SAN ANTONIO NORTH NURSING AND REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for 3 of 37 residents (Residents #3, #6, and #8) reviewed for reasonable accommodations, in that:<BR/>1. Resident #3 had no access to her call light that was observed on the floor approximately four feet away from Resident #3.<BR/>2. Resident # 6 had no access to his call light that was observed on the floor behind the headboard of Resident #6's bed.<BR/>3. Resident #8 had no access to his call light that was observed on the floor approximately five feet away from Resident #8.<BR/>This deficient practice could place residents not being able to use call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being. <BR/>Findings included:<BR/>1. Record review of Resident #3's undated face sheet revealed Resident #3 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (occurs when your brain loses oxygen and could cause serious, permanent brain damage), schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), bipolar disorder (a mental illness characterized by alternating periods of elation and depression), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 11/26/2024, revealed a BIMS score of 5, indicating severe cognitive impairment. Section GG - Functional Abilities revealed Resident #2 required substantial to maximum assistance with toileting hygiene, bathing and dressing, and Resident #3 was dependent on staff for transfers. Section GG also revealed Resident #3 required partial to moderate assistance from staff for bed mobility. Section H- Bladder and Bowel revealed Resident #3 was always incontinent of bowel and bladder indicating Resident #1 would have required assistance from staff for incontinent care. <BR/>Record review of Resident #3's comprehensive care plan revealed a care plan that stated, Resident will be treated with dignity and respect while at the facility, date initiated 09/11/2024. <BR/>During an observation of Resident #3 on 01/08/2025 at 12:00 p.m., Resident #3 was lying in her bed asleep and Resident #3's call light was observed on the ground approximately four feet away from Resident #3 in front of her dresser. <BR/>During an interview with PTA, 01/08/2025 at 12:02 p.m., PTA confirmed that he observed Resident #3's call light out of the reach of Resident #3. <BR/>During an interview with CNA A on 01/08/2025 at 12:03 p.m., CNA A stated CNA A and CNA D were working B and C hall and stated resident call lights should be placed within reach of the resident when a resident was in their room. CNA A stated she had received training on call lights. CNA A stated she rounded on her patients at least every 2 hours.<BR/>During an interview with CNA D on 01/08,2025 at 12:20 p.m., CNA D stated it was his second day working on the 1st floor and stated call lights should be within reach of the residents. He stated he made rounds during his shift by going up and down the halls checking on people and CNA D stated he had been answering call lights that morning when he was making rounds.<BR/>During an interview with Resident #3 on 01/10/2025 at 2:50 p.m., Resident #3 stated that she used her call light to call for assistance and indicated that her call light was usually placed on her chest by pointing to her chest and stated here. <BR/>2. Record review of Resident #6's face sheet revealed Resident #6 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included lymphedema, (swelling due to the build-up of fluid in the body due to a problem with the lymphatic system, which is a network of tubes throughout the body that drains fluid), schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities). <BR/>Record review of Resident #6's quarterly MDS assessment, dated 11/07/2024, revealed a BIMS score of 14, indicating no cognitive impairment. Section GG- Functional Abilities revealed Resident #6 was ambulatory and was independent with ADL's and transfers. Section H - Bladder and Bowel indicated Resident #6 had frequent bowel incontinence. <BR/>Record review of Resident #6's comprehensive care plan revealed the following care plans: 1) [Resident #6] is at risk for falls r/t medications, occasional incontinence, insomnia, impaired cognition-schizophrenia, psych meds and psychosis, date initiated 03/15/2023. An intervention listed was be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, date initiated 06/12/2021. 2) [Resident #6] has an ADL self-care performance deficit medication, psychological dx and needs set up to limited assist at times, date initiated 06/12/2021. An intervention listed was encourage the resident to use bell to call for assistance, date initiated 06/12/2021. <BR/>During an observation and interview with Resident #6 on 01/08/2025 at 12:35 p.m., Resident #6's was observed sitting on the side of his bed eating lunch and Resident #6's call light was observed to be on the floor behind the head of Resident #6's bed. Resident #6 stated he did not place the call light behind his bed and stated staff usually place his call light on his bed. Resident #6 stated he did use his call light at times to call for assistance and stated he could not reach his call light from his seated position while eating lunch. <BR/>3. Record review of Resident #8's undated face sheet revealed Resident #8 was an [AGE] year old male who had an initial admission date of 02/16/2001, admission date of 04/12/2018, and admitted with diagnoses that included senile degeneration of brain (a term used to describe a cognitive decline, memory loss and difficulty learning, and problem solving in older adults), Alzheimer's disease (a progressive disease that affects memory and other important mental functions), legal blindness (a specific level of visual impairment that includes both people who are totally blind and those who have some vision but with significant limitations), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities), and disorganized schizophrenia (disorganization of thought processes, behavior, and emotions).<BR/>Record review of Resident #8's quarterly MDS assessment, dated 12/09/2024, revealed a BIMS score of 02, which indicated the resident was severely cognitively impaired. Section B- Hearing, Speech, and Vision revealed Resident #8 was sometimes able to make himself understood and express his ideas and wants and sometimes able to understand others. Section B also revealed Resident #8 had severely impaired vision. Section GG - Functional Abilities revealed Resident #8 required partial/moderate assistance with bathing and dressing and required supervision or touching assistance with bed mobility and transfers. Section H -Bladder and Bowel revealed Resident #8 was frequently incontinent of his bowel and bladder indicating Resident #8 would require staff assistance with incontinent care. <BR/>Record review of Resident #8's comprehensive care plan revealed the following care plans: 1. [Resident #8] has an ADL self-care performance deficit r/t cognition and blindness, dated initiated 9/19/2017 and revised 6/07/2021. An intervention listed was encourage the resident to use bell to call for assistance, dated initiated 6/07/2021 and revised 6/15/2023. 2. [Resident #8 is at risk for falls r/t blindness, incontinence, medications, unsteady gait, and Parkinson's, date initiated 6/07/2021 and revised 9/09/2021. An intervention listed was be sure the resident's call light is within reach and encourage the resident to use it to call for assistance as needed. The resident needs prompt response to all requests for assistance, date initiated 6/07/2021.<BR/>During an observation on 01/08/2025 at 1:16 p.m., Resident #8 was observed lying in bed asleep and Resident #8's call light was observed lying on the floor underneath a wheelchair approximately five feet away from Resident #8's bed. <BR/>During an interview with RN C on 01/08/2025 at 2:35 p.m., RN C stated he was the Charge Nurse on the first floor and stated, I educate my staff about keeping the call lights in reach at all times.<BR/>During an interview with the Administrator on 01/10/2025 at 1:48 p.m., the Administrator stated call lights should have been within reach of a resident when the resident was in their room. He stated it was important for the call light to be in reach so the resident can access the light whenever they need to meet their needs. The Administrator stated the facility staff had received training on call light placement and would receive additional training during an in-service scheduled for 1/17/2025. <BR/>During an interview with the DON on 01/10/2025 at 2:28 p.m., the DON stated she ensured call lights were in reach of facility residents by rounding and made sure call lights were attached to the resident bed or wheelchair. The DON stated the call light should have been in reach of each resident and it was important for the call light to be in reach so the resident could call for help when needed. The DON stated when she started in her role 2 weeks ago, the DON rounded with staff in resident rooms to demonstrate observations each staff member should have made when rounding in rooms and that included call light placement. The DON also stated call light placement was a part of the skills competency check off trainings completed by direct care staff. <BR/>Record review of a facility policy titled Call System, Resident, MED-PASS, Inc. (September 2022), revealed a policy heading that stated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Listed under, Policy Interpretation and Implementation, the policy stated, 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it for 1 of 7 residents (Resident #1) reviewed for pharmaceutical services. The facility failed to document review and response to irregularities identified in Resident #1's medication regimen in August and September 2025. This failure could result in unintended effects of medications and/or illness. Findings included: Record review of Resident #1's face sheet dated 10/08/2025 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included intentional self-harm by unspecified firearm discharge and other chronic pain. Record review of Resident #1's quarterly MDS, submitted 8/5/2025, reflected a BIMS score of 15, which indicated intact cognition. Section N0415 reflected Resident #1 was taking opioid medication. Section N2001 (did a complete drug regimen review identify potentially clinically significant medication issues?) was not answered. Record review of a facility document titled All Recommendations dated 8/25/2025 reflected communication from RPh to the facility that read as follows: [Resident #1]Please assess the risk/benefit of the combination of:Buprenorphine 300mcg BIDMethadone 15mg TIDCyclobenzaprine 10mg BIDTizanidine 2mg QHSIn the column of the document labeled follow-through, there was text that read note written to physician in the area next to Resident #1's medication regimen. Record review of a facility document titled All Recommendations dated 9/26/2025 reflected communication from RPh to the facility that read as follows: [Resident #1]CMS Mega Rule Phase II- PRN orders for psychotropic drugs are limited to 14 days . prescriber should document the rationale in the resident's medical record and indicated the duration for the PRN order [sic]Current Medication: Hydroxyzine HCl 25mg every 12 hours PRN for anxiety since 9/22/25In the column of the document labeled follow-through, there was text that read note written to physician in the area next to Resident #1's medication regimen. Record review of Resident #1's progress notes written August and September 2025 did not reveal documentation from a provider indicating review of pharmacy identified regularities had been acknowledged and reviewed. In an interview with the RPh on 10/08/2025 at 12:48 PM, she said she had sent communication to the facility regarding Resident #1's medications in August and September 2025. She said she had documented in her notes a positive response for August 2025, but she could not locate the specific documentation indicating the response from the provider. She said she thought she did not receive a direct response, and it was her process to accept a non-response to indicate that a resident's medication regimen should continue as it was originally ordered. She said she had not received a response from the facility or the provider regarding Resident #1's medication review for September 2025. In an interview with the ADON on 10/9/2025 at 10:30 AM, she said she was the staff member responsible for the medication regimen reviews. She said her process was to send the reviews to the providers immediately after receiving them, and she would receive a response either by e-mail or in person. She said if she does not receive a response, then she does not follow-up with the providers, and the facility will continue the medication regimen as it was ordered. She said the potential harm to residents of not having their medication regimen reviews completed was dependent on the medication, but it could include increased pain or infection. In an interview with the MD on 10/9/2025 at 11:27 AM, he stated he was the physician overseeing the care provided to residents at the facility by the nurse practitioners. He was unaware that Resident #1 had pharmacy recommendation that were unanswered in August and September 2025. He said his expectation was the responsible party will immediately respond to any communication from the pharmacist, and the facility should contact him if they do not receive a timely response. Record review of the facility policy titled Pharmacy Services (revised 6/15/2025) revealed the following:8. The pharmacist, in collaboration with the facility and the medical director, should include within its services to:a. Develop, implement, evaluate and revise (as necessary) the procedures for the provision of all pharmaceutical services, including procedures to support resident quality of life such as those that support safe, individualized medication administration programs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 residents (Resident #10 and Resident #8) reviewed for incontinence care. <BR/>1. The facility failed to ensure Resident #10's urinary catheter bag was emptied and not backing up into the catheter tubing. <BR/>2. The facility failed to ensure Resident #8 received timely incontinent care, which led to a strong foul odor about her person. <BR/>This failure could place residents at risk of urinary tract infections.<BR/>Findings include:<BR/>1. Record review of Resident #10's, undated, face sheet reflected a [AGE] year-old male resident who was admitted to the facility on [DATE] with diagnoses which included Congenital and Developmental Myasthenia (inherited disorder that usually develops at or near birth and involves muscle weakness and fatigue), Type 2 Diabetes Mellitus (chronic condition that affects the way body processes blood sugar), Schizoaffective Disorder, Depressive type (chronic mental health condition characterized by symptoms of schizophrenia such as hallucinations or delusions with symptoms of mood disorder), low back pain, Essential Hypertension (high blood pressure), Neuromuscular dysfunction of bladder (lack of bladder control due to a brain, spinal cord or nerve problem) and need for assistance with personal care. <BR/>Record review of Resident #10's Care Plan reflected he had an indwelling catheter related to neuromuscular dysfunction bladder. Goal: (He) will show no signs/symptoms of urinary function through review date 06/22/2023. Interventions: none were noted regarding emptying the urinary catheter bag. <BR/>Record review of Resident #10's Comprehensive MDS assessment, dated 03/20/2023, reflected a BIMS score of 14, which indicated intact cognitive status. <BR/>Observation and interview on 04/12/2023 at 9:35 AM in Resident #10's room revealed his urinary catheter bag totally full, stretched out like a blown-up balloon with urine backing up into the catheter tubing. The resident complained that no one would empty his catheter bag and he had to empty it himself. He stated when he was admitted to the facility, he had an E-coli (type of bacteria) infection in his urine and had received intravenous antibiotics at the hospital for a urinary tract infection. He stated sometimes the urine backed up into his bladder, leaked out and wet his bed. <BR/>Interview on 4/12/2023 at 9:40 AM, the MDSN observed Resident #10's full urinary catheter bag and stated it could cause him discomfort, and a urinary tract infection by urine backing up into bladder. <BR/>Interview on 04/12/2023 at 9:45 AM, LVN A stated she came to work at the facility at 6:10 am. She observed the full, stretched tight urinary catheter bag for Resident #10, and stated the aides were supposed to empty the bags. She stated the urine could back up into his bladder and cause infections. She stated he had finished his oral antibiotic for a urinary tract infection. <BR/>Interview on 04/14/2023 at 9:44 AM, CNA E stated she had been at the facility since February 2022. She stated she emptied the catheter bags by the end of her shift because she did not want them to fill up and bust. She stated the resident could get an infection because there was a lot of bacteria in the bag. <BR/>Interview on 04/14/2023 at 9:49 AM, CNA F stated she emptied the urinary catheter bags first thing in the morning and at the end of the shift. She stated if the urinary catheter bag got too full it could backflow into the bladder and cause an infection. She stated urine could end up on the floor and a resident could slip on it. She stated most CNAs checked the bags during the shift and at the end of the shift and it was rare to see them totally full.<BR/>Interview on 04/14/2023 at 10:14 AM, the DON stated the CNAs were responsible for emptying urinary catheters at the end of the shift and the nurses should make sure they were doing it. She stated the potential risk to the resident if they were too full was a urinary tract infection.<BR/>Interview on 04/14/2023 at 2:40 PM, the ADM stated if urinary catheter bags were not being emptied the urine could get on the floor and the resident could get a urinary tract infection. He stated his expectation was for the staff to empty the catheters.<BR/>Record review of the facility policy and procedure titled Catheter care, Urinary, dated Quarter 3, 2018, stated The purpose of this procedure is to prevent catheter-associated urinary tract infections. Infection control: Empty the collection bag at least every eight (8) hours.<BR/>2. Record review of Resident #8's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included cellulitis, cerebral ischemia memory deficits, need for assistance with personal care, type two diabetes mellitus, anxiety disorder, and schizoaffective disorder.<BR/>Record review of the quarterly MDS for Resident #8, dated 03/22/23, reflected a BIMS score of 13, which indicated mild cognitive impairment. It also reflected she required extensive assistance of one person for toileting. <BR/>Record review of the care plan for Resident #8, dated 09/14/22, reflected the following: [Resident #8] has an ADL self-care performance deficit related impaired mobility, obesity. [Resident #8] will maintain current level of function through the review date. Toilet Use: The resident requires limited to extensive assist x 1 staff for toileting. [Resident #8] is resistive to care r/t schizophrenia. At times will refuse to shower, follow diet a recommended, follow fluid restriction as recommended. Resident will participate in her plan of care daily and ongoing. Allow the resident to make decisions about treatment regime, to provide sense of control. o Encourage as much participation/interaction by the resident as possible during care activities. o Give clear explanation of all care activities prior to an as they occur during each contact. o If possible, negotiate a time for ADLs so that the resident participates in the decision making process. Return at the agreed upon time. o If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. o Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. o psych services as ordered.<BR/>Record review of POC (CNA) tasks for Resident #8 from 03/15/23 to 04/13/23 reflected provision of incontinent care twice a day for eight days, three times per day for 17 days, four times per day for three days, and one time per day for two days.<BR/>Observations on 04/12/23 at 09:41 AM, 12:03 PM, and 02:24 PM revealed a strong unpleasant odor in the hall surrounding and inside the room of Resident #8.<BR/>Observation and interview on 04/13/23 at 08:36 AM revealed Resident #8 was in her room, and the unpleasant odor was still strong. There was a sign on the bathroom with the title Toileting Schedule and one X: written for Tuesday 9:00 AM with dry erase marker. There were no dates or year on the schedule. When asked if the staff were helping her get to the toilet, Resident #8 stated they sometimes did and sometimes did not. Resident #8 stated she had not been changed today and was in a diaper. Resident #8 stated she did not remember when she last had her brief changed, but she did not need a change. <BR/>Observation on 04/14/23 at 08:11 AM revealed a strong unpleasant odor lingered in the hall outside and inside the room for Resident #8.<BR/>During an interview on 04/14/23 at 08:25 AM, CNA G stated he smelled the foul odor and knew it was urine. He stated housekeeping had a closet right near Resident #8's room and maybe that was the source of the odor. He stated he thought there could be an old mattress in the closet or something. CAN G stated he had walked int the building thought something smelled really bad, and he guessed it could be one or more of the residents producing the odor, but he was not sure. <BR/>During observation and interview on 04/14/23 at 08:43 AM, the DON stated she did sometimes smell the foul odor in the hall near Resident #8's room, and she wondered if it was the janitorial closet. The DON had the housekeeping supervisor open the closet, and the foul odor was not stronger or present inside. The DON stated the odor might be Resident #8, and there may have been some issues with incontinent care. The DON stated the CNAs who usually work in that area were not in that day. <BR/>During an interview on 04/14/23 at 08:59 AM, CNA F stated her opinion was that the foul odor, which she could detect, was Resident #8. CNA F stated Resident #8 urinated a lot and will soak four to five briefs in one shift and will still be soaking wet. CNA F stated they get the size 3X briefs for Resident #8, but it is still hard to ensure they work properly, but the bigger problem is that Resident #8 will receive incontinent care but not get her clothes changes, so the soaked clothing stays on her and creates the odor. CNA F stated the CNAs were trying everything they knew to do to help with the situation. CNA F stated it was an obvious problem, and management knew about it and had not provided the CNAs with any specific guidance about it. CNA F stated she was not sure what management had come up with to try to help Resident #8. CNA F stated Resident #8's roommate complained about the odor. CNA F stated Resident #8's roommate was very neat and tidy. <BR/>During an interview on 04/14/23 at 11:03 AM, LVN C stated she has noticed the foul odor in the hall and in Resident #8's room since she began working there three months prior. LVN C stated she was not sure why it happened, but she thought it might be because housekeeping was not cleaning the bed when they changed the sheets. LVN C stated Resident #8 wet her brief very heavily during the night, and every morning it reeked of urine. LVN C stated they have a toileting schedule for Resident #8, and it should be followed, but a lot of times Resident #8 would say she did not need to go. LVN C stated there were also times when Resident #8 would not let them know ahead of time. LVN C stated she had suggested a bedside commode but she did not know if Resident #8 would make the effort. LCN C stated Resident #8 needed to be checked and changed more often at night, but she could not say exactly how often would be enough. LVN C stated her opinion was Resident #8 was probably changed only three times each night and probably needed more frequent changes. LVN C stated Resident #8 did not have skin breakdown currently, but potential negative impacts of the failure were skin issues, excoriation, and it could have become worse and developed ulcers. LVN C stated she had never had anyone complain about the odor, but she was sure it bothered anyone who came down the hall. <BR/>During an interview on 04/14/23 at 12:32 PM, the ADON stated she had been at the facility since December 2022. The ADON stated she had noticed the odor in the hallway around Resident #8's room. When asked what she thought was causing the odor, she stated she assumed it was residents using the toilet. The ADON stated the residents who lived on this hall could use the toilet, including Resident #8. The ADON stated she and the other managers went down each hall to make sure they were clean. The ADON stated she had not specifically looked into why there was always an odor of urine around Resident #8's room. The ADON stated she had never had any residents, staff, or visitors complain about the odor. The ADON stated she did not have any knowledge of Resident #8 being on a toileting program. She stated her expectation was for incontinent residents to be checked and changed every two hours and then as needed. The ADON stated potential negative impacts were skin breakdown, infections, and wounds. The ADON stated other residents could feel frustrated and morale could go down. <BR/>During an interview on 04/14/23 at 01:49 PM, the DON stated if Resident #8 was refusing to change clothes or refusing to use the toilet, what should have been happening was they should be getting the nurse on duty. The [NAME] stated when she went looking for the source of the odor, she thought it was possible that it might be the floor and that urine may have soaked in. The DON stated she told the staff to document in the progress notes and the nurse to let them know in the morning meeting if there were refusals or issues. The DON stated the nurses checked the shower sheets for refusals and they tried to do in-services and talk about it with staff to help them learn how to approach refusals. The DON stated potential negative impacts were unpleasant smells, UTIs, rashes, and chafing. <BR/>During an interview on 04/14/23 at 02:24 PM, the ADM stated he had never perceived the smell of urine or other foul odors in the facility. He stated a strong unpleasant odor could have a negative impact on residents and staff alike. <BR/>Record review of the facility policy titled Activities of Daily Living, dated 2018, reflected the following: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care, and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility; c. elimination (toileting): d. dining: e. and communication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 11 residents (Resident #1) reviewed for accuracy of records, in that:<BR/>The facility failed to ensure the treatment administration records (TAR) for Resident #1 accurately reflected the administration of the bilateral wound treatment on 01/03/2025 and 01/07/2025. <BR/>This deficient practice could place residents receiving treatments at risk for not receiving appropriate care.<BR/>The findings were:<BR/>Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included congestive heart failure (a condition in which the heart doesn't pump blood as well as it should), type 2 diabetes (a condition that occurs when the body does not regulate or use sugar properly), bipolar disorder (a mental illness characterized by alternating periods of elation and depression), and lymphedema (swelling due to the build-up of fluid in the body due to a problem with the lymphatic system, which is a network of tubes throughout the body that drains fluid).<BR/>Record review of Resident #1's annual MDS assessment, dated 12/15/2024, revealed a BIMS score of 14, Indicating no cognitive impairment. Section C - Cognitive Patterns revealed Resident #1 had difficulty focusing attention and had disorganized thinking, defined on the MDS as rambling or irrelevant conversation, unclear or illogical flow of ideas or unpredictable switching from subject to subject, and that these symptoms fluctuated in severity. Section E- Behavior revealed Resident #1 rejected care (e.g., bloodwork, taking medications, ADL assistance) 4 to 6 days a week. Section GG - Functional Abilities revealed Resident #1 used a wheelchair for mobility and had impaired range of motion on both sides of her lower extremities. Section GG also revealed Resident #1 was dependent on staff assistance for toileting, lower body dressing, putting on or taking off footwear, and chair/bed to chair transfers. <BR/>Record review of Resident #1's comprehensive care plan revealed the following care plans [Resident #1] is at risk for pressure injuries due to impaired mobility, morbid obesity, dated 04/05/2023 and revised 04/29/2023. Altered skin integrity non pressure related to: BLE vascular wounds, dated 04/07/2023 and revised 05/04/2024. [Resident #1] has a behavior problem. She will refuse wound tx, refuse weekly wound measurements, refuse ADL assistance, say derogatory terms to staff, argue with roommate, dated 04/29/2023 and revised 09/09/2024. Altered skin integrity non pressure related to: vascular wound Lt lower leg circumferential, dated 07/24/2023 and revised 12/24/2024. Altered skin integrity non pressure related to: vascular wounds Rt lower leg circumferential, dated 07/24/2023 and revised 12/24/2024. <BR/>Record review on 01/08/2025 at 10:49 a.m., of Resident #1's December TAR revealed the following orders scheduled for 6 a.m. to: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR was initialed by the Wound Care LVN as completed on 12/24/2024 and coded 3- refused and initialed by the Wound Care LVN on 12/27/2024. B) Wound #1 left lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR was initialed by the Wound Care LVN as completed on 12/24/2024 and coded 3- refused and initialed by the Wound Care LVN on 12/27/2024. The TAR revealed the following orders scheduled PRN: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/09/2024. The TAR revealed Resident #1 received a prn treatment, 12/23/2024 at 5:42 p.m. by Wound Care LVN. B) Wound #1 left lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/09/2024. The TAR revealed Resident #1 received a prn treatment, 12/23/2024 at 5:42 p.m. by Wound Care LVN. <BR/>Record review, on 01/08/2025 at 10:49 a.m., of Resident #1's January TAR revealed the following orders scheduled for 6 a.m. to: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR was not initialed by a nurse as completed on 01/03/2025 and 01/07/2025. B) Wound #1 left lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR was not initialed by a nurse as completed on 01/03/2025 and 01/07/2025.