weight as taught by the training academy. [Resident #2] began kicking and resisting while still on the ground and was fighting to get out of the grasp of officers. Officer [#1] went to retrieve leg restraints so that we could better secure him and get him out to the patrol vehicle since he was refusing transport by ambulance. While waiting on the leg restraints, Officer [#3] and I continued to hold body weight on him to keep him from assaulting officers. Once Officer [#1] came back with the leg restraints, they were placed on [Resident #2]'s legs and secured. EMS provided a body tarp so that officers could more easily transport [Resident #2] to the vehicle. He was rolled onto the body tarp and picked up by me, Officer [#3], Officer [#1], and Sgt. While we were attempting to carry him on the tarp, he became physically combative again and began kicking at officers. [Resident #2] kicked me with his left foot in the right side of my jaw causing pain. Due to him kicking, we opted to take him off the body tarp and carry him ourselves so that we could secure his legs and keep him from kicking officers. Once [Resident #2] was off the tarp, Officer [#3] and Officer [#1] both grabbed one of his arms, and Sgt. and I got his feet, and we began carrying out to the patrol vehicle outside. [Resident #2] continued to resist by squirming and shrimping up his body in attempts to get officers to drop him. We had to put him down once more and attempt to carry him right side up and were finally able to get him into the back of Officer [#1]'s patrol vehicle for transport to [Local Hospital] for treatment. Once on scene at [Local Hospital], [Resident #2] was removed from the back of the patrol vehicle and taken into the hospital by nursing staff to be treated. Before being placed on the gurney, he was searched incident to arrest where officers located a small black, circular tin containing a small number of unknown pills. This item and its contents were seized for further examination. At one point while in the hospital with officers, [Resident #2] became irate again due to finding out that he was going to be charged with Aggravated Assault. At this time, he only had one hand handcuffed to the bed. When officers entered the room to handcuff the other hand to the bed, [Resident #2] began resisting and would not willingly give his hand to officers. He then pushed himself off the hospital bed and onto the floor while his left hand was still handcuffed to the railing. Nursing staff and hospital security came into assist getting him back into the bed and secured. Once he was medically cleared, he was released from the hospital. I then transported him to the [local] City Jail where he was released to the care, custody, and control of jail staff. Officer [#1] called [local] Texas Poison Control and identified two out of three of the unknown pills. He weighed them, took pictures with his body worn camera, and booked them into the [local] Station Property Room. Please see his supplement to this report regarding his identification of and booking of the substances. Officer [#1] informed me that there was 0.01g of Methamphetamine, .5g of Tizanidine, a dangerous drug, 1g of Clonazepam, and an unknown substance in a red and black capsule that weighed 1.76g. In total [Resident #2] was charged with several charges. First, Assault Family Household W/Previous Conviction for intentionally and knowingly causing bodily injury to [Resident #1] by punching her multiple times in the face. Second, Aggravated Assault W/Deadly Weapon for exhibiting a knife during the commission of an assault and cutting [RN-A] multiple times on the hands with the knife. Third, Assault on Peace Officer for intentionally and knowingly causing pain to a person he knows is a peace officer for kicking me in the jaw while officers were attempting to take him from the location into the patrol vehicle. Fourth, Resist Arrest Search Transport for intentionally obstructing a peace officer from effecting transportation by using force for kicking, squirming, and attempting to get out of the grasp of officers as we were trying to escort him into the patrol vehicle. Lastly, he was charged with the drug offenses Possession of Dangerous Drug, Poss of CS PG 3&lt;28g, and Poss of CS PG 11 &lt;1g for having in his care, custody, and control the Clonazepam, Tizanidine, and Methamphetamine. I seized the small knife that was used in the commission of the Aggravated Assault offense and booked it into the [Local] Station Property Room. It was booked in as item one and placed in the drop box. Hospital staff advised that the Agg Assault would have been captured on surveillance footage and will be able to retrieve it upon the request of detectives if needed. A completed Family Violence Packet was also turned into Jail Central.'Review of facility's Resident-to-Resident Altercations policy dated December 2016 reflected, 2. If two residents are involved in an altercation, staff will: a. Separate the residents, and institute measures to calm the situation; b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation;Review of facility's Abuse and Neglect-Clinical Protocol, dated March 2018 reflected, 2. Neglect, as defined at 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 1. The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes.Record review of facility Call Lights: Accessibility and Timely Response dated 10/2022 reflected, 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light.2. All residents will be educated on how to call for help by using the resident call system.6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.5. Staff will ensure the call light is within reach of resident and secured, as needed.An IJ was identified on 07/24/25. The IJ template was provided to Administrator-B and Regional Nursing Director on 07/24/25 at 5:20 PM and a Plan of Removal was requested. The POR was accepted on 07/25/25 at 5:47PM.The POR reflected the following: Plan of Removal For F6001. Immediate Corrective Actions Taken Date/Time of IJ Notification: 7/24/25 @5:20 PM Resident Safety: Resident #1 was immediately assessed by bedside staff nurse for injuries and provided appropriate medical care; completed on 7/23/25. Resident #1 was relocated to a private room to ensure safety and prevent further incidents and call light was verified as operational; completed on 7/24/25. Roommate Removal: The male roommate involved in the assault was removed from the facility by law enforcement after evaluation by EMS on 7/23/25. BOM and Social worker provided Notice of immediate discharge to male resident via certified mail to [Local][NAME] County Jail mailed on 7/25/2025. Communication System: All residents' rooms were audited by Maintenance Super to ensure functioning call lights or alternative communication devices were present and accessible; completed 7/25/2025. Temporary communication devices (bells) were installed within reach of residents identified with malfunctioning call system until permanent solutions were in place; completed 7/25/25. Education of each resident with an alternative device (bell) was completed at time of placement by maintenance and will be documented in the EHR by DON; completed 7/25/25.________________________________________2. Systemic Corrective Measures Facility-Wide Audit: A full audit of all resident rooms was completed on 7/25/25 to verify the presence and accessibility of communication systems. Maintenance logs were reviewed by maintenance supervisor to identify any prior reports of malfunctioning call lights. An outside Vendor, was contacted to repair malfunctioning call lights/system on 7/25/25. Init[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for four residents (Resident #1, Resident #2, Resident #6, and Resident #7) of 83 residents reviewed for resident call system in that: The facility failed to ensure the call lights in Resident #1's and Resident #2's shared room were in working order. Resident #1 was not able to use her call light to call for help when she was physically assaulted by her roommate, Resident #2. On 07/25/25 at 11:20 AM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/26/25 the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that was not immediate jeopardy due to the facility's need to monitor the implementation and the effectiveness of their Plan of Removal. The facility failed to ensure call lights were flashing outside Resident #6's and Resident #7's rooms to ensure staff knew the Residents needed assistance. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.Based on observations, interviews and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for four residents (Resident #1, Resident #2, Resident #6, and Resident #7) of 83 residents reviewed for resident call system in that: The facility failed to ensure the call lights in Resident #1's and Resident #2's shared room were in working order. Resident #1 was not able to use her call light to call for help when she was physically assaulted by her roommate, Resident #2.xOn 07/25/25 at 11:20 AM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/26/25 the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that was not immediate jeopardy due to the facility's need to monitor the implementation and the effectiveness of their Plan of Removal. The facility failed to ensure call lights were flashing outside Resident #6's and Resident #7's rooms to ensure staff knew the Residents needed assistance . This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.Findings included:Record review of Resident #1's admission record, dated 07/24/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, cognitive communication deficit (communication disorder stemming from cognitive impairments that affect a person's ability to communicate effectively), bipolar disorder (associated with episode of mood swings ranging from depressive lows to manic highs), calculus of kidney(small, hard deposit that forms in the kidneys and is often painful when passed), morbid (severe) obesity (a disorder that involves having too much body fat, which increases the risk of health problems), and paraplegia (condition characterized by the loss or impairment of motor and sensory functions in the lower half of the body).Record review of Resident #1's care plan dated 6/13/25 reflected the resident had limited physical mobility, does not walk, used manual wheelchair for locomotion, is totally dependent on staff for repositioning and turning in bed, and totally dependent on (2) staff for transferring. Record review of Resident #2's admission record, dated 07/24/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included, a diffuse traumatic brain injury (widespread damage to the brain's white matter), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life activities), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), chronic pain syndrome (persistent pain that last weeks to years by be caused by inflammation or dysfunctional nerves), bipolar disorder (associated with episode of mood swings ranging from depressive lows to manic highs), and antisocial personality disorder (a mental health disorder characterized by disregard for other people).Record review of Resident #2's care plan dated 6/13/25 reflected the resident requires limited assistance by (1) staff to move between surfaces, the resident does not walk, and resident uses manual wheelchair for locomotion.Record review of Resident #6's admission record, dated 7/24/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included, Depression (the elevation or lowering of a person's mood), Anxiety (intense, excessive, and persistent worry and fear about everyday situations), Cognitive Communication Deficit (difficulties in communication arising from impairments), Type 2 Diabetes (long-term condition in which the body has trouble controlling blood sugar and using it for energy), and Parkinsonism (clinical syndrome characterized by tremor).Record review of Resident #7's admission record, dated 7/24/25, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident #7 had diagnoses which included cerebral infarction (a medical condition where brain tissue dies due to a lack of blood supply), Crohn's disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract), Schizophrenia ( a disorder that affects a person's ability to think, feel, and behave clearly), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Current MDS requested for Resident #1, Resident #2, Resident #6, and Resident #7 on 07/26/25 at 2:11 PM, and reminder sent on 07/28/25 at 5:16 PM. Received MDS for Resident #1 and Resident #2 on 07/29/25 at 5:04 PM the BIMS was blank.On 07/31/25 at 6:10 AM emailed Administrator-B and Director of Clinical Services and informed the MDS' for Resident's #1 and #2 had no BIMS and if the admission MDS could be provided. On 08/06/25 at 12:07 PM an email was sent to Administrator-B, the MDS for Residents #1, #2, #6, and #7 were requested but not received.Interview on 07/24/25 at 11:04 AM with Resident #1 revealed she and Resident #2 were roommates. She stated he was her fiance. She stated another resident's friend gave Resident #2 drugs and when he came to the room to try to smoke it, she told him he could not smoke it and got upset and began to beat on her. She stated she was yelling for help, she stated RN-B came into the room and screamed for Resident #2 to stop hitting her. She stated Resident #2 did stop hitting her then EMS arrived and took her to the hospital, and she was there for about two hours then she was brought back to the facility. She stated her injuries were a black right eye, a busted upper lip, bruises to both cheeks, and a large bruise to her left breast. She stated she did not feel safe at the facility because someone else could come in the room and she could not protect herself. She stated they had not had any physical altercations in the past. She stated he had taken care of her he had never hurt her. When asked if she pushed the call light button, she stated the call light had not worked in four months. She stated she was given a bell to ring when she needed assistance, but they had put the bell on the door. She stated no one had told her she needed to keep the bell out of the drawer. Observation on 07/24/25 at 11:30 AM revealed there were two call light cords plugged into the wall in the room of Residents #1 and #2. Observation of the call light cords revealed both cords on the floor. Further observation of the room revealed a bell hanging on a short rope/string on the back of the door to the room, out of reach of the resident. Resident #1 was observed in her bed. Face to face interview with Maintence Director on 07/24/25 at 3:15 PM revealed he had been employed since late February. He stated he knew there were some call lights that were not working throughout the building. He stated he would fix the call lights then they would go out again, because the system was old. He stated if the call light was not working the residents would be given a bell to ring for help until the light could be fixed. He stated he was not sure if the call lights were working in Resident #1's and Resident #2's room. He stated when an aide would report the light was not working, he would fix the light on the spot. He stated he did not believe the light situation got to a point that he needed to notify Administrator - A. He stated there was not any room that had to have the call light fixed more than one time. He stated the staff would come to him face to face to report a call light was not working. He stated the staff could always call him on his cell phone to report issues. He stated when the call light was not working it could delay or not allow a resident to receive help. Face to face interview with Administrator-B on 07/24/25 at 3:36 PM, revealed the day was her fourth day working at the facility. She stated she was not aware Resident #1 and Resident #2 did not have a call light in their room. She stated when she found out about the call light, she was trying to move Resident #1 to another room, but she had refused to move. She stated she did not know how long Resident #1 and Resident #2 had been without a call light or any way to communicate to staff the need for assistance. She stated she did not know how the residents were supposed to let staff know they needed assistance. She stated she would assume the maintence director was responsible to ensure the call light worked in the rooms. She stated the CNAs, and nurses would be responsible to ensure the placement of the bell was in reach of the resident. She stated there was a severe risk of injury or a lack of care to the resident's when they did not have access to communication.Observation and interview on 07/25/25 with Resident #6 at 12:54 PM, revealed when asked to push her call light, the light did not flash above her door. Staff were observed walking throughout the hall, but no one came to Resident #6's room until they were notified in person by the investigator the resident had pushed the call light. Observation and interview with Resident #7 on 07/25/25 at 1:05 PM, revealed Resident #7 was asked to push his call light and the light did not flash above his door. Resident #7 stated he thought the light was working properly. Staff were observed walking throughout the hall, but no one came to Resident #7's room until they were notified in person by the investigator the resident had pushed the call light. In an interview with the Regional Director of Clinical Services on 07/26/25 at 2:15 PM, she stated she was not aware that the resident's (Resident #1 and Resident #2) call light was not working, she stated Resident #1 informed her and wrote a statement that the bell provided to her was in the drawer next to her bed. She stated the maintence director would have been responsible to ensure the call lights were working. She stated it would be the responsibility of the nursing staff to let the maintence director know when the lights are not working. She and the maintence director checked the lights in the rooms of Resident's #6 and #7 and the notification was going to the board at the nurses station, but the light was not lighting up outside the door. She stated Resident #1 was moved to a room with a working call light and Resident #2 was taken to jail and given a discharge notice. She stated if a resident's call light was not working it could delay their care.In a telephone interview with RN-B on 07/26/25 at 6:15 PM, reflected she was aware some of the call lights were not working but she was not sure how long the lights had been out. She stated she thought the administrator and maintence knew the lights were not working but she had not checked with them. She stated when a resident's call light did not work, it could cause the resident to not receive proper care.Record review of Call Light and Communication Device dated/revised 7/25/25, reflected All staff are responsible for responding promptly to resident call lights and communication devices. The facility shall maintain functional systems for resident communication and implement escalation procedures when systems fail, or response times are inadequate.Procedure1. Resident Education Upon admission and as needed, residents will be educated on: The purpose and use of the call light system. The importance of [keeping the call light within reach at all times]. How to request assistance using the call light or other communication devices.2. Call Light Accessibility Staff must ensure the call light is: Within easy reach of the resident [at all times]. Positioned appropriately after any care, repositioning, or transfer. Available in both the bedside and restroom areas.3. Response Expectations All call lights must be answered promptly, ideally within 5 minutes. If the responding staff member is not the assigned caregiver, they must: Address the need if within their scope. Notify the appropriate caregiver immediately if not.4. Escalation ProtocolIf a call light is not answered within 10 minutes or a communication device is non-functional:5. Backup MeasuresIn the event of call light system failure or during power outages: Place manual bells or battery-operated call devices at: Each resident's bedside. Each resident-accessible restroom. Implement Q15-minute visual safety rounds to assess resident needs. Document each round in the designated log.An IJ was identified on 07/25/25. The IJ template was provided to Administrator-B and Regional Nursing Director on 07/25/25 at 11:20 AM and a Plan of Removal was requested. The POR was accepted on 07/25/25 at 5:47PM.The POR reflected the following:Plan of Removal For F9191. Immediate Corrective Actions Taken Date/Time of IJ Notification: 7/25/25 @11:20 AM Resident Safety: Resident #1 was immediately assessed by bedside staff nurse for injuries and provided appropriate medical care; completed on 7/23/25. Resident #1 was relocated to a private room to ensure safety and prevent further incidents and call light was verified as operational; completed on 7/24/25. Roommate Removal: The male roommate involved in the assault was removed from the facility by law enforcement after evaluation by EMS on 7/23/25. BOM and Social worker provided Notice of immediate discharge to male resident via certified mail to [NAME] County Jail mailed on 7/25/2025. Communication System: All residents' rooms were audited by Maintenance Super to ensure functioning call lights or alternative communication devices were present and accessible; completed 7/25/2025. Temporary communication devices (bells) were installed within reach of residents identified with malfunctioning call system until permanent solutions were in place; completed 7/25/25. Education of each resident with an alternative device (bell) was completed at time of placement by maintenance and will be documented in the EHR by DON; completed 7/25/25.2. Systemic Corrective Measures Facility-Wide Audit: A full audit of all resident rooms was completed on 7/25/25 to verify the presence and accessibility of communication systems. Maintenance logs were reviewed by maintenance supervisor to identify any prior reports of malfunctioning call lights. An outside Vendor, Summit Fire and Security was contacted to repair malfunctioning call lights/system on 7/25/25. Initial visit will occur on Monday 7/28/25. Staff Training: All staff will receive re-education on: Resident rights to a safe environment (F600). Proper placement and testing of communication devices (F919). Immediate reporting and escalation procedures for malfunctioning equipment. Started on 7/23/25; ongoing until all staff educated; no staff will be allowed to work their next shift until completed; education by ADON/DON; PRNs via phone if needed. Included education:- Call lights must be in reach and operational. If found to be inoperable then must immediately notify the administrator, DON and Maintenance Supervisor.- Implement an alternate call system; including Q15 min checks until provided.- Maintenance will provide manual bell and education to resident for use until malfunctioning issue is resolved. - Must take manual bell to restroom with resident and place in reach, if toileting is needed and then ensure it is returned to bedside and in reach once done in restroom. Monitoring and Oversight: A designated staff member (e.g., DON or Maintenance Supervisor) will conduct daily rounds for 14 days to ensure compliance; started 7/25/25. Random weekly audits by DON will continue for 4 weeks. Results will be reviewed in QAPI by administrator/DON for 3 months starting with adhoc on July 30th.3. Prevention of Recurrence Resident Interviews: All residents were interviewed to ensure they feel safe and have access to communication systems; started Safe surveys by social worker started on 7/23/25. Ongoing Staff Education: Monthly in-services on abuse prevention, neglect, and emergency response. Next all-staff in-service scheduled for Friday August 8th, 2025. 4. Verification of Compliance Documentation: Audit logs, training rosters, and maintenance reports will be maintained and available for review. Follow-Up: The Administrator and Director of Nursing will verify completion of all corrective actions.Monitoring of the facility plan of removal was as follows: Record review at 9:00 AM on 07/26/25 of facility POR training with staff dated 7/23/25 thru 7/26/25, reflected, the training consisted of ensuring the call light was within reach and operational, if call light was found to be inoperable then DON and Maintenance Supervisor should be notified immediately, and an alternate call system should be implemented including Q15 min. checks until provided. The maintenance staff would provide a manual bell and the resident would be educated to use the bell until the malfunctioned issue was resolved. Staff should remind the resident to take the manual bell with them when toileting and it should be kept until they had returned to their bed.Observation of Resident #1's current room on 07/26/25 revealed she had a working call light. Resident #1 was not in the building at the time of this observation. Interview with CNA-C on 07/26/25 at 10:00 AM reflected she had received training on how to work the call light system, she stated she had not been received training that she needed to check the rooms on hall 200 Q shift when she started her shift on 07/26/25.Interview with CNA-D on 07/26/25 at 10:10 AM reflected she was trained on the call lights, she stated she was told to check rooms every 15 minutes on hall 200 because the residents were not cognitive enough to know how and wen to use the call lights. Interview with CNA-E on 07/26/25 at 11:34 AM, reflected she received training on answering the call lights, when a residents call light was out, she should notify the charge nurse and maintence, provide the resident with a bell and do 15-minute checks on the resident. Additional interview with Interview with CNA-C on 07/26/25 at 11:50 AM, reflected she had been trained to check all rooms on 200 hall every 15-minutes because they may not understand how to use the light, and residents on other halls if a light was not working she would notify the charge nurse and maintence and provide a bell for the resident to notify her when they need help. Interview with LVN-C on 07/26/25 at 12:10 PM reflected, she had received an in-service training on answering the call light, if the light was not working she should check the rooms every 15-minutes and give the resident a bell and notify maintence.Interview with LVN-D on 07/26/25 at 12:23 PM reflected, she had been trained on what to do if the call light was not working, she needed to notify the administrator, the DON, and the maintence director, do 15-minute checks on the resident and provide the resident with a bell and make sure the bell is within reach and not in a drawer. Interview with CNA-G on 07/26/25 at 12:33 PM reflected, she had been trained to make sure the call lights were working and in reach, if the light was not working she must notify the administrator, DON, and maintence, give the resident a bell and make sure it is within reach and when the resident went to the bathroom to make sure the bell was with them if she stepped out of the room, if the resident cannot use the bell to make 15-minute checks in the room. Interview with CNA-H on 07/26/25 at 12:41 PM reflected, she had been trained to provide a bell to the resident if the call light was not working, she should notify the administrator and maintence, the call light should be in reach of the resident, if the light did not work to give the resident a bell and do 15 minute checks to make sure the resident was okay, and make sure the resident had to bell with them if in the bathroom. Interview with CNA-I on 07/26/25 at 12:48 PM reflected, she had been trained to make sure the call light was in reach, if the light was not working to get the resident a bell, notify the administrator and maintence to fix the light, if the resident has a bell make sure the bell is accessible to the resident and not in a drawer, if the resident went to the bathroom to make sure they had the bell. Interview with CNA-J on 07/26/25 at 12:55 PM, reflected she received training that if a call light was not working, she should contact maintence, give the resident a bell and make sure it stayed within reach, and if the resident went to the bathroom wait for them or provide a bell, do 15-minute checks. Interview with LVN-E on 07/26/25 at 1:12 PM, reflected she had been in-serviced on call lights, if they were not working she should notify the administrator, DON and maintence, she should check on the resident every 15-minutes, give the resident a bell and educate the resident to always keep the bell with them. Interview with CNA-K on 07/26/25 at 1:18 PM, reflected he had received training on the call light, that it should be answered by everyone, if the light was not working to report it to the nurse who would give a bell for resident to use, the resident should be checked every 15-minutes until the light is fixed. Interview with LPN-F on 07/26/25 at 1:24 PM, reflected she had received training on the call lights that if she noticed the light was not working, she should give the resident a bell and notify the administrator, the resident should be checked every 15-minutes to ensure safety, if they went to the bathroom to take the bell. Interview with MA-G on 07/26/25 at 1:32 PM, reflected she had received in-service on call lights, if the light was not working, she should notify the DON, administrator, and maintence, give the resident a bell, if the resident cannot use the bell to do 15-minute checks until the light was fixed. Observation of Hall 200 on 07/26/25 from 1:45 PM to 2:15 PM revealed CNA's C and D had walked in rooms in 15-minute intervals. Telephone call from RN-B on 07/26/25 at 6:15 PM, reflected she had received additional training on making sure the call light was within reach of the resident, if the light was not working to provide a bell within reach and notify the nurse and maintence. Review of the facility abuse, and neglect in-service dated 07/23/25-07/26/25 reflected all facility staff had been in-serviced prior to shift on abuse and neglect. An Immediate Jeopardy (IJ) was identified on 07/25/25 at 11:20 AM. While the IJ was removed on 07/26/25 at 2:35 PM the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort, which included incorporating the recommendations from the Preadmission Screening and Resident Review level II determination and the Pre-admission Screening and Resident Review evaluation report into a resident's assessment, care planning and transitions of care for one (Resident #4) of five residents reviewed for Pre-admission Screening and Resident Review assessments. The facility failed to provide Habilitation Coordination, Independent Living Skills, Physical Therapy, Occupational Therapy, Speech Therapy. to Resident #4 as recommended and agreed upon by the Interdisciplinary Team (IDT) within the time frame set by PASRR. This failure could place residents with intellectual disabilities or mental illness at risk of not receiving services that would enhance their quality of life.Findings included:Review of Resident #4's annual Minimum Data Set, dated [DATE] reflected the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a condition caused by damage to the developing brain that affects a person's ability to control their muscles, problems with movement, coordination) kidney failure (kidneys are no longer able to properly filter waste and extra fluid from the blood), contracture (a muscle, tendon, or joint becomes permanently stiff or tight), and dysphagia (trouble swallowing). Review of Resident #4's annual Minimum Data Set assessment dated [DATE] reflected he had no speech, rarely/never made himself-understood, and sometimes was able to understand others. His Brief Interview for Mental Status was not completed. He was totally dependent on two staff for dressing, transferring, bathing and toilet use. He was totally dependent on staff for locomotion, eating, and personal hygiene. He was not ambulatory and had functional limitations in range of motion for upper extremity and lower extremity on both sides. He was indicated as always incontinent of bowel and bladder. He had a physical therapy start date of 03/29/25 with an end date of 04/21/25 with no minutes of treatment recorded during that duration. Record review of Resident #4's Comprehensive Care Plan initiated on 4/11/2018 and revised on 5/27/25 reflected Resident #4 focus area indicated Resident #4 had been identified as PASRR positive status (when a resident is found to need specialized services or supports due to a serious mental health illness, intellectual disability, developmental disability, or related condition through the PASRR screening process) related to an intellectual disability, and Cerebral Palsy. His interventions indicated his family/local mental health authority had agreed to the following PASRR services: Habilitative Physical and Occupational therapy services, Habilitation coordination, and independent living skills. Review of Resident #4's Preadmission Screening and Resident Review Comprehensive Service Plan dated 12/18/24 reflected the type of meeting held was Initial IDT. The form reflected in attendance was a representative from the local mental health authority, Registered Nurse, Minimum Data Set Nurse, Social Worker, Director of Rehabilitation, Hospice Registered Nurse, and Resident's responsible party/family member. The form reflected the Habilitation Coordinator recommended the following services for Resident #4: Habilitation Coordination, Independent Living Skills, Behavioral Enhancement Services, Physical Therapy, Occupational Therapy, Speech Therapy, and Durable Medical Equipment. The form also reflected that Habilitation Coordination, Independent Living Skills, Physical Therapy, Occupational Therapy, Speech Therapy and assessments were accepted, and all other services declined at that time. Review of Resident #4's PASRR Comprehensive Service Plan Form dated 3/12/25 reflected the type of meeting was quarterly IDT. The form reflected in attendance was Resident #4, local mental health authority, Minimum Data Set Nurse, Hospice Social Worker, Director of Rehabilitation, and Resident's responsible party/family member. The plan reflected Resident #4 would continue the following services: Habilitation Coordination, Independent Living Skills, Physical Therapy, Occupational Therapy, Speech Therapy. Review of Resident #4's Habilitative Service Plan/Form 1057 dated 3/12/25 indicated recommended services for Resident #4 were Habilitation Coordination, Independent Living Skills, Physical Therapy, Occupational Therapy and Durable Medical Equipment. Section 6 of the form titled Nursing Facility Specialized Services to be Monitored by the IDT stated to enter all Nursing Facility Specialized Services provided to the individual during the Habilitative Service Plan year. The specialized services listed for Resident #4 were Occupational Therapy with outcome/goal of: Patient will exhibit anatomically correct positioning while sitting in wheelchair with use of adaptive equipment/devices for 2 hours with fair-sitting balance during activities of daily living to reduce pressure and decrease risk of wounds and achieve proper joint alignment. Physical Therapy with outcome/goal of: Patient will maintain mobility with maximum assistance to maintain functional mobility in facility. Speech Therapy, with outcome/goal of: Patient will communicate yes/no responses using non-speech generating augmentative alternative communication system with moderate cueing, patient will communicate basic wants and needs using non-speech generating augmentative alternative communication system with moderate cueing. A review of Resident #4's online Long-Term Care Portal submissions indicated that the facility submitted the NFSS form requesting both Physical Therapy and Occupational Therapy assessments and services on 4/3/25. Both services were initially approved; however, because the authorizations were only valid for one month, the facility was required to resubmit requests to continue services. On 5/11/25, the facility resubmitted the NFSS form for Physical Therapy and was approved. The Occupational assessment and services request was denied. The facility submitted another request for Occupational Therapy assessment and services on 6/2/25, which was again denied. The facility resubmitted a third request for Occupational Therapy on 6/6/25 and was denied. As of 7/1/25, Resident remained in denial status for Occupational Therapy assessment and services. As of 7/1/25, the facility had not submitted an NFSS request for Speech Therapy Assessment or services. In a telephone interview on 7/1/25 at 9:50 a.m. with the PASRR Representative, it was revealed that Resident #4 was identified as PASRR positive and qualified for all services. She stated he had an initial IDT on 12/18/24. She stated that the NFSS forms were due 20 business days after the initial IDT or review meeting. She stated the facility submitted the NFSS for Physical Therapy in April. She stated the facility had to resubmit the NFSS forms because the authorization for services was good for one month only. She stated that the facility then submitted Physical Therapy and Occupational Therapy in May, but Occupational Therapy was denied. She said they resubmitted Occupational Therapy again in June and was denied. She stated Resident #4 was currently in denial status for Occupational Therapy and that the facility had never submitted the NFSS for Speech Therapy. In an interview on 7/1/25 at 11:29 a.m. with the MDS Nurse, she reported she was not responsible for submitting NFSS requests for residents. She stated their rehabilitation therapist was responsible, and she was not at the facility. The MDS Nurse stated her responsibility to PASRR was ensuring a PASRR Level I screen (a required assessment for all applicants to Medicaid-certified nursing facilities to determine whether they might have a severe mental illness or intellectual disability) for residents were completed and referred to Level 2 screen (Individuals who test positive at Level I are then evaluated in depth, called Level II PASRR. The results of this evaluation results in determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care). The MDS nurse stated she was familiar with the 20-business day deadline to submit the NFSS request in the portal but that the Director of Rehabilitation oversaw doing those. She reported she attended the IDT meeting for Resident #4 a couple of weeks ago but could not recall the services recommended. She stated the NFSS forms had been submitted except one was denied. She stated she would have to get in touch with the Director of Rehabilitation to see the status of that. In an interview on 7/1/25 at 12:40 p.m. with the Regional Consultant Nurse, she reported she could not recall if she had participated in Resident #4's last IDT meeting. She stated the MDS Nurse handled PASRR, and the Director of Nursing would ultimately oversee the MDS Nurse. She stated she was not aware of what services Resident #4 was receiving. In an interview on 7/1/25 at 10:50 a.m. with the Director of Nursing, she reported Resident #4 was not receiving any specialized services because he was on hospice. She stated she believed he was PASRR Positive and could not remember what services were recommended. She stated she would participate in resident IDT meetings. She stated that the social worker or MDS nurse was responsible for submitting NFSS requests. She stated the MDS nurse was overseen by the Corporate Nurse. After checking records, the Director of Nursing stated Resident #4 had been receiving physical therapy since 5/7/25 and had been waiting approval for occupational therapy. In an interview on 7/2/25 at 10:45 a.m. with the Director of Rehabilitation, she stated she had overseen submitting the NFSS for PASRR positive residents. She stated she participated in Resident #4's IDT meeting on 6/18/25 over the phone. She stated Resident #4's NFSS was requested and approved and was good until 7/20/25. She stated they were in the process of resubmitting the NFSS for Occupational Therapy. She stated that Speech Therapy was never recommended for Resident #4; a NFSS had not been submitted. Review of an email dated 7/2/25 at 4:14 p.m. from the Regional Director of Nursing stated: Our admission Criteria policy also includes multiple references to the IDT and its use in care/decision making. As far as PASRR- we do not have a policy strictly for that program- but our admission Criteria policy (attached) covers the program under section 9: 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD.b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.(1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD.(2) The social worker is responsible for making referrals to the appropriate state-designated authority.c. Upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.d. The State PASARR representative provides a copy of the report to the facility.e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation.f. Once a decision is made, the State PASARR representative, the potential resident and his or her representative are notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 9 residents (Resident #1) reviewed for care plans. <BR/>The facility failed to ensure Resident #1, who resided in the memory care unit, had a comprehensive care plan identifying reasons for aggression, appropriate supervision, interventions to prevent Resident #1 from eating non-edible items in order to attain and maintain the highest practicable physical, mental, and psychosocial well-being and safety. <BR/>An Immediate Jeopardy situation was identified on 06/08/2023 at 9:45 AM. The Immediate Jeopardy was removed on 06/09/2023 at 4:18 PM. The facility remained out of compliance at a scope of Isolated and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. <BR/>This failure could place residents at risk for not being provided necessary care and services. <BR/>Findings Included:<BR/>Record review of Resident #1's electronic face sheet, dated 06/07/2023, revealed Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's diagnoses included dementia with agitation (walk up and down, move objects around or fixate on tasks such as tidying), major depressive disorder (mood disorder that interferes with daily life), anxiety disorder (involves persistent and excessive worry that interferes with daily activities), and delusional disorders (type of mental health condition in which a person can't tell what's real from what's imagined).<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 04/21/2023, revealed Resident #1's BIMS score was 00 which indicated severe cognitive impairment. Review of behaviors reflected physical behavioral symptoms directed toward others and self, wandering occured daily. <BR/>Record review of Resident #1's care plan, initiated on 05/30/2023, reflected Resident #1 was at risk of elopement / non-goal directed wandering, interventions included Disguise exits .identify pattern of wandering. Is it purposeful? Further review revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes and impaired decision-making skill. Resident #1 exhibited verbal and physical aggression, exhibited hitting and biting during ADL care and interventions included Provide physical and verbal cues to alleviate anxiety .give the resident as many choices as possible about care and activities. The care plan also reflected a diagnosis of dementia and need for a secure environment due to risk of elopement, exit seeking and wandering. Interventions included Assess for reasons for wandering and provide redirection as needed. Resident #1 had a history of resisting or refusing care and became aggressive during care. <BR/>Record review of Resident #1's Progress Notes dated 04/13/2023, RN A documented, Resident came out from her room and was holding pull up full of feces and writer tried to take it away from her and resident pushed nurse and nurse landed on the floor and hit her right leg on double door. Nurse was assisted off from the floor by two staff members. Resident was then attended by two staff members. Family, Md, and ADON notified. Progress notes dated 05/15/2023, 05/16/2023, 05/16/2023, 05/22/2023, and 05/24/2023 reflected LVN E documented the following on each date, Resident is up wandering up and down the hallway, checked V/S and gave all medications as ordered, tolerated well, resident is at high risk for elopement, requires constant redirection by staff members. Resident requires 2 to 3 staff members to provide cares, resident has a very aggressive behavior, such as kicking and biting. Resident is developing a new habit, messing with her own poop, staff members has to help her thoroughly cleaned her and sanitize all the places she touched. Will continue to monitor. Progress notes dated 06/06/2023 reflected LVN E documented, Resident was seen be states surveyor possibly eating and notified first nurse aide and next the nurse who was told by the DON immediately notified the MD at 12:33PM, that was 3 minutes after this nurse was notified, MD immediately responded and ordered to call poison control center and checked resident's V/S, BP .poison control advised us to rinse resident's mouth and provide more fluids, we did as ordered, no S/S of nausea or vomiting noted at this time. Will continue to monitor resident and continue to encourage fluids. Called poison control regarding possible ingestion of deodorant. Poison control indicated that a possible adverse effect would b, mild GI upset, limited diarrhea, and upset stomach. Was told to monitor for upset stomach and encourage fluids. Case #75554424. <BR/>Observation and interview on 06/07/2023 at 11:45AM revealed Resident #1, in the hall facing the patio, eating a stick of deodorant with a plastic spoon. Resident #1 turned the deodorant stick up and used the spoon to scoop chunks of the deodorant from the container and then ate it. CNA B and LVN C were observed around the corner on the room hall passing lunch trays. The surveyor called down the hall to notify LVN C and CNA B that Resident #1 was eating the deodorant stick. CNA B came to the hall where Resident #1 was and stated she could not take the deodorant from Resident #1 without assistance because Resident #1 had bitten her in the past when she took something away from her. CNA B called for LVN C to assist. During the time LVN C came to assist, Resident #1 was observed placing the deodorant container in a sock she was holding. LVN C was observed trying to get the sock that contained the deodorant stick from Resident #1. Resident #1 refused to give it and LVN C then distracted Resident #1 from her left side while CNA B took the sock from Residnet#1's grip. Resident #1 still had the plastic spoon in her hand and walked down the hall to the rear door exit area where she began taking items from the trash can. Resident #1 used the spoon to scrape particles of deodorant from her arms and licked the spoon. <BR/>An observation and interview on 06/07/2023 at 11:50AM, with LVN C and CNA B, revealed the deodorant container was empty. LVN C said Resident #1 could get very aggressive when staff took items from her that she should not have. LVN C said Resident #1 constantly wandered from room to room taking any items she could find. LVN C stated the deodorant stick was not from the facility and may have been brought into the secured unit by another resident's family members. He said there was one resident in the secured unit who did have personal care items in her room because she was only diagnosed with schizophrenia and able to do her own personal care. He said each room had child covers on the doorknob which prevented residents from entering rooms, however, Resident #1 was able to open doors with the child cover on. CNA B stated Resident #1 needed constant supervision because she wandered from room to room taking anything she could find. She stated when staff attempted to redirect Resident #1 or take something from her she would be aggressive. <BR/>An interview on 06/07/2023 at 12:16PM with the Administrator revealed she was informed that Resident #1 had eaten the deodorant. She stated she did not know where Resident #1 could have gotten the deodorant from because all personal care items should have been secured in the shower room. She said family members often brought items into the secured unit for residents and left the items in their room. She said she directed staff to do a sweep of the secured unit to ensure there were no more hazardous items accessible to residents; she stated they did find additional personal care items in resident rooms and removed them. She said she was not aware of any resident in the secured unit who kept personal care items in their room but the DON may have told her about such a resident but was not sure. She said there were child covers on the doorknobs in the secured unit to prevent residents from entering rooms. She said she had not been informed Resident #1 could open the doors with the child covers on. She stated typically one nurse and two CNAs worked in the secured unit to ensure appropriate supervision of the 17 residents. She stated the facility's policy stated that all personal and hazardous items should be locked to prevent a risk of harm to residents. She said she understood Resident #1's eating deodorant posed an immediate concern for a risk of harm to all the residents in the secured unit. <BR/>An observation and interview on 06/07/2023 at 12:23PM, in the secured unit, with the Administrator and DON revealed Resident #1 in the room hall with a small can of shaving cream. Resident #1 was trying to push the button at the top of the can and held the can to her mouth but was unsuccessful in getting the contents to come out. The DON was observed taking the can of shaving cream from Resident #1. When asked if they had removed all the hazardous items from the secured unit, The Administrator stated staff had already done that and stated she did not know where Resident #1 got the can of shaving cream from. <BR/>An observation and interview on 06/07/2023 at 12:25PM with Resident #2 revealed she recently came to the facility. She stated she had her own room and was allowed to keep her personal care items in her room. She stated she hid the items in her dresser drawers as residents often came inter her room and took them. She said she hid her purse under a chair for the same reason. Resident #2's purse was observed stuffed under a chair in her room and personal care items (toothpaste, shampoo, and deodorant) were observed in the top drawer of the dresser in her room. <BR/>An interview on 06/07/2023 at 12:40PM with LVN C revealed Resident #1 was hard to redirect and constantly wandered from room to room. He said Resident #1 likely got the deodorant from another resident's room. He stated staff do not check rooms regularly for items that may be hazardous to residents. He said residents' family often bring items and leave them in the residents' rooms. He stated he noted Resident #1 started to mess with her poop and said he had never seen her eat anything non-edible before. He stated his note referred to her taking her adult diaper off and smearing poop all over. <BR/>An interview on 06/07/2023 at 12:52PM with CNA B revealed Resident #1 would get into anything she could including briefs, wipes, and deodorant. She said she had not seen her eat anything hazardous but Resident #1 had to be supervised all the time to ensure her safety. She said she thought Resident #1 may have taken the deodorant from the shower room because she had found the lid to the deodorant stick in the locked shower room when she completed the sweep. She stated the shower room was always locked but this morning a hospice aide was in the secured unit caring for a resident and Resident #1 could have gotten the deodorant while the aide was showering another resident. CNA B stated during her sweep of the secured unit, she found five deodorants in five different rooms, soap, two large bottles of lotion, and three large bottles of shampoo. She said the items were labeled Keep out of reach of children. CNA B stated Resident #1 bit her on her breast, on 04/19/2023, when she tried to take lotion from Resident #1. She stated she informed the DON and Administrator. She stated Human Resources had her go to the hospital for treatment. She stated she had not receive any in-service related to handling Resident #1's aggressive behavior.<BR/>An interview on 06/07/2023 at 1:41PM with the Administrator revealed when CNA B was bit by Resident #1 she was primarily concerned with ensuring CNA B was taken care of and followed up with human resources. She said she did not follow up with any behaviors that may have led to why Resident #1 bit CNA B and ultimately kept Resident #1 safe. She said in reviewing progress notes, the staff knew Resident #1 wandered and got into any items she could find; all staff could assume Resident #1 could possibly consume them as well. She stated she should have followed up to ensure the safety of Resident #1. She stated the DON and ADON were responsible for reviewing the progress notes to ensure information was brought to her. She stated she was not made aware of an incident where Resident #1 pushed RN A to the ground on 4/13/2023. She said the incident may have been reported to human resources. She said it should have been brought to her attention by staff or the DON because it was documented in the progress notes. She said she expected the DON and ADON to review the progress notes and bring any concerns to her attention. She stated she expected staff to ensure residents, who did not have the cognitive ability to understand their actions, were safe and any hazards were secured to prevent residents from any harm. <BR/>An interview on 06/07/2023 at 2:25PM with RN A revealed she was pushed to the ground on 4/13/2023, when she tried to take a soiled adult brief from Resident #1. RN A said Resident #1 came out of her room with the soiled brief in her hand. She said the brief was tore and Resident #1 had feces on her hands, face and inside her mouth. She stated she believed Resident #1 was eating the brief. RN A stated she had never seen Resident #1 eat deodorant but was not surprised as she wandered from room to room looking for anything she could find. RN A stated she told the DON, ADON, Administrator and Human Resources about the incident. She stated Human Resources directed her to get medical attention. RN A stated there were no care plan changes, in-services, or direction from the DON or ADON to address Resident #1's behaviors. <BR/>In an interview on 06/07/2023 at 3:00PM the Social Worker stated she and the MDS Coordinator held a care plan meeting for Resident #1 on 05/23/2023. She stated there was no information about Resident #1 eating poop or any other non-consumable items. She stated she gained resident information from the DON or ADON regarding issues or concerns and concerns of the resident's specific behaviors should have been relayed to her and the MDS Coordinator for care planning. She said Resident #1's aggressiveness was discussed in the care plan but no specific details regarding when aggression occurred or why. <BR/>An interview on 06/07/2023 at 3:30PM with the DON revealed she had not seen any of the progress notes related to Resident #1. She said it was her and the ADON's responsibility to review the notes and care plans to ensure any concerns were addressed. She said she held a stand-up meeting every morning at 10:00AM where issues would be discussed. She said she was working with staff to ensure they brought concerns to the stand-up meetings but realized they had not always done that. She said she was aware Resident #1 had aggressive behaviors but did not know why. She stated she knew Resident #1 had bitten CNA B but did not why. She said she did not know Resident #1 pushed RN A to the ground when she tried to take a soiled adult diaper from her. The DON said Resident #1's aggressive behaviors that occurred when staff tried to take things from her should have been in the care plan. She stated there should not be any potentially hazardous items accessible to any resident in the secured because they did not have the mental capacity to know what could be consumed. She said Resident #1 eating deodorant posed a potential risk of harm and could have been avoided. <BR/>An interview on 06/07/2023 at 4:22PM with CNA D revealed Resident #1 was aggressive when staff tried to redirect her or take something she should not have away. She said she had seen Resident #1 eat feces from her adult diaper and told the nursing staff but did not know what was done from there. She stated she did not recall the nurse she told or the time she observed Resident #1 eat feces from her adult diaper. She said Resident #1 needed constant supervision because she constantly looked for anything she could get into. <BR/>An interview on 06/07/2023 at 4:35PM with MDS Coordinator/LVN revealed she and the SW conducted a care plan meeting for Resident #1 on 05/23/2023. She said information for Resident #1's care plan would be communicated to her by the ADON or the DON during morning meetings. She said she was aware of Resident #1 biting a staff member but was not sure why it occurred. She said she was not informed of specific circumstances that may have caused Resident's #1's behavior. She stated those circumstances should be communicated from nursing staff and reflected in the care plan. <BR/>An interview on 06/07/2023 at 5:03PM with the ADON revealed she had not reviewed Resident #1's progress notes. She said it was the DON and her responsibility to review them for any concerns related to residents. She said that information would be passed on to the MDS Coordinator to be addressed in care plans. The ADON said she was not aware Resident #1 was messing with her poop and did not know RN A was pushed to the ground by Resident #1 when she took a soiled adult diaper from her. She stated specific interventions should have been reflected in the care plan to ensure Resident #1's safety. She said the facility did not have a system in place to ensure rooms were checked for hazardous items. She said since Resident #1 wandered and got into things, the facility needed to ensure her safety by making sure all potentially hazardous items were secured. <BR/>In an interview on 06/07/2023 at 5:15PM, the Administrator stated she dropped the ball. She said in hindsight, she should have followed up with the DON regarding Resident #1's aggression. She said she should have investigated as to the circumstances of Resident #1's aggression. She stated there was not an incident report done when Resident #1 bit CNA E or pushed RN A. She said she and the DON should have known about Resident #1 eating a solid adult diaper. She said she felt like she needed to have better communication with nursing staff to ensure all resident's safety. She said the facility should have a system in place to ensure resident did not have access to non-consumable items and ensure their safety. <BR/>An interview on 06/07/2023 at 5:57PM with the COO revealed he expected staff to ensure all residents were safe. He stated the DON and ADON should have known about the context of Resident #1's behaviors and ensured the care plan reflected specific issues. He stated there seemed to be a breakdown in communication between the front-line staff, nurse management, and the Administrator. <BR/>Record review of the facility's incident / accident report between 03/01/2023 to 06/07/2023 revealed no record of incidents involving Resident #1, CNA B, or RN A. <BR/>Record review of the MSDS for the deodorant consumed on 06/07/2023 by Resident #1 revealed Hazards Identification: Eye: Classification Eye Contact may cause mild, transient irritation. Some redness and/or stinging may occur. Ingestion: Product used as intended is not expected to cause gastrointestinal irritation. Accidental ingestion of undiluted product may cause mild gastrointestinal irritation with nausea, vomiting and diarrhea.<BR/>Record review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, dated 12/2009 reflected, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.including time and date .nature .circumstances .name of witnesses .complete report sent to the DON within 24 hours .DON shall ensure that the Administrator receives a copy of the Report .<BR/>Record review of the facility's policy titled, Safety and Supervision of Residents, dated 12/2008 reflected, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA and A reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. Staff shall use various sources to identify risk factors for residents, including information obtained from the medical history, physical exam, observation of the resident, and the MDS. Implementing interventions to reduce accident risk and hazards shall include the following: communicating specific interventions to all relevant staff, providing training .documenting interventions .<BR/>Record review of the facility's policy titled, Care Plans - Comprehensive, dated 12/2010 reflected, An individualized comprehensive care plan that includes measurable objectives and timetables to meet resident's medical, nursing, mental, and psychosocial needs is developed for each resident. Each resident's comprehensive care plan is designed to: .incorporate identified problems .incorporate risk factors associated with identified problems <BR/>The Administrator was notified on 06/08/2023 at 9:30AM, that an Immediate Jeopardy had been identified due to the above failures. The IJ Template was provided to the Administrator on 06/08/2023 at 9:45AM and she was informed the POR was due to HHSC by 12:00PM on 06/08/2023. <BR/>The Plan of Removal (POR) was accepted on 06/08/2023 at 4:20PM. <BR/>The Plan of Removal reflected the following:<BR/>Immediate Corrective Action for residents affected by the alleged deficient practice:<BR/>The resident who allegedly ingested deodorant was assessed, all vital signs within normal limits. Despite finding no evidence of deodorant within her mouth, the resident's mouth was rinsed, fluids encouraged. Medical director, poison control, and family were notified. The medical director instructed facility to continue to monitor for signs of GI distress. <BR/>This deficient practice had the potential to affect 17 residents residing on the secure unit, however, no other resident was found to be affected.<BR/>The secure unit was swept for personal care items on 06/07/23 and again on 06/08/23. All personal care items found were removed from resident rooms and given to the charge nurse to be secured behind locked doors, including items from resident who was previously reluctant to let them go. <BR/>All family members were called on 06/07/2023 and informed that personal care items must be labeled and turned into management staff or nursing to be locked for the safety of all residents. Signs were also posted at the front of the building to turn in personal care items which will be made available for use at the appropriate time. <BR/>Care plans updated to reflect the residents wandering and aggression being further agitated by attempts to remove items or redirect resident. The care plan updated to reflect the residents alleged tendency to ingest non-food items. <BR/>Staff members in-serviced on the need to lock personal care items out of reach of residents, particularly those who tend to become confused or exhibit behaviors related to wandering and picking up items found in other rooms. Education occurred on 06/07/23 and again on 06/08/23 and will continue.<BR/>Actions taken to prevent a serious adverse outcome from recurring:<BR/>Management staff swept the rest of the facility on 06/08/2023 and ensured personal care items were secured appropriately. Anything found not stored appropriately was labeled by resident name and given to charge nurses to secure in locked room on 300 hall. <BR/>Additional checks were conducted of locked supply, shower, and utility rooms. The facility will continue to monitor to ensure the security of these areas. Additional education completed on the need to keep personal care items away from residents who might become confused or exhibit behaviors.<BR/>Ad Hoc QAPI Meeting was held on 06/08/2023 to discuss the incident, make staff members aware of the new policy on personal care items. MD and management staff present, corporate staff available by phone. <BR/>Additional sweeps of the area daily by staff members x 2 weeks, then weekly for 2 weeks, and monthly thereafter. <BR/>The facility will utilize a daily behavior monitoring sheet for changes in behavior/condition. This sheet will be reviewed weekly and as necessary, changes in behavior or condition will be discussed and care planned appropriately. <BR/>When will actions be complete:<BR/>Coral Nursing and Rehabilitation of Arlington requests the removal of the immediate jeopardy on 06/08/2023<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>An interview on 06/09/2023 at 1:30PM with the Administrator revealed 57 of 110 staff have been in-serviced regarding the Behavior monitoring log and Securing personal care items. She stated the management team had been completed to ensure any hazardous items were secured for the safety of residents. She stated sweeps will be completed daily by the management team for two weeks and then weekly. She said she would be completing the sweeps on weekends until a weekend supervisor was hired. She stated she would be addressing progress notes, the results of sweeps, and any aggressive incidents daily stand-up meetings. She stated the management team participated in an Ad Hoc QUPI meeting on 06/08/2023 wiht the medical director, Corporate RN, DON, ADON, and MDS Coordinator present. She said she had implemented a behavioral log to be completed by staff daily and monitored by the DON in an effort to catch any changes in resident behaviors. She said the DON was expected to report any changes in resident behavior to her, daily. She stated the families of all Secured Unit residents were contacted and instructed that any items they bring to the facility must be secured by staff. <BR/>A record review of the medical record for Resident #1 revealed she was assessed for complications and ongoing monitoring of adverse effects. Resident #1's care plan was updated to reflect the residents wandering and aggression, further agitated by attempts to remove items or redirect the resident and resident's tendency to ingest non-food items. <BR/>Observations on 06/09/2023 from 3:00PM to 3:10PM revealed all rooms and areas in the memory care unit were free from hazardous products.<BR/>Interviews were conducted on 06/09/2023 from 12:40 PM to 3:00 PM with 18 staff members (6 CNAs, 2 RNs, 4 LVNs, 2 MAs, 1 Restorative Aide, and 3 Housekeeping staff) from multiple shifts. The staff all indicated they had been in-serviced on safety awareness, which included a list of prohibited items in memory care, how hazardous items should be stored, the procedures on storing prohibited items that family members might bring for resident use, ongoing sweeps for hazardous items and their security, and procedures in case they were not sure if an item was hazardous.<BR/>In a telephone interview on 06/09/2023 at 2:55PM, the Corporate RN said he understood the components of the IJ and was not aware the DON and ADON had not been reviewing the progress notes. He said it was impossible to complete a comprehensive care plan without considering behaviors. He said he expected the Administrator to ensure residents were safe from hazardous items. He said he expected the DON to ensure behaviors were monitored and communicated to staff for appropriate care planning. He said he provided a behavior log to the Administrator to assist with this. He said he in-serviced the Administrator, DON, ADON, and MDS Coordinator on the need to address changes in resident behavior in care planning, reviewing progress notes to ensure behaviors are addressed and care planed appropriately, and ensuring resident were cared for in a safe environment. <BR/>Record review of in-service dated 06/07/2023, 06/08/2023, and 06/09/2023 on Personal Care Items .Inform family members that all personal care items must be labeled and turned into management staff or nursing staff to be locked for the safety of all residents .Personal care items include but are not limited to the following: Soap, shampoo, conditioner, deodorant, lotions, mouthwash, toothpaste, hand sanitizer, and other potentially hazardous chemical items .In continuing sweeps, if such items are found please remove them from the room. Make sure they are labeled and give it to the nursing staff to be secured revealed 57 signatures from multiple shifts and multiple departments (RNs, LVNs, CNAs, MAs, Housekeeping, Laundry, and Maintenance) had received in-services which covered all aspects of the POR. <BR/>Record review of in-service dated 06/07/2023, 06/08/2023, and 06/09/2023 on Behavior Monitoring Log .the facility will distribute behaviors monitoring sheets to the nursing staff to be filled out daily. The DON will collect the sheets weekly or as necessary to be discussed at the Standards of Care meeting. Any changes will be communicated to management staff in the meeting and care planned appropriately. Changes will also be discussed in the morning IDT meeting so all staff can be aware of changes, revealed 57 signatures from multiple shifts and multiple departments (RNs, LVNs, CNAs, MAs, Housekeeping, Laundry, and Maintenance) had received in-services which covered all aspects of the POR. <BR/>Record review of signed in-service dated 06/09/2023 and conducted by the Corporate RN revealed the Administrator, DON, ADON, and MDS Coordinator were educated on their .responsibility that every resident within my facility receives quality, appropriate care .understand that changes in resident's behavior must be discussed promptly, with the DON, ADON, and IDT team for intervention and appropriate care planning .understand that it is my responsibility to periodically read and review the charts of my residents with behaviors, to ensure completeness and that all behaviors are addressed and care planned appropriately. <BR/>Record review of the Behavior Monitoring Log reflected behavior, intervention and outcome codes with a monthly calendar noting day, evening, and night shifts. <BR/>The Administrator was informed the Immediate Jeopardy was removed on 06/09/2023 at 4:18PM; however, the facility remained out of compliance at a scope of Pattern and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #2 and Resident #3) of five residents reviewed for ADLs. <BR/>The facility failed to provide showers or bed baths consistently for Residents #2 and #3 per the facility bathing schedule in January 2025. <BR/>This failure placed residents who were dependent on staff for bathing at risk for poor personal hygiene, odors, and a decline in their quality of life. <BR/>Findings included:<BR/>1. Record review of Resident #2's Face Sheet reflected dated 01/30/25 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2's active diagnoses included paraplegia (a condition that causes paralysis or loss of muscle function in both legs), neuromuscular dysfunction of bladder (impaired bladder control due to disrupted communication between the brain and the bladder muscles), Stage 4 pressure ulcer of right heel and Stage 4 pressure ulcer of right lower back (a pressure ulcer is localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction; Stage 4 means full thickness tissue loss with exposed bone, tendon or muscle).<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 15 which indicated no cognitive impairment. Resident #2 had range of motion impairment on both sides of his lower extremities and used a wheelchair for mobility. Resident #2 required partial/moderate assistance from staff for bathing and personal hygiene. He had an indwelling and external catheter (a flexible tube inserted into the body to drain or deliver fluids) and ostomy (a surgical procedure that creates an opening in the abdomen to allow waste to exit the body).<BR/>Record review of Resident #2's baseline care plan dated 01/22/25 reflected he was dependent on staff for toileting hygiene and showers/bathing.<BR/>An interview with Resident #2 on 01/30/25 at 1:49 PM revealed he had been moved to the room he was presently in several days prior and there was no hot or warm water available in his bathroom to use. Resident #2 stated he had let the water run in his bathroom sink for over an hour when he first moved to the room, but there was only cold water. He said the shower at the end of his hall also did not have any hot or warm water. Resident #2 said he had not received a shower the past two scheduled times (01/27/25 and 01/29/25). Resident #2 stated he felt not having hot or warm water available in his room made him feel very dirty, he said he could not wash his face well and it was starting to breakout and his skin was starting to get itchy all over.<BR/>Record review of Resident #2's nursing progress notes reflected no shower refusals since his readmission to the facility from the hospital on [DATE].<BR/>2. Record review of Resident #3's Face Sheet dated 01/30/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #3's active diagnoses included paraplegia (a condition that causes paralysis or loss of muscle function in both legs), colostomy status (a surgical procedure that creates an opening in the colon, allowing stool to be diverted from the rectum and collected in a bag), Stage 4 right and left lower back pressure ulcer, stage 4 of sacral region (Full thickness tissue loss with exposed bone, tendon or muscle) and flaccid neuropathic bladder (a condition where the bladder muscles are weak and unable to contract properly, leading to difficulty or inability to urinate). <BR/>Record review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated no cognitive impairment. Resident #3 had range of motion impairment on one side of his upper extremities and on both sides of his lower extremities. He used a wheelchair for mobility and was dependent on staff for all ADLs, including showering and personal hygiene. <BR/>Record review of Resident #3's care plan last revised 01/28/25 reflected Resident #3 had an ADL self-care performance. Interventions, Bathing/Showering: Resident prefers showers 3 times per week likes to get oob daily; The resident requires extensive assistance by (1) staff with bathing/showering (start 09/30/24)<BR/>An interview and observation of Resident #3 on 01/30/25 at 2:03 PM revealed he was sitting in a reclined wheelchair in his room with his eyes closed. Resident #3 stated he had not been bathed or showered in the past week. He said he could not remember the last time he had been bathed but it had been a long time, over a month. During the interview, Resident #3 kept trying to peel his right eye open with his fingers as it was observed to be crusty and sealed shut. Resident #3 said he did not know why the staff were not bathing him and stated, They don't tell me why. I want one though. Resident #3's bathroom sink was observed to have no hot or warm water available. <BR/>Record review of Resident #3's nursing progress notes reflected no shower refusals for the month of January 2025. <BR/>3. An observation of Resident #2 and #3's shower room at the end of Hall 400 on 01/30/25 at 1:56 PM revealed there was no hot or warm water coming from the shower faucet.<BR/>4. Review of the facility shower binder for Hall 400 reflected no shower sheets for Residents #2 and #3 for January 2025. There were daily lists of residents to be showered with a space for the nurse to sign with any comments. However, neither Resident #2 nor Resident #3 were checked off as completed. <BR/>5. An interview with ADON A on 01/30/25 at 12:19 PM revealed completed shower sheets were important because that was the way the facility kept track of any new resident skin issues. ADON A stated she had looked in the binders and verified there were no shower sheets for Resident #2 and #3. ADON A stated what she saw in the shower binders at the 400-hall nursing station was just a list for the charge nurse to sign off on which residents were supposed to get showered that day. ADON A stated, But they were not the shower sheets. ADON A stated she did not know how long the CNAs and charge nurses had not been using shower sheets. ADON A stated the list of who needed a shower was not acceptable. She said the shower sheets needed to be completed and turned in by the CNAs for review to see if there were any changes to a resident's skin condition. ADON A stated the form they were using currently did not indicate if any skin was looked at or if any skin issues were noted. ADON A said she was going to ensure that the required blank shower sheets were copied and placed back into the shower binders along with the schedule list of residents to be showered for that day so they can be tracked and monitored. ADON A stated she did not know why the system changed except laziness and no one put more shower sheets in the binders, so they all defaulted to just signing a schedule, Which is not appropriate. <BR/>An interview with the ADM on 01/30/25 at 9:30 AM revealed the DON was out sick on leave and was unable to be interviewed. <BR/>An interview with CNA C on 01/31/25 at 12:37 PM revealed she had not seen any skin observation sheets (shower sheets) and when she gave a resident a shower, she just circled on a list if the resident received it or if they refused. If any skin issues, she would circle yes/no and then report to the charge nurse. When shown a blank shower sheet/skin observation sheet, CNA C stated she had not seen them before and had not been filling those out. CNA C stated showering a resident was important because no one wanted to have body odor and they want to smell fresh. CNA C stated infection control was also another reason showers were important, We have bacteria on our skin and we need to shower to remove it and protect the skin, like rashes and stuff, showering is good. <BR/>An interview with CNA D on 01/31/25 at 12:56 PM revealed she was picking up a shift and had showered Resident #1 that morning (01/31/25). CNA D stated she had another CNA help her shower Resident #1 and he took them a lot of time. She stated when a resident shower was completed, there was a paper that had the name and room number of the residents assigned to be showered for that day. If the resident refused the shower, the CNA had to tell the nurse. CNA D stated she had not seen the shower sheet form/skin observation sheet recently. <BR/>An interview with the ADM on 01/31/25 at 1:54 PM revealed he had heard about Resident #2 not being showered because his family member had contacted him on 01/30/25 about it. The ADM stated he completed a grievance form as a result. The ADM reviewed the shower binder and the schedule the nurse checked off that staff were using as shower sheets and said it was not the right form. He said the shower sheets to be used were more comprehensive. <BR/>6. A policy on ADL care related to showers was requested on 01/30/25 and 01/31/25 from the ADM but was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 help prevent the development and transmission of infection for 5 (Residents #2, #3, #4, #5, and #6) of 12 residents reviewed for infection control. <BR/>1. <BR/>On 04/30/24 MA A, CNA B, and CNA C brought Residents #2, #3, #4, #5, and #6 to the locked unit dining room and fed them and did not wash their hands nor the hands of the residents.<BR/>2. <BR/>On 04/30/24 CNA B assisted Residents #2, #3, and #4 with their noon meals, he cut up their food and fed them and did not sanitize his hands.<BR/>3. <BR/>On 04/30/24 CNA C touched the hand of Resident #5 and assisted him to his seat then touched his eating utensil without sanitizing her hands.<BR/>4. <BR/>On 04/30/24 during the noon meal on the locked unit a visitor brought cookies to the residents, this visitor used her ungloved hands and gave each resident present (#2, #3, #4, #5, #6) a cookie without sanitizing her hands.<BR/>This deficient practice placed residents who received assistance with meals in the Locked Unit Dining Room at risk for cross contamination and infections.<BR/>Findings included:<BR/>Review of Resident #2's Care Plan dated 07/12/23, revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with an intervention of limited assistance by staff to eat. Diagnoses included Dementia (a group of thinking and social symptom that interferes with daily functioning), and bipolar disorder (associated with episodes of mood swings ranging from depressive lows to manic highs). <BR/>Review of the most recent quarterly MDS assessment dated [DATE], revealed Resident #2, had a BIMS score of 3 (cognition was severely impaired). Resident #2's eating assessment reflected she required partial/moderate assistance-Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.<BR/>Review of Resident #3's Care Plan dated 01/24/24, revealed Resident #3 was an [AGE] year-old male admitted to the facility on [DATE] with an intervention of set up assistance by staff to eat. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #3's quarterly MDS assessment reflected he had a BIMS score of 00 (cognition was severely impaired). Resident #3's eating assessment reflected he required setup or clean-up assistance-Helper sets up or cleans up; resident completes activity.<BR/>Review of Resident #4's Care Plan dated 11/07/23, revealed Resident #4 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #4's quarterly MDS assessment reflected no BIMS score noted. Resident #4's eating assessment reflected she required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>Review of Resident #5's Care Plan dated 02/06/24, revealed Resident #5 was an [AGE] year-old female admitted to the facility on [DATE] with an intervention that the resident is independent for eating. Diagnoses included Dementia (a group of thinking and social symptom that interferes with daily functioning).<BR/> Review of Resident #5's quarterly MDS assessment reflected a BIMS score was not completed. Resident #5's eating assessment reflected she required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>Review of Resident #6's Care Plan dated 04/14/23, revealed Resident #6 was an [AGE] year-old male admitted to the facility on [DATE] with an intervention of limited assistance by staff to eat. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #6's change in condition MDS assessment reflected a BIMS score was not completed. Resident #6's eating assessment was not completed.<BR/>Observation on 04/30/24 at 12:45 PM revealed MA A walked into the dining room on the locked unit, and she assisted Resident #2 to a table and helped her to sit. MA A took the lid off the plate of Resident #2 then she touched her eating utensil and fed Resident #2. MA A did not sanitize her hands or the hands of Resident #2.<BR/>During an observation on 04/30/24 at 12:46 PM, CNA B took the eating utensil of Resident #3 and cut up his food. Then he went to Resident #4 and used her eating utensil to cut up her food. CNA B then moved to Resident #5, picked up her eating utensil and fed her. He did not sanitize his hands before he moved to and from each resident to assist. He did not sanitize the hands of the resident before assisting them to eat.<BR/>During an observation on 04/30/24 at 12:48 PM, Resident #6 got up from the table. CNA B went outside the door of the dining area to follow Resident #6 out of the dining room. CNA B touched Resident #6 on his arm to redirect him back to the dining table, then CNA B returned to Resident #5 and fed her again. He did not sanitize his hands after he touched or fed a resident. <BR/>Observation on 04/30/24 at 12:49 PM revealed CNA B left Resident #5 and went to assist Resident #4 back to her table to eat by touching her arm. Then he returned to Resident #5 without sanitizing his hands. <BR/>Observation on 04/30/24 at 12:50 PM revealed CNA C assisted Resident #6 back to his table when she took his hand and helped him sit down. Then she picked up his eating utensil from his plate and assisted him to eat. She did not sanitize her hands or the hands of the resident.<BR/>Observation on 04/30/24 at 12:51 PM revealed CNA B moved from Resident #5 and took the eating utensil for Resident #3 and put it back in his hand and encouraged him to eat. He did not sanitize his hands. <BR/>Observation on 04/30/24 at 12:55 PM revealed a visitor entered the dining area on the locked unit with a container of cookies. The visitor handed out cookies to Residents #2, #3, #4, #5, and #6. The visitor did not sanitize her hands before she gave the residents cookies. The visitor did not put on gloves prior to passing out the cookies to the residents.<BR/>In an interview on 04/30/24 at 1:09 PM with CNA B revealed he did not have any hand sanitizer on his person in the dining area and there was not any in the dining area at lunch. He stated there was some hand sanitizer in the nursing station which was located down the hall. He stated he had been trained on infection control. He stated he was not supposed to move from one table to another table or one resident to another resident and touch them without sanitizing his hands. He stated the residents should not have been given cookies by the visitor. He stated the risk to the residents was the transmission of germs that could cause infection.<BR/>In an interview on 04/30/24 at 1:21 PM with CNA C revealed she did not have any hand sanitizer on her person when she was in the dining area at lunch. She stated they do not keep the sanitizer out in the dining room because of the residents' attempts to get the sanitizer. She stated there is hand sanitizer in the closet in the nurses' station. She stated the visitor should have asked if they could give the residents cookies. She stated the risk to the residents was the spread of germs and infection when the staff did not sanitize their hands when working with several residents.<BR/>In an interview on 04/30/24 at 1:40 PM with LVN revealed she was the supervisor of the staff working in the locked unit. She stated during lunch she mostly worked on another hall. She stated the hand sanitizer was available in the nurse room, but the door has been taken down and they must keep all the sanitizer put up out of reach of the residents. She stated all the staff should have known the hand sanitizer was in the closet in the nurse room. She stated she did not remember the last infection control training they took. She stated the visitor should not have handed out cookies to the residents without sanitizing hands. She stated the risk to residents was infection, passing germs, and viruses because staff had not sanitized their hands during the lunch meal.<BR/>In an interview on 04/30/24 at 2:15 PM with MA A revealed she did not have hand sanitizer in her pocket. She stated hand sanitizer was in the nurses' room down the hall. She stated she had washed her hands before she went into the dining area. She stated staff should have sanitized their hands when they worked with several residents during the lunch meal. She stated the resident was at risk of infection when the staff did not sanitize between residents. <BR/>In an interview on 04/30/24 at 4:35 PM with the Administrator revealed the DON and herself was responsible to ensure staff was trained on IC. She stated the DON completed monthly in-services on IC. She stated the DON was currently in the hospital and not available for interview. She stated the staff had put the residents at potential risk of infection and illness when they did not sanitize their hands. She stated the staff should have told the residents to wash their hands before the meal. She stated there was hand hygiene supplies available throughout the building and if there was not any in the dining area, the staff could have asked her or the housekeeper. <BR/>Record review of facility's Policies and Practices -Infection Control revised August 2010 reflected, All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program, so the facility was free from pests and rodents for 2 of 2 residents (Resident #2 and Resident #3) reviewed for pest control. <BR/>The facility failed to maintain an effective pest control program to ensure the facility was free of rodents and roaches in the facility kitchen and the rooms of Resident #2 and Resident #3. <BR/>This failure could place residents at risk for an unsanitary environment in the kitchen and rooms of Residents #2 and Resident #3 and a decreased quality of life. <BR/> Findings included: <BR/>Record review of Resident #2's admission Record dated 02/27/24 reflected a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted to the facility on [DATE].<BR/>Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 13 which indicated he was cognitively intact. His diagnoses included paraplegia (inability to move the lower part of the body); peripheral vascular disease (reduced blood flow to the limbs), and Stage 4 (full thickness) pressure ulcer to right heel. He utilized a wheelchair for mobility.<BR/>Record review of Resident #3's admission Record dated 02/27/25 reflected a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted to the facility on [DATE].<BR/>Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 which indicated he was cognitively intact. His diagnoses included Type 2 Diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Hypertension (a condition in which the force of the blood against the artery walls is too high), Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Crohn's Disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract), Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), he was mobile without assistance. <BR/>Interview on 02/26/25 at 10:55 AM with Resident #3 revealed he had seen four rats run back into the wall in his bathroom when the facility was repairing the wall in his bathroom. He stated he told the maintenance director at the time. He stated he could not remember exactly when, it was a few months ago. He stated he had two cats and the cats sometimes reacted to sounds heard in the walls of his room. <BR/>During an observation and interview on 02/26/25 at 11:45 AM, Resident #2 was sitting up in his wheelchair discussing an upcoming appointment. During the conversation, a large water bug was observed crawling out from behind the resident's duffle bag situated against the wall toward the middle of the room. It turned and returned behind his bag. Resident #2 reached and moved his bag, and the bug ran out of the room. Resident #2 stated he saw them pretty often, I see those little roaches too. He stated he had complained about it a while back but no one ever did anything about it. He stated he knew nothing was done because the bugs were still there. He stated, it's pretty nasty.<BR/>Interview with pest control service provider on 02/26/25 at 11:50 AM revealed the contract with the facility had been cancelled because of slow payment. He stated the last date of service was mid December 2024. <BR/>Interview on 02/26/25 at 12:15 PM, the Dishwasher revealed she had seen a rodent in the kitchen on 02/24/25. She stated she had seen a rodent on the dish racks that are used to wash the dishes. She stated the rodent ran to the laundry room from the kitchen. She stated she had to disinfect the dishwasher prior to sending the dishes through the dishwasher because of the rodent droppings on the dishwasher. She stated told the Administrator and the previous Maintenance Director. She stated they said they would contact pest control. She stated rodents in the kitchen could cause infection or sickness to the residents and it was very unsanitary.<BR/>Observation on 02/26/25 at 12:22 PM of the dishwashing area of the kitchen revealed under crates sitting on a cart were shavings from the crate and rodent droppings. Observation of another cart holding crates revealed rodent droppings and food particles. <BR/>Interview with Kitchen Manager on 02/26/25 at 12:25 PM revealed he stated he had not seen any rodents in the kitchen. When Kitchen Manager was asked if any kitchen staff had informed him that rodents had been seen in the kitchen, he replied, that he had not seen any rodents in the kitchen. He stated the residents were at risk of sickness and disease. <BR/>Interview with Administrator on 02/26/25 at 1:30 PM revealed he had asked the previous Maintenance Director about the pest control visits to the facility because he had never seen a person from a pest control company at the building. He stated he was told the pest control staff came to treat the building at 6:00 AM. He stated he instructed the maintenance director that the pest control staff should have come to the building during the day so that he could meet with him. He stated he was not aware that the contract had been terminated. He stated he was the person responsible to ensure there was a pest control contract in place. He stated the residents had been at risk of cross contamination, infection, and diseases. <BR/>During an interview on 2/26/25 at 2:13 PM, the ADON stated she saw bugs occasionally and let the maintenance staff know whenever she saw anything. She stated she had seen what looked like a tiny cockroach in a resident room on 2/24/25 and immediately told maintenance in person. She stated they came and took care of it. They removed the bug and said they would treat the area. The ADON stated she had not seen any rodents. <BR/>During an interview on 02/27/25 at 6:21 AM, CNA C stated she worked the night shift and had been there about a year. She stated she saw rats in the facility near the kitchen and laundry rooms when she took the trash out at night. She stated she saw them there a lot including the current week. CNA C stated she saw a rat in the employee break room a couple of nights ago. She entered the room and saw a rat run from near a chair and crawl under a cabined under the sink. When asked if she had reported it, she replied, No, we're just used to it, it's been like that a long time. CNA C stated she had never seen rats in the resident rooms, shower rooms or near any resident. She stated, Most of the time they are near the kitchen.<BR/>Record review of the facility pest control visit log reflected service was last provided on 02/07/25. The last invoice from service provider was dated 12/12/2024.<BR/>Record review reflected prior to exit facility obtained a new pest control policy dated 02/26/25.<BR/>Record review of the facility Pest Control Policy review dated 12/1/22, review date 2/26/25 reflected <BR/>Pest Prevention Measures: <BR/>Conduct regular inspections of the facility to identify potential pest entry points and nesting sites.<BR/>Seal cracks, crevices, and other openings in the building structure.<BR/>Maintain cleanliness in all areas, including dining, kitchen, and resident rooms, to eliminate food sources and habitats for pests.<BR/>Proper waste management practices, including regular disposal and secure containers.<BR/>1. <BR/>Monitoring: <BR/>Schedule routine pest inspections by qualified pest control professionals at least quarterly.<BR/>Document findings and actions taken during inspections.<BR/>Maintain a pest sighting log for staff to report any pest activity promptly.<BR/>2. <BR/>Pest Control Treatment: <BR/>Employ licensed pest control operators to handle infestations when necessary, ensuring they follow HHSC guidelines.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services.<BR/>1) <BR/>The facility failed to ensure food items were properly labeled and dated with the product's name.<BR/>2) <BR/>The facility failed to ensure food items were properly sealed when not in use.<BR/>These failures could place residents at risk for food-borne illness and food contamination.<BR/>Findings include:<BR/>An observation on 5/21/2025 at 11:50 AM revealed in the dry food pantry one large plastic container of rice (was not labeled with the product type or dated); one opened bag of potato chips wrapped in plastic wrap (was undated and not properly stored according to the facility's policy); one opened bag of tortilla chips wrapped in plastic wrap (was undated and not properly stored according to the facility's policy).<BR/>An observation on 5/21/2025 at 12:10 PM in the large refrigerator revealed two bags of opened bread (was not labeled, dated, nor properly stored); white gravy in a plastic container covered with plastic wrap (had a large hole in the plastic wrap); chopped up meat (was not labeled with the product type or dated); one opened pack of deli meat (was not labeled with the product name or dated); one large bowl was uncovered which contained chocolate pudding (was not labeled with the product name or dated).<BR/>An observation on 5/21/2025 at 12:30 PM in the walk-in freezer revealed an opened plastic bag with four meat patties (were not labeled with the product name or dated); two opened large packs of hamburger buns (was not labeled or dated) and one large roll of ground beef (was not labeled with the product name or dated).<BR/>In an interview on 5/21/2025 at 1:25 PM, the DM stated she worked at the facility for 3 days. The DM stated all kitchen staff were responsible for labeling and dating all items. The DM stated when staff opened anything, all unused products must be placed inside of a Ziplock bag or container and labeled and dated. The DM stated all leftover cooked items, must be stored in a closed container, labeled, and dated. The DM stated the brown substance in the large bowl was chocolate pudding the worker had just made for tonight's dinner. The DM stated frozen foods should be dated upon arrival to the facility. The DM stated if the frozen boxes were emptied all removed bags of that item, must be labeled, and dated. The DM stated based on her first 3 days of observations, she needed to in-service staff regarding proper labeling and dating. The DM stated serving residents expired food or food not properly stored according to the facility's policy could cause food poisoning and make the resident ill. <BR/>In an interview on 5/21/2025 at 2:00 PM, DA A stated whenever stocked the food from the delivery truck, must date it. DA A stated any opened dry food must be placed in a container, properly labeled and dated. DA A stated any opened perishable food must be placed in a Zip Loc bag, labeled, and dated. DA A stated not following protocol could make the residents sick.<BR/>In an interview on 5/21/2025 at 3:20 PM, DA B stated the entire staff was responsible for labeling and dating opened containers and packages. DA B stated without a proper label and date, the next worker would not know when the items were placed there. DA B said the DM was in charge of overseeing the kitchen and she instructed them to label everything. DA B said failing to do so placed the residents at risk of becoming ill.<BR/>In an interview on 5/21/2025 at 3:35 PM, the ADM stated all food should be labeled, dated, and stored properly. The ADM stated the kitchen staff should know when food was made and what it was being used for at the time. The ADM stated this was important to prevent the residents from becoming ill. The ADM stated they must continue to educate staff on proper food storage and safety.<BR/>Record review of the facility's policy titled Accepting Food Deliveries, published date of 2013, reflected Food deliveries will be accepted into the facility only by the following procedure . 4. Perishable foods will be properly covered, labeled, and dated and promptly stored in the refrigerator or freezer as appropriate.<BR/>Record review of the facility's policy titled Food Storage, published date of 2013, reflected:<BR/> .4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated . <BR/>c. Food should be dated as it is placed on the shelves .<BR/>13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded.<BR/>14. Refrigerated Food Storage . f. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.<BR/>15. Frozen Foods . c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary comfortable, environment for residents staff and the public for one (room [ROOM NUMBER]) of nine resident rooms reviewed for environment.<BR/>The facility failed to ensure the AC/heating unit located in room [ROOM NUMBER] was clean.<BR/>This failure could place residents at risk for diminished quality of life due to a lack of a well-kept environment and reduced air quality in the room.<BR/>Findings included:<BR/>An observation on 1/17/24 at 9:20 AM, revealed Resident #1 was in room [ROOM NUMBER]B, sitting on the side of his bed facing the window. His knees were directly in front of an AC/heating unit located beneath a window. The resident was cognitively impaired and unable to be interviewed. The AC/heating unit was on and blowing warm air. Front cover appeared loose. A moist black substance was observed along the edges of the louvers from where the air was blowing. The top portion of the cover surrounding the louvers and control panel was dirty. The control panel face was also covered in dirt that was heavier in the area typically obscured by the cover, but visible because the cover was loose. <BR/>An observation on 1/17/24 at 9:28 AM, revealed a housekeeping cart was parked outside the room next door.<BR/>Another observation on 1/17/24 at 10:10 AM revealed Resident #1 was sitting in the same position in his room, no changes were observed to the unit, photos were taken by this surveyor. <BR/>An observation and interview on 1/17/24 at 10:55 AM, revealed a housekeeping cart was seen in the doorway of room [ROOM NUMBER]. Housekeeping Staff A was observed inside the room removing trash from the trashcans. An interview with Housekeeping Staff A revealed the floors were typically cleaned twice a day and the AC/heating units were cleaned daily. <BR/>An observation on 1/17/24 at 12:15 PM, revealed Resident #1 was sitting on the side of his bed, now facing the door, eating lunch. Observation of his AC/Heating unit revealed the front center portion of the control panel appeared clean but the surrounding area was still dirty. The black substance could still be seen along the edges of the louvers from where the air was blowing.<BR/>An interview with the DON on 1/17/24 at 1:30 PM, revealed Resident #1's family member mentioned the dirty AC/heating unit to him the evening of 1/16/24. He stated he had planned to discuss it with the maintenance staff today (1/17/24) but had not done so yet because State investigators had entered this morning. The DON accompanied this surveyor to room [ROOM NUMBER] to examine the unit. The DON removed the cover and pointed out the rust on the metal frame and stated he believed that was the material and not dirt. When the other dirty areas were pointed out including the black substance on the louvers, dirt around the control panel, dust buildup beneath the control panel, and dirt buildup within grate over the blower portion of the unit, he stated he would let them know. <BR/>In another interview with the DON on 1/17/24 at 1:55 PM, he presented photos on his phone he said he received on 1/16/24 and stated, it was much worse yesterday. The photo revealed the condenser portion of the unit had been completely caked in dust and had been cleaned and was now clear. He was unsure why the rest had not been cleaned and thought someone may have planned to return and complete.<BR/>In an interview on 1/17/24 at 2:05 PM, with the Housekeeping Supervisor, she stated the housekeepers were responsible for cleaning the outside of the AC/heating units daily and they should check them, along with everything else, during their daily walkthroughs. She stated she did periodic checks behind the housekeeping staff to ensure quality work. She stated Resident #1's family member] had told her the day before that they had bumped into the unit causing the cover to come off which exposed heavy dust buildup. She stated the family member told her it was already getting addressed. She stated she thought she had just seen the Maintenance Tech in the room wiping it down today. <BR/>In an interview with the Maintenance Tech on 1/17/24 at 2:16 PM, he stated he checks the maintenance log at the nurses' station daily for any maintenance issues. He stated he checked the log on 1/16/24 and there was an entry for room [ROOM NUMBER] that said the heat was not working. He said he just went in the room and switched it on and it worked fine. The Maintenance Tech stated someone had asked him if he had cleaned the unit and he told them, 'no'. He stated he thought housekeeping had cleaned it up. The Maintenance Tech stated he had walked through the building two months ago and changed all the filters. He was unaware whether there was any routine cleaning of the interior parts but he could take the unit outside and wash it. He stated he could have removed the cover and clean it, but he had only been told it was not working. The Maintenance Tech provided the Maintenance Logbook for review. <BR/>Record review of the Maintenance Logbook at the main nurses station revealed individual pages titled Maintenance Request. A page dated 1/16/24 reflected the following: <BR/>Time: 8:50 AM. <BR/>Reported by: Resident to the nurse<BR/>Room: 411<BR/>Location: 400 Hall<BR/>Nature of Work Order: Heat is not working<BR/>Work Completed Date: 1/16/24<BR/>By: [Maintenance Tech]<BR/>An interview with the Administrator and the DON on 1/17/24 at 4:00 PM revealed the Administrator stated she had received a text message from the Dietary Manager on 1/3/24 informing her of the complaint. She stated she was told the unit had been cleaned and everything was fine. She stated she did not follow-up with Resident #1's [family member] because the Dietary Manager told her Resident #1's [family member] was satisfied with the outcome. When the Administrator was shown photos taken by this surveyor and asked if she felt it was acceptable, she stated she had been told it was cleaned. When asked about the possible risks to residents having dirty AC/heating equipment close to their beds, the Administrator stated, well that sticks to the plastic and we can get it cleaned and the [family member] was satisfied according to my Dietary Manager. <BR/>During an interview on 1/17/24 at 4:30 PM, the Dietary Manager stated she had been standing near the nurses' station when Resident #1's [family member] approached her and appeared upset. She stated the family member told her they had bumped the AC/heating unit by accident causing the cover to fall off and she noticed it was very dusty. The Dietary Manager stated she retrieved some sanitizing wipes and wiped down the inside of the unit. She stated Resident #1's [family member] was present in the room at the time. The Dietary Manager stated she did not leave the room until the [family member] was satisfied. She stated she saw the [family member] again the next day and was told everything was fine. She stated she had notified the Administrator via text message but did not fill out a grievance form because she thought the issue was resolved. <BR/>Record review of the facility's policy and procedure titled Cleaning and Disinfection of Environmental Surfaces dated 2001, revised August 2010 revealed the following:<BR/>Policy Statement: Environmental surfaces will be cleaned and disinfected according to the current CDC recommendations for disinfection of healthcare and the OSHA Bloodborne Pathogens Standard.<BR/>Policy Interpretation and Implementation .Environmental Surfaces .10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visible soiled