<BR/>Record review, on 01/09/2025 at 11:45 a.m., of Resident #1's January TAR revealed the following orders scheduled for 6 a.m. to: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR is initialed as completed on 01/03/2024 and initialed with '19-other see progress note' by Wound Care LVN. B) Wound #1 left lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR is initialed as completed on 01/03/2024 and initialed with '19-other see progress note' by Wound Care LVN. The TAR revealed the following orders scheduled PRN: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/09/2024. The TAR revealed Resident #1 received a prn treatment, 01/08/2024 at 12:35 a.m. by RN C.<BR/>Record review of the facility wound care log, dated 01/03/2025, revealed Resident #1 had a venous wound to the right lower circumferential and a venous wound to the left lower circumferential. The log revealed Resident #1 admitted with the wounds on 12/22/2023 and the wounds measured 45 x 35 x 0.2cm.<BR/>Record review of Resident #1's progress note, 12/27/2024 at 3:21 p.m. by Wound Care LVN, stated resident refused wound care. [physician group name] RN notified. No new orders.<BR/>During an observation on 01/08/2025 at 11:25 a.m., Resident #1 was observed lying in bed with bilateral lower legs wrapped in compression wraps and toes were wrapped in gauze. The wraps and gauze were clean and intact and dated 01/08/2025 at 12:35 a.m.<BR/>During an interview with RN B on 01/08/2025 at 2:20 p.m., RN B stated she worked with Resident #1 on the overnight shift of 01/07/2025. RN B stated RN C completed Resident #1's wound care and RN B stated she did not see the dates on Resident #1's bilateral dressings prior to RN C completing Resident #1's wound care. RN B stated Resident #1 refused care and refused for wound care to be completed at times but did allow RN C to complete wound care on the overnight shift on 01/07/2025.<BR/>During an interview with RN C on 01/08/2025 at 2:35 p.m., RN C stated he completed Resident #1's wound care on 01/08/2025 around 12:30 a.m. RN C stated he did Resident #1's wound care if Resident #1 refused wound care earlier in the day and was told by Wound Care LVN that Resident #1 had refused wound care during the day shift. RN C stated he did not document that he completed the wound care on the TAR. He stated he texted Wound Care LVN to notify the Wound Care LVN the wound care was completed and Wound Care LVN would document on Resident #1's TAR. RN C stated the TAR was only managed by the Wound Care LVN and RN C did not document on the TAR. RN C stated he can view the TAR to follow the treatment order and was notified when a treatment needed to be completed by the Wound Care LVN. RN C stated he did not pay attention to the date of the previous bandage on Resident #1's bilateral legs when he completed the treatment on 01/08/2025. He stated he could not remember the last time he was asked to complete Resident #1's wound care but stated her wounds looked the same in appearance as he had observed in previous observations. <BR/>During an interview with Resident #1 on 01/09/2025 at 8:05 a.m., Resident #1 stated RN C completed Resident #1's bilateral leg treatments overnight on 01/08/2025. Resident #1 stated the Wound Care LVN would usually complete her dressing changes on Tuesdays and Fridays, but sometimes RN C will do it. Resident #1 stated she did not think her wound care had been completed since 12/23/2024 and stated, that is the date I remember Wound Care LVN doing it. Resident #1 denied refusing wound care or refusing dressing changes. Resident #1 stated she has had the bilateral venous wounds since 2008 and Resident #1 stated she had refused to be seen by the wound care physician at the facility for several months.<BR/>During an interview with the Wound Care LVN on 01/09/2025 at 11:50 a.m., the Wound Care LVN stated she was responsible for providing wound care to Resident #1 and if she was not able to complete the wound care, Resident #1 refused or Wound Care LVN was not scheduled to work, Wound Care LVN would assign a nurse to complete wound care. Wound Care LVN stated she attempted to complete wound care on Resident #1 on 01/07/2025 in the afternoon and stated Resident #1 said she was not ready and did not want Wound Care LVN completing the wound care at that time. Wound Care LVN asked Resident #1 if RN C could do the wound care for Resident #1 later in the day and Resident #1 agreed. Wound Care LVN stated RN C let her know the following day that the wound care was completed and Wound Care LVN initialed 01/07/2025 with a 19- other see progress note and Wound Care LVN stated she added a late entry progress to document that she had asked RN C to complete the wound care. Wound Care LVN stated she educated RN C to document the treatment RN C completed on Resident #1's TAR on the prn orders for the bilateral wound care for 01/08/2025. Wound LVN C stated she also initialed Resident #1's TAR for bilateral wound care as completed on 01/03/2025 because I noticed I had not signed off on the TAR. Wound Care LVN stated Resident #1's bilateral venous wound measurements remain at 45 x 35 x 0.2 cm. Wound Care LVN stated she knew she completed the wound care because she would have entered a progress note for the refusal if Resident #1 had refused the treatment. She stated she had written it down in her personal notes and stated the wound size had not changed. Wound Care LVN stated she had been trained on documenting wound care in the TAR at the time of the wound care and stated it was important to document the treatments at the time they were completed to make sure the treatments are done and report any changes in a timely manner.<BR/>During an interview with the DON on 01/10/2025 at 2:28 p.m., the DON stated missing documentation on the TAR was monitored by nursing managers who run a missing documentation report daily. The DON stated she ran the report on 01/08/2025 after having a conversation with RN C about RN C not documenting Resident #1's treatment on Resident #1's TAR. The DON stated RN C and Wound Care LVN were provided reeducation on 01/08/2025 regarding documentation of treatments on the TAR and documentation of treatments would be completed at the time the wound care was provided. The DON stated she reviewed Resident #1's January TAR with Wound Care LVN and stated Wound Care LVN stated she had completed the treatment on 01/03/2025. The DON stated documentation of wound care should occur right after the treatment has been completed and stated it was important to document timely because we are able to show that the treatment was done or that the treatment was refused and so the physician can see if the treatment is effective for the benefit of the patient.<BR/>Record review of a facility document titled Licensed Nurse Orientation/Annual Skills/Competency Checklist for Wound Care LVN, dated 2/14/2024, revealed Wound Care LVN successfully completed Skill/Task #10. Review shift documentation process, requirements of obtaining physician orders (dx, location, parameters, monitoring, dose, freq, medication times, entering onto MAR/TAR, etc.).<BR/>Record review of a facility document titled Competency Assessment Wound Care, signed by Wound Care LVN listed the date completed as 10/2024. The competency assessment revealed check marks indicating the competency had been demonstrated by Wound Care LVN for E. 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. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any changes in resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason (s) why. 10. The signature and title of the person recording the data. <BR/>Record review of a facility policy titled Wound Care, 2001 Med-Pass, Inc. Revised October 2010, under the section labeled, Documentation, the policy stated 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 car was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any changes in resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerates the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason (s) why. 10. The signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to assist residents in obtaining routine and 24- hour emergency dental care to meet the needs of 1 of 3 residents (Resident #1) reviewed for dental services in that: <BR/>The facility did not assist Resident #1 with obtaining dental services when her top dentures were reported missing on 9/29/24 .<BR/>This failure could place residents at risk of not having their oral health care needs met.<BR/>The findings included: <BR/>Record review of Resident #1's electronic medical record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: Cerebral infarction (is a medical condition where blood flow to the brain is interrupted), kidney disease (is a condition where the kidneys are damaged and cannot function properly), and Dementia (condition that cause a progressive decline in cognitive function, memory, and behavior). <BR/>Record review of Resident #1's inventory sheet, 9/10/24 , revealed Resident #1 had a top denture upon admission. <BR/>Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated intact cognition. Further review revealed Section L did not indicate the resident had upper or lower dentures.<BR/>Record review of Resident #1's care plan, dated 9/25/2024, revealed, [Name of resident] is at risk for oral health problems related to no natural teeth. Interventions: Coordinate arrangements for dental care. Further review revealed the resident's dentures were not mentioned.<BR/>Record review of Resident #1's physician monthly orders from February 2025 revealed a diet order for a regular diet.<BR/>Record review of Resident #1's weight record from 9/9/24 to 2/19/25 revealed resident #1 gained 3 lbs. <BR/>Record review of an email conversation between the previous Texas area president and a family representative for Resident #1, dated 9/27/24, revealed, It appears she is missing top dentures. <BR/>During an interview with the DON on 2/28/25 at 10:10 a.m., revealed she was unaware Resident #1 was missing her top dentures, and by Resident #1 continuing to eat without her top dentures could risk possible choking. <BR/>During an interview with the Texas area president on 2/28/25 at 12:55 p.m. revealed she recalled email conversations between Resident #1 family representative but could not recall the contents of the email conversation. <BR/>During an interview with Resident #1 on 2/28/2025 at 11:41 a.m., Resident #1's revealed, The current nursing home lost my top false teeth. I'm worried that I could choke while eating.<BR/>During an interview with Resident #1's representative on 2/28/25 at 12:30 p.m., revealed she notified the Texas area president (previous administrator) on 9/27/24 top dentures for Resident #1 were missing. <BR/>Observation on 2/28/2025 at 11:42 a.m. revealed Resident #1 had no natural teeth on the top of her mouth. <BR/>During an interview with CNA A on 2/28/25, at 11:55 a.m., CNA A stated Resident #1 had upper dentures at the time of her admission in September 2024 but could not remember when they went missing. CNA A expressed concern Resident #1 was at risk of choking if she continued to eat without her upper dentures.<BR/>During an interview with the Administrator on 2/28/25, at 12:00 p.m., the Administrator indicated he was unaware Resident #1 was missing her upper dentures. The Administrator further noted Resident #1 could potentially choke if she continued to eat without her upper dentures. The Administrator highlighted the importance of assessing residents' oral health, stating that if a dental consultation was necessary, the facility should arrange for one.<BR/>Record review of the facility's policy titled Dental Services revised 2018, revealed, Dentures will be protected from loss or damage to the extent practicable, while being stored.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for 3 of 37 residents (Residents #3, #6, and #8) reviewed for reasonable accommodations, in that:<BR/>1. Resident #3 had no access to her call light that was observed on the floor approximately four feet away from Resident #3.<BR/>2. Resident # 6 had no access to his call light that was observed on the floor behind the headboard of Resident #6's bed.<BR/>3. Resident #8 had no access to his call light that was observed on the floor approximately five feet away from Resident #8.<BR/>This deficient practice could place residents not being able to use call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being. <BR/>Findings included:<BR/>1. Record review of Resident #3's undated face sheet revealed Resident #3 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (occurs when your brain loses oxygen and could cause serious, permanent brain damage), schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), bipolar disorder (a mental illness characterized by alternating periods of elation and depression), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 11/26/2024, revealed a BIMS score of 5, indicating severe cognitive impairment. Section GG - Functional Abilities revealed Resident #2 required substantial to maximum assistance with toileting hygiene, bathing and dressing, and Resident #3 was dependent on staff for transfers. Section GG also revealed Resident #3 required partial to moderate assistance from staff for bed mobility. Section H- Bladder and Bowel revealed Resident #3 was always incontinent of bowel and bladder indicating Resident #1 would have required assistance from staff for incontinent care. <BR/>Record review of Resident #3's comprehensive care plan revealed a care plan that stated, Resident will be treated with dignity and respect while at the facility, date initiated 09/11/2024. <BR/>During an observation of Resident #3 on 01/08/2025 at 12:00 p.m., Resident #3 was lying in her bed asleep and Resident #3's call light was observed on the ground approximately four feet away from Resident #3 in front of her dresser. <BR/>During an interview with PTA, 01/08/2025 at 12:02 p.m., PTA confirmed that he observed Resident #3's call light out of the reach of Resident #3. <BR/>During an interview with CNA A on 01/08/2025 at 12:03 p.m., CNA A stated CNA A and CNA D were working B and C hall and stated resident call lights should be placed within reach of the resident when a resident was in their room. CNA A stated she had received training on call lights. CNA A stated she rounded on her patients at least every 2 hours.<BR/>During an interview with CNA D on 01/08,2025 at 12:20 p.m., CNA D stated it was his second day working on the 1st floor and stated call lights should be within reach of the residents. He stated he made rounds during his shift by going up and down the halls checking on people and CNA D stated he had been answering call lights that morning when he was making rounds.<BR/>During an interview with Resident #3 on 01/10/2025 at 2:50 p.m., Resident #3 stated that she used her call light to call for assistance and indicated that her call light was usually placed on her chest by pointing to her chest and stated here. <BR/>2. Record review of Resident #6's face sheet revealed Resident #6 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included lymphedema, (swelling due to the build-up of fluid in the body due to a problem with the lymphatic system, which is a network of tubes throughout the body that drains fluid), schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities). <BR/>Record review of Resident #6's quarterly MDS assessment, dated 11/07/2024, revealed a BIMS score of 14, indicating no cognitive impairment. Section GG- Functional Abilities revealed Resident #6 was ambulatory and was independent with ADL's and transfers. Section H - Bladder and Bowel indicated Resident #6 had frequent bowel incontinence. <BR/>Record review of Resident #6's comprehensive care plan revealed the following care plans: 1) [Resident #6] is at risk for falls r/t medications, occasional incontinence, insomnia, impaired cognition-schizophrenia, psych meds and psychosis, date initiated 03/15/2023. An intervention listed was be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, date initiated 06/12/2021. 2) [Resident #6] has an ADL self-care performance deficit medication, psychological dx and needs set up to limited assist at times, date initiated 06/12/2021. An intervention listed was encourage the resident to use bell to call for assistance, date initiated 06/12/2021. <BR/>During an observation and interview with Resident #6 on 01/08/2025 at 12:35 p.m., Resident #6's was observed sitting on the side of his bed eating lunch and Resident #6's call light was observed to be on the floor behind the head of Resident #6's bed. Resident #6 stated he did not place the call light behind his bed and stated staff usually place his call light on his bed. Resident #6 stated he did use his call light at times to call for assistance and stated he could not reach his call light from his seated position while eating lunch. <BR/>3. Record review of Resident #8's undated face sheet revealed Resident #8 was an [AGE] year old male who had an initial admission date of 02/16/2001, admission date of 04/12/2018, and admitted with diagnoses that included senile degeneration of brain (a term used to describe a cognitive decline, memory loss and difficulty learning, and problem solving in older adults), Alzheimer's disease (a progressive disease that affects memory and other important mental functions), legal blindness (a specific level of visual impairment that includes both people who are totally blind and those who have some vision but with significant limitations), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities), and disorganized schizophrenia (disorganization of thought processes, behavior, and emotions).<BR/>Record review of Resident #8's quarterly MDS assessment, dated 12/09/2024, revealed a BIMS score of 02, which indicated the resident was severely cognitively impaired. Section B- Hearing, Speech, and Vision revealed Resident #8 was sometimes able to make himself understood and express his ideas and wants and sometimes able to understand others. Section B also revealed Resident #8 had severely impaired vision. Section GG - Functional Abilities revealed Resident #8 required partial/moderate assistance with bathing and dressing and required supervision or touching assistance with bed mobility and transfers. Section H -Bladder and Bowel revealed Resident #8 was frequently incontinent of his bowel and bladder indicating Resident #8 would require staff assistance with incontinent care. <BR/>Record review of Resident #8's comprehensive care plan revealed the following care plans: 1. [Resident #8] has an ADL self-care performance deficit r/t cognition and blindness, dated initiated 9/19/2017 and revised 6/07/2021. An intervention listed was encourage the resident to use bell to call for assistance, dated initiated 6/07/2021 and revised 6/15/2023. 2. [Resident #8 is at risk for falls r/t blindness, incontinence, medications, unsteady gait, and Parkinson's, date initiated 6/07/2021 and revised 9/09/2021. An intervention listed was be sure the resident's call light is within reach and encourage the resident to use it to call for assistance as needed. The resident needs prompt response to all requests for assistance, date initiated 6/07/2021.<BR/>During an observation on 01/08/2025 at 1:16 p.m., Resident #8 was observed lying in bed asleep and Resident #8's call light was observed lying on the floor underneath a wheelchair approximately five feet away from Resident #8's bed. <BR/>During an interview with RN C on 01/08/2025 at 2:35 p.m., RN C stated he was the Charge Nurse on the first floor and stated, I educate my staff about keeping the call lights in reach at all times.<BR/>During an interview with the Administrator on 01/10/2025 at 1:48 p.m., the Administrator stated call lights should have been within reach of a resident when the resident was in their room. He stated it was important for the call light to be in reach so the resident can access the light whenever they need to meet their needs. The Administrator stated the facility staff had received training on call light placement and would receive additional training during an in-service scheduled for 1/17/2025. <BR/>During an interview with the DON on 01/10/2025 at 2:28 p.m., the DON stated she ensured call lights were in reach of facility residents by rounding and made sure call lights were attached to the resident bed or wheelchair. The DON stated the call light should have been in reach of each resident and it was important for the call light to be in reach so the resident could call for help when needed. The DON stated when she started in her role 2 weeks ago, the DON rounded with staff in resident rooms to demonstrate observations each staff member should have made when rounding in rooms and that included call light placement. The DON also stated call light placement was a part of the skills competency check off trainings completed by direct care staff. <BR/>Record review of a facility policy titled Call System, Resident, MED-PASS, Inc. (September 2022), revealed a policy heading that stated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Listed under, Policy Interpretation and Implementation, the policy stated, 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents had the right to personal privacy during personal care for 1 of 3 residents (Resident #3) reviewed for privacy, in that:<BR/>CNA E and CNA J did not maintain privacy while providing incontinent care for Resident #3.<BR/>This failure could place residents who require assistance with incontinent care at risk of being exposed. <BR/>Findings included:<BR/>Record review of Resident #3's undated face sheet revealed Resident #3 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (occurs when your brain loses oxygen and could cause serious, permanent brain damage), schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), bipolar disorder (a mental illness characterized by alternating periods of elation and depression), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 11/26/2024, revealed a BIMS score of 5, indicating severe cognitive impairment. Section GG - Functional Abilities revealed Resident #2 required substantial to maximum assistance with toileting hygiene, bathing and dressing, and Resident #3 was dependent on staff for transfers. Section H- Bladder and Bowel revealed Resident #3 was always incontinent of bowel and bladder.<BR/>Record review of Resident #3's comprehensive care plan revealed a care plan that stated, Resident will be treated with dignity and respect while at the facility, date initiated 09/11/2024. <BR/>During an observation by Surveyor L on 01/09/2025 at 1:40 p.m., Surveyor L observed incontinent care provided to Resident #3 by CNA J and CNA E. Resident #3 was observed lying in the middle bed, Bed B, of a room with 3 residents. CNA J and CNA E were observed pulling the privacy curtain closed for bed A and for bed C to provide privacy for Resident #3 from her roommates. Surveyor L observed that Resident #3 did not have a privacy curtain on the track above her bed that would have provided Resident #3 privacy if a person opened Resident #3's bedroom door during care. <BR/>During an interview with CNA J on 01/09/2025 at 2:01 p.m., CNA J told Surveyor L that CNA E made sure the other curtains were closed all the way during incontinent care and stated there was no curtain available for Resident #3. <BR/>During an interview with CNA E on 01/09/2025 at 2:02 p.m., CNA E told Surveyor L that the windows and privacy curtains should be closed when providing incontinent care to residents. <BR/>During an interview with the Housekeeping Director on 01/09/2025 at 2:43 p.m., the Housekeeping Director told Surveyor K that he ordered privacy curtains and stated every resident room and bed should have a privacy curtain. The Housekeeping Director stated he made rounds daily to make sure privacy curtains were in place. The Housekeeping Director and Surveyor K entered Resident #3's room on 01/09/2025 at 2:46 p.m., and the Housekeeping Director observed Resident #3's privacy curtain was missing and stated, I have been trying to order more hooks for the track. The Housekeeping Director stated the curtain had been down for about a month. The Housekeeping Director stated he would check the housekeeping and maintenance work order system to see if there was a work order for the missing privacy curtain. The Housekeeping Director stated it was important for each resident to have a privacy curtain to maintain their privacy. <BR/>During an interview with the Housekeeping Director on 01/09/2025 at 3:15 p.m., the Housekeeping Director provided a work order and stated, based on the work order, the privacy curtain had been missing from Resident #3's bed since 2022. He stated, if anyone would have told me I would have added it and stated he had the parts and was going to install the privacy curtain. <BR/>During an interview with the Administrator on 01/10/2025 at 1:48 p.m., the Administrator stated each resident should have a privacy curtain and the privacy curtain should be used to provide privacy to the resident during care and at the resident's request. The Administrator stated the use of privacy curtains were important so the residents felt dignified in their personal care and space and stated staff were trained on privacy during new hire orientation, competency checks, and resident rights training. <BR/>During an interview with the DON on 01/10/2025 at 2:28 p.m., the DON stated the expectation for staff was to use the resident privacy curtain when providing incontinent care and the staff should have reported any issues with the privacy curtain to the Housekeeping Director. The DON stated it was important that each resident had a privacy curtain because we can provide the resident privacy during any treatment or care and so they have a curtain to close if they want the privacy in their own space. The DON stated staff were trained on resident privacy. <BR/>During an interview with Resident #3 on 01/10/2025 at 2:50 p.m., Resident #3 stated she was happy with her new privacy curtain.<BR/>Record review of a facility document titled CNA/Nurse Aide Orientation/Annual Sills Competency Checklist revealed a Skill/Task listed on the competency check off that stated Promotes and protects participant's dignity and privacy (knocks on doors, pulls curtains during care, and speaks respectfully to participants).<BR/>Record review of a facility policy titled Resident Rights, 2001 MED-PASS, Inc. (Revised February 2021), revealed a policy statement that stated, Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation stated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; t. privacy and confidentiality.<BR/>Record review of a facility policy titled Dignity, 2001 MED-PASS, Inc. (Revised February 2021), revealed a policy statement that stated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation stated, 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 11 residents (Resident #1) reviewed for accuracy of records, in that:<BR/>The facility failed to ensure the treatment administration records (TAR) for Resident #1 accurately reflected the administration of the bilateral wound treatment on 01/03/2025 and 01/07/2025. <BR/>This deficient practice could place residents receiving treatments at risk for not receiving appropriate care.<BR/>The findings were:<BR/>Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included congestive heart failure (a condition in which the heart doesn't pump blood as well as it should), type 2 diabetes (a condition that occurs when the body does not regulate or use sugar properly), bipolar disorder (a mental illness characterized by alternating periods of elation and depression), and lymphedema (swelling due to the build-up of fluid in the body due to a problem with the lymphatic system, which is a network of tubes throughout the body that drains fluid).