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #2 and Resident #3) of five residents reviewed for ADLs. <BR/>The facility failed to provide showers or bed baths consistently for Residents #2 and #3 per the facility bathing schedule in January 2025. <BR/>This failure placed residents who were dependent on staff for bathing at risk for poor personal hygiene, odors, and a decline in their quality of life. <BR/>Findings included:<BR/>1. Record review of Resident #2's Face Sheet reflected dated 01/30/25 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2's active diagnoses included paraplegia (a condition that causes paralysis or loss of muscle function in both legs), neuromuscular dysfunction of bladder (impaired bladder control due to disrupted communication between the brain and the bladder muscles), Stage 4 pressure ulcer of right heel and Stage 4 pressure ulcer of right lower back (a pressure ulcer is localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction; Stage 4 means full thickness tissue loss with exposed bone, tendon or muscle).<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 15 which indicated no cognitive impairment. Resident #2 had range of motion impairment on both sides of his lower extremities and used a wheelchair for mobility. Resident #2 required partial/moderate assistance from staff for bathing and personal hygiene. He had an indwelling and external catheter (a flexible tube inserted into the body to drain or deliver fluids) and ostomy (a surgical procedure that creates an opening in the abdomen to allow waste to exit the body).<BR/>Record review of Resident #2's baseline care plan dated 01/22/25 reflected he was dependent on staff for toileting hygiene and showers/bathing.<BR/>An interview with Resident #2 on 01/30/25 at 1:49 PM revealed he had been moved to the room he was presently in several days prior and there was no hot or warm water available in his bathroom to use. Resident #2 stated he had let the water run in his bathroom sink for over an hour when he first moved to the room, but there was only cold water. He said the shower at the end of his hall also did not have any hot or warm water. Resident #2 said he had not received a shower the past two scheduled times (01/27/25 and 01/29/25). Resident #2 stated he felt not having hot or warm water available in his room made him feel very dirty, he said he could not wash his face well and it was starting to breakout and his skin was starting to get itchy all over.<BR/>Record review of Resident #2's nursing progress notes reflected no shower refusals since his readmission to the facility from the hospital on [DATE].<BR/>2. Record review of Resident #3's Face Sheet dated 01/30/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #3's active diagnoses included paraplegia (a condition that causes paralysis or loss of muscle function in both legs), colostomy status (a surgical procedure that creates an opening in the colon, allowing stool to be diverted from the rectum and collected in a bag), Stage 4 right and left lower back pressure ulcer, stage 4 of sacral region (Full thickness tissue loss with exposed bone, tendon or muscle) and flaccid neuropathic bladder (a condition where the bladder muscles are weak and unable to contract properly, leading to difficulty or inability to urinate). <BR/>Record review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated no cognitive impairment. Resident #3 had range of motion impairment on one side of his upper extremities and on both sides of his lower extremities. He used a wheelchair for mobility and was dependent on staff for all ADLs, including showering and personal hygiene. <BR/>Record review of Resident #3's care plan last revised 01/28/25 reflected Resident #3 had an ADL self-care performance. Interventions, Bathing/Showering: Resident prefers showers 3 times per week likes to get oob daily; The resident requires extensive assistance by (1) staff with bathing/showering (start 09/30/24)<BR/>An interview and observation of Resident #3 on 01/30/25 at 2:03 PM revealed he was sitting in a reclined wheelchair in his room with his eyes closed. Resident #3 stated he had not been bathed or showered in the past week. He said he could not remember the last time he had been bathed but it had been a long time, over a month. During the interview, Resident #3 kept trying to peel his right eye open with his fingers as it was observed to be crusty and sealed shut. Resident #3 said he did not know why the staff were not bathing him and stated, They don't tell me why. I want one though. Resident #3's bathroom sink was observed to have no hot or warm water available. <BR/>Record review of Resident #3's nursing progress notes reflected no shower refusals for the month of January 2025. <BR/>3. An observation of Resident #2 and #3's shower room at the end of Hall 400 on 01/30/25 at 1:56 PM revealed there was no hot or warm water coming from the shower faucet.<BR/>4. Review of the facility shower binder for Hall 400 reflected no shower sheets for Residents #2 and #3 for January 2025. There were daily lists of residents to be showered with a space for the nurse to sign with any comments. However, neither Resident #2 nor Resident #3 were checked off as completed. <BR/>5. An interview with ADON A on 01/30/25 at 12:19 PM revealed completed shower sheets were important because that was the way the facility kept track of any new resident skin issues. ADON A stated she had looked in the binders and verified there were no shower sheets for Resident #2 and #3. ADON A stated what she saw in the shower binders at the 400-hall nursing station was just a list for the charge nurse to sign off on which residents were supposed to get showered that day. ADON A stated, But they were not the shower sheets. ADON A stated she did not know how long the CNAs and charge nurses had not been using shower sheets. ADON A stated the list of who needed a shower was not acceptable. She said the shower sheets needed to be completed and turned in by the CNAs for review to see if there were any changes to a resident's skin condition. ADON A stated the form they were using currently did not indicate if any skin was looked at or if any skin issues were noted. ADON A said she was going to ensure that the required blank shower sheets were copied and placed back into the shower binders along with the schedule list of residents to be showered for that day so they can be tracked and monitored. ADON A stated she did not know why the system changed except laziness and no one put more shower sheets in the binders, so they all defaulted to just signing a schedule, Which is not appropriate. <BR/>An interview with the ADM on 01/30/25 at 9:30 AM revealed the DON was out sick on leave and was unable to be interviewed. <BR/>An interview with CNA C on 01/31/25 at 12:37 PM revealed she had not seen any skin observation sheets (shower sheets) and when she gave a resident a shower, she just circled on a list if the resident received it or if they refused. If any skin issues, she would circle yes/no and then report to the charge nurse. When shown a blank shower sheet/skin observation sheet, CNA C stated she had not seen them before and had not been filling those out. CNA C stated showering a resident was important because no one wanted to have body odor and they want to smell fresh. CNA C stated infection control was also another reason showers were important, We have bacteria on our skin and we need to shower to remove it and protect the skin, like rashes and stuff, showering is good. <BR/>An interview with CNA D on 01/31/25 at 12:56 PM revealed she was picking up a shift and had showered Resident #1 that morning (01/31/25). CNA D stated she had another CNA help her shower Resident #1 and he took them a lot of time. She stated when a resident shower was completed, there was a paper that had the name and room number of the residents assigned to be showered for that day. If the resident refused the shower, the CNA had to tell the nurse. CNA D stated she had not seen the shower sheet form/skin observation sheet recently. <BR/>An interview with the ADM on 01/31/25 at 1:54 PM revealed he had heard about Resident #2 not being showered because his family member had contacted him on 01/30/25 about it. The ADM stated he completed a grievance form as a result. The ADM reviewed the shower binder and the schedule the nurse checked off that staff were using as shower sheets and said it was not the right form. He said the shower sheets to be used were more comprehensive. <BR/>6. A policy on ADL care related to showers was requested on 01/30/25 and 01/31/25 from the ADM but was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for one of five residents (Resident #1) reviewed for accuracy of assessments. <BR/>The facility failed to accurately reflect Resident #1's use of high risk medications in his most recent quarterly MDS assessment. <BR/>The failure placed residents at risk for having inaccurate assessments. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 03/05/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's DX included: Paranoid schizophrenia (Paranoia is a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly. Delusions and hallucinations are the two symptoms that can involve paranoia.), Acute bronchitis (is an inflammation of the bronchial tubes (airways) that leads to a persistent cough. It is typically caused by a viral infection, although it can also be caused by bacteria or other irritants.), Schizoaffective Disorder, Bipolar Type (a rare mental illness that combines symptoms of schizophrenia and bipolar disorder. It's also known as schizoaffective disorder, bipolar type.), Insomnia (is a common sleep disorder that can make it hard to fall asleep or stay asleep.), Generalized anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Schizophrenia (a chronic mental health condition characterized by significant disruptions in thought processes, perceptions, emotions, and social interactions.), Major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Constipation (difficulty passing stool), Mild cognitive impairment of uncertain etiology (when a person is experiencing symptoms of mild cognitive impairment memory decline cause of decline is unknown.)<BR/>Record review of Resident #1's quarterly MDS assessment, dated 02/20/25, reflected Resident #1 had a BIMS of 10, which indicated he was moderately impaired cognitively. Section D Mood, total severity scores 00, indicating there were no mood concerns. Section E-Behaviors E0200 behaviors symptoms presence and frequency: score of 1 behavior of this type occurred 1 to 3 days (verbal behaviors symptoms directed toward others (threatening others, screaming at others, cursing at others .1 for C. other behavioral symptoms not directed toward others (pacing, verbal/vocal symptoms like screaming disruptive. I Active Diagnosis I330. Hyperlipidemia (high cholesterol) .Section J: Health Conditions did not address acute bronchitis and pain management, pain assessment . N0415. High-Risk Drug Classes: did not document the high-risk medication resident #1 was ordered by the MD. The MDS assessment had not been reviewed and signed, due to it being incomplete and signed by the SW and Dietary manager only at the time of the review and exit. <BR/>Record review of Resident #1's BIMS assessment, dated 03/06/25, reflected a score of BIMS of 14, indicating he was cognitively intact.<BR/>Record review of Resident #1's quarterly care plan dated 03/05/25 reflected the following: Resident has behaviors not directed towards others has a Hx of substance abuse will also verbalize he uses drugs and also verbalized he would like a sex change psych involved in care. Resident#1 was resistive to care r/t psychiatric illness, curses staff. refuses therapy. Resident #1 requires 24-hour supervision/assistance. Discharge to the community is not feasible, requires LTC. Resident #1 uses psychotropic medications Olanzapine r/t Schizophrenia (is a chronic mental health condition characterized by disruptions in thought, perception, emotion, and behavior.) common side effects Hyperprolactinemia (is a condition characterized by abnormally high levels of prolactin, a hormone produced by the pituitary gland. ), Hypertriglyceridemia (s a condition characterized by elevated levels of triglycerides in the bloodstream. ), Personality Disorders (a class of mental health conditions characterized by enduring maladaptive patterns of behavior,), Parkinsonism (a term used to describe a group of disorders that share similar symptoms to Parkinson's disease), Toxic Amblyopia (a condition of vision loss.), Orthostatic Hypotension (a condition where blood pressures drops significantly when a person stans up from a sitting or lying positions), Rhinitis Xerostomia (Allergic rhinitis (hay fever) can indirectly lead to xerostomia (dry mouth) through nasal congestion causing mouth breathing, or as a side effect of antihistamine medications used to treat allergies.),Constipation, Back Pain, Drowsy Dizziness. Resident #1 uses anti-anxiety medications r/t anxiety disorder. Resident #1 has episodes of agitation and can become irritated easily. He forgets to sign out, have to reorient, refusing psych meds.<BR/>Record review of the physician orders tab of Resident #1's electronic health record reflected the following active medication orders: Olanzapine Oral Tablet 20 MG (Olanzapine)Give 20 mg by mouth at bedtime for schizophrenia, dated 08/8/24. Buspirone HCl Oral Tablet 15 MG (Buspirone HCl ) Give 15 mg by mouth three times a day for anxiety .dated 08/08/24. Atorvastatin Calcium Oral tablet 10 mg. Give 10 mg by mouth at bedtime for Hyperlipidemia (high cholesterol a condition where there are elevated levels of cholesterol in the blood.) .dated 08/08/24. Tessalon [NAME] capsule give 1 capsule 100 mg by mouth as needed for cough or sore throat TID (Tessalon [NAME] medication is used to treat coughs caused by the common cold and other breathing problems (such as pneumonia, bronchitis, emphysema, asthma). 08/24/24. Ibuprofen Oral Tablet 600 MG (Ibuprofen) Give 1 tablet by mouth every 6 hours as needed for Pain Give with Food 02/22/25. Bromfed DM (Dextromethorphan) Oral Syrup 2-30-10 MG/5ML: Pseudoephedrine-Bromphen- DM Give 10 ml by mouth.3very 4 hours as needed for cough/ congestion. 12/26/24. Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for pain related to pain unspecified. (R52) 08/24/24.<BR/>Record review of Resident #1's February 2025 MARs reflected the following:<BR/>Olanzapine 10 mg <BR/>Resident #1 was administered Olanzapine 10 mg on the following dates: <BR/>02/01/25, 02/08/25, 02/14/25, 02/21/25, 02/22/25, 02/23/25. <BR/>Resident #1 was offered Olanzapine on the following dates, and he refused: 02/02/25, 02/03/25, 02/04/25, 02/05/25, 02/06/25, 02/07/25, 02/09/25, 02/10/25, 02/11/25, 02/12/25, 02/13/25, 02/15/25, 02/16/25, 02/17/25, 02/18/25, 02/19/25, 02/20/25, 02/2425, 02/25/25, 02/26/25, 02/27/25. 02/28/25.<BR/>Buspirone 15 mg <BR/>Resident #1 was administered Buspirone 15 mg on the following dates: 02/01/25, 02/08/25, 02/14/25, 02/21/25, 02/22/25, 02/23/25. <BR/>Resident #1 was offered Buspirone 15 mg on the following dates and he refused: 02/02/25, 02/03/25, 02/04/25, 02/05/25, 02/06/25, 02/07/25, 02/09/25, 02/10/25, 02/11/25, 02/12/25, 02/13/25, 02/15/25, 02/16/25, 02/17/25, 02/18/25, 02/19/25, 02/20/25, 02/2425, 02/25/25, 02/26/25, 02/27/25. 02/28/25.<BR/>In an interview with the MDS C on 03/06/25 at 3:00 PM, she said the look back date of 2/20/25, and she reviewed 7 days of Resident #1's medical records (hospital discharge orders, skilled nursing notes current physician orders, mood, behaviors, and medication administration) to complete Resident #1's MDS assessment. MDS C said upon completing the assessment, the DON would review for accuracy and sign once competed. MDS C stated that though the resident had a history of mood, behavior, prescribed high risk medication, if Resident #1 was not administered his medication during the 7 days look back, she would not code it in the current MDS. MDS C said the MDS assessment was utilized to develop a plan of care for a resident. She stated care planning was completed by the interdisciplinary team and any missed information could lead to a lack of needed care, monitoring or services for the resident. She stated the MDS was not due until 3/6/25. At the time of exit on 03/06/25 at 4:09 PM Resident #1's MDS had not been updated and completed.<BR/>In an interview on 03/06/25 at 3:37 p.m., The DON stated MDS staff were expected collaborate with all staff departments to complete specialty areas of care. She expected the MDS coordinator to document high risk medications, current treatments, and care for all resident assessments to be accurately document resident needs for care. The DON stated not doing so could potentially lead to misinformation/understanding of a resident condition, which could affect the care residents received. The DON stated she and the MDS Coordinator were responsible for the accuracy of the MDS assessments, as the MDS Coordinator completed the assessment, and she finalized the assessment. The DON stated the MDS was not due until 03/06/25.<BR/>In an interview on 03/06/25 at 3:53 p.m., The Administrator stated he expected for assessments to be accurate, as not doing so could lead to the resident receiving a lower level of care. The Administrator stated the MDS Coordinator and DON was responsible for all facility assessments, which included the MDS. <BR/>Record review of requested facility MDS policy was provided by the ADM and MDS coordinator on 03/06/25. The document was titled RAI Version 3.0 Manual MDS dated [DATE] .the policy reflected .Section N: Medications Intent: The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and/or select medications were received by the resident. In addition, two medication sections have been added. The first is an Antipsychotic Medication Review. Including this information will assist facilities to evaluate the use and management of these medications. Each aspect of antipsychotic medication uses, and management has important associations with the quality of life and quality of care of residents receiving these medications. The second is a series of data elements addressing Drug Regimen Review. These data elements document whether a drug regimen review was conducted upon the start of a SNF PPS stay through the end of the SNF PPS stay and whether any clinically significant medication issues identified were. addressed in a timely manner. N0415: High-Risk Drug Classes: Use and Indication N0415. High-Risk Drug Classes: Use and Indication1. Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or recently admitted in less than 7 days 2. Indication noted If Column 1is checked, check if there is an indication noted for all medications in the drug class. N0415: High-Risk Drug Classes: Use and I Planning for Care The indications for initiating, withdrawing, or withholding medication(s), as well as the use of non pharmacological interventions, are determined by assessing the resident's underlying. condition, current signs and symptoms, and preferences and goals for treatment. This includes, where possible, the identification of the underlying cause(s), since a diagnosis alone may not warrant treatment with medication. Target symptoms and goals for use of these medication should be established for each resident. Progress toward meeting the goals should be evaluated routinely. Possible adverse effects of these medications should be well understood by nursing staff. Educate nursing home staff to be observant for these adverse effects. Implement systematic monitoring of each resident taking any of these medications to identify adverse consequences early. Review documentation from other health care settings where the resident may have received any of these medications while a resident of the nursing home (e.g., valium given in the emergency room).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 3 (Resident #5, #14, and #62) of 7 residents reviewed for respiratory care, in that:<BR/>The facility failed to:<BR/>A.) Label and date the oxygen tubing and concentrator water bottle for Resident #5 and Resident #62.<BR/>B) Label and date Resident # 14 oxygen tubing<BR/>These deficient practices could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. <BR/>Findings Included:<BR/>Resident #5<BR/>Record review of Resident #5 face sheet dated 1/24/24 reflected a [AGE] year-old female admitted on [DATE], diagnosis include Chronic Respiratory failure with Hypoxia (low oxygen). <BR/>Record review of Resident #5's MDS dated [DATE], reflected a BIMS score of 14 indicating she was cognitively in tack. Functional level impaired on both sides and needs staff supervision for mobility, incontinent, eating set up or clean up assistance. MDS Section O - Special Treatments, Procedures, and Programs was left blank.<BR/>Record review of Resident #5's Care plan dated 12/07/23 Continuously on oxygen. via n/c. Administer medications as ordered. Monitor/document for side effects and effectiveness. The resident has shortness of breath (SOB) r/t chronic respiratory failure with hypoxia 02 at 2 LPM continuous via nasal to keep oxygen level above 92% every shift for SOB. Resident # 5 will have no complications related to SOB though the review date .Monitor/document breathing patterns. Report abnormalities to MD: Use universal precautions as appropriate. The care plan did not address changing oxygen tubing.<BR/>Record review of Resident #5's MD orders dated 09/27/23 reflected 02 at 2 LPM continuous via nasal to keep oxygen level above 92% every shift for SOB. There was no order for tubing change.<BR/>Observation on 01/24/25 at 12:00 PM of Resident #5's oxygen tubing and oxygen concentrator bottle was not dated and labeled.<BR/>In an interview on 01/24/24 at 12:00 PM with Resident #5 revealed she was on oxygen, and she does not know when the tubing was changed, however staff does change the tubing. She did not know which shift.<BR/>Resident #14<BR/>Record review of Resident #14 face sheet dated 01/24/24 reflected a [AGE] year-old male admitted on admission 6/23/23 with diagnosis: Paroxysmal Atrial Fibrillation (irregular heartbeats), Cardiovascular and Coagulations (heart attack, Chronic Obstructive Pulmonary Disease (inflammatory of lungs); Intermittent Asthma chronic lung disease, <BR/>Record review of resident # 14's MDS dated [DATE] reflected a BIMS score of 15 cognitively intact. Independent, uses a walker or manual wheelchair and has oxygen treatments.<BR/>Record review of Resident #14's care plan dated 01/09/24 reflected. The resident has Oxygen Therapy r/t . The resident will have no s/sx of poor oxygen absorption through the review date .Oxygen Settings: The resident has O2 via nasal cannula prn Oxygen @ 2L via NC . Resident will have no complications related to SOB. The care plan did not address changing oxygen tubing.<BR/>Observation on 01/24/25 at 12:05 PM of Resident #14's he was lying in bed with his NC positioned in his nose and concentrator on with oxygen flowing and his oxygen tubing was not dated and labeled.<BR/>In an interview on 01/24/24 at 12:10 PM with Resident #14 revealed he was a little confused and could not articulate responses to questions about tubing change. he said his oxygen was flowing well. <BR/>Resident #62<BR/>Record Review of resident #62 reflected a [AGE] year-old male with an admission date of 06/08/22, Dx Disorganized Schizophrenia, Pan lobular Emphysema condition effecting the whole acinus of the lungs permanently damaging the air sacs. Schizoaffective Disorder (mental illness), Chronic Obstructive Pulmonary Disease (inflammatory of lungs), Unspecified, chronic diastolic congestive heart failure. <BR/>Record review of Resident #62's quarterly MDS dated [DATE] reflected he had a BIMS score of 15, indicating he was cognitively intact. Resident is independent, uses a walker or manual wheelchair, has mood and behaviors. MDS Section O - Special Treatments, Procedures, and Programs was left blank <BR/>Record review of Resident #62's care plan dated 01/9/24 indicated the resident received O2 at 2 L per as needed to keep sat above 90%Resident will have no reports of unrelieved shortness of breath through next review date .Observe for SOB, respiratory distress, wheezing, fatigue, increased anxiety and implement appropriate ordered interventions and notify MD if interventions are not effective Provide medication as ordered. The care plan did not address changing oxygen tubing.<BR/>Record review of Resident #62's MD orders dated 08/12/22 reflected O2 at 2 L per (NC/FM/Non-rebreather) as <BR/>needed to keep sat above 90% as needed for SOB.<BR/>Observation and interview with Resident #62 on 01/24/25 at 12:50 PM revealed his oxygen tubing and oxygen concentrator bottle was not dated and labeled, the tubing was lying across the nightstand and inside the trash can. Resident #62 said the tubing was changed this morning by LVN D He does not recall staff dating tubing. <BR/>In an interview on 01/24/24 at 2:-10 PM with LVN D, the charge nurse for Resident #5, Resident #14, and Resident #62. LVN D said she assess resident's oxygen treatment and tubing during rounds and check for date the tubing was change in the nurse notes. LVN D said she had conducted rounds every 2 hours and had observed that the water bottle and tubing for Resident #5, Resident #14, and Resident #62 were not dated. LVN D said she would change the tubing at this time. LVN D said it was the assigned nurse for each shift to check for dates on all oxygen equipment and assess oxygen flow during resident rounds. LVN D said concentrator water bottles should be changed every 24 hours and she observe water bottle levels every 2 hours. LVN D said oxygen tubing should be changed, dated, and documented PRN and every Sunday by night shift. LVN D said failing to change the tubing, label, and date tubing and water bottle cold lead to overuse, kinks in hose, bacteria, respiratory infection, poor air flow, sepsis, and death.<BR/>In an interview with DON on 01/25/24 at 12:12 PM revealed oxygen tubing should be changed, dated, and labeled weekly by the overnight night nursing staff. He said the concentrator water bottles should be changed as needed and assessed during nursing rounds for accurate flow, tubing kinks, dates, and labels. The DON stated that facility protocols would develop and implement protocol for documentation moving forward. The DON said failing to change oxygen tubing for resident could lead to bacterial infection, or respiratory infection. He stated that the facility protocol does not mandate that oxygen tubing and treatment be documented, however he has educated nursing staff today on documentation, changing and dated. The DON said the facility does not use the TAR to document treatment at this time, however it was his plan to educate the nursing staff to document the change in tubing, dating, and labeling. The DON said it was the nursing staff responsibility to monitor oxygen for change and date. The DON the facility plan moving forward would include all nursing staff being in-serviced to change resident tubing weekly on Sunday 10AM-6PM shift. The DON said the morning charge nurses will check documentation, labels, and dates to assure nursing task was completed, and the ADON and DON will then monitor charge nursing task to assure accuracy. The DON expects the nursing staff to monitor for dates.<BR/>In an interview with the ADM on 01/25/24 at 1:30 PM wtih the ADM, and AIT, she expected staff to change the tubing, if visibly soiled. She was not sure of complications related to respiratory treatment task and maintenance as she does not have a clinical background. She said ADON, DON, and charge nurse are responsible for monitoring nursing and treatment procedures. <BR/>Review of facility's in-service dated 10/15/2022 and titled with topic: O2 therapy - weekly and PRN changing of O2 tubing (must date) revealed staff was in-serviced on changing and dating oxygen tubing.<BR/>Record review of facility policy Titled Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, 5 .Other infection control measures include: Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated .Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. Use only sterile water for humidification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary comfortable, environment for residents staff and the public for one (room [ROOM NUMBER]) of nine resident rooms reviewed for environment.<BR/>The facility failed to ensure the AC/heating unit located in room [ROOM NUMBER] was clean.<BR/>This failure could place residents at risk for diminished quality of life due to a lack of a well-kept environment and reduced air quality in the room.<BR/>Findings included:<BR/>An observation on 1/17/24 at 9:20 AM, revealed Resident #1 was in room [ROOM NUMBER]B, sitting on the side of his bed facing the window. His knees were directly in front of an AC/heating unit located beneath a window. The resident was cognitively impaired and unable to be interviewed. The AC/heating unit was on and blowing warm air. Front cover appeared loose. A moist black substance was observed along the edges of the louvers from where the air was blowing. The top portion of the cover surrounding the louvers and control panel was dirty. The control panel face was also covered in dirt that was heavier in the area typically obscured by the cover, but visible because the cover was loose. <BR/>An observation on 1/17/24 at 9:28 AM, revealed a housekeeping cart was parked outside the room next door.<BR/>Another observation on 1/17/24 at 10:10 AM revealed Resident #1 was sitting in the same position in his room, no changes were observed to the unit, photos were taken by this surveyor. <BR/>An observation and interview on 1/17/24 at 10:55 AM, revealed a housekeeping cart was seen in the doorway of room [ROOM NUMBER]. Housekeeping Staff A was observed inside the room removing trash from the trashcans. An interview with Housekeeping Staff A revealed the floors were typically cleaned twice a day and the AC/heating units were cleaned daily. <BR/>An observation on 1/17/24 at 12:15 PM, revealed Resident #1 was sitting on the side of his bed, now facing the door, eating lunch. Observation of his AC/Heating unit revealed the front center portion of the control panel appeared clean but the surrounding area was still dirty. The black substance could still be seen along the edges of the louvers from where the air was blowing.<BR/>An interview with the DON on 1/17/24 at 1:30 PM, revealed Resident #1's family member mentioned the dirty AC/heating unit to him the evening of 1/16/24. He stated he had planned to discuss it with the maintenance staff today (1/17/24) but had not done so yet because State investigators had entered this morning. The DON accompanied this surveyor to room [ROOM NUMBER] to examine the unit. The DON removed the cover and pointed out the rust on the metal frame and stated he believed that was the material and not dirt. When the other dirty areas were pointed out including the black substance on the louvers, dirt around the control panel, dust buildup beneath the control panel, and dirt buildup within grate over the blower portion of the unit, he stated he would let them know. <BR/>In another interview with the DON on 1/17/24 at 1:55 PM, he presented photos on his phone he said he received on 1/16/24 and stated, it was much worse yesterday. The photo revealed the condenser portion of the unit had been completely caked in dust and had been cleaned and was now clear. He was unsure why the rest had not been cleaned and thought someone may have planned to return and complete.<BR/>In an interview on 1/17/24 at 2:05 PM, with the Housekeeping Supervisor, she stated the housekeepers were responsible for cleaning the outside of the AC/heating units daily and they should check them, along with everything else, during their daily walkthroughs. She stated she did periodic checks behind the housekeeping staff to ensure quality work. She stated Resident #1's family member] had told her the day before that they had bumped into the unit causing the cover to come off which exposed heavy dust buildup. She stated the family member told her it was already getting addressed. She stated she thought she had just seen the Maintenance Tech in the room wiping it down today. <BR/>In an interview with the Maintenance Tech on 1/17/24 at 2:16 PM, he stated he checks the maintenance log at the nurses' station daily for any maintenance issues. He stated he checked the log on 1/16/24 and there was an entry for room [ROOM NUMBER] that said the heat was not working. He said he just went in the room and switched it on and it worked fine. The Maintenance Tech stated someone had asked him if he had cleaned the unit and he told them, 'no'. He stated he thought housekeeping had cleaned it up. The Maintenance Tech stated he had walked through the building two months ago and changed all the filters. He was unaware whether there was any routine cleaning of the interior parts but he could take the unit outside and wash it. He stated he could have removed the cover and clean it, but he had only been told it was not working. The Maintenance Tech provided the Maintenance Logbook for review. <BR/>Record review of the Maintenance Logbook at the main nurses station revealed individual pages titled Maintenance Request. A page dated 1/16/24 reflected the following: <BR/>Time: 8:50 AM. <BR/>Reported by: Resident to the nurse<BR/>Room: 411<BR/>Location: 400 Hall<BR/>Nature of Work Order: Heat is not working<BR/>Work Completed Date: 1/16/24<BR/>By: [Maintenance Tech]<BR/>An interview with the Administrator and the DON on 1/17/24 at 4:00 PM revealed the Administrator stated she had received a text message from the Dietary Manager on 1/3/24 informing her of the complaint. She stated she was told the unit had been cleaned and everything was fine. She stated she did not follow-up with Resident #1's [family member] because the Dietary Manager told her Resident #1's [family member] was satisfied with the outcome. When the Administrator was shown photos taken by this surveyor and asked if she felt it was acceptable, she stated she had been told it was cleaned. When asked about the possible risks to residents having dirty AC/heating equipment close to their beds, the Administrator stated, well that sticks to the plastic and we can get it cleaned and the [family member] was satisfied according to my Dietary Manager. <BR/>During an interview on 1/17/24 at 4:30 PM, the Dietary Manager stated she had been standing near the nurses' station when Resident #1's [family member] approached her and appeared upset. She stated the family member told her they had bumped the AC/heating unit by accident causing the cover to fall off and she noticed it was very dusty. The Dietary Manager stated she retrieved some sanitizing wipes and wiped down the inside of the unit. She stated Resident #1's [family member] was present in the room at the time. The Dietary Manager stated she did not leave the room until the [family member] was satisfied. She stated she saw the [family member] again the next day and was told everything was fine. She stated she had notified the Administrator via text message but did not fill out a grievance form because she thought the issue was resolved. <BR/>Record review of the facility's policy and procedure titled Cleaning and Disinfection of Environmental Surfaces dated 2001, revised August 2010 revealed the following:<BR/>Policy Statement: Environmental surfaces will be cleaned and disinfected according to the current CDC recommendations for disinfection of healthcare and the OSHA Bloodborne Pathogens Standard.<BR/>Policy Interpretation and Implementation .Environmental Surfaces .10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visible soiled

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program, so the facility was free from pests and rodents for 2 of 2 residents (Resident #2 and Resident #3) reviewed for pest control. <BR/>The facility failed to maintain an effective pest control program to ensure the facility was free of rodents and roaches in the facility kitchen and the rooms of Resident #2 and Resident #3. <BR/>This failure could place residents at risk for an unsanitary environment in the kitchen and rooms of Residents #2 and Resident #3 and a decreased quality of life. <BR/> Findings included: <BR/>Record review of Resident #2's admission Record dated 02/27/24 reflected a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted to the facility on [DATE].<BR/>Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 13 which indicated he was cognitively intact. His diagnoses included paraplegia (inability to move the lower part of the body); peripheral vascular disease (reduced blood flow to the limbs), and Stage 4 (full thickness) pressure ulcer to right heel. He utilized a wheelchair for mobility.<BR/>Record review of Resident #3's admission Record dated 02/27/25 reflected a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted to the facility on [DATE].<BR/>Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 which indicated he was cognitively intact. His diagnoses included Type 2 Diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Hypertension (a condition in which the force of the blood against the artery walls is too high), Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Crohn's Disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract), Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), he was mobile without assistance. <BR/>Interview on 02/26/25 at 10:55 AM with Resident #3 revealed he had seen four rats run back into the wall in his bathroom when the facility was repairing the wall in his bathroom. He stated he told the maintenance director at the time. He stated he could not remember exactly when, it was a few months ago. He stated he had two cats and the cats sometimes reacted to sounds heard in the walls of his room. <BR/>During an observation and interview on 02/26/25 at 11:45 AM, Resident #2 was sitting up in his wheelchair discussing an upcoming appointment. During the conversation, a large water bug was observed crawling out from behind the resident's duffle bag situated against the wall toward the middle of the room. It turned and returned behind his bag. Resident #2 reached and moved his bag, and the bug ran out of the room. Resident #2 stated he saw them pretty often, I see those little roaches too. He stated he had complained about it a while back but no one ever did anything about it. He stated he knew nothing was done because the bugs were still there. He stated, it's pretty nasty.<BR/>Interview with pest control service provider on 02/26/25 at 11:50 AM revealed the contract with the facility had been cancelled because of slow payment. He stated the last date of service was mid December 2024. <BR/>Interview on 02/26/25 at 12:15 PM, the Dishwasher revealed she had seen a rodent in the kitchen on 02/24/25. She stated she had seen a rodent on the dish racks that are used to wash the dishes. She stated the rodent ran to the laundry room from the kitchen. She stated she had to disinfect the dishwasher prior to sending the dishes through the dishwasher because of the rodent droppings on the dishwasher. She stated told the Administrator and the previous Maintenance Director. She stated they said they would contact pest control. She stated rodents in the kitchen could cause infection or sickness to the residents and it was very unsanitary.<BR/>Observation on 02/26/25 at 12:22 PM of the dishwashing area of the kitchen revealed under crates sitting on a cart were shavings from the crate and rodent droppings. Observation of another cart holding crates revealed rodent droppings and food particles. <BR/>Interview with Kitchen Manager on 02/26/25 at 12:25 PM revealed he stated he had not seen any rodents in the kitchen. When Kitchen Manager was asked if any kitchen staff had informed him that rodents had been seen in the kitchen, he replied, that he had not seen any rodents in the kitchen. He stated the residents were at risk of sickness and disease. <BR/>Interview with Administrator on 02/26/25 at 1:30 PM revealed he had asked the previous Maintenance Director about the pest control visits to the facility because he had never seen a person from a pest control company at the building. He stated he was told the pest control staff came to treat the building at 6:00 AM. He stated he instructed the maintenance director that the pest control staff should have come to the building during the day so that he could meet with him. He stated he was not aware that the contract had been terminated. He stated he was the person responsible to ensure there was a pest control contract in place. He stated the residents had been at risk of cross contamination, infection, and diseases. <BR/>During an interview on 2/26/25 at 2:13 PM, the ADON stated she saw bugs occasionally and let the maintenance staff know whenever she saw anything. She stated she had seen what looked like a tiny cockroach in a resident room on 2/24/25 and immediately told maintenance in person. She stated they came and took care of it. They removed the bug and said they would treat the area. The ADON stated she had not seen any rodents. <BR/>During an interview on 02/27/25 at 6:21 AM, CNA C stated she worked the night shift and had been there about a year. She stated she saw rats in the facility near the kitchen and laundry rooms when she took the trash out at night. She stated she saw them there a lot including the current week. CNA C stated she saw a rat in the employee break room a couple of nights ago. She entered the room and saw a rat run from near a chair and crawl under a cabined under the sink. When asked if she had reported it, she replied, No, we're just used to it, it's been like that a long time. CNA C stated she had never seen rats in the resident rooms, shower rooms or near any resident. She stated, Most of the time they are near the kitchen.<BR/>Record review of the facility pest control visit log reflected service was last provided on 02/07/25. The last invoice from service provider was dated 12/12/2024.<BR/>Record review reflected prior to exit facility obtained a new pest control policy dated 02/26/25.<BR/>Record review of the facility Pest Control Policy review dated 12/1/22, review date 2/26/25 reflected <BR/>Pest Prevention Measures: <BR/>Conduct regular inspections of the facility to identify potential pest entry points and nesting sites.<BR/>Seal cracks, crevices, and other openings in the building structure.<BR/>Maintain cleanliness in all areas, including dining, kitchen, and resident rooms, to eliminate food sources and habitats for pests.<BR/>Proper waste management practices, including regular disposal and secure containers.<BR/>1. <BR/>Monitoring: <BR/>Schedule routine pest inspections by qualified pest control professionals at least quarterly.<BR/>Document findings and actions taken during inspections.<BR/>Maintain a pest sighting log for staff to report any pest activity promptly.<BR/>2. <BR/>Pest Control Treatment: <BR/>Employ licensed pest control operators to handle infestations when necessary, ensuring they follow HHSC guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency in accordance with state law through established procedures for one of two incidents (Resident #1) reviewed for abuse, neglect, and misappropriation. <BR/>1. The facility failed to report to the State Survey Agency when Resident #1 eloped from the facility on 12/31/24. <BR/>This failure could place the residents in the facility at risk of continued abuse and neglect.<BR/>Findings included:<BR/>1. Record review of Resident #1's Face sheet, dated 02/20/25, reflected the resident admitted on [DATE]. The resident's diagnoses included cerebral infarction (stroke), Bell's Palsy (condition that causes sudden weakness in the muscles on one side of the face), and dementia. <BR/>Record review of Resident #1's discharge MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure) and chronic obstructive pulmonary disease (disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough). Resident #1 did not have a BIMS score documented. <BR/>Resident #1 did not have a care plan. (New admit)<BR/>Review of Resident #1's progress notes reflected:<BR/>12/30/25 9:25 AM<BR/>Resident was a [AGE] year-old male admitted from the hospital accompanied by two ambulance attendants via stretcher with diagnoses atrial fibrillation (abnormal heart rhythm), coronary artery disease (heart disease), cerebrovascular accident (stroke), altered mental status, and high blood pressure. Physician notified, all orders verified by physician and sent to the pharmacy. Resident was alert and oriented x2 verbally with confusion. Head to toe assessment done, PERRLA (pupils (are) equal, round, reactive (to) light and accommodation), skin warm and dry to touch, respirations even and unlabored. No shortness of breath, no cough, no congestion noted. Abdomen soft, non-tender, bowel sounds x4 quadrants noted, bladder non-distended, pedal pulses present and strong, skin intact. Resident made comfortable in bed. Resident oriented to bed and tv remote control, call light. Safety maintained, call light within reach. Resident instructed to call for assistance, verbalized understanding. Resident wanders back and forth the unit with unsteady gait.<BR/>Written by RN A<BR/>12/31/24 12:58 AM <BR/>At approximately 12:19 AM, resident with diagnosis of hallucination and altered mental status, was observed to have eloped from the facility. Resident was last seen at 12:17 AM walking the hall. Immediate steps were taken to locate resident by notifying 911, DON and power of attorney. Resident was located outside of facility. Tried to talk to resident to come back to facility but resident refused. Resident appeared to be very combative and screaming, You bitches trying to fucking kill me. Killers, killers. Was unable to redirect. Resident ran to another facility and got into their building. 911 was able to apprehend the resident and he was taken to hospital for further evaluation.<BR/>Written by LVN B<BR/>A record review of Facility In-service (Abuse/Neglect - Elopement) revealed facility staff were in-serviced on 12/31/24. <BR/>An interview at on 02/20/25 at 12:25 PM with RN C revealed she admitted Resident #1 on 12/30/24. She said she admitted the resident to Hall 100 on the 2:00 PM - 10:00 PM shift, gave report, and left the facility. She said she was not at the facility when the resident eloped.<BR/>An interview on 02/20/25 at 12:20 PM with LVN B revealed on 12/31/24 on the 10:00 PM - 6:00 AM shift she was assigned to Resident #1. She said that she took him with her to the Memory Care Unit on Hall 200 because he was walking up and down Hall 100. LVN B said while she and Resident #1 were in the Memory Care Unit, a resident fell and she had to go to assist the resident. LVN B said while she was assisting the resident who fell, she heard the door alarm to the Memory Care Unit and then the door alarm to the front door go off. She said she went running after the resident and she saw him outside running. He was running to the facility that was close by. She said she called 911 and the DON and the police were able to take him to the hospital. <BR/>An interview on 02/20/25 at 1:20 PM with the DON revealed Resident #1 was a new admit and was not exit-seeking per the family member. The DON said one second, he was in the hall and then the next minute he was gone. The DON said the nurse called her, because the staff saw him running to the facility next door. 911 was called and they picked him up. The DON said she did not know how Resident #1 eloped from the facility. She said it was possible that someone held the door open from him. The DON said she did not know why the elopement was not self-reported, but it was probably not reported because the staff had eyes on him when he was outside. <BR/>An interview on 02/20/25 at 5:30 PM with the Administrator revealed he did not self-report the incident, because he thought the resident needed to be missing 4-6 hours before it was self-reported. The Administrator said Resident #1 was only missing for a matter of about two minutes. The Administrator said it was important to self-report elopements to ensure the correct procedure was followed. <BR/>A record review of the facility policy and procedure, Abuse Prevention Program, revised 2016 reflected:<BR/>7. Investigate and report any allegations of abuse within timeframes as required by federal requirements .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services for 1 of 3 residents (Resident #2) reviewed for catheter care.<BR/>The facility failed to ensure LVN A followed relevant clinical guidelines and provided appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.<BR/>This failure could place the resident at risk of urethral tears or dislodging the catheter and urinary tract infections.<BR/>Findings included:<BR/>1. Record review of Resident #1's annual MDS assessment, dated 12/17/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 13 indicating his cognitive status was intact. His diagnoses included neurogenic bladder (a condition that affects the bladder's ability to function properly due to damage or dysfunction in the nerves that control it), paraplegia (a condition characterized by the loss of motor and sensory function in the lower half of the body, including the legs, feet, and genitals), pressure ulcer of sacral regions stage 4, and hypertension. The resident was dependent on staff for toileting. The resident was always incontinent of bowel and bladder. <BR/>Record review of Resident #2's care plans, dated 02/02/25, reflected:<BR/>The resident had an ADL Self Care Performance Deficit related to paraplegia. <BR/>Facility interventions included: The resident required extensive assistance with toileting.<BR/>Record review of Resident #2's orders, dated 08/08/24, reflected:<BR/>Foley catheter to be changed monthly and as needed for malfunction.<BR/>An observation on 02/20/25 at 1:00 PM revealed Resident #2 was lying in bed and his indwelling catheter drainage bag was on the floor. The catheter was not anchored to a non-moveable part of the bed.<BR/>An observation 02/20/25 at 1:10 PM revealed the indwelling catheter bag was still on the floor. <BR/>An interview on 02/20/25 at 1:13 PM with LVN A revealed that when LVN A went to administer the resident's IV antibiotic, the foley catheter drainage bag was on the floor. LVN A stated that she was going to finish other things and that she would return later to get the drainage bag off the floor. LVN A left the resident's room without getting the drainage bag off the floor.<BR/>An interview on 02/20/25 at 2:47 PM with the ADON revealed leaving the Foley bag on the floor would put the resident at risk for infection.<BR/>An interview on 02/20/25 at 3:37 PM with LVN A revealed the Foley catheter drainage bag needed to be positioned below the bladder, hang on the side of the bed, and not be on the floor. LVN A stated that she did not remove the bag from the floor because it was going to take a long time to clean the catheter bag and secure it on the bedside. LVN A stated that the risk to the patient was risk for infection.<BR/>An interview on 02/20/25 at 4:26 PM with the DON revealed the Foley catheter drainage bags should never be on the floor and they should be secured to the bed frame. The DON stated that placing the drainage bag on the floor could put the resident at risk of further infection and dislodgment of the catheter.<BR/>Review of the facility policy, Urinary continence and incontinence -Assessment and Management and urinary tract infection/bacteriuria clinical protocol reflected: <BR/>Indwelling catheters should be anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances residents had and ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for two months (December 2024 and January 2025) of two months reviewed of resident council meetings and facility-received grievances.<BR/>1. The facility failed to document any attempts to resolve Resident #2's grievance when he expressed concern there was no hot or warm water available in his room. <BR/>2. The facility failed to document show evidence of attempts to resolve all grievances from the Resident Council for December 2024 and January 2025. <BR/>This failure could place residents at risk with unresolved grievances and unmet care needs. <BR/>Findings included:<BR/>1. Record review of Resident #2's Face Sheet reflected dated 01/30/25 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2's active diagnoses included paraplegia (a condition that causes paralysis or loss of muscle function in both legs), neuromuscular dysfunction of bladder (impaired bladder control due to disrupted communication between the brain and the bladder muscles), Stage 4 pressure ulcer of right heel and Stage 4 pressure ulcer of right lower back.<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 15 which indicated no cognitive impairment. Resident #2 had range of motion impairment on both sides of his lower extremities and used a wheelchair for mobility. Resident #2 required partial/moderate assistance from staff for bathing and personal hygiene. He had an indwelling and external catheter (a flexible tube inserted into the body to drain or deliver fluids) and ostomy (a surgical procedure that creates an opening in the abdomen to allow waste to exit the body).<BR/>An interview with Resident #2 on 01/30/25 at 1:49 PM revealed he had been moved to the room he was in several days prior and there was no hot or warm water available in his bathroom to use. Resident #2 stated he had let the water run in his bathroom sink for over an hour when he first got moved to the room but there was nothing but cold water. He said the shower at the end of his hall also did not have any hot or warm water. Resident #2 said he had not received a shower the past two scheduled times (01/27/25 and 01/29/25). Resident #2 stated he felt not having hot or warm water available in his room made him feel very dirty, he said he could not wash his face well and it was starting to breakout and his skin was starting to get itchy all over. <BR/>An observation of Resident #2's bathroom sink faucet on 01/30/25 at 1:50 PM revealed it did not have hot or warm water. <BR/>An observation of Resident #2' shower room at the end of Hall 400 on 01/30/25 at 1:56 PM revealed there was no hot or warm water coming from the shower faucet. <BR/>Review of a grievance from Resident #2 dated 01/28/25 reflected he communicated to the SW a concern there was no hot water in his bathroom. The grievance form noted the maintenance director was assigned responsibility to follow up on the concern on 01/29/25. The grievance's sections for 1) Documentation of the Investigation (which included findings, plan to resolve, results of action taken, reportable to state agency), 2) Resolution (which included if the complaint/grievance was resolved, was complainant satisfied, complainant remarks and how was the investigation results communicated to the person-verbal or written, and 3) Signatures of Resident/Department Head and Dates were all blank. <BR/>Review of the SW's Monthly Grievance Log provided by the ADM reflected an entry for Resident #2's concern about not hot/warm water on 01/28/25 and showed it was sent to the maintenance director for follow up. <BR/>An interview with the ADM on 01/30/25 at 9:30 AM revealed the DON was out sick on leave.<BR/>An interview with the Maintenance Director on 01/30/25 at 2:30 PM revealed he knew the hot water heater was broken on hall 400 and he thought it had been broken for about two weeks. He stated Resident #2 did not have any hot water in his room and had been moved to that room over the past weekend and was upset about it. The Maintenance Director stated he had seen a grievance filed for Resident #2 on 01/28/25 related to the lack of hot water and stated he was just waiting for the owner of the facility to approve the repairs. He stated. I kind of wish it wasn't out of my hands because I would not have let it last that long. <BR/>2. Record review of the facility's Resident Council Meeting Minutes for December 2024 reflected concerns related to:<BR/>- A resident was not getting enough portions to eat and would like double portions.<BR/>- A resident asked for more food and was denied <BR/>-Nobody listens to the residents and they do not get any help from the staff. <BR/>-A CNA (identified by name) was lazy and refused to assist residents, did not listen to them, or answer the call lights and refused to do the residents' smoke breaks. <BR/>-Residents complained of sleep deprivation due to loud TVs and music playing at night <BR/>Additionally, the resident council meeting minutes form documented the grievances related to food were sent to the dietary manager and the DON was routed the rest of them. <BR/>Record review of the facility's Resident Council Meeting Minutes for January 2025 reflected concerns related to:<BR/>- The weekend staff do not answer call lights<BR/>- Facility nurses did not help when needed<BR/>- There was no staff assistance available at night to help residents<BR/>- Rat! Rats are eating up food. Rats are in rooms, holes in ceiling.<BR/>- Heat complaints that it was too cold in the facility and residents were freezing at night. <BR/>- A staff member (identified by name) was refusing to assist the residents<BR/>- The fried food served was too hard and residents could not chew it.<BR/>- Dialysis residents continued to be served food they were not supposed to have. <BR/>- There was no coffee available at the facility. <BR/>Record review of the facility grievances provided by the ADM on 01/30/25 revealed only three resident specific issues (not listed above) had written grievances that had been resolved. None of the other concerns voiced by the residents during the two resident council meetings had been addressed. <BR/>3. An interview with the SW on 01/30/25 at 2:45 PM revealed in general the facility grievances came to her, but not always. When she received them, she would log them in a binder. The SW stated when concerns were voiced during a resident council meeting, the activity director was supposed to document it on a grievance form and then give it to whatever department head was in charge of the issue. The SW stated if the activity director did not make a copy for the SW, then the SW did not have a record of it and could not log it and track it to its conclusion. The SW stated she did not know why the activity director was not writing up the concerns voiced by the residents during their resident council and making sure they got to the SW. Regarding Resident #2, the SW revealed Resident #2 had voiced a concern during the past few days related to not having any hot water in his room. The SW stated she logged the grievance for him on the form and put it in the maintenance director's box. The SW stated Resident #2 wanted to have hot water in his room so she told him she would let the maintenance department know. The SW stated with grievances, she tried to identify who was responsible for the resolution of the grievances and then forward them the form to complete. The SW stated she had not been getting them back from the persons responsible and that the DON had been out on leave. The SW stated completing a grievance form in its entirety was important because, We are supposed to resolve them and it is hard if no one is investigating and no one is speaking to the resident or family. The SW stated in the morning meetings, she had not developed a good system yet for going over the grievances. She said she would remind the staff during those meetings if they had any grievance forms completed, to give them to her. The SW said when she first started working at the facility, she saw the grievance system needed to be addressed and she wanted to be able to talk more about them during the morning meetings. However, she was told by other staff the meetings were long enough as it was. The SW stated at the end of December 2024, she tried to bring up grievances again when she saw that the resident council concerns were not being addressed and there were numerous complaints with no resolution. The SW said she wanted to know what happened and the staff in those meetings told her, Oh, they are all psychotic and Shut me down in wanting to discuss concerns of the residents.<BR/>An interview with the AD on 01/31/25 at 11:08 AM revealed she was the scribe for the resident council meetings and when the residents in the meetings voiced complaints, she wrote them up on grievance forms. Once those forms were started, the AD sent them to the SW and the SW handed the form(s) out to the department head responsible for the issue the resident had. The AD stated sometimes she (AD) also gave the resident council concerns directly to the ADM who would say to hold onto them until the next morning meeting when the department heads would be present. The AD stated the SW was responsible to go to the resident council members and let them know about the resolution of their concerns, but the AD also let the resident council know that she had sent them in and they would be notified about results. The AD stated she rarely knew what the resolution was of a grievance from the resident council except for dietary. She said with dietary issues, the dietary manager was on top of it and would let the AD know what was done about any complaints. The AD stated if the resident council brought up an issue that was general in nature and not resident specific, she would still complete a grievance and give it to the DON to follow up, not the SW, but the SW would still get a copy to log. The AD stated she had received numerous complaints that the SW was not doing her job and was putting grievances to the side and did not see them as a priority. The AD stated the residents were frustrated their concerns were not being addressed and felt they were not being heard. The AD stated, That is why I talked to the Administrator and he said let's start passing them out in stand-up as well as give a copy to the social worker so everyone is on the same page. <BR/>An interview with the ADM on 01/31/25 at 1:54 PM revealed his expectation was when a grievance was made, it was written on a grievance form, dated, a copy made and turned into the SW or ADM. Typically, the ADM then would see the concern before it got routed to the specific department head and he would tell that department head they had 72 business hours to look into the issue. Then the department head was supposed to fill out the outcome portion of the form and let the person know who made the grievance what the outcome was and then give it to the SW to track and trend. The ADM stated grievances were important to address because it was a resident right, and the residents had the right to ensure the facility was tracking their concerns and showing what they did to resolve them in a timely manner. <BR/>4. Review of the facility's policy titled, Filing Grievances/Complaints, revised August 2008, reflected, Our facility will help residents, their representatives (sponsors) other interested family members, or resident advocated file grievances or complaints when such requests are made .4. The Administrator has designated the responsibility of grievance and/or complaint investigation to [blank]; 5. Upon receipt of a grievance and/or complaint, [blank] will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint; 6. The Administrator will review the findings with the person investigation the complaint to determine what corrective actions, if any, need to be taken; 7. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The Administrator, or his or her designee, will make such reports orally within [blank] working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #2 and Resident #3) of five residents reviewed for ADLs. <BR/>The facility failed to provide showers or bed baths consistently for Residents #2 and #3 per the facility bathing schedule in January 2025. <BR/>This failure placed residents who were dependent on staff for bathing at risk for poor personal hygiene, odors, and a decline in their quality of life. <BR/>Findings included:<BR/>1. Record review of Resident #2's Face Sheet reflected dated 01/30/25 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2's active diagnoses included paraplegia (a condition that causes paralysis or loss of muscle function in both legs), neuromuscular dysfunction of bladder (impaired bladder control due to disrupted communication between the brain and the bladder muscles), Stage 4 pressure ulcer of right heel and Stage 4 pressure ulcer of right lower back (a pressure ulcer is localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction; Stage 4 means full thickness tissue loss with exposed bone, tendon or muscle).<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 15 which indicated no cognitive impairment. Resident #2 had range of motion impairment on both sides of his lower extremities and used a wheelchair for mobility. Resident #2 required partial/moderate assistance from staff for bathing and personal hygiene. He had an indwelling and external catheter (a flexible tube inserted into the body to drain or deliver fluids) and ostomy (a surgical procedure that creates an opening in the abdomen to allow waste to exit the body).<BR/>Record review of Resident #2's baseline care plan dated 01/22/25 reflected he was dependent on staff for toileting hygiene and showers/bathing.<BR/>An interview with Resident #2 on 01/30/25 at 1:49 PM revealed he had been moved to the room he was presently in several days prior and there was no hot or warm water available in his bathroom to use. Resident #2 stated he had let the water run in his bathroom sink for over an hour when he first moved to the room, but there was only cold water. He said the shower at the end of his hall also did not have any hot or warm water. Resident #2 said he had not received a shower the past two scheduled times (01/27/25 and 01/29/25). Resident #2 stated he felt not having hot or warm water available in his room made him feel very dirty, he said he could not wash his face well and it was starting to breakout and his skin was starting to get itchy all over.<BR/>Record review of Resident #2's nursing progress notes reflected no shower refusals since his readmission to the facility from the hospital on [DATE].<BR/>2. Record review of Resident #3's Face Sheet dated 01/30/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #3's active diagnoses included paraplegia (a condition that causes paralysis or loss of muscle function in both legs), colostomy status (a surgical procedure that creates an opening in the colon, allowing stool to be diverted from the rectum and collected in a bag), Stage 4 right and left lower back pressure ulcer, stage 4 of sacral region (Full thickness tissue loss with exposed bone, tendon or muscle) and flaccid neuropathic bladder (a condition where the bladder muscles are weak and unable to contract properly, leading to difficulty or inability to urinate). <BR/>Record review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated no cognitive impairment. Resident #3 had range of motion impairment on one side of his upper extremities and on both sides of his lower extremities. He used a wheelchair for mobility and was dependent on staff for all ADLs, including showering and personal hygiene. <BR/>Record review of Resident #3's care plan last revised 01/28/25 reflected Resident #3 had an ADL self-care performance. Interventions, Bathing/Showering: Resident prefers showers 3 times per week likes to get oob daily; The resident requires extensive assistance by (1) staff with bathing/showering (start 09/30/24)<BR/>An interview and observation of Resident #3 on 01/30/25 at 2:03 PM revealed he was sitting in a reclined wheelchair in his room with his eyes closed. Resident #3 stated he had not been bathed or showered in the past week. He said he could not remember the last time he had been bathed but it had been a long time, over a month. During the interview, Resident #3 kept trying to peel his right eye open with his fingers as it was observed to be crusty and sealed shut. Resident #3 said he did not know why the staff were not bathing him and stated, They don't tell me why. I want one though. Resident #3's bathroom sink was observed to have no hot or warm water available. <BR/>Record review of Resident #3's nursing progress notes reflected no shower refusals for the month of January 2025. <BR/>3. An observation of Resident #2 and #3's shower room at the end of Hall 400 on 01/30/25 at 1:56 PM revealed there was no hot or warm water coming from the shower faucet.<BR/>4. Review of the facility shower binder for Hall 400 reflected no shower sheets for Residents #2 and #3 for January 2025. There were daily lists of residents to be showered with a space for the nurse to sign with any comments. However, neither Resident #2 nor Resident #3 were checked off as completed. <BR/>5. An interview with ADON A on 01/30/25 at 12:19 PM revealed completed shower sheets were important because that was the way the facility kept track of any new resident skin issues. ADON A stated she had looked in the binders and verified there were no shower sheets for Resident #2 and #3. ADON A stated what she saw in the shower binders at the 400-hall nursing station was just a list for the charge nurse to sign off on which residents were supposed to get showered that day. ADON A stated, But they were not the shower sheets. ADON A stated she did not know how long the CNAs and charge nurses had not been using shower sheets. ADON A stated the list of who needed a shower was not acceptable. She said the shower sheets needed to be completed and turned in by the CNAs for review to see if there were any changes to a resident's skin condition. ADON A stated the form they were using currently did not indicate if any skin was looked at or if any skin issues were noted. ADON A said she was going to ensure that the required blank shower sheets were copied and placed back into the shower binders along with the schedule list of residents to be showered for that day so they can be tracked and monitored. ADON A stated she did not know why the system changed except laziness and no one put more shower sheets in the binders, so they all defaulted to just signing a schedule, Which is not appropriate. <BR/>An interview with the ADM on 01/30/25 at 9:30 AM revealed the DON was out sick on leave and was unable to be interviewed. <BR/>An interview with CNA C on 01/31/25 at 12:37 PM revealed she had not seen any skin observation sheets (shower sheets) and when she gave a resident a shower, she just circled on a list if the resident received it or if they refused. If any skin issues, she would circle yes/no and then report to the charge nurse. When shown a blank shower sheet/skin observation sheet, CNA C stated she had not seen them before and had not been filling those out. CNA C stated showering a resident was important because no one wanted to have body odor and they want to smell fresh. CNA C stated infection control was also another reason showers were important, We have bacteria on our skin and we need to shower to remove it and protect the skin, like rashes and stuff, showering is good. <BR/>An interview with CNA D on 01/31/25 at 12:56 PM revealed she was picking up a shift and had showered Resident #1 that morning (01/31/25). CNA D stated she had another CNA help her shower Resident #1 and he took them a lot of time. She stated when a resident shower was completed, there was a paper that had the name and room number of the residents assigned to be showered for that day. If the resident refused the shower, the CNA had to tell the nurse. CNA D stated she had not seen the shower sheet form/skin observation sheet recently. <BR/>An interview with the ADM on 01/31/25 at 1:54 PM revealed he had heard about Resident #2 not being showered because his family member had contacted him on 01/30/25 about it. The ADM stated he completed a grievance form as a result. The ADM reviewed the shower binder and the schedule the nurse checked off that staff were using as shower sheets and said it was not the right form. He said the shower sheets to be used were more comprehensive. <BR/>6. A policy on ADL care related to showers was requested on 01/30/25 and 01/31/25 from the ADM but was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of five residents reviewed for pressure ulcers.<BR/>1. <BR/>The facility failed to ensure Resident #1 received all physician ordered wound care 10 out of 31 days in December 2024. <BR/>2. <BR/>The facility failed to ensure Resident #1 received all physician ordered wound care 5 out of 30 days in January 2025. <BR/>This facility failure could place residents at risk of developing infections or worsening of their wounds.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 01/30/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included paraplegia (a condition that causes paralysis or loss of muscle function in the lower half of the body, including both legs), pressure ulcer of sacral region-stage 4, pressure ulcer of right heel-stage 3, pressure ulcer of left heel-stage 3, non-pressure chronic ulcer of back, neuromuscular dysfunction of bladder (impaired bladder control due to disrupted communication between the brain and the bladder muscles), colostomy status(a surgical procedure that creates an opening in the abdomen through which waste from the large intestine can be expelled into a bag) and chronic pain syndrome (a condition characterized by persistent pain that lasts for at least three to six months). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 13, which indicated intact cognition. Resident #1 had no rejection of care issues and no verbal or physical behaviors. Resident #1 had range of motion impairment on both sides of his lower body and was dependent on staff for transfers, bed mobility and ADLs that included dressing, showering, personal hygiene and incontinent care. Resident #1 had an indwelling catheter and an ostomy appliance. Resident #1's assessment reflected he was at risk of developing pressure ulcers/injuries and had four unhealed pressure ulcers and one unstageable deep tissue injury that were present upon admission to the facility. Skin and ulcer/injury treatments included pressure ulcer/injury care, application of nonsurgical dressings and applications of ointments/medications. <BR/>Record review of Resident #1's care plan dated 10/02/24 and last revised on 01/29/25 reflected the following focus areas:<BR/>-Wound Management-Skin tear to the left instep of his foot due to hitting the bedrail during a spasm episode (Initiated12/02/2024); Intervention: Wound will show signs of improvement, provide wound care per treatment order. <BR/>-Resident is at risk for pain related to wound; Site #1: Stage 4 pressure wound sacrum full thickness, wound size: 13.5 x 21.8 x 0.2cm; Site #5: Stage 4 pressure wound of left heel full thickness, wound size: 2.1 x 1.5 x 0.1cm; Site #6: Stage 4 pressure wound of right lateral foot full thickness, wound size: 1.1 x 0.7 x Non measurable cm; Site #12: Non-pressure wound of the left buttock full thickness, wound size: Resolved- 01/22/25. Interventions included to provide wound treatment per MD order, Site #1: Stage 4 pressure wound sacrum full thickness: clean surrounding skin with skin prep, clean wound with NS or wound cleanser, pat dry, apply collagen powder and calcium alginate to wound bed, island dressing or ABD pad and paper tape daily. Site #5- skin prep surround skin, clean wound with NS, pat dry, apply Xeroform to wound, apply island border dressing daily. Site #6- Skin prep three times a week.<BR/>Record review of Resident #1's care plan also reflected a revision on 01/02/25 reflected he was resistent to wound care and skin assessments. The intervention reflected, Give one on one care as needed.<BR/>Record review of Resident #1's physician's order summary for December 2024 and January 2025 reflected the following treatments were ordered:<BR/>1) Cleansed open area on top of left foot, apply triple antibiotic ointment, cover with dry gauze dressing one time a day for open wound on top of left foot (start date 11/30/24, discontinued 01/02/25)<BR/>2) Non-pressure wound right medial heel, skin prep three times per week on Monday, Wednesday and Friday for preventative measure (start date 01/03/25, discontinued 01/15/25)<BR/>3) Non-pressure wound to left lateral ankle - apply skin prep daily (start date 01/02/25, discontinued 01/15/25)<BR/>4) Non-pressure wound left 2nd toe apply skin prep three times per week every day shift every Mon, Wed, Friday for Preventative Measure (start date 01/03/2025, discontinued 01/15/25)<BR/>5) Non-pressure wound of the left 2nd toe partial thickness, once a day every Monday, Wednesday and Friday for 23 days, Apply skin prep; Off-load wound; Pressure off-loading boot (start 12/05/24, discontinued 12/28/24)<BR/>6) Non-pressure wound of the left buttock full thickness, skin prep skin around wound, clean wound with NS, apply xeroform to wound bed, island border dressing or ABD pad daily x23 days. one time a day (start 01/16/25, discontinued 01/22/2025)<BR/>7) Non-pressure wound of the right toe of undetermined thickness once a day for 30 days, apply skin prep, off-load wound with pressure offloading boot (start 12/05/24, discontinued 01/02/25)<BR/>8) Non-pressure wound of the right medial heel partial thickness once a day on Monday, Wednesday and Friday for 16 days, apply skin prep, offload wound with offloading boot (start 12/05/25, discontinued 12/21/24)<BR/>9) Non-pressure wound to left superior lateral ankle-apply skin prep daily for preventative measure (start 01/03/25, discontinued 01/15/25) <BR/>10) Right Lateral Foot: cleanse with NS, pat dry. Apply [NAME] and leave open to air Tuesdays/Thursdays. every day shift for Wound Treatment (start 01/05/25, discontinued 01/15/25)<BR/>11) Stage 4 pressure wound of right lateral foot full thickness: skin prep three times a week x16 days once a day on Monday, Wednesday and Friday (start date 01/17/25 to present)<BR/>12) Stage 4 pressure wound of the left heel full thickness once a day for 30 days apply skin prep, use Xeroform gauze to wound bed and cover with island bordered dressing (start date 12/05/24 through present)<BR/>13) Stage 4 pressure wound of the left heel full thickness: clean with NS, pat dry apply xeroform to wound bed and island border dressing daily x16 days once a day (start date 01/16/25, discontinued 01/29/25). <BR/>14) Stage 4 pressure wound of the left heel full thickness, skin prep surround skin of wound, clean with NS, pat dry apply xeroform to wound bed and island border dressing daily for 30 days once a day (start 01/30/25)<BR/>15) Stage 4 pressure wound of the right lateral foot thickness once a day on Monday, Wednesday, Friday for 30 days (start date 12/05/24, discontinued 01/04/25).<BR/>16) Stage 4 pressure wound sacrum full thickness-apply xeroform gauze to wound bed and cover with ABD pads, use tape/island bordered gauze for retention every day (start 12/31/24, discontinued 01/02/25)<BR/>17) Stage 4 pressure wound sacrum full thickness, once a day on Monday, Wednesday, Friday for 30 days, apply xeroform gauze to wound bed and cover with ABD pads, use tape/island bordered gauze for retention (start date 12/04/24, discontinued 12/20/24)<BR/>18) Stage 4 pressure wound sacrum full thickness, skin prep around wound, clean with NS, Pat dry, apply collagen powder and calcium alginate to wound bed, island dressing or ABD pad and paper tap daily, and as needed. Monitor for s/s of infection once a day (start date 01/16/25 through present)<BR/>19) Stage 4 pressure wound sacrum full thickness, one time a day every Monday, Wednesday, Friday for 30 days apply xeroform guaze to wound bed and cover with ABD pads, use tape/island border gauze for retention (start date 12/05/24, discontinued 12/30/24)<BR/>20) Stage 4 pressure wound sacrum full thickness, apply peri-wound skin prep, aliginate calcium gauze to wound bed and cover with ABD pads, use tape/island border gauze for retention as needed (start date 01/02/25, discontine 01/15/25)<BR/>Record review of Resident #1's December 2024 TAR reflected he did not receive wound care to his sacrum and heel as ordered by his physician on 12/03/24, 12/05/24, 12/12/24, 12/16/24, 12/19/24, 12/20/24, 12/23/24, 12/24/24, 12/25/24 and 12/27/24.<BR/>Record review of Resident #1's January 2025 TAR reflected he did not receive wound care to his sacrum and heel as ordered by his physician on 01/06/25, 01/09/25, 01/14/25, 01/21/25 and 01/29/25.<BR/>Record review of Resident #1's nursing progress notes reflected no entries on the dates of the missed wound care in December 2024 and January 2025 to explain why it was not provided. <BR/>Record review of Resident #1's Wound Evaluation and Management Summaries dated 12/11/24 and 01/29/25 reflected in each visit under the Expanded Evaluation Performed that Resident #1 was a current smoker which was known to affect wound healing and healing progression. Continued interventions for wound healing ordered and implemented included a multivitamin once a day, vitamin C twice a day, low air loss mattress, off-loading wound, repositioning per facility protocol and offloading chair cushion. The following measurements were reflected for his current wounds:<BR/>1) 11/06/24- Stage 4 pressure wound to sacrum over 675 days: The measurements were 20.3 x 14.5 x 0.2 cm with a surface area: 294.35 cm, Cluster Wound open ulceration area of 88.31 cm, Sharp selective debridement procedure was used to remove biofilm over the wound surface area of 88.305 cm, Wound progress: At Goal. (Note: A cluster wound is a grouping of multiple wounds that are close to one another and documenting them as a single wound 'clustered wound' could simplify assessment, when appropriate.)<BR/>-12/11/24- Stage 4 pressure wound to sacrum over 710 days: The measurements were 16x 6x 0.2cm with a surface area of 96 cm with noted improvement, Cluster Wound open ulceration of 19.2 cm, Wound progress: Improved-evidenced by decreased surface area. A sharp selective debridement procedure was used to remove biofilm over the wound surface area of 19.2 cm. Goal of treatment is healing as evidenced by a 61.5 % decrease in surface area within the wound bed in comparison to the last wound visit. <BR/>-01/01/25-Stage 4 pressure wound to sacrum over 731 days: The measurements were 16.5 x22.5 x 0.2 cm with a surface area of 371.25 cm&sup2; and a Cluster Wound open ulceration area of 111.38 cm, Wound progress: Exacerbated due to multifactorial. A surgical excisional debridement procedure was used to surgically excise 37.12 cm of devitalized tissue and necrotic muscle tissue along with slough and biofilm were removed at a depth of 0.3cm and healthy bleeding tissue was observed. As a result of the procedure, the nonviable tissue in the wound bed decreased form 20 percent to 10 percent. Hemostasis was achieved and a clean dressing was applied. <BR/>-01/15/25- Stage 4 pressure wound to sacrum over 745 days: The measurements were 13.4 x22.5 x 0.2 cm with a surface area: of 301.50 cm&sup2; and a Cluster Wound open ulceration area of 90.45 cm, Wound progress: Improved evidence by decreased surface area. A surgical excisional debridement procedure was used to surgically excise 30.15 cm of devitalized tissue including slough, biofilm and non-viable muscle tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of the procedure, the nonviable tissue in the wound bed decreased form 10 percent to 0 percent. Hemostasis was achieved and a clean dressing was applied.<BR/>-01/29/25-Stage 4 pressure wound to sacrum over over 758 days: The measurements were 13.5 x21.9 x0.2cm with a surface area of 294.30 cm with the wound progress noted to be at goal. <BR/>2) Stage 4 pressure wound to the left heel: On 12/11/24, the measurements were 3.5x 3.5x 0.1 cm with a surface area of 12.25 and was not at goal. On 01/29/25, the measurements were 2.1x 5.0x 0.1 cm with a surface area of 3.15cm and was not at goal. <BR/>3) Stage 4 pressure wound of the right lateral foot: On 12/11/24, the measurements were 1.1x 0.5x not measurable cm with a surface area of .55 cm. On 01/29/25, the measurements were 1.1x 0.7x not measurable cm with a with a surface area of .77 cm with noted wound improvement. <BR/>An interview with Resident #1 on 01/30/25 at 1:07 PM revealed he had a very large wound that he admitted to the facility with on his bottom and it had almost gotten healed up by the previous ADON, but when he left employment at the end of November 2024, Resident #1's wounds got worse. Resident #1 said the floor nurses were providing the wound care during December 2024 because there was no wound care nurse designated for the facility. He said the floor nurse would tell him they would get to the wound care, but no one was coming into his room to do it consistently. Resident #1 said he told the ADM, who ended up getting a nurse to start coming in [ADON A] to do the wound care, but he was not sure when she started. Resident #1 stated since ADON A started working on his wounds during the weekdays they had gotten better. However, when ADON A was not at the facility, the floor nurses doing the wound care were not always knowledgeable on the required supplies, technique and application of dressings. Resident #1 stated there had never been a consistent wound care nurse until recently and there had been numerous times when ADON A was not working that his wound care did not get provided. Resident #1 felt that the lack of wound care being done consistently in December 2024 set him back two months on his healing. <BR/>An interview with Resident #1's RP on 01/31/25 at 10:11 AM revealed she had been having concerns about his wound care not being done as well as the nurses not coming to check on him. The RP stated she had seen Resident #1's wounds via photos and they had almost healed around Thanksgiving 2024, but within a few weeks after that, the one on his bottom started going downhill and getting bad. The RP stated Resident #1 could not feel his feet and the wounds on them were chronic and always recurring. As a result, they were not as much of an issue as the one on his bottom. The RP stated, But the bottom wound, they weren't doing right. The RP stated she had tried to get in touch the DON with no success as well as the ADON. <BR/>Record review of a grievance form for Resident #1 dated 12/30/24 reflected a concern that Resident #1 was not getting his wound care done daily. The grievance resolution reflected the DON educated the Resident #1 that his wound care was not done daily and a documented he was told a majority of his wound care was done on Mondays, Wednesdays and Fridays and that the resident should speak with the doctor regarding any order changes. The grievance also reflected Resident #1 then stated, Well they are not doing it on Mondays, Wednesdays and Fridays either and showed me [DON] pictures of his wounds and said they are getting worse. I asked if I could do a full head to toe assessment and the resident refused.<BR/>An interview with the ADM on 01/30/25 at 9:30 AM revealed the DON was out sick on leave. <BR/>An interview with the SW on 01/30/25 at 2:45 PM revealed Resident #1 did make a complaint about his wounds and said he was going to contact the State [HHSC] because he was not getting wound care every day. The SW said, however, the doctor did not order wound care every day and Resident #1 wanted to know why. The SW stated, I think the nurse talked to him and helped him understand that we are only following doctor's orders .He gets worked up sometimes. <BR/>An interview with the wound care nurse, ADON A on 01/31/25 at 11:23 AM revealed she started as the wound care nurse on 01/08/25 and prior to that she was a PRN floor nurse at the facility. ADON A said any wounds from 01/08/25 to present were wounds she had done wound care for, unless she was working on the floor. ADON A stated that she could not speak for anyone else, but if there were blanks on the TAR during January 2025 when she was doing wound care, it may have been due to updating orders in the system, but she was not sure. ADON A stated she was at the facility during the weekdays and the only time she delegated wound care to the charge nurses was if she was working on the floor She stated, Sometimes I try to do wounds before the floor shift starts; sometimes I don't and will delegate to the nurses who are capable of doing treatments. ADON A stated the weekend charge nurses were responsible for doing wound care on the weekends. Regarding Resident #1, ADON A stated he had told her the nurses were not doing the wound care correctly but she did not know what he meant. She said Resident #1's wound drained a lot and she taped them up very well and they did not come undone, so she thinks when other nurses did it, Resident #1 may feel that the bandages were falling off. ADON A stated residents' wounds in the facility were tracked by herself. She said she would know if wound care was not getting done because of how the bandages were dated when came in for her next shift.<BR/>An interview with the ADM on 01/31/25 at 1:54 PM revealed ADON A was in charge of monitoring wound care and sometimes the DON did weekly random audits of wounds. <BR/>Record review of the facility's policy titled Wound Care revised October 2010 reflected, Purpose: The purpose of this procedure is to provider guidelines for the care of wounds to promote healing .Steps in the Procedure .12. Apply treatments as indicated, 13. Dress wound .Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given, 2. The date and time the wound care was given .4. The name of the individual performing the wound care, 5. Any change in the resident's condition .10. The signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary comfortable, environment for residents staff and the public for one (room [ROOM NUMBER]) of nine resident rooms reviewed for environment.<BR/>The facility failed to ensure the AC/heating unit located in room [ROOM NUMBER] was clean.<BR/>This failure could place residents at risk for diminished quality of life due to a lack of a well-kept environment and reduced air quality in the room.<BR/>Findings included:<BR/>An observation on 1/17/24 at 9:20 AM, revealed Resident #1 was in room [ROOM NUMBER]B, sitting on the side of his bed facing the window. His knees were directly in front of an AC/heating unit located beneath a window. The resident was cognitively impaired and unable to be interviewed. The AC/heating unit was on and blowing warm air. Front cover appeared loose. A moist black substance was observed along the edges of the louvers from where the air was blowing. The top portion of the cover surrounding the louvers and control panel was dirty. The control panel face was also covered in dirt that was heavier in the area typically obscured by the cover, but visible because the cover was loose. <BR/>An observation on 1/17/24 at 9:28 AM, revealed a housekeeping cart was parked outside the room next door.<BR/>Another observation on 1/17/24 at 10:10 AM revealed Resident #1 was sitting in the same position in his room, no changes were observed to the unit, photos were taken by this surveyor. <BR/>An observation and interview on 1/17/24 at 10:55 AM, revealed a housekeeping cart was seen in the doorway of room [ROOM NUMBER]. Housekeeping Staff A was observed inside the room removing trash from the trashcans. An interview with Housekeeping Staff A revealed the floors were typically cleaned twice a day and the AC/heating units were cleaned daily. <BR/>An observation on 1/17/24 at 12:15 PM, revealed Resident #1 was sitting on the side of his bed, now facing the door, eating lunch. Observation of his AC/Heating unit revealed the front center portion of the control panel appeared clean but the surrounding area was still dirty. The black substance could still be seen along the edges of the louvers from where the air was blowing.<BR/>An interview with the DON on 1/17/24 at 1:30 PM, revealed Resident #1's family member mentioned the dirty AC/heating unit to him the evening of 1/16/24. He stated he had planned to discuss it with the maintenance staff today (1/17/24) but had not done so yet because State investigators had entered this morning. The DON accompanied this surveyor to room [ROOM NUMBER] to examine the unit. The DON removed the cover and pointed out the rust on the metal frame and stated he believed that was the material and not dirt. When the other dirty areas were pointed out including the black substance on the louvers, dirt around the control panel, dust buildup beneath the control panel, and dirt buildup within grate over the blower portion of the unit, he stated he would let them know. <BR/>In another interview with the DON on 1/17/24 at 1:55 PM, he presented photos on his phone he said he received on 1/16/24 and stated, it was much worse yesterday. The photo revealed the condenser portion of the unit had been completely caked in dust and had been cleaned and was now clear. He was unsure why the rest had not been cleaned and thought someone may have planned to return and complete.<BR/>In an interview on 1/17/24 at 2:05 PM, with the Housekeeping Supervisor, she stated the housekeepers were responsible for cleaning the outside of the AC/heating units daily and they should check them, along with everything else, during their daily walkthroughs. She stated she did periodic checks behind the housekeeping staff to ensure quality work. She stated Resident #1's family member] had told her the day before that they had bumped into the unit causing the cover to come off which exposed heavy dust buildup. She stated the family member told her it was already getting addressed. She stated she thought she had just seen the Maintenance Tech in the room wiping it down today. <BR/>In an interview with the Maintenance Tech on 1/17/24 at 2:16 PM, he stated he checks the maintenance log at the nurses' station daily for any maintenance issues. He stated he checked the log on 1/16/24 and there was an entry for room [ROOM NUMBER] that said the heat was not working. He said he just went in the room and switched it on and it worked fine. The Maintenance Tech stated someone had asked him if he had cleaned the unit and he told them, 'no'. He stated he thought housekeeping had cleaned it up. The Maintenance Tech stated he had walked through the building two months ago and changed all the filters. He was unaware whether there was any routine cleaning of the interior parts but he could take the unit outside and wash it. He stated he could have removed the cover and clean it, but he had only been told it was not working. The Maintenance Tech provided the Maintenance Logbook for review. <BR/>Record review of the Maintenance Logbook at the main nurses station revealed individual pages titled Maintenance Request. A page dated 1/16/24 reflected the following: <BR/>Time: 8:50 AM. <BR/>Reported by: Resident to the nurse<BR/>Room: 411<BR/>Location: 400 Hall<BR/>Nature of Work Order: Heat is not working<BR/>Work Completed Date: 1/16/24<BR/>By: [Maintenance Tech]<BR/>An interview with the Administrator and the DON on 1/17/24 at 4:00 PM revealed the Administrator stated she had received a text message from the Dietary Manager on 1/3/24 informing her of the complaint. She stated she was told the unit had been cleaned and everything was fine. She stated she did not follow-up with Resident #1's [family member] because the Dietary Manager told her Resident #1's [family member] was satisfied with the outcome. When the Administrator was shown photos taken by this surveyor and asked if she felt it was acceptable, she stated she had been told it was cleaned. When asked about the possible risks to residents having dirty AC/heating equipment close to their beds, the Administrator stated, well that sticks to the plastic and we can get it cleaned and the [family member] was satisfied according to my Dietary Manager. <BR/>During an interview on 1/17/24 at 4:30 PM, the Dietary Manager stated she had been standing near the nurses' station when Resident #1's [family member] approached her and appeared upset. She stated the family member told her they had bumped the AC/heating unit by accident causing the cover to fall off and she noticed it was very dusty. The Dietary Manager stated she retrieved some sanitizing wipes and wiped down the inside of the unit. She stated Resident #1's [family member] was present in the room at the time. The Dietary Manager stated she did not leave the room until the [family member] was satisfied. She stated she saw the [family member] again the next day and was told everything was fine. She stated she had notified the Administrator via text message but did not fill out a grievance form because she thought the issue was resolved. <BR/>Record review of the facility's policy and procedure titled Cleaning and Disinfection of Environmental Surfaces dated 2001, revised August 2010 revealed the following:<BR/>Policy Statement: Environmental surfaces will be cleaned and disinfected according to the current CDC recommendations for disinfection of healthcare and the OSHA Bloodborne Pathogens Standard.<BR/>Policy Interpretation and Implementation .Environmental Surfaces .10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visible soiled