<BR/>Record review of Resident #1's annual MDS assessment, dated 12/15/2024, revealed a BIMS score of 14, Indicating no cognitive impairment. Section C - Cognitive Patterns revealed Resident #1 had difficulty focusing attention and had disorganized thinking, defined on the MDS as rambling or irrelevant conversation, unclear or illogical flow of ideas or unpredictable switching from subject to subject, and that these symptoms fluctuated in severity. Section E- Behavior revealed Resident #1 rejected care (e.g., bloodwork, taking medications, ADL assistance) 4 to 6 days a week. Section GG - Functional Abilities revealed Resident #1 used a wheelchair for mobility and had impaired range of motion on both sides of her lower extremities. Section GG also revealed Resident #1 was dependent on staff assistance for toileting, lower body dressing, putting on or taking off footwear, and chair/bed to chair transfers. <BR/>Record review of Resident #1's comprehensive care plan revealed the following care plans [Resident #1] is at risk for pressure injuries due to impaired mobility, morbid obesity, dated 04/05/2023 and revised 04/29/2023. Altered skin integrity non pressure related to: BLE vascular wounds, dated 04/07/2023 and revised 05/04/2024. [Resident #1] has a behavior problem. She will refuse wound tx, refuse weekly wound measurements, refuse ADL assistance, say derogatory terms to staff, argue with roommate, dated 04/29/2023 and revised 09/09/2024. Altered skin integrity non pressure related to: vascular wound Lt lower leg circumferential, dated 07/24/2023 and revised 12/24/2024. Altered skin integrity non pressure related to: vascular wounds Rt lower leg circumferential, dated 07/24/2023 and revised 12/24/2024. <BR/>Record review on 01/08/2025 at 10:49 a.m., of Resident #1's December TAR revealed the following orders scheduled for 6 a.m. to: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR was initialed by the Wound Care LVN as completed on 12/24/2024 and coded 3- refused and initialed by the Wound Care LVN on 12/27/2024. B) Wound #1 left lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR was initialed by the Wound Care LVN as completed on 12/24/2024 and coded 3- refused and initialed by the Wound Care LVN on 12/27/2024. The TAR revealed the following orders scheduled PRN: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/09/2024. The TAR revealed Resident #1 received a prn treatment, 12/23/2024 at 5:42 p.m. by Wound Care LVN. B) Wound #1 left lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/09/2024. The TAR revealed Resident #1 received a prn treatment, 12/23/2024 at 5:42 p.m. by Wound Care LVN. <BR/>Record review, on 01/08/2025 at 10:49 a.m., of Resident #1's January TAR revealed the following orders scheduled for 6 a.m. to: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR was not initialed by a nurse as completed on 01/03/2025 and 01/07/2025. B) Wound #1 left lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR was not initialed by a nurse as completed on 01/03/2025 and 01/07/2025.<BR/>Record review, on 01/09/2025 at 11:45 a.m., of Resident #1's January TAR revealed the following orders scheduled for 6 a.m. to: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR is initialed as completed on 01/03/2024 and initialed with '19-other see progress note' by Wound Care LVN. B) Wound #1 left lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR is initialed as completed on 01/03/2024 and initialed with '19-other see progress note' by Wound Care LVN. The TAR revealed the following orders scheduled PRN: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/09/2024. The TAR revealed Resident #1 received a prn treatment, 01/08/2024 at 12:35 a.m. by RN C.<BR/>Record review of the facility wound care log, dated 01/03/2025, revealed Resident #1 had a venous wound to the right lower circumferential and a venous wound to the left lower circumferential. The log revealed Resident #1 admitted with the wounds on 12/22/2023 and the wounds measured 45 x 35 x 0.2cm.<BR/>Record review of Resident #1's progress note, 12/27/2024 at 3:21 p.m. by Wound Care LVN, stated resident refused wound care. [physician group name] RN notified. No new orders.<BR/>During an observation on 01/08/2025 at 11:25 a.m., Resident #1 was observed lying in bed with bilateral lower legs wrapped in compression wraps and toes were wrapped in gauze. The wraps and gauze were clean and intact and dated 01/08/2025 at 12:35 a.m.<BR/>During an interview with RN B on 01/08/2025 at 2:20 p.m., RN B stated she worked with Resident #1 on the overnight shift of 01/07/2025. RN B stated RN C completed Resident #1's wound care and RN B stated she did not see the dates on Resident #1's bilateral dressings prior to RN C completing Resident #1's wound care. RN B stated Resident #1 refused care and refused for wound care to be completed at times but did allow RN C to complete wound care on the overnight shift on 01/07/2025.<BR/>During an interview with RN C on 01/08/2025 at 2:35 p.m., RN C stated he completed Resident #1's wound care on 01/08/2025 around 12:30 a.m. RN C stated he did Resident #1's wound care if Resident #1 refused wound care earlier in the day and was told by Wound Care LVN that Resident #1 had refused wound care during the day shift. RN C stated he did not document that he completed the wound care on the TAR. He stated he texted Wound Care LVN to notify the Wound Care LVN the wound care was completed and Wound Care LVN would document on Resident #1's TAR. RN C stated the TAR was only managed by the Wound Care LVN and RN C did not document on the TAR. RN C stated he can view the TAR to follow the treatment order and was notified when a treatment needed to be completed by the Wound Care LVN. RN C stated he did not pay attention to the date of the previous bandage on Resident #1's bilateral legs when he completed the treatment on 01/08/2025. He stated he could not remember the last time he was asked to complete Resident #1's wound care but stated her wounds looked the same in appearance as he had observed in previous observations. <BR/>During an interview with Resident #1 on 01/09/2025 at 8:05 a.m., Resident #1 stated RN C completed Resident #1's bilateral leg treatments overnight on 01/08/2025. Resident #1 stated the Wound Care LVN would usually complete her dressing changes on Tuesdays and Fridays, but sometimes RN C will do it. Resident #1 stated she did not think her wound care had been completed since 12/23/2024 and stated, that is the date I remember Wound Care LVN doing it. Resident #1 denied refusing wound care or refusing dressing changes. Resident #1 stated she has had the bilateral venous wounds since 2008 and Resident #1 stated she had refused to be seen by the wound care physician at the facility for several months.<BR/>During an interview with the Wound Care LVN on 01/09/2025 at 11:50 a.m., the Wound Care LVN stated she was responsible for providing wound care to Resident #1 and if she was not able to complete the wound care, Resident #1 refused or Wound Care LVN was not scheduled to work, Wound Care LVN would assign a nurse to complete wound care. Wound Care LVN stated she attempted to complete wound care on Resident #1 on 01/07/2025 in the afternoon and stated Resident #1 said she was not ready and did not want Wound Care LVN completing the wound care at that time. Wound Care LVN asked Resident #1 if RN C could do the wound care for Resident #1 later in the day and Resident #1 agreed. Wound Care LVN stated RN C let her know the following day that the wound care was completed and Wound Care LVN initialed 01/07/2025 with a 19- other see progress note and Wound Care LVN stated she added a late entry progress to document that she had asked RN C to complete the wound care. Wound Care LVN stated she educated RN C to document the treatment RN C completed on Resident #1's TAR on the prn orders for the bilateral wound care for 01/08/2025. Wound LVN C stated she also initialed Resident #1's TAR for bilateral wound care as completed on 01/03/2025 because I noticed I had not signed off on the TAR. Wound Care LVN stated Resident #1's bilateral venous wound measurements remain at 45 x 35 x 0.2 cm. Wound Care LVN stated she knew she completed the wound care because she would have entered a progress note for the refusal if Resident #1 had refused the treatment. She stated she had written it down in her personal notes and stated the wound size had not changed. Wound Care LVN stated she had been trained on documenting wound care in the TAR at the time of the wound care and stated it was important to document the treatments at the time they were completed to make sure the treatments are done and report any changes in a timely manner.<BR/>During an interview with the DON on 01/10/2025 at 2:28 p.m., the DON stated missing documentation on the TAR was monitored by nursing managers who run a missing documentation report daily. The DON stated she ran the report on 01/08/2025 after having a conversation with RN C about RN C not documenting Resident #1's treatment on Resident #1's TAR. The DON stated RN C and Wound Care LVN were provided reeducation on 01/08/2025 regarding documentation of treatments on the TAR and documentation of treatments would be completed at the time the wound care was provided. The DON stated she reviewed Resident #1's January TAR with Wound Care LVN and stated Wound Care LVN stated she had completed the treatment on 01/03/2025. The DON stated documentation of wound care should occur right after the treatment has been completed and stated it was important to document timely because we are able to show that the treatment was done or that the treatment was refused and so the physician can see if the treatment is effective for the benefit of the patient.<BR/>Record review of a facility document titled Licensed Nurse Orientation/Annual Skills/Competency Checklist for Wound Care LVN, dated 2/14/2024, revealed Wound Care LVN successfully completed Skill/Task #10. Review shift documentation process, requirements of obtaining physician orders (dx, location, parameters, monitoring, dose, freq, medication times, entering onto MAR/TAR, etc.).<BR/>Record review of a facility document titled Competency Assessment Wound Care, signed by Wound Care LVN listed the date completed as 10/2024. The competency assessment revealed check marks indicating the competency had been demonstrated by Wound Care LVN for E. 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. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any changes in resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason (s) why. 10. The signature and title of the person recording the data. <BR/>Record review of a facility policy titled Wound Care, 2001 Med-Pass, Inc. Revised October 2010, under the section labeled, Documentation, the policy stated 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 car was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any changes in resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerates the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason (s) why. 10. The signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents had the right to personal privacy during personal care for 1 of 3 residents (Resident #3) reviewed for privacy, in that:<BR/>CNA E and CNA J did not maintain privacy while providing incontinent care for Resident #3.<BR/>This failure could place residents who require assistance with incontinent care at risk of being exposed. <BR/>Findings included:<BR/>Record review of Resident #3's undated face sheet revealed Resident #3 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (occurs when your brain loses oxygen and could cause serious, permanent brain damage), schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), bipolar disorder (a mental illness characterized by alternating periods of elation and depression), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 11/26/2024, revealed a BIMS score of 5, indicating severe cognitive impairment. Section GG - Functional Abilities revealed Resident #2 required substantial to maximum assistance with toileting hygiene, bathing and dressing, and Resident #3 was dependent on staff for transfers. Section H- Bladder and Bowel revealed Resident #3 was always incontinent of bowel and bladder.<BR/>Record review of Resident #3's comprehensive care plan revealed a care plan that stated, Resident will be treated with dignity and respect while at the facility, date initiated 09/11/2024. <BR/>During an observation by Surveyor L on 01/09/2025 at 1:40 p.m., Surveyor L observed incontinent care provided to Resident #3 by CNA J and CNA E. Resident #3 was observed lying in the middle bed, Bed B, of a room with 3 residents. CNA J and CNA E were observed pulling the privacy curtain closed for bed A and for bed C to provide privacy for Resident #3 from her roommates. Surveyor L observed that Resident #3 did not have a privacy curtain on the track above her bed that would have provided Resident #3 privacy if a person opened Resident #3's bedroom door during care. <BR/>During an interview with CNA J on 01/09/2025 at 2:01 p.m., CNA J told Surveyor L that CNA E made sure the other curtains were closed all the way during incontinent care and stated there was no curtain available for Resident #3. <BR/>During an interview with CNA E on 01/09/2025 at 2:02 p.m., CNA E told Surveyor L that the windows and privacy curtains should be closed when providing incontinent care to residents. <BR/>During an interview with the Housekeeping Director on 01/09/2025 at 2:43 p.m., the Housekeeping Director told Surveyor K that he ordered privacy curtains and stated every resident room and bed should have a privacy curtain. The Housekeeping Director stated he made rounds daily to make sure privacy curtains were in place. The Housekeeping Director and Surveyor K entered Resident #3's room on 01/09/2025 at 2:46 p.m., and the Housekeeping Director observed Resident #3's privacy curtain was missing and stated, I have been trying to order more hooks for the track. The Housekeeping Director stated the curtain had been down for about a month. The Housekeeping Director stated he would check the housekeeping and maintenance work order system to see if there was a work order for the missing privacy curtain. The Housekeeping Director stated it was important for each resident to have a privacy curtain to maintain their privacy. <BR/>During an interview with the Housekeeping Director on 01/09/2025 at 3:15 p.m., the Housekeeping Director provided a work order and stated, based on the work order, the privacy curtain had been missing from Resident #3's bed since 2022. He stated, if anyone would have told me I would have added it and stated he had the parts and was going to install the privacy curtain. <BR/>During an interview with the Administrator on 01/10/2025 at 1:48 p.m., the Administrator stated each resident should have a privacy curtain and the privacy curtain should be used to provide privacy to the resident during care and at the resident's request. The Administrator stated the use of privacy curtains were important so the residents felt dignified in their personal care and space and stated staff were trained on privacy during new hire orientation, competency checks, and resident rights training. <BR/>During an interview with the DON on 01/10/2025 at 2:28 p.m., the DON stated the expectation for staff was to use the resident privacy curtain when providing incontinent care and the staff should have reported any issues with the privacy curtain to the Housekeeping Director. The DON stated it was important that each resident had a privacy curtain because we can provide the resident privacy during any treatment or care and so they have a curtain to close if they want the privacy in their own space. The DON stated staff were trained on resident privacy. <BR/>During an interview with Resident #3 on 01/10/2025 at 2:50 p.m., Resident #3 stated she was happy with her new privacy curtain.<BR/>Record review of a facility document titled CNA/Nurse Aide Orientation/Annual Sills Competency Checklist revealed a Skill/Task listed on the competency check off that stated Promotes and protects participant's dignity and privacy (knocks on doors, pulls curtains during care, and speaks respectfully to participants).<BR/>Record review of a facility policy titled Resident Rights, 2001 MED-PASS, Inc. (Revised February 2021), revealed a policy statement that stated, Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation stated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; t. privacy and confidentiality.<BR/>Record review of a facility policy titled Dignity, 2001 MED-PASS, Inc. (Revised February 2021), revealed a policy statement that stated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation stated, 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 11 residents (Resident #1) reviewed for accuracy of records, in that:<BR/>The facility failed to ensure the treatment administration records (TAR) for Resident #1 accurately reflected the administration of the bilateral wound treatment on 01/03/2025 and 01/07/2025. <BR/>This deficient practice could place residents receiving treatments at risk for not receiving appropriate care.<BR/>The findings were:<BR/>Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included congestive heart failure (a condition in which the heart doesn't pump blood as well as it should), type 2 diabetes (a condition that occurs when the body does not regulate or use sugar properly), bipolar disorder (a mental illness characterized by alternating periods of elation and depression), and lymphedema (swelling due to the build-up of fluid in the body due to a problem with the lymphatic system, which is a network of tubes throughout the body that drains fluid).<BR/>Record review of Resident #1's annual MDS assessment, dated 12/15/2024, revealed a BIMS score of 14, Indicating no cognitive impairment. Section C - Cognitive Patterns revealed Resident #1 had difficulty focusing attention and had disorganized thinking, defined on the MDS as rambling or irrelevant conversation, unclear or illogical flow of ideas or unpredictable switching from subject to subject, and that these symptoms fluctuated in severity. Section E- Behavior revealed Resident #1 rejected care (e.g., bloodwork, taking medications, ADL assistance) 4 to 6 days a week. Section GG - Functional Abilities revealed Resident #1 used a wheelchair for mobility and had impaired range of motion on both sides of her lower extremities. Section GG also revealed Resident #1 was dependent on staff assistance for toileting, lower body dressing, putting on or taking off footwear, and chair/bed to chair transfers. <BR/>Record review of Resident #1's comprehensive care plan revealed the following care plans [Resident #1] is at risk for pressure injuries due to impaired mobility, morbid obesity, dated 04/05/2023 and revised 04/29/2023. Altered skin integrity non pressure related to: BLE vascular wounds, dated 04/07/2023 and revised 05/04/2024. [Resident #1] has a behavior problem. She will refuse wound tx, refuse weekly wound measurements, refuse ADL assistance, say derogatory terms to staff, argue with roommate, dated 04/29/2023 and revised 09/09/2024. Altered skin integrity non pressure related to: vascular wound Lt lower leg circumferential, dated 07/24/2023 and revised 12/24/2024. Altered skin integrity non pressure related to: vascular wounds Rt lower leg circumferential, dated 07/24/2023 and revised 12/24/2024. <BR/>Record review on 01/08/2025 at 10:49 a.m., of Resident #1's December TAR revealed the following orders scheduled for 6 a.m. to: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR was initialed by the Wound Care LVN as completed on 12/24/2024 and coded 3- refused and initialed by the Wound Care LVN on 12/27/2024. B) Wound #1 left lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR was initialed by the Wound Care LVN as completed on 12/24/2024 and coded 3- refused and initialed by the Wound Care LVN on 12/27/2024. The TAR revealed the following orders scheduled PRN: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/09/2024. The TAR revealed Resident #1 received a prn treatment, 12/23/2024 at 5:42 p.m. by Wound Care LVN. B) Wound #1 left lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/09/2024. The TAR revealed Resident #1 received a prn treatment, 12/23/2024 at 5:42 p.m. by Wound Care LVN. <BR/>Record review, on 01/08/2025 at 10:49 a.m., of Resident #1's January TAR revealed the following orders scheduled for 6 a.m. to: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR was not initialed by a nurse as completed on 01/03/2025 and 01/07/2025. B) Wound #1 left lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR was not initialed by a nurse as completed on 01/03/2025 and 01/07/2025.<BR/>Record review, on 01/09/2025 at 11:45 a.m., of Resident #1's January TAR revealed the following orders scheduled for 6 a.m. to: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR is initialed as completed on 01/03/2024 and initialed with '19-other see progress note' by Wound Care LVN. B) Wound #1 left lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/10/2024. The TAR is initialed as completed on 01/03/2024 and initialed with '19-other see progress note' by Wound Care LVN. The TAR revealed the following orders scheduled PRN: A) Wound #1 right lower leg circumferential cleanse with wound cleanser, pat dry and appl zinc cream to the entire leg. Gauze may weave between toes and cap toes. Use ABD pad, Kerlix to heel. Compression wrap to the affected leg to apply compression wrap from the base of the toes to 2 finger length below the knee covering the heel. Every day shift every Tue, Fri for wound care, start date 12/09/2024. The TAR revealed Resident #1 received a prn treatment, 01/08/2024 at 12:35 a.m. by RN C.<BR/>Record review of the facility wound care log, dated 01/03/2025, revealed Resident #1 had a venous wound to the right lower circumferential and a venous wound to the left lower circumferential. The log revealed Resident #1 admitted with the wounds on 12/22/2023 and the wounds measured 45 x 35 x 0.2cm.<BR/>Record review of Resident #1's progress note, 12/27/2024 at 3:21 p.m. by Wound Care LVN, stated resident refused wound care. [physician group name] RN notified. No new orders.<BR/>During an observation on 01/08/2025 at 11:25 a.m., Resident #1 was observed lying in bed with bilateral lower legs wrapped in compression wraps and toes were wrapped in gauze. The wraps and gauze were clean and intact and dated 01/08/2025 at 12:35 a.m.<BR/>During an interview with RN B on 01/08/2025 at 2:20 p.m., RN B stated she worked with Resident #1 on the overnight shift of 01/07/2025. RN B stated RN C completed Resident #1's wound care and RN B stated she did not see the dates on Resident #1's bilateral dressings prior to RN C completing Resident #1's wound care. RN B stated Resident #1 refused care and refused for wound care to be completed at times but did allow RN C to complete wound care on the overnight shift on 01/07/2025.<BR/>During an interview with RN C on 01/08/2025 at 2:35 p.m., RN C stated he completed Resident #1's wound care on 01/08/2025 around 12:30 a.m. RN C stated he did Resident #1's wound care if Resident #1 refused wound care earlier in the day and was told by Wound Care LVN that Resident #1 had refused wound care during the day shift. RN C stated he did not document that he completed the wound care on the TAR. He stated he texted Wound Care LVN to notify the Wound Care LVN the wound care was completed and Wound Care LVN would document on Resident #1's TAR. RN C stated the TAR was only managed by the Wound Care LVN and RN C did not document on the TAR. RN C stated he can view the TAR to follow the treatment order and was notified when a treatment needed to be completed by the Wound Care LVN. RN C stated he did not pay attention to the date of the previous bandage on Resident #1's bilateral legs when he completed the treatment on 01/08/2025. He stated he could not remember the last time he was asked to complete Resident #1's wound care but stated her wounds looked the same in appearance as he had observed in previous observations. <BR/>During an interview with Resident #1 on 01/09/2025 at 8:05 a.m., Resident #1 stated RN C completed Resident #1's bilateral leg treatments overnight on 01/08/2025. Resident #1 stated the Wound Care LVN would usually complete her dressing changes on Tuesdays and Fridays, but sometimes RN C will do it. Resident #1 stated she did not think her wound care had been completed since 12/23/2024 and stated, that is the date I remember Wound Care LVN doing it. Resident #1 denied refusing wound care or refusing dressing changes. Resident #1 stated she has had the bilateral venous wounds since 2008 and Resident #1 stated she had refused to be seen by the wound care physician at the facility for several months.<BR/>During an interview with the Wound Care LVN on 01/09/2025 at 11:50 a.m., the Wound Care LVN stated she was responsible for providing wound care to Resident #1 and if she was not able to complete the wound care, Resident #1 refused or Wound Care LVN was not scheduled to work, Wound Care LVN would assign a nurse to complete wound care. Wound Care LVN stated she attempted to complete wound care on Resident #1 on 01/07/2025 in the afternoon and stated Resident #1 said she was not ready and did not want Wound Care LVN completing the wound care at that time. Wound Care LVN asked Resident #1 if RN C could do the wound care for Resident #1 later in the day and Resident #1 agreed. Wound Care LVN stated RN C let her know the following day that the wound care was completed and Wound Care LVN initialed 01/07/2025 with a 19- other see progress note and Wound Care LVN stated she added a late entry progress to document that she had asked RN C to complete the wound care. Wound Care LVN stated she educated RN C to document the treatment RN C completed on Resident #1's TAR on the prn orders for the bilateral wound care for 01/08/2025. Wound LVN C stated she also initialed Resident #1's TAR for bilateral wound care as completed on 01/03/2025 because I noticed I had not signed off on the TAR. Wound Care LVN stated Resident #1's bilateral venous wound measurements remain at 45 x 35 x 0.2 cm. Wound Care LVN stated she knew she completed the wound care because she would have entered a progress note for the refusal if Resident #1 had refused the treatment. She stated she had written it down in her personal notes and stated the wound size had not changed. Wound Care LVN stated she had been trained on documenting wound care in the TAR at the time of the wound care and stated it was important to document the treatments at the time they were completed to make sure the treatments are done and report any changes in a timely manner.<BR/>During an interview with the DON on 01/10/2025 at 2:28 p.m., the DON stated missing documentation on the TAR was monitored by nursing managers who run a missing documentation report daily. The DON stated she ran the report on 01/08/2025 after having a conversation with RN C about RN C not documenting Resident #1's treatment on Resident #1's TAR. The DON stated RN C and Wound Care LVN were provided reeducation on 01/08/2025 regarding documentation of treatments on the TAR and documentation of treatments would be completed at the time the wound care was provided. The DON stated she reviewed Resident #1's January TAR with Wound Care LVN and stated Wound Care LVN stated she had completed the treatment on 01/03/2025. The DON stated documentation of wound care should occur right after the treatment has been completed and stated it was important to document timely because we are able to show that the treatment was done or that the treatment was refused and so the physician can see if the treatment is effective for the benefit of the patient.<BR/>Record review of a facility document titled Licensed Nurse Orientation/Annual Skills/Competency Checklist for Wound Care LVN, dated 2/14/2024, revealed Wound Care LVN successfully completed Skill/Task #10. Review shift documentation process, requirements of obtaining physician orders (dx, location, parameters, monitoring, dose, freq, medication times, entering onto MAR/TAR, etc.).<BR/>Record review of a facility document titled Competency Assessment Wound Care, signed by Wound Care LVN listed the date completed as 10/2024. The competency assessment revealed check marks indicating the competency had been demonstrated by Wound Care LVN for E. 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. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any changes in resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason (s) why. 10. The signature and title of the person recording the data. <BR/>Record review of a facility policy titled Wound Care, 2001 Med-Pass, Inc. Revised October 2010, under the section labeled, Documentation, the policy stated 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 car was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any changes in resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerates the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason (s) why. 10. The signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility for 1 of 3 residents (Resident #1) reviewed for discharge rights, in that:<BR/>The facility failed to ensure Resident #1's legal guardian was sufficiently prepared and oriented for Resident #1's transfer to hospital.<BR/>This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and services and denying them a voice regarding their treatment plan.<BR/>The findings were:<BR/>Record review of Resident #1's admission record, dated 06/29/24, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include dementia (loss of thinking, remembering, and reasoning skills), schizoaffective disorder (a chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors). <BR/>Record review of Resident #1's MDS assessment (Nursing Home Comprehensive), dated 04/25/24, reflected she had a BIMS score of 10 out of 15, indicating moderately impaired cognition. <BR/>Record review of Resident #1's care plan, dated 06/29/24, reflected Resident #1 had impaired cognitive function/dementia or impaired thought processes [related to] schizophrenia, dementia, initiated 04/19/24, with an intervention [Resident #1[ needs supervision/assistance with all decision making.<BR/>Record review of Resident #1's Letter of Guardianship, dated 01/24/24, reflected [Guardianship Program] was appointed as guardian of Resident #1, an incapacitated person. <BR/>There was no record of a written discharge/transfer notice for Resident #1's legal guardian. <BR/>There was no record of the facility making efforts to get an accurate state of the resident's condition while he was in the hospital. <BR/>During an interview on 06/28/24 at 09:03 PM, Resident #1's legal guardian revealed he was not aware Resident #1 was not resident at this nursing home facility anymore. He revealed he was not told Resident #1 was transferred to a hospital so he was unable to follow up with resident. When he came to visit the facility on 06/24/24 at 01:30 PM, he found Resident #1 was not in the facility. He revealed ADON A did not know Resident #1's whereabouts at this time. The legal guardian further revealed he was unable to locate resident and filed a missing person's report to the local Police Department on 06/26/24 at 10:30 AM. <BR/>During an interview on 06/29/24 at 11:15 AM, the Administrator revealed Resident #1 was anticipated to return to the facility and there was no reason for the facility to not take this resident back. She revealed they had communication with the hospital and the case manager there was finding placement for Resident #1. The Administrator revealed she assumed the hospital was working with Resident #1's legal guardian to ensure the guardian knew where Resident #1 would be discharged to, from the hospital. She further revealed another nursing home facility accepted Resident #1 to be admitted to their facility. There was no documentation of any of these actions being done. <BR/>During a record review, interview, and observation on 06/29/24 at 04:18 PM, Resident #1 was observed at a different nursing home facility. He revealed he did not remember anything about the facility he was prior to hospitalization. He revealed he did not have a legal guardian and he was responsible for himself. Record review of his admission record at this second nursing home facility reflected Resident #1 was his own responsible party with no mention of a legal guardian. <BR/>During an interview on 06/29/24 at 04:55 PM, Resident #1's legal guardian revealed he was not notified Resident #1 was discharged to a hospital on [DATE]. He revealed he would have followed up with Resident #1 at the hospital. He further revealed he was not notified Resident #1 was at another facility. <BR/>During an interview and record review on 06/29/24 at 06:26 PM, ADON A confirmed she spoke to the legal guardian about Resident #1 discharging to a hospital on [DATE] at 09:15 PM (per a nursing progress note authored by ADON A). She revealed she sent the hospital all pertinent paperwork, including Resident #1's admission record that listed legal guardian's contact information. She further revealed she expected and assumed the hospital would contact the legal guardian and discharge residents appropriately. <BR/>Record review of grievances since January 2024 revealed no grievances regarding discharges. <BR/>Record Review of facility's policy, Transfer or Discharge, Facility-Initiated, dated October 2022, reflected Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer . and Notice of Facility Bed-Hold and return policies are provided to the resident and representative within 24 hours of emergency transfer.<BR/>4. If the facility determines that the resident cannot return to the facility, the medical record will indicate the facility made efforts to: b. ascertain an accurate status of the resident's condition, which can be accomplished via communication between hospital and facility staff and/or through visits by facility staff to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 of 6 residents (Resident #1) reviewed for foot care. <BR/>The facility failed to ensure Resident #1 was provided with adequate foot care and access to podiatry services.<BR/>This failure could place residents at risk of discomfort, poor foot hygiene, or a decline in residents' physical condition.<BR/>The findings were:<BR/>Record review of the admission Record, printed 6/04/2024, reflected Resident #1 was a [AGE] year-old female, originally admitted on [DATE]. <BR/>Record review of the quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS summary score of 4, indicative of severe cognitive impairment. Resident #1's primary medical condition category that best described the primary reason for admission was coded as medically complex conditions related to a diagnosis of paranoid schizophrenia. Other active diagnoses included Huntington's Disease. Resident #1 had a clinical assessment that indicated she was at risk of developing pressure injuries. <BR/>Record review of the Care Plan reflected a focus area for Resident #1 potential for pressure ulcer development, with a revision date of 7/19/2023; with the following interventions: Administer treatments as ordered; educate as to causes of skin breakdown; monitor nutritional status; obtain lab/diagnostic work as ordered. Additional focus area of ADL self-care performance deficit; with the following interventions: bathing - check nail length and trim and clean on bath day and as necessary, last revised 7/19/2023. <BR/>Record review of the Order Summary Report, active as of 6/04/2024, reflected Resident #1 had orders may see podiatrist, dentist, audiologist, ophthalmologist, with a start date of 7/06/2023.<BR/>In an interview and observation on 6/06/2024 at 9:20 AM, Hospital RN A removed bilateral heel protector boots from Resident #1's feet to inspect and assess pressure injuries. Hospital RN A pointed out that Resident #1 had long curving toenails. Resident #1 had a scabbed over sore to the anterior surface of the distal end of the 2nd toe, caused by the thick and overgrown toenail of the hallux (great toe). Hospital RN A stated that all of Resident #1's toenails needed to be trimmed and filed smooth, but the hospital does not allow hospital staff to do that procedure; Resident #1 was not expected to be admitted long enough to be seen by the hospitals' podiatrist for treatment. Hospital RN A stated the length of her toenails would have grown out slowly over several months. Hospital RN A stated the scabbed over sore could have been prevented by routine foot care. <BR/>In an interview on 6/05/2024 at 10:45 AM, the Family Member stated she had requested months ago for Resident #1 to be seen by the podiatrist. The family member stated that the last two times a podiatrist was in the building, Resident #1 was not seen by the podiatrist. The family member stated that Resident #1's roommate was seen the last time the podiatrist was on site, which prompted Family Member to inquire as to when Resident #1 would be seen; Family Member was told Resident #1 would not be seen that day because she was not on the list to be seen by the podiatrist. The family member stated Resident #1 was not seen the time before that when the podiatrist was in the building. The family member stated that no one at the facility could tell her when Resident #1 would be seen by a podiatrist next.<BR/>In a joint interview on 6/06/2024 at 11:30 AM, the DON stated that nurses were responsible for trimming or filing residents' fingernails and toenails on a weekly basis. The DON stated he cleaned Resident #1's nails on 5/29/2024 which was the date of the last skin assessment. The DON stated he did not recall if there was anything concerning about Resident #1's fingernails or toenails. The Treatment Nurse stated she may have forgotten to document the last time she trimmed Resident #1's nails, but she recalled that, it was several months ago, and I asked the SW we had at the time to put Resident #1 on the list to be seen by podiatry. The ADON stated the previous SW was only employed for 90 days or less before she was terminated. The ADON stated Resident #1 was not placed on the list to be seen by the podiatrist at that time. The ADON stated she could find no documentation as to why this was not done. The ADON stated she could find no documentation that Resident #1 had ever been seen by a podiatrist. The ADON stated Resident #1 would be seen during the podiatrist's next visit on site. The ADON stated she was not sure of when that would be. The DON stated that the podiatrist would be next on site sometime during the month of July. The Treatment Nurse stated she was responsible for spot checking that assessments were completed timely. The Treatment Nurse stated she expected the nurses to document at the time the assessment or a treatment was done. The ADON stated the risk to residents not getting a documented skin assessment could be result in missed care or treatment. The ADON stated that if nails cause skin breakdown there was a risk for infection or pain to the resident. <BR/>Record review of policy Foot Care, revised October 2022, reflected the following: 4. Trained staff may provide routine foot care (e.g., toenail clipping) for residents without complicating disease process; 5. Residents with foot disorders or medical conditions associated with foot complications are referred to qualified professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 (Resident #1) of 13 residents reviewed for abuse and neglect.<BR/>The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #1 attempted suicide.<BR/>This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.<BR/>The findings included:<BR/>Record review of Resident #1's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder. Resident #1 was noted as discharged on 05/02/2024 to an acute care hospital. <BR/>Record review of Resident #1's State Optional MDS, dated [DATE], revealed the resident had a BIMS score of 8, which indicated the resident was mildly cognitively impaired for daily decision-making skills.<BR/>Record review of Resident #1's MDS PHQ9 (Resident Mood Interview), dated 03/12/2024, revealed Resident #1 with score of 18, he had moderately severe depression. The SW wrote under explanation, He said that he is hearing voices and forgetting things that he does not want to live. He is open to getting psych services. <BR/>Record review of Resident #1's care plan revealed:<BR/> - A focus, initiated on 03/13/2024, revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions with intervention, date initiated 03/13/2024, Monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. <BR/> - A focus, initiated on 03/19/2024, revealed Resident #1 had a potential psychosocial well-being problem related to depression, anxiety, inability to problem solve, ineffective coping, and lack of acceptance to current condition with intervention, date initiated 03/19/2024, Consult with: Pastoral care, Social services, Psych services. <BR/>Record review of Resident #1's progress note, dated 05/02/2024 and authored by LVN A, revealed Incident of apparent suicide attempt. Resident #1 attempted suicide on 05/02/2024 by tying a shirt, fashioned to look like a rope, around his neck in a noose fashion, and pulling hard on the shirt to make it tighten enough to cut off his airflow.<BR/>Record review of Resident #1's progress note, dated 05/02/2024 and authored by the ADMIN, revealed Resident #1 was admitted and stable at a local hospital. <BR/>Attempted interview of LVN A on 05/22/2024 at 10:01 a.m., on 05/23/2024 at 08:07 a.m., and on 05/25/2024 at 10:59 p.m. and 11:03 p.m. was unsuccessful. LVN A worked night shift (10 p.m. to 6 a.m.).<BR/>In an interview with Director of Case Management at local hospital on [DATE] at 05:40 p.m., the Director of Case Management at local hospital stated Resident #1 was admitted to the hospital for suicide attempt. She stated that Resident #1 had confirmed that he attempted suicide. <BR/>In an interview with the ADMIN on 05/28/2024 at 06:26 p.m., the ADMIN stated she had reviewed the pathway to determine if an attempted suicide was reportable and didn't see it qualifying as a reportable incident. The ADMIN stated she had discussed the incident with the RDCS, but it was her decision to not report. The ADMIN stated she followed the facility's prior procedures for attempted suicides, which occurred prior to her employment at the facility, and if there were future incidents, she and the management staff would still follow the pathways and determine if the management team missed anything in regard to reporting incidents. <BR/>Record review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not limited to: .j. any other individual .8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. <BR/>Record review of the facility's policy, Recognizing Signs and Symptoms of Abuse/Neglect, revised April 2021, revealed 4. The following are signs and symptoms of abuse/neglect that should be promptly reported .d. Psychological or behavioral signs of abuse or neglect .(10) Suicidal ideation.<BR/>Record review of the HHSC Long-Term Care Regulatory Provider Letter, Number PL 19-17, date issued 7/10/19 and titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC), revealed in part, .This letter provides guidance for reporting incidents to HHSC .A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: Abuse, Neglect, .The following table describes required reporting timeframes for each incident type .abuse (with or without serious bodily injury) .Immediately, but not later than two hours after the incident occurs or is suspected .Attachment 1: Definitions and Examples of ANE and other Reportable Incidents .Abuse: HHSC rules define abuse as: 'The negligent or willful infliction of injury .with resulting physical or emotional harm or pain to a resident .' .CMS defines abuse as: 'The willful infliction of injury .instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .'.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse and neglect for 1 (Resident #1) of 13 residents reviewed.<BR/>The facility did not have evidence that a thorough investigation was completed for Resident #1 who had attempted suicide.<BR/>This failure could place residents at risk of incidents not being thoroughly investigated.<BR/>The findings included:<BR/>Record review of Resident'#1's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder. Resident #1 was noted as discharged on 05/02/2024 to an acute care hospital. <BR/>Record review of Resident #1's State Optional MDS, dated [DATE], revealed the resident had a BIMS score of 8, which indicated the resident was mildly cognitively impaired for daily decision-making skills.<BR/>Record review of Resident #1's MDS PHQ9 (Resident Mood Interview), dated 03/12/2024 revealed Resident #1 with score of 18, he had moderately severe depression. The SW wrote under explanation He said that he is hearing voices and forgetting things that he does not want to live. He is open to getting psych services. <BR/>Record review of Resident #1's care plan revealed:<BR/> - A focus, initiated on 03/13/2024, revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions with intervention, date initiated 03/13/2024, Monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. <BR/> - A focus, initiated on 03/19/2024, revealed Resident #1 had a potential psychosocial well-being problem related to depression, anxiety, inability to problem solve, ineffective coping, and lack of acceptance to current condition with intervention, date initiated 03/19/2024, Consult with: Pastoral care, Social services, Psych services. <BR/>Record review of Resident #1's progress note, dated 05/02/2024 and authored by LVN A, revealed Incident of apparent suicide attempt. Resident #1 attempted suicide on 05/02/2024 by tying a shirt, fashioned to look like a rope, around his neck in a noose fashion, and pulling hard on the shirt to make it tighten enough to cut off his airflow.<BR/>Record review of Resident #1's progress note, dated 05/02/2024 and authored by the ADMIN, revealed Resident #1 was admitted and stable at a local hospital. <BR/>Record review of the facility report Incidents by Incident Type, dated 02/01/2024 to 05/17/2024, revealed no evidence of an incident on 05/02/2024 involving Resident #1. <BR/>Record review of Resident #1's documentation in the facility EHR revealed no evidence of an investigation of an incident on 05/02/2024 involving Resident #1. <BR/>In an interview with the ADMIN on 05/22/2024 between 9:00 a.m. - 10:00 a.m., the ADMIN stated Resident #1's incident on 05/02/2024 had been reported to her by the reporting nurse (LVN A); however, his report was inconsistent with the charge nurse, RN F. The ADMIN revealed the incident was not further investigated or reported because the incident was believed to have been incorrectly documented as an attempted suicide.<BR/>Attempted interview of LVN A on 05/22/2024 at 10:01 p.m., on 05/23/2024 at 08:07 a.m., and on 05/25/2024 at 10:59 p.m., and 11:03 p.m. was unsuccessful. LVN A worked night shift (10 p.m. to 6 a.m.).<BR/>In an interview with RN F on 05/23/2024 at 02:39 p.m., RN F stated he was working on the first floor of the facility on the night of Resident #1's attempted suicide. When he was called upstairs for the incident, he did not see any physical signs expected on Resident #1 from someone that tried to hurt themselves. RN F stated Resident #1 did not have a mark on his body, had no redness around his neck, did not appear in distress, and was lying perfectly in bed. RN F stated he took Resident #1's vitals, which were okay. <BR/>In an interview with Director of Case Management at local hospital on [DATE] at 05:40 p.m., the Director of Case Management at local hospital stated Resident #1 was admitted to the hospital for suicide attempt. She stated that Resident #1 had confirmed that he attempted suicide. <BR/>Attempted record request on 05/24/2024 at 09:11 a.m. for local hospital admission records for Resident #1. Records not received prior to investigation exit. <BR/>In an interview with the ADMIN on 05/28/2024 at 06:26 p.m., the ADMIN stated she had discussed Resident #1's incident on 05/02/2024 with the RDCS but it was her decision to not report. The ADMIN stated she followed the facility's prior procedures for attempted suicides, which occurred prior to her employment at the facility, and if there were future incidents, she and the management staff would still follow the pathways and determined if the management team missed anything in regard to reporting incidents. <BR/>Record review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not limited to: .j. any other individual .8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. <BR/>Record review of the facility's policy, Recognizing Signs and Symptoms of Abuse/Neglect, revised April 2021, revealed 4. The following are signs and symptoms of abuse/neglect that should be promptly reported .d. Psychological or behavioral signs of abuse or neglect .(10) Suicidal ideation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 (Resident #1) of 13 residents reviewed for comprehensive care plan, in that:<BR/>LVN A failed to follow the plan of care on 05/01/2024 which required Resident #1 to be monitored and a PCP to be notified if Resident demonstrated a fear of being alone. Resident #1 attempted suicide on 05/02/2024.<BR/>This failure resulted in the identification of Immediate Jeopardy (IJ) on 05/26/2024 at 06:00 p.m. While the IJ was removed on 05/28/2024, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility's need to monitor the implementation of the plan of removal.<BR/>This failure could result in residents not receiving the necessary care to prevent a decline in health due to failure to follow a resident's care plan. <BR/>Findings included:<BR/>Record review of Resident #1's admission Record, dated 05/24/2024 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder. Resident #1 was noted as discharged on 05/02/2024 to an acute care hospital. <BR/>Record review of Resident #1's State Optional MDS, dated [DATE], revealed the resident had a BIMS score of 8, which indicated the resident was mildly cognitively impaired for daily decision-making skills.<BR/>Record review of Resident #1's MDS PHQ9 (Resident Mood Interview), dated 03/12/2024, revealed the resident had a score of 18, which indicated the resident had moderate severe depression. Further review revealed the SW wrote under explanation, He said that he is hearing voices and forgetting things that he does not want to live. He is open to getting psych services. <BR/>Record review of Resident #1's care plan revealed:<BR/> - A focus, initiated on 03/13/2024, revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions with intervention, date initiated 03/13/2024, Monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. <BR/> - A focus, initiated on 03/15/2024 and revised on 04/30/2024, revealed Resident #1 used anti-histamine medications related to anxiety/agitation with interventions, date initiated 03/15/2024, [Resident #1] is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety and Monitor/record occurrence of for target behavior symptoms and document per facility protocol. <BR/> - A focus, initiated on 03/19/2024, revealed Resident #1 used antidepressant medication related to depression with interventions, date initiated 03/19/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad, .suicidal ideations, .fear of being alone or with others .anxiety . <BR/> - A focus, initiated on 03/19/2024, revealed Resident #1 had a potential psychosocial well-being problem related to depression, anxiety, inability to problem solve, ineffective coping, and lack of acceptance to current condition with intervention, date initiated 03/19/2024, Consult with: Pastoral care, Social services, Psych services. <BR/>Record review of Resident #1's MAR/TAR for April and May 2024 did not reveal behavior was being monitored according to the care plan.<BR/>Record review of Resident #1's Psychiatry Follow-Up note, dated 04/29/2024 revealed a note by Psych NP that stated He was recently in an altercation and he was not the aggressor .No increased depression. He is sleeping and eating well. He is nervous about the aggressors hurting him again. He is having some anxiety regarding the situation. Further review revealed Resident #1 was noted as not currently a danger to self/others, not a risk factor for self-harm, and not a risk factor for suicidal ideation. Under assessment and plan, increased anxiety due to altercation was noted. <BR/>Record review of Resident #1's progress note, dated 05/01/2024 did not reveal an entry by LVN A and did not reveal a notation regarding Resident #1 displaying increased fear or a request for a staff member to stay with him. <BR/>Record review of Resident #1's progress note, dated 05/02/2024 revealed a note by LVN A that stated he asked me the previous evening to stay in the room with him because he was scared. He did not clarify what he was scared of, only that he was afraid and wanted me to stay with. The note revealed Further review revealed Resident #1 attempted suicide on 05/02/2024 by tying a shirt, fashioned to look like a rope, around his neck in a noose fashion and pulling hard on the shirt to make it tighten enough to cut off his airflow.<BR/>Attempted interview of LVN A on 05/22/2024 at 10:01 p.m., on 05/23/2024 at 08:07 a.m., and on 05/25/2024 at 10:59 p.m. and 11:03 p.m. was unsuccessful. LVN A worked night shift (10:00 p.m. to 6:00 a.m.).<BR/>Interview with Psych NP on 05/23/2024 at 04:33 p.m., revealed the Psych NP stated she had assessed Resident #1 on 04/29/2024 and found that he had been okay. The Psych NP stated Resident #1 had initially been very anxious and impulse upon admission to the facility but with medication therapy he had been fine and no longer had depression. The Psych NP stated she thought Resident #1 was anxious after the altercation on 04/28/2024 and he did not want to be alone with anyone with aggression. The Psych NP stated Resident #1 did not have any indication of being at risk for self-harm. The Psych NP stated she never observed, and no one ever reported to her that Resident #1 was at risk for self-harm or suicidal. The Psych NP stated that the facility had standard orders for behavioral monitoring for residents on psychotropics. The Psych NP stated the facility staff was really good at notifying her of any issues when she was in the facility, at least weekly, or calling her. The Psych NP stated the nurses could contact the psych care team twenty-four hours, seven days a week by calling the call center. <BR/>Interview with MD E on 05/25/2024 at 12:52 p.m., MD E stated she had received notification by a facility nurse on 05/02/2024 that Resident #1 had been sent out to the hospital. MD E stated she had not seen Resident #1 but that he was being seen by the Psych NP, who last saw the resident on 04/29/2024. MD E stated the facility nurses reported incidents or changes of conditions to the medical team's call center. MD E stated the reported information would disseminate to the entire care team, including the psychiatric services team. MD E stated she deferred to the psychiatric services team for behavioral issues or concerns. MD E stated the facility nurses' process of charting in the facility EHR and reporting to the care team or medical call center any changes was adequate for behavioral monitoring. <BR/>Interview with LVN B on 05/26/2024 at 04:15 p.m., LVN B stated she reviewed resident care plans when she had a question about the resident's care but would only review the specific parts of care plan that she needed information on. <BR/>Interview with ADON C on 05/26/2024 at 04:58 p.m., ADON C stated her expectation was that direct care staff were to follow the care plan. <BR/>Interview with MD E on 05/28/2024 at 12:33 p.m., MD E stated she did not recall being notified of Resident #1 ever saying that he did not want to live, per his 03/12/2024 PHQ9 Assessment, or received a report the resident was afraid on the night of 05/01/2024. MD E stated she would have to check her notes. A return call was not received by [Investigator I] prior to the investigation exit, 05/28/2024 at 06:00 p.m. <BR/>Interview with the Psych NP on 05/28/2024 at 01:44 p.m., the Psych NP stated she did not recall Resident #1 ever saying that he did not want to live. The Psych NP stated Resident #1 was referred to psych services on 03/14/2024 by a facility nurse and could not recall a staff member reporting to her that during his PHQ9 Assessment, Resident #1 said he did not want to live. The Psych NP stated she had a hard time seeing Resident #1 making that statement and stated that she felt the screening assessments could sometimes lead to a response or misunderstanding due to the wording of the questions. The Psych NP stated she did not feel that people with dementia could complete those screeners appropriately. <BR/>Record review of facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including .(3) which professional services are responsible for each element of care; .<BR/>This was determined to be an Immediate Jeopardy (IJ) and the ADMIN was provided with the IJ template on 05/26/2024 at 6:00 p.m. <BR/>The plan of removal was accepted on 05/27/2024 at 1:18 p.m. and read as follows:<BR/>Summary of details which leads to outcomes.<BR/>On 5/17/24 an investigation on a facility reported incident was initiated at [the facility]. On 5/26/2023 at 6:00pm, [Investigator I] provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health.<BR/>The Immediate Jeopardy findings were identified in the following areas:<BR/>F656: The facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for Resident #1. <BR/>Immediate Corrective Actions for Removal of Immediate Jeopardy:<BR/>On May 25, 2024, at approximately 12:00 [p.m.] the following actions were initiated upon facility identification of concern:<BR/>- Ad hoc QAPI meeting held with Administrator, Regional Director of Clinical Operations, ADONs and MD to review process for psychosocial management to include monitoring orders for side effects and effectiveness of medications, and psychosocial assessments. <BR/>- All resident charts were audited to ensure that care plans include measurable objective and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. <BR/>- All residents who are currently prescribed psychotropic medication were audited to ensure side effect monitoring and effectiveness of medication monitoring were in place and care planned.<BR/>- All residents who did not currently have side effects and medication effectiveness monitoring were assessed for adverse effects to psychosocial wellbeing related to monitoring orders not being in place. All residents remained at base line with no adverse effects noted. <BR/>- Education was initiated immediately with licensed nursing staff, on side effect monitoring and medication effectiveness and reporting psychosocial changes to provider with a completion date of 05/26/2024.