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 2 residents (Resident #1) reviewed for intravenous medications. <BR/>1. The facility failed to ensure the dressing on Resident #1's Midline catheter (used to deliver intravenous medications directly to the large central veins near heart) was changed timely. Resident #1 went without a dressing change for 15 days. <BR/>2. The facility failed to have orders for Midline catheter dressing changes.<BR/>The failures could affect residents by placing them at risk for infections and cross-contamination. <BR/>Findings included: <BR/>Record review of Resident #1's admission Record dated 12/21/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #1's Quarterly MDS dated [DATE] reflected she was in a persistent vegetative state, she was dependent on staff for all ADLs and her diagnoses included hypertension (high blood pressure); Diabetes; aphasia (disorder that affects the ability to verbally communicate); and stroke.<BR/>Record review of Resident #1's Order Recap Report dated 1/2/25 reflected the following orders: 12/16/24: Insert Midline. <BR/>12/17/24: Imipenem-Cilastatin Intravenous Solution 500 mg intravenously every 6 hours for UTI until 12/24/24.<BR/>There were no orders for dressing changes to be performed to her midline catheter site. <BR/>Record review of Resident #1's MAR and TAR dated December 2024 reflected no entries for dressing changes to her midline catheter site. <BR/>An observation on 12/31/24 at 9:46 AM revealed Resident #1 was in bed. Her eyes were open but she made no response to verbal greeting. A midline IV insertion site on her left upper arm had a dressing intact and dated 12/16/24. <BR/>In an interview on 12/31/24 at 2:23 PM, RN A stated she had an order to discontinue the midline catheter and she was checking the facility policies related to removal. She stated she had come from another facility to help out due to staff calling in sick. She stated she could not say why Resident #1's dressing had not been changed.<BR/>During an interview on 12/31/24 at 3:35 PM, the DON stated Resident #1's midline IV was getting discontinued that day. She stated it would have been removed sooner but her family wanted it left in a little longer in case she needed additional medications. The DON stated they usually ordered dressing changes every 7 days and she could not say why hers had not been ordered or why her dressing had not been changed. She stated she usually had an ADON to assist with reviewing orders and MARS but had been without one for the past month. She stated she had a new ADON scheduled to start soon. The DON stated the risk of not changing the dressings was infection.<BR/>During an interview on 1/2/25 at 3:05 PM, LVN B stated he typically cared for Resident #1 and did not know how often the dressing to her IV site needed to be changed. He stated they checked the IV site every shift to ensure it was intact and hers had been removed on 12/31/24 . LVN B stated the risk of not changing dressings included infection.<BR/>Record review of the facility's policy titled, Peripheral IV Dressing Changes dated Revised April 2016 reflected: Purpose-This purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. General Guidelines .2. Change the dressing if it becomes damp, loosened or visibly soiled and at least every 5-7 days. Change dressing and perform site care if signs and symptoms of site infection are present .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 6 residents reviewed for pharmacy services in that:<BR/>The facility failed to ensure Resident #1's Ketoconazole External Shampoo (used to treat hair loss and dandruff) was available and applied as ordered between 11/27/24 and 12/2/24.<BR/>This failure placed the residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition. <BR/>Findings included:<BR/>Record review of Resident #1's admission Record dated 12/21/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #1's Quarterly MDS dated [DATE] reflected she was in a persistent vegetative state, she was dependent on staff for all ADLs and her diagnoses included hypertension (high blood pressure); Diabetes; aphasia (disorder that affects the ability to verbally communicate); and stroke.<BR/>Record review of Resident #1's care plan reflected an entry dated initiated 11/26/24: [Resident #1] is on Ketoconazole External Shampoo 1%. Apply to scalp one time a day every Wed and Fri for rash until 12/02/2024. Intervention: Provide wound care per treatment order give as ordered.<BR/>Record review of Resident #1's Order Recap Report dated 1/2/25 reflected the following order:<BR/>11/25/24: Ketoconazole External Shampoo 1%. Apply to scalp topically one time a day every Wednesday and Friday for rash until 12/2/24. Start date 11/27/24. End date 12/2/24.<BR/>Record review of Resident #1's Administration Record dated November 2024 reflected and entry for Ketoconazole External Shampoo 1%. Apply to scalp topically one time a day every Wednesday and Friday for rash until 12/2/24. An entry dated 11/27/24 (Wednesday) was coded 13 which indicated, pending arrival from pharmacy. An entry dated 11/29/24 (Friday) was coded 9 which indicated, other/see Nurses Notes. <BR/>Record review of Resident #1's nursing progress notes reflected:<BR/>11/25/24 8:22 PM: [Family member] is concerned about the res hair falling off. She requests the nurse to get an order from the MD . Phone call placed, and a N/O received for Ketoconazole External Shampoo 1 % (Ketoconazole (Topical)) Apply to scalp topically one time a day every Wed, Fri for Rash until 12/02/2024 .Order placed on PCC. [Family member] and res aware. The entry was signed by LVN B.<BR/>11/29/24 12:37 PM: Ketoconazole External Shampoo 1 % Apply to scalp topically one time a day every Wed, Fri for Rash until 12/02/2024 .shampoo not found in patient room or nurse cart. The entry was signed by RN C. <BR/>An observation on 12/31/24 at 9:46 AM revealed Resident #1 was in bed. Her eyes were open but she made no response to verbal greeting. She appeared clean and well groomed. Her hair appeared clean and groomed . <BR/>During and observation and interview on 12/31/24 at 12:10 PM, CNA D stated she had assisted with Resident #1's showers and was unaware of any orders for special shampoo to be used during her care. She stated Resident #1's family had wanted them to use the products they provided for her and pointed out a shelf in the resident's closet which had various bottles of shampoo and body wash. CNA D stated she always retrieved items from that shelf when preparing the resident for her showers. <BR/>During an interview on 12/31/24 at 3:35 PM, the DON stated she was unsure whether the shampoo ordered for Resident #1 had been used. She stated she had been made aware the day before by Resident #1's family that they did not believe it had been used. She stated she checked the medication cart and located a partially used bottle of her Ketoconazole. She stated she had not had an opportunity to follow-up with the CNAs yet because the staff that cared for her that week were not working. The DON stated the nurses were responsible for letting the CNAs know if there was an order for special shampoo. She stated the risk of not using the shampoo would be ongoing condition. She stated she did not observe a rash or other condition when she checked Resident #1.<BR/>During an interview on 12/31/24 at 4:24 PM, LVN B stated he had called the physician and entered the order for the shampoo when her family member expressed concerns about her scalp. He stated the family member had approached him at a later date and complained the shampoo had not been used. He stated he had checked with the staff the same day and learned the shampoo had been used on at least one occasion during the morning shift. He was unable to recall the date or identify the staff with whom he spoke. LVN B stated the charge nurse should have alerted the CNA of the need for the shampoo and should have signed the administration record or documented in the nurses' notes. He stated the risk for failing to use the shampoo was worsening of the condition. LVN B retrieved the bottle from his medication cart and it appeared to have been opened and used. <BR/>During an interview on 1/2/25 at 3:46 PM, RN C stated she recalled a CNA asking her about Resident #1's Ketoconazole and that she had been unable to locate it in her medication cart. She stated she thought she asked someone about it and was told it had been ordered but she could not recall anything after that day. She stated the risk of not administering treatments as ordered depended on the condition for which it was ordered. She stated she never noted any rash or other condition on Resident #1's scalp. <BR/>Record review of the facility's Policy titled, Pharmacy Services Overview dated revised April 2007 reflected: The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed Pharmacist. Policy Interpretation and Implementation, .3. The facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility and Medical Director to: a. Develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services (including ordering, delivery and acceptance, storage, distribution, preparation, dispensing, administration, disposal, documentation, and reconciliation of all medications and biologicals in the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received services with reasonable accommodations for 2 of 5 residents (Resident #8, and Resident #14) reviewed for call light system access. The facility failed to ensure Resident #8 had access to their call light by allowing it to remain on the floor at the side of the bed, out of the resident's reach. The facility failed to ensure Resident #14 had access to their call light by allowing it to remain between the wall and mattress at the foot of the bed, out of the resident's reach. This failure could place residents at risk for delayed assistance and an inability to request help when needed. 1.) Record review of Resident #8's annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility with an original admission date of 09/20/2024 and had severely impaired cognitive function. Diagnoses included: cerebral palsy (a neurological disorder that affects body movement and muscle coordination). Resident #8 was dependent on staff for all self-care tasks such as eating, oral and toileting hygiene, shower/bathing, upper and lower body dressing, and personal hygiene. He was dependent on staff for mobility tasks such as sitting to lying, lying to sitting on side of the bed, sitting to standing, chair/bed-to-chair transfers, and toilet transfers, tub/shower transfers. Record review of Resident #8's Comprehensive Care plan dated 05/15/2025 showed a medical focus: [Resident] has alteration in musculoskeletal status related to Kyphosis (excessive outward curvature of the spine). Goal: [Resident] will remain free from pain or at a level of discomfort acceptable to the resident. Interventions included: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. During an interview and observation on 09/14/2025 at 2:40 PM, Resident #8 was observed in bed. The call light was on the floor, out of the reach of the resident. He said he was not sure why it was there. He said he was unable to reach it. 2) Record review of Resident #14 annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE] and had severely impaired cognitive function. Diagnosis included unspecified dementia (a term used when a person exhibits symptoms of dementia, but the specific type cannot be identified), chronic kidney disease (gradual loss of kidney function over time), Orthostatic hypotension (a condition characterized by a sudden drop in blood pressure when a person stands up after sitting or lying down), muscle weakness, and repeated falls. Record review of Resident #14's Comprehensive Care plan dated 5/23/2025 showed a fall focus: {Resident] is at risk of falls due to (specify: unsteady gait, decreased balance, medications and poor safety awareness). Goal: [Resident] will have no reports of injuries that requires hospitalization or fractures related to falls through next review date. Interventions included: Call light in reach in room and answered promptly. Encourage and remind resident to use call light to ask for assistance. During an interview and observation on 08/24/2025 at 9:30 AM, Resident #14 was observed in bed. Due to cognitive impairment, he was unable to provide reliable information during the interview. The call light cord was observed at the end of the bed, in between the resident's mattress and wall, hanging down toward the floor. During an interview with CNA A on 09/14/2025 at 3:00 PM, in response to the Resident's call light placements, LVN A reported responsibility for ensuring call lights were within reach of residents fell on the CNA's as well as all staff. CNA A said when she left a resident's room, she always placed the call light within reach. She reported rounds were done frequently and as needed since staff were always present in the hallway. CNA A reported the facility call light policy required staff to make sure call lights were within reach, to encourage residents to use them, and, if a call light was not working, to report it immediately and provide an alternative means for the resident to call for assistance. She reported if a call light was not within reach, the risk to residents was they might not be able to communicate their needs or obtain help in a timely manner. She added staff conducted frequent checks to help minimize that risk. During an interview with DON on 09/16/2025 at 10:50 AM, she indicated she was unsure if the facility had a formal policy regarding keeping call lights within residents' reach but noted that it should be considered basic nursing knowledge. She reported there had been no complaints or incidents related to call lights being inaccessible. However, she acknowledged a potential risk might be unable to call for help if a call light was out of reach. On 09/16/2025 at 11:30 AM, the administrator reported the facility did not have a policy regarding call light accessibility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from any physical restraint imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms for 6 (Resident #70, Resident # 23, Resident # 39, Resident # 36, Resident #25, Resident #63) of 6 residents reviewed for restraints. The facility failed to ensure Resident #70, Resident #23, Resident #39, Resident #36, Resident #25 and Resident #63 were not inhibited from freedom of movement or activity in the secure unit when facility staff pushed two dining tables together and placed them in front of the single entrance to the dining area, to prevent the residents from leaving the area. This failure places the residents at risk of being restrained without medication indication.Findings Included: Record review of Resident #70's MDS, dated [DATE], revealed he admitted to the facility on [DATE]. Resident #70 had primary diagnoses of non-Alzheimer's dementia, and left side paralysis due to cerebral infarction (blood flow to the brain is interrupted, leading to tissue damage). Record review of Resident #23's MDS, dated [DATE], revealed he admitted to the facility on [DATE]. Resident #23 had primary diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion and cognitive decline) and Type 2 diabetes (condition where the body does not use insulin effectively). Record review of Resident #39's MDS, dated [DATE], revealed she admitted to the facility on [DATE]. Resident #39 had primary diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion and cognitive decline) and orthostatic hypotension (condition where blood pressure drops significantly upon standing or sitting up from a lying position.) Record review of Resident #36's MDS, dated [DATE], revealed she admitted to the facility on [DATE]. Resident #36 had primary diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion and cognitive decline) and hypertension (condition in which the force of blood against the artery walls is consistently high). Record review of Resident #25's MDS, dated [DATE], revealed she admitted to the facility on [DATE]. Resident #25 had primary diagnoses of non-Alzheimer's dementia and hypertension (condition in which the force of blood against the artery walls is consistently high). Record review of Resident #63's MDS, dated [DATE], revealed he admitted to the facility on [DATE]. Resident #63 had primary diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion and cognitive decline) and hyperlipidemia (condition characterized by high levels of fats in the blood). Observation on 09/14/2025 at 9:20am in the secure unit revealed two dining tables pushed together, blocking the single entrance to the dining area. CNA G was sitting in the hall on the outside of the dining area, while Resident #70, Resident #23, Resident #39, Resident #36, Resident #25 and Resident #63 were inside the dining area. CNA H was observed sitting in an office down the hall with line of sight for both hallways in the secure unit. During an interview with CNA G on 09/14/2025 at 09:25am, CNA G was asked why the tables were placed in front of the doorway. CNA G stated it was to keep the residents from wandering. During an interview with CNA H 09/14/2025 at 1:40pm, CNA H was asked why the tables were placed in front of the doorway to the dining room earlier in the day. CNA H stated the tables are there to keep them from wandering while they are trying to get residents to the dining room. She further stated sometimes it takes more than one aide to get a resident ready for breakfast, so the tables keep them from wandering while the aides go back to get another resident. If they (the residents) are mobile, they're more likely to have an incident or accident. During an interview with the DON on 09/15/2025 at 2:30pm, the DON stated she did not know the weekend aides in the secure unit were restraining the residents in the dining area and it was not acceptable for them to do that. The DON identified risks for the residents as detrimental in every way. If the resident has the need to use the bathroom or whatever. The DON further stated the secure unit is secure so the residents can wander freely and be safe in their environment. A review of the facility policy titled Identifying Involuntary Seclusion and Unauthorized Restraint revealed the following: Policy Statement: As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify involuntary seclusion and/or unauthorized restraint of residents. 1. Involuntary seclusion is defined as a separation of a resident from other residents or from his or her room or confined to his or her room against the resident's will. 2. Examples of involuntary seclusion include: a. Any attempt to keep a resident confined to a certain area by blocking the exit with furniture or a closed door. 3. Secluding or confining a resident against his or her will is prohibited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort, which included incorporating the recommendations from the Preadmission Screening and Resident Review level II determination and the Pre-admission Screening and Resident Review evaluation report into a resident's assessment, care planning and transitions of care for one (Resident #4) of five residents reviewed for Pre-admission Screening and Resident Review assessments. The facility failed to provide Habilitation Coordination, Independent Living Skills, Physical Therapy, Occupational Therapy, Speech Therapy. to Resident #4 as recommended and agreed upon by the Interdisciplinary Team (IDT) within the time frame set by PASRR. This failure could place residents with intellectual disabilities or mental illness at risk of not receiving services that would enhance their quality of life.Findings included:Review of Resident #4's annual Minimum Data Set, dated [DATE] reflected the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a condition caused by damage to the developing brain that affects a person's ability to control their muscles, problems with movement, coordination) kidney failure (kidneys are no longer able to properly filter waste and extra fluid from the blood), contracture (a muscle, tendon, or joint becomes permanently stiff or tight), and dysphagia (trouble swallowing). Review of Resident #4's annual Minimum Data Set assessment dated [DATE] reflected he had no speech, rarely/never made himself-understood, and sometimes was able to understand others. His Brief Interview for Mental Status was not completed. He was totally dependent on two staff for dressing, transferring, bathing and toilet use. He was totally dependent on staff for locomotion, eating, and personal hygiene. He was not ambulatory and had functional limitations in range of motion for upper extremity and lower extremity on both sides. He was indicated as always incontinent of bowel and bladder. He had a physical therapy start date of 03/29/25 with an end date of 04/21/25 with no minutes of treatment recorded during that duration. Record review of Resident #4's Comprehensive Care Plan initiated on 4/11/2018 and revised on 5/27/25 reflected Resident #4 focus area indicated Resident #4 had been identified as PASRR positive status (when a resident is found to need specialized services or supports due to a serious mental health illness, intellectual disability, developmental disability, or related condition through the PASRR screening process) related to an intellectual disability, and Cerebral Palsy. His interventions indicated his family/local mental health authority had agreed to the following PASRR services: Habilitative Physical and Occupational therapy services, Habilitation coordination, and independent living skills. Review of Resident #4's Preadmission Screening and Resident Review Comprehensive Service Plan dated 12/18/24 reflected the type of meeting held was Initial IDT. The form reflected in attendance was a representative from the local mental health authority, Registered Nurse, Minimum Data Set Nurse, Social Worker, Director of Rehabilitation, Hospice Registered Nurse, and Resident's responsible party/family member. The form reflected the Habilitation Coordinator recommended the following services for Resident #4: Habilitation Coordination, Independent Living Skills, Behavioral Enhancement Services, Physical Therapy, Occupational Therapy, Speech Therapy, and Durable Medical Equipment. The form also reflected that Habilitation Coordination, Independent Living Skills, Physical Therapy, Occupational Therapy, Speech Therapy and assessments were accepted, and all other services declined at that time. Review of Resident #4's PASRR Comprehensive Service Plan Form dated 3/12/25 reflected the type of meeting was quarterly IDT. The form reflected in attendance was Resident #4, local mental health authority, Minimum Data Set Nurse, Hospice Social Worker, Director of Rehabilitation, and Resident's responsible party/family member. The plan reflected Resident #4 would continue the following services: Habilitation Coordination, Independent Living Skills, Physical Therapy, Occupational Therapy, Speech Therapy. Review of Resident #4's Habilitative Service Plan/Form 1057 dated 3/12/25 indicated recommended services for Resident #4 were Habilitation Coordination, Independent Living Skills, Physical Therapy, Occupational Therapy and Durable Medical Equipment. Section 6 of the form titled Nursing Facility Specialized Services to be Monitored by the IDT stated to enter all Nursing Facility Specialized Services provided to the individual during the Habilitative Service Plan year. The specialized services listed for Resident #4 were Occupational Therapy with outcome/goal of: Patient will exhibit anatomically correct positioning while sitting in wheelchair with use of adaptive equipment/devices for 2 hours with fair-sitting balance during activities of daily living to reduce pressure and decrease risk of wounds and achieve proper joint alignment. Physical Therapy with outcome/goal of: Patient will maintain mobility with maximum assistance to maintain functional mobility in facility. Speech Therapy, with outcome/goal of: Patient will communicate yes/no responses using non-speech generating augmentative alternative communication system with moderate cueing, patient will communicate basic wants and needs using non-speech generating augmentative alternative communication system with moderate cueing. A review of Resident #4's online Long-Term Care Portal submissions indicated that the facility submitted the NFSS form requesting both Physical Therapy and Occupational Therapy assessments and services on 4/3/25. Both services were initially approved; however, because the authorizations were only valid for one month, the facility was required to resubmit requests to continue services. On 5/11/25, the facility resubmitted the NFSS form for Physical Therapy and was approved. The Occupational assessment and services request was denied. The facility submitted another request for Occupational Therapy assessment and services on 6/2/25, which was again denied. The facility resubmitted a third request for Occupational Therapy on 6/6/25 and was denied. As of 7/1/25, Resident remained in denial status for Occupational Therapy assessment and services. As of 7/1/25, the facility had not submitted an NFSS request for Speech Therapy Assessment or services. In a telephone interview on 7/1/25 at 9:50 a.m. with the PASRR Representative, it was revealed that Resident #4 was identified as PASRR positive and qualified for all services. She stated he had an initial IDT on 12/18/24. She stated that the NFSS forms were due 20 business days after the initial IDT or review meeting. She stated the facility submitted the NFSS for Physical Therapy in April. She stated the facility had to resubmit the NFSS forms because the authorization for services was good for one month only. She stated that the facility then submitted Physical Therapy and Occupational Therapy in May, but Occupational Therapy was denied. She said they resubmitted Occupational Therapy again in June and was denied. She stated Resident #4 was currently in denial status for Occupational Therapy and that the facility had never submitted the NFSS for Speech Therapy. In an interview on 7/1/25 at 11:29 a.m. with the MDS Nurse, she reported she was not responsible for submitting NFSS requests for residents. She stated their rehabilitation therapist was responsible, and she was not at the facility. The MDS Nurse stated her responsibility to PASRR was ensuring a PASRR Level I screen (a required assessment for all applicants to Medicaid-certified nursing facilities to determine whether they might have a severe mental illness or intellectual disability) for residents were completed and referred to Level 2 screen (Individuals who test positive at Level I are then evaluated in depth, called Level II PASRR. The results of this evaluation results in determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care). The MDS nurse stated she was familiar with the 20-business day deadline to submit the NFSS request in the portal but that the Director of Rehabilitation oversaw doing those. She reported she attended the IDT meeting for Resident #4 a couple of weeks ago but could not recall the services recommended. She stated the NFSS forms had been submitted except one was denied. She stated she would have to get in touch with the Director of Rehabilitation to see the status of that. In an interview on 7/1/25 at 12:40 p.m. with the Regional Consultant Nurse, she reported she could not recall if she had participated in Resident #4's last IDT meeting. She stated the MDS Nurse handled PASRR, and the Director of Nursing would ultimately oversee the MDS Nurse. She stated she was not aware of what services Resident #4 was receiving. In an interview on 7/1/25 at 10:50 a.m. with the Director of Nursing, she reported Resident #4 was not receiving any specialized services because he was on hospice. She stated she believed he was PASRR Positive and could not remember what services were recommended. She stated she would participate in resident IDT meetings. She stated that the social worker or MDS nurse was responsible for submitting NFSS requests. She stated the MDS nurse was overseen by the Corporate Nurse. After checking records, the Director of Nursing stated Resident #4 had been receiving physical therapy since 5/7/25 and had been waiting approval for occupational therapy. In an interview on 7/2/25 at 10:45 a.m. with the Director of Rehabilitation, she stated she had overseen submitting the NFSS for PASRR positive residents. She stated she participated in Resident #4's IDT meeting on 6/18/25 over the phone. She stated Resident #4's NFSS was requested and approved and was good until 7/20/25. She stated they were in the process of resubmitting the NFSS for Occupational Therapy. She stated that Speech Therapy was never recommended for Resident #4; a NFSS had not been submitted. Review of an email dated 7/2/25 at 4:14 p.m. from the Regional Director of Nursing stated: Our admission Criteria policy also includes multiple references to the IDT and its use in care/decision making. As far as PASRR- we do not have a policy strictly for that program- but our admission Criteria policy (attached) covers the program under section 9: 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD.b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.(1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD.(2) The social worker is responsible for making referrals to the appropriate state-designated authority.c. Upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.d. The State PASARR representative provides a copy of the report to the facility.e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation.f. Once a decision is made, the State PASARR representative, the potential resident and his or her representative are notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that baseline care plans were completed within 48 hours of the resident's admission for 3 out of 5 residents (Resident #6, Resident #7, Resident #8) whose care was reviewed for baseline care plans.<BR/>The facility failed to ensure that baseline care plans were completed within 48 hours for Resident #6, Resident #7, and Resident #8.<BR/>This failure could place the resident at risk for not having continuity of care among nursing home staff to safeguard against adverse events that are most likely to occur right after admission.<BR/>The findings included:<BR/>Record Review of Resident #6's admission MDS assessment dated [DATE] reflected she was an [AGE] year-old female, admitted to the facility on [DATE]. She had a BIMS scoring of 14/15 indicating no cognitive impairment. Her diagnoses included: Muscle weakness, chronic respiratory failure with hypoxia (Condition where your body is not getting enough oxygen to your blood) and cognitive communication deficit (condition that refers to difficulties with communications that are affected by disruptions in cognition).<BR/>Record Review of Resident #6's Care Plans on 07/15/24 reflected no baseline care plan was completed. <BR/>Record Review of Resident #7's admission MDS assessment dated [DATE] reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. He had a BIMS scoring of 14/15 indicating no cognitive impairment. His diagnosis included: Malignant neoplasm of bladder (abnormal growth or cancerous tissue found in the bladder), muscle weakness and urinary tract infections. <BR/>Record Review of Resident #7's Care Plans on 07/15/24 reflected no baseline care plan completed. <BR/>Record Review of Resident #8's admission MDS assessment dated [DATE] reflected a [AGE] year-old female, re-admitted to the facility on [DATE]. He had a BIMS scoring of 9/15 indicating moderately impaired cognition. Her diagnoses included: Cerebral infarction (condition where the blood flow to the brain is disrupted) , Edema (condition that causes excess fluid accumulation in the body tissues) and Cognitive Communication Deficit (condition that refers to difficulties with communications that are affected by disruptions in cognition). <BR/>Record Review of Resident #8's Care Plans on 07/15/24 reflected no baseline care plan completed.<BR/>An interview on 07/16/24 with the DON at 9:35 AM revealed that he was unsure of what the baseline care plan was. The DON said the MDS Nurse was responsible for completing the baseline care plan on admission. The DON revealed that risks to the residents without baseline care plans could include missing care for the resident.<BR/>An interview on 07/16/24 at 9:50 AM with the MDS nurse revealed that the admitting nurses were responsible for completing the baseline care plans. The MDS Nurse revealed that the nursing management including the ADON, DON and MDS Nurse audited the residents clinical record daily to ensure compliance of baseline care plans. The MDS Nurse revealed that risks to the residents without base care plans could include missing items in the resident's comprehensive plan of care. <BR/>An interview on 0 7/17/24 at 3:46 PM with LVN B revealed that it would be the admitting nurse's responsibility to complete the baseline care plan. LVN B revealed that the baseline care plan should be completed within 24 hours admission. <BR/>Interview on o7/18/24 at 4:08 PM with the Administrator revealed that the admitting nursing staff was responsible for ensuring all admitting assessments and documentation was completed. The administrator stated that the resident could face service delays if baseline care plans were not completed. <BR/>A review of the facility policy titled, Care plans Preliminary, revised on August 2006, reflected that a preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission. Per the facility policy, the preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop the interdisciplinary plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #2 and Resident #3) of five residents reviewed for ADLs. <BR/>The facility failed to provide showers or bed baths consistently for Residents #2 and #3 per the facility bathing schedule in January 2025. <BR/>This failure placed residents who were dependent on staff for bathing at risk for poor personal hygiene, odors, and a decline in their quality of life. <BR/>Findings included:<BR/>1. Record review of Resident #2's Face Sheet reflected dated 01/30/25 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2's active diagnoses included paraplegia (a condition that causes paralysis or loss of muscle function in both legs), neuromuscular dysfunction of bladder (impaired bladder control due to disrupted communication between the brain and the bladder muscles), Stage 4 pressure ulcer of right heel and Stage 4 pressure ulcer of right lower back (a pressure ulcer is localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction; Stage 4 means full thickness tissue loss with exposed bone, tendon or muscle).<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 15 which indicated no cognitive impairment. Resident #2 had range of motion impairment on both sides of his lower extremities and used a wheelchair for mobility. Resident #2 required partial/moderate assistance from staff for bathing and personal hygiene. He had an indwelling and external catheter (a flexible tube inserted into the body to drain or deliver fluids) and ostomy (a surgical procedure that creates an opening in the abdomen to allow waste to exit the body).<BR/>Record review of Resident #2's baseline care plan dated 01/22/25 reflected he was dependent on staff for toileting hygiene and showers/bathing.<BR/>An interview with Resident #2 on 01/30/25 at 1:49 PM revealed he had been moved to the room he was presently in several days prior and there was no hot or warm water available in his bathroom to use. Resident #2 stated he had let the water run in his bathroom sink for over an hour when he first moved to the room, but there was only cold water. He said the shower at the end of his hall also did not have any hot or warm water. Resident #2 said he had not received a shower the past two scheduled times (01/27/25 and 01/29/25). Resident #2 stated he felt not having hot or warm water available in his room made him feel very dirty, he said he could not wash his face well and it was starting to breakout and his skin was starting to get itchy all over.<BR/>Record review of Resident #2's nursing progress notes reflected no shower refusals since his readmission to the facility from the hospital on [DATE].<BR/>2. Record review of Resident #3's Face Sheet dated 01/30/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #3's active diagnoses included paraplegia (a condition that causes paralysis or loss of muscle function in both legs), colostomy status (a surgical procedure that creates an opening in the colon, allowing stool to be diverted from the rectum and collected in a bag), Stage 4 right and left lower back pressure ulcer, stage 4 of sacral region (Full thickness tissue loss with exposed bone, tendon or muscle) and flaccid neuropathic bladder (a condition where the bladder muscles are weak and unable to contract properly, leading to difficulty or inability to urinate). <BR/>Record review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated no cognitive impairment. Resident #3 had range of motion impairment on one side of his upper extremities and on both sides of his lower extremities. He used a wheelchair for mobility and was dependent on staff for all ADLs, including showering and personal hygiene. <BR/>Record review of Resident #3's care plan last revised 01/28/25 reflected Resident #3 had an ADL self-care performance. Interventions, Bathing/Showering: Resident prefers showers 3 times per week likes to get oob daily; The resident requires extensive assistance by (1) staff with bathing/showering (start 09/30/24)<BR/>An interview and observation of Resident #3 on 01/30/25 at 2:03 PM revealed he was sitting in a reclined wheelchair in his room with his eyes closed. Resident #3 stated he had not been bathed or showered in the past week. He said he could not remember the last time he had been bathed but it had been a long time, over a month. During the interview, Resident #3 kept trying to peel his right eye open with his fingers as it was observed to be crusty and sealed shut. Resident #3 said he did not know why the staff were not bathing him and stated, They don't tell me why. I want one though. Resident #3's bathroom sink was observed to have no hot or warm water available. <BR/>Record review of Resident #3's nursing progress notes reflected no shower refusals for the month of January 2025. <BR/>3. An observation of Resident #2 and #3's shower room at the end of Hall 400 on 01/30/25 at 1:56 PM revealed there was no hot or warm water coming from the shower faucet.<BR/>4. Review of the facility shower binder for Hall 400 reflected no shower sheets for Residents #2 and #3 for January 2025. There were daily lists of residents to be showered with a space for the nurse to sign with any comments. However, neither Resident #2 nor Resident #3 were checked off as completed. <BR/>5. An interview with ADON A on 01/30/25 at 12:19 PM revealed completed shower sheets were important because that was the way the facility kept track of any new resident skin issues. ADON A stated she had looked in the binders and verified there were no shower sheets for Resident #2 and #3. ADON A stated what she saw in the shower binders at the 400-hall nursing station was just a list for the charge nurse to sign off on which residents were supposed to get showered that day. ADON A stated, But they were not the shower sheets. ADON A stated she did not know how long the CNAs and charge nurses had not been using shower sheets. ADON A stated the list of who needed a shower was not acceptable. She said the shower sheets needed to be completed and turned in by the CNAs for review to see if there were any changes to a resident's skin condition. ADON A stated the form they were using currently did not indicate if any skin was looked at or if any skin issues were noted. ADON A said she was going to ensure that the required blank shower sheets were copied and placed back into the shower binders along with the schedule list of residents to be showered for that day so they can be tracked and monitored. ADON A stated she did not know why the system changed except laziness and no one put more shower sheets in the binders, so they all defaulted to just signing a schedule, Which is not appropriate. <BR/>An interview with the ADM on 01/30/25 at 9:30 AM revealed the DON was out sick on leave and was unable to be interviewed. <BR/>An interview with CNA C on 01/31/25 at 12:37 PM revealed she had not seen any skin observation sheets (shower sheets) and when she gave a resident a shower, she just circled on a list if the resident received it or if they refused. If any skin issues, she would circle yes/no and then report to the charge nurse. When shown a blank shower sheet/skin observation sheet, CNA C stated she had not seen them before and had not been filling those out. CNA C stated showering a resident was important because no one wanted to have body odor and they want to smell fresh. CNA C stated infection control was also another reason showers were important, We have bacteria on our skin and we need to shower to remove it and protect the skin, like rashes and stuff, showering is good. <BR/>An interview with CNA D on 01/31/25 at 12:56 PM revealed she was picking up a shift and had showered Resident #1 that morning (01/31/25). CNA D stated she had another CNA help her shower Resident #1 and he took them a lot of time. She stated when a resident shower was completed, there was a paper that had the name and room number of the residents assigned to be showered for that day. If the resident refused the shower, the CNA had to tell the nurse. CNA D stated she had not seen the shower sheet form/skin observation sheet recently. <BR/>An interview with the ADM on 01/31/25 at 1:54 PM revealed he had heard about Resident #2 not being showered because his family member had contacted him on 01/30/25 about it. The ADM stated he completed a grievance form as a result. The ADM reviewed the shower binder and the schedule the nurse checked off that staff were using as shower sheets and said it was not the right form. He said the shower sheets to be used were more comprehensive. <BR/>6. A policy on ADL care related to showers was requested on 01/30/25 and 01/31/25 from the ADM but was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 8 residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 was provided with adequate supervision to prevent her from eloping from the facility on 02/17/24.<BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/09/24 and ended on 02/27/24. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Record review Resident #1's Face sheet dated was admitted to the facility on [DATE]. Resident #1 was diagnosed with unspecified Dementia, major depressive disorder, psychotic disorder with delusions due to known physiological condition, and adjustment disorder with anxiety.<BR/>Record review of Resident #1's MDS assessment dated [DATE] revealed she had a BIMS score of 0 indicating severe cognitive impairment. She was rarely/never understood. The MDS Assessment indicated she did not exhibit wandering behavior symptoms. The MDS Assessment indicated the resident did not have an electronic device that monitored resident movement and alerted staff.<BR/>Record review of Resident#1 care plan dated 11/15/21 revealed: Resident #1 was an elopement risk/wander as evidenced by non-goal directed wandering in/out of rooms, exhibited exit seeking behaviors. Resident #1 goals revised on 02/06/24 revealed: Resident #1's safety will be maintained Record review of care plan revealed: Interventions dated 11/15/21: disguise exits, cover doors knobs and handles, tape floor, identify the pattern of wandering and intervene as appropriate. Provide structed activities .reorientation strategies including signs, pictures .<BR/>Record review of progress notes revealed, no documentation of time when Resident#1 went missing and what time the resident was found and returned to the facility. Record review of the progress note revealed, staff did not notice resident#1 was missing until mealtime. The facility was searched, and a code yellow was called. Progress note revealed Resident #1 was found loitering by the police down the street and staff returned her to the facility with Progress reports revealed, Resident #1 received a skin, pain and elopement risk assessment. Progress note revealed Resident#1's family member, Administrator, acting Director of Nursing, Medical Doctor was notified. Progress notes revealed Resident was monitored every 15 minutes.<BR/>Record review of the facility's Provider Investigation report undated revealed the following: <BR/>[Resident#1] was in the dining room, we believe a visitor or staff held the door for [Resident#1], not realizing she was an elopement risk. Staff realized resident was missing approximately 10 minute and called code pink was called She was not located in the facility One staff member got in her vehicle to look for resident. Record review of Provider Investigation Report revealed, Staff flagged a police officer down and the police had located resident at an apartment complex down the street and returned her to the facility. nursing staff did a head to toe skin assessment with no injuries noted, pain assessment . Completed new elopement risk assessment and checked on Resident#1 every 15 minutes <BR/>Record review of staff in-services dated 02/19/24, 02/20/24 and 02/27/24 revealed, abuse, neglect, resident care and elopement were covered.<BR/>Observation on 02/28/24 at 8: 20 AM revealed, residents who needed to be in the secure unit were present. <BR/>Interview on 02/28/24 at 08:30 AM, CNA N stated residents in the secure unit were moved to the general population because of construction that was going on in the facility. General population residents and secure unit's residents were mixed between halls 500, 300 and 400. CNA N stated the risk to the residents was they could escape from the facility. CNA N stated she did not witness the elopement. CNA N stated Resident #1 eloped during dinner on second shift. CNA N stated she was in-serviced on the facility procedures for elopement. <BR/>Interview on 02/28/24 at 8:40 AM, CNA P stated he was on vacation when Resident #1 eloped from the facility. CNA P stated he was in-serviced on elopement when he returned to the facility and the residents were back in the secure unit. <BR/>Interview on 02/28/24 at 9:00 AM with LVN X stated the elopement happened around dinner time and staff believed a visitor held the door open for her not knowing she was a resident. LVN X stated she had been in-serviced on elopement and the residents who belong in the secure unit were back in the unit.<BR/>A telephone interview on 02/28/24 at 1:37 PM with the local police department dispatcher stated, no police report was completed for Resident#1. <BR/>A telephone interview on 02/28/24 at 2:52 PM with the CNA C revealed she was on break and when she returned, she was told the resident was missing. CNA C stated, she did a head count, and the resident was not found. CNA C stated residents were in danger of elopement if they are not supervised. Certified Nurse Aide C stated she understood the facilities policy and procedures for when a resident elopes. CNA C stated, was in-serviced about elopements. <BR/>A telephone interview on 02/28/24 at 2:39 PM with LVN D stated, Resident#1 could not be found in the dining room when trays were passed out. Licensed Vocational Nurse D stated, she drove around the neighborhood and met up with a police officer who stated they found a lady wandering in the apartments LVN D followed the police officer to the apartment. LVN D stated Resident#1 was combative and LVN D called the weekend supervisor who drove to the apartments and was able to get Resident#1 into the car. LVN D stated some of the residents were moved back into the secure unit, but she said that they did not get full clearance to put all the residents back. Some of the secure unit residents were left in general population. LVN D stated all residents were returned to the secure unit on 02/18/24. LVN D stated she was in-serviced on elopement before and after Resident #1 left the facility. <BR/>Interview on 02/28/24 at 3:30 PM with the Administrator revealed residents from the secure unit were brought to general population because of construction and both exits in the secure unit needed to be accessible. The Administrator stated Resident #1 went missing around dinner time 02/17/24, which usually started at 5:30 PM. The Administrator stated Resident#1 was found outside the facility down the street and brought back. The Administrator stated she believed that Resident#1 walked out of the facility with a visitor.<BR/>Interview on 02/29/24 at 2:15 PM with the Administrator revealed residents from the secure unit were mixed with the general population on 02/09/24 and were able to return to the secure unit on 02/14/24, according to her records. The Administrator stated she did not realize secure unit residents were still in general population until 02/18/24. The Administrator stated that in the future she would have more staff to come in to monitor the exits if the secure unit residents must come back to general population.

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to 1 of 1 treatment carts and 1 (300 Hall) of 4 Nurse Medication Carts. <BR/>1. <BR/>Nursing Staff failed to ensure the facility's only treatment cart was locked. <BR/>2. <BR/>LVN B failed to ensure the 300 Hall Nurse Medication Cart was locked and secured. <BR/>These failures could affect all residents by placing them at risk of ingestion/exposure to medications not intended for them and possible drug diversion. <BR/>Findings included:<BR/>An observation on 07/27/2023 at 9:50AM revealed an unlocked treatment cart in the lounge area near 300 Hall. One resident was observed in a wheelchair directly in front of the cart and one resident, who used a walker, was observed in the area arranging furniture and tidying up the room. A review of the contents of the cart revealed Santyl (used to help the healing of burns and skin ulcers), scissors, Nystatin Cream (a medicated cream or ointment that treats fungal or yeast infections in your skin), Zinc Oxide (used to treat and prevent diaper rash), and vitamin A and D ointment (used as a moisturizer to prevent dry skin). <BR/>In an interview with the DON on 07/27/2023 at 9:55AM, she said the treatment cart was not assigned to any one person. She said all nurses had access to the only treatment cart they used. She said the cart should be locked to prevent residents from getting into the treatment ointments kept in the cart. She said they could be potentially harmful if consumed. <BR/>In an interview on 07/27/2023 at 10:40AM with LVN A, she said the treatment cart was shared by nursing staff but should be kept locked to ensure residents could not get into treatment ointments or sharp objects that were in the cart. She said she had not used the cart today and had not noticed that it was unlocked. She said she had been in-serviced on locking medication carts but could not recall when. <BR/>An interview on 07/27/2023 at 10:40AM with LVN B revealed nursing staff were responsible to ensure their carts were secured and any expired medications were removed from the cart. She said she had not used the treatment cart today, but it should be locked to prevent residents from getting into it. <BR/>In an interview on 07/27/2023 at 2:04PM with the Administrator and DON, the Administrator stated she expected nursing staff to secure their medication carts and treatment cart at all times. She said this was necessary to ensure the safety of residents by preventing them from getting into meds not prescribed to them. <BR/>In an interview on 07/27/2023 at 3:08PM the DON said nurses were responsible to ensure thier medication carts were locked and she and the ADON were responsible for monitoring this. The DON said she would provide the last in-service training for locking medication carts and removing expired medications from carts. None were provided at the time of exit. <BR/>An observation on 07/27/2023 at 3:35PM revealed the 300 Hall nurse medication cart was unlocked. The cart's drawers were faced outward to the hall and one resident, in a wheelchair, was in front of the cart. LVN C was observed seated behind the nurse station faced to opposite direction. <BR/>In an interview on 07/27/2023 at 3:36PM, LVN C said he was responsible for the 300 Hall Nurse Medication Cart and should have locked the cart because he could not see it from behind the nurses' station. He said medication carts should always be secured to ensure residents could not consume medications not prescribed to them and limit the possibility of a drug diversion.<BR/>Review of the facility's policy titled Medication Storage Policy, revised April 2007, reflected The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services.<BR/>1) <BR/>The facility failed to ensure food items were properly labeled and dated with the product's name.<BR/>2) <BR/>The facility failed to ensure food items were properly sealed when not in use.<BR/>These failures could place residents at risk for food-borne illness and food contamination.<BR/>Findings include:<BR/>An observation on 5/21/2025 at 11:50 AM revealed in the dry food pantry one large plastic container of rice (was not labeled with the product type or dated); one opened bag of potato chips wrapped in plastic wrap (was undated and not properly stored according to the facility's policy); one opened bag of tortilla chips wrapped in plastic wrap (was undated and not properly stored according to the facility's policy).<BR/>An observation on 5/21/2025 at 12:10 PM in the large refrigerator revealed two bags of opened bread (was not labeled, dated, nor properly stored); white gravy in a plastic container covered with plastic wrap (had a large hole in the plastic wrap); chopped up meat (was not labeled with the product type or dated); one opened pack of deli meat (was not labeled with the product name or dated); one large bowl was uncovered which contained chocolate pudding (was not labeled with the product name or dated).<BR/>An observation on 5/21/2025 at 12:30 PM in the walk-in freezer revealed an opened plastic bag with four meat patties (were not labeled with the product name or dated); two opened large packs of hamburger buns (was not labeled or dated) and one large roll of ground beef (was not labeled with the product name or dated).<BR/>In an interview on 5/21/2025 at 1:25 PM, the DM stated she worked at the facility for 3 days. The DM stated all kitchen staff were responsible for labeling and dating all items. The DM stated when staff opened anything, all unused products must be placed inside of a Ziplock bag or container and labeled and dated. The DM stated all leftover cooked items, must be stored in a closed container, labeled, and dated. The DM stated the brown substance in the large bowl was chocolate pudding the worker had just made for tonight's dinner. The DM stated frozen foods should be dated upon arrival to the facility. The DM stated if the frozen boxes were emptied all removed bags of that item, must be labeled, and dated. The DM stated based on her first 3 days of observations, she needed to in-service staff regarding proper labeling and dating. The DM stated serving residents expired food or food not properly stored according to the facility's policy could cause food poisoning and make the resident ill. <BR/>In an interview on 5/21/2025 at 2:00 PM, DA A stated whenever stocked the food from the delivery truck, must date it. DA A stated any opened dry food must be placed in a container, properly labeled and dated. DA A stated any opened perishable food must be placed in a Zip Loc bag, labeled, and dated. DA A stated not following protocol could make the residents sick.<BR/>In an interview on 5/21/2025 at 3:20 PM, DA B stated the entire staff was responsible for labeling and dating opened containers and packages. DA B stated without a proper label and date, the next worker would not know when the items were placed there. DA B said the DM was in charge of overseeing the kitchen and she instructed them to label everything. DA B said failing to do so placed the residents at risk of becoming ill.<BR/>In an interview on 5/21/2025 at 3:35 PM, the ADM stated all food should be labeled, dated, and stored properly. The ADM stated the kitchen staff should know when food was made and what it was being used for at the time. The ADM stated this was important to prevent the residents from becoming ill. The ADM stated they must continue to educate staff on proper food storage and safety.<BR/>Record review of the facility's policy titled Accepting Food Deliveries, published date of 2013, reflected Food deliveries will be accepted into the facility only by the following procedure . 4. Perishable foods will be properly covered, labeled, and dated and promptly stored in the refrigerator or freezer as appropriate.<BR/>Record review of the facility's policy titled Food Storage, published date of 2013, reflected:<BR/> .4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated . <BR/>c. Food should be dated as it is placed on the shelves .<BR/>13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded.<BR/>14. Refrigerated Food Storage . f. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.<BR/>15. Frozen Foods . c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 help prevent the development and transmission of infection for 5 (Residents #2, #3, #4, #5, and #6) of 12 residents reviewed for infection control. <BR/>1. <BR/>On 04/30/24 MA A, CNA B, and CNA C brought Residents #2, #3, #4, #5, and #6 to the locked unit dining room and fed them and did not wash their hands nor the hands of the residents.<BR/>2. <BR/>On 04/30/24 CNA B assisted Residents #2, #3, and #4 with their noon meals, he cut up their food and fed them and did not sanitize his hands.<BR/>3. <BR/>On 04/30/24 CNA C touched the hand of Resident #5 and assisted him to his seat then touched his eating utensil without sanitizing her hands.<BR/>4. <BR/>On 04/30/24 during the noon meal on the locked unit a visitor brought cookies to the residents, this visitor used her ungloved hands and gave each resident present (#2, #3, #4, #5, #6) a cookie without sanitizing her hands.<BR/>This deficient practice placed residents who received assistance with meals in the Locked Unit Dining Room at risk for cross contamination and infections.<BR/>Findings included:<BR/>Review of Resident #2's Care Plan dated 07/12/23, revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with an intervention of limited assistance by staff to eat. Diagnoses included Dementia (a group of thinking and social symptom that interferes with daily functioning), and bipolar disorder (associated with episodes of mood swings ranging from depressive lows to manic highs). <BR/>Review of the most recent quarterly MDS assessment dated [DATE], revealed Resident #2, had a BIMS score of 3 (cognition was severely impaired). Resident #2's eating assessment reflected she required partial/moderate assistance-Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.<BR/>Review of Resident #3's Care Plan dated 01/24/24, revealed Resident #3 was an [AGE] year-old male admitted to the facility on [DATE] with an intervention of set up assistance by staff to eat. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #3's quarterly MDS assessment reflected he had a BIMS score of 00 (cognition was severely impaired). Resident #3's eating assessment reflected he required setup or clean-up assistance-Helper sets up or cleans up; resident completes activity.<BR/>Review of Resident #4's Care Plan dated 11/07/23, revealed Resident #4 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #4's quarterly MDS assessment reflected no BIMS score noted. Resident #4's eating assessment reflected she required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>Review of Resident #5's Care Plan dated 02/06/24, revealed Resident #5 was an [AGE] year-old female admitted to the facility on [DATE] with an intervention that the resident is independent for eating. Diagnoses included Dementia (a group of thinking and social symptom that interferes with daily functioning).<BR/> Review of Resident #5's quarterly MDS assessment reflected a BIMS score was not completed. Resident #5's eating assessment reflected she required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>Review of Resident #6's Care Plan dated 04/14/23, revealed Resident #6 was an [AGE] year-old male admitted to the facility on [DATE] with an intervention of limited assistance by staff to eat. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #6's change in condition MDS assessment reflected a BIMS score was not completed. Resident #6's eating assessment was not completed.<BR/>Observation on 04/30/24 at 12:45 PM revealed MA A walked into the dining room on the locked unit, and she assisted Resident #2 to a table and helped her to sit. MA A took the lid off the plate of Resident #2 then she touched her eating utensil and fed Resident #2. MA A did not sanitize her hands or the hands of Resident #2.<BR/>During an observation on 04/30/24 at 12:46 PM, CNA B took the eating utensil of Resident #3 and cut up his food. Then he went to Resident #4 and used her eating utensil to cut up her food. CNA B then moved to Resident #5, picked up her eating utensil and fed her. He did not sanitize his hands before he moved to and from each resident to assist. He did not sanitize the hands of the resident before assisting them to eat.<BR/>During an observation on 04/30/24 at 12:48 PM, Resident #6 got up from the table. CNA B went outside the door of the dining area to follow Resident #6 out of the dining room. CNA B touched Resident #6 on his arm to redirect him back to the dining table, then CNA B returned to Resident #5 and fed her again. He did not sanitize his hands after he touched or fed a resident. <BR/>Observation on 04/30/24 at 12:49 PM revealed CNA B left Resident #5 and went to assist Resident #4 back to her table to eat by touching her arm. Then he returned to Resident #5 without sanitizing his hands. <BR/>Observation on 04/30/24 at 12:50 PM revealed CNA C assisted Resident #6 back to his table when she took his hand and helped him sit down. Then she picked up his eating utensil from his plate and assisted him to eat. She did not sanitize her hands or the hands of the resident.<BR/>Observation on 04/30/24 at 12:51 PM revealed CNA B moved from Resident #5 and took the eating utensil for Resident #3 and put it back in his hand and encouraged him to eat. He did not sanitize his hands. <BR/>Observation on 04/30/24 at 12:55 PM revealed a visitor entered the dining area on the locked unit with a container of cookies. The visitor handed out cookies to Residents #2, #3, #4, #5, and #6. The visitor did not sanitize her hands before she gave the residents cookies. The visitor did not put on gloves prior to passing out the cookies to the residents.<BR/>In an interview on 04/30/24 at 1:09 PM with CNA B revealed he did not have any hand sanitizer on his person in the dining area and there was not any in the dining area at lunch. He stated there was some hand sanitizer in the nursing station which was located down the hall. He stated he had been trained on infection control. He stated he was not supposed to move from one table to another table or one resident to another resident and touch them without sanitizing his hands. He stated the residents should not have been given cookies by the visitor. He stated the risk to the residents was the transmission of germs that could cause infection.<BR/>In an interview on 04/30/24 at 1:21 PM with CNA C revealed she did not have any hand sanitizer on her person when she was in the dining area at lunch. She stated they do not keep the sanitizer out in the dining room because of the residents' attempts to get the sanitizer. She stated there is hand sanitizer in the closet in the nurses' station. She stated the visitor should have asked if they could give the residents cookies. She stated the risk to the residents was the spread of germs and infection when the staff did not sanitize their hands when working with several residents.<BR/>In an interview on 04/30/24 at 1:40 PM with LVN revealed she was the supervisor of the staff working in the locked unit. She stated during lunch she mostly worked on another hall. She stated the hand sanitizer was available in the nurse room, but the door has been taken down and they must keep all the sanitizer put up out of reach of the residents. She stated all the staff should have known the hand sanitizer was in the closet in the nurse room. She stated she did not remember the last infection control training they took. She stated the visitor should not have handed out cookies to the residents without sanitizing hands. She stated the risk to residents was infection, passing germs, and viruses because staff had not sanitized their hands during the lunch meal.<BR/>In an interview on 04/30/24 at 2:15 PM with MA A revealed she did not have hand sanitizer in her pocket. She stated hand sanitizer was in the nurses' room down the hall. She stated she had washed her hands before she went into the dining area. She stated staff should have sanitized their hands when they worked with several residents during the lunch meal. She stated the resident was at risk of infection when the staff did not sanitize between residents. <BR/>In an interview on 04/30/24 at 4:35 PM with the Administrator revealed the DON and herself was responsible to ensure staff was trained on IC. She stated the DON completed monthly in-services on IC. She stated the DON was currently in the hospital and not available for interview. She stated the staff had put the residents at potential risk of infection and illness when they did not sanitize their hands. She stated the staff should have told the residents to wash their hands before the meal. She stated there was hand hygiene supplies available throughout the building and if there was not any in the dining area, the staff could have asked her or the housekeeper. <BR/>Record review of facility's Policies and Practices -Infection Control revised August 2010 reflected, All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 8 residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 was provided with adequate supervision to prevent her from eloping from the facility on 02/17/24.<BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/09/24 and ended on 02/27/24. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Record review Resident #1's Face sheet dated was admitted to the facility on [DATE]. Resident #1 was diagnosed with unspecified Dementia, major depressive disorder, psychotic disorder with delusions due to known physiological condition, and adjustment disorder with anxiety.<BR/>Record review of Resident #1's MDS assessment dated [DATE] revealed she had a BIMS score of 0 indicating severe cognitive impairment. She was rarely/never understood. The MDS Assessment indicated she did not exhibit wandering behavior symptoms. The MDS Assessment indicated the resident did not have an electronic device that monitored resident movement and alerted staff.<BR/>Record review of Resident#1 care plan dated 11/15/21 revealed: Resident #1 was an elopement risk/wander as evidenced by non-goal directed wandering in/out of rooms, exhibited exit seeking behaviors. Resident #1 goals revised on 02/06/24 revealed: Resident #1's safety will be maintained Record review of care plan revealed: Interventions dated 11/15/21: disguise exits, cover doors knobs and handles, tape floor, identify the pattern of wandering and intervene as appropriate. Provide structed activities .reorientation strategies including signs, pictures .<BR/>Record review of progress notes revealed, no documentation of time when Resident#1 went missing and what time the resident was found and returned to the facility. Record review of the progress note revealed, staff did not notice resident#1 was missing until mealtime. The facility was searched, and a code yellow was called. Progress note revealed Resident #1 was found loitering by the police down the street and staff returned her to the facility with Progress reports revealed, Resident #1 received a skin, pain and elopement risk assessment. Progress note revealed Resident#1's family member, Administrator, acting Director of Nursing, Medical Doctor was notified. Progress notes revealed Resident was monitored every 15 minutes.<BR/>Record review of the facility's Provider Investigation report undated revealed the following: <BR/>[Resident#1] was in the dining room, we believe a visitor or staff held the door for [Resident#1], not realizing she was an elopement risk. Staff realized resident was missing approximately 10 minute and called code pink was called She was not located in the facility One staff member got in her vehicle to look for resident. Record review of Provider Investigation Report revealed, Staff flagged a police officer down and the police had located resident at an apartment complex down the street and returned her to the facility. nursing staff did a head to toe skin assessment with no injuries noted, pain assessment . Completed new elopement risk assessment and checked on Resident#1 every 15 minutes <BR/>Record review of staff in-services dated 02/19/24, 02/20/24 and 02/27/24 revealed, abuse, neglect, resident care and elopement were covered.<BR/>Observation on 02/28/24 at 8: 20 AM revealed, residents who needed to be in the secure unit were present. <BR/>Interview on 02/28/24 at 08:30 AM, CNA N stated residents in the secure unit were moved to the general population because of construction that was going on in the facility. General population residents and secure unit's residents were mixed between halls 500, 300 and 400. CNA N stated the risk to the residents was they could escape from the facility. CNA N stated she did not witness the elopement. CNA N stated Resident #1 eloped during dinner on second shift. CNA N stated she was in-serviced on the facility procedures for elopement. <BR/>Interview on 02/28/24 at 8:40 AM, CNA P stated he was on vacation when Resident #1 eloped from the facility. CNA P stated he was in-serviced on elopement when he returned to the facility and the residents were back in the secure unit. <BR/>Interview on 02/28/24 at 9:00 AM with LVN X stated the elopement happened around dinner time and staff believed a visitor held the door open for her not knowing she was a resident. LVN X stated she had been in-serviced on elopement and the residents who belong in the secure unit were back in the unit.<BR/>A telephone interview on 02/28/24 at 1:37 PM with the local police department dispatcher stated, no police report was completed for Resident#1. <BR/>A telephone interview on 02/28/24 at 2:52 PM with the CNA C revealed she was on break and when she returned, she was told the resident was missing. CNA C stated, she did a head count, and the resident was not found. CNA C stated residents were in danger of elopement if they are not supervised. Certified Nurse Aide C stated she understood the facilities policy and procedures for when a resident elopes. CNA C stated, was in-serviced about elopements. <BR/>A telephone interview on 02/28/24 at 2:39 PM with LVN D stated, Resident#1 could not be found in the dining room when trays were passed out. Licensed Vocational Nurse D stated, she drove around the neighborhood and met up with a police officer who stated they found a lady wandering in the apartments LVN D followed the police officer to the apartment. LVN D stated Resident#1 was combative and LVN D called the weekend supervisor who drove to the apartments and was able to get Resident#1 into the car. LVN D stated some of the residents were moved back into the secure unit, but she said that they did not get full clearance to put all the residents back. Some of the secure unit residents were left in general population. LVN D stated all residents were returned to the secure unit on 02/18/24. LVN D stated she was in-serviced on elopement before and after Resident #1 left the facility. <BR/>Interview on 02/28/24 at 3:30 PM with the Administrator revealed residents from the secure unit were brought to general population because of construction and both exits in the secure unit needed to be accessible. The Administrator stated Resident #1 went missing around dinner time 02/17/24, which usually started at 5:30 PM. The Administrator stated Resident#1 was found outside the facility down the street and brought back. The Administrator stated she believed that Resident#1 walked out of the facility with a visitor.<BR/>Interview on 02/29/24 at 2:15 PM with the Administrator revealed residents from the secure unit were mixed with the general population on 02/09/24 and were able to return to the secure unit on 02/14/24, according to her records. The Administrator stated she did not realize secure unit residents were still in general population until 02/18/24. The Administrator stated that in the future she would have more staff to come in to monitor the exits if the secure unit residents must come back to general population.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services.<BR/>1) <BR/>The facility failed to ensure food items were properly labeled and dated with the product's name.<BR/>2) <BR/>The facility failed to ensure food items were properly sealed when not in use.<BR/>These failures could place residents at risk for food-borne illness and food contamination.<BR/>Findings include:<BR/>An observation on 5/21/2025 at 11:50 AM revealed in the dry food pantry one large plastic container of rice (was not labeled with the product type or dated); one opened bag of potato chips wrapped in plastic wrap (was undated and not properly stored according to the facility's policy); one opened bag of tortilla chips wrapped in plastic wrap (was undated and not properly stored according to the facility's policy).<BR/>An observation on 5/21/2025 at 12:10 PM in the large refrigerator revealed two bags of opened bread (was not labeled, dated, nor properly stored); white gravy in a plastic container covered with plastic wrap (had a large hole in the plastic wrap); chopped up meat (was not labeled with the product type or dated); one opened pack of deli meat (was not labeled with the product name or dated); one large bowl was uncovered which contained chocolate pudding (was not labeled with the product name or dated).<BR/>An observation on 5/21/2025 at 12:30 PM in the walk-in freezer revealed an opened plastic bag with four meat patties (were not labeled with the product name or dated); two opened large packs of hamburger buns (was not labeled or dated) and one large roll of ground beef (was not labeled with the product name or dated).<BR/>In an interview on 5/21/2025 at 1:25 PM, the DM stated she worked at the facility for 3 days. The DM stated all kitchen staff were responsible for labeling and dating all items. The DM stated when staff opened anything, all unused products must be placed inside of a Ziplock bag or container and labeled and dated. The DM stated all leftover cooked items, must be stored in a closed container, labeled, and dated. The DM stated the brown substance in the large bowl was chocolate pudding the worker had just made for tonight's dinner. The DM stated frozen foods should be dated upon arrival to the facility. The DM stated if the frozen boxes were emptied all removed bags of that item, must be labeled, and dated. The DM stated based on her first 3 days of observations, she needed to in-service staff regarding proper labeling and dating. The DM stated serving residents expired food or food not properly stored according to the facility's policy could cause food poisoning and make the resident ill. <BR/>In an interview on 5/21/2025 at 2:00 PM, DA A stated whenever stocked the food from the delivery truck, must date it. DA A stated any opened dry food must be placed in a container, properly labeled and dated. DA A stated any opened perishable food must be placed in a Zip Loc bag, labeled, and dated. DA A stated not following protocol could make the residents sick.<BR/>In an interview on 5/21/2025 at 3:20 PM, DA B stated the entire staff was responsible for labeling and dating opened containers and packages. DA B stated without a proper label and date, the next worker would not know when the items were placed there. DA B said the DM was in charge of overseeing the kitchen and she instructed them to label everything. DA B said failing to do so placed the residents at risk of becoming ill.<BR/>In an interview on 5/21/2025 at 3:35 PM, the ADM stated all food should be labeled, dated, and stored properly. The ADM stated the kitchen staff should know when food was made and what it was being used for at the time. The ADM stated this was important to prevent the residents from becoming ill. The ADM stated they must continue to educate staff on proper food storage and safety.<BR/>Record review of the facility's policy titled Accepting Food Deliveries, published date of 2013, reflected Food deliveries will be accepted into the facility only by the following procedure . 4. Perishable foods will be properly covered, labeled, and dated and promptly stored in the refrigerator or freezer as appropriate.<BR/>Record review of the facility's policy titled Food Storage, published date of 2013, reflected:<BR/> .4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated . <BR/>c. Food should be dated as it is placed on the shelves .<BR/>13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded.<BR/>14. Refrigerated Food Storage . f. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.<BR/>15. Frozen Foods . c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for four residents (Resident #1, Resident #2, Resident #6, and Resident #7) of 83 residents reviewed for resident call system in that: The facility failed to ensure the call lights in Resident #1's and Resident #2's shared room were in working order. Resident #1 was not able to use her call light to call for help when she was physically assaulted by her roommate, Resident #2. On 07/25/25 at 11:20 AM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/26/25 the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that was not immediate jeopardy due to the facility's need to monitor the implementation and the effectiveness of their Plan of Removal. The facility failed to ensure call lights were flashing outside Resident #6's and Resident #7's rooms to ensure staff knew the Residents needed assistance. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.Based on observations, interviews and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for four residents (Resident #1, Resident #2, Resident #6, and Resident #7) of 83 residents reviewed for resident call system in that: The facility failed to ensure the call lights in Resident #1's and Resident #2's shared room were in working order. Resident #1 was not able to use her call light to call for help when she was physically assaulted by her roommate, Resident #2.xOn 07/25/25 at 11:20 AM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/26/25 the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that was not immediate jeopardy due to the facility's need to monitor the implementation and the effectiveness of their Plan of Removal. The facility failed to ensure call lights were flashing outside Resident #6's and Resident #7's rooms to ensure staff knew the Residents needed assistance . This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.Findings included:Record review of Resident #1's admission record, dated 07/24/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, cognitive communication deficit (communication disorder stemming from cognitive impairments that affect a person's ability to communicate effectively), bipolar disorder (associated with episode of mood swings ranging from depressive lows to manic highs), calculus of kidney(small, hard deposit that forms in the kidneys and is often painful when passed), morbid (severe) obesity (a disorder that involves having too much body fat, which increases the risk of health problems), and paraplegia (condition characterized by the loss or impairment of motor and sensory functions in the lower half of the body).Record review of Resident #1's care plan dated 6/13/25 reflected the resident had limited physical mobility, does not walk, used manual wheelchair for locomotion, is totally dependent on staff for repositioning and turning in bed, and totally dependent on (2) staff for transferring. Record review of Resident #2's admission record, dated 07/24/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included, a diffuse traumatic brain injury (widespread damage to the brain's white matter), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life activities), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), chronic pain syndrome (persistent pain that last weeks to years by be caused by inflammation or dysfunctional nerves), bipolar disorder (associated with episode of mood swings ranging from depressive lows to manic highs), and antisocial personality disorder (a mental health disorder characterized by disregard for other people).Record review of Resident #2's care plan dated 6/13/25 reflected the resident requires limited assistance by (1) staff to move between surfaces, the resident does not walk, and resident uses manual wheelchair for locomotion.Record review of Resident #6's admission record, dated 7/24/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included, Depression (the elevation or lowering of a person's mood), Anxiety (intense, excessive, and persistent worry and fear about everyday situations), Cognitive Communication Deficit (difficulties in communication arising from impairments), Type 2 Diabetes (long-term condition in which the body has trouble controlling blood sugar and using it for energy), and Parkinsonism (clinical syndrome characterized by tremor).Record review of Resident #7's admission record, dated 7/24/25, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident #7 had diagnoses which included cerebral infarction (a medical condition where brain tissue dies due to a lack of blood supply), Crohn's disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract), Schizophrenia ( a disorder that affects a person's ability to think, feel, and behave clearly), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Current MDS requested for Resident #1, Resident #2, Resident #6, and Resident #7 on 07/26/25 at 2:11 PM, and reminder sent on 07/28/25 at 5:16 PM. Received MDS for Resident #1 and Resident #2 on 07/29/25 at 5:04 PM the BIMS was blank.On 07/31/25 at 6:10 AM emailed Administrator-B and Director of Clinical Services and informed the MDS' for Resident's #1 and #2 had no BIMS and if the admission MDS could be provided. On 08/06/25 at 12:07 PM an email was sent to Administrator-B, the MDS for Residents #1, #2, #6, and #7 were requested but not received.Interview on 07/24/25 at 11:04 AM with Resident #1 revealed she and Resident #2 were roommates. She stated he was her fiance. She stated another resident's friend gave Resident #2 drugs and when he came to the room to try to smoke it, she told him he could not smoke it and got upset and began to beat on her. She stated she was yelling for help, she stated RN-B came into the room and screamed for Resident #2 to stop hitting her. She stated Resident #2 did stop hitting her then EMS arrived and took her to the hospital, and she was there for about two hours then she was brought back to the facility. She stated her injuries were a black right eye, a busted upper lip, bruises to both cheeks, and a large bruise to her left breast. She stated she did not feel safe at the facility because someone else could come in the room and she could not protect herself. She stated they had not had any physical altercations in the past. She stated he had taken care of her he had never hurt her. When asked if she pushed the call light button, she stated the call light had not worked in four months. She stated she was given a bell to ring when she needed assistance, but they had put the bell on the door. She stated no one had told her she needed to keep the bell out of the drawer. Observation on 07/24/25 at 11:30 AM revealed there were two call light cords plugged into the wall in the room of Residents #1 and #2. Observation of the call light cords revealed both cords on the floor. Further observation of the room revealed a bell hanging on a short rope/string on the back of the door to the room, out of reach of the resident. Resident #1 was observed in her bed. Face to face interview with Maintence Director on 07/24/25 at 3:15 PM revealed he had been employed since late February. He stated he knew there were some call lights that were not working throughout the building. He stated he would fix the call lights then they would go out again, because the system was old. He stated if the call light was not working the residents would be given a bell to ring for help until the light could be fixed. He stated he was not sure if the call lights were working in Resident #1's and Resident #2's room. He stated when an aide would report the light was not working, he would fix the light on the spot. He stated he did not believe the light situation got to a point that he needed to notify Administrator - A. He stated there was not any room that had to have the call light fixed more than one time. He stated the staff would come to him face to face to report a call light was not working. He stated the staff could always call him on his cell phone to report issues. He stated when the call light was not working it could delay or not allow a resident to receive help. Face to face interview with Administrator-B on 07/24/25 at 3:36 PM, revealed the day was her fourth day working at the facility. She stated she was not aware Resident #1 and Resident #2 did not have a call light in their room. She stated when she found out about the call light, she was trying to move Resident #1 to another room, but she had refused to move. She stated she did not know how long Resident #1 and Resident #2 had been without a call light or any way to communicate to staff the need for assistance. She stated she did not know how the residents were supposed to let staff know they needed assistance. She stated she would assume the maintence director was responsible to ensure the call light worked in the rooms. She stated the CNAs, and nurses would be responsible to ensure the placement of the bell was in reach of the resident. She stated there was a severe risk of injury or a lack of care to the resident's when they did not have access to communication.Observation and interview on 07/25/25 with Resident #6 at 12:54 PM, revealed when asked to push her call light, the light did not flash above her door. Staff were observed walking throughout the hall, but no one came to Resident #6's room until they were notified in person by the investigator the resident had pushed the call light. Observation and interview with Resident #7 on 07/25/25 at 1:05 PM, revealed Resident #7 was asked to push his call light and the light did not flash above his door. Resident #7 stated he thought the light was working properly. Staff were observed walking throughout the hall, but no one came to Resident #7's room until they were notified in person by the investigator the resident had pushed the call light. In an interview with the Regional Director of Clinical Services on 07/26/25 at 2:15 PM, she stated she was not aware that the resident's (Resident #1 and Resident #2) call light was not working, she stated Resident #1 informed her and wrote a statement that the bell provided to her was in the drawer next to her bed. She stated the maintence director would have been responsible to ensure the call lights were working. She stated it would be the responsibility of the nursing staff to let the maintence director know when the lights are not working. She and the maintence director checked the lights in the rooms of Resident's #6 and #7 and the notification was going to the board at the nurses station, but the light was not lighting up outside the door. She stated Resident #1 was moved to a room with a working call light and Resident #2 was taken to jail and given a discharge notice. She stated if a resident's call light was not working it could delay their care.In a telephone interview with RN-B on 07/26/25 at 6:15 PM, reflected she was aware some of the call lights were not working but she was not sure how long the lights had been out. She stated she thought the administrator and maintence knew the lights were not working but she had not checked with them. She stated when a resident's call light did not work, it could cause the resident to not receive proper care.Record review of Call Light and Communication Device dated/revised 7/25/25, reflected All staff are responsible for responding promptly to resident call lights and communication devices. The facility shall maintain functional systems for resident communication and implement escalation procedures when systems fail, or response times are inadequate.Procedure1. Resident Education Upon admission and as needed, residents will be educated on: The purpose and use of the call light system. The importance of [keeping the call light within reach at all times]. How to request assistance using the call light or other communication devices.2. Call Light Accessibility Staff must ensure the call light is: Within easy reach of the resident [at all times]. Positioned appropriately after any care, repositioning, or transfer. Available in both the bedside and restroom areas.3. Response Expectations All call lights must be answered promptly, ideally within 5 minutes. If the responding staff member is not the assigned caregiver, they must: Address the need if within their scope. Notify the appropriate caregiver immediately if not.4. Escalation ProtocolIf a call light is not answered within 10 minutes or a communication device is non-functional:5. Backup MeasuresIn the event of call light system failure or during power outages: Place manual bells or battery-operated call devices at: Each resident's bedside. Each resident-accessible restroom. Implement Q15-minute visual safety rounds to assess resident needs. Document each round in the designated log.An IJ was identified on 07/25/25. The IJ template was provided to Administrator-B and Regional Nursing Director on 07/25/25 at 11:20 AM and a Plan of Removal was requested. The POR was accepted on 07/25/25 at 5:47PM.The POR reflected the following:Plan of Removal For F9191. Immediate Corrective Actions Taken Date/Time of IJ Notification: 7/25/25 @11:20 AM Resident Safety: Resident #1 was immediately assessed by bedside staff nurse for injuries and provided appropriate medical care; completed on 7/23/25. Resident #1 was relocated to a private room to ensure safety and prevent further incidents and call light was verified as operational; completed on 7/24/25. Roommate Removal: The male roommate involved in the assault was removed from the facility by law enforcement after evaluation by EMS on 7/23/25. BOM and Social worker provided Notice of immediate discharge to male resident via certified mail to [NAME] County Jail mailed on 7/25/2025. Communication System: All residents' rooms were audited by Maintenance Super to ensure functioning call lights or alternative communication devices were present and accessible; completed 7/25/2025. Temporary communication devices (bells) were installed within reach of residents identified with malfunctioning call system until permanent solutions were in place; completed 7/25/25. Education of each resident with an alternative device (bell) was completed at time of placement by maintenance and will be documented in the EHR by DON; completed 7/25/25.2. Systemic Corrective Measures Facility-Wide Audit: A full audit of all resident rooms was completed on 7/25/25 to verify the presence and accessibility of communication systems. Maintenance logs were reviewed by maintenance supervisor to identify any prior reports of malfunctioning call lights. An outside Vendor, Summit Fire and Security was contacted to repair malfunctioning call lights/system on 7/25/25. Initial visit will occur on Monday 7/28/25. Staff Training: All staff will receive re-education on: Resident rights to a safe environment (F600). Proper placement and testing of communication devices (F919). Immediate reporting and escalation procedures for malfunctioning equipment. Started on 7/23/25; ongoing until all staff educated; no staff will be allowed to work their next shift until completed; education by ADON/DON; PRNs via phone if needed. Included education:- Call lights must be in reach and operational. If found to be inoperable then must immediately notify the administrator, DON and Maintenance Supervisor.- Implement an alternate call system; including Q15 min checks until provided.- Maintenance will provide manual bell and education to resident for use until malfunctioning issue is resolved. - Must take manual bell to restroom with resident and place in reach, if toileting is needed and then ensure it is returned to bedside and in reach once done in restroom. Monitoring and Oversight: A designated staff member (e.g., DON or Maintenance Supervisor) will conduct daily rounds for 14 days to ensure compliance; started 7/25/25. Random weekly audits by DON will continue for 4 weeks. Results will be reviewed in QAPI by administrator/DON for 3 months starting with adhoc on July 30th.3. Prevention of Recurrence Resident Interviews: All residents were interviewed to ensure they feel safe and have access to communication systems; started Safe surveys by social worker started on 7/23/25. Ongoing Staff Education: Monthly in-services on abuse prevention, neglect, and emergency response. Next all-staff in-service scheduled for Friday August 8th, 2025. 4. Verification of Compliance Documentation: Audit logs, training rosters, and maintenance reports will be maintained and available for review. Follow-Up: The Administrator and Director of Nursing will verify completion of all corrective actions.Monitoring of the facility plan of removal was as follows: Record review at 9:00 AM on 07/26/25 of facility POR training with staff dated 7/23/25 thru 7/26/25, reflected, the training consisted of ensuring the call light was within reach and operational, if call light was found to be inoperable then DON and Maintenance Supervisor should be notified immediately, and an alternate call system should be implemented including Q15 min. checks until provided. The maintenance staff would provide a manual bell and the resident would be educated to use the bell until the malfunctioned issue was resolved. Staff should remind the resident to take the manual bell with them when toileting and it should be kept until they had returned to their bed.Observation of Resident #1's current room on 07/26/25 revealed she had a working call light. Resident #1 was not in the building at the time of this observation. Interview with CNA-C on 07/26/25 at 10:00 AM reflected she had received training on how to work the call light system, she stated she had not been received training that she needed to check the rooms on hall 200 Q shift when she started her shift on 07/26/25.Interview with CNA-D on 07/26/25 at 10:10 AM reflected she was trained on the call lights, she stated she was told to check rooms every 15 minutes on hall 200 because the residents were not cognitive enough to know how and wen to use the call lights. Interview with CNA-E on 07/26/25 at 11:34 AM, reflected she received training on answering the call lights, when a residents call light was out, she should notify the charge nurse and maintence, provide the resident with a bell and do 15-minute checks on the resident. Additional interview with Interview with CNA-C on 07/26/25 at 11:50 AM, reflected she had been trained to check all rooms on 200 hall every 15-minutes because they may not understand how to use the light, and residents on other halls if a light was not working she would notify the charge nurse and maintence and provide a bell for the resident to notify her when they need help. Interview with LVN-C on 07/26/25 at 12:10 PM reflected, she had received an in-service training on answering the call light, if the light was not working she should check the rooms every 15-minutes and give the resident a bell and notify maintence.Interview with LVN-D on 07/26/25 at 12:23 PM reflected, she had been trained on what to do if the call light was not working, she needed to notify the administrator, the DON, and the maintence director, do 15-minute checks on the resident and provide the resident with a bell and make sure the bell is within reach and not in a drawer. Interview with CNA-G on 07/26/25 at 12:33 PM reflected, she had been trained to make sure the call lights were working and in reach, if the light was not working she must notify the administrator, DON, and maintence, give the resident a bell and make sure it is within reach and when the resident went to the bathroom to make sure the bell was with them if she stepped out of the room, if the resident cannot use the bell to make 15-minute checks in the room. Interview with CNA-H on 07/26/25 at 12:41 PM reflected, she had been trained to provide a bell to the resident if the call light was not working, she should notify the administrator and maintence, the call light should be in reach of the resident, if the light did not work to give the resident a bell and do 15 minute checks to make sure the resident was okay, and make sure the resident had to bell with them if in the bathroom. Interview with CNA-I on 07/26/25 at 12:48 PM reflected, she had been trained to make sure the call light was in reach, if the light was not working to get the resident a bell, notify the administrator and maintence to fix the light, if the resident has a bell make sure the bell is accessible to the resident and not in a drawer, if the resident went to the bathroom to make sure they had the bell. Interview with CNA-J on 07/26/25 at 12:55 PM, reflected she received training that if a call light was not working, she should contact maintence, give the resident a bell and make sure it stayed within reach, and if the resident went to the bathroom wait for them or provide a bell, do 15-minute checks. Interview with LVN-E on 07/26/25 at 1:12 PM, reflected she had been in-serviced on call lights, if they were not working she should notify the administrator, DON and maintence, she should check on the resident every 15-minutes, give the resident a bell and educate the resident to always keep the bell with them. Interview with CNA-K on 07/26/25 at 1:18 PM, reflected he had received training on the call light, that it should be answered by everyone, if the light was not working to report it to the nurse who would give a bell for resident to use, the resident should be checked every 15-minutes until the light is fixed. Interview with LPN-F on 07/26/25 at 1:24 PM, reflected she had received training on the call lights that if she noticed the light was not working, she should give the resident a bell and notify the administrator, the resident should be checked every 15-minutes to ensure safety, if they went to the bathroom to take the bell. Interview with MA-G on 07/26/25 at 1:32 PM, reflected she had received in-service on call lights, if the light was not working, she should notify the DON, administrator, and maintence, give the resident a bell, if the resident cannot use the bell to do 15-minute checks until the light was fixed. Observation of Hall 200 on 07/26/25 from 1:45 PM to 2:15 PM revealed CNA's C and D had walked in rooms in 15-minute intervals. Telephone call from RN-B on 07/26/25 at 6:15 PM, reflected she had received additional training on making sure the call light was within reach of the resident, if the light was not working to provide a bell within reach and notify the nurse and maintence. Review of the facility abuse, and neglect in-service dated 07/23/25-07/26/25 reflected all facility staff had been in-serviced prior to shift on abuse and neglect. An Immediate Jeopardy (IJ) was identified on 07/25/25 at 11:20 AM. While the IJ was removed on 07/26/25 at 2:35 PM the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that take into account nonsmoking residents for one (Resident #15) of three residents reviewed for smoking. <BR/>The facility failed to ensure Resident #15 had a smoking evaluation. <BR/>This failure could place residents at risk for injury, burns, and an unsafe smoking environment. <BR/>Findings Include:<BR/>1. Review of Resident #15's admission MDS assessment, dated 06/28/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her cognition was intact. Her diagnoses included high blood pressure, diabetes, and paraplegia (inability to voluntarily move the lower parts of the body). The resident did not use tobacco. <BR/>Review of Resident #15's Care Plan for July 2024, reflected the resident did not have a care plan for smoking. <BR/>Review of Resident #15's Safe Smoking Evaluation reflected it was dated 07/16/24 following surveyor intervention. The evaluation indicated the resident was a smoker and was non-compliant with the smoking policy. The resident would sneak out to go smoke. <BR/>An observation on 07/16/24 at 11:05 AM revealed Resident #15 went out the side door close to the front desk and started smoking. <BR/>An interview on 07/17/24 at 3:00 PM with Resident #15 revealed she was awake, alert, and oriented. The resident said that she smoked in the non- <BR/>smoking area and had been told by staff several times that she was not to smoke in the non-smoking area of the facility. She stated that she was advised by staff to only smoke during the designated smoking times in the smoking only area of the facility which was located adjacent to the Dining Hall. <BR/>An interview on 07/17/24 at 10:30 AM with MDS E revealed she had worked at the facility for two years. She said the smoking evaluation was supposed to be completed when a resident was admitted and quarterly. MDS E said she found out Resident #15 smoked after a week of being admitted . She said for Resident #15 there was no risk if her smoking evaluation had not been completed. <BR/>An interview on 7/17/24 at 10:40 AM with the DON revealed he was not aware that Resident #15 was a smoker and that he did not find out until 07/16/24 that she was. He said once he found out, he completed her smoking evaluation. The DON said without a smoking evaluation, the resident was at risk of burning herself. <BR/>Review of the facility, Smoking Policy-Supervised and Unsupervised, revised March 2024 reflected:<BR/>Safe Smoking Environment<BR/>It is the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed as being safe for Facility smoking privileges. The facility is responsible for informing residents, staff, visitors and other affected parties of facility smoking policies through verbal means, distribution and posting. This policy is intended to minimize the risks to:<BR/>o Residents who smoke, including possible adverse effects on treatment<BR/>o Passive smoke to others<BR/>o Fire<BR/>Smoking Evaluation<BR/>Residents wishing to smoke while at the facility will have a Smoking Safety Evaluation completed by the interdisciplinary team to determine the resident's ability to follow smoking policies safely.<BR/>o If resident is determined to be a Safe Smoker and can smoke unsupervised then the resident can keep their smoking supplies, and smoke in designated areas at their leisure.<BR/>o If resident is determined to be an Unsafe Smoker then they must be supervised at all times when smoking.<BR/>Facility staff will keep all smoking supplies and smoking times will be established by the facility and adhered to by the resident.<BR/>A supervised smoking schedule will be posted and residents will be required to smoke with supervision only, according to the schedule.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency in accordance with state law through established procedures for one of two incidents (Resident #1) reviewed for abuse, neglect, and misappropriation. <BR/>1. The facility failed to report to the State Survey Agency when Resident #1 eloped from the facility on 12/31/24. <BR/>This failure could place the residents in the facility at risk of continued abuse and neglect.<BR/>Findings included:<BR/>1. Record review of Resident #1's Face sheet, dated 02/20/25, reflected the resident admitted on [DATE]. The resident's diagnoses included cerebral infarction (stroke), Bell's Palsy (condition that causes sudden weakness in the muscles on one side of the face), and dementia. <BR/>Record review of Resident #1's discharge MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure) and chronic obstructive pulmonary disease (disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough). Resident #1 did not have a BIMS score documented. <BR/>Resident #1 did not have a care plan. (New admit)<BR/>Review of Resident #1's progress notes reflected:<BR/>12/30/25 9:25 AM<BR/>Resident was a [AGE] year-old male admitted from the hospital accompanied by two ambulance attendants via stretcher with diagnoses atrial fibrillation (abnormal heart rhythm), coronary artery disease (heart disease), cerebrovascular accident (stroke), altered mental status, and high blood pressure. Physician notified, all orders verified by physician and sent to the pharmacy. Resident was alert and oriented x2 verbally with confusion. Head to toe assessment done, PERRLA (pupils (are) equal, round, reactive (to) light and accommodation), skin warm and dry to touch, respirations even and unlabored. No shortness of breath, no cough, no congestion noted. Abdomen soft, non-tender, bowel sounds x4 quadrants noted, bladder non-distended, pedal pulses present and strong, skin intact. Resident made comfortable in bed. Resident oriented to bed and tv remote control, call light. Safety maintained, call light within reach. Resident instructed to call for assistance, verbalized understanding. Resident wanders back and forth the unit with unsteady gait.<BR/>Written by RN A<BR/>12/31/24 12:58 AM <BR/>At approximately 12:19 AM, resident with diagnosis of hallucination and altered mental status, was observed to have eloped from the facility. Resident was last seen at 12:17 AM walking the hall. Immediate steps were taken to locate resident by notifying 911, DON and power of attorney. Resident was located outside of facility. Tried to talk to resident to come back to facility but resident refused. Resident appeared to be very combative and screaming, You bitches trying to fucking kill me. Killers, killers. Was unable to redirect. Resident ran to another facility and got into their building. 911 was able to apprehend the resident and he was taken to hospital for further evaluation.<BR/>Written by LVN B<BR/>A record review of Facility In-service (Abuse/Neglect - Elopement) revealed facility staff were in-serviced on 12/31/24. <BR/>An interview at on 02/20/25 at 12:25 PM with RN C revealed she admitted Resident #1 on 12/30/24. She said she admitted the resident to Hall 100 on the 2:00 PM - 10:00 PM shift, gave report, and left the facility. She said she was not at the facility when the resident eloped.<BR/>An interview on 02/20/25 at 12:20 PM with LVN B revealed on 12/31/24 on the 10:00 PM - 6:00 AM shift she was assigned to Resident #1. She said that she took him with her to the Memory Care Unit on Hall 200 because he was walking up and down Hall 100. LVN B said while she and Resident #1 were in the Memory Care Unit, a resident fell and she had to go to assist the resident. LVN B said while she was assisting the resident who fell, she heard the door alarm to the Memory Care Unit and then the door alarm to the front door go off. She said she went running after the resident and she saw him outside running. He was running to the facility that was close by. She said she called 911 and the DON and the police were able to take him to the hospital. <BR/>An interview on 02/20/25 at 1:20 PM with the DON revealed Resident #1 was a new admit and was not exit-seeking per the family member. The DON said one second, he was in the hall and then the next minute he was gone. The DON said the nurse called her, because the staff saw him running to the facility next door. 911 was called and they picked him up. The DON said she did not know how Resident #1 eloped from the facility. She said it was possible that someone held the door open from him. The DON said she did not know why the elopement was not self-reported, but it was probably not reported because the staff had eyes on him when he was outside. <BR/>An interview on 02/20/25 at 5:30 PM with the Administrator revealed he did not self-report the incident, because he thought the resident needed to be missing 4-6 hours before it was self-reported. The Administrator said Resident #1 was only missing for a matter of about two minutes. The Administrator said it was important to self-report elopements to ensure the correct procedure was followed. <BR/>A record review of the facility policy and procedure, Abuse Prevention Program, revised 2016 reflected:<BR/>7. Investigate and report any allegations of abuse within timeframes as required by federal requirements .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 help prevent the development and transmission of infection for 5 (Residents #2, #3, #4, #5, and #6) of 12 residents reviewed for infection control. <BR/>1. <BR/>On 04/30/24 MA A, CNA B, and CNA C brought Residents #2, #3, #4, #5, and #6 to the locked unit dining room and fed them and did not wash their hands nor the hands of the residents.<BR/>2. <BR/>On 04/30/24 CNA B assisted Residents #2, #3, and #4 with their noon meals, he cut up their food and fed them and did not sanitize his hands.<BR/>3. <BR/>On 04/30/24 CNA C touched the hand of Resident #5 and assisted him to his seat then touched his eating utensil without sanitizing her hands.<BR/>4. <BR/>On 04/30/24 during the noon meal on the locked unit a visitor brought cookies to the residents, this visitor used her ungloved hands and gave each resident present (#2, #3, #4, #5, #6) a cookie without sanitizing her hands.<BR/>This deficient practice placed residents who received assistance with meals in the Locked Unit Dining Room at risk for cross contamination and infections.<BR/>Findings included:<BR/>Review of Resident #2's Care Plan dated 07/12/23, revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with an intervention of limited assistance by staff to eat. Diagnoses included Dementia (a group of thinking and social symptom that interferes with daily functioning), and bipolar disorder (associated with episodes of mood swings ranging from depressive lows to manic highs). <BR/>Review of the most recent quarterly MDS assessment dated [DATE], revealed Resident #2, had a BIMS score of 3 (cognition was severely impaired). Resident #2's eating assessment reflected she required partial/moderate assistance-Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.<BR/>Review of Resident #3's Care Plan dated 01/24/24, revealed Resident #3 was an [AGE] year-old male admitted to the facility on [DATE] with an intervention of set up assistance by staff to eat. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #3's quarterly MDS assessment reflected he had a BIMS score of 00 (cognition was severely impaired). Resident #3's eating assessment reflected he required setup or clean-up assistance-Helper sets up or cleans up; resident completes activity.<BR/>Review of Resident #4's Care Plan dated 11/07/23, revealed Resident #4 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #4's quarterly MDS assessment reflected no BIMS score noted. Resident #4's eating assessment reflected she required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>Review of Resident #5's Care Plan dated 02/06/24, revealed Resident #5 was an [AGE] year-old female admitted to the facility on [DATE] with an intervention that the resident is independent for eating. Diagnoses included Dementia (a group of thinking and social symptom that interferes with daily functioning).<BR/> Review of Resident #5's quarterly MDS assessment reflected a BIMS score was not completed. Resident #5's eating assessment reflected she required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>Review of Resident #6's Care Plan dated 04/14/23, revealed Resident #6 was an [AGE] year-old male admitted to the facility on [DATE] with an intervention of limited assistance by staff to eat. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #6's change in condition MDS assessment reflected a BIMS score was not completed. Resident #6's eating assessment was not completed.<BR/>Observation on 04/30/24 at 12:45 PM revealed MA A walked into the dining room on the locked unit, and she assisted Resident #2 to a table and helped her to sit. MA A took the lid off the plate of Resident #2 then she touched her eating utensil and fed Resident #2. MA A did not sanitize her hands or the hands of Resident #2.<BR/>During an observation on 04/30/24 at 12:46 PM, CNA B took the eating utensil of Resident #3 and cut up his food. Then he went to Resident #4 and used her eating utensil to cut up her food. CNA B then moved to Resident #5, picked up her eating utensil and fed her. He did not sanitize his hands before he moved to and from each resident to assist. He did not sanitize the hands of the resident before assisting them to eat.<BR/>During an observation on 04/30/24 at 12:48 PM, Resident #6 got up from the table. CNA B went outside the door of the dining area to follow Resident #6 out of the dining room. CNA B touched Resident #6 on his arm to redirect him back to the dining table, then CNA B returned to Resident #5 and fed her again. He did not sanitize his hands after he touched or fed a resident. <BR/>Observation on 04/30/24 at 12:49 PM revealed CNA B left Resident #5 and went to assist Resident #4 back to her table to eat by touching her arm. Then he returned to Resident #5 without sanitizing his hands. <BR/>Observation on 04/30/24 at 12:50 PM revealed CNA C assisted Resident #6 back to his table when she took his hand and helped him sit down. Then she picked up his eating utensil from his plate and assisted him to eat. She did not sanitize her hands or the hands of the resident.<BR/>Observation on 04/30/24 at 12:51 PM revealed CNA B moved from Resident #5 and took the eating utensil for Resident #3 and put it back in his hand and encouraged him to eat. He did not sanitize his hands. <BR/>Observation on 04/30/24 at 12:55 PM revealed a visitor entered the dining area on the locked unit with a container of cookies. The visitor handed out cookies to Residents #2, #3, #4, #5, and #6. The visitor did not sanitize her hands before she gave the residents cookies. The visitor did not put on gloves prior to passing out the cookies to the residents.<BR/>In an interview on 04/30/24 at 1:09 PM with CNA B revealed he did not have any hand sanitizer on his person in the dining area and there was not any in the dining area at lunch. He stated there was some hand sanitizer in the nursing station which was located down the hall. He stated he had been trained on infection control. He stated he was not supposed to move from one table to another table or one resident to another resident and touch them without sanitizing his hands. He stated the residents should not have been given cookies by the visitor. He stated the risk to the residents was the transmission of germs that could cause infection.<BR/>In an interview on 04/30/24 at 1:21 PM with CNA C revealed she did not have any hand sanitizer on her person when she was in the dining area at lunch. She stated they do not keep the sanitizer out in the dining room because of the residents' attempts to get the sanitizer. She stated there is hand sanitizer in the closet in the nurses' station. She stated the visitor should have asked if they could give the residents cookies. She stated the risk to the residents was the spread of germs and infection when the staff did not sanitize their hands when working with several residents.<BR/>In an interview on 04/30/24 at 1:40 PM with LVN revealed she was the supervisor of the staff working in the locked unit. She stated during lunch she mostly worked on another hall. She stated the hand sanitizer was available in the nurse room, but the door has been taken down and they must keep all the sanitizer put up out of reach of the residents. She stated all the staff should have known the hand sanitizer was in the closet in the nurse room. She stated she did not remember the last infection control training they took. She stated the visitor should not have handed out cookies to the residents without sanitizing hands. She stated the risk to residents was infection, passing germs, and viruses because staff had not sanitized their hands during the lunch meal.<BR/>In an interview on 04/30/24 at 2:15 PM with MA A revealed she did not have hand sanitizer in her pocket. She stated hand sanitizer was in the nurses' room down the hall. She stated she had washed her hands before she went into the dining area. She stated staff should have sanitized their hands when they worked with several residents during the lunch meal. She stated the resident was at risk of infection when the staff did not sanitize between residents. <BR/>In an interview on 04/30/24 at 4:35 PM with the Administrator revealed the DON and herself was responsible to ensure staff was trained on IC. She stated the DON completed monthly in-services on IC. She stated the DON was currently in the hospital and not available for interview. She stated the staff had put the residents at potential risk of infection and illness when they did not sanitize their hands. She stated the staff should have told the residents to wash their hands before the meal. She stated there was hand hygiene supplies available throughout the building and if there was not any in the dining area, the staff could have asked her or the housekeeper. <BR/>Record review of facility's Policies and Practices -Infection Control revised August 2010 reflected, All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility for 1 of 8 (Resident #2) residents reviewed for transfer and discharged rights.<BR/>The facility failed to ensure Resident #2 was given a safe discharge on [DATE].<BR/>This deficient practice could place residents at risk of improper discharge or transfer.<BR/>The findings were:<BR/>Record review Resident #2's Face sheet dated was admitted to the facility on [DATE]. Resident #2 was diagnosed with acute embolism and thrombosis of left femoral vein (both conditions that disrupt blood flow), anxiety disorders (A type of mental health condition-may respond to things with fear), chronic pain syndrome (A condition that causes pain beyond the normal healing process) and morbid obesity (Chronic disease in which a person has a body mass index of 35 or higher).<BR/>Record review of Resident #2's MDS assessment dated [DATE] revealed, he had a BIMS score of 13 indicated cognitive intact. The MDS Assessment revealed, behavior symptoms not exhibited.<BR/>Record review of Resident#2's care plan dated 02/03/24 revealed, <BR/>Resident#2's focus: refusing care and can become verbally/physically aggressive towards staff at time during care.<BR/> Goals: No reports of complications due to refusing medication. Interventions: If resident's behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate Assess reports of behaviors, assess pain .Implement appropriate interventions document and notify medical doctor .<BR/>. <BR/>Record review of Resident's #2 progress notes revealed no documentation of a skin injury.<BR/>Record review of Resident's #2 progress notes revealed no documentation of resident to resident altercations.<BR/>Record review of progress notes revealed Resident #2 was out to hospital Resident is not coming back to facility because he had an altercation with staff.<BR/>Record review of admission/discharge report that dated 12/28/2023 to 02/28/14 revealed Resident #1 was discharged home on [DATE]. <BR/>Record review of discharge letter dated 02/22/24 revealed, our staff will assist you in making arrangements for the immediate discharge and will provide support during the process .We will arrange for services provided for Resident#2 at your home. Record review of discharge letter revealed, that it was not signed by Resident#2.<BR/>In an interview on 02/28/24 at 10:30 AM Hospital staff stated resident #2 was brought to the hospital and did not have a medical need. The Hospital Staff stated the resident did not come in an ambulance and was dropped off. The Hospital Staff called the facility and was unable to reach anyone in the facility to have resident transported back. The Hospital staff stated she tried to place him at 20 other facilities and no other facilities would accept the resident because of his behavior history. The Hospital staff stated the resident was left at the hospital for twenty-six hours. The hospital staff stated the resident's family member icked him up and Adult Protective Services were called to follow up with resident.<BR/>In an interview on 02/28/24 at 2:25 PM with LVN J revealed Resident#1 was aggressive with the medication aide and wanted his pain medication. LVN J stated the medication aide had already administered his pain medication. LVN J stated she came to help the medication aide with Resident #2. LVN J stated Resident#2 continued to scream and cuss at the medication aide. LVN J stated, Resident #2 threw water off of the medication cart on the floor and ran over the medication aide foot with his wheelchair. LVN J stated she did not know how the resident was transported to the hospital or why. <BR/>In an interview on 02/28/24 at 2:30 PM with Medication Aide K revealed Resident#2 was cussing at her because he wanted more pain medication on 02/22/24 in the hallway. Medication Aide K told him it was not time for another pain pill. Medication Aide K stated Resident#2 pushed the medication cart and threw water on the floor. Medication Aide K stated the LVN J and Administrator came to help calm him down. Medication Aide K stated, Resident#2 started swinging his arms at the Administrator. <BR/>In an interview on 02/29/24 at 9:00 AM with the Administrator stated the police were called and nothing happened. Administrator stated the police refused to give her a report number. Administrator stated Resident#2 was sent to the hospital because he was bleeding from his foot. Administrator did not answer when asked how Resident#2 was transported to hospital. The Administrator stated Resident#2 discharge paperwork was sent with him to the hospital. The Administrator stated Resident#2's family and Ombudsman was contacted and informed that Resident#2 would not be able to return to facility for safety of the staff and residents. <BR/>In an interview on 02/29/24 at 10:30 AM with police dispatcher stated a police report was not completed. <BR/>In an interview on 02/29/24 at 10:45 AM with social worker revealed she had not worked with Resident #2 too much because she was new (3 weeks). The Social Worker provided a number for Resident#2.<BR/>In an interview on 02/29/24 at 11:00 AM, Resident#2 family member was called and respondent stated she did not know that person. <BR/>Ombudsman was called twice with no return call. <BR/>Record review of the facility's policy transfer and discharge (including AMA), (undated), it is the policy of the facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 8 residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 was provided with adequate supervision to prevent her from eloping from the facility on 02/17/24.<BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/09/24 and ended on 02/27/24. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Record review Resident #1's Face sheet dated was admitted to the facility on [DATE]. Resident #1 was diagnosed with unspecified Dementia, major depressive disorder, psychotic disorder with delusions due to known physiological condition, and adjustment disorder with anxiety.<BR/>Record review of Resident #1's MDS assessment dated [DATE] revealed she had a BIMS score of 0 indicating severe cognitive impairment. She was rarely/never understood. The MDS Assessment indicated she did not exhibit wandering behavior symptoms. The MDS Assessment indicated the resident did not have an electronic device that monitored resident movement and alerted staff.<BR/>Record review of Resident#1 care plan dated 11/15/21 revealed: Resident #1 was an elopement risk/wander as evidenced by non-goal directed wandering in/out of rooms, exhibited exit seeking behaviors. Resident #1 goals revised on 02/06/24 revealed: Resident #1's safety will be maintained Record review of care plan revealed: Interventions dated 11/15/21: disguise exits, cover doors knobs and handles, tape floor, identify the pattern of wandering and intervene as appropriate. Provide structed activities .reorientation strategies including signs, pictures .<BR/>Record review of progress notes revealed, no documentation of time when Resident#1 went missing and what time the resident was found and returned to the facility. Record review of the progress note revealed, staff did not notice resident#1 was missing until mealtime. The facility was searched, and a code yellow was called. Progress note revealed Resident #1 was found loitering by the police down the street and staff returned her to the facility with Progress reports revealed, Resident #1 received a skin, pain and elopement risk assessment. Progress note revealed Resident#1's family member, Administrator, acting Director of Nursing, Medical Doctor was notified. Progress notes revealed Resident was monitored every 15 minutes.<BR/>Record review of the facility's Provider Investigation report undated revealed the following: <BR/>[Resident#1] was in the dining room, we believe a visitor or staff held the door for [Resident#1], not realizing she was an elopement risk. Staff realized resident was missing approximately 10 minute and called code pink was called She was not located in the facility One staff member got in her vehicle to look for resident. Record review of Provider Investigation Report revealed, Staff flagged a police officer down and the police had located resident at an apartment complex down the street and returned her to the facility. nursing staff did a head to toe skin assessment with no injuries noted, pain assessment . Completed new elopement risk assessment and checked on Resident#1 every 15 minutes <BR/>Record review of staff in-services dated 02/19/24, 02/20/24 and 02/27/24 revealed, abuse, neglect, resident care and elopement were covered.<BR/>Observation on 02/28/24 at 8: 20 AM revealed, residents who needed to be in the secure unit were present. <BR/>Interview on 02/28/24 at 08:30 AM, CNA N stated residents in the secure unit were moved to the general population because of construction that was going on in the facility. General population residents and secure unit's residents were mixed between halls 500, 300 and 400. CNA N stated the risk to the residents was they could escape from the facility. CNA N stated she did not witness the elopement. CNA N stated Resident #1 eloped during dinner on second shift. CNA N stated she was in-serviced on the facility procedures for elopement. <BR/>Interview on 02/28/24 at 8:40 AM, CNA P stated he was on vacation when Resident #1 eloped from the facility. CNA P stated he was in-serviced on elopement when he returned to the facility and the residents were back in the secure unit. <BR/>Interview on 02/28/24 at 9:00 AM with LVN X stated the elopement happened around dinner time and staff believed a visitor held the door open for her not knowing she was a resident. LVN X stated she had been in-serviced on elopement and the residents who belong in the secure unit were back in the unit.<BR/>A telephone interview on 02/28/24 at 1:37 PM with the local police department dispatcher stated, no police report was completed for Resident#1. <BR/>A telephone interview on 02/28/24 at 2:52 PM with the CNA C revealed she was on break and when she returned, she was told the resident was missing. CNA C stated, she did a head count, and the resident was not found. CNA C stated residents were in danger of elopement if they are not supervised. Certified Nurse Aide C stated she understood the facilities policy and procedures for when a resident elopes. CNA C stated, was in-serviced about elopements. <BR/>A telephone interview on 02/28/24 at 2:39 PM with LVN D stated, Resident#1 could not be found in the dining room when trays were passed out. Licensed Vocational Nurse D stated, she drove around the neighborhood and met up with a police officer who stated they found a lady wandering in the apartments LVN D followed the police officer to the apartment. LVN D stated Resident#1 was combative and LVN D called the weekend supervisor who drove to the apartments and was able to get Resident#1 into the car. LVN D stated some of the residents were moved back into the secure unit, but she said that they did not get full clearance to put all the residents back. Some of the secure unit residents were left in general population. LVN D stated all residents were returned to the secure unit on 02/18/24. LVN D stated she was in-serviced on elopement before and after Resident #1 left the facility. <BR/>Interview on 02/28/24 at 3:30 PM with the Administrator revealed residents from the secure unit were brought to general population because of construction and both exits in the secure unit needed to be accessible. The Administrator stated Resident #1 went missing around dinner time 02/17/24, which usually started at 5:30 PM. The Administrator stated Resident#1 was found outside the facility down the street and brought back. The Administrator stated she believed that Resident#1 walked out of the facility with a visitor.<BR/>Interview on 02/29/24 at 2:15 PM with the Administrator revealed residents from the secure unit were mixed with the general population on 02/09/24 and were able to return to the secure unit on 02/14/24, according to her records. The Administrator stated she did not realize secure unit residents were still in general population until 02/18/24. The Administrator stated that in the future she would have more staff to come in to monitor the exits if the secure unit residents must come back to general population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 3 (Resident #5, #14, and #62) of 7 residents reviewed for respiratory care, in that:<BR/>The facility failed to:<BR/>A.) Label and date the oxygen tubing and concentrator water bottle for Resident #5 and Resident #62.<BR/>B) Label and date Resident # 14 oxygen tubing<BR/>These deficient practices could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. <BR/>Findings Included:<BR/>Resident #5<BR/>Record review of Resident #5 face sheet dated 1/24/24 reflected a [AGE] year-old female admitted on [DATE], diagnosis include Chronic Respiratory failure with Hypoxia (low oxygen). <BR/>Record review of Resident #5's MDS dated [DATE], reflected a BIMS score of 14 indicating she was cognitively in tack. Functional level impaired on both sides and needs staff supervision for mobility, incontinent, eating set up or clean up assistance. MDS Section O - Special Treatments, Procedures, and Programs was left blank.<BR/>Record review of Resident #5's Care plan dated 12/07/23 Continuously on oxygen. via n/c. Administer medications as ordered. Monitor/document for side effects and effectiveness. The resident has shortness of breath (SOB) r/t chronic respiratory failure with hypoxia 02 at 2 LPM continuous via nasal to keep oxygen level above 92% every shift for SOB. Resident # 5 will have no complications related to SOB though the review date .Monitor/document breathing patterns. Report abnormalities to MD: Use universal precautions as appropriate. The care plan did not address changing oxygen tubing.<BR/>Record review of Resident #5's MD orders dated 09/27/23 reflected 02 at 2 LPM continuous via nasal to keep oxygen level above 92% every shift for SOB. There was no order for tubing change.<BR/>Observation on 01/24/25 at 12:00 PM of Resident #5's oxygen tubing and oxygen concentrator bottle was not dated and labeled.<BR/>In an interview on 01/24/24 at 12:00 PM with Resident #5 revealed she was on oxygen, and she does not know when the tubing was changed, however staff does change the tubing. She did not know which shift.<BR/>Resident #14<BR/>Record review of Resident #14 face sheet dated 01/24/24 reflected a [AGE] year-old male admitted on admission 6/23/23 with diagnosis: Paroxysmal Atrial Fibrillation (irregular heartbeats), Cardiovascular and Coagulations (heart attack, Chronic Obstructive Pulmonary Disease (inflammatory of lungs); Intermittent Asthma chronic lung disease, <BR/>Record review of resident # 14's MDS dated [DATE] reflected a BIMS score of 15 cognitively intact. Independent, uses a walker or manual wheelchair and has oxygen treatments.<BR/>Record review of Resident #14's care plan dated 01/09/24 reflected. The resident has Oxygen Therapy r/t . The resident will have no s/sx of poor oxygen absorption through the review date .Oxygen Settings: The resident has O2 via nasal cannula prn Oxygen @ 2L via NC . Resident will have no complications related to SOB. The care plan did not address changing oxygen tubing.<BR/>Observation on 01/24/25 at 12:05 PM of Resident #14's he was lying in bed with his NC positioned in his nose and concentrator on with oxygen flowing and his oxygen tubing was not dated and labeled.<BR/>In an interview on 01/24/24 at 12:10 PM with Resident #14 revealed he was a little confused and could not articulate responses to questions about tubing change. he said his oxygen was flowing well. <BR/>Resident #62<BR/>Record Review of resident #62 reflected a [AGE] year-old male with an admission date of 06/08/22, Dx Disorganized Schizophrenia, Pan lobular Emphysema condition effecting the whole acinus of the lungs permanently damaging the air sacs. Schizoaffective Disorder (mental illness), Chronic Obstructive Pulmonary Disease (inflammatory of lungs), Unspecified, chronic diastolic congestive heart failure. <BR/>Record review of Resident #62's quarterly MDS dated [DATE] reflected he had a BIMS score of 15, indicating he was cognitively intact. Resident is independent, uses a walker or manual wheelchair, has mood and behaviors. MDS Section O - Special Treatments, Procedures, and Programs was left blank <BR/>Record review of Resident #62's care plan dated 01/9/24 indicated the resident received O2 at 2 L per as needed to keep sat above 90%Resident will have no reports of unrelieved shortness of breath through next review date .Observe for SOB, respiratory distress, wheezing, fatigue, increased anxiety and implement appropriate ordered interventions and notify MD if interventions are not effective Provide medication as ordered. The care plan did not address changing oxygen tubing.<BR/>Record review of Resident #62's MD orders dated 08/12/22 reflected O2 at 2 L per (NC/FM/Non-rebreather) as <BR/>needed to keep sat above 90% as needed for SOB.<BR/>Observation and interview with Resident #62 on 01/24/25 at 12:50 PM revealed his oxygen tubing and oxygen concentrator bottle was not dated and labeled, the tubing was lying across the nightstand and inside the trash can. Resident #62 said the tubing was changed this morning by LVN D He does not recall staff dating tubing. <BR/>In an interview on 01/24/24 at 2:-10 PM with LVN D, the charge nurse for Resident #5, Resident #14, and Resident #62. LVN D said she assess resident's oxygen treatment and tubing during rounds and check for date the tubing was change in the nurse notes. LVN D said she had conducted rounds every 2 hours and had observed that the water bottle and tubing for Resident #5, Resident #14, and Resident #62 were not dated. LVN D said she would change the tubing at this time. LVN D said it was the assigned nurse for each shift to check for dates on all oxygen equipment and assess oxygen flow during resident rounds. LVN D said concentrator water bottles should be changed every 24 hours and she observe water bottle levels every 2 hours. LVN D said oxygen tubing should be changed, dated, and documented PRN and every Sunday by night shift. LVN D said failing to change the tubing, label, and date tubing and water bottle cold lead to overuse, kinks in hose, bacteria, respiratory infection, poor air flow, sepsis, and death.<BR/>In an interview with DON on 01/25/24 at 12:12 PM revealed oxygen tubing should be changed, dated, and labeled weekly by the overnight night nursing staff. He said the concentrator water bottles should be changed as needed and assessed during nursing rounds for accurate flow, tubing kinks, dates, and labels. The DON stated that facility protocols would develop and implement protocol for documentation moving forward. The DON said failing to change oxygen tubing for resident could lead to bacterial infection, or respiratory infection. He stated that the facility protocol does not mandate that oxygen tubing and treatment be documented, however he has educated nursing staff today on documentation, changing and dated. The DON said the facility does not use the TAR to document treatment at this time, however it was his plan to educate the nursing staff to document the change in tubing, dating, and labeling. The DON said it was the nursing staff responsibility to monitor oxygen for change and date. The DON the facility plan moving forward would include all nursing staff being in-serviced to change resident tubing weekly on Sunday 10AM-6PM shift. The DON said the morning charge nurses will check documentation, labels, and dates to assure nursing task was completed, and the ADON and DON will then monitor charge nursing task to assure accuracy. The DON expects the nursing staff to monitor for dates.<BR/>In an interview with the ADM on 01/25/24 at 1:30 PM wtih the ADM, and AIT, she expected staff to change the tubing, if visibly soiled. She was not sure of complications related to respiratory treatment task and maintenance as she does not have a clinical background. She said ADON, DON, and charge nurse are responsible for monitoring nursing and treatment procedures. <BR/>Review of facility's in-service dated 10/15/2022 and titled with topic: O2 therapy - weekly and PRN changing of O2 tubing (must date) revealed staff was in-serviced on changing and dating oxygen tubing.<BR/>Record review of facility policy Titled Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, 5 .Other infection control measures include: Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated .Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. Use only sterile water for humidification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received services with reasonable accommodations for 2 of 5 residents (Resident #8, and Resident #14) reviewed for call light system access. The facility failed to ensure Resident #8 had access to their call light by allowing it to remain on the floor at the side of the bed, out of the resident's reach. The facility failed to ensure Resident #14 had access to their call light by allowing it to remain between the wall and mattress at the foot of the bed, out of the resident's reach. This failure could place residents at risk for delayed assistance and an inability to request help when needed. 1.) Record review of Resident #8's annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility with an original admission date of 09/20/2024 and had severely impaired cognitive function. Diagnoses included: cerebral palsy (a neurological disorder that affects body movement and muscle coordination). Resident #8 was dependent on staff for all self-care tasks such as eating, oral and toileting hygiene, shower/bathing, upper and lower body dressing, and personal hygiene. He was dependent on staff for mobility tasks such as sitting to lying, lying to sitting on side of the bed, sitting to standing, chair/bed-to-chair transfers, and toilet transfers, tub/shower transfers. Record review of Resident #8's Comprehensive Care plan dated 05/15/2025 showed a medical focus: [Resident] has alteration in musculoskeletal status related to Kyphosis (excessive outward curvature of the spine). Goal: [Resident] will remain free from pain or at a level of discomfort acceptable to the resident. Interventions included: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. During an interview and observation on 09/14/2025 at 2:40 PM, Resident #8 was observed in bed. The call light was on the floor, out of the reach of the resident. He said he was not sure why it was there. He said he was unable to reach it. 2) Record review of Resident #14 annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE] and had severely impaired cognitive function. Diagnosis included unspecified dementia (a term used when a person exhibits symptoms of dementia, but the specific type cannot be identified), chronic kidney disease (gradual loss of kidney function over time), Orthostatic hypotension (a condition characterized by a sudden drop in blood pressure when a person stands up after sitting or lying down), muscle weakness, and repeated falls. Record review of Resident #14's Comprehensive Care plan dated 5/23/2025 showed a fall focus: {Resident] is at risk of falls due to (specify: unsteady gait, decreased balance, medications and poor safety awareness). Goal: [Resident] will have no reports of injuries that requires hospitalization or fractures related to falls through next review date. Interventions included: Call light in reach in room and answered promptly. Encourage and remind resident to use call light to ask for assistance. During an interview and observation on 08/24/2025 at 9:30 AM, Resident #14 was observed in bed. Due to cognitive impairment, he was unable to provide reliable information during the interview. The call light cord was observed at the end of the bed, in between the resident's mattress and wall, hanging down toward the floor. During an interview with CNA A on 09/14/2025 at 3:00 PM, in response to the Resident's call light placements, LVN A reported responsibility for ensuring call lights were within reach of residents fell on the CNA's as well as all staff. CNA A said when she left a resident's room, she always placed the call light within reach. She reported rounds were done frequently and as needed since staff were always present in the hallway. CNA A reported the facility call light policy required staff to make sure call lights were within reach, to encourage residents to use them, and, if a call light was not working, to report it immediately and provide an alternative means for the resident to call for assistance. She reported if a call light was not within reach, the risk to residents was they might not be able to communicate their needs or obtain help in a timely manner. She added staff conducted frequent checks to help minimize that risk. During an interview with DON on 09/16/2025 at 10:50 AM, she indicated she was unsure if the facility had a formal policy regarding keeping call lights within residents' reach but noted that it should be considered basic nursing knowledge. She reported there had been no complaints or incidents related to call lights being inaccessible. However, she acknowledged a potential risk might be unable to call for help if a call light was out of reach. On 09/16/2025 at 11:30 AM, the administrator reported the facility did not have a policy regarding call light accessibility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 8 residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 was provided with adequate supervision to prevent her from eloping from the facility on 02/17/24.<BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/09/24 and ended on 02/27/24. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Record review Resident #1's Face sheet dated was admitted to the facility on [DATE]. Resident #1 was diagnosed with unspecified Dementia, major depressive disorder, psychotic disorder with delusions due to known physiological condition, and adjustment disorder with anxiety.<BR/>Record review of Resident #1's MDS assessment dated [DATE] revealed she had a BIMS score of 0 indicating severe cognitive impairment. She was rarely/never understood. The MDS Assessment indicated she did not exhibit wandering behavior symptoms. The MDS Assessment indicated the resident did not have an electronic device that monitored resident movement and alerted staff.<BR/>Record review of Resident#1 care plan dated 11/15/21 revealed: Resident #1 was an elopement risk/wander as evidenced by non-goal directed wandering in/out of rooms, exhibited exit seeking behaviors. Resident #1 goals revised on 02/06/24 revealed: Resident #1's safety will be maintained Record review of care plan revealed: Interventions dated 11/15/21: disguise exits, cover doors knobs and handles, tape floor, identify the pattern of wandering and intervene as appropriate. Provide structed activities .reorientation strategies including signs, pictures .<BR/>Record review of progress notes revealed, no documentation of time when Resident#1 went missing and what time the resident was found and returned to the facility. Record review of the progress note revealed, staff did not notice resident#1 was missing until mealtime. The facility was searched, and a code yellow was called. Progress note revealed Resident #1 was found loitering by the police down the street and staff returned her to the facility with Progress reports revealed, Resident #1 received a skin, pain and elopement risk assessment. Progress note revealed Resident#1's family member, Administrator, acting Director of Nursing, Medical Doctor was notified. Progress notes revealed Resident was monitored every 15 minutes.<BR/>Record review of the facility's Provider Investigation report undated revealed the following: <BR/>[Resident#1] was in the dining room, we believe a visitor or staff held the door for [Resident#1], not realizing she was an elopement risk. Staff realized resident was missing approximately 10 minute and called code pink was called She was not located in the facility One staff member got in her vehicle to look for resident. Record review of Provider Investigation Report revealed, Staff flagged a police officer down and the police had located resident at an apartment complex down the street and returned her to the facility. nursing staff did a head to toe skin assessment with no injuries noted, pain assessment . Completed new elopement risk assessment and checked on Resident#1 every 15 minutes <BR/>Record review of staff in-services dated 02/19/24, 02/20/24 and 02/27/24 revealed, abuse, neglect, resident care and elopement were covered.<BR/>Observation on 02/28/24 at 8: 20 AM revealed, residents who needed to be in the secure unit were present. <BR/>Interview on 02/28/24 at 08:30 AM, CNA N stated residents in the secure unit were moved to the general population because of construction that was going on in the facility. General population residents and secure unit's residents were mixed between halls 500, 300 and 400. CNA N stated the risk to the residents was they could escape from the facility. CNA N stated she did not witness the elopement. CNA N stated Resident #1 eloped during dinner on second shift. CNA N stated she was in-serviced on the facility procedures for elopement. <BR/>Interview on 02/28/24 at 8:40 AM, CNA P stated he was on vacation when Resident #1 eloped from the facility. CNA P stated he was in-serviced on elopement when he returned to the facility and the residents were back in the secure unit. <BR/>Interview on 02/28/24 at 9:00 AM with LVN X stated the elopement happened around dinner time and staff believed a visitor held the door open for her not knowing she was a resident. LVN X stated she had been in-serviced on elopement and the residents who belong in the secure unit were back in the unit.<BR/>A telephone interview on 02/28/24 at 1:37 PM with the local police department dispatcher stated, no police report was completed for Resident#1. <BR/>A telephone interview on 02/28/24 at 2:52 PM with the CNA C revealed she was on break and when she returned, she was told the resident was missing. CNA C stated, she did a head count, and the resident was not found. CNA C stated residents were in danger of elopement if they are not supervised. Certified Nurse Aide C stated she understood the facilities policy and procedures for when a resident elopes. CNA C stated, was in-serviced about elopements. <BR/>A telephone interview on 02/28/24 at 2:39 PM with LVN D stated, Resident#1 could not be found in the dining room when trays were passed out. Licensed Vocational Nurse D stated, she drove around the neighborhood and met up with a police officer who stated they found a lady wandering in the apartments LVN D followed the police officer to the apartment. LVN D stated Resident#1 was combative and LVN D called the weekend supervisor who drove to the apartments and was able to get Resident#1 into the car. LVN D stated some of the residents were moved back into the secure unit, but she said that they did not get full clearance to put all the residents back. Some of the secure unit residents were left in general population. LVN D stated all residents were returned to the secure unit on 02/18/24. LVN D stated she was in-serviced on elopement before and after Resident #1 left the facility. <BR/>Interview on 02/28/24 at 3:30 PM with the Administrator revealed residents from the secure unit were brought to general population because of construction and both exits in the secure unit needed to be accessible. The Administrator stated Resident #1 went missing around dinner time 02/17/24, which usually started at 5:30 PM. The Administrator stated Resident#1 was found outside the facility down the street and brought back. The Administrator stated she believed that Resident#1 walked out of the facility with a visitor.<BR/>Interview on 02/29/24 at 2:15 PM with the Administrator revealed residents from the secure unit were mixed with the general population on 02/09/24 and were able to return to the secure unit on 02/14/24, according to her records. The Administrator stated she did not realize secure unit residents were still in general population until 02/18/24. The Administrator stated that in the future she would have more staff to come in to monitor the exits if the secure unit residents must come back to general population.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services.<BR/>1) <BR/>The facility failed to ensure food items were properly labeled and dated with the product's name.<BR/>2) <BR/>The facility failed to ensure food items were properly sealed when not in use.<BR/>These failures could place residents at risk for food-borne illness and food contamination.<BR/>Findings include:<BR/>An observation on 5/21/2025 at 11:50 AM revealed in the dry food pantry one large plastic container of rice (was not labeled with the product type or dated); one opened bag of potato chips wrapped in plastic wrap (was undated and not properly stored according to the facility's policy); one opened bag of tortilla chips wrapped in plastic wrap (was undated and not properly stored according to the facility's policy).<BR/>An observation on 5/21/2025 at 12:10 PM in the large refrigerator revealed two bags of opened bread (was not labeled, dated, nor properly stored); white gravy in a plastic container covered with plastic wrap (had a large hole in the plastic wrap); chopped up meat (was not labeled with the product type or dated); one opened pack of deli meat (was not labeled with the product name or dated); one large bowl was uncovered which contained chocolate pudding (was not labeled with the product name or dated).<BR/>An observation on 5/21/2025 at 12:30 PM in the walk-in freezer revealed an opened plastic bag with four meat patties (were not labeled with the product name or dated); two opened large packs of hamburger buns (was not labeled or dated) and one large roll of ground beef (was not labeled with the product name or dated).<BR/>In an interview on 5/21/2025 at 1:25 PM, the DM stated she worked at the facility for 3 days. The DM stated all kitchen staff were responsible for labeling and dating all items. The DM stated when staff opened anything, all unused products must be placed inside of a Ziplock bag or container and labeled and dated. The DM stated all leftover cooked items, must be stored in a closed container, labeled, and dated. The DM stated the brown substance in the large bowl was chocolate pudding the worker had just made for tonight's dinner. The DM stated frozen foods should be dated upon arrival to the facility. The DM stated if the frozen boxes were emptied all removed bags of that item, must be labeled, and dated. The DM stated based on her first 3 days of observations, she needed to in-service staff regarding proper labeling and dating. The DM stated serving residents expired food or food not properly stored according to the facility's policy could cause food poisoning and make the resident ill. <BR/>In an interview on 5/21/2025 at 2:00 PM, DA A stated whenever stocked the food from the delivery truck, must date it. DA A stated any opened dry food must be placed in a container, properly labeled and dated. DA A stated any opened perishable food must be placed in a Zip Loc bag, labeled, and dated. DA A stated not following protocol could make the residents sick.<BR/>In an interview on 5/21/2025 at 3:20 PM, DA B stated the entire staff was responsible for labeling and dating opened containers and packages. DA B stated without a proper label and date, the next worker would not know when the items were placed there. DA B said the DM was in charge of overseeing the kitchen and she instructed them to label everything. DA B said failing to do so placed the residents at risk of becoming ill.<BR/>In an interview on 5/21/2025 at 3:35 PM, the ADM stated all food should be labeled, dated, and stored properly. The ADM stated the kitchen staff should know when food was made and what it was being used for at the time. The ADM stated this was important to prevent the residents from becoming ill. The ADM stated they must continue to educate staff on proper food storage and safety.<BR/>Record review of the facility's policy titled Accepting Food Deliveries, published date of 2013, reflected Food deliveries will be accepted into the facility only by the following procedure . 4. Perishable foods will be properly covered, labeled, and dated and promptly stored in the refrigerator or freezer as appropriate.<BR/>Record review of the facility's policy titled Food Storage, published date of 2013, reflected:<BR/> .4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated . <BR/>c. Food should be dated as it is placed on the shelves .<BR/>13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded.<BR/>14. Refrigerated Food Storage . f. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.<BR/>15. Frozen Foods . c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.