<BR/>- Education initiated to nursing staff on comprehensive care planning and identification of psychosocial interventions with a completion date of 05/26/2024<BR/>Identification of Other Affected: <BR/>All residents who are diagnosed with a mental disorder or psychosocial adjustment have the <BR/>potential to be affected.<BR/>Systemic Changes and/or Measures: <BR/>- Education provided to all nursing staff on May 26, 2024, on Behavioral monitoring, including the requirement to monitor resident for altered mood, behavior, and function and alert the physician via phone with any observations noted, with a completion date of 05/27/2024.<BR/>- Education provided to all nursing staff on May 26, 2024, on Comprehensive, person-centered care planning, and requirement that nursing staff is aware of residents' plan of care when providing resident care. Education also included that care plans include measurable, person-centered, objectives and timetables to assure residents highest functional, and psychosocial well-being are attained, with a completion date of 05/24/2024.<BR/>- Ad hoc QAPI meeting held with IDT team and MD to review findings of immediate jeopardy, and to review Plan of Removal/response to Immediate Jeopardy Citation on 5/26/24 @ 8:00 p.m.<BR/>Tracking and Monitoring: <BR/>- Assistant Director of Nursing, or designee, will monitor daily through daily clinical meeting and review, Monday through Friday, all new admissions, and new orders, for any psychotropic medications, to validate all residents on psychotropics, have behavior monitoring, monitoring for adverse side effects, and care plan is person-centered and addresses specific behaviors being monitored. Any identified concerns will be addressed immediately, and physician will be notified via phone with any observations noted.<BR/>- Assistant Director of Nursing, or designee, will review 24 hours report in EHR, to identify any new, acute, mental, or psychosocial concerns from previous day, to validate they were addressed and follow up with provider/physician was completed as indicated. Physician will be notified via phone with any observations noted. The 24 hours report shall include indication of monitoring orders in place and verification of observations noted. Any identified concerns will be addressed immediately.<BR/>The facility's POR verification was as follows:<BR/>Interview with the ADMIN on 05/27/2024 at 03:00 p.m., the ADON stated all the nursing staff had received education on behavioral monitoring and care plans. The Administrator stated that the facility had a QAPI meeting on 05/26/2024 and discussed the findings of the deficient practice and the plan of removal. The Administrator stated MD E was the facility medical director. <BR/>Record review of facility POR Binder on 05/27/2024 at 03:00 p.m. revealed:<BR/> 1. A copy of the two Ad hoc QAPI Meetings: <BR/> - The first Ad hoc QAPI document was dated 05/24/2024 and noted with an agenda: Psychotropic Medications, Monitoring and Observations Orders, Auditing, and Psych. Services auditing. Attendees were noted as: the ADMIN, MD E, ADON C, ADON D, and the RDCS. <BR/> - The second Ad Hoc QAPI document was dated 05/26/2024 and noted with agenda: Immediate Jeopardy Citations- F656, F742, and Plan of Removal. Attendees were noted as: the ADMIN, MD E, ADON C, ADON D, and the RDCS. The binder contained a list of 19 licensed nursing staff. <BR/> 2. An In-service document, dated 05/26/2024 and titled All nurses must monitor residents for psych issues such as withdrawn behaviors, signs/symptoms or verbalization of fear, depression, anxiety, anger/aggressive behavior, self-harm or attempted self-harm, suicidal ideation or statements and must else report it to nurse managers, administrator, doctor/nurse practitioner, and responsible party. The in-service document included a note *orders for monitoring psych diagnosis and psych meds must be added on admission or new orders. MD must be notified if behaviors observed and included 19 (9 LVN and 10 RN) licensed nurses noted as had received the training. <BR/> 3. A document titled F656 Develop/Implement Comprehensive Care Plans revealed care plans were audited on 05/26/2025, the corrected care plans were noted on the order listing report, and the reviewer was the ADON and MDS staff. The document noted the care plans were audited on 05/27/2024 and found to be up to date by the ADON and MDS staff. A facility report, Daily Census, dated 05/26/2024 was included with the audit document with each resident name checked off. <BR/> 4. A document titled F742 Treatment/Services for Mental/Psychosocial Concerns revealed psychosocial monitoring orders were audited on 05/25/2025, 05/26/2024, and 05/27/2024. For 05/25/2024 and 05/26/2024, the audit form indicated the need for psychosocial assessments. A facility report, Order Listing Report, dated 05/24/2024 - 05/25/2024 was included with the audit document with 36 resident names highlighted and checked off and 14 residents were noted as having a current monitoring order. <BR/>Interviews with 17 of 19 licensed nursing staff from different shifts was completed on 05/27/2024 and 05/28/2024 which consisted of 2 of 3 licensed nursing staff from morning shift (6:00 a.m. to 2:00 p.m.), 5 of 5 licensed nursing staff from afternoon shift (2:00 p.m. to 10:00 p.m.), 1 of 2 licensed nursing staff from night shift (10:00 p.m. to 6:00 a.m.), 4 of 4 PRN licensed nursing staff, 2 of 2 weekend licensed nursing staff, and 3 of 3 administrative (MDS, ADON C, ADON D) licensed nursing staff. All 17 staff members reported they received education and were trained on behavioral monitoring, notifying the physician of behaviors, and reviewing and updating the residents' care plan. <BR/>Attempted interview of RN G on 05/27/2024 at 06:19 p.m. and LVN A on 05/27/2024 at 7:11 p.m. to confirm training was unsuccessful. RN G worked morning shift (6:00 a.m. to 2:00 p.m.) and LVN A worked night shift (10:00 p.m. to 6:00 a.m.). <BR/>Interview with ADON D on 05/28/2024 at 10:48 a.m., ADON D stated she received training from the RDCS regarding behavioral monitoring and care planning, and she provided the training to ADON C and facility licensed nursing staff. ADON D stated the ADONs will be monitoring the psychosocial medications by reviewing the facility 24-hour, 72-hour, and Order Listing reports to identify if there were any new psychosocial mediations, reported behaviors, new treatment orders, new antibiotic medications, new monitoring orders, and any reported behaviors. The report on incidents would also be reviewed. ADON D stated the reports would be reviewed in the morning clinical meeting with the floor nurses and ADON C, to discuss if any changes or incidents occurred the prior day and/or over the weekend. ADON D revealed that by reviewing the Order Listing report and 24-hour or 72-hour report, the ADONs were able to audit that if a new medication order was entered, a progress note for that new medication was entered and verify that additional orders for monitoring the side effects, behaviors, and efficacy were entered. ADON D stated that by reviewing the Order Listing report and 24-hour or 72-hour report, the ADONs were able to review that when a PRN psychosocial medication was provided, a monitor for the behavior and efficacy was entered, and if needed, a progress note indicating that the physician was notified and description of the behavior or reason for providing the PRN medication was documented. ADON D stated that after the IJs were called, each residents' chart was audited for monitoring orders. ADON D stated that for some residents' charts, behavior monitoring, or side effect monitoring was found but not both, and for those residents the other monitor was added. ADON D revealed that the Psych NP was asked to also complete an audit, checking her records and notes to verify that all the monitoring orders were in. She revealed for the care plan audit, she and the MDS nurse reviewed the care plans for every resident and ensured that the interventions in the care plans were also in the orders. ADON D stated they only identified Resident #1 as having the type of monitoring language for sadness and fear of being alone in his care plan. ADON D stated that it was discussed with the Psych NP on how the facility would going forward word their monitor and interventions to reflect the facility's resident's needs and behaviors more accurately. <BR/>Interview with the RDCS on 05/28/2024 at 06:08 p.m., the RDCS stated she had attended Ad hoc QAPI Meetings on 05/25/2024 and 05/26/2024. The RDCS stated she provided training to ADON D on behavioral monitoring and care planning so ADON D could train the licensed nursing staff. <BR/>Interview with the MD E on 05/28/2024 at 12:36 p.m., MD E stated she had attended Ad hoc QAPI Meetings on 05/25/2024 and 05/26/2024. MD E stated she was informed of the IJ and the plans for removal.<BR/>Interview with the Psych NP on 05/28/2024 at 01:44 p.m., the Psych NP stated she was notified of the IJ at the facility and was contacted by her supervisor regarding a request that she provide follow up assessments on specific residents to review current behaviors and monitoring orders. <BR/>Interview with the ADMIN and record review of facility report Order Summary Report on 05/28/2024 at 04:50 p.m. revealed the facility staff did not create a tracking log of resident orders that were entered as a part of their plan of correction but stated the Order Summary Report start date 05/25/2024 with active orders as of 05/25/2024 captured the new orders created per the order audit. The report noted five (5) residents (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) with new orders ordered on 05/24/2024 or 05/25/2024 with start dates 05/25/2024. New orders included observation for anti-depressant medication, observation for anti-anxiety medication, monitor for depression, monitor for anxiety, and monitor for side effects of sedative/hypnotics. The ADMIN revealed a new psychosocial assessment was completed on the five (5) identified residents. <BR/>1. Record review of Resident #2's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and post-traumatic stress disorder (a condition characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). <BR/>Record review of Resident #2's State Optional MDS, dated [DATE], revealed Resident #2 had a BIMS score of 99, which indicated the resident was severely cognitively impaired for daily decision-making skills and/or unable to complete the interview.<BR/>Record review of Resident #2's MDS PHQ9 (Resident Mood Interview), dated 04/11/2024, revealed Resident #2 had a score of NA.<BR/>Record review of Resident #2's care plan revealed:<BR/> - A focus, initiated on 04/15/2024, revealed Resident #2 used antidepressant medication related to depression with interventions, date initiated 04/15/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad, .suicidal ideations, .fear of being alone or with others .anxiety . <BR/> - A focus, initiated on 04/15/2024, revealed Resident #2 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions, impaired decision making, long term memory loss, psychotropic drug use, short term memory loss with interventions, date initiated 04/15/2024, Administer meds as ordered and Review medications and record possible causes of cognitive deficit .adverse drug reactions, drug toxicity. <BR/> - A focus, initiated on 04/17/2024 and revised on 04/23/2024, revealed Resident #2 used anti-anxiety medications and anti-convulsant medications related to anxiety disorder with interventions, date initiated 04/17/2024, [Resident #2] is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety, Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness .Paradoxical side effects: mania, hostility and rage, aggressive or impulsive behavior, hallucinations, and Monitor/record occurrence of for target behavior symptoms and document per facility protocol. <BR/> -A focus, initiated 04/15/2024, revealed Resident #2 had potential mood problems related to PTSD and dementia with intervention, date initiated 04/15/2024, Monitor/record/report to MD prn acute episode feelings or sadness . <BR/>Record review of facility report Order Summary Report, start date on 05/25/2024 and active orders as of 05/25/2024, revealed two (2) orders for Resident #2, ordered on 05/24/2024 to start on 05/25/2024. The first order was: Observation: AntiDepressant Medication- Observe for behavior WITHDRAWN/ AGITATION. Observe for side effects .every shift. The second order was: Observation: Antianxiety Medication- Observe for behavior AGITATION. Observe for side effects .every shift. <BR/>Record review of Psychosocial Assessment, dated 05/25/2024, revealed Resident #2 was unable to participate in assessment due to severe cognitive impairment directly related to admitting diagnosis of dementia. Resident remained at baseline. No adverse psychosocial effects noted. Plan of Care revealed continue with current care plan and psych services involvement. Provide quiet space if resident appears to become overstimulated. Monitor for adverse effects to psychosocial well being. <BR/>2. Record review of Resident #3's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder, depression, and mild cognitive impairment (difficulty with language, memory, and thinking). <BR/>Record review of Resident #3's State Optional MDS, dated [DATE], revealed Resident #3 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision-making skills.<BR/>Record review of Resident #3's MDS PHQ9 (Resident Mood Interview), dated 01/03/2024, revealed Resident #3 had a score of 4, which indicated the resident was minimally depressed.<BR/>Record review of Resident #3's care plan revealed:<BR/> - A focus, initiated on 11/13/2023 and revised 05/07/2024, revealed Resident #3 had impaired cognitive function/ impaired thought processes related to difficulty making decisions, impaired decision making, mild cognitive impairment caused by history of alcoholic intoxication with interventions, date initiated 11/13/2023, Administer meds as ordered, Monitor/document/report to MD any changes in cognitive function ., and Review medications and record possible causes of cognitive deficit: .adverse drug reactions, drug toxicity. <BR/> -A focus, initiated on 11/16/2023, revealed Resident #3 had potential psychosocial well-being problem related to illness/disease Process, disease process with intervention, date initiated 11/16/2023, Consult with .Psych services, Other. <BR/> - A focus, initiated on 12/11/2023, revealed Resident #3 used antidepressant medication related to depression with interventions, date initiated 12/11/2023, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad, .suicidal ideations, .fear of being alone or with others .anxiety . <BR/>Record review of facility report Order Summary Report, start date on 05/25/2024 and active orders as of 05/25/2024, revealed two (2) orders for Resident #3, ordered on 05/24/2024 to start on 05/25/2024. The first order was: Depression: Monitor for depressive symptomology .every shift Enter progress note describing behaviors observed if applicable. The second order was: Observation: AntiDepressant Medication- Observe for side effects .every shift. <BR/>Record review of Psychosocial Assessment, dated 05/25/2024, revealed Resident #3 remained at baseline for psychosocial well-being with no adverse effects noted. Plan of Care revealed continue with current care plan. <BR/>3. Record review of Resident #4's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), insomnia (trouble falling and/or staying asleep), major depressive disorder(a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder, and suicide attempt, noted as initial encounter and dated 02/28/2024. <BR/>Record review of Resident #4's State Optional MDS, dated [DATE], revealed Resident #4 had a BIMS score of 1, which indicated the resident was moderately cognitively impaired for daily decision-making skills.<BR/>Record review of Resident #4's MDS PHQ9 (Resident Mood Interview), dated 04/08/2024, revealed Resident #4 had a score of 4, which indicated the resident was minimally depressed. <BR/>Record review of Resident #4's care plan revealed:<BR/> - A focus, initiated on 02/28/2024 and revised on 05/18/2024, Resident #4 needed pain management and monitoring related depression with intervention, date initiated 02/28/2024, Observe for potential medication side effects. <BR/> - A focus, initiated on 02/29/2024, revealed Resident #4 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions, impaired decision making, psychotropic drug use, short term memory loss with interventions, date initiated 02/29/2024, Administer meds as ordered, Monitor/document/report to MD any changes in cognitive function ., and Review medications and record possible causes of cognitive deficit: .adverse drug reactions, drug toxicity. <BR/> - A focus, initiated on 03/04/2024 and revised on 04/18/2024, revealed Resident #4 used anti-histamine medications related to adjustment issues and anxiety disorder with interventions, date initiated 03/04/2024, Give anti-anxiety medications ordered by physician. Monitor/documents side effects and effectiveness ., Monitor/record occurrence of for target behavior symptoms and document per facility protocol, and [Resident #4] is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety.<BR/> - A focus, initiated on 03/06/2024, revealed Resident #4 used antidepressant and antiseizure medication related to depression and poor adjustment to admission with interventions, date initiated 03/06/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad, .suicidal ideations, .fear of being alone or with others .anxiety . <BR/> - A focus, initiated 03/13/2024, revealed Resident #4 was at risk for psychosocial well-being problems related to dependent behavior, lack of acceptance to current condition, recent admission, dementia, and depression with intervention, date initiated 03/13/2024, Consult with .Psych services. <BR/> - A focus, initiated 02/29/2024, revealed Resident #4 had potential mood problems related to dementia with behaviors and history or suicidal behaviors with interventions, date initiated 02/29/2024, Monitor/record/report to MD prn acute episode feelings or sadness ., Monitor/record/repo[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 (Resident #1) of 13 residents reviewed for psychosocial concerns. <BR/>LVN A failed to put interventions in place or promptly arrange for psychiatric services for Resident #1 after he displayed increased signs of fear on 05/01/2024. Resident #1 attempted suicide on 05/02/2024.<BR/>This failure resulted in the identification of Immediate Jeopardy (IJ) on 05/26/2024 at 06:00 p.m. While the IJ was removed on 05/28/2024, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility's need to monitor the implementation of the plan of removal.<BR/>This failure to ensure interventions were implemented or psychiatric services were promptly arranged can result in the individual not receiving the necessary care to prevent a decline in health. <BR/>Findings included:<BR/>Record review of Resident #1's admission Record, dated 05/24/2024 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder. Resident #1 was noted as discharged on 05/02/2024 to an acute care hospital. <BR/>Record review of Resident #1's State Optional MDS, dated [DATE], revealed the resident had a BIMS score of 8, which indicated the resident was mildly cognitively impaired for daily decision-making skills.<BR/>Record review of Resident #1's MDS PHQ9 (Resident Mood Interview), dated 03/12/2024, revealed the resident had a score of 18, which indicated he had moderately severe depression. Further review revealed the SW wrote under explanation, He said that he is hearing voices and forgetting things that he does not want to live. He is open to getting psych services. <BR/>Record review of Resident #1's care plan revealed:<BR/> - A focus, initiated on 03/13/2024, revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions with intervention, date initiated 03/13/2024, Monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. <BR/> - A focus, initiated on 03/15/2024 and revised on 04/30/2024, revealed Resident #1 used anti-histamine medications related to anxiety/agitation with interventions, date initiated 03/15/2024, [Resident #1] is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety and Monitor/record occurrence of for target behavior symptoms and document per facility protocol. <BR/> - A focus, initiated on 03/19/2024, revealed Resident #1 used antidepressant medication related to depression with interventions, date initiated 03/19/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad .suicidal ideations .fear of being alone or with others .anxiety . <BR/> - A focus, initiated on 03/19/2024, revealed Resident #1 had a potential psychosocial well-being problem related to depression, anxiety, inability to problem solve, ineffective coping, and lack of acceptance to current condition with intervention, date initiated 03/19/2024, Consult with: Pastoral care, Social services, Psych services. <BR/>Record review of Resident #1's MAR/TAR for April and May 2024 did not reveal behavior was being monitored according to the care plan.<BR/>Record review of Resident #1's Psychiatry Follow-Up note, dated 04/29/2024 revealed a note by Psych NP that stated He was recently in an altercation, and he was not the aggressor .No increased depression. He is sleeping and eating well. He is nervous about the aggressors hurting him again. He is having some anxiety regarding the situation. Further review revealed Resident #1 was noted as not currently a danger to self/others, not a risk factor for self-harm, and not a risk factor for suicidal ideation. Under assessment and plan, increased anxiety due to altercation was noted. <BR/>Record review of Resident #1's progress note, dated 05/01/2024 did not reveal an entry by LVN A and did not reveal a notation regarding Resident #1 displaying increased fear or a request for a staff member to stay with him. <BR/>Record review of Resident #1's progress note, dated 05/02/2024 revealed a note by LVN A that stated he asked me the previous evening to stay in the room with him because he was scared. He did not clarify what he was scared of, only that he was afraid and wanted me to stay with. Further review revealed Resident #1 attempted suicide on 05/02/2024 by tying a shirt, fashioned to look like a rope, around his neck in a noose fashion, and pulling hard on the shirt to make it tighten enough to cut off his airflow.<BR/>Attempted interview of LVN A on 05/22/2024 at 10:01 p.m., on 05/23/2024 at 08:07 a.m., and on 05/25/2024 at 10:59 p.m. and 11:03 p.m. was unsuccessful. LVN A worked night shift (10:00 p.m. to 6:00 a.m.).<BR/>In an interview with Psych NP on 05/23/2024 at 04:33 p.m., revealed the Psych NP stated she had assessed Resident #1 on 04/29/2024 and found that he had been okay. The Psych NP stated Resident #1 had initially been very anxious and impulse upon admission to the facility but with medication therapy he had been fine and no longer had depression. The Psych NP stated she thought Resident #1 was anxious after the altercation on 04/28/2024 and he did not want to be alone with anyone with aggression. The Psych NP stated Resident #1 did not have any indication of being at risk for self-harm. The Psych NP stated she never observed, and no one ever reported to her that Resident #1 was at risk for self-harm or suicidal. The Psych NP stated that the facility had standard orders for behavioral monitoring for residents on psychotropics. The Psych NP stated the facility staff were really good at notifying her of any issues when she was in the facility, at least weekly, or calling her. The Psych NP stated the nurses could contact the psych care team twenty-four hours, seven days a week by calling the call center. <BR/>In an interview with MD E on 05/25/2024 at 12:52 p.m., MD E stated she had received notification by a facility nurse on 05/02/2024 that Resident #1 had been sent out to the hospital. MD E stated she had not seen Resident #1 but that he was being seen by the Psych NP, who last saw the resident on 04/29/2024. MD E stated the facility nurses reported incidents or changes of conditions to the medical team's call center. MD E stated the reported information would disseminate to the entire care team, including the psychiatric services team. MD E stated she deferred to the psychiatric services team for behavioral issues or concerns. MD E stated the facility nurses' process of charting in the facility EHR and reporting to the care team or medical call center any changes was adequate for behavioral monitoring.<BR/>In an interview with LVN B on 05/26/2024 at 04:15 p.m., LVN B stated she reviewed resident care plans when she had a question about the resident's care but would only review the specific parts of the care plan that she needed information on. <BR/>In an interview with ADON C on 05/26/2024 at 04:58 p.m., ADON C stated her expectation was that direct care staff were to follow the care plan. <BR/>In an interview with MD E on 05/28/2024 at 12:33 p.m., MD E stated she did not recall being notified of Resident #1 ever saying that he did not want to live, per his 03/12/2024 PHQ9 Assessment, or received a report the resident was afraid on the night of 05/01/2024. MD E stated she would have to check her notes. A return call was not received by [Investigator I] prior to the investigation exit, 05/28/2024 at 06:00 p.m. <BR/>In an interview with the Psych NP on 05/28/2024 at 01:44 p.m., the Psych NP stated she did not recall Resident #1 ever saying that he did not want to live. The Psych NP stated Resident #1 was referred to psych services on 03/14/2024 by a facility nurse and could not recall a staff member reporting to her that during his PHQ9 Assessment, Resident #1 said he did not want to live. The Psych NP stated she had a hard time seeing Resident #1 making that statement and stated that she felt the screening assessments could sometimes lead to a response or misunderstanding due to the wording of the questions. The Psych NP stated she did not feel that people with dementia could complete those screeners appropriately. <BR/>Record review of facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including (3) which professional services are responsible for each element of care .<BR/>This was determined to be an Immediate Jeopardy (IJ) and the ADMIN was provided with the IJ template on 05/26/2024 at 6:00 p.m. <BR/>The plan of removal was accepted on 05/27/2024 at 1:18 p.m. and read as follows:<BR/>Summary of details which lead to outcomes.<BR/>On 5/17/24 an investigation on a facility reported incident was initiated at [the facility]. On 5/26/2023 at 6:00pm, [Investigator I] provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health.<BR/>The Immediate Jeopardy findings were identified in the following areas:<BR/>0742: The facility failed to ensure a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for Resident #1. <BR/>Immediate Corrective Actions for Removal of Immediate Jeopardy:<BR/>On May 25, 2024, at approximately 12:00 [p.m.] the following actions were initiated upon facility identification of concern:<BR/>- Ad hoc QAPI meeting held with Administrator, Regional Director of Clinical Operations, ADONs and MD to review process for psychosocial management to include monitoring orders for side effects and effectiveness of medications, and psychosocial assessments. <BR/>- All resident charts were audited to ensure that care plans include measurable objective and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs. <BR/>- All residents who are currently prescribed psychotropic medication were audited to ensure side effect monitoring and effectiveness of medication monitoring were in place and care planned. <BR/>- All residents who did not currently have side effects and medication effectiveness monitoring were assessed for adverse effects to psychosocial wellbeing related to monitoring orders not being in place. All residents remained at base line with no adverse effects noted. <BR/>- Education was initiated immediately with licensed nursing staff, on side effect monitoring and medication effectiveness, and reporting psychosocial changes to provider with a completion date of 5/26/2024.<BR/>- Education initiated to nursing staff on comprehensive care planning and identification of psychosocial interventions with a completion date of 5/26/2024. <BR/>Identification of other affected: <BR/>All residents who are diagnosed with a mental disorder or psychosocial adjustment have the <BR/>potential to be affected.<BR/>Systemic Changes and/or Measures: <BR/>- Education provided to all nursing staff on May 26, 2024, on behavioral monitoring, including the requirement to monitor resident for altered mood, behavior, and function and alert the physician via phone with any observations noted with a completion date of 5/27/2024.<BR/>- Education provided to all nursing staff on May 26, 2024, on Comprehensive, person-centered care planning, and requirement that nursing staff is aware of residents' plan of care when providing resident care. Education also included that care plans include measurable, person-centered, objectives, and timetables to assure residents highest functional, and psychosocial well-being are attained with a completion date of 5/27/2024.