**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, recognizing each resident's individuality for one (Resident #124) of seventeen residents reviewed for resident rights.<BR/>The facility failed to ensure the shower chair used to transport Resident #124 from the shower room to is room was clean and free of feces. <BR/>This failure could cause the resident embarrassment and place him at risk for poor personal hygiene and a decline in quality of life. <BR/>Findings included:<BR/>Record review of Resident #124's face sheet dated 09/01/2023, reflected an [AGE] year-old male admitted on [DATE]. His diagnoses included Parkinson's Disease (A brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination, Syncope and collapse (Medical term for fainting or passing out), hearing loss, chronic kidney disease (Kidneys are damaged and cannot filter blood as well as they should), and unspecified arterial fabulation (The heart's upper chambers beat chaotically and irregularly). <BR/>Record review of Resident #124's admission MDS assessment, dated 08/31/2023, reflected a Brief Interview for Mental Status (BIMS) of 10, which indicated moderate impaired cognition. Futher review reflected he required extensive assist for bedmobility, transfers, locomotion on the unit, personal hygiene, and was totally dependent on staff for bathing. <BR/>Record review of Resident #124's Care Plan, dated 08/29/2023, reflected the resident had limited physical mobility, and ADL self-performance deficit, communication problem, fall risk, bowel incontinence, a urinary catheter, and required tube feeding. <BR/>An observation and interview on 08/30/2023 at 9:13 AM, with the CEO, at the doorway of Resident #124's room revealed CNA F transporting Resident #124, from the shower room through 100 Hall, to Resident #124's room, in a shower chair. Feces was observed on the front left leg of the shower chair and smeared in the hall outside the shower room and outside Resident #124's room, where the surveyor and CEO were standing. CNA F proceeded to take Resident #124 into the room and closed the door. The CEO said he saw the feces in the hall and on the shower chair as CAN F passed by with Resident #124 on their way to the room. When asked about the observation, the CEO stated he would address it. MA E was standing at her medication cart across the hall. <BR/>In an interview on 08/30/2023 at 9:25 AM, MA E said she saw the feces smear in the hall when CNA F brought Resident #124 to his room. She said she cleaned it up and then went into Resident 124's room to tell CNA F about the feces in the hall. She said it was an infection control issue as well as a dignity concern for Resident #124. <BR/>In an interview on 08/30/2023 at 9:31 AM, CNA F, stated he had not noticed the feces on the shower chair and did not notice that it was smearing down the hall when he took Resident #124 to his room. He said MA E told him about it and told him she had cleaned it up a few minutes ago. He said he should have made sure the shower chair was clean before leaving the shower room to prevent any infection control concerns. He said Resident #124 would be embarrassed if he knew what had happened. <BR/>In an interview on 08/30/2023 at 9:44 AM, Resident #124 said he had not realized there was feces on the shower chair. He said it was embarrassing and CNA F should have checked the chair before taking him to his room. <BR/>In an interview on 08/31/2023 at 2:47 PM, the Administrator said CNA F should have checked the shower chair prior to leaving the shower room with Resident #124 to ensure it was clean. She said smeared feces in the hall was definitely an infection control concern and could be a dignity issue as well. <BR/>In an interview on 08/31/2023 at 11:58 AM, the DON stated CNA F should have made sure the shower chair was clean for transporting Resident #124 through the hall. She said feces on the chair and smeared in the hall was an infection control concern as well as a dignity concern for the resident. She said the CNAs were expected to ensure equipment was clean and all nursing staff were responsible to monitor this. <BR/>Record review of the facility's in-service records reflected, and undated in-service titled Disinfection of Equipment.<BR/>Record review of the facility's policy titled, Quality of Life - Dignity, revised August 2009, reflected, : Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Treated with dignity means, the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #2 and Resident #3) of five residents reviewed for ADLs. <BR/>The facility failed to provide showers or bed baths consistently for Residents #2 and #3 per the facility bathing schedule in January 2025. <BR/>This failure placed residents who were dependent on staff for bathing at risk for poor personal hygiene, odors, and a decline in their quality of life. <BR/>Findings included:<BR/>1. Record review of Resident #2's Face Sheet reflected dated 01/30/25 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2's active diagnoses included paraplegia (a condition that causes paralysis or loss of muscle function in both legs), neuromuscular dysfunction of bladder (impaired bladder control due to disrupted communication between the brain and the bladder muscles), Stage 4 pressure ulcer of right heel and Stage 4 pressure ulcer of right lower back (a pressure ulcer is localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction; Stage 4 means full thickness tissue loss with exposed bone, tendon or muscle).<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 15 which indicated no cognitive impairment. Resident #2 had range of motion impairment on both sides of his lower extremities and used a wheelchair for mobility. Resident #2 required partial/moderate assistance from staff for bathing and personal hygiene. He had an indwelling and external catheter (a flexible tube inserted into the body to drain or deliver fluids) and ostomy (a surgical procedure that creates an opening in the abdomen to allow waste to exit the body).<BR/>Record review of Resident #2's baseline care plan dated 01/22/25 reflected he was dependent on staff for toileting hygiene and showers/bathing.<BR/>An interview with Resident #2 on 01/30/25 at 1:49 PM revealed he had been moved to the room he was presently in several days prior and there was no hot or warm water available in his bathroom to use. Resident #2 stated he had let the water run in his bathroom sink for over an hour when he first moved to the room, but there was only cold water. He said the shower at the end of his hall also did not have any hot or warm water. Resident #2 said he had not received a shower the past two scheduled times (01/27/25 and 01/29/25). Resident #2 stated he felt not having hot or warm water available in his room made him feel very dirty, he said he could not wash his face well and it was starting to breakout and his skin was starting to get itchy all over.<BR/>Record review of Resident #2's nursing progress notes reflected no shower refusals since his readmission to the facility from the hospital on [DATE].<BR/>2. Record review of Resident #3's Face Sheet dated 01/30/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #3's active diagnoses included paraplegia (a condition that causes paralysis or loss of muscle function in both legs), colostomy status (a surgical procedure that creates an opening in the colon, allowing stool to be diverted from the rectum and collected in a bag), Stage 4 right and left lower back pressure ulcer, stage 4 of sacral region (Full thickness tissue loss with exposed bone, tendon or muscle) and flaccid neuropathic bladder (a condition where the bladder muscles are weak and unable to contract properly, leading to difficulty or inability to urinate). <BR/>Record review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated no cognitive impairment. Resident #3 had range of motion impairment on one side of his upper extremities and on both sides of his lower extremities. He used a wheelchair for mobility and was dependent on staff for all ADLs, including showering and personal hygiene. <BR/>Record review of Resident #3's care plan last revised 01/28/25 reflected Resident #3 had an ADL self-care performance. Interventions, Bathing/Showering: Resident prefers showers 3 times per week likes to get oob daily; The resident requires extensive assistance by (1) staff with bathing/showering (start 09/30/24)<BR/>An interview and observation of Resident #3 on 01/30/25 at 2:03 PM revealed he was sitting in a reclined wheelchair in his room with his eyes closed. Resident #3 stated he had not been bathed or showered in the past week. He said he could not remember the last time he had been bathed but it had been a long time, over a month. During the interview, Resident #3 kept trying to peel his right eye open with his fingers as it was observed to be crusty and sealed shut. Resident #3 said he did not know why the staff were not bathing him and stated, They don't tell me why. I want one though. Resident #3's bathroom sink was observed to have no hot or warm water available. <BR/>Record review of Resident #3's nursing progress notes reflected no shower refusals for the month of January 2025. <BR/>3. An observation of Resident #2 and #3's shower room at the end of Hall 400 on 01/30/25 at 1:56 PM revealed there was no hot or warm water coming from the shower faucet.<BR/>4. Review of the facility shower binder for Hall 400 reflected no shower sheets for Residents #2 and #3 for January 2025. There were daily lists of residents to be showered with a space for the nurse to sign with any comments. However, neither Resident #2 nor Resident #3 were checked off as completed. <BR/>5. An interview with ADON A on 01/30/25 at 12:19 PM revealed completed shower sheets were important because that was the way the facility kept track of any new resident skin issues. ADON A stated she had looked in the binders and verified there were no shower sheets for Resident #2 and #3. ADON A stated what she saw in the shower binders at the 400-hall nursing station was just a list for the charge nurse to sign off on which residents were supposed to get showered that day. ADON A stated, But they were not the shower sheets. ADON A stated she did not know how long the CNAs and charge nurses had not been using shower sheets. ADON A stated the list of who needed a shower was not acceptable. She said the shower sheets needed to be completed and turned in by the CNAs for review to see if there were any changes to a resident's skin condition. ADON A stated the form they were using currently did not indicate if any skin was looked at or if any skin issues were noted. ADON A said she was going to ensure that the required blank shower sheets were copied and placed back into the shower binders along with the schedule list of residents to be showered for that day so they can be tracked and monitored. ADON A stated she did not know why the system changed except laziness and no one put more shower sheets in the binders, so they all defaulted to just signing a schedule, Which is not appropriate. <BR/>An interview with the ADM on 01/30/25 at 9:30 AM revealed the DON was out sick on leave and was unable to be interviewed. <BR/>An interview with CNA C on 01/31/25 at 12:37 PM revealed she had not seen any skin observation sheets (shower sheets) and when she gave a resident a shower, she just circled on a list if the resident received it or if they refused. If any skin issues, she would circle yes/no and then report to the charge nurse. When shown a blank shower sheet/skin observation sheet, CNA C stated she had not seen them before and had not been filling those out. CNA C stated showering a resident was important because no one wanted to have body odor and they want to smell fresh. CNA C stated infection control was also another reason showers were important, We have bacteria on our skin and we need to shower to remove it and protect the skin, like rashes and stuff, showering is good. <BR/>An interview with CNA D on 01/31/25 at 12:56 PM revealed she was picking up a shift and had showered Resident #1 that morning (01/31/25). CNA D stated she had another CNA help her shower Resident #1 and he took them a lot of time. She stated when a resident shower was completed, there was a paper that had the name and room number of the residents assigned to be showered for that day. If the resident refused the shower, the CNA had to tell the nurse. CNA D stated she had not seen the shower sheet form/skin observation sheet recently. <BR/>An interview with the ADM on 01/31/25 at 1:54 PM revealed he had heard about Resident #2 not being showered because his family member had contacted him on 01/30/25 about it. The ADM stated he completed a grievance form as a result. The ADM reviewed the shower binder and the schedule the nurse checked off that staff were using as shower sheets and said it was not the right form. He said the shower sheets to be used were more comprehensive. <BR/>6. A policy on ADL care related to showers was requested on 01/30/25 and 01/31/25 from the ADM but was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Residents #15) of 4 residents reviewed for quality of care. <BR/>1. Resident #15 did not receive care on the overnight shift (10PM-6AM) on 08/05/24. Resident #15's entire, right leg hung from the bed throughout the night and was observed swollen. Resident #15 was in distress, discomfort, pain, shed tears and had a flushed face (blood vessels below the skin dilate and fill with more blood, making the skin appear pink, red.) Resident #15 call light and bathroom call light did not work properly. Resident #15 yelled and cried out for help continuously for thirty minutes at 7:00 AM on 08/06/24.<BR/>On 08/07/24 at 3:46 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/12/24, the facility remained out of compliance at a severity level of - no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. <BR/>These failures could place all residents at risk for abuse that could lead to serious injury, harm, impairment, or death. <BR/>Findings included: <BR/>Record review of Resident #15's face sheet, dated 08/12/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: paraplegia (the loss of muscle function in the lower half of the body, including both legs), abnormalities of gait and mobility, intervertebral disc degeneration (a condition that occurs when the spinal discs break down and lose function), lumbar region (spinal disks wear down), post-traumatic stress disorder (a mental health condition that caused by extremely stressful or terrifying event), pain unspecified, and retention of urine. <BR/>Record review of Resident #15's initial MDS assessment, dated 06/28/24, reflected her BIMS score was 13, which indicated she was cognitively intact. <BR/>Record review of Resident #15's care plan, revised on 08/02/24, reflected Resident #15 required skilled nursing care related to paraplegia. Resident #15 will safely transition to long term care. Resident #15 will continue to improve. Resident #15 has limited physical mobility/ADL deficit related to paraplegia, Chronic Obstructive Pulmonary Disease, anxiety, and bipolar disorder. Resident #15 were on skilled services and decided she wanted long term care instead of short stay. Resident #15 had rails on bed for positioning and turning. Resident #15 required bed mobility with 1 staff, transfers with 2 staff with a sliding board and a Hoyer lift with showers, toileting with 1 staff, and dressing/grooming with 1 staff. Goals: free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, and fall related injury through the next review date. Interventions: Monitor/document/report to MD PRN s/sx of immobility: contractures forming or worsening, thrombus formation, skin break down, and fall related injury .Provide supportive care, assistance with mobility as needed. Document assistance as needed.<BR/>Record review of Resident #15's progress note, late entry dated 08/08/24 by the social worker, reflected the following: [Resident #15] asked if she had to move rooms. SS explained to the resident that once a resident transition to long-term, they get a roommate. The resident then stated a staff member said she could stay in a private room if her family could pay the difference. When asked who told her that, resident said she could not remember. SS told the resident that they would ask the administrator and see what he says. The [Resident #15] then said she plans on leaving the facility September 1st and will move in with her.<BR/>Observation on 08/06/24 at 7:00 AM revealed Resident #15 yelled for help from her bedroom. Observed Resident #15 right entire leg hanging out of the bed and appeared to be red and swollen. Observed Resident #15 face was red, in distress and she was crying. <BR/>Observation on 08/06/24 at 7:30 AM of the social worker went into the room and then walked out. Observed Resident #15 call out for help again.<BR/>Observation on 08/06/24 at 7:40 AM revealed LVN H and CNA N lifted Resident #15's leg back in the bed and gave her pain medication. LVN H stated to Resident #15 that they will assist her after breakfast with getting dressed and changed.<BR/>Observation on 08/06/24 at 7:45 AM revealed Resident #15's call light in the room and in the bathroom did not work. <BR/>Observation on 08/06/24 at 4:30 PM revealed Resident #15's call light worked properly. <BR/>Interview and observation on 08/06/24 at 7:21 AM with Resident #15 who stated she was not checked on by the overnight shift. Resident #15 stated she had been calling out for help for a while and no one had been by to help her. Resident #15 was distressed and crying. Resident #15 stated that she felt alone and abandoned. Resident #15 stated the last time she saw staff was when she moved into the room.<BR/>In an interview on 08/06/24 at 7:45 AM Resident #15 stated she did not know why she was moved to hallway 500, she was moved yesterday and was the only resident on that hall. Resident #15 stated her call light in the room and bathroom did not work. Resident #15 stated she had told the DON and other staff that her call light did not work on 08/05/24 around dinner time at 4:30 PM.<BR/>In an interview on 08/06/24 at 8:10 AM with the social worker revealed Resident #15 was moved to the 500 hall because she wanted to be transferred to long term care and have a single room.<BR/>In an interview on 08/06/24 at 9:00 AM LVN H stated Resident #15 was transferred to the 500 hall on 08/05/24 between first and second shift. LVN H stated that she was responsible for 300 and 500 hall. LVN H stated the facility had problems in the past with the call lights not working. LVN H stated that if residents were not checked on every 2 hours and as needed, they were in danger of falls and skin break down.<BR/>In an interview on 08/06/24 at 9:10 AM CNA F revealed she did not know there was a resident on hallway 500. CNA F revealed residents were to be checked on every 2 hours. <BR/>In an interview over the phone on 08/06/24 at 9:15 AM CNA N (overnight shift) stated she did not know a resident was on 500 hall.<BR/>In an interview on 08/06/24 at 3:00 PM the DON stated that staff knew Resident #15 was on 500 hall and she had a history of lying, drinking, and smoking in the room and that was part of the reason why she was put on the hall by herself. The DON revealed that Resident #15 was transferring to long term care and wanted to stay in a room by herself. The DON stated the call light system just started to act up on 08/05/24. The DON stated the call light company would be out to repair the system. The DON stated residents are checked on every 2 hours and the residents who call lights did not work then bells would be provided. The DON stated residents are in danger of skin break down or falls if they are not checked every 2 hours. <BR/>In an interview on 08/06/24 at 3:08 PM with Resident #15 stated that her entire left leg hung out of the bed all night and she did not know until she started to feel pain. Resident #15 stated her pain level this morning was at a ten and now she was down to an 8. Resident #15 stated she expected staff to answer the call light and help her as soon as they could. Resident #15 stated she understood the staff were busy but when they tell her they will come back staff don't. Resident #15 stated the social worker told her she was moved because she wanted to move to long term care and stay in a single room. Resident #15 stated the DON asked her if she wanted to move back to hall 100 and she told him no because she had too much stuff too.<BR/>In an interview on 08/07/24 at 5:15 AM with LVN R (Overnight shift) stated she was responsible for hall 300, 400, and 500. LVN R revealed she changed Resident #15 once overnight the night before. LVN R stated since Resident #15's call light was not working she was checked on every 2 hours.<BR/>In an interview on 08/07/24 at 5:20 AM with CNA N (Overnight shift) revealed she worked halls 100, 300, and 500. CNA N revealed that Resident #15 was checked on once.<BR/>In an interview on 08/07/24 at 7:00 AM with the Maintenance Director stated the facility was in the process of updating the call light system and the owner would know more information about that. The Maintenance Director stated when the call light system did not work resident rounds should be every 30 minutes. The Maintenance Director stated residents could be at risk of not getting care when needed. The Maintenance Director stated the facility had on and off issues with the call lights. The Maintenance Director stated the call light company would be out on 08/07/24 after 12:00 PM to work on the system. <BR/>Record review of facility in-service dated 08/06/24 titled: call light and resident care reflected: <BR/>Resident should be up in a WC and back to bed as needed and requested. If a resident wants to get up, we need to do all we can to get him/her up. If they want to go back to bed, assist them back in bed as need. Let us work with our residents to meet their needs. We should always encourage residents to get out if bed; not discourage them. We should also empower residents by allowing them to participate in the decision-making process. For example, we can ask: What time would you like to get up: What time would you like to go back to bed? I know you want to get up at 5 PM. At that time, we are passing dinner on the floor. Is it possible for you to get up earlier or later than 5pm? Make residents feel in control of daily lives. We need to do round on residents all the time and provide incontinent care as needed without delays to all halls INCLUDING 500 HALL Do not delay care or wait for the end of the shift when we know that a resident is wet and needs assistance. We cannot let our residents lie in urine and feces: placing them at remarkably high risks of all types of infection. We should always treat our residents with dignity and respect. DO not display a behavior or attitude that may be misinterpreted or make residents uncomfortable. Do not make fun at residents. When they need something, please take time to explain and answer all their questions to the best of your ability. <BR/>Call lights should be answered in a timely manner without delays by all departments. When answering the call light, please refer to the service resident is requesting. Make sure to return and update resident. Leave the call light on until residents' needs have been met.<BR/>No staff signatures included with in services.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 08/07/24 at 3:46 PM. The Administrator and DON was notified. The Administrator was provided with the IJ template on 08/07/24 at 4:00 PM. <BR/>The following Plan of Removal was submitted by the facility and was accepted on 08/09/24 at 3:11 PM and reflected: <BR/>Immediate Corrective Action for residents affected by the alleged deficient practice: <BR/>Identified Immediate Jeopardy (IJ) Issues: Policy and procedure have and will be reviewed and will be re-in-serviced if change is required. <BR/>1. <BR/>Noncompliance with &sect;483.12 (F 600) Freedom from Abuse, Neglect, and Exploitation<BR/>o <BR/>Resident #1 was not checked on the overnight shift.<BR/>o <BR/>Call lights and bathroom lights were not functional. <BR/>Corrective Actions and Steps for Removal of Immediate Jeopardy:<BR/>1. Ensuring Resident Safety and Dignity<BR/>Immediate Staff Training:<BR/>o <BR/>Action: Conduct immediate in-service training for all staff on the importance of resident checks, especially during night shifts, and proper use of the call light system. Review of Policy and Procedure for call light and ADL's.<BR/>o <BR/>Responsible Party: Director of Nursing (DON)<BR/>o <BR/>Completion Date: 08/09/2024<BR/>Immediate Resident Checks:<BR/>o <BR/>Action: Implement a system to ensure residents are checked every two hours, with documentation of each check. Review of Policy and Procedure ADL's.<BR/>o <BR/>Responsible Party: Nursing Staff<BR/>o <BR/>Completion Date: Ongoing with immediate effect<BR/>2. Functionality of Call Lights and Electrical Systems<BR/>Repair Call Lights and Electrical Issues:<BR/>o <BR/>Action: Ensure all call lights in resident rooms and bathrooms are fully functional. A certified electrician will repair any non-functional lights immediately. Review of Policy and Procedure for call light and ADL's.<BR/>o <BR/>Responsible Party: Maintenance Supervisor<BR/>o <BR/>Completion Date: 08/09/2024<BR/>Routine Maintenance Checks:<BR/>o <BR/>Action: Conduct daily checks of call light systems for two weeks, followed by weekly checks to ensure ongoing functionality.<BR/>o <BR/>Responsible Party: Maintenance Supervisor<BR/>o <BR/>Completion Date: Start immediately and continue weekly<BR/>4. Resident Assistance and ADL Care<BR/>Enhance ADL Care:<BR/>o <BR/>Action: Review and revise hall assignments to ensure adequate staffing on all halls, including hall 500. Ensure staff are aware of and meet residents' ADL needs promptly.<BR/>o <BR/>Responsible Party: DON and Nursing Supervisor<BR/>o <BR/>Completion Date: 08/09/2024<BR/>Frequent Monitoring and Assistance:<BR/>o <BR/>Action: Implement a policy requiring staff to respond to call lights within 5 minutes. Regularly audit compliance and address any delays promptly.<BR/>o <BR/>Responsible Party: Nursing Supervisor<BR/>o <BR/>Completion Date: Start immediately with ongoing monitoring<BR/>5. Family and Resident Communication<BR/>Communication with Residents and Families:<BR/>o <BR/>Action: Inform residents and their families about the steps being taken to address the identified issues and ensure their safety and well-being.<BR/>o <BR/>Responsible Party: Administrator and Social Worker<BR/>o <BR/>Completion Date: 08/09/2024<BR/>Monitoring and Verification<BR/>Regular Audits:<BR/>o <BR/>Action: Conduct weekly audits for compliance with the above actions for the next three months, then transition to monthly audits.<BR/>o <BR/>Responsible Party: Quality Assurance Team<BR/>o <BR/>Completion Date: Ongoing<BR/>Immediate Reporting:<BR/>o <BR/>Action: Any noncompliance or issues identified during audits must be reported to the DON and Administrator immediately for corrective action.<BR/>o <BR/>Responsible Party: Audit Team<BR/>o <BR/>Completion Date: Ongoing<BR/>Completion and Documentation<BR/>Document All Actions:<BR/>o <BR/>Action: Maintain thorough documentation of all corrective actions, training sessions, maintenance checks, and communication with residents and families.<BR/>o <BR/>Responsible Party: Administrator<BR/>o <BR/>Completion Date: On going<BR/>The facility's implementation of the Plan of Removal was verified through the following:<BR/>Record review of in-service record sheet dated 08/07/24 titled: Call light/check residents. Purpose: plan of correction. Ensure resident safety and dignity: Make sure to check all residents at least every two hours every shift and as needed, especially at night. Before leaving the room make sure call light is working in room and the bathroom and within patients reach.<BR/>Enhance ADL Care: Check residents in hall 500 at least every two hours every shift and throughout the night. Hall 500 assignments will be added to the staffing book. Check staffing book assignment daily to know who is assigned to hall 500. DO not ignore call light. Call light needs to be answered promptly. Even if you are not assigned to a resident, you must answer call light and address residents needs as much as you could. Provide showers to residents as scheduled and as needed. If a patient missed shower for more some reasons, we should provide it to them when requested even if it's not their shower day. When a patient refuses shower, notify the nurse immediately who will then inform family and document under PCC notes.<BR/>Frequent Monitoring and assistance: We need to respond to call light immediately; within 5 minutes or less. Any staff that delay care or call light response will face disciplinary action.<BR/>Record review of NMAR reflected: [ Resident #15] check on resident at least every two hours every shift initiated on 08/08/24.<BR/>Record review for in-services were initiated on 08/12/24 at 11:11 AM in a message to the team. Message reflected: Good morning, Team! Please see in-service regarding call lights/resident rooms from DON. We need to answer call light immediately. When we go to room, check to make sure call lights works in the room and bathroom. If it does not report it to charge nurse, DON and/or Maintenance. <BR/>There are patients on 500 hall that need to be monitored as well. Check on all patients including the ones on hall 500 at least every two hours. Hall 500 assignments will be in staffing book. Please check it at the beginning of each shift. Please respond to acknowledge the in-service. <BR/>An interview on 08/09/24 at 5:15 AM with RN P revealed residents were checked on every 2 hours and as needed. RN P revealed that checks were documented on the EMAR.<BR/>An interview on 08/09/24 at 5:20 AM with RN Q revealed she worked over night with Resident #15, and she was checked on every 2 hours and as needed. RN Q revealed that checks were documented on the EMAR.<BR/>An interview on 08/09/24 at 5:25 AM with CNA F revealed residents were checked on every 2 hours and as needed. CNA F revealed that checks were documented on the EMAR.<BR/>An interview on 08/09/24 at 5:30 AM with LVN A revealed residents were checked on every 2 hours and as needed. LVN A revealed that checks were documented on the EMAR.<BR/>An interview on 08/09/24 at 6:10 AM with LVN B revealed residents were checked on every 2 hours and as needed. LVN B revealed that checks were documented on the EMAR.<BR/>An interview on 08/09/24 at 6:20 AM with LVN D revealed she worked with Resident #15 overnight and she was checked on every 2 hours and as needed. LVN D revealed that checks were documented on the EMAR. <BR/>An interview on 08/10/24 at 1:30 PM with CNA X who stated residents are checked on every 2 hours. CNA X stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/10.24 at 1:37 PM with RN Y who stated residents are checked on every 2 hours. RN Y stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/11/24 at 5:45 AM with Med Aide S who stated residents are checked on every 2 hours. Med Aide S stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/11/24 at 5:58 AM with LVN R who stated residents are checked on every 2 hours. LVN R stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/11/24 at 6:00 AM with CNA T who stated residents are checked on every 2 hours. CNA T stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/11/24 at 6:00 AM with CNA V who stated residents are checked on every 2 hours. <BR/>An interview on 08/11/24 at 6:03 AM with CNA U who stated residents are checked on every 2 hours.<BR/>An interview on 08/11/24 at 6:03 AM with RN W who stated residents are checked on every 2 hours. RN W stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/11/24 at 8:41 AM with the DON stated the MAR needed to be updated to reflect every 2-hour check for residents. DON stated he needed to do in-services for residents on hall 500 and assigned task. DON stated he would send updated information before the end of the day. DON stated residents are checked on every 2 hours. DON stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/12/24 at 5:30 AM CNA J who stated residents are checked on every 2 hours. CNA J stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/12/24 at 6:00 AM LVN B stated who stated residents are checked on every 2 hours. LVN B stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>An interview on 08/12/24 at 6:04 AM LVN H who stated she worked the day shift and is responsible for Resident #15 and she is checked on every 2 hours. LVN H stated if a resident's call light did not work then they should be given a bell until the system was fixed. <BR/>The Administrator was notified the IJ was removed on 08/12/24 at 12:15 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolation due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services for 1 of 3 residents (Resident #2) reviewed for catheter care.<BR/>The facility failed to ensure LVN A followed relevant clinical guidelines and provided appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.<BR/>This failure could place the resident at risk of urethral tears or dislodging the catheter and urinary tract infections.<BR/>Findings included:<BR/>1. Record review of Resident #1's annual MDS assessment, dated 12/17/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 13 indicating his cognitive status was intact. His diagnoses included neurogenic bladder (a condition that affects the bladder's ability to function properly due to damage or dysfunction in the nerves that control it), paraplegia (a condition characterized by the loss of motor and sensory function in the lower half of the body, including the legs, feet, and genitals), pressure ulcer of sacral regions stage 4, and hypertension. The resident was dependent on staff for toileting. The resident was always incontinent of bowel and bladder. <BR/>Record review of Resident #2's care plans, dated 02/02/25, reflected:<BR/>The resident had an ADL Self Care Performance Deficit related to paraplegia. <BR/>Facility interventions included: The resident required extensive assistance with toileting.<BR/>Record review of Resident #2's orders, dated 08/08/24, reflected:<BR/>Foley catheter to be changed monthly and as needed for malfunction.<BR/>An observation on 02/20/25 at 1:00 PM revealed Resident #2 was lying in bed and his indwelling catheter drainage bag was on the floor. The catheter was not anchored to a non-moveable part of the bed.<BR/>An observation 02/20/25 at 1:10 PM revealed the indwelling catheter bag was still on the floor. <BR/>An interview on 02/20/25 at 1:13 PM with LVN A revealed that when LVN A went to administer the resident's IV antibiotic, the foley catheter drainage bag was on the floor. LVN A stated that she was going to finish other things and that she would return later to get the drainage bag off the floor. LVN A left the resident's room without getting the drainage bag off the floor.<BR/>An interview on 02/20/25 at 2:47 PM with the ADON revealed leaving the Foley bag on the floor would put the resident at risk for infection.<BR/>An interview on 02/20/25 at 3:37 PM with LVN A revealed the Foley catheter drainage bag needed to be positioned below the bladder, hang on the side of the bed, and not be on the floor. LVN A stated that she did not remove the bag from the floor because it was going to take a long time to clean the catheter bag and secure it on the bedside. LVN A stated that the risk to the patient was risk for infection.<BR/>An interview on 02/20/25 at 4:26 PM with the DON revealed the Foley catheter drainage bags should never be on the floor and they should be secured to the bed frame. The DON stated that placing the drainage bag on the floor could put the resident at risk of further infection and dislodgment of the catheter.<BR/>Review of the facility policy, Urinary continence and incontinence -Assessment and Management and urinary tract infection/bacteriuria clinical protocol reflected: <BR/>Indwelling catheters should be anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (Residents #73) out of 7 residents reviewed for sufficient staff.<BR/>The facility failed to have adequate staff to prevent Resident #73 from wandering out of the secured unit and into the main area of the facility. An assigned Charge Nurse and CNA were both off the unit at the time Resident #73 left the unit. <BR/>This failure could place residents at risk of not receiving the necessary care and services to maintain their highest practicable physical, mental, and psychosocial well-being. <BR/>Findings included: <BR/>Record review of Resident #73's admission Record dated 11/1/24 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. <BR/>Record review of Resident #73's admission MDS assessment dated [DATE] reflected he had moderately impaired cognition, he had fluctuating periods of inattention and had wandering behaviors. The MDS Assessment reflected he was dependent on staff for toileting, required maximum assistance for bathing, and was incontinent of bowel and bladder. He used a wheelchair and required partial assistance transferring from bed to chair. The MDS Assessment reflected his diagnoses included hypertension (high blood pressure); psychotic disorder; and schizophrenia (a mental health condition that can cause delusions, paranoia, and disorganized behaviors). <BR/>Record review of Resident #73's Care Plan entry dated 8/11/24 reflected a focus of his required placement on secure unit due to: 1-To minimize behaviors due to overstimulation elicited from more active units. 2-To provide safe/secure environment for wandering aimlessly. 3-To provide secure environment due to risk of elopement. Goal: [Resident #73] will have no episodes of wandering into unsafe area through next review date .Interventions/Tasks: .Review quarterly for continues need for secure unit. If appropriate, implement process to place on less secure unit.<BR/>An observation and interview on 10/29/24 at 11:52 revealed CNA M who was observed in the secured unit passing lunch trays while redirecting multiple residents away from the exit doors and toward the dining room. She stated she had worked there about a month. CNA M stated there were 2 CNAs assigned to the hall and a LVN who also had to work another hall outside the unit. <BR/>An observation and interview on 10/29/24 at 12:00 PM revealed multiple residents were observed in the secured unit dining room. LVN L was observed checking the trays and passing them to residents. LVN L stated she was the Charge Nurse for the secured unit as well as the 100 Hall. She stated the trays had already been passed to the 100 Hall residents. CNA N was observed setting up meals for residents and frequently redirecting and cueing residents. CNA M was observed entering the dining room. She sanitized her hands and sat down with a resident to feed them. Resident #73 was observed in the dining room, sitting alone and feeding himself. <BR/>Observations and interviews on 10/30/24 at 8:32 AM, revealed Resident #73 was in his wheelchair pressing on the glass exit door leading from the locked unit [200 Hall] to main hallway. No staff were observed in the hallway on the secured unit or in the immediate vicinity outside the door. LVN L was observed returning from the 100 Hall toward the nurses' station that faced the secure unit door. Resident #73 was then observed outside the secured unit wheeling into the main area in the facility. LVN L approached Resident #73 and assisted him back into the secured unit. No other staff were observed in the secured unit's main hallway at that time. LVN L stated the door leading to the locked unit had a delay of about 15 seconds. She stated, if a resident pressed on the door handle, the door would eventually open. The door was tested by this surveyor. Upon pressing the door handle, an audible alarm was heard along with a voice coming from the keypad indicating a security alert. A medication cart was observed outside a resident's room approximately halfway down the hall. MA O was observed exiting the resident's room and approaching the medication cart. MA O stated she had not seen Resident #73 attempting to exit the unit nor did she hear the alarm because she was inside a resident's room passing medications. LVN L stated there were two CNAs on the unit as well as the MA. CNA M entered the unit and stated she had left the unit to return breakfast trays to the kitchen. She stated she believed it was ok to leave the unit because the MA was on the hall. <BR/>During an interview on 10/30/24 at 9:37 AM, CNA N stated she had seen Resident #73 wheeling himself in the hallway when CNA M left to return the breakfast trays earlier on 10/30/2024. She stated she had specifically told MA O that she needed to go and change a resident and that the other aide had stepped away. She stated she assumed MA O was watching the hall. CNA N stated she could not always hear the door alarm when she was in a resident room providing care especially if she was in the bathroom and the water was running. <BR/>In an observation and interview on 10/30/24 at 12:20 PM, LVN L was observed in the secured unit attending a resident with emergency medical personnel. She stated they were attempting to get the resident transferred to a hospital related to threats he had made to himself. <BR/>Observation and interview on 10/30/24 at 12:26 PM in the secured unit revealed multiple residents were gathered at the opposite end of the hall from where LVN L was attending her resident and other residents were observed wandering in the hall. The unit was very loud. Two of the residents at the end of the hall began yelling and pushing each other. CNA M and CNA N were attempting to redirect the residents and move others away from the altercation. RA S assisted and redirected one of residents involved in the altercation back to his room while CNA M redirected the other. Both residents calmed down and returned to their rooms. RA S stated she was not typically on the secured unit but was only there to help monitor the doors while testing was being conducted on the facility's electrical systems. She stated she was glad she happened to be in the unit and was able to assist. <BR/>In an observation and interview on 10/30/24 at 12:51 PM, the Administrator was observed in the secured unit speaking with the emergency medical personnel. He stated he believed the staffing was adequate within the secured unit and stated, some days good, some days they need more help. The Administrator stated staffing was based using standard PPD (per patient day calculation) type and resident acuity. He stated the staff could always call for help if needed. The Administrator stated he was aware of Resident #73 leaving the secured unit that morning. He stated he had started working there in July 2024 and that was the only known time that had occurred since he began working there. He stated it was the first facility he had worked in where a resident could press the exit door on a secured unit and it would release after 15 seconds. The Administrator stated the other facility exit doors were locked and required a code and he felt there had been no immediate risk for Resident #73. He stated he felt the staffing level was sufficient. <BR/>During an interview on 10/30/24 at 2:05 PM, CNA P stated she worked in the secured unit on the 2 PM to 10 PM shift and had worked for the facility for 2 years. She stated there were typically 2 CNAs, a nurse and a MA working the secured unit, but the nurse and MA also worked on the 100 Hall and were not always there. CNA P stated they tried to make the staffing work the best they could. She stated, due to safety, they always had 2 CNAs present during showers and made sure the nurse or MA was available to watch the unit during those times. She stated she knew Resident #73 liked to go for the door but was unaware of any residents leaving the unit during her shift. <BR/>During an observation and interview on 10/30/24 at 3:57 PM, the DON was in the secured unit. Multiple residents were observed in the sitting area and ambulating in the halls and getting frequent redirection by staff. The DON stated she had only worked at the facility for two weeks. She stated they could probably use additional staff in the secured unit because so much redirection was required for the residents. She stated there were always 2 CNAs, a nurse and a MA assigned to the unit and the nurse and MA were also assigned to the 100 Hall. She stated some of the residents on the unit became combative and required 2 CNAs to provide ADL care. The DON sated the risks included what had occurred earlier that day where they needed additional assistance and participation from staff. She stated, if the charge nurse was busy assisting a resident on the 100 Hall, that left residents at risk for altercations. She stated she believed they needed to re-evaluate staffing levels based on the needs of the residents in the secured unit. <BR/>During a telephone interview on 10/31/24 at 12:43 AM, RN Q stated she was the charge nurse for the secured unit and 100 Hall for the 10 PM to 6 AM shift. She stated there were several residents on the secured unit who tried to get out all the time. RN Q stated they had to watch the door and communicate with each other. She stated, if she needed to be on another hall, she let the CNAs know they needed to watch the door. She stated the hardest hours were between 4 AM and 6 AM. She stated she was unaware of any residents leaving the secured unit during her shift but there were occasional falls. RN Q stated Resident #73 was very confused, could get combative during ADLs and would refuse care a lot. <BR/>During an interview on 11/1/24 at 3:14 PM, RN R stated she worked on the secured unit and 100 Hall during the 2 PM to 10 PM shift. She stated she had a MA that also worked the 100 Hall and 2 CNAs who stayed in the secured unit. RN R stated staffing could be difficult because some residents had sundowners (neurological phenomenon associated with increased confusion and restlessness in people with dementia) and they would see increased agitation and behaviors in the evening. She stated they had to really watch the halls for residents attempting to leave and communicate well with the CNAs. She sated she tried to coordinate her resident care with the CNAs to ensure someone always monitoring the hall. RN R stated it was very difficult if she had a new resident admitted on her shift as she had to assess the resident and enter orders. She stated the risks included increased altercations between residents, injuries, or residents leaving the unit it, the doors were not monitored at all times. RN R stated she had not had any residents leave the unit during her shifts. <BR/>During an interview with the Administrator and DON on 11/1/24 at 1:02 PM, the Administrator stated he determined staffing by running the PPD and acuity. He stated resident cognitive levels were a factor. The Administrator stated he had previously received complaints from the facility staff regarding staffing levels because some residents were combative and required 2 staff to provide showers and ADL care. He stated he felt there were times they could use more help. The DON stated the nurses may be challenged because the 100 Hall had skilled nursing residents. She stated, if the resident was receiving IV medications or other treatments that required monitoring while residents on the secured unit were having behaviors, it could be a challenge for the charge nurse to manage both. Both the DON and the Administrator stated risk to residents exiting the secured unit was low because the facility exit doors were locked and that provided an extra barrier to elopement. The Administrator stated there was a risk for injuries to the resident if staff were attempting to address one altercation and another one occurred. <BR/>Record review of the facility's policy titled, Staffing, dated Revised April 2007 reflected, Our facility provides adequate staffing to meet needed care and services for out resident population. Policy Interpretation and Implementation: 1. Our facility maintains adequate staffing on each shift to ensure that out resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. 2. Certified Nursing Assistants are available on each shift to provide the needed care and services as outlined on the resident comprehensive care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 4 residents (Resident #55) reviewed for unnecessary medications. <BR/>The facility failed to ensure Resident #55 did not receive duplicate medication therapy for Bupropion (anti-depressant medication). <BR/>This failure could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the duplicate use of these medications) and receiving unnecessary medications.<BR/>Findings included:<BR/>Record review of Resident #55's annual MDS assessment, dated 08/03/24, reflected Resident #55 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #55's BIMS score was 15 indicating her cognition was intact. Her diagnoses included anxiety disorder and depression. <BR/>Record review of Resident #55's Care Plan dated 11/22/23, reflected the resident had depression. <BR/>Record review of Resident #55's Order Summary Report reflected:<BR/>07/06/24 Wellbutrin XL (Bupropion HCL) oral tablet extended release 150 milligrams every evening shift. <BR/>10/23/24 Bupropion HCl ER oral tablet extended release 150 milligrams every 24 hours.<BR/>Record review of Resident #55's Medication Administration Records, dated October 2024, reflected:<BR/>07/06/24 Wellbutrin XL (Bupropion HCL) oral tablet extended release 150 milligrams every evening shift. Resident refused dose on multiple days. The resident did take the medication daily 10/26/24 - 10/29/24. <BR/>10/23/24 Bupropion HCl ER oral tablet extended release 150 milligrams every 24 hours. Resident received dose daily 10/23/24 - 10/30/24. <BR/>An observation and interview on 10/29/24 at 10:36 AM with Resident #55 revealed she was in bed. She was awake, alert, and oriented. She said she did not have any issues with her medications. There was no indication that she was experiencing any negative outcomes.<BR/>An interview on 11/01/24 at 11:02 AM with LVN G revealed she made the medication error with Resident #55. She said she received a new order for Buproprion on 10/23/24 and thought she discontinued the order for Bupropion written on 07/06/24. She said the risk to the resident was increased confusion and adverse medication reaction.<BR/>An interview on 10/30/24 at 4:43 PM with the DON revealed she was new to the facility and she did not know why Resident #55 received double doses of Bupropion. She said the resident was at risk because the medication was a black box listed medication (Black box warning: may cause changes in behavior and increase the risk of suicidal thoughts.) She said she would address the issue immediately. <BR/>An interview on 10/31/24 at 2:23 PM with the Physician revealed he was aware of the medication error for Resident #55. He said he did not anticipate the resident would have any adverse outcomes because 300 milligrams was still within the dosage requirements for the medication. <BR/>Record review of facility policies revealed the facility did not have a policy for unnecessary medications. The facility used the CMS Tool, Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review<BR/>Critical Element Pathway, dated May 2017 as the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication administration error rate below 5 percent. There were 5 errors out of 32 opportunities which resulted in a 15 percent error rate for three (Resident #8, #58, and #45) of three residents reviewed for medication errors. <BR/>1) LVN A failed to administer to Resident #8 his famotidine dose via J-tube (tube inserted into the small intestine to deliver food or medications) during the medication administration observation.<BR/>2) MA B failed to administer to Resident #58 his Baclofen tablet and pregabalin tablets and failed to administer the correct dose and type of Colace during the medication administration observation.<BR/>3) MA B failed to administer to Resident #45 her Flonase during the medication administration observation. <BR/>This failure could place residents at risk of not receiving the intended therapeutics effects of medications. <BR/>Findings included:<BR/>1) Record review of Resident #8's admission Record dated 11/1/24 reflected he was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE]. <BR/>Record review of Resident #8's Annual MDS assessment dated [DATE] reflected he was cognitively intact. The MDS Assessment reflected his diagnoses included GERD (occurs when stomach acid irritates the lining of the esophagus); seizure disorder; intellectual disabilities; and dysphagia (difficulty swallowing), and he received some of his nutrition through a feeding tube. <BR/>Record review of Resident #8's Order Summary Report dated 10/30/24 reflected an order for Famotidine Oral Suspension (used to treat GERD). Give 5 ml via J-tube one time a day for indigestion. Give 40 mg/5 ml (8 mg/ml) suspension. The order was dated 3/9/24.<BR/>During an observation on 10/30/24 at 8:00 AM, LVN A stated she had used up Resident #8's supply of Famotidine the day before and had notified the pharmacy. She stated the medication showed as delivered in the computer, but she did not have it available. LVN A stated Resident #8 had recently began taking food by mouth rather than using formula through his feeding tube and talked about stopping the medication because he was no longer having GERD symptoms. She stated she would search for the medication and notify the pharmacy if she was unable to locate it.<BR/>Record review of Resident #8's MAR dated October 2024 reflected the entry for his Famotidine was coded with 9 See Nurses Notes. <BR/>Record review of Resident #8's Progress Notes reflected the following entry dated 10/30/24 at 9:48 AM: Note Text: Famotidine Oral Suspension Reconstituted Give 5 ml via J-Tube one time a day for indigestion Give 40mg/5ml(8mg/ml) suspension Pharmacy notified. Partial medical was sent pending approval of insurance for payment. Rest of medication will be sent tonight. 10/30/24. The entry was signed by LVN A.<BR/>2) Record review of Resident #58's admission Record dated 11/1/24 reflected he was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE]. <BR/>Record review of Resident #58's admission MDS assessment dated [DATE] reflected he was cognitively intact. The MDS Assessment reflected his diagnoses included, neurogenic bladder (bladder problems caused by disease or injury to the nervous system); paraplegia (paralysis to the lower part of the body); anxiety disorder; chronic pain syndrome; and pressure ulcers to his sacrum and both heels. The MDS Assessment reflected he experienced occasional pain. <BR/>Record review of Resident #58's Order Summary Report dated 10/30/24 reflected the following orders:<BR/>Colace 2-IN-1 Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 2 tablets by mouth two times a day related to constipation. The order was dated 9/21/24. <BR/>Baclofen Oral Tablet 10 MG Give 10 mg by mouth two times a day for muscle relaxer. The order was dated 10/28/24.<BR/>Pregabalin Oral Capsule 50 MG Give 1 capsule by mouth every 12 hours for pain. The order was dated 10/12/24.<BR/>In an observation on 10/30/24 at 8:45 AM, MA B prepared the 9:00 AM medications for Resident #58. <BR/>MA B administered Docusate Sodium 100 mg 2 tablets by mouth. <BR/>MA B failed to administer his Baclofen 10 mg tablet or his pregabalin 50 mg capsule. <BR/>Record review of Resident #58's MAR, dated October 2024, reflected the following entries:<BR/>Colace 2-IN-1 Oral Tablet 8.6-50 MG 2 tablets was initialed as administered on 10/30/24 at 9:00 AM by MA B.<BR/>Baclofen Oral Tablet 10 MG Give 10 mg by mouth two times a day was left blank on 10/30/24 at 9:00 AM.<BR/>Pregabalin Oral Capsule 50 MG Give 1 capsule by mouth every 12 hours was coded as 13 indicating, Pending Arrival from Pharmacy on 10/30/24 at 9:00 AM by MA B.<BR/>3) Record Review of Resident #45's admission Record, dated 11/1/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #45's admission MDS assessment dated [DATE] reflected she was cognitively intact. The MDS Assessment reflected her diagnoses included, seizure disorder, anxiety disorder, and migraine (headaches). <BR/>Record review of Resident #45's Order Summary Report dated 10/30/24 reflected an order for Flonase Allergy Relief Nasal Suspension 50 mcg 1 puff both nostrils in the morning for allergies. <BR/>In an observation on 10/30/24 at 9:03 AM, MA B prepared the 9:00 AM medications for Resident #45. MA B failed to administer Resident #45's Flonase nasal spray along with her other medications. <BR/>Record review of Resident #45's MAR dated October 2024 reflected an entry for Flonase Allergy Relief Nasal Suspension 50 mcg was coded as 13 indicating, Pending Arrival from Pharmacy on 10/30/24 at 9:00 AM by MA B.<BR/>During an interview on 10/31/24 at 9:21 AM, MA B stated Resident #58's Baclofen order did not appear on her computerized MAR on 10/30/24 when she was passing her medications, but she noticed it was there today. She stated he would receive a dose today. MA B retrieved Resident #58's Baclofen medication card from her cart. The label on the medication card reflected an order date of 10/28/24, one tablet was missing from the card. MA B stated she could not explain why the medication did not appear in her computer yesterday but it did today. When asked about Resident #58's order for Colace 2-in-1, she confirmed the order in her computer was accurate and retrieved the bottle of docusate from her cart. She stated she had not previously noticed the difference in the medications. MA B checked her cart and was unable to locate a bottle of Colace 2-in-1. When MA B was asked about Resident #58's pregabalin, she stated the medication had not arrived yet. She stated, I told the nurse [LVN A] but I guess she never pulled it from the ekit.<BR/>MA B stated she did not administer Resident # 45's Flonase because it was not available in her cart. She checked her cart at that time and stated it still was not there. MA B stated, when a medication was not in her cart, she told the Charge Nurse so that they could look for it. MA B walked to the nurse's medication cart and asked LVN C about Resident #45's Flonase. LVN C checked her cart and located the medication. MA B stated she had told LVN A about the missing Flonase on 10/30/24. LVN C Stated medications were getting delivered on the night shift and sometimes the medications were placed on the nurse's carts instead of the Medication Aide's carts. MA B stated the risk for missing medication doses depended on the medications. She stated, if it was pain medication, it could result in unrelieved pain. She stated the risk for administering the wrong medication or doses also depended on the medication but could cause negative side effects. <BR/>During an interview on 11/1/24, LVN A stated she was unable to administer Resident #8's famotidine as it was not available. She stated she had called the pharmacy about it and was told they had called the insurance company and it was still pending approval. LVN A stated Resident #8's medications needed approval because he was covered under a different program and the medications came from a different vendor. She stated, because he had a special type of J-tube, the hospital did not want him to receive crushed medications as they had a history of clogging his tube, so his medications were sent in liquid form. LVN A stated she had called his physician on the morning of 11/1/24 and was approved to crush a tablet form and dissolve it in water. When asked about Resident #58's Baclofen, LVN A stated she was unaware he had missed any doses. She stated that medication could have easily been pulled from the ekit but she was never informed by MA B. LVN A stated she had previously called the pharmacy about Resident #58's pregabalin and learned it required approval from his pain management physician. She stated his pain management physician had been there on 10/30/24 and was reminded they needed to call the order into the pharmacy, and they did. She stated the medication had arrived and was being administered. LVN A stated she did not recall MA B ever telling her she could not locate Resident #45's Flonase on 10/30/24. She stated meds were usually delivered on night shift and sometimes placed in the wrong cart. LVN A stated the risk for residents missing medication doses included increased or uncontrolled pain, increased fall risk if pain was not managed and other symptoms depending upon the medication missed. <BR/>During an interview on 10/31/24 at 8:40 AM, the DON stated the nurses, the ADON, and herself were responsible for ensuring medications were ordered and available. She stated she was unaware of any issues with medication availability. The DON stated she just started at the facility on 10/14/24 and the pharmacy consultant was there that day. She stated she was aware the medications were delivered at night and so may not be available the same day an order was written, and she had advised the nurses to place an order as STAT if a dose was due the same day. The DON stated she expected the nurses to let her know and to contact the pharmacy if a medication was not available. She stated the physician should be called if a medication would not be available in a timely manner. The DON stated the risk for missing medication doses depended upon the medication and included increased pain and the resident would not receive the therapeutic effect of the medication ordered. She stated the risk for receiving incorrect medications or doses included unintended side-effects. <BR/>Record review of the facility's policy titled, Identifying and Managing Medication Errors and Adverse Consequences, dated, revised April 2007 reflected: Policy Statement-The staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. Policy Interpretation and Implementation-1. The staff and practitioner shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 help prevent the development and transmission of infection for 5 (Residents #2, #3, #4, #5, and #6) of 12 residents reviewed for infection control. <BR/>1. <BR/>On 04/30/24 MA A, CNA B, and CNA C brought Residents #2, #3, #4, #5, and #6 to the locked unit dining room and fed them and did not wash their hands nor the hands of the residents.<BR/>2. <BR/>On 04/30/24 CNA B assisted Residents #2, #3, and #4 with their noon meals, he cut up their food and fed them and did not sanitize his hands.<BR/>3. <BR/>On 04/30/24 CNA C touched the hand of Resident #5 and assisted him to his seat then touched his eating utensil without sanitizing her hands.<BR/>4. <BR/>On 04/30/24 during the noon meal on the locked unit a visitor brought cookies to the residents, this visitor used her ungloved hands and gave each resident present (#2, #3, #4, #5, #6) a cookie without sanitizing her hands.<BR/>This deficient practice placed residents who received assistance with meals in the Locked Unit Dining Room at risk for cross contamination and infections.<BR/>Findings included:<BR/>Review of Resident #2's Care Plan dated 07/12/23, revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with an intervention of limited assistance by staff to eat. Diagnoses included Dementia (a group of thinking and social symptom that interferes with daily functioning), and bipolar disorder (associated with episodes of mood swings ranging from depressive lows to manic highs). <BR/>Review of the most recent quarterly MDS assessment dated [DATE], revealed Resident #2, had a BIMS score of 3 (cognition was severely impaired). Resident #2's eating assessment reflected she required partial/moderate assistance-Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.<BR/>Review of Resident #3's Care Plan dated 01/24/24, revealed Resident #3 was an [AGE] year-old male admitted to the facility on [DATE] with an intervention of set up assistance by staff to eat. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #3's quarterly MDS assessment reflected he had a BIMS score of 00 (cognition was severely impaired). Resident #3's eating assessment reflected he required setup or clean-up assistance-Helper sets up or cleans up; resident completes activity.<BR/>Review of Resident #4's Care Plan dated 11/07/23, revealed Resident #4 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #4's quarterly MDS assessment reflected no BIMS score noted. Resident #4's eating assessment reflected she required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>Review of Resident #5's Care Plan dated 02/06/24, revealed Resident #5 was an [AGE] year-old female admitted to the facility on [DATE] with an intervention that the resident is independent for eating. Diagnoses included Dementia (a group of thinking and social symptom that interferes with daily functioning).<BR/> Review of Resident #5's quarterly MDS assessment reflected a BIMS score was not completed. Resident #5's eating assessment reflected she required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>Review of Resident #6's Care Plan dated 04/14/23, revealed Resident #6 was an [AGE] year-old male admitted to the facility on [DATE] with an intervention of limited assistance by staff to eat. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #6's change in condition MDS assessment reflected a BIMS score was not completed. Resident #6's eating assessment was not completed.<BR/>Observation on 04/30/24 at 12:45 PM revealed MA A walked into the dining room on the locked unit, and she assisted Resident #2 to a table and helped her to sit. MA A took the lid off the plate of Resident #2 then she touched her eating utensil and fed Resident #2. MA A did not sanitize her hands or the hands of Resident #2.<BR/>During an observation on 04/30/24 at 12:46 PM, CNA B took the eating utensil of Resident #3 and cut up his food. Then he went to Resident #4 and used her eating utensil to cut up her food. CNA B then moved to Resident #5, picked up her eating utensil and fed her. He did not sanitize his hands before he moved to and from each resident to assist. He did not sanitize the hands of the resident before assisting them to eat.<BR/>During an observation on 04/30/24 at 12:48 PM, Resident #6 got up from the table. CNA B went outside the door of the dining area to follow Resident #6 out of the dining room. CNA B touched Resident #6 on his arm to redirect him back to the dining table, then CNA B returned to Resident #5 and fed her again. He did not sanitize his hands after he touched or fed a resident. <BR/>Observation on 04/30/24 at 12:49 PM revealed CNA B left Resident #5 and went to assist Resident #4 back to her table to eat by touching her arm. Then he returned to Resident #5 without sanitizing his hands. <BR/>Observation on 04/30/24 at 12:50 PM revealed CNA C assisted Resident #6 back to his table when she took his hand and helped him sit down. Then she picked up his eating utensil from his plate and assisted him to eat. She did not sanitize her hands or the hands of the resident.<BR/>Observation on 04/30/24 at 12:51 PM revealed CNA B moved from Resident #5 and took the eating utensil for Resident #3 and put it back in his hand and encouraged him to eat. He did not sanitize his hands. <BR/>Observation on 04/30/24 at 12:55 PM revealed a visitor entered the dining area on the locked unit with a container of cookies. The visitor handed out cookies to Residents #2, #3, #4, #5, and #6. The visitor did not sanitize her hands before she gave the residents cookies. The visitor did not put on gloves prior to passing out the cookies to the residents.<BR/>In an interview on 04/30/24 at 1:09 PM with CNA B revealed he did not have any hand sanitizer on his person in the dining area and there was not any in the dining area at lunch. He stated there was some hand sanitizer in the nursing station which was located down the hall. He stated he had been trained on infection control. He stated he was not supposed to move from one table to another table or one resident to another resident and touch them without sanitizing his hands. He stated the residents should not have been given cookies by the visitor. He stated the risk to the residents was the transmission of germs that could cause infection.<BR/>In an interview on 04/30/24 at 1:21 PM with CNA C revealed she did not have any hand sanitizer on her person when she was in the dining area at lunch. She stated they do not keep the sanitizer out in the dining room because of the residents' attempts to get the sanitizer. She stated there is hand sanitizer in the closet in the nurses' station. She stated the visitor should have asked if they could give the residents cookies. She stated the risk to the residents was the spread of germs and infection when the staff did not sanitize their hands when working with several residents.<BR/>In an interview on 04/30/24 at 1:40 PM with LVN revealed she was the supervisor of the staff working in the locked unit. She stated during lunch she mostly worked on another hall. She stated the hand sanitizer was available in the nurse room, but the door has been taken down and they must keep all the sanitizer put up out of reach of the residents. She stated all the staff should have known the hand sanitizer was in the closet in the nurse room. She stated she did not remember the last infection control training they took. She stated the visitor should not have handed out cookies to the residents without sanitizing hands. She stated the risk to residents was infection, passing germs, and viruses because staff had not sanitized their hands during the lunch meal.<BR/>In an interview on 04/30/24 at 2:15 PM with MA A revealed she did not have hand sanitizer in her pocket. She stated hand sanitizer was in the nurses' room down the hall. She stated she had washed her hands before she went into the dining area. She stated staff should have sanitized their hands when they worked with several residents during the lunch meal. She stated the resident was at risk of infection when the staff did not sanitize between residents. <BR/>In an interview on 04/30/24 at 4:35 PM with the Administrator revealed the DON and herself was responsible to ensure staff was trained on IC. She stated the DON completed monthly in-services on IC. She stated the DON was currently in the hospital and not available for interview. She stated the staff had put the residents at potential risk of infection and illness when they did not sanitize their hands. She stated the staff should have told the residents to wash their hands before the meal. She stated there was hand hygiene supplies available throughout the building and if there was not any in the dining area, the staff could have asked her or the housekeeper. <BR/>Record review of facility's Policies and Practices -Infection Control revised August 2010 reflected, All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 (Resident #1) of 4 residents reviewed for discharge planning. <BR/>The facility failed to develop a discharge plan for Resident #1 after he expressed his desire to return home on [DATE]. Resident #1 made his own arrangements and left the faciity on [DATE] with no documented discharge plan in place.<BR/>This failure could place residents at risk of not receiving care and services to meet their needs upon discharge.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 12/13/23 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including lack of coordination, muscle weakness, altered mental status, repeated falls, essential hypertension (high blood pressure), age-related debility, chronic pain syndrome, acquired absence of left leg below the knee, and alcohol abuse.<BR/>Record review of Resident #1's Discharge MDS assessment dated [DATE] revealed the Staff Assessment for Mental Status was coded as Independent-decisions consistent/reasonable. He required extensive assistance for bed mobility, dressing, eating, toileting, and hygiene and was totally dependent for bathing. The MDS revealed discharge planning was not already occurring for the resident to return to the community and no referrals had been made to a local contact agency. <BR/>Record review of Resident #1's Care Plan dated closed 09/11/23 revealed the following entry:<BR/>Focus: Discharge Plan-Date initiated 4/22/23<BR/>Goal: The resident's discharge goals are back to him [sic] home after rehab. Date initiated 5/13/23.<BR/>Intervention: Wishes to return home.<BR/>Record review of Resident #1's Progress Notes revealed the following entries:<BR/>7/23/23 10:33 AM Type: MDS Note.resident prefers to be asked about d/c plans on every assessment and he is going home with a friend who is taking care of him on Thursday 7/27/23. He says his ride is picking him up on Thursday and that he has his w/c [wheelchair] at home and has a friend who will care for him 24/7 [24 hours a day/7 days a week]. I told him that it was not safe for him to go back home this soon, but resident stated he has a caregiver now and is going home this Thursday.<BR/>7/26/23 4:40 PM Type: Social Services Note. Note text: Resident plans to discharge home tomorrow, July 27, 2023. Resident's [family member] does not want resident to discharge until after he ahs [sic] been seen by neurologist but resident wants to discharge tomorrow. Resident does not have caregiver at home and [family member] is not willing to provide care. They live in separate houses and [family member] states that he cannot come to her house. Resident stated that [family member] will pick him up tomorrow, but [family member] is not going to pick up resident. <BR/>7/27/23 12:39 PM Type: Social Services Note: Resident will not discharge today. Family is working on having a caregiver to provide care at home. Tentative date set for Monday. SW called [name and phone number] with APS [Adult Protective Services] to inform her that resident wants to discharge home but does not have a caregiver. Left message on voicemail for her to call this SW.<BR/>8/24/23 1:53 PM Type: Communication-with Resident. Resident called 911 today and was attempting to get assistance leaving the facility. I went to his room to discuss the fact that he is free to leave however we like to discharge people in the safest manner possible. This includes arranging home health, DME [durable medical equipment], and other tasks. Resident stated he already purchase his DME and arranges for a private caretaker. Resident listed his purchases as a bed, wheelchair, hoyer lift [mechanical lift to assist with transfers], slide board, and shower chair. He also stated his caretaker would be the person picking him up from the facility and taking him home. I explained that since these things are in place he would be considered a safe discharge and the facility would be happy to assist him. Explained that we would send him with medications and instructions and he would need to follow up with his PCP after he returned home. He understands and will have caregiver here to receive instructions and DC [discharge] at 3:00 PM. The entry was signed by the Administrator.<BR/>8/24/23 2:26 PM Type: Communication-with Family/NOK/POA. Spoke to resident's [family member] that he had made the determination to return home, as he is his own responsible party and is of sound mind, I cannot keep him against his will. She states she understands however does not feel that he would be safe and doesn't know how much training his caregiver has had. I let her know he has arranged for his DME and care taking but if he needs to return, he is more than welcome. We can also reach out to APS if his situation is determined to be unsafe. The entry was signed by the Administrator.<BR/>8/24/23 6:11 PM Type: Nurses Note. Resident discharged home with meds and all his belongings accompanied by taxi driver. Resident educated on his meds, how to take them, usage and side effects and resident verbalized understanding. No distress noted. Skin intact. No c/o [complaints of] pain voiced. Signed by RN A <BR/>During an interview with the Administrator on 12/13/23 at 12:45 PM, she stated they had no full-time social worker in the facility at this time as the previous one was no longer employed with the company. She stated they had one that was helping part time and she was handling things with the help of her Business Office Manager for now. She stated Resident #1 had a [family member] but was separated and she thought he had a girlfriend as well. He had been there on a skilled stay. She stated he had received his letter letting him know his Medicare coverage was ending. She stated his [family member] wanted him to stay longer and arranged for private pay. She stated, He woke up one day and said, 'I'm leaving.' She said he told them he had a ride coming and he was leaving. The Administrator stated she offered to try and get him home health set up or other services, but he said no and he had already arranged everything. The Administrator stated his [family member] was very angry about him leaving. She stated she thought he was able to transfer himself, she remembered he had an amputation, but it was an older one. She stated she couldn't force him to stay.<BR/>In an interview on 12/13/23 at 2:49 PM, the Business Office Manager stated she was familiar with Resident #1. She stated she knew he had a [family member] and the two were separated. She stated Resident #1 told them he had a girlfriend who lived with him and had agreed to take care of him. She stated he had arranged his own transportation home. The Business Office Manager stated Resident #1 was private pay at the time of his discharge and payment arrangements were made with his [family member]. When asked if there was any documentation regarding his discharge preparations, she stated, Not that I know of, other than a care plan. A copy of the care plan and any other discharge documents was requested during the interview. <BR/>In a follow-up interview with the Business Office Manager on 12/13/23 at 3:20 PM, she stated she had not located any other discharge documentation or updated care plans in Resident #1's record.<BR/>In an interview on 12/13/23 at 3:23 PM, the DON stated he was not working at the facility at the time Resident #1 lived there but he had reviewed his records. He stated it was very hard for a facility to keep a resident when they wanted to leave. When asked if he had located any documentation to show any follow-up from the Social Worker's notes or updated discharge plans, he stated he had not. <BR/>In another interview with the Administrator on 12/3/23 at 4:52 PM, she stated no discharge summary or discharge plan had been completed for Resident #1 because he left abruptly, and she did not feel they needed one. She stated discharge planning was important to ensure plans were made for the resident once they left the facility. She stated, in Resident #1's case, he left suddenly. She stated he told her he felt safe leaving at that time and had made his own arrangements. The Administrator was referred to the Social Workers note written on 07/27/23 that reflected Resident #1 wanted to leave and she had left a message with APS out of concern he did not have a caretaker. The Administrator was asked if any follow-up had occurred with APS or discharge planning initiated, as the note was written a month before he left. The Administrator stated, We don't deal with APS. I told his [family member] she could call them if she wanted to. We cannot keep someone against their will.<BR/>Record review of the facility's Discharge Summary and Plan policy, revised December 2016, reflected: <BR/>Policy Statement<BR/> When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment.<BR/>Policy Interpretation and Implementation<BR/>1. When the facility anticipates a resident's discharge to a private residence, another nursing care facility .a discharge summary the resident and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment.<BR/>2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's:<BR/>a. Current diagnosis;<BR/>b. Medical History (including any history of mental disorders and intellectual disabilities);<BR/>c. Course of illness, treatment and/or therapy since entering the facility; <BR/> .e. Physical and mental functional status;<BR/>f. Ability to perform activities of daily living including:<BR/>(1) bathing, dressing and grooming, transferring and ambulating, toilet use, eating, and using speech, language, and other communication systems;<BR/>(2) the need for staff assistance and assistive devices or equipment to maintain or improve functional abilities; and<BR/>(3) the ability to form relationships, make decisions including health care decisions, and participate (to the extent physically able) in day-to-day activities of the facility.<BR/>g. Sensory and physical impairments <BR/>4. Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan.<BR/>5. The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include:<BR/>a. Where the individual plans to reside;<BR/>b. Arrangements that have been made for follow-up care and services;<BR/>c. A description of the residents stated discharge goals;<BR/>d. The degree of caregiver/support person availability, capacity and capability to perform required care;<BR/>e. How the IDT will support the resident or representative in the transition to post-discharge care;<BR/>f. What factors may make the resident vulnerable to preventable readmission; and <BR/>g. How those factors will be addressed. <BR/>6. The discharge plan will be re-evaluated based on the changes in the resident's condition or needs prior to discharge.<BR/>7. The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. <BR/>8. Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post discharge preferences

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to provide appropriate treatment and services for three (Residents #1, #2, #3) of nine residents reviewed for G-Tube services. <BR/>1. The facility failed to know they had four G-tube Decloggers at this facility until it was brought to their attention on 06/16/23. <BR/>2. The facility failed to ensure the nursing staff did not use G-tube decloggers that were stored in their over the counter medication room until it was brought to their attention on 06/16/23. <BR/>3. The facility failed to ensure the nurses did not use a G-tube Declogger to unclog Resident #1's G-tube and used the water from the bathroom sink to flush out his g-tube as reported by Resident #1. <BR/>4. The facility failed to ensure G-tube decloggers were not used to unclog Residents #2 and #3 G-tubes as reported by ADON A. <BR/>5. The facility failed to ensure LVN C did not use the bathroom sink water for G-tube care until it was brought to their attention on 06/16/23. <BR/>These failures could affect all residents with G-Tubes which could result in a decrease in their nutritional intake and cross contamination resulting in a decline in their physical, mental and psycho-social wellbeing. <BR/>Findings included:<BR/>1. Record review of Resident #1's Order Summary Report printed 06/16/23 revealed a [AGE] year old male who admitted to this facility 09/15/22 and re-admitted [DATE] with diagnoses paraplegia, encounter for attention to gastrostomy, gastro-esophageal reflux disease .with orders for: Enteral feed order 22 hours continuous enteral feeding. Formula Jevity 1.5 @60 ml/hr. x22 hours .Enteral feed order every 6 hours for diet order start water flush q 6 hours with 150 mls of water to run concurrently with enteral feeding .every shift check gastric residual volume q shift. <BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 (cognitively intact), extensive two person assist for bed mobility and transfers, paraplegia, encounter with gastronomy, feeding tube . <BR/>Interview on 06/16/23 at 10:34 am, Resident #1 stated the nurses had a problem all the time with unclogging his G-Tube and sometimes used the bathroom sink water or bag of water brought in for his G-Tube care. He stated about two weeks ago his G-Tube got clogged and a nurse used a stick to unclog it and added he did not experience and distress or pain afterwards. He stated he was unsure of the nurse's name who did that. <BR/>Record review of Resident #1's Nurses Notes did not reveal any documentation of a declogger device being used to unclog his G-tube. <BR/>2. Record review of Resident #2's Order Summary Report printed 06/15/23 revealed a [AGE] year old female who admitted on [DATE] with diagnoses . Gastronomy status, constipation, moderate protein-calorie malnutrition . with orders: NPO G-tube diet: Glucerna 1.5 calorie rate: 50 ml/hr. to run concurrently with water flush of 200 mls q 4hrs x 22 hours for nutritional supplement related to Aphasia (loss to understand and express speech caused by brain damage) .Enteral feed order: every day shift Provide oral care every shift .Enteral feed order: every shift check gastric residual volume q shift . <BR/>Record review of Resident #2's Nurses Notes did not reveal any documentation of a declogger device being used to unclog her G-tube. <BR/>3.Record review of Resident #3's Order Summary Report printed 06/16/23 revealed a 51 year male who admitted to this facility on 01/09/23 with diagnoses Unspecified Protein-calorie malnutrition, gastropareses (stomach muscle loss), gastro-esophageal reflux without esophagitis (heartburn), nausea with vomiting, gastronomy status, enterostomy complication (leakage and bowel obstruction) .with orders: Flush 125 ml every 6 hours to run concurrently with feeding, every shift for hydration .Osmolite 1.2 at 60 ml/hr. x 22 hours continuous every shift related to Dysphagia (difficulty swallowing), oropharyngeal phase (difficulty initiating a swallow) .<BR/>Record review of Resident #3's Nurses Notes did not reveal any documentation of a declogger device being used to unclog his G-tube. <BR/>Observation and interview on 06/16/23 at 10:50 am, ADON A stated they had decloggers (flexible threaded device used to clear obstructed gastronomy tubes located in the central supply room on the 400 hall. She stated she looked for them and could not find them then said Central Supply knew where they were. <BR/>Observation and interview on 06/16/23 at 10:57 am, Central Supply stated the Declogger devices were in the OTC room and walked to the OTC room on the 500 hall and there was 4 unopened Decloggers (two 18-24 F/Orange and two 16-22 F/Yellow) on the bottom shelf. Then Central Supply grabbed a yellow and orange Declogger and handed two of them to the HHSC Surveyor. <BR/>Record review of the list of resident's with G-tubes undated revealed they had nine Residents G-Tube at this facility. <BR/>Interview on 06/16/23 at 11:04 am, ADON A stated the nurses used water from the bathroom sink and medication room to flush the G-tubes and stated when G-Tubes were clogged they flushed them by massaging (milking) the tube and at times used a thin brush like thing that went into the tubing. She stated it was called a Declogging device that was used every now and then at this facility. She stated if that method did not work the residents were sent to the hospital. She stated the declogger device had been used on Resident #3 a long time ago December 2022 and on Resident #2 a while ago this year. She denied using the Decloggers and did not remember which nurses used them in the past. She stated there was not any risks involved with using Decloggers to unclog the resident's G-Tubes. <BR/>Interview on 06/16/23 at 11:05 am, LVN F stated had been working at the facility for four months and she said she had not had any G-tube training.<BR/>Interview on 06/16/23 at 1:15 pm, ADON A stated last year some of the nurses were here when they did the G-tube Declogger training and maybe the nurses needed to be re-trained on how to use them because they had such a high turnover of nursing staff and most of those nurses were no longer at this facility. She stated not using a G-Tube Declogger in many years and did not see any risks involved with using them. She stated as long as You don't force the Declogger in there and don't meet any resistance but if you did then you would take the Declogger out. <BR/>Interview on 06/16/23 at 2:05 pm, the Administrator stated if the nurse could not unclog the G-Tubes then they should call the Doctor for further direction to send them out to the hospital. She stated she did not know what G-tube Decloggers were until today 06/16/23 and said to her knowledge the nurses did not use Decloggers on any of the residents and just received confirmation from the DON they no longer had decloggers in the building as of today 06/16/23. She stated not being sure what the risks were for using Decloggers initially but now knew the nurses should never use them because of the risk of injuring the residents. <BR/>Interview on 06/16/23 at 2:13 pm, Resident #1's Doctor stated none of the residents had orders for Decloggers and added this facility had some issues with some of the resident's G-Tubes lately resulting in the residents having to be sent out to the hospital. He stated G-Tube Decloggers were effective with unclogging G-tubes as long as the nurse knew what they were doing and if they did not, it could cause a perforation. He stated not being aware of any of the staff using the Decloggers.<BR/>Interview on 06/16/23 at 3:08 pm, LVN B stated working here for a month and had no formal G-Tube training. <BR/>Interview on 4:51 pm, LVN C stated whenever she did the Resident's G-Tube flushes she used the water from the bathroom sink or from the water pitcher from the medication cart. <BR/>Interview on 06/16/23 at 5:13 pm, the DON stated G-tube care was not one of her problems at this facility and the reason why she had not done any G-tube trainings with the nurses. She stated she was not being aware the nurses used the bathroom sink water for G-Tube flushes, and they should use the water next to the ice machine in the dining room. She stated she would start doing G-Tube trainings with new hires and when residents had G-Tube problems. She stated she was responsible for ensuring G-Tube care was done properly and planned to do spot checks with the nurses.<BR/>Interview on 06/16/23 at 5:50 pm, the Administrator stated the nurses should not use the bathroom sink water for G-Tube flushes because they had plenty of distilled water they could use. She stated they were ensuring the nursing staff knew not to ever use a declogger and to notify the DON and Doctor and follow up with what the Doctor said. She stated Resident #1's Doctor who was also the Medical Director was aware of this issue and he said to continue to do what they recently put in place. She stated the DON and ADON were responsible for ensuring G-Tube services were appropriate. She stated she was not sure why the nurses had no G-Tube training but as of today (06/16/23) they were training the nurses. She stated their Corporate Clinical Consultant would be coming to their facility this Sunday, Monday and Tuesday to help with looking over their G-tube services. <BR/>Record review of ADON A's Training records provided by the Administrator revealed she was hired 11/02/22 and no G-Tube trainings or skills checks had been done. <BR/>Record review of LVN B Training records provided by the Administrator revealed she was hired 03/29/23 and no G-Tube trainings or skills checks had been done.<BR/>Record review of LVN C Training records provided by the Administrator revealed she was hired 05/29/23 and no G-Tube trainings or skills checks had been done.<BR/>Record review of LVN D Training records provided by the Administrator revealed he was hired 11/30/22 and no G-Tube trainings or skills checks had been done.<BR/>Record review of the Wound care nurse E Training records provided by the Administrator revealed she was hired 02/01/23 and no G-Tube trainings or skills checks had been done.<BR/>Record review of the Nurse's G-tube Skills checkoff's was requested but the Administrator and DON stated they did not have any within the past year. <BR/>Record reviews and interviews revealed LVN B, LVN C, LVN D and Woundcare Nurse E had taken care of Residents #1, #2 and #3. <BR/>Record review of the facility's Appropriate use of feeding tubes dated 2022 revealed, Policy: It is a policy of this facility to ensure that a resident maintains acceptable parameters of nutritional and hydration status .6. A resident who is fed by enteral means receives the appropriate treatment and services to restore, If possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its written policies and procedures that prohibit and prevent abuse and neglect for one (Resident #39) of one resident reviewed for abuse. <BR/>The facility failed to immediately report an incident of abuse to the State Survey Agency when on 07/11/23, Resident #39 made an allegation of CNA K spitting in his food.<BR/>This failure could place residents in CNA K's care at risk for abuse. <BR/>Findings included:<BR/>Review of the facility's Abuse Prevention policy dated 2001 (Revised December 2016) reflected the following: <BR/>Our 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, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms . 6. Identify and assess all possible incidents of abuse. 7. Investigate and report any allegations of abuse within timeframes as <BR/>required by federal requirements; 8. Protect residents during abuse investigations.<BR/>Review of Resident #39's MDS (Minimum Data Set) Form dated 07/15/23 reflected Resident #39 was a <BR/>[AGE] year-old male with a BIM's (Brief Interview for Mental Status) score of 15 indicating Resident # 39 <BR/>was cognitively intact. Resident was admitted to the facility 3/06/23 and discharged [DATE]. His <BR/>diagnoses included Schizophrenia, depression and anxiety. Behavior symptoms included resisting care. <BR/>Resident #39 used a manual wheelchair and required minimal assist with transfers.<BR/>Review of Resident # 39's Care Plan dated 08/07/23 reflected Resident #39 had a behavior problem of <BR/>refusing care, therapy, showers, and medications; cursing at staff and urinating in waste baskets.<BR/>Review of Resident #39's nurse's notes reflected the following on 7/11/23 written by LVN J: This writer <BR/>was in the dining room with the other residents when she heard this resident yelling out. When this <BR/>nurse got to where the resident was (TV room), an Aide was found talking to the resident. The CNA said <BR/>she saw this resident eating in the TV room, and she asked him if he got his dinner tray because he was <BR/>not in the room when trays were passed earlier. This resident responded by saying why are you <BR/>looking at me Bitch, I was not talking to you, and I was sitting calmly by myself. When this nurse asked <BR/>the resident what happened, he said She was spitting into my food, Bitch was spitting into my food. <BR/>This nurse cautioned resident from using such words to anybody, but he refused. The Aide also said she <BR/>did not spit at him at all (totally surprised at resident's accusation). This writer asked the resident to <BR/>calm down since he was still eating and tell him to apologize to the aide but he refused. It looks like <BR/>resident is transferring aggression to the aide (because of what transpired in the AM shift regarding his <BR/>PT order and possible discontinuation of Narcotics if no indication is seen).<BR/>Review of the facility's Employee Punch Report reflected LVN J worked 9 shifts after abuse allegation and <BR/>submitted resignation 7/31/23. Facility Punch Report reflected CNA K worked 21 shifts after abuse<BR/>allegation and was termed 8/14/23 for cause not related to Abuse allegation. LVN L continues to be <BR/>employed in the facility. Review of CNA K's personnel file revealed background checks were performed, <BR/>per regulation.<BR/>Phone interview on 9/01/23 at 10:54 AM with LVN J stated she remembered incident with Resident <BR/>#39. LVN J stated she heard yelling and responded to area where Resident was agitated/upset. LVN J<BR/>stated Resident #39 was sleeping when trays were passed, and CNA K was asking if Resident #39 <BR/>received his meal tray. LVN J stated Resident #39 made allegation of CNA K spitting in his food. LVN J <BR/>stated she documented incident as behavior. LVN J stated she did not report the abuse allegation <BR/>because the DON/ADON was not available. <BR/>Interview on 8/31/23 at 12:25 PM with LVN L stated she had worked with Resident #39 prior to his <BR/>discharge. She stated she was alerted during shift change of Resident #39's allegation of staff spitting in <BR/>food. Nurse stated Resident #39 was always complaining/angry, calling 911. LVN L stated all allegations <BR/>should be reported to abuse coordinator and DON. LVN L stated she did not report Resident #39 <BR/>spitting incident to the abuse coordinator because she thought incident had already been reported.<BR/>A phone interview on 9/01/23 at 11:19AM was attempted with CNA K without success.<BR/>Review of facility Incident Log did not reflect an incident for Resident #39 on 7/11/23 related to spitting <BR/>allegation.<BR/>Interview on 9/01/23 at 10:05 AM with the facility administrator/abuse coordinator stated she should <BR/>have learned of theabuse allegation made by Resident #39 but failed to read the 24-hour report. The <BR/>administrator stated she should have been immediately informed of the abuse allegation; stated she <BR/>would have reported the incident within 24 hours and begun an immediate investigation. The <BR/>administrator stated there was an incident with injury the morning of 7/11/23 and she was distracted.<BR/> The Administrator stated she did not know of the abuse allegation until surveyor asked her about the <BR/>incident. The Administrator stated she failed to report Resident #39's allegation of abuse and failed to <BR/>report Resident #39'sincident. The Administrator stated she was reporting incident this morning. The <BR/>Administrator stated resident abuse was not tolerated, and staff received frequent Abuse/Neglect In-<BR/>services. The Administrator stated Resident #39 had frequent behaviors.<BR/>Interview on 9/01/23 at 9:16 AM with the DON stated she was not employed in the facility until 7/17/23 <BR/>and had no knowledge of the incident. The DON stated she thought all staff had been in-serviced on <BR/>Abuse/Neglect. She stated multiple staff were responsible for Abuse/Neglect in-services. The DON<BR/>stated she had not performed an Abuse/Neglect in-service. The DON stated all Abuse/Neglect <BR/>allegations should be reported to the Abuse Coordinator. <BR/>Interview on 9/01/23 at 12:21 PM with the DON stated she was currently in-servicing all staff on<BR/>Abuse/Neglect and importance of reporting to Abuse Coordinator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency in accordance with state law through established procedures for one of two incidents (Resident #1) reviewed for abuse, neglect, and misappropriation. <BR/>1. The facility failed to report to the State Survey Agency when Resident #1 eloped from the facility on 12/31/24. <BR/>This failure could place the residents in the facility at risk of continued abuse and neglect.<BR/>Findings included:<BR/>1. Record review of Resident #1's Face sheet, dated 02/20/25, reflected the resident admitted on [DATE]. The resident's diagnoses included cerebral infarction (stroke), Bell's Palsy (condition that causes sudden weakness in the muscles on one side of the face), and dementia. <BR/>Record review of Resident #1's discharge MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure) and chronic obstructive pulmonary disease (disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough). Resident #1 did not have a BIMS score documented. <BR/>Resident #1 did not have a care plan. (New admit)<BR/>Review of Resident #1's progress notes reflected:<BR/>12/30/25 9:25 AM<BR/>Resident was a [AGE] year-old male admitted from the hospital accompanied by two ambulance attendants via stretcher with diagnoses atrial fibrillation (abnormal heart rhythm), coronary artery disease (heart disease), cerebrovascular accident (stroke), altered mental status, and high blood pressure. Physician notified, all orders verified by physician and sent to the pharmacy. Resident was alert and oriented x2 verbally with confusion. Head to toe assessment done, PERRLA (pupils (are) equal, round, reactive (to) light and accommodation), skin warm and dry to touch, respirations even and unlabored. No shortness of breath, no cough, no congestion noted. Abdomen soft, non-tender, bowel sounds x4 quadrants noted, bladder non-distended, pedal pulses present and strong, skin intact. Resident made comfortable in bed. Resident oriented to bed and tv remote control, call light. Safety maintained, call light within reach. Resident instructed to call for assistance, verbalized understanding. Resident wanders back and forth the unit with unsteady gait.<BR/>Written by RN A<BR/>12/31/24 12:58 AM <BR/>At approximately 12:19 AM, resident with diagnosis of hallucination and altered mental status, was observed to have eloped from the facility. Resident was last seen at 12:17 AM walking the hall. Immediate steps were taken to locate resident by notifying 911, DON and power of attorney. Resident was located outside of facility. Tried to talk to resident to come back to facility but resident refused. Resident appeared to be very combative and screaming, You bitches trying to fucking kill me. Killers, killers. Was unable to redirect. Resident ran to another facility and got into their building. 911 was able to apprehend the resident and he was taken to hospital for further evaluation.<BR/>Written by LVN B<BR/>A record review of Facility In-service (Abuse/Neglect - Elopement) revealed facility staff were in-serviced on 12/31/24. <BR/>An interview at on 02/20/25 at 12:25 PM with RN C revealed she admitted Resident #1 on 12/30/24. She said she admitted the resident to Hall 100 on the 2:00 PM - 10:00 PM shift, gave report, and left the facility. She said she was not at the facility when the resident eloped.<BR/>An interview on 02/20/25 at 12:20 PM with LVN B revealed on 12/31/24 on the 10:00 PM - 6:00 AM shift she was assigned to Resident #1. She said that she took him with her to the Memory Care Unit on Hall 200 because he was walking up and down Hall 100. LVN B said while she and Resident #1 were in the Memory Care Unit, a resident fell and she had to go to assist the resident. LVN B said while she was assisting the resident who fell, she heard the door alarm to the Memory Care Unit and then the door alarm to the front door go off. She said she went running after the resident and she saw him outside running. He was running to the facility that was close by. She said she called 911 and the DON and the police were able to take him to the hospital. <BR/>An interview on 02/20/25 at 1:20 PM with the DON revealed Resident #1 was a new admit and was not exit-seeking per the family member. The DON said one second, he was in the hall and then the next minute he was gone. The DON said the nurse called her, because the staff saw him running to the facility next door. 911 was called and they picked him up. The DON said she did not know how Resident #1 eloped from the facility. She said it was possible that someone held the door open from him. The DON said she did not know why the elopement was not self-reported, but it was probably not reported because the staff had eyes on him when he was outside. <BR/>An interview on 02/20/25 at 5:30 PM with the Administrator revealed he did not self-report the incident, because he thought the resident needed to be missing 4-6 hours before it was self-reported. The Administrator said Resident #1 was only missing for a matter of about two minutes. The Administrator said it was important to self-report elopements to ensure the correct procedure was followed. <BR/>A record review of the facility policy and procedure, Abuse Prevention Program, revised 2016 reflected:<BR/>7. Investigate and report any allegations of abuse within timeframes as required by federal requirements .

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to 1 of 1 treatment carts and 1 (300 Hall) of 4 Nurse Medication Carts. <BR/>1. <BR/>Nursing Staff failed to ensure the facility's only treatment cart was locked. <BR/>2. <BR/>LVN B failed to ensure the 300 Hall Nurse Medication Cart was locked and secured. <BR/>These failures could affect all residents by placing them at risk of ingestion/exposure to medications not intended for them and possible drug diversion. <BR/>Findings included:<BR/>An observation on 07/27/2023 at 9:50AM revealed an unlocked treatment cart in the lounge area near 300 Hall. One resident was observed in a wheelchair directly in front of the cart and one resident, who used a walker, was observed in the area arranging furniture and tidying up the room. A review of the contents of the cart revealed Santyl (used to help the healing of burns and skin ulcers), scissors, Nystatin Cream (a medicated cream or ointment that treats fungal or yeast infections in your skin), Zinc Oxide (used to treat and prevent diaper rash), and vitamin A and D ointment (used as a moisturizer to prevent dry skin). <BR/>In an interview with the DON on 07/27/2023 at 9:55AM, she said the treatment cart was not assigned to any one person. She said all nurses had access to the only treatment cart they used. She said the cart should be locked to prevent residents from getting into the treatment ointments kept in the cart. She said they could be potentially harmful if consumed. <BR/>In an interview on 07/27/2023 at 10:40AM with LVN A, she said the treatment cart was shared by nursing staff but should be kept locked to ensure residents could not get into treatment ointments or sharp objects that were in the cart. She said she had not used the cart today and had not noticed that it was unlocked. She said she had been in-serviced on locking medication carts but could not recall when. <BR/>An interview on 07/27/2023 at 10:40AM with LVN B revealed nursing staff were responsible to ensure their carts were secured and any expired medications were removed from the cart. She said she had not used the treatment cart today, but it should be locked to prevent residents from getting into it. <BR/>In an interview on 07/27/2023 at 2:04PM with the Administrator and DON, the Administrator stated she expected nursing staff to secure their medication carts and treatment cart at all times. She said this was necessary to ensure the safety of residents by preventing them from getting into meds not prescribed to them. <BR/>In an interview on 07/27/2023 at 3:08PM the DON said nurses were responsible to ensure thier medication carts were locked and she and the ADON were responsible for monitoring this. The DON said she would provide the last in-service training for locking medication carts and removing expired medications from carts. None were provided at the time of exit. <BR/>An observation on 07/27/2023 at 3:35PM revealed the 300 Hall nurse medication cart was unlocked. The cart's drawers were faced outward to the hall and one resident, in a wheelchair, was in front of the cart. LVN C was observed seated behind the nurse station faced to opposite direction. <BR/>In an interview on 07/27/2023 at 3:36PM, LVN C said he was responsible for the 300 Hall Nurse Medication Cart and should have locked the cart because he could not see it from behind the nurses' station. He said medication carts should always be secured to ensure residents could not consume medications not prescribed to them and limit the possibility of a drug diversion.<BR/>Review of the facility's policy titled Medication Storage Policy, revised April 2007, reflected The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update and revise the comprehensive care plan for one resident (Resident #1) of one resident reviewed for care plans.<BR/>The facility failed to revise the care plan of Resident #1 to accurately reflect the resident was not allergic to leafy green vegetables but was a preference from the family.<BR/>This failure could affect the resident by placing her at risk for decreased quality of care, quality of life and not having her needs met.<BR/>Findings included: <BR/>Review of Resident #1's face sheet undated reflected she was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] after hospital stay with a diagnoses of other Lack of Coordination, Heart Failure, Pure hypercholesterolemia, and Hyperlipidemia. Allergies listed [NAME] Leafy Vegetables. <BR/>Review of Resident #1's Minimums Data Set (MDS) dated [DATE] reflected Resident #1 had no BIMS summary score enter. Staff Assessment for Mental Status reflected the resident has severely impaired cognitive skills for daily decision making .<BR/>Review of Resident #1's Care Plan dated 06/29/23 reflected Allergy: Resident has an identified allergy and is at risk for an adverse reaction. Resident is allergic to [NAME] Leafy Vegetable. Date initiated: 12/08/22 Revision on 12/08/22. Goal: Resident's risk for allergic reactions will be minimized and resident will not experience and allergic reaction to identified allergens through the next review. Interventions: Do not administer mediation or foods resident is allergic to. Date initiated: 12/08/22. Update allergy list as needed Date initiated: 12/08/22. Focus: Potential for complications and/or injury related to anticoagulant therapy warfarin, diagnosis of heart failure. Goal: Resident #1 will be free from discomfort or adverse reactions related to anticoagulant use through the review date. <BR/>Review of Resident #1's meal ticket dated 07/17/23 reflected diet; Regular, finger foods. The record did not reflect resident food allergy, food likes, or food dislikes. <BR/>Review of Resident #1's Electronic Medical Record dated 11/25/22 reflected, .View Allergy, Status: Active, Category: Food, Allergen: [NAME] Leafy Vegetable, Allergy Type: Propensity to adverse reactions, Severity: Severe, Reaction Type: Serum sickness, Reaction Note: Resident is taking Warfarin . <BR/>Review of Resident #1's orders dated 05/12/23 reflected Coumadin oral tablet 2.5 MG (warfarin sodium) give 1 tablet by mouth one time a day. <BR/>Observation on 07/17/23 at 12:00 PM revealed Resident #1 sitting at the dining table in secure unit with a lunch place in front of her. Observation of the lunch plate revealed a spaghetti dish and leafy green salad. <BR/>Interview with LVN A on 07/17/23 at 12:00 PM revealed LVN A could not recall if Resident #1 had any food allergies. LVN A reviewed Electronic Medical Record and noticed Resident #1's allergy alert in red. LVN A along with DON re-entered the dining room, then removed the lunch plate from the resident. Observation of the lunch plate reflected the resident did not consume the leafy green salad. <BR/>Interview on 07/17/23 at 12:46 PM with LVN A reflected she reviewed meal tickets prior to residents receiving meal. She stated she was not aware of the food allergy. She stated the resident was being monitored for side effects. She stated the admitting nurse would enter any restrictions into the electronic medical record the restriction would then be reflected on the resident's meal ticket. <BR/>Interview on 07/17/23 at 12:57 PM with the Dietary Manager reflected that she received a Diet Oder/Change of Diet form within 24 hours of admission or change for the resident. She stated that she did not have record of a form for Resident #1. She stated that meal tickets were printed directly from the information in the resident's electronic medical records. <BR/>Interview on 07/17/23 at 1:15 PM with the DON revealed the leafy green vegetable allergy mentioned was not a doctor's order but a family food preference. She stated that the information should have been reflected on the resident's meal ticket as a food dislike. <BR/>Interview on 07/17/23 at 1:30 PM with the MDS coordinator reflected quarterly care plan for the resident is scheduled for 07/18/23. She stated that the correction should have been addressed at resident re-admission on [DATE]. She stated the purpose of the care plan is so that everyone can do what is in the best interest of the resident. <BR/>Interview on 07/17/23 at 2:20 PM with the ADMIN stated that it was an oversight that is being corrected. She stated that the IDT (interdisciplinary team) meets every Friday and during that time residents with new orders are addressed. The risk of a resident having an allergic reaction was GI issues. <BR/>Review of facility's policy Care Plans-Comprehensive revised December 2010 reflected 3.b. Incorporate risk factors associated with identified problems; 4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools before interventions are added to the care plan; 6 Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. 9. The care planning/interdisciplinary team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident had been readmitted to the facility from a hospital stay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to provide appropriate treatment and services for three (Residents #1, #2, #3) of nine residents reviewed for G-Tube services. <BR/>1. The facility failed to know they had four G-tube Decloggers at this facility until it was brought to their attention on 06/16/23. <BR/>2. The facility failed to ensure the nursing staff did not use G-tube decloggers that were stored in their over the counter medication room until it was brought to their attention on 06/16/23. <BR/>3. The facility failed to ensure the nurses did not use a G-tube Declogger to unclog Resident #1's G-tube and used the water from the bathroom sink to flush out his g-tube as reported by Resident #1. <BR/>4. The facility failed to ensure G-tube decloggers were not used to unclog Residents #2 and #3 G-tubes as reported by ADON A. <BR/>5. The facility failed to ensure LVN C did not use the bathroom sink water for G-tube care until it was brought to their attention on 06/16/23. <BR/>These failures could affect all residents with G-Tubes which could result in a decrease in their nutritional intake and cross contamination resulting in a decline in their physical, mental and psycho-social wellbeing. <BR/>Findings included:<BR/>1. Record review of Resident #1's Order Summary Report printed 06/16/23 revealed a [AGE] year old male who admitted to this facility 09/15/22 and re-admitted [DATE] with diagnoses paraplegia, encounter for attention to gastrostomy, gastro-esophageal reflux disease .with orders for: Enteral feed order 22 hours continuous enteral feeding. Formula Jevity 1.5 @60 ml/hr. x22 hours .Enteral feed order every 6 hours for diet order start water flush q 6 hours with 150 mls of water to run concurrently with enteral feeding .every shift check gastric residual volume q shift. <BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 (cognitively intact), extensive two person assist for bed mobility and transfers, paraplegia, encounter with gastronomy, feeding tube . <BR/>Interview on 06/16/23 at 10:34 am, Resident #1 stated the nurses had a problem all the time with unclogging his G-Tube and sometimes used the bathroom sink water or bag of water brought in for his G-Tube care. He stated about two weeks ago his G-Tube got clogged and a nurse used a stick to unclog it and added he did not experience and distress or pain afterwards. He stated he was unsure of the nurse's name who did that. <BR/>Record review of Resident #1's Nurses Notes did not reveal any documentation of a declogger device being used to unclog his G-tube. <BR/>2. Record review of Resident #2's Order Summary Report printed 06/15/23 revealed a [AGE] year old female who admitted on [DATE] with diagnoses . Gastronomy status, constipation, moderate protein-calorie malnutrition . with orders: NPO G-tube diet: Glucerna 1.5 calorie rate: 50 ml/hr. to run concurrently with water flush of 200 mls q 4hrs x 22 hours for nutritional supplement related to Aphasia (loss to understand and express speech caused by brain damage) .Enteral feed order: every day shift Provide oral care every shift .Enteral feed order: every shift check gastric residual volume q shift . <BR/>Record review of Resident #2's Nurses Notes did not reveal any documentation of a declogger device being used to unclog her G-tube. <BR/>3.Record review of Resident #3's Order Summary Report printed 06/16/23 revealed a 51 year male who admitted to this facility on 01/09/23 with diagnoses Unspecified Protein-calorie malnutrition, gastropareses (stomach muscle loss), gastro-esophageal reflux without esophagitis (heartburn), nausea with vomiting, gastronomy status, enterostomy complication (leakage and bowel obstruction) .with orders: Flush 125 ml every 6 hours to run concurrently with feeding, every shift for hydration .Osmolite 1.2 at 60 ml/hr. x 22 hours continuous every shift related to Dysphagia (difficulty swallowing), oropharyngeal phase (difficulty initiating a swallow) .<BR/>Record review of Resident #3's Nurses Notes did not reveal any documentation of a declogger device being used to unclog his G-tube. <BR/>Observation and interview on 06/16/23 at 10:50 am, ADON A stated they had decloggers (flexible threaded device used to clear obstructed gastronomy tubes located in the central supply room on the 400 hall. She stated she looked for them and could not find them then said Central Supply knew where they were. <BR/>Observation and interview on 06/16/23 at 10:57 am, Central Supply stated the Declogger devices were in the OTC room and walked to the OTC room on the 500 hall and there was 4 unopened Decloggers (two 18-24 F/Orange and two 16-22 F/Yellow) on the bottom shelf. Then Central Supply grabbed a yellow and orange Declogger and handed two of them to the HHSC Surveyor. <BR/>Record review of the list of resident's with G-tubes undated revealed they had nine Residents G-Tube at this facility. <BR/>Interview on 06/16/23 at 11:04 am, ADON A stated the nurses used water from the bathroom sink and medication room to flush the G-tubes and stated when G-Tubes were clogged they flushed them by massaging (milking) the tube and at times used a thin brush like thing that went into the tubing. She stated it was called a Declogging device that was used every now and then at this facility. She stated if that method did not work the residents were sent to the hospital. She stated the declogger device had been used on Resident #3 a long time ago December 2022 and on Resident #2 a while ago this year. She denied using the Decloggers and did not remember which nurses used them in the past. She stated there was not any risks involved with using Decloggers to unclog the resident's G-Tubes. <BR/>Interview on 06/16/23 at 11:05 am, LVN F stated had been working at the facility for four months and she said she had not had any G-tube training.<BR/>Interview on 06/16/23 at 1:15 pm, ADON A stated last year some of the nurses were here when they did the G-tube Declogger training and maybe the nurses needed to be re-trained on how to use them because they had such a high turnover of nursing staff and most of those nurses were no longer at this facility. She stated not using a G-Tube Declogger in many years and did not see any risks involved with using them. She stated as long as You don't force the Declogger in there and don't meet any resistance but if you did then you would take the Declogger out. <BR/>Interview on 06/16/23 at 2:05 pm, the Administrator stated if the nurse could not unclog the G-Tubes then they should call the Doctor for further direction to send them out to the hospital. She stated she did not know what G-tube Decloggers were until today 06/16/23 and said to her knowledge the nurses did not use Decloggers on any of the residents and just received confirmation from the DON they no longer had decloggers in the building as of today 06/16/23. She stated not being sure what the risks were for using Decloggers initially but now knew the nurses should never use them because of the risk of injuring the residents. <BR/>Interview on 06/16/23 at 2:13 pm, Resident #1's Doctor stated none of the residents had orders for Decloggers and added this facility had some issues with some of the resident's G-Tubes lately resulting in the residents having to be sent out to the hospital. He stated G-Tube Decloggers were effective with unclogging G-tubes as long as the nurse knew what they were doing and if they did not, it could cause a perforation. He stated not being aware of any of the staff using the Decloggers.<BR/>Interview on 06/16/23 at 3:08 pm, LVN B stated working here for a month and had no formal G-Tube training. <BR/>Interview on 4:51 pm, LVN C stated whenever she did the Resident's G-Tube flushes she used the water from the bathroom sink or from the water pitcher from the medication cart. <BR/>Interview on 06/16/23 at 5:13 pm, the DON stated G-tube care was not one of her problems at this facility and the reason why she had not done any G-tube trainings with the nurses. She stated she was not being aware the nurses used the bathroom sink water for G-Tube flushes, and they should use the water next to the ice machine in the dining room. She stated she would start doing G-Tube trainings with new hires and when residents had G-Tube problems. She stated she was responsible for ensuring G-Tube care was done properly and planned to do spot checks with the nurses.<BR/>Interview on 06/16/23 at 5:50 pm, the Administrator stated the nurses should not use the bathroom sink water for G-Tube flushes because they had plenty of distilled water they could use. She stated they were ensuring the nursing staff knew not to ever use a declogger and to notify the DON and Doctor and follow up with what the Doctor said. She stated Resident #1's Doctor who was also the Medical Director was aware of this issue and he said to continue to do what they recently put in place. She stated the DON and ADON were responsible for ensuring G-Tube services were appropriate. She stated she was not sure why the nurses had no G-Tube training but as of today (06/16/23) they were training the nurses. She stated their Corporate Clinical Consultant would be coming to their facility this Sunday, Monday and Tuesday to help with looking over their G-tube services. <BR/>Record review of ADON A's Training records provided by the Administrator revealed she was hired 11/02/22 and no G-Tube trainings or skills checks had been done. <BR/>Record review of LVN B Training records provided by the Administrator revealed she was hired 03/29/23 and no G-Tube trainings or skills checks had been done.<BR/>Record review of LVN C Training records provided by the Administrator revealed she was hired 05/29/23 and no G-Tube trainings or skills checks had been done.<BR/>Record review of LVN D Training records provided by the Administrator revealed he was hired 11/30/22 and no G-Tube trainings or skills checks had been done.<BR/>Record review of the Wound care nurse E Training records provided by the Administrator revealed she was hired 02/01/23 and no G-Tube trainings or skills checks had been done.<BR/>Record review of the Nurse's G-tube Skills checkoff's was requested but the Administrator and DON stated they did not have any within the past year. <BR/>Record reviews and interviews revealed LVN B, LVN C, LVN D and Woundcare Nurse E had taken care of Residents #1, #2 and #3. <BR/>Record review of the facility's Appropriate use of feeding tubes dated 2022 revealed, Policy: It is a policy of this facility to ensure that a resident maintains acceptable parameters of nutritional and hydration status .6. A resident who is fed by enteral means receives the appropriate treatment and services to restore, If possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 9 residents (Resident #1) reviewed for care plans. <BR/>The facility failed to ensure Resident #1, who resided in the memory care unit, had a comprehensive care plan identifying reasons for aggression, appropriate supervision, interventions to prevent Resident #1 from eating non-edible items in order to attain and maintain the highest practicable physical, mental, and psychosocial well-being and safety. <BR/>An Immediate Jeopardy situation was identified on 06/08/2023 at 9:45 AM. The Immediate Jeopardy was removed on 06/09/2023 at 4:18 PM. The facility remained out of compliance at a scope of Isolated and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. <BR/>This failure could place residents at risk for not being provided necessary care and services. <BR/>Findings Included:<BR/>Record review of Resident #1's electronic face sheet, dated 06/07/2023, revealed Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's diagnoses included dementia with agitation (walk up and down, move objects around or fixate on tasks such as tidying), major depressive disorder (mood disorder that interferes with daily life), anxiety disorder (involves persistent and excessive worry that interferes with daily activities), and delusional disorders (type of mental health condition in which a person can't tell what's real from what's imagined).<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 04/21/2023, revealed Resident #1's BIMS score was 00 which indicated severe cognitive impairment. Review of behaviors reflected physical behavioral symptoms directed toward others and self, wandering occured daily. <BR/>Record review of Resident #1's care plan, initiated on 05/30/2023, reflected Resident #1 was at risk of elopement / non-goal directed wandering, interventions included Disguise exits .identify pattern of wandering. Is it purposeful? Further review revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes and impaired decision-making skill. Resident #1 exhibited verbal and physical aggression, exhibited hitting and biting during ADL care and interventions included Provide physical and verbal cues to alleviate anxiety .give the resident as many choices as possible about care and activities. The care plan also reflected a diagnosis of dementia and need for a secure environment due to risk of elopement, exit seeking and wandering. Interventions included Assess for reasons for wandering and provide redirection as needed. Resident #1 had a history of resisting or refusing care and became aggressive during care. <BR/>Record review of Resident #1's Progress Notes dated 04/13/2023, RN A documented, Resident came out from her room and was holding pull up full of feces and writer tried to take it away from her and resident pushed nurse and nurse landed on the floor and hit her right leg on double door. Nurse was assisted off from the floor by two staff members. Resident was then attended by two staff members. Family, Md, and ADON notified. Progress notes dated 05/15/2023, 05/16/2023, 05/16/2023, 05/22/2023, and 05/24/2023 reflected LVN E documented the following on each date, Resident is up wandering up and down the hallway, checked V/S and gave all medications as ordered, tolerated well, resident is at high risk for elopement, requires constant redirection by staff members. Resident requires 2 to 3 staff members to provide cares, resident has a very aggressive behavior, such as kicking and biting. Resident is developing a new habit, messing with her own poop, staff members has to help her thoroughly cleaned her and sanitize all the places she touched. Will continue to monitor. Progress notes dated 06/06/2023 reflected LVN E documented, Resident was seen be states surveyor possibly eating and notified first nurse aide and next the nurse who was told by the DON immediately notified the MD at 12:33PM, that was 3 minutes after this nurse was notified, MD immediately responded and ordered to call poison control center and checked resident's V/S, BP .poison control advised us to rinse resident's mouth and provide more fluids, we did as ordered, no S/S of nausea or vomiting noted at this time. Will continue to monitor resident and continue to encourage fluids. Called poison control regarding possible ingestion of deodorant. Poison control indicated that a possible adverse effect would b, mild GI upset, limited diarrhea, and upset stomach. Was told to monitor for upset stomach and encourage fluids. Case #75554424. <BR/>Observation and interview on 06/07/2023 at 11:45AM revealed Resident #1, in the hall facing the patio, eating a stick of deodorant with a plastic spoon. Resident #1 turned the deodorant stick up and used the spoon to scoop chunks of the deodorant from the container and then ate it. CNA B and LVN C were observed around the corner on the room hall passing lunch trays. The surveyor called down the hall to notify LVN C and CNA B that Resident #1 was eating the deodorant stick. CNA B came to the hall where Resident #1 was and stated she could not take the deodorant from Resident #1 without assistance because Resident #1 had bitten her in the past when she took something away from her. CNA B called for LVN C to assist. During the time LVN C came to assist, Resident #1 was observed placing the deodorant container in a sock she was holding. LVN C was observed trying to get the sock that contained the deodorant stick from Resident #1. Resident #1 refused to give it and LVN C then distracted Resident #1 from her left side while CNA B took the sock from Residnet#1's grip. Resident #1 still had the plastic spoon in her hand and walked down the hall to the rear door exit area where she began taking items from the trash can. Resident #1 used the spoon to scrape particles of deodorant from her arms and licked the spoon. <BR/>An observation and interview on 06/07/2023 at 11:50AM, with LVN C and CNA B, revealed the deodorant container was empty. LVN C said Resident #1 could get very aggressive when staff took items from her that she should not have. LVN C said Resident #1 constantly wandered from room to room taking any items she could find. LVN C stated the deodorant stick was not from the facility and may have been brought into the secured unit by another resident's family members. He said there was one resident in the secured unit who did have personal care items in her room because she was only diagnosed with schizophrenia and able to do her own personal care. He said each room had child covers on the doorknob which prevented residents from entering rooms, however, Resident #1 was able to open doors with the child cover on. CNA B stated Resident #1 needed constant supervision because she wandered from room to room taking anything she could find. She stated when staff attempted to redirect Resident #1 or take something from her she would be aggressive. <BR/>An interview on 06/07/2023 at 12:16PM with the Administrator revealed she was informed that Resident #1 had eaten the deodorant. She stated she did not know where Resident #1 could have gotten the deodorant from because all personal care items should have been secured in the shower room. She said family members often brought items into the secured unit for residents and left the items in their room. She said she directed staff to do a sweep of the secured unit to ensure there were no more hazardous items accessible to residents; she stated they did find additional personal care items in resident rooms and removed them. She said she was not aware of any resident in the secured unit who kept personal care items in their room but the DON may have told her about such a resident but was not sure. She said there were child covers on the doorknobs in the secured unit to prevent residents from entering rooms. She said she had not been informed Resident #1 could open the doors with the child covers on. She stated typically one nurse and two CNAs worked in the secured unit to ensure appropriate supervision of the 17 residents. She stated the facility's policy stated that all personal and hazardous items should be locked to prevent a risk of harm to residents. She said she understood Resident #1's eating deodorant posed an immediate concern for a risk of harm to all the residents in the secured unit. <BR/>An observation and interview on 06/07/2023 at 12:23PM, in the secured unit, with the Administrator and DON revealed Resident #1 in the room hall with a small can of shaving cream. Resident #1 was trying to push the button at the top of the can and held the can to her mouth but was unsuccessful in getting the contents to come out. The DON was observed taking the can of shaving cream from Resident #1. When asked if they had removed all the hazardous items from the secured unit, The Administrator stated staff had already done that and stated she did not know where Resident #1 got the can of shaving cream from. <BR/>An observation and interview on 06/07/2023 at 12:25PM with Resident #2 revealed she recently came to the facility. She stated she had her own room and was allowed to keep her personal care items in her room. She stated she hid the items in her dresser drawers as residents often came inter her room and took them. She said she hid her purse under a chair for the same reason. Resident #2's purse was observed stuffed under a chair in her room and personal care items (toothpaste, shampoo, and deodorant) were observed in the top drawer of the dresser in her room. <BR/>An interview on 06/07/2023 at 12:40PM with LVN C revealed Resident #1 was hard to redirect and constantly wandered from room to room. He said Resident #1 likely got the deodorant from another resident's room. He stated staff do not check rooms regularly for items that may be hazardous to residents. He said residents' family often bring items and leave them in the residents' rooms. He stated he noted Resident #1 started to mess with her poop and said he had never seen her eat anything non-edible before. He stated his note referred to her taking her adult diaper off and smearing poop all over. <BR/>An interview on 06/07/2023 at 12:52PM with CNA B revealed Resident #1 would get into anything she could including briefs, wipes, and deodorant. She said she had not seen her eat anything hazardous but Resident #1 had to be supervised all the time to ensure her safety. She said she thought Resident #1 may have taken the deodorant from the shower room because she had found the lid to the deodorant stick in the locked shower room when she completed the sweep. She stated the shower room was always locked but this morning a hospice aide was in the secured unit caring for a resident and Resident #1 could have gotten the deodorant while the aide was showering another resident. CNA B stated during her sweep of the secured unit, she found five deodorants in five different rooms, soap, two large bottles of lotion, and three large bottles of shampoo. She said the items were labeled Keep out of reach of children. CNA B stated Resident #1 bit her on her breast, on 04/19/2023, when she tried to take lotion from Resident #1. She stated she informed the DON and Administrator. She stated Human Resources had her go to the hospital for treatment. She stated she had not receive any in-service related to handling Resident #1's aggressive behavior.<BR/>An interview on 06/07/2023 at 1:41PM with the Administrator revealed when CNA B was bit by Resident #1 she was primarily concerned with ensuring CNA B was taken care of and followed up with human resources. She said she did not follow up with any behaviors that may have led to why Resident #1 bit CNA B and ultimately kept Resident #1 safe. She said in reviewing progress notes, the staff knew Resident #1 wandered and got into any items she could find; all staff could assume Resident #1 could possibly consume them as well. She stated she should have followed up to ensure the safety of Resident #1. She stated the DON and ADON were responsible for reviewing the progress notes to ensure information was brought to her. She stated she was not made aware of an incident where Resident #1 pushed RN A to the ground on 4/13/2023. She said the incident may have been reported to human resources. She said it should have been brought to her attention by staff or the DON because it was documented in the progress notes. She said she expected the DON and ADON to review the progress notes and bring any concerns to her attention. She stated she expected staff to ensure residents, who did not have the cognitive ability to understand their actions, were safe and any hazards were secured to prevent residents from any harm. <BR/>An interview on 06/07/2023 at 2:25PM with RN A revealed she was pushed to the ground on 4/13/2023, when she tried to take a soiled adult brief from Resident #1. RN A said Resident #1 came out of her room with the soiled brief in her hand. She said the brief was tore and Resident #1 had feces on her hands, face and inside her mouth. She stated she believed Resident #1 was eating the brief. RN A stated she had never seen Resident #1 eat deodorant but was not surprised as she wandered from room to room looking for anything she could find. RN A stated she told the DON, ADON, Administrator and Human Resources about the incident. She stated Human Resources directed her to get medical attention. RN A stated there were no care plan changes, in-services, or direction from the DON or ADON to address Resident #1's behaviors. <BR/>In an interview on 06/07/2023 at 3:00PM the Social Worker stated she and the MDS Coordinator held a care plan meeting for Resident #1 on 05/23/2023. She stated there was no information about Resident #1 eating poop or any other non-consumable items. She stated she gained resident information from the DON or ADON regarding issues or concerns and concerns of the resident's specific behaviors should have been relayed to her and the MDS Coordinator for care planning. She said Resident #1's aggressiveness was discussed in the care plan but no specific details regarding when aggression occurred or why. <BR/>An interview on 06/07/2023 at 3:30PM with the DON revealed she had not seen any of the progress notes related to Resident #1. She said it was her and the ADON's responsibility to review the notes and care plans to ensure any concerns were addressed. She said she held a stand-up meeting every morning at 10:00AM where issues would be discussed. She said she was working with staff to ensure they brought concerns to the stand-up meetings but realized they had not always done that. She said she was aware Resident #1 had aggressive behaviors but did not know why. She stated she knew Resident #1 had bitten CNA B but did not why. She said she did not know Resident #1 pushed RN A to the ground when she tried to take a soiled adult diaper from her. The DON said Resident #1's aggressive behaviors that occurred when staff tried to take things from her should have been in the care plan. She stated there should not be any potentially hazardous items accessible to any resident in the secured because they did not have the mental capacity to know what could be consumed. She said Resident #1 eating deodorant posed a potential risk of harm and could have been avoided. <BR/>An interview on 06/07/2023 at 4:22PM with CNA D revealed Resident #1 was aggressive when staff tried to redirect her or take something she should not have away. She said she had seen Resident #1 eat feces from her adult diaper and told the nursing staff but did not know what was done from there. She stated she did not recall the nurse she told or the time she observed Resident #1 eat feces from her adult diaper. She said Resident #1 needed constant supervision because she constantly looked for anything she could get into. <BR/>An interview on 06/07/2023 at 4:35PM with MDS Coordinator/LVN revealed she and the SW conducted a care plan meeting for Resident #1 on 05/23/2023. She said information for Resident #1's care plan would be communicated to her by the ADON or the DON during morning meetings. She said she was aware of Resident #1 biting a staff member but was not sure why it occurred. She said she was not informed of specific circumstances that may have caused Resident's #1's behavior. She stated those circumstances should be communicated from nursing staff and reflected in the care plan. <BR/>An interview on 06/07/2023 at 5:03PM with the ADON revealed she had not reviewed Resident #1's progress notes. She said it was the DON and her responsibility to review them for any concerns related to residents. She said that information would be passed on to the MDS Coordinator to be addressed in care plans. The ADON said she was not aware Resident #1 was messing with her poop and did not know RN A was pushed to the ground by Resident #1 when she took a soiled adult diaper from her. She stated specific interventions should have been reflected in the care plan to ensure Resident #1's safety. She said the facility did not have a system in place to ensure rooms were checked for hazardous items. She said since Resident #1 wandered and got into things, the facility needed to ensure her safety by making sure all potentially hazardous items were secured. <BR/>In an interview on 06/07/2023 at 5:15PM, the Administrator stated she dropped the ball. She said in hindsight, she should have followed up with the DON regarding Resident #1's aggression. She said she should have investigated as to the circumstances of Resident #1's aggression. She stated there was not an incident report done when Resident #1 bit CNA E or pushed RN A. She said she and the DON should have known about Resident #1 eating a solid adult diaper. She said she felt like she needed to have better communication with nursing staff to ensure all resident's safety. She said the facility should have a system in place to ensure resident did not have access to non-consumable items and ensure their safety. <BR/>An interview on 06/07/2023 at 5:57PM with the COO revealed he expected staff to ensure all residents were safe. He stated the DON and ADON should have known about the context of Resident #1's behaviors and ensured the care plan reflected specific issues. He stated there seemed to be a breakdown in communication between the front-line staff, nurse management, and the Administrator. <BR/>Record review of the facility's incident / accident report between 03/01/2023 to 06/07/2023 revealed no record of incidents involving Resident #1, CNA B, or RN A. <BR/>Record review of the MSDS for the deodorant consumed on 06/07/2023 by Resident #1 revealed Hazards Identification: Eye: Classification Eye Contact may cause mild, transient irritation. Some redness and/or stinging may occur. Ingestion: Product used as intended is not expected to cause gastrointestinal irritation. Accidental ingestion of undiluted product may cause mild gastrointestinal irritation with nausea, vomiting and diarrhea.<BR/>Record review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, dated 12/2009 reflected, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.including time and date .nature .circumstances .name of witnesses .complete report sent to the DON within 24 hours .DON shall ensure that the Administrator receives a copy of the Report .<BR/>Record review of the facility's policy titled, Safety and Supervision of Residents, dated 12/2008 reflected, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA and A reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. Staff shall use various sources to identify risk factors for residents, including information obtained from the medical history, physical exam, observation of the resident, and the MDS. Implementing interventions to reduce accident risk and hazards shall include the following: communicating specific interventions to all relevant staff, providing training .documenting interventions .<BR/>Record review of the facility's policy titled, Care Plans - Comprehensive, dated 12/2010 reflected, An individualized comprehensive care plan that includes measurable objectives and timetables to meet resident's medical, nursing, mental, and psychosocial needs is developed for each resident. Each resident's comprehensive care plan is designed to: .incorporate identified problems .incorporate risk factors associated with identified problems <BR/>The Administrator was notified on 06/08/2023 at 9:30AM, that an Immediate Jeopardy had been identified due to the above failures. The IJ Template was provided to the Administrator on 06/08/2023 at 9:45AM and she was informed the POR was due to HHSC by 12:00PM on 06/08/2023. <BR/>The Plan of Removal (POR) was accepted on 06/08/2023 at 4:20PM. <BR/>The Plan of Removal reflected the following:<BR/>Immediate Corrective Action for residents affected by the alleged deficient practice:<BR/>The resident who allegedly ingested deodorant was assessed, all vital signs within normal limits. Despite finding no evidence of deodorant within her mouth, the resident's mouth was rinsed, fluids encouraged. Medical director, poison control, and family were notified. The medical director instructed facility to continue to monitor for signs of GI distress. <BR/>This deficient practice had the potential to affect 17 residents residing on the secure unit, however, no other resident was found to be affected.<BR/>The secure unit was swept for personal care items on 06/07/23 and again on 06/08/23. All personal care items found were removed from resident rooms and given to the charge nurse to be secured behind locked doors, including items from resident who was previously reluctant to let them go. <BR/>All family members were called on 06/07/2023 and informed that personal care items must be labeled and turned into management staff or nursing to be locked for the safety of all residents. Signs were also posted at the front of the building to turn in personal care items which will be made available for use at the appropriate time. <BR/>Care plans updated to reflect the residents wandering and aggression being further agitated by attempts to remove items or redirect resident. The care plan updated to reflect the residents alleged tendency to ingest non-food items. <BR/>Staff members in-serviced on the need to lock personal care items out of reach of residents, particularly those who tend to become confused or exhibit behaviors related to wandering and picking up items found in other rooms. Education occurred on 06/07/23 and again on 06/08/23 and will continue.<BR/>Actions taken to prevent a serious adverse outcome from recurring:<BR/>Management staff swept the rest of the facility on 06/08/2023 and ensured personal care items were secured appropriately. Anything found not stored appropriately was labeled by resident name and given to charge nurses to secure in locked room on 300 hall. <BR/>Additional checks were conducted of locked supply, shower, and utility rooms. The facility will continue to monitor to ensure the security of these areas. Additional education completed on the need to keep personal care items away from residents who might become confused or exhibit behaviors.<BR/>Ad Hoc QAPI Meeting was held on 06/08/2023 to discuss the incident, make staff members aware of the new policy on personal care items. MD and management staff present, corporate staff available by phone. <BR/>Additional sweeps of the area daily by staff members x 2 weeks, then weekly for 2 weeks, and monthly thereafter. <BR/>The facility will utilize a daily behavior monitoring sheet for changes in behavior/condition. This sheet will be reviewed weekly and as necessary, changes in behavior or condition will be discussed and care planned appropriately. <BR/>When will actions be complete:<BR/>Coral Nursing and Rehabilitation of Arlington requests the removal of the immediate jeopardy on 06/08/2023<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>An interview on 06/09/2023 at 1:30PM with the Administrator revealed 57 of 110 staff have been in-serviced regarding the Behavior monitoring log and Securing personal care items. She stated the management team had been completed to ensure any hazardous items were secured for the safety of residents. She stated sweeps will be completed daily by the management team for two weeks and then weekly. She said she would be completing the sweeps on weekends until a weekend supervisor was hired. She stated she would be addressing progress notes, the results of sweeps, and any aggressive incidents daily stand-up meetings. She stated the management team participated in an Ad Hoc QUPI meeting on 06/08/2023 wiht the medical director, Corporate RN, DON, ADON, and MDS Coordinator present. She said she had implemented a behavioral log to be completed by staff daily and monitored by the DON in an effort to catch any changes in resident behaviors. She said the DON was expected to report any changes in resident behavior to her, daily. She stated the families of all Secured Unit residents were contacted and instructed that any items they bring to the facility must be secured by staff. <BR/>A record review of the medical record for Resident #1 revealed she was assessed for complications and ongoing monitoring of adverse effects. Resident #1's care plan was updated to reflect the residents wandering and aggression, further agitated by attempts to remove items or redirect the resident and resident's tendency to ingest non-food items. <BR/>Observations on 06/09/2023 from 3:00PM to 3:10PM revealed all rooms and areas in the memory care unit were free from hazardous products.<BR/>Interviews were conducted on 06/09/2023 from 12:40 PM to 3:00 PM with 18 staff members (6 CNAs, 2 RNs, 4 LVNs, 2 MAs, 1 Restorative Aide, and 3 Housekeeping staff) from multiple shifts. The staff all indicated they had been in-serviced on safety awareness, which included a list of prohibited items in memory care, how hazardous items should be stored, the procedures on storing prohibited items that family members might bring for resident use, ongoing sweeps for hazardous items and their security, and procedures in case they were not sure if an item was hazardous.<BR/>In a telephone interview on 06/09/2023 at 2:55PM, the Corporate RN said he understood the components of the IJ and was not aware the DON and ADON had not been reviewing the progress notes. He said it was impossible to complete a comprehensive care plan without considering behaviors. He said he expected the Administrator to ensure residents were safe from hazardous items. He said he expected the DON to ensure behaviors were monitored and communicated to staff for appropriate care planning. He said he provided a behavior log to the Administrator to assist with this. He said he in-serviced the Administrator, DON, ADON, and MDS Coordinator on the need to address changes in resident behavior in care planning, reviewing progress notes to ensure behaviors are addressed and care planed appropriately, and ensuring resident were cared for in a safe environment. <BR/>Record review of in-service dated 06/07/2023, 06/08/2023, and 06/09/2023 on Personal Care Items .Inform family members that all personal care items must be labeled and turned into management staff or nursing staff to be locked for the safety of all residents .Personal care items include but are not limited to the following: Soap, shampoo, conditioner, deodorant, lotions, mouthwash, toothpaste, hand sanitizer, and other potentially hazardous chemical items .In continuing sweeps, if such items are found please remove them from the room. Make sure they are labeled and give it to the nursing staff to be secured revealed 57 signatures from multiple shifts and multiple departments (RNs, LVNs, CNAs, MAs, Housekeeping, Laundry, and Maintenance) had received in-services which covered all aspects of the POR. <BR/>Record review of in-service dated 06/07/2023, 06/08/2023, and 06/09/2023 on Behavior Monitoring Log .the facility will distribute behaviors monitoring sheets to the nursing staff to be filled out daily. The DON will collect the sheets weekly or as necessary to be discussed at the Standards of Care meeting. Any changes will be communicated to management staff in the meeting and care planned appropriately. Changes will also be discussed in the morning IDT meeting so all staff can be aware of changes, revealed 57 signatures from multiple shifts and multiple departments (RNs, LVNs, CNAs, MAs, Housekeeping, Laundry, and Maintenance) had received in-services which covered all aspects of the POR. <BR/>Record review of signed in-service dated 06/09/2023 and conducted by the Corporate RN revealed the Administrator, DON, ADON, and MDS Coordinator were educated on their .responsibility that every resident within my facility receives quality, appropriate care .understand that changes in resident's behavior must be discussed promptly, with the DON, ADON, and IDT team for intervention and appropriate care planning .understand that it is my responsibility to periodically read and review the charts of my residents with behaviors, to ensure completeness and that all behaviors are addressed and care planned appropriately. <BR/>Record review of the Behavior Monitoring Log reflected behavior, intervention and outcome codes with a monthly calendar noting day, evening, and night shifts. <BR/>The Administrator was informed the Immediate Jeopardy was removed on 06/09/2023 at 4:18PM; however, the facility remained out of compliance at a scope of Pattern and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 8 residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 was provided with adequate supervision to prevent her from eloping from the facility on 02/17/24.<BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/09/24 and ended on 02/27/24. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Record review Resident #1's Face sheet dated was admitted to the facility on [DATE]. Resident #1 was diagnosed with unspecified Dementia, major depressive disorder, psychotic disorder with delusions due to known physiological condition, and adjustment disorder with anxiety.<BR/>Record review of Resident #1's MDS assessment dated [DATE] revealed she had a BIMS score of 0 indicating severe cognitive impairment. She was rarely/never understood. The MDS Assessment indicated she did not exhibit wandering behavior symptoms. The MDS Assessment indicated the resident did not have an electronic device that monitored resident movement and alerted staff.<BR/>Record review of Resident#1 care plan dated 11/15/21 revealed: Resident #1 was an elopement risk/wander as evidenced by non-goal directed wandering in/out of rooms, exhibited exit seeking behaviors. Resident #1 goals revised on 02/06/24 revealed: Resident #1's safety will be maintained Record review of care plan revealed: Interventions dated 11/15/21: disguise exits, cover doors knobs and handles, tape floor, identify the pattern of wandering and intervene as appropriate. Provide structed activities .reorientation strategies including signs, pictures .<BR/>Record review of progress notes revealed, no documentation of time when Resident#1 went missing and what time the resident was found and returned to the facility. Record review of the progress note revealed, staff did not notice resident#1 was missing until mealtime. The facility was searched, and a code yellow was called. Progress note revealed Resident #1 was found loitering by the police down the street and staff returned her to the facility with Progress reports revealed, Resident #1 received a skin, pain and elopement risk assessment. Progress note revealed Resident#1's family member, Administrator, acting Director of Nursing, Medical Doctor was notified. Progress notes revealed Resident was monitored every 15 minutes.<BR/>Record review of the facility's Provider Investigation report undated revealed the following: <BR/>[Resident#1] was in the dining room, we believe a visitor or staff held the door for [Resident#1], not realizing she was an elopement risk. Staff realized resident was missing approximately 10 minute and called code pink was called She was not located in the facility One staff member got in her vehicle to look for resident. Record review of Provider Investigation Report revealed, Staff flagged a police officer down and the police had located resident at an apartment complex down the street and returned her to the facility. nursing staff did a head to toe skin assessment with no injuries noted, pain assessment . Completed new elopement risk assessment and checked on Resident#1 every 15 minutes <BR/>Record review of staff in-services dated 02/19/24, 02/20/24 and 02/27/24 revealed, abuse, neglect, resident care and elopement were covered.<BR/>Observation on 02/28/24 at 8: 20 AM revealed, residents who needed to be in the secure unit were present. <BR/>Interview on 02/28/24 at 08:30 AM, CNA N stated residents in the secure unit were moved to the general population because of construction that was going on in the facility. General population residents and secure unit's residents were mixed between halls 500, 300 and 400. CNA N stated the risk to the residents was they could escape from the facility. CNA N stated she did not witness the elopement. CNA N stated Resident #1 eloped during dinner on second shift. CNA N stated she was in-serviced on the facility procedures for elopement. <BR/>Interview on 02/28/24 at 8:40 AM, CNA P stated he was on vacation when Resident #1 eloped from the facility. CNA P stated he was in-serviced on elopement when he returned to the facility and the residents were back in the secure unit. <BR/>Interview on 02/28/24 at 9:00 AM with LVN X stated the elopement happened around dinner time and staff believed a visitor held the door open for her not knowing she was a resident. LVN X stated she had been in-serviced on elopement and the residents who belong in the secure unit were back in the unit.<BR/>A telephone interview on 02/28/24 at 1:37 PM with the local police department dispatcher stated, no police report was completed for Resident#1. <BR/>A telephone interview on 02/28/24 at 2:52 PM with the CNA C revealed she was on break and when she returned, she was told the resident was missing. CNA C stated, she did a head count, and the resident was not found. CNA C stated residents were in danger of elopement if they are not supervised. Certified Nurse Aide C stated she understood the facilities policy and procedures for when a resident elopes. CNA C stated, was in-serviced about elopements. <BR/>A telephone interview on 02/28/24 at 2:39 PM with LVN D stated, Resident#1 could not be found in the dining room when trays were passed out. Licensed Vocational Nurse D stated, she drove around the neighborhood and met up with a police officer who stated they found a lady wandering in the apartments LVN D followed the police officer to the apartment. LVN D stated Resident#1 was combative and LVN D called the weekend supervisor who drove to the apartments and was able to get Resident#1 into the car. LVN D stated some of the residents were moved back into the secure unit, but she said that they did not get full clearance to put all the residents back. Some of the secure unit residents were left in general population. LVN D stated all residents were returned to the secure unit on 02/18/24. LVN D stated she was in-serviced on elopement before and after Resident #1 left the facility. <BR/>Interview on 02/28/24 at 3:30 PM with the Administrator revealed residents from the secure unit were brought to general population because of construction and both exits in the secure unit needed to be accessible. The Administrator stated Resident #1 went missing around dinner time 02/17/24, which usually started at 5:30 PM. The Administrator stated Resident#1 was found outside the facility down the street and brought back. The Administrator stated she believed that Resident#1 walked out of the facility with a visitor.<BR/>Interview on 02/29/24 at 2:15 PM with the Administrator revealed residents from the secure unit were mixed with the general population on 02/09/24 and were able to return to the secure unit on 02/14/24, according to her records. The Administrator stated she did not realize secure unit residents were still in general population until 02/18/24. The Administrator stated that in the future she would have more staff to come in to monitor the exits if the secure unit residents must come back to general population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medical records in accordance with accepted professional standards and practices, were maintained on each resident that was accurately documented for 10 of 12 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10) reviewed for accuracy of medical records.<BR/>The facility failed to ensure there was documentation in the clinical record of weekly skin assessments for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10. <BR/>This failure could place residents at increased risk of developing pressure ulcers/injuries. <BR/>Findings include: <BR/>1. Record review of Resident #1's, face sheet, dated 6/5/2023, reflected an [AGE] year-old male who was admitted to the facility 05/17/2023. His diagnoses included: fracture of the right hip, tracheostomy (tube surgically placed in the neck for breathing), weakness and paralysis on the right side of the body caused by a stroke and generalized muscle weakness. <BR/>Record review of Residents #1's admission MDS, dated [DATE], revealed Resident #1 was never or rarely understood. Resident #1 was dependent on facility staff for bed mobility, personal hygiene, toileting, dressing and bathing. Resident #1 was identified as being at risk for skin breakdown caused by pressure and had 2 unstageable (unable to evaluate) deep tissue (maroon/purplish discoloration) injuries present on admission to the facility. <BR/>Record review of Resident #1's, undated, care plan reflected Resident #1 was at risk for impaired skin r/t immobility, has unstageable deep tissue injury on the right 5th toe, partial [does not extend past the layers of the skin]thickness with approaches which included: monitor/document/report to MD prn changes in skin status: appearance, color, wound healing. Resident #1 had actual impairment to skin integrity Unstageable d/t necrosis (non-living tissue) sacrum (lower back) full thickness (Involves all skin layers and the fatty layer below the skin) (8x5 x11.5 x0.1cm with moderate serous (clearish/yellowish) drainage and unstageable right 5th toe partial thickness with approaches which included: elevate heels off the bed, monitor for s/s of infection, monitor pain and administer pain medications/treatments as ordered and/or per pain problem, turn and reposition frequently r/t unstageable to sacrum. <BR/>Record review of Resident #1's skin assessments reflected as of 5/17/2023 skin observations were to be completed weekly. Review of skin assessments revealed, no skin observations for 5/24/2023 and 5/31/2023. <BR/>Record review of Resident #1's Order Summary Report, dated 6/5/2023, revealed the absence of an order for weekly skin assessments. <BR/>2. Record review of Resident #2's face sheet, dated 6/5/2023, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with a recent admission of 5/1/2023. His diagnoses included: the inability to move his legs, 1 stage 4 (may involve loss of muscle, tendon and ligaments) pressure ulcer (open crater created by pressure) on the lower back, stage 4 pressure ulcer of the right ankle, stage 3 (crater with loss of skin involving the fat layer) pressure ulcer of the upper back, stage 2 (crater involving all layers of the skin) pressure ulcer of the right lower back, non-pressure non-healing ulcer of the buttock with necrosis (death) of muscle. <BR/>Record review of Resident #2's quarterly MDS, dated [DATE], revealed Resident #2 had a BIMS score of 11 indicative of moderate cognitive impairment. Resident #2 was dependent on staff for bed mobility, personal hygiene, toileting, dressing and bathing. Resident #2 had unhealed pressure injuries (1 stage 2, 5 stage 3 and 1 stage 4) on admission to the facility. <BR/>Record review of Resident #2's, undated, care plan reflected [Resident #2] had actual impairment to skin integrity. Stage 3 wound to the back and lower portion of the left leg and right thigh, and side of the left foot and ankle, right buttock surgical wound. Resident had a stage 4 wound to right knee, right lower back, right hip and left foot. Approaches included: elevate heels off the bed, involve/educate resident and/or family/designee, monitor for s/s of infection, monitor pain and administer pain medications/treatments as ordered and/or per pain problem. <BR/>Record review of Resident #2's Order Summary Report, dated 6/5/2023, revealed the absence of an order for weekly skin assessments. <BR/>Record review of Resident #2's skin assessments reflected as of 5/2/2023 skin observations were to be completed weekly. Review of the skin assessments revealed, no skin observations for 5/9/2023, 5/16,2023, 5/23/2023 and 5/30/2023. <BR/>3. Record review of Resident #3's face sheet, dated 6/5/2023, reflected a [AGE] year-old female admitted to the facility on [DATE] with a readmission on [DATE]. Her diagnoses included: the inability to speak after a stroke, generalized muscle weakness, contracture (in a fixed position) of muscles multiple sites. <BR/>Record review of Resident #3's reentry MDS, dated [DATE], revealed Resident #3 was never or rarely understood. Resident #3 was dependent on facility staff for bed mobility, personal hygiene, toileting, dressing and bathing. Resident #3 was at risk for developing pressure related injuries or ulcerations with none identified. <BR/>Record review of Resident #3's care plan, dated 4/4/2023, reflected Resident #3 was at risk for potential impairment to skin integrity with approaches which included: elevate heels off the bed, involve/educate resident and/or family/designee, Monitor for s/s of infection, Monitor pain and administer pain medication/treatments as ordered and/or per pain problem.<BR/>Record review of Resident #3's Order Summary Report, dated 6/5/2023, revealed as of 1/6/2022, no end date weekly skin documentation every day shift every Monday. <BR/>Record review of Resident #3's skin assessments reflected the last documented skin assessment was dated 4/24/2023 skin observations were to be completed weekly. Review of the skin assessments revealed, no skin observations for 5/1/2023, 5/22/2023 and 5/29/2023. <BR/>4. Record review of Resident #4 face sheet, dated 6/5/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a readmission on [DATE]. His diagnoses included: inability to move the legs, stroke, unstageable pressure ulcer of the left heel and generalized muscle weakness. <BR/>Record review of Resident #4's quarterly MDS assessment, dated 5/26/2023, revealed a BIMS score of 13 indicative of no cognitive impairment. Resident #4 required moderate assistance for bed mobility, dressing, eating, toileting and bathing. Resident #4 had 2 unstageable pressure ulcers. <BR/>Record review of Resident #4's care plan, dated 5/30/2023, reflected Resident #4 was at risk for actual impairment to skin integrity with approaches which included: elevate heels off the bed, involve/educate resident and/or family/designee, Monitor for s/s of infection, Monitor pain and administer pain medication/treatments as ordered and/or per pain problem.<BR/>Record review of Resident #4's Order Summary Report, dated 6/5/2023, revealed the absence of an order for weekly skin assessments. <BR/>Record review of Resident #4's skin assessments reflected prior to 6/5/2023 revealed the last documented skin observation was dated 3/22/2023. Skin observations were to be completed weekly. Review of the skin assessments revealed, no skin observations for 3/29/2023, 4/12/2023, 4/19/2023, 4/26/2023, 5/3/2023, 5/24/2023 and 5/31/2023. <BR/>Observation on 6/2/2023 at 2:35 PM revealed Resident #4 was awake, alert and able to make his needs known. The resident was noted to have limited mobility, unable to move his legs, limited ability to move his arms, hands and fingers appear to be in a fixed position making gripping objects difficult. On the little toe side of the left foot is a small bump slightly larger than a pin head with small hole in the center. A small amount of fluid was noted on the old dressing. No new skin concerns identified. <BR/>5. Record review of Residents #5's face sheet, dated 6/5/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a readmission on [DATE]. His diagnosis included stroke which resulted in left sided weakness, muscle weakness, and an inability to move the legs, stage 4 pressure ulcer of the lower back. <BR/>Record review of Resident #5's quarterly MDS, dated [DATE], revealed Resident #5 required extensive assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Resident #5 had 1 unhealed stage 4 pressure injury. <BR/>Record review of Resident #5's care plan, dated 4/29/2023, reflected [Resident #5] admitted with actual impairment to skin integrity, stage 4 pressure injury to right middle of the foot and right heel with approaches which included: monitor for s/s of infection. <BR/>Record review of Resident #5's Order Summary Report, dated 6/5/2023, revealed the absence of an order for weekly skin assessments. <BR/>Record review of Resident #5's skin assessments reflected the last documented skin observation was dated 2/3/2023. Skin observations were to be completed weekly. Review of the skin assessments revealed, no skin observations for 2/10/23, 2/17/2023, 2/24/2023, 3/3/2023, 3/10/2023, 3/17/2023, 3/24/2023, 3/31/2023, 4/7/2023, 4/14/2023, 4/21/2023, 4/28/2023, 5/5/2023, 5/12/2023, 5/19/2023, 5/26/2023 and 6/2/2023. <BR/>6. Record review of Resident #6's face sheet, dated 6/5/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: Respiratory failure, tracheostomy (tube surgically placed in the neck for breathing), anoxia (brain injury caused by a lack of oxygen). <BR/>Record review of Resident #6's quarterly MDS, dated [DATE], revealed Resident #6 was never or rarely understood. Resident #6 required extensive assistance for bed mobility, toileting and bathing. Moderate assistance was needed for personal hygiene and dressing. Resident #6 had 1 stage 3 pressure injury present on admission. <BR/>Record review of Resident #6's care plan, dated 4/17/2023, reflected Resident #3 was at risk for actual impairment to skin integrity with approaches which included: Monitor for s/s of infection, Monitor pain and administer pain medication/treatments as ordered and/or per pain problem.<BR/>Record review of Resident #6's Order Summary Report, dated 6/5/2023, revealed the absence of an order for weekly skin assessments. <BR/>Record review of Resident #6's skin assessments reflected the last documented skin assessment was dated 1/6/2023, skin observations were to be completed weekly. Review of the skin assessments revealed, no skin observations for the month of February, March, April and May of 2023. <BR/>7. Record review of Resident #7's face sheet, dated 6/5/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a readmission on [DATE]. His diagnoses included: Multiple sclerosis (disease of the central nervous system), the inability to move the arm and legs, diabetes with foot ulcer, unstageable pressure ulcer of the right heel, stage 4 pressure ulcer of the lower back. <BR/>Record review of Resident #7's admission MDS, dated [DATE], revealed no cognitive impairment as evidence by a BIMS score of 14. Resident #7 required extensive assistance for bed mobility, dressing, personal hygiene and moderate assistance for toileting and bathing. On admission to the facility Resident # 7 had 1 stage 4 unhealed pressure ulcer/injury and 1 Unstageable pressure ulcer/injury. <BR/>Record review of Resident #7's care plan, dated 3/23/2023, reflected Resident #7 was at risk for actual impairment to skin integrity with approaches which included: elevate heels of bed, Monitor for s/s of infection, Monitor pain and administer pain medication/treatments as ordered and/or per pain problem.<BR/>Record review of Resident #7's Order Summary Report, dated 6/5/2023, revealed the absence of an order for weekly skin assessments. <BR/>Record review of Resident #7's skin assessments reflected the last documented skin assessment was dated 4/5/2023, skin observations were to be completed weekly. Review of the skin assessments revealed, no skin observations for 4/12/2023, 4/19/2023, 4/26/2023, 5/3/2023, 5/10/2023, 5/17/2023, 5/24/2023 and 5/31/2023. <BR/>8. Record review of Residents #8's face sheet, dated 6/5/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a readmission on [DATE]. His diagnoses included: fractured hip, seizure disorder, intellectual disabilities, generalized muscle weakness. <BR/>Record review of Resident #8's quarterly MDS, dated [DATE], revealed Resident #8 had moderate cognitive impairment as evidenced by a BIMS score of 11. Resident #8 required minimal assistance with bed mobility, transfers, dressing, eating, toileting and personal hygiene. Resident #8 was at risk for the development of pressure injuries, none noted. <BR/>Record review of Resident #8's care plan, dated 4/28/2023, reflected Resident #8 was at risk for potential impairment to skin integrity with approaches which included: Use caution during transfers and bed mobility to prevent striking arm, legs, and hands against any sharp or hard surface.<BR/>Record review of Resident #8's Order Summary Report, dated 6/5/2023, revealed the absence of an order for weekly skin assessments. <BR/>Record review of Resident #8's skin assessments reflected the last documented skin assessment was dated 4/10/2023. Skin observations were to be completed weekly. Review of the skin assessments revealed, no skin observations for 4/17/2023, 4/24/2023, 5/1/2023, 5/8/2023, 5/15/2023, 5/22/2023 and 5/29/2023. <BR/>9. Record review of Resident #9's face sheet, dated 6/5/2023, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: disrupted brain function, respiratory failure, tracheostomy, stage 3 pressure ulcer of the lower back, generalized muscle weakness. <BR/>Record review of Resident #9's admission MDS, dated [DATE], revealed Resident #9 was rarely or never understood. Resident #9 required extensive assistance for bed mobility, dressing, toileting, personal hygiene and bathing. Resident #9 had 1 stage 3 pressure injury on admission. <BR/>Record review of Resident #9's, undated, care plan reflected Resident #9 had actual impairment to skin integrity with approaches which included: elevate heels off the bed, Monitor for s/s of infection, Monitor pain and administer pain medication/treatments as ordered and/or per pain problem.<BR/>Record review of Resident #9's skin assessments reflected the last documented skin assessment was dated 5/4/2023. Skin observations were to be completed weekly. Review of the skin assessments revealed, no skin observations for 5/11/2023, 5/18/2023, 5/25/2023. <BR/>Record review of Resident #9's Order Summary Report, dated 6/5/2023, revealed the absence of an order for weekly skin assessments. <BR/>10. Record review of Resident #10's face sheet, dated 6/5/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a readmission of 3/17/2023. His diagnoses included: infection of the bones of the right ankle and foot, diabetes, kidney failure. <BR/>Record review of Resident #10's quarterly MDS, dated [DATE], revealed the resident had no cognitive impairment as evidence by a BIMS score of 14. Resident #10 required minimal assistance with bed mobility, transfers, dressing, eating, toileting, personal hygiene. Resident #10 was at risk for the development of pressure ulcer/injuries and currently had none. Resident #10 had 1 diabetic foot ulcer. <BR/>Record review of Resident #10's care plan, dated 5/30/2023, reflected [Resident #10] was at risk for skin alteration r/t decreased mobility/transfers without staff support r/t weakness and occasional bowel/bladder incontinence with approaches which included: elevate heels off the bed, encourage good nutrition and hydration I order to promote healthier skin. Monitor for s/s of infection. <BR/>Record review of Resident #10's Order Summary Report, dated 6/5/2023, revealed as of 1/6/2022, no end date weekly skin documentation every day shift every Monday. <BR/>Record review of Resident #10's skin assessments reflected the last documented skin assessment was dated 4/4/2023. Skin observations were to be completed weekly. Review of the skin assessments revealed, no skin observations for 4/11/2023, 4/18/2023, 4/25/2023, 5/2/2023, 5/9/2023,5/16/2023, 5/23/2023 and 5/30/2023. <BR/>In an interview on 06/02/2023 at 3:58 PM with the DON, she stated she was not aware of an issue regarding skin assessments not being done. The UDA feature in PCC notified the nursing staff of a due skin assessment. When the notification remained red, the DON followed up with the staff to remind them of the impending skin assessment. An overdue skin assessment did not populate on the DON's computer for Resident #4. <BR/>In an interview on 06/05/2023 at 10:17 AM, LVN A stated weekly skin assessments were completed by the nurse assigned to the resident. Notification of a due assessment came up on the nurses UDA in PCC. LVN A stated weekly skin checks were standard protocol and a physician's order was not necessary. Skin assessments were entered into the computer on admission. <BR/>In an interview on 6/5/2023 at 10:31 AM with LVN B, who stated the nurses would look at their UDA to see which resident had an assessment due. LVN B stated she was not aware until this morning that skin assessments were not populating on the UDA's. LVN B stated if the UDA does not indicate a skin assessment was due, a skin assessment was not done. <BR/>In an interview on 6/5/2023 at 10:37 AM, LVN C stated weekly skin assessments were completed by the nurses. Due assessments populated on the nurses UDA in PCC. LVN C said she had not seen assessments popping up lately and had not mentioned it to anyone. Weekly skin assessments could alert the facility of condition changes in a resident. LVN C said she had not done weekly skin assessments when the UDA did not notify her that one was due. <BR/>In an interview on 6/5/2023 at 10:57 AM, the ADON stated she was not aware of an issue with due skin assessments not appearing on the UDA prior to 6/2/2023. Weekly skin assessments were part of the standard assessments for all residents, a physician's order was not needed. Weekly skin assessments allowed staff to identify, notify and treat conditions early. <BR/>In an interview on 6/5/2023 at 11:09 AM, the DON stated the due skin assessments used to pop up on the nurses UDA in PCC. Weekly skin assessments were done to make sure residents were not having a skin issue. The DON said they relied on the UDA for notification of overdue skin assessments. Weekly skin assessments were considered standard of care, meaning a physician's order was not required. <BR/>In an interview on 6/5/2023 at 3:44 PM, RN D stated she noticed the UDA did not always populate with due skin assessments. RN D said she did not recall saying anything about it to nursing leadership. <BR/>In an interview on 6/5/2023 at 3:49 PM, RN E stated weekly skin assessments were done as it popped up on the UDA. RN E only did the weekly skin assessment when it came up due on the UDA. RN E had not spoken to any member of leadership about due skin assessments not showing up on the UDA. Weekly skin assessments helped to catch skin issues in time before they deteriorated.<BR/>In an interview on 6/5/2023 at 4:00 PM, the Adm stated she was not aware of issues regarding the UDA and skin assessments prior to Friday 6/2/2023. <BR/>Record review of the facility's, undated, Skin Assessment policy, Policy Explanation and Compliance Guidelines revealed: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for 3 days, and weekly thereafter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of five residents reviewed for pressure ulcers.<BR/>1. <BR/>The facility failed to ensure Resident #1 received all physician ordered wound care 10 out of 31 days in December 2024. <BR/>2. <BR/>The facility failed to ensure Resident #1 received all physician ordered wound care 5 out of 30 days in January 2025. <BR/>This facility failure could place residents at risk of developing infections or worsening of their wounds.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 01/30/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included paraplegia (a condition that causes paralysis or loss of muscle function in the lower half of the body, including both legs), pressure ulcer of sacral region-stage 4, pressure ulcer of right heel-stage 3, pressure ulcer of left heel-stage 3, non-pressure chronic ulcer of back, neuromuscular dysfunction of bladder (impaired bladder control due to disrupted communication between the brain and the bladder muscles), colostomy status(a surgical procedure that creates an opening in the abdomen through which waste from the large intestine can be expelled into a bag) and chronic pain syndrome (a condition characterized by persistent pain that lasts for at least three to six months). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 13, which indicated intact cognition. Resident #1 had no rejection of care issues and no verbal or physical behaviors. Resident #1 had range of motion impairment on both sides of his lower body and was dependent on staff for transfers, bed mobility and ADLs that included dressing, showering, personal hygiene and incontinent care. Resident #1 had an indwelling catheter and an ostomy appliance. Resident #1's assessment reflected he was at risk of developing pressure ulcers/injuries and had four unhealed pressure ulcers and one unstageable deep tissue injury that were present upon admission to the facility. Skin and ulcer/injury treatments included pressure ulcer/injury care, application of nonsurgical dressings and applications of ointments/medications. <BR/>Record review of Resident #1's care plan dated 10/02/24 and last revised on 01/29/25 reflected the following focus areas:<BR/>-Wound Management-Skin tear to the left instep of his foot due to hitting the bedrail during a spasm episode (Initiated12/02/2024); Intervention: Wound will show signs of improvement, provide wound care per treatment order. <BR/>-Resident is at risk for pain related to wound; Site #1: Stage 4 pressure wound sacrum full thickness, wound size: 13.5 x 21.8 x 0.2cm; Site #5: Stage 4 pressure wound of left heel full thickness, wound size: 2.1 x 1.5 x 0.1cm; Site #6: Stage 4 pressure wound of right lateral foot full thickness, wound size: 1.1 x 0.7 x Non measurable cm; Site #12: Non-pressure wound of the left buttock full thickness, wound size: Resolved- 01/22/25. Interventions included to provide wound treatment per MD order, Site #1: Stage 4 pressure wound sacrum full thickness: clean surrounding skin with skin prep, clean wound with NS or wound cleanser, pat dry, apply collagen powder and calcium alginate to wound bed, island dressing or ABD pad and paper tape daily. Site #5- skin prep surround skin, clean wound with NS, pat dry, apply Xeroform to wound, apply island border dressing daily. Site #6- Skin prep three times a week.<BR/>Record review of Resident #1's care plan also reflected a revision on 01/02/25 reflected he was resistent to wound care and skin assessments. The intervention reflected, Give one on one care as needed.<BR/>Record review of Resident #1's physician's order summary for December 2024 and January 2025 reflected the following treatments were ordered:<BR/>1) Cleansed open area on top of left foot, apply triple antibiotic ointment, cover with dry gauze dressing one time a day for open wound on top of left foot (start date 11/30/24, discontinued 01/02/25)<BR/>2) Non-pressure wound right medial heel, skin prep three times per week on Monday, Wednesday and Friday for preventative measure (start date 01/03/25, discontinued 01/15/25)<BR/>3) Non-pressure wound to left lateral ankle - apply skin prep daily (start date 01/02/25, discontinued 01/15/25)<BR/>4) Non-pressure wound left 2nd toe apply skin prep three times per week every day shift every Mon, Wed, Friday for Preventative Measure (start date 01/03/2025, discontinued 01/15/25)<BR/>5) Non-pressure wound of the left 2nd toe partial thickness, once a day every Monday, Wednesday and Friday for 23 days, Apply skin prep; Off-load wound; Pressure off-loading boot (start 12/05/24, discontinued 12/28/24)<BR/>6) Non-pressure wound of the left buttock full thickness, skin prep skin around wound, clean wound with NS, apply xeroform to wound bed, island border dressing or ABD pad daily x23 days. one time a day (start 01/16/25, discontinued 01/22/2025)<BR/>7) Non-pressure wound of the right toe of undetermined thickness once a day for 30 days, apply skin prep, off-load wound with pressure offloading boot (start 12/05/24, discontinued 01/02/25)<BR/>8) Non-pressure wound of the right medial heel partial thickness once a day on Monday, Wednesday and Friday for 16 days, apply skin prep, offload wound with offloading boot (start 12/05/25, discontinued 12/21/24)<BR/>9) Non-pressure wound to left superior lateral ankle-apply skin prep daily for preventative measure (start 01/03/25, discontinued 01/15/25) <BR/>10) Right Lateral Foot: cleanse with NS, pat dry. Apply [NAME] and leave open to air Tuesdays/Thursdays. every day shift for Wound Treatment (start 01/05/25, discontinued 01/15/25)<BR/>11) Stage 4 pressure wound of right lateral foot full thickness: skin prep three times a week x16 days once a day on Monday, Wednesday and Friday (start date 01/17/25 to present)<BR/>12) Stage 4 pressure wound of the left heel full thickness once a day for 30 days apply skin prep, use Xeroform gauze to wound bed and cover with island bordered dressing (start date 12/05/24 through present)<BR/>13) Stage 4 pressure wound of the left heel full thickness: clean with NS, pat dry apply xeroform to wound bed and island border dressing daily x16 days once a day (start date 01/16/25, discontinued 01/29/25). <BR/>14) Stage 4 pressure wound of the left heel full thickness, skin prep surround skin of wound, clean with NS, pat dry apply xeroform to wound bed and island border dressing daily for 30 days once a day (start 01/30/25)<BR/>15) Stage 4 pressure wound of the right lateral foot thickness once a day on Monday, Wednesday, Friday for 30 days (start date 12/05/24, discontinued 01/04/25).<BR/>16) Stage 4 pressure wound sacrum full thickness-apply xeroform gauze to wound bed and cover with ABD pads, use tape/island bordered gauze for retention every day (start 12/31/24, discontinued 01/02/25)<BR/>17) Stage 4 pressure wound sacrum full thickness, once a day on Monday, Wednesday, Friday for 30 days, apply xeroform gauze to wound bed and cover with ABD pads, use tape/island bordered gauze for retention (start date 12/04/24, discontinued 12/20/24)<BR/>18) Stage 4 pressure wound sacrum full thickness, skin prep around wound, clean with NS, Pat dry, apply collagen powder and calcium alginate to wound bed, island dressing or ABD pad and paper tap daily, and as needed. Monitor for s/s of infection once a day (start date 01/16/25 through present)<BR/>19) Stage 4 pressure wound sacrum full thickness, one time a day every Monday, Wednesday, Friday for 30 days apply xeroform guaze to wound bed and cover with ABD pads, use tape/island border gauze for retention (start date 12/05/24, discontinued 12/30/24)<BR/>20) Stage 4 pressure wound sacrum full thickness, apply peri-wound skin prep, aliginate calcium gauze to wound bed and cover with ABD pads, use tape/island border gauze for retention as needed (start date 01/02/25, discontine 01/15/25)<BR/>Record review of Resident #1's December 2024 TAR reflected he did not receive wound care to his sacrum and heel as ordered by his physician on 12/03/24, 12/05/24, 12/12/24, 12/16/24, 12/19/24, 12/20/24, 12/23/24, 12/24/24, 12/25/24 and 12/27/24.<BR/>Record review of Resident #1's January 2025 TAR reflected he did not receive wound care to his sacrum and heel as ordered by his physician on 01/06/25, 01/09/25, 01/14/25, 01/21/25 and 01/29/25.<BR/>Record review of Resident #1's nursing progress notes reflected no entries on the dates of the missed wound care in December 2024 and January 2025 to explain why it was not provided. <BR/>Record review of Resident #1's Wound Evaluation and Management Summaries dated 12/11/24 and 01/29/25 reflected in each visit under the Expanded Evaluation Performed that Resident #1 was a current smoker which was known to affect wound healing and healing progression. Continued interventions for wound healing ordered and implemented included a multivitamin once a day, vitamin C twice a day, low air loss mattress, off-loading wound, repositioning per facility protocol and offloading chair cushion. The following measurements were reflected for his current wounds:<BR/>1) 11/06/24- Stage 4 pressure wound to sacrum over 675 days: The measurements were 20.3 x 14.5 x 0.2 cm with a surface area: 294.35 cm, Cluster Wound open ulceration area of 88.31 cm, Sharp selective debridement procedure was used to remove biofilm over the wound surface area of 88.305 cm, Wound progress: At Goal. (Note: A cluster wound is a grouping of multiple wounds that are close to one another and documenting them as a single wound 'clustered wound' could simplify assessment, when appropriate.)<BR/>-12/11/24- Stage 4 pressure wound to sacrum over 710 days: The measurements were 16x 6x 0.2cm with a surface area of 96 cm with noted improvement, Cluster Wound open ulceration of 19.2 cm, Wound progress: Improved-evidenced by decreased surface area. A sharp selective debridement procedure was used to remove biofilm over the wound surface area of 19.2 cm. Goal of treatment is healing as evidenced by a 61.5 % decrease in surface area within the wound bed in comparison to the last wound visit. <BR/>-01/01/25-Stage 4 pressure wound to sacrum over 731 days: The measurements were 16.5 x22.5 x 0.2 cm with a surface area of 371.25 cm&sup2; and a Cluster Wound open ulceration area of 111.38 cm, Wound progress: Exacerbated due to multifactorial. A surgical excisional debridement procedure was used to surgically excise 37.12 cm of devitalized tissue and necrotic muscle tissue along with slough and biofilm were removed at a depth of 0.3cm and healthy bleeding tissue was observed. As a result of the procedure, the nonviable tissue in the wound bed decreased form 20 percent to 10 percent. Hemostasis was achieved and a clean dressing was applied. <BR/>-01/15/25- Stage 4 pressure wound to sacrum over 745 days: The measurements were 13.4 x22.5 x 0.2 cm with a surface area: of 301.50 cm&sup2; and a Cluster Wound open ulceration area of 90.45 cm, Wound progress: Improved evidence by decreased surface area. A surgical excisional debridement procedure was used to surgically excise 30.15 cm of devitalized tissue including slough, biofilm and non-viable muscle tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of the procedure, the nonviable tissue in the wound bed decreased form 10 percent to 0 percent. Hemostasis was achieved and a clean dressing was applied.<BR/>-01/29/25-Stage 4 pressure wound to sacrum over over 758 days: The measurements were 13.5 x21.9 x0.2cm with a surface area of 294.30 cm with the wound progress noted to be at goal. <BR/>2) Stage 4 pressure wound to the left heel: On 12/11/24, the measurements were 3.5x 3.5x 0.1 cm with a surface area of 12.25 and was not at goal. On 01/29/25, the measurements were 2.1x 5.0x 0.1 cm with a surface area of 3.15cm and was not at goal. <BR/>3) Stage 4 pressure wound of the right lateral foot: On 12/11/24, the measurements were 1.1x 0.5x not measurable cm with a surface area of .55 cm. On 01/29/25, the measurements were 1.1x 0.7x not measurable cm with a with a surface area of .77 cm with noted wound improvement. <BR/>An interview with Resident #1 on 01/30/25 at 1:07 PM revealed he had a very large wound that he admitted to the facility with on his bottom and it had almost gotten healed up by the previous ADON, but when he left employment at the end of November 2024, Resident #1's wounds got worse. Resident #1 said the floor nurses were providing the wound care during December 2024 because there was no wound care nurse designated for the facility. He said the floor nurse would tell him they would get to the wound care, but no one was coming into his room to do it consistently. Resident #1 said he told the ADM, who ended up getting a nurse to start coming in [ADON A] to do the wound care, but he was not sure when she started. Resident #1 stated since ADON A started working on his wounds during the weekdays they had gotten better. However, when ADON A was not at the facility, the floor nurses doing the wound care were not always knowledgeable on the required supplies, technique and application of dressings. Resident #1 stated there had never been a consistent wound care nurse until recently and there had been numerous times when ADON A was not working that his wound care did not get provided. Resident #1 felt that the lack of wound care being done consistently in December 2024 set him back two months on his healing. <BR/>An interview with Resident #1's RP on 01/31/25 at 10:11 AM revealed she had been having concerns about his wound care not being done as well as the nurses not coming to check on him. The RP stated she had seen Resident #1's wounds via photos and they had almost healed around Thanksgiving 2024, but within a few weeks after that, the one on his bottom started going downhill and getting bad. The RP stated Resident #1 could not feel his feet and the wounds on them were chronic and always recurring. As a result, they were not as much of an issue as the one on his bottom. The RP stated, But the bottom wound, they weren't doing right. The RP stated she had tried to get in touch the DON with no success as well as the ADON. <BR/>Record review of a grievance form for Resident #1 dated 12/30/24 reflected a concern that Resident #1 was not getting his wound care done daily. The grievance resolution reflected the DON educated the Resident #1 that his wound care was not done daily and a documented he was told a majority of his wound care was done on Mondays, Wednesdays and Fridays and that the resident should speak with the doctor regarding any order changes. The grievance also reflected Resident #1 then stated, Well they are not doing it on Mondays, Wednesdays and Fridays either and showed me [DON] pictures of his wounds and said they are getting worse. I asked if I could do a full head to toe assessment and the resident refused.<BR/>An interview with the ADM on 01/30/25 at 9:30 AM revealed the DON was out sick on leave. <BR/>An interview with the SW on 01/30/25 at 2:45 PM revealed Resident #1 did make a complaint about his wounds and said he was going to contact the State [HHSC] because he was not getting wound care every day. The SW said, however, the doctor did not order wound care every day and Resident #1 wanted to know why. The SW stated, I think the nurse talked to him and helped him understand that we are only following doctor's orders .He gets worked up sometimes. <BR/>An interview with the wound care nurse, ADON A on 01/31/25 at 11:23 AM revealed she started as the wound care nurse on 01/08/25 and prior to that she was a PRN floor nurse at the facility. ADON A said any wounds from 01/08/25 to present were wounds she had done wound care for, unless she was working on the floor. ADON A stated that she could not speak for anyone else, but if there were blanks on the TAR during January 2025 when she was doing wound care, it may have been due to updating orders in the system, but she was not sure. ADON A stated she was at the facility during the weekdays and the only time she delegated wound care to the charge nurses was if she was working on the floor She stated, Sometimes I try to do wounds before the floor shift starts; sometimes I don't and will delegate to the nurses who are capable of doing treatments. ADON A stated the weekend charge nurses were responsible for doing wound care on the weekends. Regarding Resident #1, ADON A stated he had told her the nurses were not doing the wound care correctly but she did not know what he meant. She said Resident #1's wound drained a lot and she taped them up very well and they did not come undone, so she thinks when other nurses did it, Resident #1 may feel that the bandages were falling off. ADON A stated residents' wounds in the facility were tracked by herself. She said she would know if wound care was not getting done because of how the bandages were dated when came in for her next shift.<BR/>An interview with the ADM on 01/31/25 at 1:54 PM revealed ADON A was in charge of monitoring wound care and sometimes the DON did weekly random audits of wounds. <BR/>Record review of the facility's policy titled Wound Care revised October 2010 reflected, Purpose: The purpose of this procedure is to provider guidelines for the care of wounds to promote healing .Steps in the Procedure .12. Apply treatments as indicated, 13. Dress wound .Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given, 2. The date and time the wound care was given .4. The name of the individual performing the wound care, 5. Any change in the resident's condition .10. The signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 help prevent the development and transmission of infection for 5 (Residents #2, #3, #4, #5, and #6) of 12 residents reviewed for infection control. <BR/>1. <BR/>On 04/30/24 MA A, CNA B, and CNA C brought Residents #2, #3, #4, #5, and #6 to the locked unit dining room and fed them and did not wash their hands nor the hands of the residents.<BR/>2. <BR/>On 04/30/24 CNA B assisted Residents #2, #3, and #4 with their noon meals, he cut up their food and fed them and did not sanitize his hands.<BR/>3. <BR/>On 04/30/24 CNA C touched the hand of Resident #5 and assisted him to his seat then touched his eating utensil without sanitizing her hands.<BR/>4. <BR/>On 04/30/24 during the noon meal on the locked unit a visitor brought cookies to the residents, this visitor used her ungloved hands and gave each resident present (#2, #3, #4, #5, #6) a cookie without sanitizing her hands.<BR/>This deficient practice placed residents who received assistance with meals in the Locked Unit Dining Room at risk for cross contamination and infections.<BR/>Findings included:<BR/>Review of Resident #2's Care Plan dated 07/12/23, revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with an intervention of limited assistance by staff to eat. Diagnoses included Dementia (a group of thinking and social symptom that interferes with daily functioning), and bipolar disorder (associated with episodes of mood swings ranging from depressive lows to manic highs). <BR/>Review of the most recent quarterly MDS assessment dated [DATE], revealed Resident #2, had a BIMS score of 3 (cognition was severely impaired). Resident #2's eating assessment reflected she required partial/moderate assistance-Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.<BR/>Review of Resident #3's Care Plan dated 01/24/24, revealed Resident #3 was an [AGE] year-old male admitted to the facility on [DATE] with an intervention of set up assistance by staff to eat. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #3's quarterly MDS assessment reflected he had a BIMS score of 00 (cognition was severely impaired). Resident #3's eating assessment reflected he required setup or clean-up assistance-Helper sets up or cleans up; resident completes activity.<BR/>Review of Resident #4's Care Plan dated 11/07/23, revealed Resident #4 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #4's quarterly MDS assessment reflected no BIMS score noted. Resident #4's eating assessment reflected she required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>Review of Resident #5's Care Plan dated 02/06/24, revealed Resident #5 was an [AGE] year-old female admitted to the facility on [DATE] with an intervention that the resident is independent for eating. Diagnoses included Dementia (a group of thinking and social symptom that interferes with daily functioning).<BR/> Review of Resident #5's quarterly MDS assessment reflected a BIMS score was not completed. Resident #5's eating assessment reflected she required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>Review of Resident #6's Care Plan dated 04/14/23, revealed Resident #6 was an [AGE] year-old male admitted to the facility on [DATE] with an intervention of limited assistance by staff to eat. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #6's change in condition MDS assessment reflected a BIMS score was not completed. Resident #6's eating assessment was not completed.<BR/>Observation on 04/30/24 at 12:45 PM revealed MA A walked into the dining room on the locked unit, and she assisted Resident #2 to a table and helped her to sit. MA A took the lid off the plate of Resident #2 then she touched her eating utensil and fed Resident #2. MA A did not sanitize her hands or the hands of Resident #2.<BR/>During an observation on 04/30/24 at 12:46 PM, CNA B took the eating utensil of Resident #3 and cut up his food. Then he went to Resident #4 and used her eating utensil to cut up her food. CNA B then moved to Resident #5, picked up her eating utensil and fed her. He did not sanitize his hands before he moved to and from each resident to assist. He did not sanitize the hands of the resident before assisting them to eat.<BR/>During an observation on 04/30/24 at 12:48 PM, Resident #6 got up from the table. CNA B went outside the door of the dining area to follow Resident #6 out of the dining room. CNA B touched Resident #6 on his arm to redirect him back to the dining table, then CNA B returned to Resident #5 and fed her again. He did not sanitize his hands after he touched or fed a resident. <BR/>Observation on 04/30/24 at 12:49 PM revealed CNA B left Resident #5 and went to assist Resident #4 back to her table to eat by touching her arm. Then he returned to Resident #5 without sanitizing his hands. <BR/>Observation on 04/30/24 at 12:50 PM revealed CNA C assisted Resident #6 back to his table when she took his hand and helped him sit down. Then she picked up his eating utensil from his plate and assisted him to eat. She did not sanitize her hands or the hands of the resident.<BR/>Observation on 04/30/24 at 12:51 PM revealed CNA B moved from Resident #5 and took the eating utensil for Resident #3 and put it back in his hand and encouraged him to eat. He did not sanitize his hands. <BR/>Observation on 04/30/24 at 12:55 PM revealed a visitor entered the dining area on the locked unit with a container of cookies. The visitor handed out cookies to Residents #2, #3, #4, #5, and #6. The visitor did not sanitize her hands before she gave the residents cookies. The visitor did not put on gloves prior to passing out the cookies to the residents.<BR/>In an interview on 04/30/24 at 1:09 PM with CNA B revealed he did not have any hand sanitizer on his person in the dining area and there was not any in the dining area at lunch. He stated there was some hand sanitizer in the nursing station which was located down the hall. He stated he had been trained on infection control. He stated he was not supposed to move from one table to another table or one resident to another resident and touch them without sanitizing his hands. He stated the residents should not have been given cookies by the visitor. He stated the risk to the residents was the transmission of germs that could cause infection.<BR/>In an interview on 04/30/24 at 1:21 PM with CNA C revealed she did not have any hand sanitizer on her person when she was in the dining area at lunch. She stated they do not keep the sanitizer out in the dining room because of the residents' attempts to get the sanitizer. She stated there is hand sanitizer in the closet in the nurses' station. She stated the visitor should have asked if they could give the residents cookies. She stated the risk to the residents was the spread of germs and infection when the staff did not sanitize their hands when working with several residents.<BR/>In an interview on 04/30/24 at 1:40 PM with LVN revealed she was the supervisor of the staff working in the locked unit. She stated during lunch she mostly worked on another hall. She stated the hand sanitizer was available in the nurse room, but the door has been taken down and they must keep all the sanitizer put up out of reach of the residents. She stated all the staff should have known the hand sanitizer was in the closet in the nurse room. She stated she did not remember the last infection control training they took. She stated the visitor should not have handed out cookies to the residents without sanitizing hands. She stated the risk to residents was infection, passing germs, and viruses because staff had not sanitized their hands during the lunch meal.<BR/>In an interview on 04/30/24 at 2:15 PM with MA A revealed she did not have hand sanitizer in her pocket. She stated hand sanitizer was in the nurses' room down the hall. She stated she had washed her hands before she went into the dining area. She stated staff should have sanitized their hands when they worked with several residents during the lunch meal. She stated the resident was at risk of infection when the staff did not sanitize between residents. <BR/>In an interview on 04/30/24 at 4:35 PM with the Administrator revealed the DON and herself was responsible to ensure staff was trained on IC. She stated the DON completed monthly in-services on IC. She stated the DON was currently in the hospital and not available for interview. She stated the staff had put the residents at potential risk of infection and illness when they did not sanitize their hands. She stated the staff should have told the residents to wash their hands before the meal. She stated there was hand hygiene supplies available throughout the building and if there was not any in the dining area, the staff could have asked her or the housekeeper. <BR/>Record review of facility's Policies and Practices -Infection Control revised August 2010 reflected, All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide specialized rehabilitative services for one of one resident (Resident #1) reviewed for specialized rehabilitative services. <BR/>The facility failed to ensure Resident #1 received occupational therapy (OT), physical therapy (PT), and speech therapy (ST) evaluations/treatment per physician order.<BR/>This failure could place the resident at risk of not meeting their highest practicable well-being.<BR/>Findings included:<BR/>The admission record dated 03/14/23 reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Cerebrovascular Accident (stroke), Post Traumatic Stress Disorder (is a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it), Bipolar Disorder (causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression), Schizophrenia (a serious mental disorder in which people interpret reality abnormally), depression, Panic Disorder (an overreaction of fear and anxiety to daily life stressors), Obsessive-Compulsive Disorder(features a pattern of unwanted thoughts and fears (obsessions) that lead you to do repetitive behaviors (compulsions), Epilepsy (seizure), impaired cognition, Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), heart disease, Diabetes ( your body doesn't make enough insulin or can't use it as well as it should) and Hypertension (high blood pressure).<BR/>Review of Physician records for Resident #1 included orders dated 4/20/23 for .PT to treat 3 x's per week x's 30 days; OT to treat 3 x's per week x's 8 weeks. <BR/>Review of Physician records for Resident #1 included order dated 4/21/23 for ST to treat 3 x's per week x's 4 weeks.<BR/>The admission MDS indicated Resident #1 had moderately impaired cognition and required extensive assistance of 1 person for bed mobility, transfers, toileting and eating. She was described as totally dependent on 1 person for locomotion, dressing, personal hygiene, and bathing. She was described as having impairment on one side - upper extremity Range of Motion and impairment on both sides - lower extremity Range of Motion.<BR/>Review of the clinical record for Resident #1 did not indicate evaluations or treatment from PT, OT or ST.<BR/>Interview on 5/16/23 at 10:51 AM with MDS Coordinator stated she had completed Resident #1's PCSP for PASRR; needed to submit NFSS forms for Resident #1 today. The MDS Coordinator stated she had not submitted the PCSP. Stated Resident #1 was supposed to be in facility a short time and then discharge to a group home; stated family changed their mind and decided facility was best for Resident #1. Stated she submitted an alert in the Portal that a new resident needed assess. MHMR contacted MDS Coord on 3/20/23 @ 12:30pm. MDS Coordinator stated specialized therapy had not yet been approved.<BR/>Interview on 5/16/23 at 11:04 AM with Therapy Director stated she was not involved in initial PASRR evaluation; stated she participated in 2nd meeting with MDS Coord., Social Worker, RN, PASRR Representative and Resident. The Director stated Resident #1's meeting was not as clear-cut as usual PASRR meetings. The Director stated she could not remember exactly what the problems were with Resident #1. Stated Resident opts for services and then therapy evaluates and gives evaluations to the MDS nurse and then therapy department waited for approval; stated wait time was usually less than 30 days. The Director stated if forms were accepted on 1st submission, then approval given within 2 weeks. The Director stated when approved, therapy department was given a schedule of specific services and how often to provide services. The Director stated from time of 2nd meeting therapy had 21 days to complete the Resident evaluation and submit to the MDS nurse. The Director stated once approved, therapy was given a start/stop date for specific services. Director reiterated she was not involved in initial PASSR evaluation. <BR/>Interview with MHMR Habilitation Coordinator stated the nursing facility had 20 calendar from day of IDT meeting to initiate services. Stated to initiate just means the process was started to get services started and Resident #1 had not received services yet. Resident #1 IDT was 4/19/23 and facility was in compliance. <BR/>Interview on 5/16/23 at 5:09 PM with the DON stated she never reviewed PASSR or had any dealings with it; stated she never attended PASSR meetings. DONstated failure to provide specialized services would cause resident decline; stated residents entitled to additional services should get services in a timely manner. <BR/>Interview on 5/16/23 at 4:55 PM with Administrator stated she expected PASSR to be submitted per time requirements; stated a PASSR was required for each admission and if resident met criteria for additional services, she expected those services to occur within the required time frames. <BR/>Review of the facility's PASRR (Pre-admission Screening and Resident Review) dated 2001 (Revised February 2018) revealed the following:<BR/>The purpose of this procedure is to ensure any resident with a PASSR need is identified.<BR/>The PASRR, required by OBRA, is the major function of this office. Under the PASRR program, all persons seeking admission to a nursing facility who are seriously mentally ill and/or have an intellectual/developmental disability are required to be evaluated to determine whether the nursing facility is the most appropriate place for them to receive services and whether they require specialized behavioral/mental health services. In addition, persons residing in a nursing facility who are seriously mentally ill and/or have an intellectual / developmental disability are required to undergo a similar review annually or when there is a significant change in condition to determine whether they continue to require the services of a nursing facility or whether they require specialized mental health services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of five residents reviewed for pressure ulcers.<BR/>1. <BR/>The facility failed to ensure Resident #1 received all physician ordered wound care 10 out of 31 days in December 2024. <BR/>2. <BR/>The facility failed to ensure Resident #1 received all physician ordered wound care 5 out of 30 days in January 2025. <BR/>This facility failure could place residents at risk of developing infections or worsening of their wounds.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 01/30/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included paraplegia (a condition that causes paralysis or loss of muscle function in the lower half of the body, including both legs), pressure ulcer of sacral region-stage 4, pressure ulcer of right heel-stage 3, pressure ulcer of left heel-stage 3, non-pressure chronic ulcer of back, neuromuscular dysfunction of bladder (impaired bladder control due to disrupted communication between the brain and the bladder muscles), colostomy status(a surgical procedure that creates an opening in the abdomen through which waste from the large intestine can be expelled into a bag) and chronic pain syndrome (a condition characterized by persistent pain that lasts for at least three to six months). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 13, which indicated intact cognition. Resident #1 had no rejection of care issues and no verbal or physical behaviors. Resident #1 had range of motion impairment on both sides of his lower body and was dependent on staff for transfers, bed mobility and ADLs that included dressing, showering, personal hygiene and incontinent care. Resident #1 had an indwelling catheter and an ostomy appliance. Resident #1's assessment reflected he was at risk of developing pressure ulcers/injuries and had four unhealed pressure ulcers and one unstageable deep tissue injury that were present upon admission to the facility. Skin and ulcer/injury treatments included pressure ulcer/injury care, application of nonsurgical dressings and applications of ointments/medications. <BR/>Record review of Resident #1's care plan dated 10/02/24 and last revised on 01/29/25 reflected the following focus areas:<BR/>-Wound Management-Skin tear to the left instep of his foot due to hitting the bedrail during a spasm episode (Initiated12/02/2024); Intervention: Wound will show signs of improvement, provide wound care per treatment order. <BR/>-Resident is at risk for pain related to wound; Site #1: Stage 4 pressure wound sacrum full thickness, wound size: 13.5 x 21.8 x 0.2cm; Site #5: Stage 4 pressure wound of left heel full thickness, wound size: 2.1 x 1.5 x 0.1cm; Site #6: Stage 4 pressure wound of right lateral foot full thickness, wound size: 1.1 x 0.7 x Non measurable cm; Site #12: Non-pressure wound of the left buttock full thickness, wound size: Resolved- 01/22/25. Interventions included to provide wound treatment per MD order, Site #1: Stage 4 pressure wound sacrum full thickness: clean surrounding skin with skin prep, clean wound with NS or wound cleanser, pat dry, apply collagen powder and calcium alginate to wound bed, island dressing or ABD pad and paper tape daily. Site #5- skin prep surround skin, clean wound with NS, pat dry, apply Xeroform to wound, apply island border dressing daily. Site #6- Skin prep three times a week.<BR/>Record review of Resident #1's care plan also reflected a revision on 01/02/25 reflected he was resistent to wound care and skin assessments. The intervention reflected, Give one on one care as needed.<BR/>Record review of Resident #1's physician's order summary for December 2024 and January 2025 reflected the following treatments were ordered:<BR/>1) Cleansed open area on top of left foot, apply triple antibiotic ointment, cover with dry gauze dressing one time a day for open wound on top of left foot (start date 11/30/24, discontinued 01/02/25)<BR/>2) Non-pressure wound right medial heel, skin prep three times per week on Monday, Wednesday and Friday for preventative measure (start date 01/03/25, discontinued 01/15/25)<BR/>3) Non-pressure wound to left lateral ankle - apply skin prep daily (start date 01/02/25, discontinued 01/15/25)<BR/>4) Non-pressure wound left 2nd toe apply skin prep three times per week every day shift every Mon, Wed, Friday for Preventative Measure (start date 01/03/2025, discontinued 01/15/25)<BR/>5) Non-pressure wound of the left 2nd toe partial thickness, once a day every Monday, Wednesday and Friday for 23 days, Apply skin prep; Off-load wound; Pressure off-loading boot (start 12/05/24, discontinued 12/28/24)<BR/>6) Non-pressure wound of the left buttock full thickness, skin prep skin around wound, clean wound with NS, apply xeroform to wound bed, island border dressing or ABD pad daily x23 days. one time a day (start 01/16/25, discontinued 01/22/2025)<BR/>7) Non-pressure wound of the right toe of undetermined thickness once a day for 30 days, apply skin prep, off-load wound with pressure offloading boot (start 12/05/24, discontinued 01/02/25)<BR/>8) Non-pressure wound of the right medial heel partial thickness once a day on Monday, Wednesday and Friday for 16 days, apply skin prep, offload wound with offloading boot (start 12/05/25, discontinued 12/21/24)<BR/>9) Non-pressure wound to left superior lateral ankle-apply skin prep daily for preventative measure (start 01/03/25, discontinued 01/15/25) <BR/>10) Right Lateral Foot: cleanse with NS, pat dry. Apply [NAME] and leave open to air Tuesdays/Thursdays. every day shift for Wound Treatment (start 01/05/25, discontinued 01/15/25)<BR/>11) Stage 4 pressure wound of right lateral foot full thickness: skin prep three times a week x16 days once a day on Monday, Wednesday and Friday (start date 01/17/25 to present)<BR/>12) Stage 4 pressure wound of the left heel full thickness once a day for 30 days apply skin prep, use Xeroform gauze to wound bed and cover with island bordered dressing (start date 12/05/24 through present)<BR/>13) Stage 4 pressure wound of the left heel full thickness: clean with NS, pat dry apply xeroform to wound bed and island border dressing daily x16 days once a day (start date 01/16/25, discontinued 01/29/25). <BR/>14) Stage 4 pressure wound of the left heel full thickness, skin prep surround skin of wound, clean with NS, pat dry apply xeroform to wound bed and island border dressing daily for 30 days once a day (start 01/30/25)<BR/>15) Stage 4 pressure wound of the right lateral foot thickness once a day on Monday, Wednesday, Friday for 30 days (start date 12/05/24, discontinued 01/04/25).<BR/>16) Stage 4 pressure wound sacrum full thickness-apply xeroform gauze to wound bed and cover with ABD pads, use tape/island bordered gauze for retention every day (start 12/31/24, discontinued 01/02/25)<BR/>17) Stage 4 pressure wound sacrum full thickness, once a day on Monday, Wednesday, Friday for 30 days, apply xeroform gauze to wound bed and cover with ABD pads, use tape/island bordered gauze for retention (start date 12/04/24, discontinued 12/20/24)<BR/>18) Stage 4 pressure wound sacrum full thickness, skin prep around wound, clean with NS, Pat dry, apply collagen powder and calcium alginate to wound bed, island dressing or ABD pad and paper tap daily, and as needed. Monitor for s/s of infection once a day (start date 01/16/25 through present)<BR/>19) Stage 4 pressure wound sacrum full thickness, one time a day every Monday, Wednesday, Friday for 30 days apply xeroform guaze to wound bed and cover with ABD pads, use tape/island border gauze for retention (start date 12/05/24, discontinued 12/30/24)<BR/>20) Stage 4 pressure wound sacrum full thickness, apply peri-wound skin prep, aliginate calcium gauze to wound bed and cover with ABD pads, use tape/island border gauze for retention as needed (start date 01/02/25, discontine 01/15/25)<BR/>Record review of Resident #1's December 2024 TAR reflected he did not receive wound care to his sacrum and heel as ordered by his physician on 12/03/24, 12/05/24, 12/12/24, 12/16/24, 12/19/24, 12/20/24, 12/23/24, 12/24/24, 12/25/24 and 12/27/24.<BR/>Record review of Resident #1's January 2025 TAR reflected he did not receive wound care to his sacrum and heel as ordered by his physician on 01/06/25, 01/09/25, 01/14/25, 01/21/25 and 01/29/25.<BR/>Record review of Resident #1's nursing progress notes reflected no entries on the dates of the missed wound care in December 2024 and January 2025 to explain why it was not provided. <BR/>Record review of Resident #1's Wound Evaluation and Management Summaries dated 12/11/24 and 01/29/25 reflected in each visit under the Expanded Evaluation Performed that Resident #1 was a current smoker which was known to affect wound healing and healing progression. Continued interventions for wound healing ordered and implemented included a multivitamin once a day, vitamin C twice a day, low air loss mattress, off-loading wound, repositioning per facility protocol and offloading chair cushion. The following measurements were reflected for his current wounds:<BR/>1) 11/06/24- Stage 4 pressure wound to sacrum over 675 days: The measurements were 20.3 x 14.5 x 0.2 cm with a surface area: 294.35 cm, Cluster Wound open ulceration area of 88.31 cm, Sharp selective debridement procedure was used to remove biofilm over the wound surface area of 88.305 cm, Wound progress: At Goal. (Note: A cluster wound is a grouping of multiple wounds that are close to one another and documenting them as a single wound 'clustered wound' could simplify assessment, when appropriate.)<BR/>-12/11/24- Stage 4 pressure wound to sacrum over 710 days: The measurements were 16x 6x 0.2cm with a surface area of 96 cm with noted improvement, Cluster Wound open ulceration of 19.2 cm, Wound progress: Improved-evidenced by decreased surface area. A sharp selective debridement procedure was used to remove biofilm over the wound surface area of 19.2 cm. Goal of treatment is healing as evidenced by a 61.5 % decrease in surface area within the wound bed in comparison to the last wound visit. <BR/>-01/01/25-Stage 4 pressure wound to sacrum over 731 days: The measurements were 16.5 x22.5 x 0.2 cm with a surface area of 371.25 cm&sup2; and a Cluster Wound open ulceration area of 111.38 cm, Wound progress: Exacerbated due to multifactorial. A surgical excisional debridement procedure was used to surgically excise 37.12 cm of devitalized tissue and necrotic muscle tissue along with slough and biofilm were removed at a depth of 0.3cm and healthy bleeding tissue was observed. As a result of the procedure, the nonviable tissue in the wound bed decreased form 20 percent to 10 percent. Hemostasis was achieved and a clean dressing was applied. <BR/>-01/15/25- Stage 4 pressure wound to sacrum over 745 days: The measurements were 13.4 x22.5 x 0.2 cm with a surface area: of 301.50 cm&sup2; and a Cluster Wound open ulceration area of 90.45 cm, Wound progress: Improved evidence by decreased surface area. A surgical excisional debridement procedure was used to surgically excise 30.15 cm of devitalized tissue including slough, biofilm and non-viable muscle tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of the procedure, the nonviable tissue in the wound bed decreased form 10 percent to 0 percent. Hemostasis was achieved and a clean dressing was applied.<BR/>-01/29/25-Stage 4 pressure wound to sacrum over over 758 days: The measurements were 13.5 x21.9 x0.2cm with a surface area of 294.30 cm with the wound progress noted to be at goal. <BR/>2) Stage 4 pressure wound to the left heel: On 12/11/24, the measurements were 3.5x 3.5x 0.1 cm with a surface area of 12.25 and was not at goal. On 01/29/25, the measurements were 2.1x 5.0x 0.1 cm with a surface area of 3.15cm and was not at goal. <BR/>3) Stage 4 pressure wound of the right lateral foot: On 12/11/24, the measurements were 1.1x 0.5x not measurable cm with a surface area of .55 cm. On 01/29/25, the measurements were 1.1x 0.7x not measurable cm with a with a surface area of .77 cm with noted wound improvement. <BR/>An interview with Resident #1 on 01/30/25 at 1:07 PM revealed he had a very large wound that he admitted to the facility with on his bottom and it had almost gotten healed up by the previous ADON, but when he left employment at the end of November 2024, Resident #1's wounds got worse. Resident #1 said the floor nurses were providing the wound care during December 2024 because there was no wound care nurse designated for the facility. He said the floor nurse would tell him they would get to the wound care, but no one was coming into his room to do it consistently. Resident #1 said he told the ADM, who ended up getting a nurse to start coming in [ADON A] to do the wound care, but he was not sure when she started. Resident #1 stated since ADON A started working on his wounds during the weekdays they had gotten better. However, when ADON A was not at the facility, the floor nurses doing the wound care were not always knowledgeable on the required supplies, technique and application of dressings. Resident #1 stated there had never been a consistent wound care nurse until recently and there had been numerous times when ADON A was not working that his wound care did not get provided. Resident #1 felt that the lack of wound care being done consistently in December 2024 set him back two months on his healing. <BR/>An interview with Resident #1's RP on 01/31/25 at 10:11 AM revealed she had been having concerns about his wound care not being done as well as the nurses not coming to check on him. The RP stated she had seen Resident #1's wounds via photos and they had almost healed around Thanksgiving 2024, but within a few weeks after that, the one on his bottom started going downhill and getting bad. The RP stated Resident #1 could not feel his feet and the wounds on them were chronic and always recurring. As a result, they were not as much of an issue as the one on his bottom. The RP stated, But the bottom wound, they weren't doing right. The RP stated she had tried to get in touch the DON with no success as well as the ADON. <BR/>Record review of a grievance form for Resident #1 dated 12/30/24 reflected a concern that Resident #1 was not getting his wound care done daily. The grievance resolution reflected the DON educated the Resident #1 that his wound care was not done daily and a documented he was told a majority of his wound care was done on Mondays, Wednesdays and Fridays and that the resident should speak with the doctor regarding any order changes. The grievance also reflected Resident #1 then stated, Well they are not doing it on Mondays, Wednesdays and Fridays either and showed me [DON] pictures of his wounds and said they are getting worse. I asked if I could do a full head to toe assessment and the resident refused.<BR/>An interview with the ADM on 01/30/25 at 9:30 AM revealed the DON was out sick on leave. <BR/>An interview with the SW on 01/30/25 at 2:45 PM revealed Resident #1 did make a complaint about his wounds and said he was going to contact the State [HHSC] because he was not getting wound care every day. The SW said, however, the doctor did not order wound care every day and Resident #1 wanted to know why. The SW stated, I think the nurse talked to him and helped him understand that we are only following doctor's orders .He gets worked up sometimes. <BR/>An interview with the wound care nurse, ADON A on 01/31/25 at 11:23 AM revealed she started as the wound care nurse on 01/08/25 and prior to that she was a PRN floor nurse at the facility. ADON A said any wounds from 01/08/25 to present were wounds she had done wound care for, unless she was working on the floor. ADON A stated that she could not speak for anyone else, but if there were blanks on the TAR during January 2025 when she was doing wound care, it may have been due to updating orders in the system, but she was not sure. ADON A stated she was at the facility during the weekdays and the only time she delegated wound care to the charge nurses was if she was working on the floor She stated, Sometimes I try to do wounds before the floor shift starts; sometimes I don't and will delegate to the nurses who are capable of doing treatments. ADON A stated the weekend charge nurses were responsible for doing wound care on the weekends. Regarding Resident #1, ADON A stated he had told her the nurses were not doing the wound care correctly but she did not know what he meant. She said Resident #1's wound drained a lot and she taped them up very well and they did not come undone, so she thinks when other nurses did it, Resident #1 may feel that the bandages were falling off. ADON A stated residents' wounds in the facility were tracked by herself. She said she would know if wound care was not getting done because of how the bandages were dated when came in for her next shift.<BR/>An interview with the ADM on 01/31/25 at 1:54 PM revealed ADON A was in charge of monitoring wound care and sometimes the DON did weekly random audits of wounds. <BR/>Record review of the facility's policy titled Wound Care revised October 2010 reflected, Purpose: The purpose of this procedure is to provider guidelines for the care of wounds to promote healing .Steps in the Procedure .12. Apply treatments as indicated, 13. Dress wound .Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given, 2. The date and time the wound care was given .4. The name of the individual performing the wound care, 5. Any change in the resident's condition .10. The signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 help prevent the development and transmission of infection for 5 (Residents #2, #3, #4, #5, and #6) of 12 residents reviewed for infection control. <BR/>1. <BR/>On 04/30/24 MA A, CNA B, and CNA C brought Residents #2, #3, #4, #5, and #6 to the locked unit dining room and fed them and did not wash their hands nor the hands of the residents.<BR/>2. <BR/>On 04/30/24 CNA B assisted Residents #2, #3, and #4 with their noon meals, he cut up their food and fed them and did not sanitize his hands.<BR/>3. <BR/>On 04/30/24 CNA C touched the hand of Resident #5 and assisted him to his seat then touched his eating utensil without sanitizing her hands.<BR/>4. <BR/>On 04/30/24 during the noon meal on the locked unit a visitor brought cookies to the residents, this visitor used her ungloved hands and gave each resident present (#2, #3, #4, #5, #6) a cookie without sanitizing her hands.<BR/>This deficient practice placed residents who received assistance with meals in the Locked Unit Dining Room at risk for cross contamination and infections.<BR/>Findings included:<BR/>Review of Resident #2's Care Plan dated 07/12/23, revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with an intervention of limited assistance by staff to eat. Diagnoses included Dementia (a group of thinking and social symptom that interferes with daily functioning), and bipolar disorder (associated with episodes of mood swings ranging from depressive lows to manic highs). <BR/>Review of the most recent quarterly MDS assessment dated [DATE], revealed Resident #2, had a BIMS score of 3 (cognition was severely impaired). Resident #2's eating assessment reflected she required partial/moderate assistance-Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.<BR/>Review of Resident #3's Care Plan dated 01/24/24, revealed Resident #3 was an [AGE] year-old male admitted to the facility on [DATE] with an intervention of set up assistance by staff to eat. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #3's quarterly MDS assessment reflected he had a BIMS score of 00 (cognition was severely impaired). Resident #3's eating assessment reflected he required setup or clean-up assistance-Helper sets up or cleans up; resident completes activity.<BR/>Review of Resident #4's Care Plan dated 11/07/23, revealed Resident #4 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #4's quarterly MDS assessment reflected no BIMS score noted. Resident #4's eating assessment reflected she required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>Review of Resident #5's Care Plan dated 02/06/24, revealed Resident #5 was an [AGE] year-old female admitted to the facility on [DATE] with an intervention that the resident is independent for eating. Diagnoses included Dementia (a group of thinking and social symptom that interferes with daily functioning).<BR/> Review of Resident #5's quarterly MDS assessment reflected a BIMS score was not completed. Resident #5's eating assessment reflected she required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>Review of Resident #6's Care Plan dated 04/14/23, revealed Resident #6 was an [AGE] year-old male admitted to the facility on [DATE] with an intervention of limited assistance by staff to eat. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #6's change in condition MDS assessment reflected a BIMS score was not completed. Resident #6's eating assessment was not completed.<BR/>Observation on 04/30/24 at 12:45 PM revealed MA A walked into the dining room on the locked unit, and she assisted Resident #2 to a table and helped her to sit. MA A took the lid off the plate of Resident #2 then she touched her eating utensil and fed Resident #2. MA A did not sanitize her hands or the hands of Resident #2.<BR/>During an observation on 04/30/24 at 12:46 PM, CNA B took the eating utensil of Resident #3 and cut up his food. Then he went to Resident #4 and used her eating utensil to cut up her food. CNA B then moved to Resident #5, picked up her eating utensil and fed her. He did not sanitize his hands before he moved to and from each resident to assist. He did not sanitize the hands of the resident before assisting them to eat.<BR/>During an observation on 04/30/24 at 12:48 PM, Resident #6 got up from the table. CNA B went outside the door of the dining area to follow Resident #6 out of the dining room. CNA B touched Resident #6 on his arm to redirect him back to the dining table, then CNA B returned to Resident #5 and fed her again. He did not sanitize his hands after he touched or fed a resident. <BR/>Observation on 04/30/24 at 12:49 PM revealed CNA B left Resident #5 and went to assist Resident #4 back to her table to eat by touching her arm. Then he returned to Resident #5 without sanitizing his hands. <BR/>Observation on 04/30/24 at 12:50 PM revealed CNA C assisted Resident #6 back to his table when she took his hand and helped him sit down. Then she picked up his eating utensil from his plate and assisted him to eat. She did not sanitize her hands or the hands of the resident.<BR/>Observation on 04/30/24 at 12:51 PM revealed CNA B moved from Resident #5 and took the eating utensil for Resident #3 and put it back in his hand and encouraged him to eat. He did not sanitize his hands. <BR/>Observation on 04/30/24 at 12:55 PM revealed a visitor entered the dining area on the locked unit with a container of cookies. The visitor handed out cookies to Residents #2, #3, #4, #5, and #6. The visitor did not sanitize her hands before she gave the residents cookies. The visitor did not put on gloves prior to passing out the cookies to the residents.<BR/>In an interview on 04/30/24 at 1:09 PM with CNA B revealed he did not have any hand sanitizer on his person in the dining area and there was not any in the dining area at lunch. He stated there was some hand sanitizer in the nursing station which was located down the hall. He stated he had been trained on infection control. He stated he was not supposed to move from one table to another table or one resident to another resident and touch them without sanitizing his hands. He stated the residents should not have been given cookies by the visitor. He stated the risk to the residents was the transmission of germs that could cause infection.<BR/>In an interview on 04/30/24 at 1:21 PM with CNA C revealed she did not have any hand sanitizer on her person when she was in the dining area at lunch. She stated they do not keep the sanitizer out in the dining room because of the residents' attempts to get the sanitizer. She stated there is hand sanitizer in the closet in the nurses' station. She stated the visitor should have asked if they could give the residents cookies. She stated the risk to the residents was the spread of germs and infection when the staff did not sanitize their hands when working with several residents.<BR/>In an interview on 04/30/24 at 1:40 PM with LVN revealed she was the supervisor of the staff working in the locked unit. She stated during lunch she mostly worked on another hall. She stated the hand sanitizer was available in the nurse room, but the door has been taken down and they must keep all the sanitizer put up out of reach of the residents. She stated all the staff should have known the hand sanitizer was in the closet in the nurse room. She stated she did not remember the last infection control training they took. She stated the visitor should not have handed out cookies to the residents without sanitizing hands. She stated the risk to residents was infection, passing germs, and viruses because staff had not sanitized their hands during the lunch meal.<BR/>In an interview on 04/30/24 at 2:15 PM with MA A revealed she did not have hand sanitizer in her pocket. She stated hand sanitizer was in the nurses' room down the hall. She stated she had washed her hands before she went into the dining area. She stated staff should have sanitized their hands when they worked with several residents during the lunch meal. She stated the resident was at risk of infection when the staff did not sanitize between residents. <BR/>In an interview on 04/30/24 at 4:35 PM with the Administrator revealed the DON and herself was responsible to ensure staff was trained on IC. She stated the DON completed monthly in-services on IC. She stated the DON was currently in the hospital and not available for interview. She stated the staff had put the residents at potential risk of infection and illness when they did not sanitize their hands. She stated the staff should have told the residents to wash their hands before the meal. She stated there was hand hygiene supplies available throughout the building and if there was not any in the dining area, the staff could have asked her or the housekeeper. <BR/>Record review of facility's Policies and Practices -Infection Control revised August 2010 reflected, All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