<BR/>- Ad hoc QAPI meeting held with IDT team and MD to review findings of immediate jeopardy, and to review Plan of removal/response to Immediate Jeopardy Citation on 5/26/24 @ 8:00 pm<BR/>Tracking and Monitoring: <BR/>- Assistant Director of Nursing, or designee, will monitor daily through daily clinical meeting and review, Monday through Friday, all new admissions, and new orders, for any psychotropic medications, to validate all residents on psychotropics, have behavior monitoring, monitoring for adverse side effects, and care plan is person-centered and addresses specific behaviors being monitored. Any identified concerns will be addressed immediately and physician will be notified via phone with any observations noted.<BR/>- Assistant Director of Nursing, or designee, will review 24 hours report in EHR, daily Monday through Friday, to identify any new, acute, mental, or psychosocial concerns from previous day, and validate they were addressed to include follow up with provider/physician was completed as indicated. The 24 hours report shall include indication of monitoring orders in place and verification of observations noted. Any identified concerns will be addressed immediately and physician will be notified via <BR/>phone with any observations noted.<BR/>The facility's POR Verification was as follows:<BR/>Interview with the ADMIN on 05/27/2024 at 03:00 p.m., the ADON stated all the nursing staff had received education on behavioral monitoring and care plans. The Administrator stated that the facility had a QAPI meeting on 05/26/2024 and discussed the findings of the deficient practice and the plan of removal. The Administrator stated MD E was the facility medical director. <BR/>Record review of facility POR Binder on 05/27/2024 at 03:00 p.m. revealed:<BR/> 1. A copy of the two Ad hoc QAPI Meetings: <BR/> - The first Ad hoc QAPI document was dated 05/24/2024 and noted with an agenda: Psychotropic Medications, Monitoring and Observations Orders, Auditing, and Psych. Services auditing. Attendees were noted as: the ADMIN, MD E, ADON C, ADON D, and the RDCS. <BR/> - The second Ad Hoc QAPI document was dated 05/26/2024 and noted with agenda: Immediate Jeopardy Citations- F656, F742, and Plan of Removal. Attendees were noted as: the ADMIN, MD E, ADON C, ADON D, and the RDCS. The binder contained a list of 19 licensed nursing staff. <BR/> 2. An In-service document, dated 05/26/2024 and titled All nurses must monitor residents for psych issues such as withdrawn behaviors, signs/symptoms or verbalization of fear, depression, anxiety, anger/aggressive behavior, self-harm or attempted self-harm, suicidal ideation or statements and must else report it to nurse managers, administrator, doctor/nurse practitioner, and responsible party. The in-service document included a note *orders for monitoring psych diagnosis and psych meds must be added on admission or new orders. MD must be notified if behaviors observed and included 19 (9 LVN and 10 RN) licensed nurses noted as had received the training. <BR/> 3. A document titled F656 Develop/Implement Comprehensive Care Plans revealed care plans were audited on 05/26/2025, the corrected care plans were noted on the order listing report, and the reviewer was the ADON and MDS staff. The document noted the care plans were audited on 05/27/2024 and found to be up to date by the ADON and MDS staff. A facility report, Daily Census, dated 05/26/2024 was included with the audit document with each resident name checked off. <BR/> 4. A document titled F742 Treatment/Services for Mental/Psychosocial Concerns revealed psychosocial monitoring orders were audited on 05/25/2025, 05/26/2024, and 05/27/2024. For 05/25/2024 and 05/26/2024, the audit form indicated the need for psychosocial assessments. A facility report, Order Listing Report, dated 05/24/2024 - 05/25/2024 was included with the audit document with 36 resident names highlighted and checked off and 14 residents were noted as having a current monitoring orders. <BR/>Interviews with 17 of 19 licensed nursing staff from different shifts were completed on 05/27/2024 and 05/28/2024 which consisted of 2 of 3 licensed nursing staff from morning shift (6:00 a.m. to 2:00 p.m.), 5 of 5 licensed nursing staff from afternoon shift (2:00 p.m. to 10:00 p.m.), 1 of 2 licensed nursing staff from night shift (10:00 p.m. to 6:00 a.m.), 4 of 4 PRN licensed nursing staff, 2 of 2 weekend licensed nursing staff, and 3 of 3 administrative (MDS, ADON C, ADON D) licensed nursing staff. All 17 staff members reported they received education and were trained on behavioral monitoring, notifying the physician of behaviors, and reviewing and updating the residents' care plan. <BR/>Attempted interview of RN G on 05/27/2024 at 06:19 p.m. and LVN A on 05/27/2024 at 7:11 p.m. to confirm training was unsuccessful. RN G worked morning shift (6:00 a.m. to 2:00 p.m.) and LVN A worked night shift (10:00 p.m. to 6:00 a.m.). <BR/>In an interview with ADON D on 05/28/2024 at 10:48 a.m., ADON D stated she received training from the RDCS regarding behavioral monitoring and care planning, and she provided the training to ADON C and facility licensed nursing staff. ADON D stated the ADONs will be monitoring the psychosocial medications by reviewing the facility 24-hour, 72-hour, and Order Listing reports to identify if there were any new psychosocial medications, reported behaviors, new treatment orders, new antibiotic medications, new monitoring orders, and any reported behaviors. The report on incidents would also be reviewed. ADON D stated the reports would be reviewed in the morning clinical meeting with the floor nurses and ADON C, to discuss if any changes or incidents occurred the prior day and/or over the weekend. ADON D revealed that by reviewing the Order Listing report and 24-hour or 72-hour report, the ADONs were able to audit that if a new medication order was entered, a progress note for that new medication was entered, and verify that additional orders for monitoring the side effects, behaviors, and efficacy were entered. ADON D stated that by reviewing the Order Listing report and 24-hour or 72-hour report, the ADONs were able to review that when a PRN psychosocial medication was provided, a monitor for the behavior and efficacy was entered, and if needed, a progress note indicating that the physician was notified and description of the behavior or reason for providing the PRN medication was documented. ADON D stated that after the IJs were called, each residents' chart was audited for monitoring orders. ADON D stated that for some residents' charts, behavior monitoring, or side effect monitoring was found but not both, and for those residents the other monitor was added. ADON D revealed that the Psych NP was asked to also complete an audit, checking her records, and notes to verify that all the monitoring orders were in. She revealed for the care plan audit, she and the MDS nurse reviewed the care plans for every resident and ensured that the interventions in the care plans were also in the orders. ADON D stated they only identified Resident #1 as having the type of monitoring language for sadness and fear of being alone in his care plan. ADON D stated that it was discussed with the Psych NP on how the facility would going forward with their monitoring and interventions to reflect the facility's resident's needs and behaviors more accurately. <BR/>In an interview with the RDCS on 05/28/2024 at 06:08 p.m., the RDCS stated she had attended Ad hoc QAPI Meetings on 05/25/2024 and 05/26/2024. The RDCS stated she provided training to ADON D on behavioral monitoring and care planning so ADON D could train the licensed nursing staff. <BR/>In an interview with the MD E on 05/28/2024 at 12:36 p.m., MD E stated she had attended the Ad hoc QAPI Meetings on 05/25/2024 and 05/26/2024. MD E stated she was informed of the IJ and the plans for removal.<BR/>In an interview with the Psych NP on 05/28/2024 at 01:44 p.m., the Psych NP stated she was notified of the IJ at the facility and was contacted by her supervisor regarding a request that she provide follow up assessments on specific residents to review current behaviors and monitoring orders. <BR/>Interview with the ADMIN and record review of facility report Order Summary Report on 05/28/2024 at 04:50 p.m. revealed the facility staff did not create a tracking log of resident orders that were entered as a part of their plan of correction but stated the Order Summary Report dated start date 05/25/2024 with active orders as of 05/25/2024 captured the new orders created per the order audit. The report noted five (5) residents (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) with new orders on 05/24/2024 or 05/25/2024 with start dates 05/25/2024. New orders included observation for anti-depressant medication, observation for anti-anxiety medication, monitor for depression, monitor for anxiety, and monitor for side effects of sedative/hypnotics. The ADMIN revealed a new psychosocial assessment was completed on the five (5) identified residents. <BR/>1. Record review of Resident #2's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and post-traumatic stress disorder (a condition characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). <BR/>Record review of Resident #2's State Optional MDS, dated [DATE], revealed Resident #2 had a BIMS score of 99, which indicated the resident was severely cognitively impaired for daily decision-making skills and/or unable to complete the interview.<BR/>Record review of Resident #2's MDS PHQ9 (Resident Mood Interview), dated 04/11/2024, revealed Resident #2 had a score of NA.<BR/>Record review of Resident #2's care plan revealed:<BR/> - A focus, initiated on 04/15/2024, revealed Resident #2 used antidepressant medication related to depression with interventions, date initiated 04/15/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . <BR/> - A focus, initiated on 04/15/2024, revealed Resident #2 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions, impaired decision-making, long-term memory loss, psychotropic drug use, short term memory loss with interventions, date initiated 04/15/2024, Administer meds as ordered and Review medications and record possible causes of cognitive deficit .adverse drug reactions, drug toxicity. <BR/> - A focus, initiated on 04/17/2024 and revised on 04/23/2024, revealed Resident #2 used anti-anxiety medications and anti-convulsant medications related to anxiety disorder with interventions, date initiated 04/17/2024, [Resident #2] is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety, Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness .Paradoxical side effects: mania, hostility, and rage, aggressive or impulsive behavior, hallucinations, and Monitor/record occurrence of for target behavior symptoms and document per facility protocol. <BR/> -A focus, initiated 04/15/2024, revealed Resident #2 had potential mood problems related to PTSD and dementia with intervention, date initiated 04/15/2024, Monitor/record/report to MD prn acute episode feelings or sadness .<BR/>Record review of facility report Order Summary Report, start date on 05/25/2024 and active orders as of 05/25/2024, revealed two (2) orders for Resident #2, ordered on 05/24/2024 to start on 05/25/2024. The first order was: Observation: antidepressant medication- observe for behavior WITHDRAWN/ AGITATION. Observe for side effects .every shift. The second order was: Observation: antianxiety medication- observe for behavior AGITATION. Observe for side effects .every shift. <BR/>Record review of Psychosocial Assessment, dated 05/25/2024, revealed Resident #2 was unable to participate in assessment due to severe cognitive impairment directly related to admitting diagnosis of dementia. Resident remained at baseline. No adverse psychosocial effects noted. Plan of Care revealed continue with current care plan and psych services involvement. Provide quiet space if resident appears to become overstimulated. Monitor for adverse effects to psychosocial well-being. <BR/>2. Record review of Resident #3's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder, depression, and mild cognitive impairment (difficulty with language, memory, and thinking). <BR/>Record review of Resident #3's State Optional MDS, dated [DATE], revealed Resident #3 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision-making skills.<BR/>Record review of Resident #3's MDS PHQ9 (Resident Mood Interview), dated 01/03/2024, revealed Resident #3 had a score of 4, which indicated the resident was minimally depressed.<BR/>Record review of Resident #3's care plan revealed:<BR/> - A focus, initiated on 11/13/2023 and revised 05/07/2024, revealed Resident #3 had impaired cognitive function/ impaired thought processes related to difficulty making decisions, impaired decision making, mild cognitive impairment caused by history of alcoholic intoxication with interventions, date initiated 11/13/2023, Administer meds as ordered, Monitor/document/report to MD any changes in cognitive function ., and Review medications and record possible causes of cognitive deficit .adverse drug reactions, drug toxicity. <BR/> -A focus, initiated on 11/16/2023, revealed Resident #3 had potential psychosocial well-being problem related to illness/disease process, disease process with intervention, date initiated 11/16/2023, Consult with .Psych services, Other. <BR/> - A focus, initiated on 12/11/2023, revealed Resident #3 used antidepressant medication related to depression with interventions, date initiated 12/11/2023, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . <BR/>Record review of facility report Order Summary Report, start date on 05/25/2024 and active orders as of 05/25/2024, revealed two (2) orders for Resident #3, ordered on 05/24/2024 to start on 05/25/2024. The first order was: Depression: Monitor for depressive symptomology .every shift enter progress note describing behaviors observed if applicable. The second order was: Observation: antidepressant medication- observe for side effects .every shift. <BR/>Record review of Psychosocial Assessment, dated 05/25/2024, revealed Resident #3 remained at baseline for psychosocial well-being with no adverse effects noted. Plan of Care revealed continue with current care plan. <BR/>3. Record review of Resident #4's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), insomnia (trouble falling and/or staying asleep), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder, and suicide attempt, noted as initial encounter and dated 02/28/2024. <BR/>Record review of Resident #4's State Optional MDS, dated [DATE], revealed Resident #4 had a BIMS score of 1, which indicated the resident was moderately cognitively impaired for daily decision-making skills.<BR/>Record review of Resident #4's MDS PHQ9 (Resident Mood Interview), dated 04/08/2024, revealed Resident #4 had a score of 4, which indicated the resident was minimally depressed. <BR/>Record review of Resident #4's care plan revealed:<BR/> - A focus, initiated on 02/28/2024 and revised on 05/18/2024, Resident #4 needed pain management and monitoring related depression with intervention, date initiated 02/28/2024, Observe for potential medication side effects. <BR/> - A focus, initiated on 02/29/2024, revealed Resident #4 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions, impaired decision making, psychotropic drug use, short term memory loss with interventions, date initiated 02/29/2024, Administer meds as ordered, Monitor/document/report to MD any changes in cognitive function ., and Review medications and record possible causes of cognitive deficit: .adverse drug reactions, drug toxicity. <BR/> - A focus, initiated on 03/04/2024 and revised on 04/18/2024, revealed Resident #4 used anti-histamine medications related to adjustment issues and anxiety disorder with interventions, date initiated 03/04/2024, Give anti-anxiety medications ordered by physician. Monitor/documents side effects and effectiveness ., Monitor/record occurrence of for target behavior symptoms and document per facility protocol, and [Resident #4] is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety.<BR/> - A focus, initiated on 03/06/2024, revealed Resident #4 used antidepressant and antiseizure medication related to depression and poor adjustment to admission with interventions, date initiated 03/06/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . <BR/> - A focus, initiated 03/13/2024, revealed Resident #4 was at risk for psychosocial well-being problems related to dependent behavior, lack of acceptance to current condition, recent admission, dementia, and depression with intervention, date initiated 03/13/2024, Consult with .Psych services. <BR/> - A focus, initiated 02/29/2024, revealed Resident #4 had potential mood proble[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to monitor based on the comprehensive assessment of a resident, residents who use psychotropic drugs for the efficacy and adverse consequences of prescribed psychotropic medications for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 12 residents reviewed for medication management. <BR/>- The facility failed to monitor Resident #1 for side effects and observe for the behaviors of the antidepressant medication Sertraline HCl and the antianxiety medication Hydroxyzine HCl. <BR/>- The facility failed to monitor Resident #2 for side effects and observe for the behaviors of the antianxiety medication Ativan, the antidepressant medication Citalopram, and the anticonvulsant medication Trileptal.<BR/>- The facility failed to monitor Resident #3 for side effects and observe for the behaviors of the antidepressant medication Mirtazapine.<BR/>- The facility failed to monitor Resident #4 for side effects and observe for the behaviors of the anticonvulsant medication Depakote, the antianxiety medication Hydroxyzine HCl, the antidepressant medication Mirtazapine, and the antidepressant medication Trazodone.<BR/>- The facility failed to monitor Resident #5 for side effects and observe for the behaviors of the antianxiety medication Ativan and the anticonvulsant medication Valproic Acid.<BR/>- The facility failed to monitor Resident #6 for side effects and observe for the behaviors of the antidepressant medication Mirtazapine and the anticonvulsant medication Trileptal.<BR/>This failure could place residents at risk for adverse consequences such as dizziness, drowsiness, oversedation, agitation, restlessness, and suicidal thoughts related to the use of psychotropic medications.<BR/>Findings included:<BR/>Resident #1<BR/>Record review of Resident #1's admission Record, dated 05/24/2024 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder. Resident #1 was noted as discharged on 05/02/2024 to an acute care hospital. <BR/>Record review of Resident #1's State Optional MDS, dated [DATE], revealed the resident had a BIMS score of 8, which indicated the resident was mildly cognitively impaired for daily decision-making skills. The resident's PHQ9 (Resident Mood Interview) revealed the resident nearly every day showed little interest or pleasure in doing things, felt bad about himself, had trouble concentrating on things, moved or spoke so slowly that other people could have noticed or the opposite- been fidgety or restless, and had thoughts that he would be better off dead or of hurting himself in some way. <BR/>Record review of Resident #1's care plan revealed:<BR/> - A focus, initiated on 03/15/2024 and revised on 04/30/2024, revealed Resident #1 used anti-histamine medications related to anxiety/agitation with interventions, date initiated 03/15/2024, [Resident #1] is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety and Monitor/record occurrence of for target behavior symptoms and document per facility protocol. <BR/> - A focus, initiated on 03/19/2024, revealed Resident #1 used antidepressant medication related to depression with interventions, date initiated 03/19/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . <BR/>Record review of Resident #1's Order Recap Report, dated 03/11/2024 - 05/31/2024 and accessed 05/21/2024, revealed Resident #1 had two (2) active psychotropic medications on the day of his discharge, 05/02/2024.<BR/> - No orders were found for monitoring for target behavior symptoms or side effects and effectiveness for either medication. <BR/> 1. An order for Hydroxyzine HCl Oral Tablet 24 MG, ordered and started on 04/29/2024, and ended on 05/13/2024. The order was for 1 tablet to be given by mouth every 12 hours as needed for anxiety and agitation for 14 days. <BR/> 2. An order for Sertraline HCl Oral Tablet 50 MG, ordered 04/16/2024 and started on 04/17/2024. The order was for 1 tablet to be given by mouth one time a day for anxiety. <BR/>Record review of Resident #1's MAR/TAR for April and May 2024 revealed side effects, effectiveness, or behaviors were not being monitored according to the care plan. Resident #1 was found to have received Sertraline HCl daily at 9:00 a.m. from 04/17/2024 - 05/01/2024, except on 04/20/2024 and 04/22/2024 and received Hydroxyzine HCl on 04/29/2024 at 9:22 p.m., on 09/30/2024 at 10:33 a.m., and on 05/01/2024 at 8:00 a.m. <BR/>Resident #2<BR/>Record review of Resident #2's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and post-traumatic stress disorder (a condition characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). <BR/>Record review of Resident #2's State Optional MDS, dated [DATE], revealed Resident #2 had a BIMS score of 99, which indicated the resident was severely cognitively impaired for daily decision-making skills and/or unable to complete the interview. The resident's PHQ9 (Resident Mood Interview) revealed the resident over the last two weeks, either never or just once, felt down, depressed, or hopeless, and felt tired or had little energy. <BR/>Record review of Resident #2's care plan revealed:<BR/> - A focus, initiated on 04/15/2024, revealed Resident #2 used antidepressant medication related to depression with interventions, date initiated 04/15/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . <BR/> - A focus, initiated on 04/17/2024 and revised on 04/23/2024, revealed Resident #2 used anti-anxiety medications and anti-convulsant medications related to anxiety disorder with interventions, date initiated 04/17/2024, [Resident #2] is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety, Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness .Paradoxical side effects: mania, hostility, and rage, aggressive or impulsive behavior, hallucinations, and Monitor/record occurrence of for target behavior symptoms and document per facility protocol. <BR/>Record review of Resident #2's Order Recap Report, dated 04/10/2024 - 05/31/2024 and accessed 05/24/2024, revealed Resident #2 had three (3) active psychotropic medications on the day accessed. <BR/> - No orders were found for monitoring for target behavior symptoms or side effects and effectiveness for the following medications. <BR/> 1. An order for Ativan Oral Tablet 0.5 MG (Lorazepam), ordered on 05/22/2024, started on 05/23/2024, and no end date. The order was for 1 tablet to be given by mouth two times a day for anxiety. <BR/> 2. An order for Citalopram Hydrobromide Oral Tablet 10 MG, ordered 04/30/2024 and started on 05/01/2024, and no end date. The order was for 1 tablet to be given by mouth in the morning for depression. <BR/> 3. An order for Trileptal Oral Tablet 150 MG, ordered 04/29/2024 and started on 04/30/2024, and no end date. The order was for 1 tablet to be given by mouth two times a day for agitation. <BR/>Resident #3<BR/>Record review of Resident #3's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder, depression, and mild cognitive impairment (difficulty with language, memory, and thinking). <BR/>Record review of Resident #3's State Optional MDS, dated [DATE], revealed Resident #3 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision-making skills. The resident's PHQ9 (Resident Mood Interview) revealed the resident over the last two weeks did not experience any mood problems. <BR/>Record review of Resident #3's care plan revealed:<BR/> - A focus, initiated on 12/11/2023, revealed Resident #3 used antidepressant medication related to depression with interventions, date initiated 12/11/2023, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . <BR/>Record review of Resident #3's Order Recap Report, dated 11/11/2023 - 05/31/2024 and accessed 05/24/2024, revealed Resident #3 had one (1) active psychotropic medication on the day accessed. <BR/> - No orders were found for monitoring for target behavior symptoms or side effects and effectiveness for the following medication. <BR/> 1. An order for Mirtazapine Oral Tablet 7.5 MG, ordered and started on 11/22/2023 and no end date. The order was for 1 tablet to be given by mouth at bedtime for depression and anxiety. <BR/>Resident #4<BR/>Record review of Resident #4's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), insomnia (trouble falling and/or staying asleep), major depressive disorder(a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder, and suicide attempt, noted as initial encounter and dated 02/28/2024. <BR/>Record review of Resident #4's State Optional MDS, dated [DATE], revealed Resident #4 had a BIMS score of 1, which indicated the resident was moderately cognitively impaired for daily decision-making skills. The resident's PHQ9 (Resident Mood Interview) revealed the resident over the last two weeks, for 2 - 6 days, had trouble falling or staying asleep, slept too much, and had a poor appetite or overate. <BR/>Record review of Resident #4's care plan revealed:<BR/> - A focus, initiated on 03/04/2024 and revised on 04/18/2024, revealed Resident #4 used anti-histamine medications related to adjustment issues and anxiety disorder with interventions, date initiated 03/04/2024, Give anti-anxiety medications ordered by physician. Monitor/documents side effects and effectiveness ., Monitor/record occurrence of for target behavior symptoms and document per facility protocol, and [Resident #4] is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety.<BR/> - A focus, initiated on 03/06/2024, revealed Resident #4 used antidepressant and antiseizure medication related to depression and poor adjustment to admission with interventions, date initiated 03/06/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . <BR/>Record review of Resident #4's Order Recap Report, dated 04/04/2024 - 05/31/2024 and accessed 05/21/2024, revealed Resident #4 had four (4) active psychotropic medications on the day accessed. <BR/> - No orders were found for monitoring for target behavior symptoms or side effects and effectiveness for the following medications. <BR/> 1. An order for Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium), ordered and started on 04/09/2024 and no end date. The order was for 1 tablet to be given by mouth two times a day for agitation. <BR/> 2. An order for Hydroxyzine HCl Oral Tablet 25 MG, ordered and started on 05/20/2024 and no end date. The order was for 1 tablet to be given by mouth every 8 hours for anxiety and agitation. <BR/> 3. An order for Mirtazapine Oral Tablet 7.5 MG, ordered and started on 04/04/2024 and no end date. The order was for 1 tablet to be given by mouth at bedtime for depression. <BR/> 4. An order for Trazodone HCl Oral Tablet 50 MG, ordered and started on 04/04/2024 an no end date. The order was for 1 tablet to be given by mouth at bedtime for insomnia.<BR/>Record review of Resident #4's MAR/TAR for May 2024, accessed on 05/24/2024 at 6:18 p.m., did not reveal side effects, effectiveness, or behaviors were being monitored according to the care plan. Resident #4 was found to have received Depakote twice a day at 9:00 a.m. and 5:00 p.m. from 05/01/2024 - 05/22/2024, then twice a day at 7:00 a.m. and 7:00 p.m. on 05/23/2024, and one time at 7:00 a.m. on 05/24/2024. He received Hydroxyzine HCl twice on 05/20/2024 at 3:00 p.m. and 11:00 p.m.; then three times a day from 05/21/2024 - 05/23/2024 at 7:00 a.m., 3:00 p.m., and 11:00 p.m.; and twice on 05/24/2024 at 7:00 a.m. and 3:00 p.m. He received Mirtazapine and Trazodone HCl daily at 8:00 p.m. from 05/01/2024 - 05/23/2024.<BR/>Resident #5<BR/>Record review of Resident #5's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included expressive language disorder (condition that affects the ability to use language to communicate), restlessness and agitation, and aphasia (inability to understand or express speech). <BR/>Record review of Resident #5's State Optional MDS, dated [DATE], revealed the resident had a BIMS score of 00, which indicated the resident was severely cognitively impaired for daily decision-making skills. The resident's PHQ9 (Resident Mood Interview) revealed the resident was not able to be complete the interview.<BR/>Record review of Resident #5's care plan revealed:<BR/> - A focus, initiated on 02/20/2024 and revised 02/23/2024, revealed Resident #5 used antidepressant and antiseizure medications related to depression with interventions, date initiated 02/20/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . <BR/> - A focus, initiated 04/02/2024, revealed Resident #5 had potential for drug related complications associated with use of psychotropic medications anti-anxiety medication with intervention, date initiated 04/02/2024, Monitor for side effects related to psychotropic medications and report to physician . <BR/>Record review of Resident #5's Order Recap Report, dated 01/01/2024 - 05/31/2024 and accessed 05/24/2024, revealed Resident #5 had two (2) active psychotropic medications on the day accessed. <BR/> - No orders were found for monitoring for target behavior symptoms or side effects and effectiveness for the following medications. <BR/> 1. An order for Ativan Oral Tablet 0.5 MG (Lorazepam), ordered and started on 04/09/2024 and no end date. The order was for 1 tablet to be given by mouth two times a day for anxiety and agitation.<BR/> 2. An order for Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium), ordered on 04/29/2024 and started on 04/30/2024 and no end date. The order was for 5 ml to be given via PEG-Tube two times a day for agitation. <BR/>Resident #6<BR/>Record review of Resident #6's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), alcohol use, and opioid use. <BR/>Record review of Resident #6's State Optional MDS, dated [DATE], revealed Resident #6 had a BIMS score of 14, which indicated the resident was cognitively intact for daily decision-making skills.<BR/>Record review of Resident #6's care plan revealed:<BR/> - A focus, initiated on 02/23/2024 and revised 04/12/2024, revealed Resident #6 used antidepressant and anticonvulsant medication related to depression with interventions, date initiated 02/23/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . <BR/>Record review of Resident #6's Order Recap Report, dated 11/10/2023 - 05/31/2024 and accessed 05/24/2024, revealed Resident #6 had two (2) active psychotropic medications on the day accessed. <BR/> - No orders were found for monitoring for target behavior symptoms or side effects and effectiveness for the following medications. <BR/> 1. An order for Mirtazapine Oral Tablet 7.5 MG, ordered and started on 12/13/2023 and no end date. The order was for 1 tablet to be given by mouth at bedtime for depression and anxiety. <BR/> 2. An order for Trileptal Oral Tablet 150 MG (Oxcarbazepine), ordered and started on 04/09/2024 and no end date. The order was for 1 tablet to be given by mouth two times a day for mood.<BR/>Ativan Oral Tablet 0.5 MG (Lorazepam), ordered and started on 04/09/2024 and no end date. The order was for 1 tablet to be given by mouth two times a day for anxiety and agitation.<BR/>In an interview with the Psych NP on 05/23/2024 at 4:33 p.m., the Psych NP stated the nursing facility had standard orders for the psychotropic medications, orders that the nurses at the facility follow. The Psych NP stated she was unsure how the psychotropic monitoring orders were generated but stated that the staff were pretty good about monitoring their residents. The Psych NP stated the facility staff were really good at notifying her of any issues by calling her or would tell her when she was in the facility for her assessments, which was generally at least one time a week. The Psych NP stated that the majority of residents at the facility were psychiatric patients, so the nurses would report to her continuously of the resident's behaviors. The Psych NP stated that she did not feel that there had to be an order for monitoring because the nurses knew to call her or call the call center, which could be reached 26 hours a day, seven days a week. <BR/>In an interview with MD E on 05/25/2024 at 12:52 p.m., MD E stated the nursing staff monitored and checked on residents daily so they would chart if there were any changes. MD E stated she felt the residents were being monitored adequately and if there was a change, the staff would have reported those changes. <BR/>In an interview with LVN B on 05/26/2024 at 4:15 p.m., LVN B stated she monitored for side effects based on the specific medications. LVN B stated she looked at what was entered into the facility's MAR to know what to look for. LVN B stated she monitored her residents for having signs and symptoms, and if they did, she reported it to the doctor. LVN B stated she documented her observations in a note and completed a change of condition form. LVN B stated if a resident were having behaviors, she would document those behaviors. <BR/>Record review of the facility's policy, Behavioral Monitoring, revised March 2019, revealed 6. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes .Monitoring .4. If antipsychotic medications are used to treat behavioral symptoms, the IDT, incoordination, and alongside behavioral health services, will monitor their indication .a. The IDT and behavioral health services will monitor for side effects and complications related to psychoactive medications .b. if such symptoms are identified, and some medication is still needed, the IDT and behavioral health services will adjust the current regimen to try to minimize side effects while maintaining therapeutic effectiveness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 44% based on 11 errors out of 25 opportunities, which involved 1 (Resident #7) of 4 residents reviewed for medication errors. <BR/>CMA H failed to administer medication as ordered to Resident #7 by administering Amlodipine (a treatment for high blood pressure), Buspirone HCl (a treatment for mood disorder), Calcium-Vitamin D supplement, Clonidine (a treatment for high blood pressure), Docusate Sodium (a treatment for constipation), Divalproex Sodium (a treatment for mood disorder), Furosemide (a treatment for edema or fluid retention), Metoprolol Tartrate (a treatment for high blood pressure), Multivitamin, Sodium Supplement, Spironolactone (a treatment for edema or fluid retention) over 1&frac12; hours after the scheduled time. <BR/>These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled pain.<BR/>Findings included: <BR/>Record review of Resident #7's admission Record, dated 05/23/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included paranoid schizophrenia (a chronic mental illness involving symptoms of schizophrenia and characterized by symptoms such as a persistent and irrational fear or suspicion of others, delusions, and hallucinations), atherosclerotic heart disease (a buildup of fats in the arterial walls), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), localized edema (swelling caused by excess fluid trapped in the body's issues), and constipation. <BR/>Record review of Resident #7's MDS, dated [DATE], revealed Resident #7 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision-making skills.<BR/>Record review of Resident #7's May MAR revealed, Resident #7's Lasix Tablet 40 MG (Furosemide), Norvasc Tablet 10 MG (Amlodipine Besylate), Aldactone Tablet 50 MG (Spironolactone), Buspirone HCl Tablet 5 MG, Calcium Carbonate-Vitamin D Tablet 600-400 MG, Clonidine HCl Tablet 0.1 MG, Colace Capsule 100 MG (Docusate Sodium), Depakote ER Tablet Extended Release 24 Hour 500 G (Divalproex Sodium ER), Metoprolol Tartrate Tablet 25 MG, Multivitamin with Minerals Tablet, and Sodium Chloride Tablet was scheduled for 7:00 a.m. <BR/>Record review of Resident #7's Order Summary Report, dated as Active Orders as of 05/23/2024 and accessed on 05/23/2024, revealed Resident #7 orders included:<BR/>- An order for Aldactone Tablet 50 MG (Spironolactone), ordered and started on 02/16/2022 and no end date. The order was for 1 tablet to be given by mouth two times a day for edema.<BR/>- An order for Buspirone HCl Tablet 5 MG, ordered 12/28/2020 and started on 12/30/2020 and no end date. The order was for 1 tablet to be given by mouth two times a day for anxiety. <BR/>- An order for Calcium Carbonate-Vitamin D Tablet 600-400 MG-UNIT, ordered and started on 04/17/2019 and no end date. The order was for 1 tablet to be given by mouth two times a day for supplement. <BR/>- An order for Clonidine HCl Tablet 0.1 MG, ordered and started on 11/16/2022 and no end date. The order was for 1 tablet to be given by mouth two times a day for hypertension (high blood pressure) and to be held if systolic blood pressure was below 110, diastolic blood pressure was below 60, and/or heart rate was below 60. <BR/>- An order for Colace Capsule 100 MG (Docusate Sodium), ordered and started on 01/11/2022, and no end date. The order was for 1 capsule to be given by mouth two times a day for bowel management. <BR/>- An order for Depakote ER Tablet Extended Release 24 Hour 500 MG (Divalproex Sodium ER), ordered and started on 09/08/2020, and no end date. The order was for 1 tablet to be given by mouth two times a day for Schizophrenia. <BR/>- An order for Lasix Tablet 40 MG (Furosemide), ordered and started on 09/28/2020, and no end date. The order was for 1 tablet to be given by mouth in the morning for edema.<BR/>- An order for Metoprolol Tartrate Tablet 25 MG, ordered and started on 09/28/2020, and no end date. The order was for 1 tablet to be given by mouth two times a day for hypertension and to be held if blood pressure was below 100/60 and/or pulse below 60. <BR/>- An order for Multivitamins with Minerals Tablet, ordered and started on 09/23/2020, and no end date. The order was for 1 tablet to be given by mouth two times a day for health supplement.<BR/>- An order for Norvasc Tablet 10 MG (Amlodipine Besylate), ordered on 07/05/2023 and started on 07/06/2023, and no end date. The order was for 1 tablet to be given by mouth one time a day for blood pressure and to be held if systolic blood pressure was below 110 and/or heart rate was below 60.<BR/>- an order for Sodium Chloride oral Tablet 1 GM (Sodium Chloride), ordered on 05/22/2024 and started on 05/23/2024, and no end date. The order was for 2 tablets to be given by mouth two times a day related to hypo-osmolality (low levels of electrolytes, proteins, and nutrients in the blood) and hyponatremia (low levels of sodium in the blood). <BR/>In an interview with CMA H on 05/22/2024 at 7:55 a.m., CMA H stated that she started her shift at 6:00 a.m., and after completing her cart counts, she started passing medications around 6:30 a.m. every day. CMA H stated that due the number of residents she was assigned with medications scheduled at 7:00 a.m., she had late administrations daily. CMA H stated that she started her medication administration on E-hall, but by the time she reached F-hall, the medications scheduled on F-hall for 7:00 a.m. were late. CMA H stated that she had reported the late medication administrations to the shift nurses, did not provide names, but had not told the ADONs, the prior DON, or the ADMIN. <BR/>Observation and interview with CMA H on 05/22/2024 at 8:28 a.m., revealed CMA H preparing medication for administration to Resident #7 with the resident's MAR red indicating late medication administration on the EHR. CMA H confirmed the red in the MAR indicated the medication administration was late. CMA H administered the medications to Resident #7 at 08:35 a.m. <BR/>Interview with MD E 5/25/2024 at 12:52 p.m., MD E stated medications had a two-hour window for administration. After review of the medications administered late to Resident #7 and the time of order and administration, MD E stated she did not have any concerns about side effects or medication interactions with the subsequent issuances or timeliness for this amount of time late. <BR/>Record review of the facility's policies, Medication Orders, dated revised November 2014, and Documentation Medication Administration, dated revised November 2022, did not reference administration timeliness or late medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #2, #3, #1) reviewed for infection control, in that: <BR/>1. During wound care of Resident #3, LVN D made several passes in multiple directions with the same gauze to clean the wound; she made several passes in multiple directions to dry the wound, and when applying the ointment to the wound, she made several passes with the tongue depressor with ointment on it without discarding the used tongue depressor and using a new one with each new pass. <BR/>2. During incontinent care for Resident #2, CNA C washed her hands before starting care and dried her hands with one soaked paper towel for both hands; after washing her hands, she closed the privacy curtain; she donned gloves without using hand sanitizer. CNA F washed his hands for only 7 seconds and used the same soaked paper towel to dry both hands. CNA C wiped areas multiple times with the same wipe.<BR/>3. During nephrostomy care for Resident #1, LVN E did not change gloves to go from the resident's left nephrostomy to the right nephrostomy; LVN E double gloved her hands before starting care on the resident's right side. <BR/>These failures could place residents at risk of infection due to improper infection control practices.<BR/>Findings include:<BR/>1. Record review of Resident #3's face sheet, dated 2/2/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Bi-polar disorder, Cerebral Palsy, Epilepsy, and anxiety disorder.<BR/>Record review of Resident #3's consolidated physician orders for February 2024 revealed an order for Wound Care: NON-PRESSURE WOUND OF THE LEFT, UPPER FACE-Cleanse site with wound cleanser, pat dry apply anasept, and leave open to air, dated 1/2/2024.<BR/>Record review of Resident #3's Quarterly MDS, dated [DATE], revealed the resident had a BIMS of 99, which indicated the resident was not able to complete the cognitive assessment, and was indicated to have a non pressure ulcer wound for care.<BR/>Record review of Resident #3's Care Plan,dated 1/24/2024, revealed the resident's care plan addressed altered skin integrity non pressure related with a skin abrasion to upper left face.<BR/>Observation on 1/31/2024 at 2:34 PM of wound care for Resident #3 by LVN D revealed that while performing wound care to a wound on the resident's left forehead, LVN D made several passes in multiple directions with the same gauze with wound cleanser without discarding the used gauze. Further observation revealed LVN D patted the wound dry and applied the anasept ointment using a tongue depressor making several passes in multiple directions with the same tongue depressor with the ointment on it without discarding the used tongue depressor and using a new one with each pass.<BR/>During an interview with LVN D and ADON B on 1/31/2024 at 2:34 PM, at the same time as the observation, LVN D stated she understood by saying, oh yeah, I knew what I did wrong. LVN D further stated she had been employeed with the facility for 3 years. ADON B was in the room during observation, and also stated, yes, she [LVN D] wiped for too many times on the wound. ADON B stated the last inservice for infection control was in November 2023.<BR/>2. Record review of Resident #2's face sheet, dated 2/2/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Traumatic brain injury, schizoaffective disorder, and anxiety disorder.<BR/>Record review of Resident #2's consolidated physician orders for February 2024 revealed an order, to have barrier cream applied daily to perineum and buttocks after each incontinent episode, dated 05/10/2023. <BR/>Record reviewof Resident #2's Quarterly MDS, dated [DATE], revealed the resident had a BIMS of 11, which indicated the resident was mildly cognitively impaired, and was indicated to be a two-person assist with all ADLs.<BR/>Record review of Resident #2's Care plan, dated 1/26/2024, revealed the resident's care plan addressed that barrier cream was to be applied after each incontinent episode.<BR/>Observation on 1/31/2024 at 2:46 PM of incontinent care for Resident #2 by CNAs C and F revealed prior to incontinent care for Resident #2 CNA F did not wash his hands according to the facility's infection control policy. CNA F used one water soaked paper towel to dry both hands. CNA C after washing her hands correctly, she used her clean hands to close the privacy curtain, contaminating her hands once more and she did not use hand sanitizer or rewash her hands before donning gloves to perform incontinent care. Further observation revealed CNA C wiped Resident #2's penis shaft multiple time with one wipe, in a back and forth wiping motion. CNA C then used another wipe to clean the glans foreskin and the urethra opening, using a circular motion several times with the same wipe. CNA C got a clean wipe to clean the scrotum. CNA C wiped the scrotum up and down several times with the same cloth.<BR/>During an interview with CNAs C and F on 1/31/2024 at 2:46 PM,at the same time of the observation,CNA F confirmed he did not wash his hands according to the facility's infection control policy. CNA C confirmed she did not use hand sanitizer after touching Resident #2's privacy curtain and did not realize she made the mistake. CNA C further confirmed she wiped Resident #2's penis shaft multiple times with one cloth, in a back and forth wiping motion, then she used another cloth to clean the glans foreskin and the urethra opening, using a circular motion several times with the same cloth; then she got a clean cloth to clean the scrotum and she wiped the scrotum up and down several times with the same cloth.<BR/>3. Record review of Resident #1's face sheet, dated 1/30/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Obstructive and reflux uropathy, chronic systolic heart failure, and spinal stenosis.<BR/>Record review of Resident #1's consolidated physician orders for February 2024 revealed an order for, cleanse nephrostomy sites with normal saline, pat dry with gauze and apply clean dry split gauze and secure with tape daily.<BR/>Record review of Resident #1's Annual MDS, dated [DATE], revealed the resident had a BIMS of 13, which indicated the resident was cognitively intact, required a two-person assisted with ADLs, and required an indwelling catheter.<BR/>Record review of Resident #1's Care Plan, dated 1/12/2024, revealed the resident's care plan addressed that the resident had bilateral nephrostomy tubes related to obstructive uropathy (difficulty passing urine), and pyelonephritis (inflamation of the substance of the kidney as a result of bacterial infection).<BR/>Observation on 1/31/2024 at 3:30 PM of nephrostomy care for Resident #1 by LVN E and assisting her was CNA/Med Aide G revealed LVN E went to right side nephrostomy to do care after completing care on the left side nephrostomy (tube that was placed in the kidney because the person was unable to urinate due to obstruction or other issues preventing them from urinating through the bladder) wearing the same gloves. LVN E proceeded to remove the gloves and then after sanitizing her hands,and she put on two pairs of gloves. LVN E cleaned the site and removed the top layer of gloves and wiped the nephrostomy site to dry with one dry gauze with two motions up and down with the same gauze. <BR/>During an interview with LVN E on 1/31/2024 at 3:30 PM, at the same time as the observation, when asked by the Surveyor about not changing her gloves, LVN E denied wrongdoing of not removing her gloves after nephrostomy care on the left side and going over to the right side to do nephrostomy care. LVNE stated she did not feel she did anything wrong with wearing two pairs of gloves.<BR/>During an interview on 1/31/2024 at 3:55 PM with DON A regarding the observation of nephrostomy care, the surveyor explained the failures of the observations, DON A stated, Oh my God. No, that is not how it should be done. And double gloves should not be worn. No. The surveyor also informed DON A about incontinent care observation and explained the failures, and DON A stated, Oh, no. They know they are to only wipe in one direction and use only one wipe for each area. She stated the last inservice for infection control was done in November of 2023 and it is usually done every 3 months where the staff goes on the computer to do the inservice or they do spot checks where they go and follow a staff member and have them wash their hands or do incontinent care and are signed off on the task. If they fail the task, and in person training would be done with staff for each shift. The ADON is the Infection Control Preventionist but the DON assists her with the task.<BR/>Record review of the facility's policy titled, Handwashing/Hand Hygiene, dated August 2019- Revised, revealed: All employees are to follow the handwashing/ had hygiene procedures to help prevent the spread of infections to personnel, residents, and visitors.<BR/>Record review of the facility's policy titled, Handwashing Competency, (no date), revealed: hands are to be vigorously washed with soap and water, creating friction to all surfaces for a minimum of 20 seconds (or longer) under a moderate stream of running water at a comfortable temperature.<BR/>Record review of the facility's policy titled, Care of Nephrostomy Tube, dated October 2020- Revised, revealed: Nephrostomy care should be done using sterile technique after removing soiled dressing from nephrostomy site. Once removed, wash hands and don sterile gloves and clean area, doffing gloves when done, clean hands and don new gloves to apply dressing.<BR/>Record review of facility's training titled, Incontinent Care, no date, revealed: Peri care is done with one wipe front to back, always away from the urethral opening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #2, #3, #1) reviewed for infection control, in that: <BR/>1. During wound care of Resident #3, LVN D made several passes in multiple directions with the same gauze to clean the wound; she made several passes in multiple directions to dry the wound, and when applying the ointment to the wound, she made several passes with the tongue depressor with ointment on it without discarding the used tongue depressor and using a new one with each new pass. <BR/>2. During incontinent care for Resident #2, CNA C washed her hands before starting care and dried her hands with one soaked paper towel for both hands; after washing her hands, she closed the privacy curtain; she donned gloves without using hand sanitizer. CNA F washed his hands for only 7 seconds and used the same soaked paper towel to dry both hands. CNA C wiped areas multiple times with the same wipe.<BR/>3. During nephrostomy care for Resident #1, LVN E did not change gloves to go from the resident's left nephrostomy to the right nephrostomy; LVN E double gloved her hands before starting care on the resident's right side. <BR/>These failures could place residents at risk of infection due to improper infection control practices.<BR/>Findings include:<BR/>1. Record review of Resident #3's face sheet, dated 2/2/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Bi-polar disorder, Cerebral Palsy, Epilepsy, and anxiety disorder.<BR/>Record review of Resident #3's consolidated physician orders for February 2024 revealed an order for Wound Care: NON-PRESSURE WOUND OF THE LEFT, UPPER FACE-Cleanse site with wound cleanser, pat dry apply anasept, and leave open to air, dated 1/2/2024.<BR/>Record review of Resident #3's Quarterly MDS, dated [DATE], revealed the resident had a BIMS of 99, which indicated the resident was not able to complete the cognitive assessment, and was indicated to have a non pressure ulcer wound for care.<BR/>Record review of Resident #3's Care Plan,dated 1/24/2024, revealed the resident's care plan addressed altered skin integrity non pressure related with a skin abrasion to upper left face.<BR/>Observation on 1/31/2024 at 2:34 PM of wound care for Resident #3 by LVN D revealed that while performing wound care to a wound on the resident's left forehead, LVN D made several passes in multiple directions with the same gauze with wound cleanser without discarding the used gauze. Further observation revealed LVN D patted the wound dry and applied the anasept ointment using a tongue depressor making several passes in multiple directions with the same tongue depressor with the ointment on it without discarding the used tongue depressor and using a new one with each pass.<BR/>During an interview with LVN D and ADON B on 1/31/2024 at 2:34 PM, at the same time as the observation, LVN D stated she understood by saying, oh yeah, I knew what I did wrong. LVN D further stated she had been employeed with the facility for 3 years. ADON B was in the room during observation, and also stated, yes, she [LVN D] wiped for too many times on the wound. ADON B stated the last inservice for infection control was in November 2023.<BR/>2. Record review of Resident #2's face sheet, dated 2/2/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Traumatic brain injury, schizoaffective disorder, and anxiety disorder.<BR/>Record review of Resident #2's consolidated physician orders for February 2024 revealed an order, to have barrier cream applied daily to perineum and buttocks after each incontinent episode, dated 05/10/2023. <BR/>Record reviewof Resident #2's Quarterly MDS, dated [DATE], revealed the resident had a BIMS of 11, which indicated the resident was mildly cognitively impaired, and was indicated to be a two-person assist with all ADLs.<BR/>Record review of Resident #2's Care plan, dated 1/26/2024, revealed the resident's care plan addressed that barrier cream was to be applied after each incontinent episode.<BR/>Observation on 1/31/2024 at 2:46 PM of incontinent care for Resident #2 by CNAs C and F revealed prior to incontinent care for Resident #2 CNA F did not wash his hands according to the facility's infection control policy. CNA F used one water soaked paper towel to dry both hands. CNA C after washing her hands correctly, she used her clean hands to close the privacy curtain, contaminating her hands once more and she did not use hand sanitizer or rewash her hands before donning gloves to perform incontinent care. Further observation revealed CNA C wiped Resident #2's penis shaft multiple time with one wipe, in a back and forth wiping motion. CNA C then used another wipe to clean the glans foreskin and the urethra opening, using a circular motion several times with the same wipe. CNA C got a clean wipe to clean the scrotum. CNA C wiped the scrotum up and down several times with the same cloth.<BR/>During an interview with CNAs C and F on 1/31/2024 at 2:46 PM,at the same time of the observation,CNA F confirmed he did not wash his hands according to the facility's infection control policy. CNA C confirmed she did not use hand sanitizer after touching Resident #2's privacy curtain and did not realize she made the mistake. CNA C further confirmed she wiped Resident #2's penis shaft multiple times with one cloth, in a back and forth wiping motion, then she used another cloth to clean the glans foreskin and the urethra opening, using a circular motion several times with the same cloth; then she got a clean cloth to clean the scrotum and she wiped the scrotum up and down several times with the same cloth.<BR/>3. Record review of Resident #1's face sheet, dated 1/30/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Obstructive and reflux uropathy, chronic systolic heart failure, and spinal stenosis.<BR/>Record review of Resident #1's consolidated physician orders for February 2024 revealed an order for, cleanse nephrostomy sites with normal saline, pat dry with gauze and apply clean dry split gauze and secure with tape daily.<BR/>Record review of Resident #1's Annual MDS, dated [DATE], revealed the resident had a BIMS of 13, which indicated the resident was cognitively intact, required a two-person assisted with ADLs, and required an indwelling catheter.<BR/>Record review of Resident #1's Care Plan, dated 1/12/2024, revealed the resident's care plan addressed that the resident had bilateral nephrostomy tubes related to obstructive uropathy (difficulty passing urine), and pyelonephritis (inflamation of the substance of the kidney as a result of bacterial infection).<BR/>Observation on 1/31/2024 at 3:30 PM of nephrostomy care for Resident #1 by LVN E and assisting her was CNA/Med Aide G revealed LVN E went to right side nephrostomy to do care after completing care on the left side nephrostomy (tube that was placed in the kidney because the person was unable to urinate due to obstruction or other issues preventing them from urinating through the bladder) wearing the same gloves. LVN E proceeded to remove the gloves and then after sanitizing her hands,and she put on two pairs of gloves. LVN E cleaned the site and removed the top layer of gloves and wiped the nephrostomy site to dry with one dry gauze with two motions up and down with the same gauze. <BR/>During an interview with LVN E on 1/31/2024 at 3:30 PM, at the same time as the observation, when asked by the Surveyor about not changing her gloves, LVN E denied wrongdoing of not removing her gloves after nephrostomy care on the left side and going over to the right side to do nephrostomy care. LVNE stated she did not feel she did anything wrong with wearing two pairs of gloves.<BR/>During an interview on 1/31/2024 at 3:55 PM with DON A regarding the observation of nephrostomy care, the surveyor explained the failures of the observations, DON A stated, Oh my God. No, that is not how it should be done. And double gloves should not be worn. No. The surveyor also informed DON A about incontinent care observation and explained the failures, and DON A stated, Oh, no. They know they are to only wipe in one direction and use only one wipe for each area. She stated the last inservice for infection control was done in November of 2023 and it is usually done every 3 months where the staff goes on the computer to do the inservice or they do spot checks where they go and follow a staff member and have them wash their hands or do incontinent care and are signed off on the task. If they fail the task, and in person training would be done with staff for each shift. The ADON is the Infection Control Preventionist but the DON assists her with the task.<BR/>Record review of the facility's policy titled, Handwashing/Hand Hygiene, dated August 2019- Revised, revealed: All employees are to follow the handwashing/ had hygiene procedures to help prevent the spread of infections to personnel, residents, and visitors.