**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, recognizing each resident's individuality for one (Resident #124) of seventeen residents reviewed for resident rights.<BR/>The facility failed to ensure the shower chair used to transport Resident #124 from the shower room to is room was clean and free of feces. <BR/>This failure could cause the resident embarrassment and place him at risk for poor personal hygiene and a decline in quality of life. <BR/>Findings included:<BR/>Record review of Resident #124's face sheet dated 09/01/2023, reflected an [AGE] year-old male admitted on [DATE]. His diagnoses included Parkinson's Disease (A brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination, Syncope and collapse (Medical term for fainting or passing out), hearing loss, chronic kidney disease (Kidneys are damaged and cannot filter blood as well as they should), and unspecified arterial fabulation (The heart's upper chambers beat chaotically and irregularly). <BR/>Record review of Resident #124's admission MDS assessment, dated 08/31/2023, reflected a Brief Interview for Mental Status (BIMS) of 10, which indicated moderate impaired cognition. Futher review reflected he required extensive assist for bedmobility, transfers, locomotion on the unit, personal hygiene, and was totally dependent on staff for bathing. <BR/>Record review of Resident #124's Care Plan, dated 08/29/2023, reflected the resident had limited physical mobility, and ADL self-performance deficit, communication problem, fall risk, bowel incontinence, a urinary catheter, and required tube feeding. <BR/>An observation and interview on 08/30/2023 at 9:13 AM, with the CEO, at the doorway of Resident #124's room revealed CNA F transporting Resident #124, from the shower room through 100 Hall, to Resident #124's room, in a shower chair. Feces was observed on the front left leg of the shower chair and smeared in the hall outside the shower room and outside Resident #124's room, where the surveyor and CEO were standing. CNA F proceeded to take Resident #124 into the room and closed the door. The CEO said he saw the feces in the hall and on the shower chair as CAN F passed by with Resident #124 on their way to the room. When asked about the observation, the CEO stated he would address it. MA E was standing at her medication cart across the hall. <BR/>In an interview on 08/30/2023 at 9:25 AM, MA E said she saw the feces smear in the hall when CNA F brought Resident #124 to his room. She said she cleaned it up and then went into Resident 124's room to tell CNA F about the feces in the hall. She said it was an infection control issue as well as a dignity concern for Resident #124. <BR/>In an interview on 08/30/2023 at 9:31 AM, CNA F, stated he had not noticed the feces on the shower chair and did not notice that it was smearing down the hall when he took Resident #124 to his room. He said MA E told him about it and told him she had cleaned it up a few minutes ago. He said he should have made sure the shower chair was clean before leaving the shower room to prevent any infection control concerns. He said Resident #124 would be embarrassed if he knew what had happened. <BR/>In an interview on 08/30/2023 at 9:44 AM, Resident #124 said he had not realized there was feces on the shower chair. He said it was embarrassing and CNA F should have checked the chair before taking him to his room. <BR/>In an interview on 08/31/2023 at 2:47 PM, the Administrator said CNA F should have checked the shower chair prior to leaving the shower room with Resident #124 to ensure it was clean. She said smeared feces in the hall was definitely an infection control concern and could be a dignity issue as well. <BR/>In an interview on 08/31/2023 at 11:58 AM, the DON stated CNA F should have made sure the shower chair was clean for transporting Resident #124 through the hall. She said feces on the chair and smeared in the hall was an infection control concern as well as a dignity concern for the resident. She said the CNAs were expected to ensure equipment was clean and all nursing staff were responsible to monitor this. <BR/>Record review of the facility's in-service records reflected, and undated in-service titled Disinfection of Equipment.<BR/>Record review of the facility's policy titled, Quality of Life - Dignity, revised August 2009, reflected, : Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Treated with dignity means, the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of five residents reviewed for pressure ulcers.<BR/>1. <BR/>The facility failed to ensure Resident #1 received all physician ordered wound care 10 out of 31 days in December 2024. <BR/>2. <BR/>The facility failed to ensure Resident #1 received all physician ordered wound care 5 out of 30 days in January 2025. <BR/>This facility failure could place residents at risk of developing infections or worsening of their wounds.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 01/30/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included paraplegia (a condition that causes paralysis or loss of muscle function in the lower half of the body, including both legs), pressure ulcer of sacral region-stage 4, pressure ulcer of right heel-stage 3, pressure ulcer of left heel-stage 3, non-pressure chronic ulcer of back, neuromuscular dysfunction of bladder (impaired bladder control due to disrupted communication between the brain and the bladder muscles), colostomy status(a surgical procedure that creates an opening in the abdomen through which waste from the large intestine can be expelled into a bag) and chronic pain syndrome (a condition characterized by persistent pain that lasts for at least three to six months). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 13, which indicated intact cognition. Resident #1 had no rejection of care issues and no verbal or physical behaviors. Resident #1 had range of motion impairment on both sides of his lower body and was dependent on staff for transfers, bed mobility and ADLs that included dressing, showering, personal hygiene and incontinent care. Resident #1 had an indwelling catheter and an ostomy appliance. Resident #1's assessment reflected he was at risk of developing pressure ulcers/injuries and had four unhealed pressure ulcers and one unstageable deep tissue injury that were present upon admission to the facility. Skin and ulcer/injury treatments included pressure ulcer/injury care, application of nonsurgical dressings and applications of ointments/medications. <BR/>Record review of Resident #1's care plan dated 10/02/24 and last revised on 01/29/25 reflected the following focus areas:<BR/>-Wound Management-Skin tear to the left instep of his foot due to hitting the bedrail during a spasm episode (Initiated12/02/2024); Intervention: Wound will show signs of improvement, provide wound care per treatment order. <BR/>-Resident is at risk for pain related to wound; Site #1: Stage 4 pressure wound sacrum full thickness, wound size: 13.5 x 21.8 x 0.2cm; Site #5: Stage 4 pressure wound of left heel full thickness, wound size: 2.1 x 1.5 x 0.1cm; Site #6: Stage 4 pressure wound of right lateral foot full thickness, wound size: 1.1 x 0.7 x Non measurable cm; Site #12: Non-pressure wound of the left buttock full thickness, wound size: Resolved- 01/22/25. Interventions included to provide wound treatment per MD order, Site #1: Stage 4 pressure wound sacrum full thickness: clean surrounding skin with skin prep, clean wound with NS or wound cleanser, pat dry, apply collagen powder and calcium alginate to wound bed, island dressing or ABD pad and paper tape daily. Site #5- skin prep surround skin, clean wound with NS, pat dry, apply Xeroform to wound, apply island border dressing daily. Site #6- Skin prep three times a week.<BR/>Record review of Resident #1's care plan also reflected a revision on 01/02/25 reflected he was resistent to wound care and skin assessments. The intervention reflected, Give one on one care as needed.<BR/>Record review of Resident #1's physician's order summary for December 2024 and January 2025 reflected the following treatments were ordered:<BR/>1) Cleansed open area on top of left foot, apply triple antibiotic ointment, cover with dry gauze dressing one time a day for open wound on top of left foot (start date 11/30/24, discontinued 01/02/25)<BR/>2) Non-pressure wound right medial heel, skin prep three times per week on Monday, Wednesday and Friday for preventative measure (start date 01/03/25, discontinued 01/15/25)<BR/>3) Non-pressure wound to left lateral ankle - apply skin prep daily (start date 01/02/25, discontinued 01/15/25)<BR/>4) Non-pressure wound left 2nd toe apply skin prep three times per week every day shift every Mon, Wed, Friday for Preventative Measure (start date 01/03/2025, discontinued 01/15/25)<BR/>5) Non-pressure wound of the left 2nd toe partial thickness, once a day every Monday, Wednesday and Friday for 23 days, Apply skin prep; Off-load wound; Pressure off-loading boot (start 12/05/24, discontinued 12/28/24)<BR/>6) Non-pressure wound of the left buttock full thickness, skin prep skin around wound, clean wound with NS, apply xeroform to wound bed, island border dressing or ABD pad daily x23 days. one time a day (start 01/16/25, discontinued 01/22/2025)<BR/>7) Non-pressure wound of the right toe of undetermined thickness once a day for 30 days, apply skin prep, off-load wound with pressure offloading boot (start 12/05/24, discontinued 01/02/25)<BR/>8) Non-pressure wound of the right medial heel partial thickness once a day on Monday, Wednesday and Friday for 16 days, apply skin prep, offload wound with offloading boot (start 12/05/25, discontinued 12/21/24)<BR/>9) Non-pressure wound to left superior lateral ankle-apply skin prep daily for preventative measure (start 01/03/25, discontinued 01/15/25) <BR/>10) Right Lateral Foot: cleanse with NS, pat dry. Apply [NAME] and leave open to air Tuesdays/Thursdays. every day shift for Wound Treatment (start 01/05/25, discontinued 01/15/25)<BR/>11) Stage 4 pressure wound of right lateral foot full thickness: skin prep three times a week x16 days once a day on Monday, Wednesday and Friday (start date 01/17/25 to present)<BR/>12) Stage 4 pressure wound of the left heel full thickness once a day for 30 days apply skin prep, use Xeroform gauze to wound bed and cover with island bordered dressing (start date 12/05/24 through present)<BR/>13) Stage 4 pressure wound of the left heel full thickness: clean with NS, pat dry apply xeroform to wound bed and island border dressing daily x16 days once a day (start date 01/16/25, discontinued 01/29/25). <BR/>14) Stage 4 pressure wound of the left heel full thickness, skin prep surround skin of wound, clean with NS, pat dry apply xeroform to wound bed and island border dressing daily for 30 days once a day (start 01/30/25)<BR/>15) Stage 4 pressure wound of the right lateral foot thickness once a day on Monday, Wednesday, Friday for 30 days (start date 12/05/24, discontinued 01/04/25).<BR/>16) Stage 4 pressure wound sacrum full thickness-apply xeroform gauze to wound bed and cover with ABD pads, use tape/island bordered gauze for retention every day (start 12/31/24, discontinued 01/02/25)<BR/>17) Stage 4 pressure wound sacrum full thickness, once a day on Monday, Wednesday, Friday for 30 days, apply xeroform gauze to wound bed and cover with ABD pads, use tape/island bordered gauze for retention (start date 12/04/24, discontinued 12/20/24)<BR/>18) Stage 4 pressure wound sacrum full thickness, skin prep around wound, clean with NS, Pat dry, apply collagen powder and calcium alginate to wound bed, island dressing or ABD pad and paper tap daily, and as needed. Monitor for s/s of infection once a day (start date 01/16/25 through present)<BR/>19) Stage 4 pressure wound sacrum full thickness, one time a day every Monday, Wednesday, Friday for 30 days apply xeroform guaze to wound bed and cover with ABD pads, use tape/island border gauze for retention (start date 12/05/24, discontinued 12/30/24)<BR/>20) Stage 4 pressure wound sacrum full thickness, apply peri-wound skin prep, aliginate calcium gauze to wound bed and cover with ABD pads, use tape/island border gauze for retention as needed (start date 01/02/25, discontine 01/15/25)<BR/>Record review of Resident #1's December 2024 TAR reflected he did not receive wound care to his sacrum and heel as ordered by his physician on 12/03/24, 12/05/24, 12/12/24, 12/16/24, 12/19/24, 12/20/24, 12/23/24, 12/24/24, 12/25/24 and 12/27/24.<BR/>Record review of Resident #1's January 2025 TAR reflected he did not receive wound care to his sacrum and heel as ordered by his physician on 01/06/25, 01/09/25, 01/14/25, 01/21/25 and 01/29/25.<BR/>Record review of Resident #1's nursing progress notes reflected no entries on the dates of the missed wound care in December 2024 and January 2025 to explain why it was not provided. <BR/>Record review of Resident #1's Wound Evaluation and Management Summaries dated 12/11/24 and 01/29/25 reflected in each visit under the Expanded Evaluation Performed that Resident #1 was a current smoker which was known to affect wound healing and healing progression. Continued interventions for wound healing ordered and implemented included a multivitamin once a day, vitamin C twice a day, low air loss mattress, off-loading wound, repositioning per facility protocol and offloading chair cushion. The following measurements were reflected for his current wounds:<BR/>1) 11/06/24- Stage 4 pressure wound to sacrum over 675 days: The measurements were 20.3 x 14.5 x 0.2 cm with a surface area: 294.35 cm, Cluster Wound open ulceration area of 88.31 cm, Sharp selective debridement procedure was used to remove biofilm over the wound surface area of 88.305 cm, Wound progress: At Goal. (Note: A cluster wound is a grouping of multiple wounds that are close to one another and documenting them as a single wound 'clustered wound' could simplify assessment, when appropriate.)<BR/>-12/11/24- Stage 4 pressure wound to sacrum over 710 days: The measurements were 16x 6x 0.2cm with a surface area of 96 cm with noted improvement, Cluster Wound open ulceration of 19.2 cm, Wound progress: Improved-evidenced by decreased surface area. A sharp selective debridement procedure was used to remove biofilm over the wound surface area of 19.2 cm. Goal of treatment is healing as evidenced by a 61.5 % decrease in surface area within the wound bed in comparison to the last wound visit. <BR/>-01/01/25-Stage 4 pressure wound to sacrum over 731 days: The measurements were 16.5 x22.5 x 0.2 cm with a surface area of 371.25 cm&sup2; and a Cluster Wound open ulceration area of 111.38 cm, Wound progress: Exacerbated due to multifactorial. A surgical excisional debridement procedure was used to surgically excise 37.12 cm of devitalized tissue and necrotic muscle tissue along with slough and biofilm were removed at a depth of 0.3cm and healthy bleeding tissue was observed. As a result of the procedure, the nonviable tissue in the wound bed decreased form 20 percent to 10 percent. Hemostasis was achieved and a clean dressing was applied. <BR/>-01/15/25- Stage 4 pressure wound to sacrum over 745 days: The measurements were 13.4 x22.5 x 0.2 cm with a surface area: of 301.50 cm&sup2; and a Cluster Wound open ulceration area of 90.45 cm, Wound progress: Improved evidence by decreased surface area. A surgical excisional debridement procedure was used to surgically excise 30.15 cm of devitalized tissue including slough, biofilm and non-viable muscle tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of the procedure, the nonviable tissue in the wound bed decreased form 10 percent to 0 percent. Hemostasis was achieved and a clean dressing was applied.<BR/>-01/29/25-Stage 4 pressure wound to sacrum over over 758 days: The measurements were 13.5 x21.9 x0.2cm with a surface area of 294.30 cm with the wound progress noted to be at goal. <BR/>2) Stage 4 pressure wound to the left heel: On 12/11/24, the measurements were 3.5x 3.5x 0.1 cm with a surface area of 12.25 and was not at goal. On 01/29/25, the measurements were 2.1x 5.0x 0.1 cm with a surface area of 3.15cm and was not at goal. <BR/>3) Stage 4 pressure wound of the right lateral foot: On 12/11/24, the measurements were 1.1x 0.5x not measurable cm with a surface area of .55 cm. On 01/29/25, the measurements were 1.1x 0.7x not measurable cm with a with a surface area of .77 cm with noted wound improvement. <BR/>An interview with Resident #1 on 01/30/25 at 1:07 PM revealed he had a very large wound that he admitted to the facility with on his bottom and it had almost gotten healed up by the previous ADON, but when he left employment at the end of November 2024, Resident #1's wounds got worse. Resident #1 said the floor nurses were providing the wound care during December 2024 because there was no wound care nurse designated for the facility. He said the floor nurse would tell him they would get to the wound care, but no one was coming into his room to do it consistently. Resident #1 said he told the ADM, who ended up getting a nurse to start coming in [ADON A] to do the wound care, but he was not sure when she started. Resident #1 stated since ADON A started working on his wounds during the weekdays they had gotten better. However, when ADON A was not at the facility, the floor nurses doing the wound care were not always knowledgeable on the required supplies, technique and application of dressings. Resident #1 stated there had never been a consistent wound care nurse until recently and there had been numerous times when ADON A was not working that his wound care did not get provided. Resident #1 felt that the lack of wound care being done consistently in December 2024 set him back two months on his healing. <BR/>An interview with Resident #1's RP on 01/31/25 at 10:11 AM revealed she had been having concerns about his wound care not being done as well as the nurses not coming to check on him. The RP stated she had seen Resident #1's wounds via photos and they had almost healed around Thanksgiving 2024, but within a few weeks after that, the one on his bottom started going downhill and getting bad. The RP stated Resident #1 could not feel his feet and the wounds on them were chronic and always recurring. As a result, they were not as much of an issue as the one on his bottom. The RP stated, But the bottom wound, they weren't doing right. The RP stated she had tried to get in touch the DON with no success as well as the ADON. <BR/>Record review of a grievance form for Resident #1 dated 12/30/24 reflected a concern that Resident #1 was not getting his wound care done daily. The grievance resolution reflected the DON educated the Resident #1 that his wound care was not done daily and a documented he was told a majority of his wound care was done on Mondays, Wednesdays and Fridays and that the resident should speak with the doctor regarding any order changes. The grievance also reflected Resident #1 then stated, Well they are not doing it on Mondays, Wednesdays and Fridays either and showed me [DON] pictures of his wounds and said they are getting worse. I asked if I could do a full head to toe assessment and the resident refused.<BR/>An interview with the ADM on 01/30/25 at 9:30 AM revealed the DON was out sick on leave. <BR/>An interview with the SW on 01/30/25 at 2:45 PM revealed Resident #1 did make a complaint about his wounds and said he was going to contact the State [HHSC] because he was not getting wound care every day. The SW said, however, the doctor did not order wound care every day and Resident #1 wanted to know why. The SW stated, I think the nurse talked to him and helped him understand that we are only following doctor's orders .He gets worked up sometimes. <BR/>An interview with the wound care nurse, ADON A on 01/31/25 at 11:23 AM revealed she started as the wound care nurse on 01/08/25 and prior to that she was a PRN floor nurse at the facility. ADON A said any wounds from 01/08/25 to present were wounds she had done wound care for, unless she was working on the floor. ADON A stated that she could not speak for anyone else, but if there were blanks on the TAR during January 2025 when she was doing wound care, it may have been due to updating orders in the system, but she was not sure. ADON A stated she was at the facility during the weekdays and the only time she delegated wound care to the charge nurses was if she was working on the floor She stated, Sometimes I try to do wounds before the floor shift starts; sometimes I don't and will delegate to the nurses who are capable of doing treatments. ADON A stated the weekend charge nurses were responsible for doing wound care on the weekends. Regarding Resident #1, ADON A stated he had told her the nurses were not doing the wound care correctly but she did not know what he meant. She said Resident #1's wound drained a lot and she taped them up very well and they did not come undone, so she thinks when other nurses did it, Resident #1 may feel that the bandages were falling off. ADON A stated residents' wounds in the facility were tracked by herself. She said she would know if wound care was not getting done because of how the bandages were dated when came in for her next shift.<BR/>An interview with the ADM on 01/31/25 at 1:54 PM revealed ADON A was in charge of monitoring wound care and sometimes the DON did weekly random audits of wounds. <BR/>Record review of the facility's policy titled Wound Care revised October 2010 reflected, Purpose: The purpose of this procedure is to provider guidelines for the care of wounds to promote healing .Steps in the Procedure .12. Apply treatments as indicated, 13. Dress wound .Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given, 2. The date and time the wound care was given .4. The name of the individual performing the wound care, 5. Any change in the resident's condition .10. The signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free of <BR/>significant medications errors for one (Resident #48) of seven residents reviewed for appropriate <BR/>administration of medications in that:<BR/>LVN M failed to ensure Resident #48's Duloxetine (Duloxetine is used to treat depression and anxiety)<BR/> was administered as physician ordered.<BR/>This failure could affect residents with G-tubes (Gastrostomy Tubes) by placing them at risk for not receiving therapeutic dosages of their medications as ordered by the physician.<BR/>Findings included:<BR/>Review of Resident #48's MDS assessment dated [DATE] reflected Resident #48 entered the facility <BR/>05/01/23 with diagnoses that included Other Neurological Conditions, Anemia, Hypertension, <BR/>Paraplegia, Malnutrition, Respiratory Failure, Gastrostomy, Colostomy and Pressure Ulcer(s). The <BR/>Resident's BIM's (Brief Interview of Mental Status) Score was 15 indicating Resident # 48 was cognitively intact.<BR/>Review of Resident #48's Physician Order dated 06/12/23 revealed Duloxetine HCl capsule Delayed <BR/>Release Sprinkle 60 mg Give 1 capsule by mouth one time a day for depression. Do Not Crush.<BR/>Observation of LVN M on 08/30/23 during routine medication pass revealed LVN M opened Duloxetine <BR/>HCl Delayed Release Capsule, placed in a small, clear bag and crushed the Duloxetine Sprinkles. LVN M was observed to carry the medication to Resident #48's bedside, open Resident's G-tube and pour <BR/>crushed Duloxetine mixed with 5 cc's of water, into the G-tube.<BR/>Observation of Resident #48 after receiving crushed medication(s) revealed no obvious signs of distress <BR/>or change in status.<BR/>Interview with LVN M on 08/30/23 at 09:15 AM stated she did not read the entire Duloxetine order and <BR/>should not have opened or crushed the medication. She stated she should have given the unopened <BR/>medication by mouth. LVN M stated she was unsure of rationale for Do Not Crush order and would ask the DON for assistance. LVN M stated <BR/>she knew the 5 Rights of Medication Administration(five rights of medication use: the right patient, <BR/>the right drug, the right time, the right dose, and the right route-all of which are generally regarded as <BR/>a standard for safe medication practices). LVN M stated giving a medication by the wrong route could <BR/>cause a resident to become ill or the medicine might not be effective.<BR/>Interview on 09/01/23 at 9:16 AM with the DON stated staff administering medications should read the <BR/>order in its entirety and follow the 5 rights of medication administration. The DON stated <BR/>opened/crushed time release capsules could affect serum blood level of drug. The DON stated opened <BR/>capsules could also impact the stomach causing nausea, vomiting and diarrhea. The DON stated she did not <BR/>know if staff had been provided any in-service on following 5 rights of medication administration. The DON <BR/>stated she and the ADON would be responsible for medication administration in-services. The DON stated <BR/>the ADON had followed some of the nurses but was unsure if the ADON was doing skill checks.<BR/>Interview on 09/01/23 at 3:44 PM with the Administrator stated her expectation was that all Physician <BR/>Orders would be followed, as written. She stated failure to follow orders could cause resident <BR/>illness/distress. <BR/>Interview on 9/10/23 at 10:05 AM with the pharmacist stated Duloxetine Capsule Delayed <BR/>Release Sprinkles was designed to cover a 24-hour period; stated crushing the medication would cause <BR/>effects of medication to occur all at once. Pharmacist stated studies were inconclusive regarding impact on system.<BR/>Review of the facility's Policy Medication Errors, undated, revealed the following:<BR/>&copy; Copyright 2022 The Compliance Store, LLC. All rights reserved. Page 1 of 2<BR/>Medication Errors<BR/>Date Implemented:<BR/>Date Reviewed/ Revised:<BR/>Reviewed/ Revised By:<BR/>Policy:<BR/>It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by <BR/>ensuring residents receive care and services safely in an environment free of significant medication <BR/>errors.<BR/>Definitions:<BR/>Medication error means the observed or identified preparation or administration of medications or <BR/>biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not <BR/>recommendations) regarding the preparation and administration of the medication or biological; or <BR/>accepted professional standards and principles which apply to professionals providing services.<BR/>Record review on 9/04/23 of http://patientsafety.pa.gov/ADVISORIES/Pages/200506_09.aspx<BR/>One of the recommendations to reduce medication errors and harm is to use the five rights: the right<BR/> patient, the right drug, the right dose, the right route, and the right time.

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to 1 of 1 treatment carts and 1 (300 Hall) of 4 Nurse Medication Carts. <BR/>1. <BR/>Nursing Staff failed to ensure the facility's only treatment cart was locked. <BR/>2. <BR/>LVN B failed to ensure the 300 Hall Nurse Medication Cart was locked and secured. <BR/>These failures could affect all residents by placing them at risk of ingestion/exposure to medications not intended for them and possible drug diversion. <BR/>Findings included:<BR/>An observation on 07/27/2023 at 9:50AM revealed an unlocked treatment cart in the lounge area near 300 Hall. One resident was observed in a wheelchair directly in front of the cart and one resident, who used a walker, was observed in the area arranging furniture and tidying up the room. A review of the contents of the cart revealed Santyl (used to help the healing of burns and skin ulcers), scissors, Nystatin Cream (a medicated cream or ointment that treats fungal or yeast infections in your skin), Zinc Oxide (used to treat and prevent diaper rash), and vitamin A and D ointment (used as a moisturizer to prevent dry skin). <BR/>In an interview with the DON on 07/27/2023 at 9:55AM, she said the treatment cart was not assigned to any one person. She said all nurses had access to the only treatment cart they used. She said the cart should be locked to prevent residents from getting into the treatment ointments kept in the cart. She said they could be potentially harmful if consumed. <BR/>In an interview on 07/27/2023 at 10:40AM with LVN A, she said the treatment cart was shared by nursing staff but should be kept locked to ensure residents could not get into treatment ointments or sharp objects that were in the cart. She said she had not used the cart today and had not noticed that it was unlocked. She said she had been in-serviced on locking medication carts but could not recall when. <BR/>An interview on 07/27/2023 at 10:40AM with LVN B revealed nursing staff were responsible to ensure their carts were secured and any expired medications were removed from the cart. She said she had not used the treatment cart today, but it should be locked to prevent residents from getting into it. <BR/>In an interview on 07/27/2023 at 2:04PM with the Administrator and DON, the Administrator stated she expected nursing staff to secure their medication carts and treatment cart at all times. She said this was necessary to ensure the safety of residents by preventing them from getting into meds not prescribed to them. <BR/>In an interview on 07/27/2023 at 3:08PM the DON said nurses were responsible to ensure thier medication carts were locked and she and the ADON were responsible for monitoring this. The DON said she would provide the last in-service training for locking medication carts and removing expired medications from carts. None were provided at the time of exit. <BR/>An observation on 07/27/2023 at 3:35PM revealed the 300 Hall nurse medication cart was unlocked. The cart's drawers were faced outward to the hall and one resident, in a wheelchair, was in front of the cart. LVN C was observed seated behind the nurse station faced to opposite direction. <BR/>In an interview on 07/27/2023 at 3:36PM, LVN C said he was responsible for the 300 Hall Nurse Medication Cart and should have locked the cart because he could not see it from behind the nurses' station. He said medication carts should always be secured to ensure residents could not consume medications not prescribed to them and limit the possibility of a drug diversion.<BR/>Review of the facility's policy titled Medication Storage Policy, revised April 2007, reflected The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services.<BR/>1) <BR/>The facility failed to ensure food items were properly labeled and dated with the product's name.<BR/>2) <BR/>The facility failed to ensure food items were properly sealed when not in use.<BR/>These failures could place residents at risk for food-borne illness and food contamination.<BR/>Findings include:<BR/>An observation on 5/21/2025 at 11:50 AM revealed in the dry food pantry one large plastic container of rice (was not labeled with the product type or dated); one opened bag of potato chips wrapped in plastic wrap (was undated and not properly stored according to the facility's policy); one opened bag of tortilla chips wrapped in plastic wrap (was undated and not properly stored according to the facility's policy).<BR/>An observation on 5/21/2025 at 12:10 PM in the large refrigerator revealed two bags of opened bread (was not labeled, dated, nor properly stored); white gravy in a plastic container covered with plastic wrap (had a large hole in the plastic wrap); chopped up meat (was not labeled with the product type or dated); one opened pack of deli meat (was not labeled with the product name or dated); one large bowl was uncovered which contained chocolate pudding (was not labeled with the product name or dated).<BR/>An observation on 5/21/2025 at 12:30 PM in the walk-in freezer revealed an opened plastic bag with four meat patties (were not labeled with the product name or dated); two opened large packs of hamburger buns (was not labeled or dated) and one large roll of ground beef (was not labeled with the product name or dated).<BR/>In an interview on 5/21/2025 at 1:25 PM, the DM stated she worked at the facility for 3 days. The DM stated all kitchen staff were responsible for labeling and dating all items. The DM stated when staff opened anything, all unused products must be placed inside of a Ziplock bag or container and labeled and dated. The DM stated all leftover cooked items, must be stored in a closed container, labeled, and dated. The DM stated the brown substance in the large bowl was chocolate pudding the worker had just made for tonight's dinner. The DM stated frozen foods should be dated upon arrival to the facility. The DM stated if the frozen boxes were emptied all removed bags of that item, must be labeled, and dated. The DM stated based on her first 3 days of observations, she needed to in-service staff regarding proper labeling and dating. The DM stated serving residents expired food or food not properly stored according to the facility's policy could cause food poisoning and make the resident ill. <BR/>In an interview on 5/21/2025 at 2:00 PM, DA A stated whenever stocked the food from the delivery truck, must date it. DA A stated any opened dry food must be placed in a container, properly labeled and dated. DA A stated any opened perishable food must be placed in a Zip Loc bag, labeled, and dated. DA A stated not following protocol could make the residents sick.<BR/>In an interview on 5/21/2025 at 3:20 PM, DA B stated the entire staff was responsible for labeling and dating opened containers and packages. DA B stated without a proper label and date, the next worker would not know when the items were placed there. DA B said the DM was in charge of overseeing the kitchen and she instructed them to label everything. DA B said failing to do so placed the residents at risk of becoming ill.<BR/>In an interview on 5/21/2025 at 3:35 PM, the ADM stated all food should be labeled, dated, and stored properly. The ADM stated the kitchen staff should know when food was made and what it was being used for at the time. The ADM stated this was important to prevent the residents from becoming ill. The ADM stated they must continue to educate staff on proper food storage and safety.<BR/>Record review of the facility's policy titled Accepting Food Deliveries, published date of 2013, reflected Food deliveries will be accepted into the facility only by the following procedure . 4. Perishable foods will be properly covered, labeled, and dated and promptly stored in the refrigerator or freezer as appropriate.<BR/>Record review of the facility's policy titled Food Storage, published date of 2013, reflected:<BR/> .4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated . <BR/>c. Food should be dated as it is placed on the shelves .<BR/>13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded.<BR/>14. Refrigerated Food Storage . f. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.<BR/>15. Frozen Foods . c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 help prevent the development and transmission of infection for 5 (Residents #2, #3, #4, #5, and #6) of 12 residents reviewed for infection control. <BR/>1. <BR/>On 04/30/24 MA A, CNA B, and CNA C brought Residents #2, #3, #4, #5, and #6 to the locked unit dining room and fed them and did not wash their hands nor the hands of the residents.<BR/>2. <BR/>On 04/30/24 CNA B assisted Residents #2, #3, and #4 with their noon meals, he cut up their food and fed them and did not sanitize his hands.<BR/>3. <BR/>On 04/30/24 CNA C touched the hand of Resident #5 and assisted him to his seat then touched his eating utensil without sanitizing her hands.<BR/>4. <BR/>On 04/30/24 during the noon meal on the locked unit a visitor brought cookies to the residents, this visitor used her ungloved hands and gave each resident present (#2, #3, #4, #5, #6) a cookie without sanitizing her hands.<BR/>This deficient practice placed residents who received assistance with meals in the Locked Unit Dining Room at risk for cross contamination and infections.<BR/>Findings included:<BR/>Review of Resident #2's Care Plan dated 07/12/23, revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with an intervention of limited assistance by staff to eat. Diagnoses included Dementia (a group of thinking and social symptom that interferes with daily functioning), and bipolar disorder (associated with episodes of mood swings ranging from depressive lows to manic highs). <BR/>Review of the most recent quarterly MDS assessment dated [DATE], revealed Resident #2, had a BIMS score of 3 (cognition was severely impaired). Resident #2's eating assessment reflected she required partial/moderate assistance-Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.<BR/>Review of Resident #3's Care Plan dated 01/24/24, revealed Resident #3 was an [AGE] year-old male admitted to the facility on [DATE] with an intervention of set up assistance by staff to eat. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #3's quarterly MDS assessment reflected he had a BIMS score of 00 (cognition was severely impaired). Resident #3's eating assessment reflected he required setup or clean-up assistance-Helper sets up or cleans up; resident completes activity.<BR/>Review of Resident #4's Care Plan dated 11/07/23, revealed Resident #4 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #4's quarterly MDS assessment reflected no BIMS score noted. Resident #4's eating assessment reflected she required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>Review of Resident #5's Care Plan dated 02/06/24, revealed Resident #5 was an [AGE] year-old female admitted to the facility on [DATE] with an intervention that the resident is independent for eating. Diagnoses included Dementia (a group of thinking and social symptom that interferes with daily functioning).<BR/> Review of Resident #5's quarterly MDS assessment reflected a BIMS score was not completed. Resident #5's eating assessment reflected she required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.<BR/>Review of Resident #6's Care Plan dated 04/14/23, revealed Resident #6 was an [AGE] year-old male admitted to the facility on [DATE] with an intervention of limited assistance by staff to eat. Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).<BR/> Review of Resident #6's change in condition MDS assessment reflected a BIMS score was not completed. Resident #6's eating assessment was not completed.<BR/>Observation on 04/30/24 at 12:45 PM revealed MA A walked into the dining room on the locked unit, and she assisted Resident #2 to a table and helped her to sit. MA A took the lid off the plate of Resident #2 then she touched her eating utensil and fed Resident #2. MA A did not sanitize her hands or the hands of Resident #2.<BR/>During an observation on 04/30/24 at 12:46 PM, CNA B took the eating utensil of Resident #3 and cut up his food. Then he went to Resident #4 and used her eating utensil to cut up her food. CNA B then moved to Resident #5, picked up her eating utensil and fed her. He did not sanitize his hands before he moved to and from each resident to assist. He did not sanitize the hands of the resident before assisting them to eat.<BR/>During an observation on 04/30/24 at 12:48 PM, Resident #6 got up from the table. CNA B went outside the door of the dining area to follow Resident #6 out of the dining room. CNA B touched Resident #6 on his arm to redirect him back to the dining table, then CNA B returned to Resident #5 and fed her again. He did not sanitize his hands after he touched or fed a resident. <BR/>Observation on 04/30/24 at 12:49 PM revealed CNA B left Resident #5 and went to assist Resident #4 back to her table to eat by touching her arm. Then he returned to Resident #5 without sanitizing his hands. <BR/>Observation on 04/30/24 at 12:50 PM revealed CNA C assisted Resident #6 back to his table when she took his hand and helped him sit down. Then she picked up his eating utensil from his plate and assisted him to eat. She did not sanitize her hands or the hands of the resident.<BR/>Observation on 04/30/24 at 12:51 PM revealed CNA B moved from Resident #5 and took the eating utensil for Resident #3 and put it back in his hand and encouraged him to eat. He did not sanitize his hands. <BR/>Observation on 04/30/24 at 12:55 PM revealed a visitor entered the dining area on the locked unit with a container of cookies. The visitor handed out cookies to Residents #2, #3, #4, #5, and #6. The visitor did not sanitize her hands before she gave the residents cookies. The visitor did not put on gloves prior to passing out the cookies to the residents.<BR/>In an interview on 04/30/24 at 1:09 PM with CNA B revealed he did not have any hand sanitizer on his person in the dining area and there was not any in the dining area at lunch. He stated there was some hand sanitizer in the nursing station which was located down the hall. He stated he had been trained on infection control. He stated he was not supposed to move from one table to another table or one resident to another resident and touch them without sanitizing his hands. He stated the residents should not have been given cookies by the visitor. He stated the risk to the residents was the transmission of germs that could cause infection.<BR/>In an interview on 04/30/24 at 1:21 PM with CNA C revealed she did not have any hand sanitizer on her person when she was in the dining area at lunch. She stated they do not keep the sanitizer out in the dining room because of the residents' attempts to get the sanitizer. She stated there is hand sanitizer in the closet in the nurses' station. She stated the visitor should have asked if they could give the residents cookies. She stated the risk to the residents was the spread of germs and infection when the staff did not sanitize their hands when working with several residents.<BR/>In an interview on 04/30/24 at 1:40 PM with LVN revealed she was the supervisor of the staff working in the locked unit. She stated during lunch she mostly worked on another hall. She stated the hand sanitizer was available in the nurse room, but the door has been taken down and they must keep all the sanitizer put up out of reach of the residents. She stated all the staff should have known the hand sanitizer was in the closet in the nurse room. She stated she did not remember the last infection control training they took. She stated the visitor should not have handed out cookies to the residents without sanitizing hands. She stated the risk to residents was infection, passing germs, and viruses because staff had not sanitized their hands during the lunch meal.<BR/>In an interview on 04/30/24 at 2:15 PM with MA A revealed she did not have hand sanitizer in her pocket. She stated hand sanitizer was in the nurses' room down the hall. She stated she had washed her hands before she went into the dining area. She stated staff should have sanitized their hands when they worked with several residents during the lunch meal. She stated the resident was at risk of infection when the staff did not sanitize between residents. <BR/>In an interview on 04/30/24 at 4:35 PM with the Administrator revealed the DON and herself was responsible to ensure staff was trained on IC. She stated the DON completed monthly in-services on IC. She stated the DON was currently in the hospital and not available for interview. She stated the staff had put the residents at potential risk of infection and illness when they did not sanitize their hands. She stated the staff should have told the residents to wash their hands before the meal. She stated there was hand hygiene supplies available throughout the building and if there was not any in the dining area, the staff could have asked her or the housekeeper. <BR/>Record review of facility's Policies and Practices -Infection Control revised August 2010 reflected, All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program, so the facility was free from pests and rodents for 2 of 2 residents (Resident #2 and Resident #3) reviewed for pest control. <BR/>The facility failed to maintain an effective pest control program to ensure the facility was free of rodents and roaches in the facility kitchen and the rooms of Resident #2 and Resident #3. <BR/>This failure could place residents at risk for an unsanitary environment in the kitchen and rooms of Residents #2 and Resident #3 and a decreased quality of life. <BR/> Findings included: <BR/>Record review of Resident #2's admission Record dated 02/27/24 reflected a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted to the facility on [DATE].<BR/>Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 13 which indicated he was cognitively intact. His diagnoses included paraplegia (inability to move the lower part of the body); peripheral vascular disease (reduced blood flow to the limbs), and Stage 4 (full thickness) pressure ulcer to right heel. He utilized a wheelchair for mobility.<BR/>Record review of Resident #3's admission Record dated 02/27/25 reflected a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted to the facility on [DATE].<BR/>Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 which indicated he was cognitively intact. His diagnoses included Type 2 Diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Hypertension (a condition in which the force of the blood against the artery walls is too high), Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Crohn's Disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract), Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), he was mobile without assistance. <BR/>Interview on 02/26/25 at 10:55 AM with Resident #3 revealed he had seen four rats run back into the wall in his bathroom when the facility was repairing the wall in his bathroom. He stated he told the maintenance director at the time. He stated he could not remember exactly when, it was a few months ago. He stated he had two cats and the cats sometimes reacted to sounds heard in the walls of his room. <BR/>During an observation and interview on 02/26/25 at 11:45 AM, Resident #2 was sitting up in his wheelchair discussing an upcoming appointment. During the conversation, a large water bug was observed crawling out from behind the resident's duffle bag situated against the wall toward the middle of the room. It turned and returned behind his bag. Resident #2 reached and moved his bag, and the bug ran out of the room. Resident #2 stated he saw them pretty often, I see those little roaches too. He stated he had complained about it a while back but no one ever did anything about it. He stated he knew nothing was done because the bugs were still there. He stated, it's pretty nasty.<BR/>Interview with pest control service provider on 02/26/25 at 11:50 AM revealed the contract with the facility had been cancelled because of slow payment. He stated the last date of service was mid December 2024. <BR/>Interview on 02/26/25 at 12:15 PM, the Dishwasher revealed she had seen a rodent in the kitchen on 02/24/25. She stated she had seen a rodent on the dish racks that are used to wash the dishes. She stated the rodent ran to the laundry room from the kitchen. She stated she had to disinfect the dishwasher prior to sending the dishes through the dishwasher because of the rodent droppings on the dishwasher. She stated told the Administrator and the previous Maintenance Director. She stated they said they would contact pest control. She stated rodents in the kitchen could cause infection or sickness to the residents and it was very unsanitary.<BR/>Observation on 02/26/25 at 12:22 PM of the dishwashing area of the kitchen revealed under crates sitting on a cart were shavings from the crate and rodent droppings. Observation of another cart holding crates revealed rodent droppings and food particles. <BR/>Interview with Kitchen Manager on 02/26/25 at 12:25 PM revealed he stated he had not seen any rodents in the kitchen. When Kitchen Manager was asked if any kitchen staff had informed him that rodents had been seen in the kitchen, he replied, that he had not seen any rodents in the kitchen. He stated the residents were at risk of sickness and disease. <BR/>Interview with Administrator on 02/26/25 at 1:30 PM revealed he had asked the previous Maintenance Director about the pest control visits to the facility because he had never seen a person from a pest control company at the building. He stated he was told the pest control staff came to treat the building at 6:00 AM. He stated he instructed the maintenance director that the pest control staff should have come to the building during the day so that he could meet with him. He stated he was not aware that the contract had been terminated. He stated he was the person responsible to ensure there was a pest control contract in place. He stated the residents had been at risk of cross contamination, infection, and diseases. <BR/>During an interview on 2/26/25 at 2:13 PM, the ADON stated she saw bugs occasionally and let the maintenance staff know whenever she saw anything. She stated she had seen what looked like a tiny cockroach in a resident room on 2/24/25 and immediately told maintenance in person. She stated they came and took care of it. They removed the bug and said they would treat the area. The ADON stated she had not seen any rodents. <BR/>During an interview on 02/27/25 at 6:21 AM, CNA C stated she worked the night shift and had been there about a year. She stated she saw rats in the facility near the kitchen and laundry rooms when she took the trash out at night. She stated she saw them there a lot including the current week. CNA C stated she saw a rat in the employee break room a couple of nights ago. She entered the room and saw a rat run from near a chair and crawl under a cabined under the sink. When asked if she had reported it, she replied, No, we're just used to it, it's been like that a long time. CNA C stated she had never seen rats in the resident rooms, shower rooms or near any resident. She stated, Most of the time they are near the kitchen.<BR/>Record review of the facility pest control visit log reflected service was last provided on 02/07/25. The last invoice from service provider was dated 12/12/2024.<BR/>Record review reflected prior to exit facility obtained a new pest control policy dated 02/26/25.<BR/>Record review of the facility Pest Control Policy review dated 12/1/22, review date 2/26/25 reflected <BR/>Pest Prevention Measures: <BR/>Conduct regular inspections of the facility to identify potential pest entry points and nesting sites.<BR/>Seal cracks, crevices, and other openings in the building structure.<BR/>Maintain cleanliness in all areas, including dining, kitchen, and resident rooms, to eliminate food sources and habitats for pests.<BR/>Proper waste management practices, including regular disposal and secure containers.<BR/>1. <BR/>Monitoring: <BR/>Schedule routine pest inspections by qualified pest control professionals at least quarterly.<BR/>Document findings and actions taken during inspections.<BR/>Maintain a pest sighting log for staff to report any pest activity promptly.<BR/>2. <BR/>Pest Control Treatment: <BR/>Employ licensed pest control operators to handle infestations when necessary, ensuring they follow HHSC guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 9 residents (Resident #1) reviewed for care plans. <BR/>The facility failed to ensure Resident #1, who resided in the memory care unit, had a comprehensive care plan identifying reasons for aggression, appropriate supervision, interventions to prevent Resident #1 from eating non-edible items in order to attain and maintain the highest practicable physical, mental, and psychosocial well-being and safety. <BR/>An Immediate Jeopardy situation was identified on 06/08/2023 at 9:45 AM. The Immediate Jeopardy was removed on 06/09/2023 at 4:18 PM. The facility remained out of compliance at a scope of Isolated and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. <BR/>This failure could place residents at risk for not being provided necessary care and services. <BR/>Findings Included:<BR/>Record review of Resident #1's electronic face sheet, dated 06/07/2023, revealed Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's diagnoses included dementia with agitation (walk up and down, move objects around or fixate on tasks such as tidying), major depressive disorder (mood disorder that interferes with daily life), anxiety disorder (involves persistent and excessive worry that interferes with daily activities), and delusional disorders (type of mental health condition in which a person can't tell what's real from what's imagined).<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 04/21/2023, revealed Resident #1's BIMS score was 00 which indicated severe cognitive impairment. Review of behaviors reflected physical behavioral symptoms directed toward others and self, wandering occured daily. <BR/>Record review of Resident #1's care plan, initiated on 05/30/2023, reflected Resident #1 was at risk of elopement / non-goal directed wandering, interventions included Disguise exits .identify pattern of wandering. Is it purposeful? Further review revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes and impaired decision-making skill. Resident #1 exhibited verbal and physical aggression, exhibited hitting and biting during ADL care and interventions included Provide physical and verbal cues to alleviate anxiety .give the resident as many choices as possible about care and activities. The care plan also reflected a diagnosis of dementia and need for a secure environment due to risk of elopement, exit seeking and wandering. Interventions included Assess for reasons for wandering and provide redirection as needed. Resident #1 had a history of resisting or refusing care and became aggressive during care. <BR/>Record review of Resident #1's Progress Notes dated 04/13/2023, RN A documented, Resident came out from her room and was holding pull up full of feces and writer tried to take it away from her and resident pushed nurse and nurse landed on the floor and hit her right leg on double door. Nurse was assisted off from the floor by two staff members. Resident was then attended by two staff members. Family, Md, and ADON notified. Progress notes dated 05/15/2023, 05/16/2023, 05/16/2023, 05/22/2023, and 05/24/2023 reflected LVN E documented the following on each date, Resident is up wandering up and down the hallway, checked V/S and gave all medications as ordered, tolerated well, resident is at high risk for elopement, requires constant redirection by staff members. Resident requires 2 to 3 staff members to provide cares, resident has a very aggressive behavior, such as kicking and biting. Resident is developing a new habit, messing with her own poop, staff members has to help her thoroughly cleaned her and sanitize all the places she touched. Will continue to monitor. Progress notes dated 06/06/2023 reflected LVN E documented, Resident was seen be states surveyor possibly eating and notified first nurse aide and next the nurse who was told by the DON immediately notified the MD at 12:33PM, that was 3 minutes after this nurse was notified, MD immediately responded and ordered to call poison control center and checked resident's V/S, BP .poison control advised us to rinse resident's mouth and provide more fluids, we did as ordered, no S/S of nausea or vomiting noted at this time. Will continue to monitor resident and continue to encourage fluids. Called poison control regarding possible ingestion of deodorant. Poison control indicated that a possible adverse effect would b, mild GI upset, limited diarrhea, and upset stomach. Was told to monitor for upset stomach and encourage fluids. Case #75554424. <BR/>Observation and interview on 06/07/2023 at 11:45AM revealed Resident #1, in the hall facing the patio, eating a stick of deodorant with a plastic spoon. Resident #1 turned the deodorant stick up and used the spoon to scoop chunks of the deodorant from the container and then ate it. CNA B and LVN C were observed around the corner on the room hall passing lunch trays. The surveyor called down the hall to notify LVN C and CNA B that Resident #1 was eating the deodorant stick. CNA B came to the hall where Resident #1 was and stated she could not take the deodorant from Resident #1 without assistance because Resident #1 had bitten her in the past when she took something away from her. CNA B called for LVN C to assist. During the time LVN C came to assist, Resident #1 was observed placing the deodorant container in a sock she was holding. LVN C was observed trying to get the sock that contained the deodorant stick from Resident #1. Resident #1 refused to give it and LVN C then distracted Resident #1 from her left side while CNA B took the sock from Residnet#1's grip. Resident #1 still had the plastic spoon in her hand and walked down the hall to the rear door exit area where she began taking items from the trash can. Resident #1 used the spoon to scrape particles of deodorant from her arms and licked the spoon. <BR/>An observation and interview on 06/07/2023 at 11:50AM, with LVN C and CNA B, revealed the deodorant container was empty. LVN C said Resident #1 could get very aggressive when staff took items from her that she should not have. LVN C said Resident #1 constantly wandered from room to room taking any items she could find. LVN C stated the deodorant stick was not from the facility and may have been brought into the secured unit by another resident's family members. He said there was one resident in the secured unit who did have personal care items in her room because she was only diagnosed with schizophrenia and able to do her own personal care. He said each room had child covers on the doorknob which prevented residents from entering rooms, however, Resident #1 was able to open doors with the child cover on. CNA B stated Resident #1 needed constant supervision because she wandered from room to room taking anything she could find. She stated when staff attempted to redirect Resident #1 or take something from her she would be aggressive. <BR/>An interview on 06/07/2023 at 12:16PM with the Administrator revealed she was informed that Resident #1 had eaten the deodorant. She stated she did not know where Resident #1 could have gotten the deodorant from because all personal care items should have been secured in the shower room. She said family members often brought items into the secured unit for residents and left the items in their room. She said she directed staff to do a sweep of the secured unit to ensure there were no more hazardous items accessible to residents; she stated they did find additional personal care items in resident rooms and removed them. She said she was not aware of any resident in the secured unit who kept personal care items in their room but the DON may have told her about such a resident but was not sure. She said there were child covers on the doorknobs in the secured unit to prevent residents from entering rooms. She said she had not been informed Resident #1 could open the doors with the child covers on. She stated typically one nurse and two CNAs worked in the secured unit to ensure appropriate supervision of the 17 residents. She stated the facility's policy stated that all personal and hazardous items should be locked to prevent a risk of harm to residents. She said she understood Resident #1's eating deodorant posed an immediate concern for a risk of harm to all the residents in the secured unit. <BR/>An observation and interview on 06/07/2023 at 12:23PM, in the secured unit, with the Administrator and DON revealed Resident #1 in the room hall with a small can of shaving cream. Resident #1 was trying to push the button at the top of the can and held the can to her mouth but was unsuccessful in getting the contents to come out. The DON was observed taking the can of shaving cream from Resident #1. When asked if they had removed all the hazardous items from the secured unit, The Administrator stated staff had already done that and stated she did not know where Resident #1 got the can of shaving cream from. <BR/>An observation and interview on 06/07/2023 at 12:25PM with Resident #2 revealed she recently came to the facility. She stated she had her own room and was allowed to keep her personal care items in her room. She stated she hid the items in her dresser drawers as residents often came inter her room and took them. She said she hid her purse under a chair for the same reason. Resident #2's purse was observed stuffed under a chair in her room and personal care items (toothpaste, shampoo, and deodorant) were observed in the top drawer of the dresser in her room. <BR/>An interview on 06/07/2023 at 12:40PM with LVN C revealed Resident #1 was hard to redirect and constantly wandered from room to room. He said Resident #1 likely got the deodorant from another resident's room. He stated staff do not check rooms regularly for items that may be hazardous to residents. He said residents' family often bring items and leave them in the residents' rooms. He stated he noted Resident #1 started to mess with her poop and said he had never seen her eat anything non-edible before. He stated his note referred to her taking her adult diaper off and smearing poop all over. <BR/>An interview on 06/07/2023 at 12:52PM with CNA B revealed Resident #1 would get into anything she could including briefs, wipes, and deodorant. She said she had not seen her eat anything hazardous but Resident #1 had to be supervised all the time to ensure her safety. She said she thought Resident #1 may have taken the deodorant from the shower room because she had found the lid to the deodorant stick in the locked shower room when she completed the sweep. She stated the shower room was always locked but this morning a hospice aide was in the secured unit caring for a resident and Resident #1 could have gotten the deodorant while the aide was showering another resident. CNA B stated during her sweep of the secured unit, she found five deodorants in five different rooms, soap, two large bottles of lotion, and three large bottles of shampoo. She said the items were labeled Keep out of reach of children. CNA B stated Resident #1 bit her on her breast, on 04/19/2023, when she tried to take lotion from Resident #1. She stated she informed the DON and Administrator. She stated Human Resources had her go to the hospital for treatment. She stated she had not receive any in-service related to handling Resident #1's aggressive behavior.<BR/>An interview on 06/07/2023 at 1:41PM with the Administrator revealed when CNA B was bit by Resident #1 she was primarily concerned with ensuring CNA B was taken care of and followed up with human resources. She said she did not follow up with any behaviors that may have led to why Resident #1 bit CNA B and ultimately kept Resident #1 safe. She said in reviewing progress notes, the staff knew Resident #1 wandered and got into any items she could find; all staff could assume Resident #1 could possibly consume them as well. She stated she should have followed up to ensure the safety of Resident #1. She stated the DON and ADON were responsible for reviewing the progress notes to ensure information was brought to her. She stated she was not made aware of an incident where Resident #1 pushed RN A to the ground on 4/13/2023. She said the incident may have been reported to human resources. She said it should have been brought to her attention by staff or the DON because it was documented in the progress notes. She said she expected the DON and ADON to review the progress notes and bring any concerns to her attention. She stated she expected staff to ensure residents, who did not have the cognitive ability to understand their actions, were safe and any hazards were secured to prevent residents from any harm. <BR/>An interview on 06/07/2023 at 2:25PM with RN A revealed she was pushed to the ground on 4/13/2023, when she tried to take a soiled adult brief from Resident #1. RN A said Resident #1 came out of her room with the soiled brief in her hand. She said the brief was tore and Resident #1 had feces on her hands, face and inside her mouth. She stated she believed Resident #1 was eating the brief. RN A stated she had never seen Resident #1 eat deodorant but was not surprised as she wandered from room to room looking for anything she could find. RN A stated she told the DON, ADON, Administrator and Human Resources about the incident. She stated Human Resources directed her to get medical attention. RN A stated there were no care plan changes, in-services, or direction from the DON or ADON to address Resident #1's behaviors. <BR/>In an interview on 06/07/2023 at 3:00PM the Social Worker stated she and the MDS Coordinator held a care plan meeting for Resident #1 on 05/23/2023. She stated there was no information about Resident #1 eating poop or any other non-consumable items. She stated she gained resident information from the DON or ADON regarding issues or concerns and concerns of the resident's specific behaviors should have been relayed to her and the MDS Coordinator for care planning. She said Resident #1's aggressiveness was discussed in the care plan but no specific details regarding when aggression occurred or why. <BR/>An interview on 06/07/2023 at 3:30PM with the DON revealed she had not seen any of the progress notes related to Resident #1. She said it was her and the ADON's responsibility to review the notes and care plans to ensure any concerns were addressed. She said she held a stand-up meeting every morning at 10:00AM where issues would be discussed. She said she was working with staff to ensure they brought concerns to the stand-up meetings but realized they had not always done that. She said she was aware Resident #1 had aggressive behaviors but did not know why. She stated she knew Resident #1 had bitten CNA B but did not why. She said she did not know Resident #1 pushed RN A to the ground when she tried to take a soiled adult diaper from her. The DON said Resident #1's aggressive behaviors that occurred when staff tried to take things from her should have been in the care plan. She stated there should not be any potentially hazardous items accessible to any resident in the secured because they did not have the mental capacity to know what could be consumed. She said Resident #1 eating deodorant posed a potential risk of harm and could have been avoided. <BR/>An interview on 06/07/2023 at 4:22PM with CNA D revealed Resident #1 was aggressive when staff tried to redirect her or take something she should not have away. She said she had seen Resident #1 eat feces from her adult diaper and told the nursing staff but did not know what was done from there. She stated she did not recall the nurse she told or the time she observed Resident #1 eat feces from her adult diaper. She said Resident #1 needed constant supervision because she constantly looked for anything she could get into. <BR/>An interview on 06/07/2023 at 4:35PM with MDS Coordinator/LVN revealed she and the SW conducted a care plan meeting for Resident #1 on 05/23/2023. She said information for Resident #1's care plan would be communicated to her by the ADON or the DON during morning meetings. She said she was aware of Resident #1 biting a staff member but was not sure why it occurred. She said she was not informed of specific circumstances that may have caused Resident's #1's behavior. She stated those circumstances should be communicated from nursing staff and reflected in the care plan. <BR/>An interview on 06/07/2023 at 5:03PM with the ADON revealed she had not reviewed Resident #1's progress notes. She said it was the DON and her responsibility to review them for any concerns related to residents. She said that information would be passed on to the MDS Coordinator to be addressed in care plans. The ADON said she was not aware Resident #1 was messing with her poop and did not know RN A was pushed to the ground by Resident #1 when she took a soiled adult diaper from her. She stated specific interventions should have been reflected in the care plan to ensure Resident #1's safety. She said the facility did not have a system in place to ensure rooms were checked for hazardous items. She said since Resident #1 wandered and got into things, the facility needed to ensure her safety by making sure all potentially hazardous items were secured. <BR/>In an interview on 06/07/2023 at 5:15PM, the Administrator stated she dropped the ball. She said in hindsight, she should have followed up with the DON regarding Resident #1's aggression. She said she should have investigated as to the circumstances of Resident #1's aggression. She stated there was not an incident report done when Resident #1 bit CNA E or pushed RN A. She said she and the DON should have known about Resident #1 eating a solid adult diaper. She said she felt like she needed to have better communication with nursing staff to ensure all resident's safety. She said the facility should have a system in place to ensure resident did not have access to non-consumable items and ensure their safety. <BR/>An interview on 06/07/2023 at 5:57PM with the COO revealed he expected staff to ensure all residents were safe. He stated the DON and ADON should have known about the context of Resident #1's behaviors and ensured the care plan reflected specific issues. He stated there seemed to be a breakdown in communication between the front-line staff, nurse management, and the Administrator. <BR/>Record review of the facility's incident / accident report between 03/01/2023 to 06/07/2023 revealed no record of incidents involving Resident #1, CNA B, or RN A. <BR/>Record review of the MSDS for the deodorant consumed on 06/07/2023 by Resident #1 revealed Hazards Identification: Eye: Classification Eye Contact may cause mild, transient irritation. Some redness and/or stinging may occur. Ingestion: Product used as intended is not expected to cause gastrointestinal irritation. Accidental ingestion of undiluted product may cause mild gastrointestinal irritation with nausea, vomiting and diarrhea.<BR/>Record review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, dated 12/2009 reflected, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.including time and date .nature .circumstances .name of witnesses .complete report sent to the DON within 24 hours .DON shall ensure that the Administrator receives a copy of the Report .<BR/>Record review of the facility's policy titled, Safety and Supervision of Residents, dated 12/2008 reflected, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA and A reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. Staff shall use various sources to identify risk factors for residents, including information obtained from the medical history, physical exam, observation of the resident, and the MDS. Implementing interventions to reduce accident risk and hazards shall include the following: communicating specific interventions to all relevant staff, providing training .documenting interventions .<BR/>Record review of the facility's policy titled, Care Plans - Comprehensive, dated 12/2010 reflected, An individualized comprehensive care plan that includes measurable objectives and timetables to meet resident's medical, nursing, mental, and psychosocial needs is developed for each resident. Each resident's comprehensive care plan is designed to: .incorporate identified problems .incorporate risk factors associated with identified problems <BR/>The Administrator was notified on 06/08/2023 at 9:30AM, that an Immediate Jeopardy had been identified due to the above failures. The IJ Template was provided to the Administrator on 06/08/2023 at 9:45AM and she was informed the POR was due to HHSC by 12:00PM on 06/08/2023. <BR/>The Plan of Removal (POR) was accepted on 06/08/2023 at 4:20PM. <BR/>The Plan of Removal reflected the following:<BR/>Immediate Corrective Action for residents affected by the alleged deficient practice:<BR/>The resident who allegedly ingested deodorant was assessed, all vital signs within normal limits. Despite finding no evidence of deodorant within her mouth, the resident's mouth was rinsed, fluids encouraged. Medical director, poison control, and family were notified. The medical director instructed facility to continue to monitor for signs of GI distress. <BR/>This deficient practice had the potential to affect 17 residents residing on the secure unit, however, no other resident was found to be affected.<BR/>The secure unit was swept for personal care items on 06/07/23 and again on 06/08/23. All personal care items found were removed from resident rooms and given to the charge nurse to be secured behind locked doors, including items from resident who was previously reluctant to let them go. <BR/>All family members were called on 06/07/2023 and informed that personal care items must be labeled and turned into management staff or nursing to be locked for the safety of all residents. Signs were also posted at the front of the building to turn in personal care items which will be made available for use at the appropriate time. <BR/>Care plans updated to reflect the residents wandering and aggression being further agitated by attempts to remove items or redirect resident. The care plan updated to reflect the residents alleged tendency to ingest non-food items. <BR/>Staff members in-serviced on the need to lock personal care items out of reach of residents, particularly those who tend to become confused or exhibit behaviors related to wandering and picking up items found in other rooms. Education occurred on 06/07/23 and again on 06/08/23 and will continue.<BR/>Actions taken to prevent a serious adverse outcome from recurring:<BR/>Management staff swept the rest of the facility on 06/08/2023 and ensured personal care items were secured appropriately. Anything found not stored appropriately was labeled by resident name and given to charge nurses to secure in locked room on 300 hall. <BR/>Additional checks were conducted of locked supply, shower, and utility rooms. The facility will continue to monitor to ensure the security of these areas. Additional education completed on the need to keep personal care items away from residents who might become confused or exhibit behaviors.<BR/>Ad Hoc QAPI Meeting was held on 06/08/2023 to discuss the incident, make staff members aware of the new policy on personal care items. MD and management staff present, corporate staff available by phone. <BR/>Additional sweeps of the area daily by staff members x 2 weeks, then weekly for 2 weeks, and monthly thereafter. <BR/>The facility will utilize a daily behavior monitoring sheet for changes in behavior/condition. This sheet will be reviewed weekly and as necessary, changes in behavior or condition will be discussed and care planned appropriately. <BR/>When will actions be complete:<BR/>Coral Nursing and Rehabilitation of Arlington requests the removal of the immediate jeopardy on 06/08/2023<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>An interview on 06/09/2023 at 1:30PM with the Administrator revealed 57 of 110 staff have been in-serviced regarding the Behavior monitoring log and Securing personal care items. She stated the management team had been completed to ensure any hazardous items were secured for the safety of residents. She stated sweeps will be completed daily by the management team for two weeks and then weekly. She said she would be completing the sweeps on weekends until a weekend supervisor was hired. She stated she would be addressing progress notes, the results of sweeps, and any aggressive incidents daily stand-up meetings. She stated the management team participated in an Ad Hoc QUPI meeting on 06/08/2023 wiht the medical director, Corporate RN, DON, ADON, and MDS Coordinator present. She said she had implemented a behavioral log to be completed by staff daily and monitored by the DON in an effort to catch any changes in resident behaviors. She said the DON was expected to report any changes in resident behavior to her, daily. She stated the families of all Secured Unit residents were contacted and instructed that any items they bring to the facility must be secured by staff. <BR/>A record review of the medical record for Resident #1 revealed she was assessed for complications and ongoing monitoring of adverse effects. Resident #1's care plan was updated to reflect the residents wandering and aggression, further agitated by attempts to remove items or redirect the resident and resident's tendency to ingest non-food items. <BR/>Observations on 06/09/2023 from 3:00PM to 3:10PM revealed all rooms and areas in the memory care unit were free from hazardous products.<BR/>Interviews were conducted on 06/09/2023 from 12:40 PM to 3:00 PM with 18 staff members (6 CNAs, 2 RNs, 4 LVNs, 2 MAs, 1 Restorative Aide, and 3 Housekeeping staff) from multiple shifts. The staff all indicated they had been in-serviced on safety awareness, which included a list of prohibited items in memory care, how hazardous items should be stored, the procedures on storing prohibited items that family members might bring for resident use, ongoing sweeps for hazardous items and their security, and procedures in case they were not sure if an item was hazardous.<BR/>In a telephone interview on 06/09/2023 at 2:55PM, the Corporate RN said he understood the components of the IJ and was not aware the DON and ADON had not been reviewing the progress notes. He said it was impossible to complete a comprehensive care plan without considering behaviors. He said he expected the Administrator to ensure residents were safe from hazardous items. He said he expected the DON to ensure behaviors were monitored and communicated to staff for appropriate care planning. He said he provided a behavior log to the Administrator to assist with this. He said he in-serviced the Administrator, DON, ADON, and MDS Coordinator on the need to address changes in resident behavior in care planning, reviewing progress notes to ensure behaviors are addressed and care planed appropriately, and ensuring resident were cared for in a safe environment. <BR/>Record review of in-service dated 06/07/2023, 06/08/2023, and 06/09/2023 on Personal Care Items .Inform family members that all personal care items must be labeled and turned into management staff or nursing staff to be locked for the safety of all residents .Personal care items include but are not limited to the following: Soap, shampoo, conditioner, deodorant, lotions, mouthwash, toothpaste, hand sanitizer, and other potentially hazardous chemical items .In continuing sweeps, if such items are found please remove them from the room. Make sure they are labeled and give it to the nursing staff to be secured revealed 57 signatures from multiple shifts and multiple departments (RNs, LVNs, CNAs, MAs, Housekeeping, Laundry, and Maintenance) had received in-services which covered all aspects of the POR. <BR/>Record review of in-service dated 06/07/2023, 06/08/2023, and 06/09/2023 on Behavior Monitoring Log .the facility will distribute behaviors monitoring sheets to the nursing staff to be filled out daily. The DON will collect the sheets weekly or as necessary to be discussed at the Standards of Care meeting. Any changes will be communicated to management staff in the meeting and care planned appropriately. Changes will also be discussed in the morning IDT meeting so all staff can be aware of changes, revealed 57 signatures from multiple shifts and multiple departments (RNs, LVNs, CNAs, MAs, Housekeeping, Laundry, and Maintenance) had received in-services which covered all aspects of the POR. <BR/>Record review of signed in-service dated 06/09/2023 and conducted by the Corporate RN revealed the Administrator, DON, ADON, and MDS Coordinator were educated on their .responsibility that every resident within my facility receives quality, appropriate care .understand that changes in resident's behavior must be discussed promptly, with the DON, ADON, and IDT team for intervention and appropriate care planning .understand that it is my responsibility to periodically read and review the charts of my residents with behaviors, to ensure completeness and that all behaviors are addressed and care planned appropriately. <BR/>Record review of the Behavior Monitoring Log reflected behavior, intervention and outcome codes with a monthly calendar noting day, evening, and night shifts. <BR/>The Administrator was informed the Immediate Jeopardy was removed on 06/09/2023 at 4:18PM; however, the facility remained out of compliance at a scope of Pattern and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 6 residents reviewed for pharmacy services in that:<BR/>The facility failed to ensure Resident #1's Ketoconazole External Shampoo (used to treat hair loss and dandruff) was available and applied as ordered between 11/27/24 and 12/2/24.<BR/>This failure placed the residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition. <BR/>Findings included:<BR/>Record review of Resident #1's admission Record dated 12/21/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #1's Quarterly MDS dated [DATE] reflected she was in a persistent vegetative state, she was dependent on staff for all ADLs and her diagnoses included hypertension (high blood pressure); Diabetes; aphasia (disorder that affects the ability to verbally communicate); and stroke.<BR/>Record review of Resident #1's care plan reflected an entry dated initiated 11/26/24: [Resident #1] is on Ketoconazole External Shampoo 1%. Apply to scalp one time a day every Wed and Fri for rash until 12/02/2024. Intervention: Provide wound care per treatment order give as ordered.<BR/>Record review of Resident #1's Order Recap Report dated 1/2/25 reflected the following order:<BR/>11/25/24: Ketoconazole External Shampoo 1%. Apply to scalp topically one time a day every Wednesday and Friday for rash until 12/2/24. Start date 11/27/24. End date 12/2/24.<BR/>Record review of Resident #1's Administration Record dated November 2024 reflected and entry for Ketoconazole External Shampoo 1%. Apply to scalp topically one time a day every Wednesday and Friday for rash until 12/2/24. An entry dated 11/27/24 (Wednesday) was coded 13 which indicated, pending arrival from pharmacy. An entry dated 11/29/24 (Friday) was coded 9 which indicated, other/see Nurses Notes. <BR/>Record review of Resident #1's nursing progress notes reflected:<BR/>11/25/24 8:22 PM: [Family member] is concerned about the res hair falling off. She requests the nurse to get an order from the MD . Phone call placed, and a N/O received for Ketoconazole External Shampoo 1 % (Ketoconazole (Topical)) Apply to scalp topically one time a day every Wed, Fri for Rash until 12/02/2024 .Order placed on PCC. [Family member] and res aware. The entry was signed by LVN B.<BR/>11/29/24 12:37 PM: Ketoconazole External Shampoo 1 % Apply to scalp topically one time a day every Wed, Fri for Rash until 12/02/2024 .shampoo not found in patient room or nurse cart. The entry was signed by RN C. <BR/>An observation on 12/31/24 at 9:46 AM revealed Resident #1 was in bed. Her eyes were open but she made no response to verbal greeting. She appeared clean and well groomed. Her hair appeared clean and groomed . <BR/>During and observation and interview on 12/31/24 at 12:10 PM, CNA D stated she had assisted with Resident #1's showers and was unaware of any orders for special shampoo to be used during her care. She stated Resident #1's family had wanted them to use the products they provided for her and pointed out a shelf in the resident's closet which had various bottles of shampoo and body wash. CNA D stated she always retrieved items from that shelf when preparing the resident for her showers. <BR/>During an interview on 12/31/24 at 3:35 PM, the DON stated she was unsure whether the shampoo ordered for Resident #1 had been used. She stated she had been made aware the day before by Resident #1's family that they did not believe it had been used. She stated she checked the medication cart and located a partially used bottle of her Ketoconazole. She stated she had not had an opportunity to follow-up with the CNAs yet because the staff that cared for her that week were not working. The DON stated the nurses were responsible for letting the CNAs know if there was an order for special shampoo. She stated the risk of not using the shampoo would be ongoing condition. She stated she did not observe a rash or other condition when she checked Resident #1.<BR/>During an interview on 12/31/24 at 4:24 PM, LVN B stated he had called the physician and entered the order for the shampoo when her family member expressed concerns about her scalp. He stated the family member had approached him at a later date and complained the shampoo had not been used. He stated he had checked with the staff the same day and learned the shampoo had been used on at least one occasion during the morning shift. He was unable to recall the date or identify the staff with whom he spoke. LVN B stated the charge nurse should have alerted the CNA of the need for the shampoo and should have signed the administration record or documented in the nurses' notes. He stated the risk for failing to use the shampoo was worsening of the condition. LVN B retrieved the bottle from his medication cart and it appeared to have been opened and used. <BR/>During an interview on 1/2/25 at 3:46 PM, RN C stated she recalled a CNA asking her about Resident #1's Ketoconazole and that she had been unable to locate it in her medication cart. She stated she thought she asked someone about it and was told it had been ordered but she could not recall anything after that day. She stated the risk of not administering treatments as ordered depended on the condition for which it was ordered. She stated she never noted any rash or other condition on Resident #1's scalp. <BR/>Record review of the facility's Policy titled, Pharmacy Services Overview dated revised April 2007 reflected: The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed Pharmacist. Policy Interpretation and Implementation, .3. The facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility and Medical Director to: a. Develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services (including ordering, delivery and acceptance, storage, distribution, preparation, dispensing, administration, disposal, documentation, and reconciliation of all medications and biologicals in the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 6 residents reviewed for pharmacy services in that:<BR/>The facility failed to ensure Resident #1's Ketoconazole External Shampoo (used to treat hair loss and dandruff) was available and applied as ordered between 11/27/24 and 12/2/24.<BR/>This failure placed the residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition. <BR/>Findings included:<BR/>Record review of Resident #1's admission Record dated 12/21/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #1's Quarterly MDS dated [DATE] reflected she was in a persistent vegetative state, she was dependent on staff for all ADLs and her diagnoses included hypertension (high blood pressure); Diabetes; aphasia (disorder that affects the ability to verbally communicate); and stroke.<BR/>Record review of Resident #1's care plan reflected an entry dated initiated 11/26/24: [Resident #1] is on Ketoconazole External Shampoo 1%. Apply to scalp one time a day every Wed and Fri for rash until 12/02/2024. Intervention: Provide wound care per treatment order give as ordered.<BR/>Record review of Resident #1's Order Recap Report dated 1/2/25 reflected the following order:<BR/>11/25/24: Ketoconazole External Shampoo 1%. Apply to scalp topically one time a day every Wednesday and Friday for rash until 12/2/24. Start date 11/27/24. End date 12/2/24.<BR/>Record review of Resident #1's Administration Record dated November 2024 reflected and entry for Ketoconazole External Shampoo 1%. Apply to scalp topically one time a day every Wednesday and Friday for rash until 12/2/24. An entry dated 11/27/24 (Wednesday) was coded 13 which indicated, pending arrival from pharmacy. An entry dated 11/29/24 (Friday) was coded 9 which indicated, other/see Nurses Notes. <BR/>Record review of Resident #1's nursing progress notes reflected:<BR/>11/25/24 8:22 PM: [Family member] is concerned about the res hair falling off. She requests the nurse to get an order from the MD . Phone call placed, and a N/O received for Ketoconazole External Shampoo 1 % (Ketoconazole (Topical)) Apply to scalp topically one time a day every Wed, Fri for Rash until 12/02/2024 .Order placed on PCC. [Family member] and res aware. The entry was signed by LVN B.<BR/>11/29/24 12:37 PM: Ketoconazole External Shampoo 1 % Apply to scalp topically one time a day every Wed, Fri for Rash until 12/02/2024 .shampoo not found in patient room or nurse cart. The entry was signed by RN C. <BR/>An observation on 12/31/24 at 9:46 AM revealed Resident #1 was in bed. Her eyes were open but she made no response to verbal greeting. She appeared clean and well groomed. Her hair appeared clean and groomed . <BR/>During and observation and interview on 12/31/24 at 12:10 PM, CNA D stated she had assisted with Resident #1's showers and was unaware of any orders for special shampoo to be used during her care. She stated Resident #1's family had wanted them to use the products they provided for her and pointed out a shelf in the resident's closet which had various bottles of shampoo and body wash. CNA D stated she always retrieved items from that shelf when preparing the resident for her showers. <BR/>During an interview on 12/31/24 at 3:35 PM, the DON stated she was unsure whether the shampoo ordered for Resident #1 had been used. She stated she had been made aware the day before by Resident #1's family that they did not believe it had been used. She stated she checked the medication cart and located a partially used bottle of her Ketoconazole. She stated she had not had an opportunity to follow-up with the CNAs yet because the staff that cared for her that week were not working. The DON stated the nurses were responsible for letting the CNAs know if there was an order for special shampoo. She stated the risk of not using the shampoo would be ongoing condition. She stated she did not observe a rash or other condition when she checked Resident #1.<BR/>During an interview on 12/31/24 at 4:24 PM, LVN B stated he had called the physician and entered the order for the shampoo when her family member expressed concerns about her scalp. He stated the family member had approached him at a later date and complained the shampoo had not been used. He stated he had checked with the staff the same day and learned the shampoo had been used on at least one occasion during the morning shift. He was unable to recall the date or identify the staff with whom he spoke. LVN B stated the charge nurse should have alerted the CNA of the need for the shampoo and should have signed the administration record or documented in the nurses' notes. He stated the risk for failing to use the shampoo was worsening of the condition. LVN B retrieved the bottle from his medication cart and it appeared to have been opened and used. <BR/>During an interview on 1/2/25 at 3:46 PM, RN C stated she recalled a CNA asking her about Resident #1's Ketoconazole and that she had been unable to locate it in her medication cart. She stated she thought she asked someone about it and was told it had been ordered but she could not recall anything after that day. She stated the risk of not administering treatments as ordered depended on the condition for which it was ordered. She stated she never noted any rash or other condition on Resident #1's scalp. <BR/>Record review of the facility's Policy titled, Pharmacy Services Overview dated revised April 2007 reflected: The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed Pharmacist. Policy Interpretation and Implementation, .3. The facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility and Medical Director to: a. Develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services (including ordering, delivery and acceptance, storage, distribution, preparation, dispensing, administration, disposal, documentation, and reconciliation of all medications and biologicals in the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 3 (Resident #5, #14, and #62) of 7 residents reviewed for respiratory care, in that:<BR/>The facility failed to:<BR/>A.) Label and date the oxygen tubing and concentrator water bottle for Resident #5 and Resident #62.<BR/>B) Label and date Resident # 14 oxygen tubing<BR/>These deficient practices could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. <BR/>Findings Included:<BR/>Resident #5<BR/>Record review of Resident #5 face sheet dated 1/24/24 reflected a [AGE] year-old female admitted on [DATE], diagnosis include Chronic Respiratory failure with Hypoxia (low oxygen). <BR/>Record review of Resident #5's MDS dated [DATE], reflected a BIMS score of 14 indicating she was cognitively in tack. Functional level impaired on both sides and needs staff supervision for mobility, incontinent, eating set up or clean up assistance. MDS Section O - Special Treatments, Procedures, and Programs was left blank.<BR/>Record review of Resident #5's Care plan dated 12/07/23 Continuously on oxygen. via n/c. Administer medications as ordered. Monitor/document for side effects and effectiveness. The resident has shortness of breath (SOB) r/t chronic respiratory failure with hypoxia 02 at 2 LPM continuous via nasal to keep oxygen level above 92% every shift for SOB. Resident # 5 will have no complications related to SOB though the review date .Monitor/document breathing patterns. Report abnormalities to MD: Use universal precautions as appropriate. The care plan did not address changing oxygen tubing.<BR/>Record review of Resident #5's MD orders dated 09/27/23 reflected 02 at 2 LPM continuous via nasal to keep oxygen level above 92% every shift for SOB. There was no order for tubing change.<BR/>Observation on 01/24/25 at 12:00 PM of Resident #5's oxygen tubing and oxygen concentrator bottle was not dated and labeled.<BR/>In an interview on 01/24/24 at 12:00 PM with Resident #5 revealed she was on oxygen, and she does not know when the tubing was changed, however staff does change the tubing. She did not know which shift.<BR/>Resident #14<BR/>Record review of Resident #14 face sheet dated 01/24/24 reflected a [AGE] year-old male admitted on admission 6/23/23 with diagnosis: Paroxysmal Atrial Fibrillation (irregular heartbeats), Cardiovascular and Coagulations (heart attack, Chronic Obstructive Pulmonary Disease (inflammatory of lungs); Intermittent Asthma chronic lung disease, <BR/>Record review of resident # 14's MDS dated [DATE] reflected a BIMS score of 15 cognitively intact. Independent, uses a walker or manual wheelchair and has oxygen treatments.<BR/>Record review of Resident #14's care plan dated 01/09/24 reflected. The resident has Oxygen Therapy r/t . The resident will have no s/sx of poor oxygen absorption through the review date .Oxygen Settings: The resident has O2 via nasal cannula prn Oxygen @ 2L via NC . Resident will have no complications related to SOB. The care plan did not address changing oxygen tubing.<BR/>Observation on 01/24/25 at 12:05 PM of Resident #14's he was lying in bed with his NC positioned in his nose and concentrator on with oxygen flowing and his oxygen tubing was not dated and labeled.<BR/>In an interview on 01/24/24 at 12:10 PM with Resident #14 revealed he was a little confused and could not articulate responses to questions about tubing change. he said his oxygen was flowing well. <BR/>Resident #62<BR/>Record Review of resident #62 reflected a [AGE] year-old male with an admission date of 06/08/22, Dx Disorganized Schizophrenia, Pan lobular Emphysema condition effecting the whole acinus of the lungs permanently damaging the air sacs. Schizoaffective Disorder (mental illness), Chronic Obstructive Pulmonary Disease (inflammatory of lungs), Unspecified, chronic diastolic congestive heart failure. <BR/>Record review of Resident #62's quarterly MDS dated [DATE] reflected he had a BIMS score of 15, indicating he was cognitively intact. Resident is independent, uses a walker or manual wheelchair, has mood and behaviors. MDS Section O - Special Treatments, Procedures, and Programs was left blank <BR/>Record review of Resident #62's care plan dated 01/9/24 indicated the resident received O2 at 2 L per as needed to keep sat above 90%Resident will have no reports of unrelieved shortness of breath through next review date .Observe for SOB, respiratory distress, wheezing, fatigue, increased anxiety and implement appropriate ordered interventions and notify MD if interventions are not effective Provide medication as ordered. The care plan did not address changing oxygen tubing.<BR/>Record review of Resident #62's MD orders dated 08/12/22 reflected O2 at 2 L per (NC/FM/Non-rebreather) as <BR/>needed to keep sat above 90% as needed for SOB.<BR/>Observation and interview with Resident #62 on 01/24/25 at 12:50 PM revealed his oxygen tubing and oxygen concentrator bottle was not dated and labeled, the tubing was lying across the nightstand and inside the trash can. Resident #62 said the tubing was changed this morning by LVN D He does not recall staff dating tubing. <BR/>In an interview on 01/24/24 at 2:-10 PM with LVN D, the charge nurse for Resident #5, Resident #14, and Resident #62. LVN D said she assess resident's oxygen treatment and tubing during rounds and check for date the tubing was change in the nurse notes. LVN D said she had conducted rounds every 2 hours and had observed that the water bottle and tubing for Resident #5, Resident #14, and Resident #62 were not dated. LVN D said she would change the tubing at this time. LVN D said it was the assigned nurse for each shift to check for dates on all oxygen equipment and assess oxygen flow during resident rounds. LVN D said concentrator water bottles should be changed every 24 hours and she observe water bottle levels every 2 hours. LVN D said oxygen tubing should be changed, dated, and documented PRN and every Sunday by night shift. LVN D said failing to change the tubing, label, and date tubing and water bottle cold lead to overuse, kinks in hose, bacteria, respiratory infection, poor air flow, sepsis, and death.<BR/>In an interview with DON on 01/25/24 at 12:12 PM revealed oxygen tubing should be changed, dated, and labeled weekly by the overnight night nursing staff. He said the concentrator water bottles should be changed as needed and assessed during nursing rounds for accurate flow, tubing kinks, dates, and labels. The DON stated that facility protocols would develop and implement protocol for documentation moving forward. The DON said failing to change oxygen tubing for resident could lead to bacterial infection, or respiratory infection. He stated that the facility protocol does not mandate that oxygen tubing and treatment be documented, however he has educated nursing staff today on documentation, changing and dated. The DON said the facility does not use the TAR to document treatment at this time, however it was his plan to educate the nursing staff to document the change in tubing, dating, and labeling. The DON said it was the nursing staff responsibility to monitor oxygen for change and date. The DON the facility plan moving forward would include all nursing staff being in-serviced to change resident tubing weekly on Sunday 10AM-6PM shift. The DON said the morning charge nurses will check documentation, labels, and dates to assure nursing task was completed, and the ADON and DON will then monitor charge nursing task to assure accuracy. The DON expects the nursing staff to monitor for dates.<BR/>In an interview with the ADM on 01/25/24 at 1:30 PM wtih the ADM, and AIT, she expected staff to change the tubing, if visibly soiled. She was not sure of complications related to respiratory treatment task and maintenance as she does not have a clinical background. She said ADON, DON, and charge nurse are responsible for monitoring nursing and treatment procedures. <BR/>Review of facility's in-service dated 10/15/2022 and titled with topic: O2 therapy - weekly and PRN changing of O2 tubing (must date) revealed staff was in-serviced on changing and dating oxygen tubing.<BR/>Record review of facility policy Titled Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, 5 .Other infection control measures include: Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated .Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. Use only sterile water for humidification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents on 3 of 5 Halls (200, 300 and 400 Halls) reviewed for environmental concerns. <BR/>The facility failed to ensure residents overhead light fixtures illuminated in the resident's bedrooms on hall 200 (Rm# 206,212, and 222), hall 300 (Rm# 301, 303, and 310) and hall 400 (Rm#405, 406 and 419).<BR/>This failure could place residents at risk of not having a safe and functional environment. <BR/>Findings included: <BR/>Interview and observation on 04/16/25 at 8:00 AM Resident#1 and Resident#2 who shared a room stated it was hard to see in their room. Right side of the room overhead fixtures did not work at all. Left side of the room overhead light fixture had one working light bulb. <BR/>Interview on 04/16/25 at 9:30 AM MD stated that he had been employed at the facility for 3 months. The MD stated the old fixtures did not provide adequate light in residents rooms. The MD stated the light in the residents' rooms did not read at 50-foot candle . The MD stated he is currently working on updating the lights in the resident's rooms to the required 50fc, but it would take some time and he did not know approximately how long it would take. The MD stated he did not have a light meter reader on him today but would bring one in. <BR/>Observation on 04/17/25 between 3:45 PM and 4:30 PM the MD tested lighting in resident's rooms which revealed: <BR/>1. Lighting measured between 20.3 fc and 25.4 fc in the resident's rooms on hall 200. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms 206,212, and 222.<BR/>2. Lighting measured approximately 19.6 fc and 20.2 fc in the residents' rooms on Hall 400. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms [ROOM NUMBER].<BR/>3. Lighting measured approximately 20.7 fc and 30.5 fc in residents' rooms on hall 300. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms 405, 406 and 419.<BR/> Attempted to do an observation and interview on 04/17/25 at 4:30 PM with Resident #1 and Resident#2 with MD. Resident#1 and Resident#2 stated they were asleep and to come back later. <BR/>Interview on 04/17/25 at 4:45 pm the Administrator stated low lighting could result in trips and falls. The DON stated residents would not be able to see. <BR/>Record review of the facility's policy and procedures revised August 2009 revealed Quality of Life-Homelike Environment read in part .Policy Statement: Resident are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to extent possible . Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The lighting design emphasizes:<BR/>1. <BR/>Sufficient general lighting in resident-use areas;<BR/>2. <BR/>Task lighting as needed;<BR/>3. <BR/>Reduction in glare (through use of light filters, no wax floors);<BR/>4. <BR/>Even light levels;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 2 residents (Resident #1) reviewed for intravenous medications. <BR/>1. The facility failed to ensure the dressing on Resident #1's Midline catheter (used to deliver intravenous medications directly to the large central veins near heart) was changed timely. Resident #1 went without a dressing change for 15 days. <BR/>2. The facility failed to have orders for Midline catheter dressing changes.<BR/>The failures could affect residents by placing them at risk for infections and cross-contamination. <BR/>Findings included: <BR/>Record review of Resident #1's admission Record dated 12/21/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #1's Quarterly MDS dated [DATE] reflected she was in a persistent vegetative state, she was dependent on staff for all ADLs and her diagnoses included hypertension (high blood pressure); Diabetes; aphasia (disorder that affects the ability to verbally communicate); and stroke.<BR/>Record review of Resident #1's Order Recap Report dated 1/2/25 reflected the following orders: 12/16/24: Insert Midline. <BR/>12/17/24: Imipenem-Cilastatin Intravenous Solution 500 mg intravenously every 6 hours for UTI until 12/24/24.<BR/>There were no orders for dressing changes to be performed to her midline catheter site. <BR/>Record review of Resident #1's MAR and TAR dated December 2024 reflected no entries for dressing changes to her midline catheter site. <BR/>An observation on 12/31/24 at 9:46 AM revealed Resident #1 was in bed. Her eyes were open but she made no response to verbal greeting. A midline IV insertion site on her left upper arm had a dressing intact and dated 12/16/24. <BR/>In an interview on 12/31/24 at 2:23 PM, RN A stated she had an order to discontinue the midline catheter and she was checking the facility policies related to removal. She stated she had come from another facility to help out due to staff calling in sick. She stated she could not say why Resident #1's dressing had not been changed.<BR/>During an interview on 12/31/24 at 3:35 PM, the DON stated Resident #1's midline IV was getting discontinued that day. She stated it would have been removed sooner but her family wanted it left in a little longer in case she needed additional medications. The DON stated they usually ordered dressing changes every 7 days and she could not say why hers had not been ordered or why her dressing had not been changed. She stated she usually had an ADON to assist with reviewing orders and MARS but had been without one for the past month. She stated she had a new ADON scheduled to start soon. The DON stated the risk of not changing the dressings was infection.<BR/>During an interview on 1/2/25 at 3:05 PM, LVN B stated he typically cared for Resident #1 and did not know how often the dressing to her IV site needed to be changed. He stated they checked the IV site every shift to ensure it was intact and hers had been removed on 12/31/24 . LVN B stated the risk of not changing dressings included infection.<BR/>Record review of the facility's policy titled, Peripheral IV Dressing Changes dated Revised April 2016 reflected: Purpose-This purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. General Guidelines .2. Change the dressing if it becomes damp, loosened or visibly soiled and at least every 5-7 days. Change dressing and perform site care if signs and symptoms of site infection are present .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary comfortable, environment for residents staff and the public for one (room [ROOM NUMBER]) of nine resident rooms reviewed for environment.<BR/>The facility failed to ensure the AC/heating unit located in room [ROOM NUMBER] was clean.<BR/>This failure could place residents at risk for diminished quality of life due to a lack of a well-kept environment and reduced air quality in the room.<BR/>Findings included:<BR/>An observation on 1/17/24 at 9:20 AM, revealed Resident #1 was in room [ROOM NUMBER]B, sitting on the side of his bed facing the window. His knees were directly in front of an AC/heating unit located beneath a window. The resident was cognitively impaired and unable to be interviewed. The AC/heating unit was on and blowing warm air. Front cover appeared loose. A moist black substance was observed along the edges of the louvers from where the air was blowing. The top portion of the cover surrounding the louvers and control panel was dirty. The control panel face was also covered in dirt that was heavier in the area typically obscured by the cover, but visible because the cover was loose. <BR/>An observation on 1/17/24 at 9:28 AM, revealed a housekeeping cart was parked outside the room next door.<BR/>Another observation on 1/17/24 at 10:10 AM revealed Resident #1 was sitting in the same position in his room, no changes were observed to the unit, photos were taken by this surveyor. <BR/>An observation and interview on 1/17/24 at 10:55 AM, revealed a housekeeping cart was seen in the doorway of room [ROOM NUMBER]. Housekeeping Staff A was observed inside the room removing trash from the trashcans. An interview with Housekeeping Staff A revealed the floors were typically cleaned twice a day and the AC/heating units were cleaned daily. <BR/>An observation on 1/17/24 at 12:15 PM, revealed Resident #1 was sitting on the side of his bed, now facing the door, eating lunch. Observation of his AC/Heating unit revealed the front center portion of the control panel appeared clean but the surrounding area was still dirty. The black substance could still be seen along the edges of the louvers from where the air was blowing.<BR/>An interview with the DON on 1/17/24 at 1:30 PM, revealed Resident #1's family member mentioned the dirty AC/heating unit to him the evening of 1/16/24. He stated he had planned to discuss it with the maintenance staff today (1/17/24) but had not done so yet because State investigators had entered this morning. The DON accompanied this surveyor to room [ROOM NUMBER] to examine the unit. The DON removed the cover and pointed out the rust on the metal frame and stated he believed that was the material and not dirt. When the other dirty areas were pointed out including the black substance on the louvers, dirt around the control panel, dust buildup beneath the control panel, and dirt buildup within grate over the blower portion of the unit, he stated he would let them know. <BR/>In another interview with the DON on 1/17/24 at 1:55 PM, he presented photos on his phone he said he received on 1/16/24 and stated, it was much worse yesterday. The photo revealed the condenser portion of the unit had been completely caked in dust and had been cleaned and was now clear. He was unsure why the rest had not been cleaned and thought someone may have planned to return and complete.<BR/>In an interview on 1/17/24 at 2:05 PM, with the Housekeeping Supervisor, she stated the housekeepers were responsible for cleaning the outside of the AC/heating units daily and they should check them, along with everything else, during their daily walkthroughs. She stated she did periodic checks behind the housekeeping staff to ensure quality work. She stated Resident #1's family member] had told her the day before that they had bumped into the unit causing the cover to come off which exposed heavy dust buildup. She stated the family member told her it was already getting addressed. She stated she thought she had just seen the Maintenance Tech in the room wiping it down today. <BR/>In an interview with the Maintenance Tech on 1/17/24 at 2:16 PM, he stated he checks the maintenance log at the nurses' station daily for any maintenance issues. He stated he checked the log on 1/16/24 and there was an entry for room [ROOM NUMBER] that said the heat was not working. He said he just went in the room and switched it on and it worked fine. The Maintenance Tech stated someone had asked him if he had cleaned the unit and he told them, 'no'. He stated he thought housekeeping had cleaned it up. The Maintenance Tech stated he had walked through the building two months ago and changed all the filters. He was unaware whether there was any routine cleaning of the interior parts but he could take the unit outside and wash it. He stated he could have removed the cover and clean it, but he had only been told it was not working. The Maintenance Tech provided the Maintenance Logbook for review. <BR/>Record review of the Maintenance Logbook at the main nurses station revealed individual pages titled Maintenance Request. A page dated 1/16/24 reflected the following: <BR/>Time: 8:50 AM. <BR/>Reported by: Resident to the nurse<BR/>Room: 411<BR/>Location: 400 Hall<BR/>Nature of Work Order: Heat is not working<BR/>Work Completed Date: 1/16/24<BR/>By: [Maintenance Tech]<BR/>An interview with the Administrator and the DON on 1/17/24 at 4:00 PM revealed the Administrator stated she had received a text message from the Dietary Manager on 1/3/24 informing her of the complaint. She stated she was told the unit had been cleaned and everything was fine. She stated she did not follow-up with Resident #1's [family member] because the Dietary Manager told her Resident #1's [family member] was satisfied with the outcome. When the Administrator was shown photos taken by this surveyor and asked if she felt it was acceptable, she stated she had been told it was cleaned. When asked about the possible risks to residents having dirty AC/heating equipment close to their beds, the Administrator stated, well that sticks to the plastic and we can get it cleaned and the [family member] was satisfied according to my Dietary Manager. <BR/>During an interview on 1/17/24 at 4:30 PM, the Dietary Manager stated she had been standing near the nurses' station when Resident #1's [family member] approached her and appeared upset. She stated the family member told her they had bumped the AC/heating unit by accident causing the cover to fall off and she noticed it was very dusty. The Dietary Manager stated she retrieved some sanitizing wipes and wiped down the inside of the unit. She stated Resident #1's [family member] was present in the room at the time. The Dietary Manager stated she did not leave the room until the [family member] was satisfied. She stated she saw the [family member] again the next day and was told everything was fine. She stated she had notified the Administrator via text message but did not fill out a grievance form because she thought the issue was resolved. <BR/>Record review of the facility's policy and procedure titled Cleaning and Disinfection of Environmental Surfaces dated 2001, revised August 2010 revealed the following:<BR/>Policy Statement: Environmental surfaces will be cleaned and disinfected according to the current CDC recommendations for disinfection of healthcare and the OSHA Bloodborne Pathogens Standard.<BR/>Policy Interpretation and Implementation .Environmental Surfaces .10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visible soiled

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 6 residents reviewed for pharmacy services in that:<BR/>The facility failed to ensure Resident #1's Ketoconazole External Shampoo (used to treat hair loss and dandruff) was available and applied as ordered between 11/27/24 and 12/2/24.<BR/>This failure placed the residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition. <BR/>Findings included:<BR/>Record review of Resident #1's admission Record dated 12/21/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #1's Quarterly MDS dated [DATE] reflected she was in a persistent vegetative state, she was dependent on staff for all ADLs and her diagnoses included hypertension (high blood pressure); Diabetes; aphasia (disorder that affects the ability to verbally communicate); and stroke.<BR/>Record review of Resident #1's care plan reflected an entry dated initiated 11/26/24: [Resident #1] is on Ketoconazole External Shampoo 1%. Apply to scalp one time a day every Wed and Fri for rash until 12/02/2024. Intervention: Provide wound care per treatment order give as ordered.<BR/>Record review of Resident #1's Order Recap Report dated 1/2/25 reflected the following order:<BR/>11/25/24: Ketoconazole External Shampoo 1%. Apply to scalp topically one time a day every Wednesday and Friday for rash until 12/2/24. Start date 11/27/24. End date 12/2/24.<BR/>Record review of Resident #1's Administration Record dated November 2024 reflected and entry for Ketoconazole External Shampoo 1%. Apply to scalp topically one time a day every Wednesday and Friday for rash until 12/2/24. An entry dated 11/27/24 (Wednesday) was coded 13 which indicated, pending arrival from pharmacy. An entry dated 11/29/24 (Friday) was coded 9 which indicated, other/see Nurses Notes. <BR/>Record review of Resident #1's nursing progress notes reflected:<BR/>11/25/24 8:22 PM: [Family member] is concerned about the res hair falling off. She requests the nurse to get an order from the MD . Phone call placed, and a N/O received for Ketoconazole External Shampoo 1 % (Ketoconazole (Topical)) Apply to scalp topically one time a day every Wed, Fri for Rash until 12/02/2024 .Order placed on PCC. [Family member] and res aware. The entry was signed by LVN B.<BR/>11/29/24 12:37 PM: Ketoconazole External Shampoo 1 % Apply to scalp topically one time a day every Wed, Fri for Rash until 12/02/2024 .shampoo not found in patient room or nurse cart. The entry was signed by RN C. <BR/>An observation on 12/31/24 at 9:46 AM revealed Resident #1 was in bed. Her eyes were open but she made no response to verbal greeting. She appeared clean and well groomed. Her hair appeared clean and groomed . <BR/>During and observation and interview on 12/31/24 at 12:10 PM, CNA D stated she had assisted with Resident #1's showers and was unaware of any orders for special shampoo to be used during her care. She stated Resident #1's family had wanted them to use the products they provided for her and pointed out a shelf in the resident's closet which had various bottles of shampoo and body wash. CNA D stated she always retrieved items from that shelf when preparing the resident for her showers. <BR/>During an interview on 12/31/24 at 3:35 PM, the DON stated she was unsure whether the shampoo ordered for Resident #1 had been used. She stated she had been made aware the day before by Resident #1's family that they did not believe it had been used. She stated she checked the medication cart and located a partially used bottle of her Ketoconazole. She stated she had not had an opportunity to follow-up with the CNAs yet because the staff that cared for her that week were not working. The DON stated the nurses were responsible for letting the CNAs know if there was an order for special shampoo. She stated the risk of not using the shampoo would be ongoing condition. She stated she did not observe a rash or other condition when she checked Resident #1.<BR/>During an interview on 12/31/24 at 4:24 PM, LVN B stated he had called the physician and entered the order for the shampoo when her family member expressed concerns about her scalp. He stated the family member had approached him at a later date and complained the shampoo had not been used. He stated he had checked with the staff the same day and learned the shampoo had been used on at least one occasion during the morning shift. He was unable to recall the date or identify the staff with whom he spoke. LVN B stated the charge nurse should have alerted the CNA of the need for the shampoo and should have signed the administration record or documented in the nurses' notes. He stated the risk for failing to use the shampoo was worsening of the condition. LVN B retrieved the bottle from his medication cart and it appeared to have been opened and used. <BR/>During an interview on 1/2/25 at 3:46 PM, RN C stated she recalled a CNA asking her about Resident #1's Ketoconazole and that she had been unable to locate it in her medication cart. She stated she thought she asked someone about it and was told it had been ordered but she could not recall anything after that day. She stated the risk of not administering treatments as ordered depended on the condition for which it was ordered. She stated she never noted any rash or other condition on Resident #1's scalp. <BR/>Record review of the facility's Policy titled, Pharmacy Services Overview dated revised April 2007 reflected: The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed Pharmacist. Policy Interpretation and Implementation, .3. The facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility and Medical Director to: a. Develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services (including ordering, delivery and acceptance, storage, distribution, preparation, dispensing, administration, disposal, documentation, and reconciliation of all medications and biologicals in the facility .

Based on observation, interview and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facilities.<BR/>The facility failed to post the daily nursing staffing information on 07/15/24.<BR/>This failure could affect residents, facility visitors, vendors and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner.<BR/>Findings Included:<BR/>Observation on 07/15/24 at 11:05 AM during rounds revealed no posted nursing staffing information was anywhere in the facility.<BR/>Observation on 07/15/24 at 1:34 PM during rounds revealed no posted nursing staffing information was anywhere in the facility.<BR/>An interview on 07/15/24 at 2:45 PM with the ADON revealed that the DON was responsible for the scheduling and posting of the daily nursing staff information.<BR/>An interview on 07/15/24 at 2:50 PM with the DON revealed that he was responsible for the daily nursing posting and forgot to do so on 07/15/24. The DON said the daily nursing staffing was supposed to be posted in the front of the facility each day.<BR/>An interview on 07/15/24 at 3:30 PM with the Administrator revealed the staffing coordinator was responsible for the daily nursing staffing posting. The Administrator did not give any risks associated with not having the daily nursing staffing schedule posted.<BR/>Record review of the facility's policy, Staffing, revised April 2007, reflected that the facility provides adequate staffing to meet needed care and services for our resident population. <BR/>No specific policy was given regarding daily nurse staffing posting requirements.

Based on observation, record review and interview the facility failed to ensure that menus were followed for one of one kitchen reviewed in that:<BR/>1. Residents with puree diets were severed chicken, greens beans and mashed potatoes instead of ravioli, green beans, salad, and gravy.<BR/>This failure could affect residents who receive puree meals from the facility in that they would not receive the meal that was on the menu listing.<BR/>Findings included:<BR/>On 08/30/23 at 9:08 AM Record review of the menu revealed that all residents were supposed to be served ravioli, buttered greens beans, bread sticks, salad, and cake with icing. <BR/>Observation on 08/30/23 at 11:30 AM revealed residents with puree diets were served pureed chicken, pureed green beans, and mashed potatoes<BR/>Interview with the Dietary [NAME] W on 08/30/23 at 11:45 AM revealed that she pureed chicken instead of ravioli because she did not think she could puree it. The Dietary [NAME] W revealed, that if the regular menu food could not be pureed, they usually used diced chicken and mashed potatoes. The Dietary [NAME] W revealed, residents need a meat, starch, and vegetable to meet their nutrition needs. <BR/>Interview On 08/31/23 at 11:55 AM with the Registered Dietitian revealed, if the menus were not followed residents could lose their nutritional value and put them at risk of weight loss.<BR/>Interview on 09/01/23 at 01:49 PM with Interim Dietary Manager revealed Dietary cook did not know that she could puree the ravioli. The Interim Dietary manager revealed the facility does not have a procedure in place for making changes to the menu. Interim Dietary Manager revealed changing the menu could affect residents because they were not getting enough nutrition or too much. The Interim Dietary manager revealed this can cause weight loss or too much weight gain.<BR/>Interview on 09/01/23 05:30 PM the Administrator revealed, if the menu was changed staff and residents should be informed and posted. Administrator revealed, The Dietary Manager is responsible for the duties in the kitchen. The Administrator revealed residents could have a lack of nutrition. <BR/>Record review of the facility policy titled. Menus and dated 2001 reflected: 6. Deviations from menus that have already been posted will be noted (including the reason for the substitution and/or deviation) in the kitchen and/or in the record book used solely for recording such changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents on 3 of 5 Halls (200, 300 and 400 Halls) reviewed for environmental concerns. <BR/>The facility failed to ensure residents overhead light fixtures illuminated in the resident's bedrooms on hall 200 (Rm# 206,212, and 222), hall 300 (Rm# 301, 303, and 310) and hall 400 (Rm#405, 406 and 419).<BR/>This failure could place residents at risk of not having a safe and functional environment. <BR/>Findings included: <BR/>Interview and observation on 04/16/25 at 8:00 AM Resident#1 and Resident#2 who shared a room stated it was hard to see in their room. Right side of the room overhead fixtures did not work at all. Left side of the room overhead light fixture had one working light bulb. <BR/>Interview on 04/16/25 at 9:30 AM MD stated that he had been employed at the facility for 3 months. The MD stated the old fixtures did not provide adequate light in residents rooms. The MD stated the light in the residents' rooms did not read at 50-foot candle . The MD stated he is currently working on updating the lights in the resident's rooms to the required 50fc, but it would take some time and he did not know approximately how long it would take. The MD stated he did not have a light meter reader on him today but would bring one in. <BR/>Observation on 04/17/25 between 3:45 PM and 4:30 PM the MD tested lighting in resident's rooms which revealed: <BR/>1. Lighting measured between 20.3 fc and 25.4 fc in the resident's rooms on hall 200. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms 206,212, and 222.<BR/>2. Lighting measured approximately 19.6 fc and 20.2 fc in the residents' rooms on Hall 400. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms [ROOM NUMBER].<BR/>3. Lighting measured approximately 20.7 fc and 30.5 fc in residents' rooms on hall 300. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms 405, 406 and 419.<BR/> Attempted to do an observation and interview on 04/17/25 at 4:30 PM with Resident #1 and Resident#2 with MD. Resident#1 and Resident#2 stated they were asleep and to come back later. <BR/>Interview on 04/17/25 at 4:45 pm the Administrator stated low lighting could result in trips and falls. The DON stated residents would not be able to see. <BR/>Record review of the facility's policy and procedures revised August 2009 revealed Quality of Life-Homelike Environment read in part .Policy Statement: Resident are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to extent possible . Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The lighting design emphasizes:<BR/>1. <BR/>Sufficient general lighting in resident-use areas;<BR/>2. <BR/>Task lighting as needed;<BR/>3. <BR/>Reduction in glare (through use of light filters, no wax floors);<BR/>4. <BR/>Even light levels;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents on 3 of 5 Halls (200, 300 and 400 Halls) reviewed for environmental concerns. <BR/>The facility failed to ensure residents overhead light fixtures illuminated in the resident's bedrooms on hall 200 (Rm# 206,212, and 222), hall 300 (Rm# 301, 303, and 310) and hall 400 (Rm#405, 406 and 419).<BR/>This failure could place residents at risk of not having a safe and functional environment. <BR/>Findings included: <BR/>Interview and observation on 04/16/25 at 8:00 AM Resident#1 and Resident#2 who shared a room stated it was hard to see in their room. Right side of the room overhead fixtures did not work at all. Left side of the room overhead light fixture had one working light bulb. <BR/>Interview on 04/16/25 at 9:30 AM MD stated that he had been employed at the facility for 3 months. The MD stated the old fixtures did not provide adequate light in residents rooms. The MD stated the light in the residents' rooms did not read at 50-foot candle . The MD stated he is currently working on updating the lights in the resident's rooms to the required 50fc, but it would take some time and he did not know approximately how long it would take. The MD stated he did not have a light meter reader on him today but would bring one in. <BR/>Observation on 04/17/25 between 3:45 PM and 4:30 PM the MD tested lighting in resident's rooms which revealed: <BR/>1. Lighting measured between 20.3 fc and 25.4 fc in the resident's rooms on hall 200. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms 206,212, and 222.<BR/>2. Lighting measured approximately 19.6 fc and 20.2 fc in the residents' rooms on Hall 400. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms [ROOM NUMBER].<BR/>3. Lighting measured approximately 20.7 fc and 30.5 fc in residents' rooms on hall 300. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms 405, 406 and 419.<BR/> Attempted to do an observation and interview on 04/17/25 at 4:30 PM with Resident #1 and Resident#2 with MD. Resident#1 and Resident#2 stated they were asleep and to come back later. <BR/>Interview on 04/17/25 at 4:45 pm the Administrator stated low lighting could result in trips and falls. The DON stated residents would not be able to see. <BR/>Record review of the facility's policy and procedures revised August 2009 revealed Quality of Life-Homelike Environment read in part .Policy Statement: Resident are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to extent possible . Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The lighting design emphasizes:<BR/>1. <BR/>Sufficient general lighting in resident-use areas;<BR/>2. <BR/>Task lighting as needed;<BR/>3. <BR/>Reduction in glare (through use of light filters, no wax floors);<BR/>4. <BR/>Even light levels;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety for three (Residents #1, #2, #3) of nine residents reviewed for Nurse competency. <BR/>1. The facility failed to ensure the nursing staff had G-tube training/competency skill checks. <BR/>2. The facility failed to ensure a nurse did not use a G-Tube Declogger to unclog Resident #1's G-Tube and use the bathroom sink water for G-Tube flushes. <BR/>3. The facility failed to ensure the nurses did not use a G-Tube Declogger to unclog Residents #2 and #3's G-Tubes. <BR/>4. The facility failed to ensure the ADON, LVN's and Central Supply knew the risks involved with using the G-tube decloggers until 06/16/23. <BR/>5. The facility failed to ensure LVN C did not use the bathroom sink water for G-tube care until it was brought to their attention on 06/16/23. <BR/>This failure could affect all residents with G-Tubes which could result in a decline in their nutritional intake, physical, mental and psycho-social well-being. <BR/>Findings included:<BR/>1. Record review of Resident #1's Order Summary Report printed 06/16/23 revealed a [AGE] year old male who admitted to this facility 09/15/22 and re-admitted [DATE] with diagnoses paraplegia, encounter for attention to gastrostomy, gastro-esophageal reflux disease .with orders for: Enteral feed order for 22 hours continuous enteral feeding at 60 mL per hour with formula Jevity 1.5 . Enteral feed order every 6 hours for a water flush of 150 mL to run concurrently with the enteral feeding .every shift check gastric residual volume. <BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 (cognitively intact), extensive two person assist for bed mobility and transfers, paraplegia, encounter with gastrostomy, feeding tube.<BR/>Interview on 06/16/23 at 10:34 am, Resident #1 stated the nurses had a problem all the time with unclogging his G-Tube and sometimes used the bathroom sink water or bag of water brought in for his G-Tube care. He stated about two weeks ago his G-Tube got clogged and a nurse used a stick to unclog it and added he did not experience and distress or pain afterwards. He stated he was unsure of the nurse's name who did that. <BR/>Record review of Resident #1's Nurses Notes did not reveal any documentation of a declogger device being used to unclog his G-tube. <BR/>2. Record review of Resident #2's Order Summary Report printed 06/15/23 revealed a [AGE] year old female who admitted on [DATE] with diagnoses . Gastronomy status, constipation, moderate protein-calorie malnutrition . with orders: NPO G-tube diet: Glucerna 1.5 at 50 mL per hour to run concurrently with water flush of 200 mL every 4 hours for 22 hours for nutritional supplement related to aphasia (loss to understand and express speech caused by brain damage) . oral care every shift .every shift check gastric residual volume.<BR/>Record review of Resident #2's Nurses Notes did not reveal any documentation of a declogger device being used to unclog her G-tube. <BR/>3.Record review of Resident #3's Order Summary Report printed 06/16/23 revealed a 51 year male who admitted to this facility on 01/09/23 with diagnoses Unspecified Protein-calorie malnutrition, gastropareses (stomach muscle loss), gastro-esophageal reflux without esophagitis (heartburn), nausea with vomiting, gastronomy status, enterostomy complication (leakage and bowel obstruction) .with orders: Flush with 125 mL every 6 hours to run concurrently with feeding, every shift for hydration .Osmolite 1.2 at 60 mL per hour for 22 hours continuous every shift related to Dysphagia (difficulty swallowing), oropharyngeal phase (difficulty initiating a swallow) .<BR/>Record review of Resident #3's Nurses Notes did not reveal any documentation of a declogger device being used to unclog his G-tube. <BR/>Observation and interview on 06/16/23 at 10:50 am, ADON A stated they had decloggers (flexible threaded device used to clear obstructed gastronomy tubes located in the central supply room on the 400 hall. She stated she looked for them and could not find them then said Central Supply knew where they were. <BR/>Observation and interview on 06/16/23 at 10:57 am, Central Supply stated the Declogger devices were in the OTC room and walked to the OTC room on the 500 hall and there was 4 unopened Decloggers (two 18-24 F/Orange and two 16-22 F/Yellow) on the bottom shelf. Then Central Supply grabbed a yellow and orange Declogger and handed two of them to the HHSC Surveyor. <BR/>Record review of the list of resident's with G-tubes undated revealed they had nine Residents G-Tube at this facility. <BR/>Interview on 06/16/23 at 11:04 am, ADON A stated the nurses used water from the bathroom sink and medication room to flush the G-tubes and stated when G-Tubes were clogged they flushed them by massaging (milking) the tube and at times used a thin brush like thing that went into the tubing. She stated it was called a Declogging device that was used every now and then at this facility. She stated if that method did not work the residents were sent to the hospital. She stated the declogger device had been used on Resident #3 a long time ago December 2022 and on Resident #2 a while ago this year. She denied using the Decloggers and did not remember which nurses used them in the past. She stated there was not any risks involved with using Decloggers to unclog the resident's G-Tubes. <BR/>Interview on 06/16/23 at 11:05 am, LVN F stated had been working at the facility for four months and she said she had not had any G-tube training.<BR/>Interview on 06/16/23 at 1:15 pm, ADON A stated last year some of the nurses were here when they did the G-tube Declogger training and maybe the nurses needed to be re-trained on how to use them because they had such a high turnover of nursing staff and most of those nurses were no longer at this facility. She stated not using a G-Tube Declogger in many years and did not see any risks involved with using them. She stated as long as You don't force the Declogger in there and don't meet any resistance but if you did then you would take the Declogger out. <BR/>Interview on 06/16/23 at 2:05 pm, the Administrator stated if the nurse could not unclog the G-Tubes then they should call the Doctor for further direction to send them out to the hospital. She stated she did not know what G-tube Decloggers were until today 06/16/23 and said to her knowledge the nurses did not use Decloggers on any of the residents and just received confirmation from the DON they no longer had decloggers in the building as of today 06/16/23. She stated not being sure what the risks were for using Decloggers initially but now knew the nurses should never use them because of the risk of injuring the residents. <BR/>Interview on 06/16/23 at 2:13 pm, Resident #1's Doctor stated none of the residents had orders for Decloggers and added this facility had some issues with some of the resident's G-Tubes lately resulting in the residents having to be sent out to the hospital. He stated G-Tube Decloggers were effective with unclogging G-tubes as long as the nurse knew what they were doing and if they did not, it could cause a perforation. He stated not being aware of any of the staff using the Decloggers.<BR/>Interview on 06/16/23 at 3:08 pm, LVN B stated working here for a month and had no formal G-Tube training. <BR/>Interview on 4:51 pm, LVN C stated whenever she did the Resident's G-Tube flushes she used the water from the bathroom sink or from the water pitcher from the medication cart. <BR/>Interview on 06/16/23 at 5:13 pm, the DON stated G-tube care was not one of her problems at this facility and the reason why she had not done any G-tube trainings with the nurses. She stated she was not being aware the nurses used the bathroom sink water for G-Tube flushes, and they should use the water next to the ice machine in the dining room. She stated she would start doing G-Tube trainings with new hires and when residents had G-Tube problems. She stated she was responsible for ensuring G-Tube care was done properly and planned to do spot checks with the nurses.<BR/>Interview on 06/16/23 at 5:50 pm, the Administrator stated the nurses should not use the bathroom sink water for G-Tube flushes because they had plenty of distilled water they could use. She stated they were ensuring the nursing staff knew not to ever use a declogger and to notify the DON and Doctor and follow up with what the Doctor said. She stated Resident #1's Doctor who was also the Medical Director was aware of this issue and he said to continue to do what they recently put in place. She stated the DON and ADON were responsible for ensuring G-Tube services were appropriate. She stated she was not sure why the nurses had no G-Tube training but as of today (06/16/23) they were training the nurses. She stated their Corporate Clinical Consultant would be coming to their facility this Sunday, Monday and Tuesday to help with looking over their G-tube services. <BR/>Record review of ADON A's Training records provided by the Administrator revealed she was hired 11/02/22 and no G-Tube trainings or skills checks had been done. <BR/>Record review of LVN B Training records provided by the Administrator revealed she was hired 03/29/23 and no G-Tube trainings or skills checks had been done.<BR/>Record review of LVN C Training records provided by the Administrator revealed she was hired 05/29/23 and no G-Tube trainings or skills checks had been done.<BR/>Record review of LVN D Training records provided by the Administrator revealed he was hired 11/30/22 and no G-Tube trainings or skills checks had been done.<BR/>Record review of the Wound care nurse E Training records provided by the Administrator revealed she was hired 02/01/23 and no G-Tube trainings or skills checks had been done.<BR/>Record review of the Nurse's G-tube Skills checkoff's was requested but the Administrator and DON stated they did not have any within the past year. <BR/>Record reviews and interviews revealed LVN B, LVN C, LVN D and Woundcare Nurse E had taken care of Residents #1, #2 and #3. <BR/>Record review of the Facility's Training Requirements Policy dated 2022 revealed, Policy: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles .2. The amount and types of training necessary are based on a facility assessment .10. Documentation of required training will be forwarded to the HR Department to be placed into the individual's personnel file .

Based on interviews and record reviews, the facility failed to use the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week in the facility for 2 (07/01/2023 and 07/02/2023) of 60 days reviewed. <BR/>The facility failed to have RN coverage in the facility for eight consecutive hours on 07/01/2023 (Saturday) and 07/02/2023 (Sunday). <BR/>This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care.<BR/>Findings included: <BR/>Review of the facility's, Punch Report, dated 07/01/2023 - 07/31/2023 reflected the only RN coverage on 07/01/2023 was RN H's time in at 9:49 PM. RN H's time out on 07/02/2023 at 7:42 AM. On 07/02/2023, RN N's time in was 10:23 PM and time out was 6:28 AM on 07/02/2023. RN coverage on 07/01/2023 was two hours and eleven minutes, RN coverage on 07/02/2023 was nine hours and nineteen minutes but not consecutive. <BR/>In an interview on 08/31/2023 at 12:42 PM, the Staffing Coordinator said she did not know why there was not eight consecutive hours of RN coverage on 07/01/2023 and 07/02/2023. She said she started as the Staffing Coordinator on 08/17/2023 and the Administrator told her about the regulation requiring eight consecutive hours of RN coverage per day. She said she had followed that direction but could not speak for the previous Staffing Coordinator. <BR/>In an interview on 08/31/2023 at 2:47 PM, the Administrator stated she was aware the facility required RN coverage for eight consecutive hours per day, seven days per week. She said she was not aware this requirement had not been met on 07/01/2023 and 07/02/2023. She said the Staffing Coordinator was responsible for ensuring RN coverage was sufficient. She said the facility recently changed Staffing Coordinators and DON. She said ultimately it was her and the DON's responsibility to ensure RN coverage was in place. <BR/>Record review of the facility's policy titled, Nursing Services - Registered Nurse (RN), revised October 2022, reflected, It is the intent of the facility to comply with Registered Nurse staffing requirements. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services for 1 of 3 residents (Resident #2) reviewed for catheter care.<BR/>The facility failed to ensure LVN A followed relevant clinical guidelines and provided appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.<BR/>This failure could place the resident at risk of urethral tears or dislodging the catheter and urinary tract infections.<BR/>Findings included:<BR/>1. Record review of Resident #1's annual MDS assessment, dated 12/17/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 13 indicating his cognitive status was intact. His diagnoses included neurogenic bladder (a condition that affects the bladder's ability to function properly due to damage or dysfunction in the nerves that control it), paraplegia (a condition characterized by the loss of motor and sensory function in the lower half of the body, including the legs, feet, and genitals), pressure ulcer of sacral regions stage 4, and hypertension. The resident was dependent on staff for toileting. The resident was always incontinent of bowel and bladder. <BR/>Record review of Resident #2's care plans, dated 02/02/25, reflected:<BR/>The resident had an ADL Self Care Performance Deficit related to paraplegia. <BR/>Facility interventions included: The resident required extensive assistance with toileting.<BR/>Record review of Resident #2's orders, dated 08/08/24, reflected:<BR/>Foley catheter to be changed monthly and as needed for malfunction.<BR/>An observation on 02/20/25 at 1:00 PM revealed Resident #2 was lying in bed and his indwelling catheter drainage bag was on the floor. The catheter was not anchored to a non-moveable part of the bed.<BR/>An observation 02/20/25 at 1:10 PM revealed the indwelling catheter bag was still on the floor. <BR/>An interview on 02/20/25 at 1:13 PM with LVN A revealed that when LVN A went to administer the resident's IV antibiotic, the foley catheter drainage bag was on the floor. LVN A stated that she was going to finish other things and that she would return later to get the drainage bag off the floor. LVN A left the resident's room without getting the drainage bag off the floor.<BR/>An interview on 02/20/25 at 2:47 PM with the ADON revealed leaving the Foley bag on the floor would put the resident at risk for infection.<BR/>An interview on 02/20/25 at 3:37 PM with LVN A revealed the Foley catheter drainage bag needed to be positioned below the bladder, hang on the side of the bed, and not be on the floor. LVN A stated that she did not remove the bag from the floor because it was going to take a long time to clean the catheter bag and secure it on the bedside. LVN A stated that the risk to the patient was risk for infection.<BR/>An interview on 02/20/25 at 4:26 PM with the DON revealed the Foley catheter drainage bags should never be on the floor and they should be secured to the bed frame. The DON stated that placing the drainage bag on the floor could put the resident at risk of further infection and dislodgment of the catheter.<BR/>Review of the facility policy, Urinary continence and incontinence -Assessment and Management and urinary tract infection/bacteriuria clinical protocol reflected: <BR/>Indwelling catheters should be anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter.

Based on observation, interview and record review the facility failed to ensure that survey results were posted and, in a place, readily accessible to residents and visitors at the facility.<BR/>The facility failed to ensure that survey results were posted and accessible for review on 07/15/24.<BR/>This failure could impact the residents and visitors' ability to freely review the facility's outcome of regulatory compliance surveys without asking staff for survey results.<BR/>Findings Included:<BR/>Observation on 07/15/24 at 12:05 PM during rounds revealed no survey results binder or sign indicating location of results was posted anywhere in the facility.<BR/>Observation on 07/15/24 at 1:34 PM during rounds revealed no survey results binder or sign indicating location of results was posted anywhere in the facility.<BR/>An interview with the Administrator on 07/15/24 at 3:37 PM revealed that she was responsible for ensuring that the survey results sign and binder was posted in a clear and accessible spot within the facility per facility policy. The Administrator said that she had the survey results and sign posted at the front of the facility in the past, but they have since disappeared. The administrator stated that the survey results should be posted at the front of the facility and residents, staff and family members should have the ability to access the results. The administrator did not give any risks associated with not having the most recent survey results posted.<BR/>A review of the facility policy titled, Survey Results, revised on April 2007, reflected:<BR/>Copies of survey results, are maintained in the administrative offices. A copy of the most recent standard survey, including any subsequent extended surveys, follow-up visits reports, etc along with state approved plans of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or activity room.

Based on observation, interview and record review the facility failed to determine and outline in the facility's, facility assessment, the necessary amount of emergency food and water necessary for their facility population during an emergency for 1 of 1 facility.<BR/>1.The facility failed to outline in their facility assessment, the amount of food and water necessary to maintain their resident population. <BR/>These failures placed residents at risk of not having emergency water and food.<BR/>Findings Included:<BR/>Record Review of the facility's, facility assessment, no date indicated on the assessment, revealed the following sections:<BR/>Facility Profile<BR/>Resident Population<BR/>Care & Competency requirements<BR/>Resident Acuity<BR/>Workforce<BR/>Training Evaluation<BR/>Physical Plant<BR/>Services<BR/>Ethnic, Cultural, Religious Needs<BR/>Resources<BR/>Contracts<BR/>Natural Hazards<BR/>Technological Hazards<BR/>Human Hazards<BR/>Hazardous Materials<BR/>Record review of the facility's, undated facility assessment section titled, facility profile revealed a current census of 71 and total capacity of 204.<BR/>Record review of the facility's, undated facility assessment section titled, ethnic, cultural religious needs revealed a subsection titled, ethnic, cultural, food or religious needs identified based on resident population was, blank.<BR/>Record review of the facility's, undated facility assessment section titled, resources revealed the heading that, the assessment must include or address the facilities resources which include, but are not limited to a facilities operating budget, supplies, equipment or other services necessary to provide the needs of residents. <BR/>Record review of the facility's, undated facility assessment section titled, resources did not include any mention of the facilities emergency food or water supply.

Based on interviews, the facility failed to protect and facilitate the resident's right to communicate with individuals and entities within and external to the facility for 1 of 1 facility reviewed for communication with privacy. The facility failed to deliver mail to residents on Saturdays. This failure infringes on the residents' rights to receive mail and communications. Findings included: During a confidential resident council meeting, the residents in attendance were asked 26 questions. Question 19 asked residents Is mail delivered unopened and on Saturdays? All 8 residents in attendance answered no to question 19. An interview conducted on 09/16/2025 at 9:45am with the BOM revealed she sorts the mail when it arrives at the facility and then it is delivered to the residents. When asked if residents receive mail on Saturdays, the BOM stated they do not, because there is no one at the facility to sort it before it gets distributed to the residents. The BOM further stated there is a possibility of important documents, like Medicaid documents, that could get passed to the resident and then lost. When asked if there was a risk to the residents not receiving mail on Saturdays, she stated she did not think there was. A facility policy related to mail distribution was requested from the Administrator twice on 09/16/2025 and was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents on 3 of 5 Halls (200, 300 and 400 Halls) reviewed for environmental concerns. <BR/>The facility failed to ensure residents overhead light fixtures illuminated in the resident's bedrooms on hall 200 (Rm# 206,212, and 222), hall 300 (Rm# 301, 303, and 310) and hall 400 (Rm#405, 406 and 419).<BR/>This failure could place residents at risk of not having a safe and functional environment. <BR/>Findings included: <BR/>Interview and observation on 04/16/25 at 8:00 AM Resident#1 and Resident#2 who shared a room stated it was hard to see in their room. Right side of the room overhead fixtures did not work at all. Left side of the room overhead light fixture had one working light bulb. <BR/>Interview on 04/16/25 at 9:30 AM MD stated that he had been employed at the facility for 3 months. The MD stated the old fixtures did not provide adequate light in residents rooms. The MD stated the light in the residents' rooms did not read at 50-foot candle . The MD stated he is currently working on updating the lights in the resident's rooms to the required 50fc, but it would take some time and he did not know approximately how long it would take. The MD stated he did not have a light meter reader on him today but would bring one in. <BR/>Observation on 04/17/25 between 3:45 PM and 4:30 PM the MD tested lighting in resident's rooms which revealed: <BR/>1. Lighting measured between 20.3 fc and 25.4 fc in the resident's rooms on hall 200. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms 206,212, and 222.<BR/>2. Lighting measured approximately 19.6 fc and 20.2 fc in the residents' rooms on Hall 400. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms [ROOM NUMBER].<BR/>3. Lighting measured approximately 20.7 fc and 30.5 fc in residents' rooms on hall 300. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms 405, 406 and 419.<BR/> Attempted to do an observation and interview on 04/17/25 at 4:30 PM with Resident #1 and Resident#2 with MD. Resident#1 and Resident#2 stated they were asleep and to come back later. <BR/>Interview on 04/17/25 at 4:45 pm the Administrator stated low lighting could result in trips and falls. The DON stated residents would not be able to see. <BR/>Record review of the facility's policy and procedures revised August 2009 revealed Quality of Life-Homelike Environment read in part .Policy Statement: Resident are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to extent possible . Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The lighting design emphasizes:<BR/>1. <BR/>Sufficient general lighting in resident-use areas;<BR/>2. <BR/>Task lighting as needed;<BR/>3. <BR/>Reduction in glare (through use of light filters, no wax floors);<BR/>4. <BR/>Even light levels;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services for 1 of 3 residents (Resident #2) reviewed for catheter care.<BR/>The facility failed to ensure LVN A followed relevant clinical guidelines and provided appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.<BR/>This failure could place the resident at risk of urethral tears or dislodging the catheter and urinary tract infections.<BR/>Findings included:<BR/>1. Record review of Resident #1's annual MDS assessment, dated 12/17/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 13 indicating his cognitive status was intact. His diagnoses included neurogenic bladder (a condition that affects the bladder's ability to function properly due to damage or dysfunction in the nerves that control it), paraplegia (a condition characterized by the loss of motor and sensory function in the lower half of the body, including the legs, feet, and genitals), pressure ulcer of sacral regions stage 4, and hypertension. The resident was dependent on staff for toileting. The resident was always incontinent of bowel and bladder. <BR/>Record review of Resident #2's care plans, dated 02/02/25, reflected:<BR/>The resident had an ADL Self Care Performance Deficit related to paraplegia. <BR/>Facility interventions included: The resident required extensive assistance with toileting.<BR/>Record review of Resident #2's orders, dated 08/08/24, reflected:<BR/>Foley catheter to be changed monthly and as needed for malfunction.<BR/>An observation on 02/20/25 at 1:00 PM revealed Resident #2 was lying in bed and his indwelling catheter drainage bag was on the floor. The catheter was not anchored to a non-moveable part of the bed.<BR/>An observation 02/20/25 at 1:10 PM revealed the indwelling catheter bag was still on the floor. <BR/>An interview on 02/20/25 at 1:13 PM with LVN A revealed that when LVN A went to administer the resident's IV antibiotic, the foley catheter drainage bag was on the floor. LVN A stated that she was going to finish other things and that she would return later to get the drainage bag off the floor. LVN A left the resident's room without getting the drainage bag off the floor.<BR/>An interview on 02/20/25 at 2:47 PM with the ADON revealed leaving the Foley bag on the floor would put the resident at risk for infection.<BR/>An interview on 02/20/25 at 3:37 PM with LVN A revealed the Foley catheter drainage bag needed to be positioned below the bladder, hang on the side of the bed, and not be on the floor. LVN A stated that she did not remove the bag from the floor because it was going to take a long time to clean the catheter bag and secure it on the bedside. LVN A stated that the risk to the patient was risk for infection.<BR/>An interview on 02/20/25 at 4:26 PM with the DON revealed the Foley catheter drainage bags should never be on the floor and they should be secured to the bed frame. The DON stated that placing the drainage bag on the floor could put the resident at risk of further infection and dislodgment of the catheter.<BR/>Review of the facility policy, Urinary continence and incontinence -Assessment and Management and urinary tract infection/bacteriuria clinical protocol reflected: <BR/>Indwelling catheters should be anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter.

Based on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population. <BR/>The facility failed to ensure a qualified dietitian or other clinically qualified nutrition professional was employed either full-time, part-time, or on a consultant basis.<BR/>This failure could place residents at risk of not having their nutritional needs met, weight loss, and an increased risk for wounds. <BR/>Findings include:<BR/>Interview on 02/15/24 at 3:42 p.m. the facility's former RD stated she stopped providing consulting services to the facility in December 2023 due to not being paid for over 5 months. She stated she was concerned for residents as the facility currently had no RD. <BR/>Interview on 02/15/24 at 3:55 p.m. the Administrator stated the facility had no dietician or other clinically qualified nutrition professional either contracted or on staff since December 2023. She stated from what she was told there was an issue with the former contracted dietician being paid. She further stated the facility had weekly weight meetings and interventions were implemented under the direction of the physician. She stated the facility had placed ads for an RD seven days ago. Additionally, The Administrator stated it was important for the facility to have a dietician because the dietician had knowledge and was able to recommend nutritional interventions. <BR/>Interview on 02/16/24 at 9:30 a.m. the Dietary Manager stated she was the facility's designated director of food and nutrition and had not received any consultation from a qualified dietitian or other clinically qualified nutrition professional since December 2023. She stated she needed a dietician to help with determining resident's caloric needs especially when there were resident weight concerns. The Dietary Manager stated she had been calling her friends who were Registered Dietitians for their opinions and help. <BR/>Interview on 02/16/24 at 3:18 p.m. the Administrator stated it was important for the facility to have a dietitian because they were knowledgeable and trained to address and prevent excessive weight loss and wounds developing due to nutritional insufficiencies. The Administrator further stated not having a dietitian placed residents at risk of possible illness, weight loss, development and/or deterioration in wounds. <BR/>Record review of the facility's Dietitian policy/procedure revised 08/2010 revealed A qualified Dietitian will help oversee clinical nutritional Dietary Services in the facility. The policy/procedure reflected the qualified dietitian would help oversee clinical nutritional services to residents. The dietitian would work closely with the Food Services Manager and clinical staff. Dietitian duties included assessing nutritional needs of residents and developing and planning regular and therapeutic diets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents on 3 of 5 Halls (200, 300 and 400 Halls) reviewed for environmental concerns. <BR/>The facility failed to ensure residents overhead light fixtures illuminated in the resident's bedrooms on hall 200 (Rm# 206,212, and 222), hall 300 (Rm# 301, 303, and 310) and hall 400 (Rm#405, 406 and 419).<BR/>This failure could place residents at risk of not having a safe and functional environment. <BR/>Findings included: <BR/>Interview and observation on 04/16/25 at 8:00 AM Resident#1 and Resident#2 who shared a room stated it was hard to see in their room. Right side of the room overhead fixtures did not work at all. Left side of the room overhead light fixture had one working light bulb. <BR/>Interview on 04/16/25 at 9:30 AM MD stated that he had been employed at the facility for 3 months. The MD stated the old fixtures did not provide adequate light in residents rooms. The MD stated the light in the residents' rooms did not read at 50-foot candle . The MD stated he is currently working on updating the lights in the resident's rooms to the required 50fc, but it would take some time and he did not know approximately how long it would take. The MD stated he did not have a light meter reader on him today but would bring one in. <BR/>Observation on 04/17/25 between 3:45 PM and 4:30 PM the MD tested lighting in resident's rooms which revealed: <BR/>1. Lighting measured between 20.3 fc and 25.4 fc in the resident's rooms on hall 200. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms 206,212, and 222.<BR/>2. Lighting measured approximately 19.6 fc and 20.2 fc in the residents' rooms on Hall 400. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms [ROOM NUMBER].<BR/>3. Lighting measured approximately 20.7 fc and 30.5 fc in residents' rooms on hall 300. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms 405, 406 and 419.<BR/> Attempted to do an observation and interview on 04/17/25 at 4:30 PM with Resident #1 and Resident#2 with MD. Resident#1 and Resident#2 stated they were asleep and to come back later. <BR/>Interview on 04/17/25 at 4:45 pm the Administrator stated low lighting could result in trips and falls. The DON stated residents would not be able to see. <BR/>Record review of the facility's policy and procedures revised August 2009 revealed Quality of Life-Homelike Environment read in part .Policy Statement: Resident are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to extent possible . Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The lighting design emphasizes:<BR/>1. <BR/>Sufficient general lighting in resident-use areas;<BR/>2. <BR/>Task lighting as needed;<BR/>3. <BR/>Reduction in glare (through use of light filters, no wax floors);<BR/>4. <BR/>Even light levels;

Based on interview and record review, the facility failed to conduct a performance review of nurse aides at least once every 12 months and provide regular in-service education based on the outcome of these reviews for 3 of 4 CNAs (CNA A, CNA B, and CNA C) reviewed for performance reviews. <BR/>The facility failed to conduct performance reviews at least every 12 months for CNA A, CNA B, and CNA C. <BR/>This failure could result in residents not receiving the necessary care and services due to nurse aides not receiving training based on their identified needs.<BR/>Findings included:<BR/>Record review of the facility's personnel files for CNA A (hired 03/22/2022), CNA B (hired 08/01/2022), and CNA C (hired 07/31/2000) had no documented evidence of a performance review the since hire. <BR/>In an interview on 08/30/2023 at 11:14 AM, the HR Director stated the CNAs A, B, and C worked at the facility prior to the current owners taking over the facility on 07/01/2022. She said the previous owners did not complete performance reviews, but CNAs A, B, and C should still have an annual performance review completed since the current owners took over on 07/01/2023. She said she normally emailed the department head prior to the employee's annual hire date and the department head would complete the review then return it to the Administrator to sign and then she would place it in the employee's personnel file. She said CNAs A, B, and C did not have a current review because the facility did not have a DON at the time their review was due. She said the review was based on the employee's performance and the employee can provide feedback on the review. She stated this enabled the managers to direct specific trained based on the employee's needs. <BR/>In an interview on 08/31/2023 at 2:47 PM, the Administrator stated she expected department heads to complete annual performance evaluations by the employees' hire date. She said they had not been completed previous to the current company taking ownership on 07/01/2023 but were expected to be completed now. She said the performance evaluation allows employees to provide feedback and assists management in directing needed training. She said they also assisted the management team in assigning raises. She said the department heads completed the reviews and she signed off on them. <BR/>In an interview on 09/01/2023 at 11:58 AM, the DON stated she started at the facility on 07/17/2023 and could not say why performance reviews were not completed prior to that time. She said they were important because they help to direct training for staff and identify staff needs to ensure they were able do their jobs well. <BR/>Record review of the facility's policy titled, Performance Evaluation Ratings, revised August 2010, reflected, Our facility evaluates the employee on the performance of his/her assigned tasks. Failure to receive a satisfactory rating indicated that in-service training is needed. The need for further in-service training is indicated in the competency evaluation column of the job description. Information in this column is used to: develop individual of group in-service training, identify weak areas of job performance, identify problem areas in the facility, and identify individuals with leadership qualities. It should include the following: Goals/objectives for the employee to accomplish before his/her next evaluation, Specific activities to be carried out by the employee and the supervisor to help the employee reach the goals .

Based on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population. <BR/>The facility failed to ensure a qualified dietitian or other clinically qualified nutrition professional was employed either full-time, part-time, or on a consultant basis.<BR/>This failure could place residents at risk of not having their nutritional needs met, weight loss, and an increased risk for wounds. <BR/>Findings include:<BR/>Interview on 02/15/24 at 3:42 p.m. the facility's former RD stated she stopped providing consulting services to the facility in December 2023 due to not being paid for over 5 months. She stated she was concerned for residents as the facility currently had no RD. <BR/>Interview on 02/15/24 at 3:55 p.m. the Administrator stated the facility had no dietician or other clinically qualified nutrition professional either contracted or on staff since December 2023. She stated from what she was told there was an issue with the former contracted dietician being paid. She further stated the facility had weekly weight meetings and interventions were implemented under the direction of the physician. She stated the facility had placed ads for an RD seven days ago. Additionally, The Administrator stated it was important for the facility to have a dietician because the dietician had knowledge and was able to recommend nutritional interventions. <BR/>Interview on 02/16/24 at 9:30 a.m. the Dietary Manager stated she was the facility's designated director of food and nutrition and had not received any consultation from a qualified dietitian or other clinically qualified nutrition professional since December 2023. She stated she needed a dietician to help with determining resident's caloric needs especially when there were resident weight concerns. The Dietary Manager stated she had been calling her friends who were Registered Dietitians for their opinions and help. <BR/>Interview on 02/16/24 at 3:18 p.m. the Administrator stated it was important for the facility to have a dietitian because they were knowledgeable and trained to address and prevent excessive weight loss and wounds developing due to nutritional insufficiencies. The Administrator further stated not having a dietitian placed residents at risk of possible illness, weight loss, development and/or deterioration in wounds. <BR/>Record review of the facility's Dietitian policy/procedure revised 08/2010 revealed A qualified Dietitian will help oversee clinical nutritional Dietary Services in the facility. The policy/procedure reflected the qualified dietitian would help oversee clinical nutritional services to residents. The dietitian would work closely with the Food Services Manager and clinical staff. Dietitian duties included assessing nutritional needs of residents and developing and planning regular and therapeutic diets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents on 3 of 5 Halls (200, 300 and 400 Halls) reviewed for environmental concerns. <BR/>The facility failed to ensure residents overhead light fixtures illuminated in the resident's bedrooms on hall 200 (Rm# 206,212, and 222), hall 300 (Rm# 301, 303, and 310) and hall 400 (Rm#405, 406 and 419).<BR/>This failure could place residents at risk of not having a safe and functional environment. <BR/>Findings included: <BR/>Interview and observation on 04/16/25 at 8:00 AM Resident#1 and Resident#2 who shared a room stated it was hard to see in their room. Right side of the room overhead fixtures did not work at all. Left side of the room overhead light fixture had one working light bulb. <BR/>Interview on 04/16/25 at 9:30 AM MD stated that he had been employed at the facility for 3 months. The MD stated the old fixtures did not provide adequate light in residents rooms. The MD stated the light in the residents' rooms did not read at 50-foot candle . The MD stated he is currently working on updating the lights in the resident's rooms to the required 50fc, but it would take some time and he did not know approximately how long it would take. The MD stated he did not have a light meter reader on him today but would bring one in. <BR/>Observation on 04/17/25 between 3:45 PM and 4:30 PM the MD tested lighting in resident's rooms which revealed: <BR/>1. Lighting measured between 20.3 fc and 25.4 fc in the resident's rooms on hall 200. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms 206,212, and 222.<BR/>2. Lighting measured approximately 19.6 fc and 20.2 fc in the residents' rooms on Hall 400. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms [ROOM NUMBER].<BR/>3. Lighting measured approximately 20.7 fc and 30.5 fc in residents' rooms on hall 300. Lighting was measured approximately 30 inches above the floor. Resident room that was randomly checked included rooms 405, 406 and 419.<BR/> Attempted to do an observation and interview on 04/17/25 at 4:30 PM with Resident #1 and Resident#2 with MD. Resident#1 and Resident#2 stated they were asleep and to come back later. <BR/>Interview on 04/17/25 at 4:45 pm the Administrator stated low lighting could result in trips and falls. The DON stated residents would not be able to see. <BR/>Record review of the facility's policy and procedures revised August 2009 revealed Quality of Life-Homelike Environment read in part .Policy Statement: Resident are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to extent possible . Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The lighting design emphasizes:<BR/>1. <BR/>Sufficient general lighting in resident-use areas;<BR/>2. <BR/>Task lighting as needed;<BR/>3. <BR/>Reduction in glare (through use of light filters, no wax floors);<BR/>4. <BR/>Even light levels;

Based on interviews, the facility failed to protect and facilitate the resident's right to communicate with individuals and entities within and external to the facility for 1 of 1 facility reviewed for communication with privacy. The facility failed to deliver mail to residents on Saturdays. This failure infringes on the residents' rights to receive mail and communications. Findings included: During a confidential resident council meeting, the residents in attendance were asked 26 questions. Question 19 asked residents Is mail delivered unopened and on Saturdays? All 8 residents in attendance answered no to question 19. An interview conducted on 09/16/2025 at 9:45am with the BOM revealed she sorts the mail when it arrives at the facility and then it is delivered to the residents. When asked if residents receive mail on Saturdays, the BOM stated they do not, because there is no one at the facility to sort it before it gets distributed to the residents. The BOM further stated there is a possibility of important documents, like Medicaid documents, that could get passed to the resident and then lost. When asked if there was a risk to the residents not receiving mail on Saturdays, she stated she did not think there was. A facility policy related to mail distribution was requested from the Administrator twice on 09/16/2025 and was not provided.