<BR/>Record review of the facility's policy titled, Handwashing Competency, (no date), revealed: hands are to be vigorously washed with soap and water, creating friction to all surfaces for a minimum of 20 seconds (or longer) under a moderate stream of running water at a comfortable temperature.<BR/>Record review of the facility's policy titled, Care of Nephrostomy Tube, dated October 2020- Revised, revealed: Nephrostomy care should be done using sterile technique after removing soiled dressing from nephrostomy site. Once removed, wash hands and don sterile gloves and clean area, doffing gloves when done, clean hands and don new gloves to apply dressing.<BR/>Record review of facility's training titled, Incontinent Care, no date, revealed: Peri care is done with one wipe front to back, always away from the urethral opening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately inform a resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for notification of changes in that:<BR/>The facility did not notify Resident #1's physician (Physician F) prior to Resident #1's discharge on [DATE]. <BR/>This deficient practice could place residents at risk of not having their physician notified of discharge resulting in a delay in continuity of care.<BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated 8/17/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy [a chemical imbalance in the blood that causes problems in the brain], thrombocytopenia [a low amount of platelets, which are blood cells that cause clotting, in the blood], unspecified, essential (primary) hypertension, muscle weakness (generalized), and dysphagia [difficulty swallowing], oral phase. Further record review of this document revealed Resident #1 did not have a responsible party or a guardian. Further record review of this document revealed Resident #1's primary physician was Physician F.<BR/>Record review of Resident #1's entry MDS, dated [DATE], revealed Resident #1 had a BIMS score of 8, signifying moderate cognitive impairment. Record review of this same document, revealed the following item: <BR/>- Section G, Item G0110. Activities of Daily Living (ADL) Assistance. Review of this item revealed Resident #1 required one-person physical assist with the following activities of daily living: bed mobility, transfer, walking in room, walking in corridor, dressing, eating, toilet use, and personal hygiene. <BR/>Record review of Resident #1's MoCA assessment [which is a test used to detect mild cognitive decline and early signs of issues with the ability to remember, think, or make decisions], dated 8/9/23, revealed Resident #1 had a MoCA score of 6 out of 30, signifying severe cognitive deficits. <BR/>Record review of Resident #1's orders, obtained on 8/17/23, revealed no physician order for Resident #1's discharge.<BR/>Record review of Resident #1's care plan, dated 8/15/23, revealed the following Focus area initiated on 8/8/23: Resident will be assessed for discharge needs, included in the discharge planning process, and educated appropriately to ensure a successful discharge. This Focus area was associated with the following intervention initiated on 8/8/23: Resident's discharge plan will be discussed with physician and orders will be obtained if needed.<BR/>Record review of Resident #1's Discharge Planning and Summary, dated 8/15/23 at 11:27 a.m., revealed an incomplete and unsigned Discharge Planning and Summary. There was no documentation indicating Physician F, was notified of any discharge plans prior to Resident #1's discharge or upon Resident #1's discharge on [DATE].<BR/>Record review of Resident #1's Progress Notes from 7/26/23 to 8/17/23, obtained 8/17/23, revealed no progress note which indicated Physician F was notified of Resident #1's discharge.<BR/>During a confidential interview on 8/17/23 on 4:38 p.m., the confidential interviewee stated they worked on 8/15/23. The interviewee stated Resident #1 did not have a discharge order.<BR/>During an interview on 8/18/23 at 10:56 a.m., the Administrator stated there was no discharge order for Resident #1. The Administrator stated he did not know if Physician F was notified regarding Resident #1's discharge. The Administrator stated, if there was no order in place, I'm assuming [Physician F] wasn't [notified]. <BR/>During an interview with the DON on 8/18/23 at 12:08 p.m., when asked what typically happened when a resident was discharged , the DON stated, we have to have an order in place. We have to call the physician and let him know. There's always an order.<BR/>During an interview on 8/19/23 at 5:09 p.m., Physician F stated Resident #1 was one of his patients. Physician F stated he was not notified of Resident #1's discharged on 8/15/23 until either 8/17/23 or 8/18/23. Physician F stated, They said he was discharged and the nursing was very disappointed in it, but [Resident #1] was discharged by the Administrator. And I'm like, why am I not being notified? The nursing said they didn't feel like it was a safe discharge. I don't know what interventions they did to prevent that from happening. Physician F stated he would have wanted to be notified before Resident #1 left. Physician F stated, They [the residents] don't get discharged without a physician discharge. Physician F stated he did not recall issuing a discharge order. <BR/>Record review of a facility policy titled, Transfer or Discharge, Facility-Initiated, dated October 2022, revealed no verbiage regarding the notification of the resident's primary care physician. <BR/>Record review of a facility policy titled, Discharging the Resident, dated December 2016, revealed no verbiage regarding the notification of the resident's primary care physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents were permitted to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility and the facility also did not provide written records when a resident was discharged for 1 of 5 residents (Resident #1) reviewed for discharge rights, in that: <BR/>The facility failed to have a valid circumstance to support discharging Resident #1 to the local homeless shelter on 8/15/23. The facility did not provide written records to the local homeless shelter upon discharging Resident #1.<BR/>This failure could result in residents being discharged without appropriate reasons and documentation communicated to help with the transition of care and could place a medically compromised resident at risk of a decline due to changing clinical environments and care continuity.<BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated 8/17/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy [a chemical imbalance in the blood that causes problems in the brain], thrombocytopenia [a low amount of platelets, which are blood cells that cause clotting, in the blood], unspecified, essential (primary) hypertension, muscle weakness (generalized), and dysphagia [difficulty swallowing], oral phase. Further record review of this document revealed Resident #1 did not have a responsible party or a guardian. Further record review of this face sheet revealed Resident #1 was discharged on 8/15/23 and his length of stay was 20 days.<BR/>Record review of Resident #1's entry MDS, dated [DATE], revealed Resident #1 had a BIMS score of 8, signifying moderate cognitive impairment. Record review of this same document, revealed the following items: <BR/>- Section G, Item G0110. Activities of Daily Living (ADL) Assistance. Review of this item revealed Resident #1 required one-person physical assist with the following activities of daily living: bed mobility, transfer, walking in room, walking in corridor, dressing, eating, toilet use, and personal hygiene. <BR/>- Item Q0300A. Resident's Overall Expectation: Select one for resident's overall goal established during assessment process. The answer to this item was: Unknown or uncertain. The other options which were not selected for item Q0300 were: Expects to be discharged to the community, expects to remain in this facility, and expects to be discharged to another facility/institution. <BR/>- Item Q0300B. Indicate information source for Q0300A. The answer to this item was: Resident. <BR/>- Item Q0400A. Discharge Plan: Is active discharge planning already occurring for the resident to return to the community? The answer to this item was: No.<BR/>- Items Q0500B. Return to the community: Ask the resident . 'Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community?' The answer to this item was Unknown or uncertain. <BR/>Record review of Resident #1's MoCA assessment [which is a test used to detect mild cognitive decline and early signs of issues with the ability to remember, think, or make decisions], dated 8/9/23, revealed Resident #1 had a MoCA score of 6 out of 30, signifying severe cognitive deficits. <BR/>Record review of Resident #1's care plan, dated 8/15/23, revealed the following Focus area initiated on 8/8/23: Resident will be assessed for discharge needs, included in the discharge planning process, and educated appropriately to ensure a successful discharge. This Focus area was associated with the following intervention initiated on 8/8/23: Resident's discharge plan will be discussed with physician and orders will be obtained if needed.<BR/>Record review of Care Conference Summary, dated 8/16/23 at 11:01 a.m., revealed the DOR documented the following in the section titled: Summary of Therapy and/or Restorative: Resident was on therapy and was D/C on 8/11/23; Resident was on OT ST and PT; Resident is not a safe DC secondary to the Montreal Cognitive Assessment (MOCA) which the resident scored 6/30 which is severe cognitive deficits. Per IDT; it was determined that the resident was not a safe DC. There was no documented on this Care Conference regarding of a future discharge location or coordination of care for a safe discharge.<BR/>Record review of Resident #1's Discharge Planning and Summary, dated 8/15/23 at 11:27 a.m., revealed an incomplete and unsigned Discharge Planning and Summary. There was no documentation regarding a discharge location or coordination of care to the local homeless shelter. <BR/>Record review of Resident #1's OT Discharge summary, dated [DATE] and signed by OT H, revealed the following: Discharge Recommendations: 24 hour care. <BR/>Record review of Resident #1's PT Discharge summary, dated [DATE] and signed by PT A, revealed the following: Discharge Recommendations: Assistance with IADLs and 24 hour care. <BR/>Record review of Resident #1's progress notes from 7/26/23 to 8/17/23, revealed the following progress notes: <BR/>- Nursing Progress Note dated 8/15/23 at 4:17 p.m. and written by LVN G: This nurse was informed that pt was d/c to [local homeless shelter.]<BR/>- Nursing Progress Note dated 8/15/23 at 11:29 a.m. and written by the DON: This nurse with the IDT agreed that this was an unsafe DC.<BR/>- Discharge Plan Update Note dated 8/14/23 at 3:29 p.m. and written by the SW: In anticipation of upcoming discharge of resident, the following agencies were contacted for possible housing for resident: [8 local agencies were listed here, including the local homeless shelter Resident #1 was ultimately discharged to.] SW was informed by agencies ID is required or other forms of identification and would have to register, and resident had no form of ID. Administrator was informed of requirements for housing and that resident had none. SW told Adm. this is an unsafe discharge Adm. responded [Resident #1] had no payor source and would have to be discharged today. Adm. stated he should have been out yesterday because we are not getting paid. SW will continue to follow closely. <BR/>Further record review of these progress notes ranging from 7/26/23 to 8/17/23 revealed no documentation that written records were provided to Resident #1's discharge location: the local homeless shelter.<BR/>During an interview on 8/17/23 at 3:36 p.m., the Driver stated he transported Resident #1 to the local homeless shelter on 8/15/23. The Driver stated that his direct supervisor, the Maintenance Director, said he [the Driver] needed to transport Resident #1 to [the local homeless shelter]. The Driver stated he transported Resident #1's to the local homeless shelter's intake area, but did not see if Resident #1 entered the premises prior to leaving the area. The Driver stated he did not know why Resident #1 was discharged and stated Resident #1 only had the clothes he [Resident #1] was wearing when Resident #1 left the facility.<BR/>During a confidential interview on 8/17/23 on 4:38 p.m., the confidential interviewee stated they worked on 8/15/23. The interviewee stated, if we know the patient is discharged , then we have to do the necessary documentation, like the discharge papers and anything, prepare all of those that needs to be done, like the medications and everything, if they [the residents] will go with their medications. The interviewee stated she had assisted someone with their lunch meal and thought Resident #1 went to therapy. The interviewee stated, I didn't know he was discharged until someone told me. And I said 'discharged ? Where?' And it was the med aide who told me he was discharged . So I said, 'to where?' And she goes, 'I don't know but he was discharged .' So when I looked back and checked the orders, there was no order from the doctor to discharge. The interviewee stated she did not know who prepared Resident #1 for discharge. <BR/>During an interview on 8/17/23 at 5:05 p.m., the SW stated the discharge planning process started at time of admission. The SW stated, I ask what their [the resident's] plans are once they meet their goals. Well, I follow up with the family and see what the family says and sometimes we have to wait until they [the resident] finish their therapy and see how they're doing if they're going to stay for long term. When asked when a resident was able to discharge, the SW stated, If they [the residents] come in for therapy, once they've met their goals on therapy, and this population, the psychiatric ones, they're long-term. Meaning they'll stay here unless the family wants them to go to another facility. When asked what was the facility's policy on facility-initiated discharges, the SW stated, Well, like in 30 days, behaviors, non-payment, once they met their needs, and if we're not able to meet their needs. I issue [the 30 day discharge.] I present it to the resident. And then I tell him this is the 30-day discharge and I tell him the reason and I tell him I will assist them in finding alternative placement. When asked if a resident was able to appeal a discharge notice, the SW stated, Yes. When asked how would a resident appeal a discharge, the SW stated I don't know, but if they [the residents] tell me they want to appeal, I'm going to find out real fast. When asked if Resident #1 required 24-hour care, the SW stated, I'm going to say no, because he is a street person. He can survive by himself. When asked if Resident #1 met criteria for long-term care, the SW stated, Well, this is my conundrum: he could do everything, but his-he was confused. Yet, he could function. When asked if Resident #1 had medical necessity to stay, the SW stated, I personally don't think so. Just because you're confused and a street person, why does that give you medical necessity? Now I may be wrong. When asked what were Resident #1's discharged goals, the SW stated, He wanted to leave . Back to the community. When asked why Resident #1 was discharged , the SW stated, Because he had already used up his Medicare days and he had no funding and there was no family member to help him get his financial Medicaid. I would have said that he has the right to leave. You may want him on Medicaid or think that he's better here, but the man has a right to leave. We can't tell him what's best for him and the way to live. That's my opinion. The SW stated, Medicare pays for 100% for the first day until the 20th day and 80% from the 21st day to the 100th day. When asked how Resident #1 was notified of his non-payment, the SW stated, we just tell him that his therapy was terminated and he can now be discharged . When asked if Resident #1 understood the explanation, the SW stated, No. When asked who initiated Resident #1's discharge, the SW stated, I guess I did. I was told [by the Administrator] that 'it's time for him to go and do what you need to do.' When asked how the Administrator made the determination to discharge Resident #1, the SW stated, when he [Resident #1] ran out of his Medicare. When asked how Resident #1 was involved in his discharge, the SW stated, He couldn't say he just-he just wanted to go And he made that clear throughout his stay . he said that he's a drifter and lives out in the streets. When asked how she ensured Resident #1 had a safe discharge, the SW stated, I told the Administrator it was not a safe discharge. Over and over, multiple times. Not only me, but the Director of Nurses, the ADON, the IDT kept saying it's not a safe discharge. [The Administrator] just said he had to go. He had to be discharged because of the money. The SW stated Resident #1 went to the local homeless shelter. The SW stated, I called multiple places but they required an ID, or some sort of ID which he didn't have, or some type of money, so he ended up having to go [the local homeless shelter.] The SW stated she started reaching out to multiple agencies on 8/14/23, the day before Resident #1 was discharged .<BR/>During an interview on 8/18/23 at 9:43 a.m., a representative from the local homeless shelter, Representative E, stated Resident #1 was not at the local homeless shelter. Representative E stated, we have a discharge process for our intake center since we're not a medical facility. We want to make sure that people who are discharged from a medical facility, we have a form that is submitted. We didn't have any records that the form was submitted [for Resident #1.] And we did search for [Resident #1] . we searched by the date of birth and SSN provided and we didn't have anyone there . And then usually the facility, they will transport by non-emergency vehicle or ambulance and they'll usually pull up in front of our intake center and then walk the individual inside, like a 'warm hand-off.' We don't have a record of anyone bringing him into our intake center and that paperwork . [Resident #1] wouldn't have been accepted here, it would have been an inappropriate placement. We do have our [clinic] that will come and look at him, but our ADLs are just different than the standard ADLs. It mainly comes down to how far they can walk on their own and things like that. <BR/>During an interview on 8/18/23 at 10:56 a.m., the Administrator stated typically discharge planning started even before the resident was admitted to the facility. The Administrator stated, There's a process to it. Sometimes they come in long-term but then they become short-term because of the resident's wishes. We have meetings. We talk about discharging if they're going to be short-term or long-term . The social worker helps with the discharge planning. When asked when a resident was able to be discharged , the Administrator stated, If the resident is expressing they want to leave and they don't want to be there anymore, obviously we can't hold them hostage in the building or keep them there. We have to find a plan and get them to a place they want to be . or if their skilled stay is up. And if it comes down to financial or behavioral, where we can't meet their needs, we've had to issue a 30-day notice. When asked what were the state guidelines for facility-initiated discharges, the Administrator stated, I know there's 30-day notices. If it's an immediate discharge there's a letter you can send out or write up. When asked if Resident #1 had medical necessity, the Administrator stated, I do believe he met medical necessity. I want to say he was on skilled services. I don't know if he was all three therapies or just one. When asked what were Resident #1's discharge goals, the Administrator stated, I do recall that he wanted to leave. I know we had an elopement at one point with him. He wanted to leave and I know [Resident #1's] hospital paperwork said Resident #1 worked for [the local homeless shelter] and resided there. That was one of the things he wanted. Personally, I wasn't the one who sat down with him and asked him what were his goals. When asked why Resident #1 was discharged , the Administrated stated, He was a short-term resident. When he first got here we saw that he was going to be potentially a long-term but due to him not having co-insurance and things, we looked at that. But he also verbalized to our social worker and the business office manager that he wanted to leave and I was aware [Resident #1] was homeless. And during our PDPM meeting it was discussed that the resident had to be discharged after 20 days. The DON and SW, we made that decision to find placement for him. That's when I looked at my SW . for discharge planning and she looked at multiple different facilities and [the local homeless shelter] came up and it seemed like she [the SW] had it under control and taken care of it and I trusted that and that's when we made the decision. When asked if Resident #1 was discharged because he (Resident #1) could not pay for his stay, the Administrator stated, It was part of that yeah . But I took the fact that he wanted to leave into consideration into it, too. When asked when was the decision made to discharge Resident #1, the Administrator stated, Maybe the week before because we had those daily meetings. The Administrator stated he was not sure exactly when the SW began looking for alternative placement for Resident #1. The Administrator stated he was aware Resident #1 was going to the local homeless shelter before Resident #1 was discharged but did not check if arrangements were made for Resident #1 to discharge. The Administrator stated, When my social worker said that [Resident #1] was ready to go to [the local homeless shelter] and we just needed someone to transport him there. Right then and there I was thinking plans had been arranged and we can proceed with this. I didn't question it. When asked how Resident #1 was involved in his discharge, the Administrator stated, I heard that he was ready to go and happy to leave over there. But I'm not sure involved he personally was. When asked what sort of items went with Resident #1, the Administrator stated, he didn't have anything. He didn't have much to begin with. When asked if Resident #1 went with any medications or medical records, the Administrator stated, I wasn't present at the time of his actual discharge. <BR/>During an interview on 8/18/23 at 12:08 p.m., the DON stated the discharge planning process started at the point of admission. When asked when a resident was able to be discharged , the DON stated, they [the residents] can be discharged at their request, but there's safety criteria that we have to meet. When asked what were the state guidelines for facility-initiated discharges, the DON stated, they have to be planned, it has to be a safe discharge, it cannot be not because of funds . It has to be safe. That's why we do PDPM to make sure we're following the plans . You have to give a 30 day [notice] and you have to assist in finding placement. When asked if Resident #1 required 24-hr care, the DON stated, yes, at first. Because of his cognition. When asked if Resident #1 had medical necessity, the DON stated, he had medications that we were giving. Basic ADLs and his food . I know he was hypertensive. He was unsteady on his feet too.And his confusion. He had a lot of queuing to sit down and eat because he'd like to walk. He'd like to go up and down the hall. I know they had to assist him with dressing, but I don't know what level. When asked what were Resident #1's discharge goals, the DON stated, He wanted to go to [the local homeless shelter.] He would say that he used to live there. When asked why Resident #1 was discharged , the DON stated, because he did not have a payer. They thought he was private pay, I believe. It was about getting him out because there was no one to pay. But he had his copay days. The DON stated she was not sure how the facility assisted in helping Resident #1 apply for another payer source such as Medicaid. The DON stated to send a resident to the local homeless shelter, the social worker will reach out to the shelter to see if the shelter can accept the resident. When asked how Resident #1 was involved in his discharge, the DON stated, he wasn't, to my knowledge. The DON stated she saw Resident #1 just as he was about to leave on 8/15/23 and stated Resident #1 did not have any medications or paperwork. <BR/>Record review of a facility policy titled, Transfer or Discharge, Facility-Initiated, dated October 2022, revealed the following: Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: a. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; b. the transfer or discharge is appropriate because the resident's health has improved sufficiency so the resident no longer needs the services provided by this facility; c. the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; d. the health of individuals in the facility would otherwise be endangered; the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at this facility . f. the facility ceases to operate. Further record review of this policy revealed the following, should a resident be transferred or discharged for any reasons, the following information is communicated to the receiving facility or provider: a. the basis for the transfer or discharge . b. contact information of the practitioner responsible for the care of the resident; c. resident representative information including contact information; d. advanced directive information; e. all special instructions or precautions for ongoing care, as appropriate . f. comprehensive care plan goal; and g. all other information necessary to meet the resident's needs, including but not limited to: (1) resident status, including baseline and current mental, behavioral, and functional status; (2) recent vital signs; (3) diagnosis and allergies; (4) medications (including when last received); (5) most recent relevant labs, other diagnostic tests, and recent immunizations; (6) a copy of the residents' discharge summary; and (7) any other documentation, as applicable to ensure a safe and effective transition of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, before the facility transferred or discharged a resident, the facility failed to notify the local Ombudsman of the transfer or discharge and failed to issue a notice of discharge to 1 of 5 residents (Resident #1) reviewed for discharge rights in that: <BR/>The facility did not issue a discharge notice to Resident #1 at least 30 days prior to his discharge to the local homeless shelter on 8/15/23. The facility did not send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman.<BR/>This failure could place the residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options and appeal process, and being discharged without alternate placement.<BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated 8/17/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy [a chemical imbalance in the blood that causes problems in the brain], thrombocytopenia [a low amount of platelets, which are blood cells that cause clotting, in the blood], unspecified, essential (primary) hypertension, muscle weakness (generalized), and dysphagia [difficulty swallowing], oral phase. Further record review of this document revealed Resident #1 did not have a responsible party or a guardian. Further record review of this face sheet revealed Resident #1 was discharged on 8/15/23 and his length of stay was 20 days.<BR/>Record review of Resident #1's entry MDS, dated [DATE], revealed Resident #1 had a BIMS score of 8, signifying moderate cognitive impairment.<BR/>Record review of Resident #1's MoCA assessment [which is a test used to detect mild cognitive decline and early signs of issues with the ability to remember, think, or make decisions], dated 8/9/23, revealed Resident #1 had a MoCA score of 6 out of 30, signifying severe cognitive deficits. <BR/>Record review of Resident #1's care plan, dated 8/15/23, revealed the following Focus area initiated on 8/8/23: Resident will be assessed for discharge needs, included in the discharge planning process, and educated appropriately to ensure a successful discharge. This Focus area was associated with the following intervention initiated on 8/8/23: Resident's discharge plan will be discussed with physician and orders will be obtained if needed.<BR/>Record review of Care Conference Summary, dated 8/16/23 at 11:01 a.m., revealed there was no documentation on this Care Conference regarding whether Resident #1 received a 30-day discharge notice or if the Ombudsman was provided a copy of the discharge notice.<BR/>Record review of Resident #1's Discharge Planning and Summary, dated 8/15/23 at 11:27 a.m., revealed an incomplete and unsigned Discharge Planning and Summary form. There was no documentation regarding whether Resident #1 received a 30-day discharge notice or if the Ombudsman was provided a copy of the discharge notice.<BR/>Record review of Resident #1's Progress Notes from 7/26/23 to 8/17/23, obtained 8/17/23, revealed no progress note which indicated whether Resident #1 received a 30-day discharge notice or if the Ombudsman was provided a copy of the discharge notice.<BR/>Record review of Resident #1's electronic miscellaneous documents revealed no documentation of a 30-day discharge notice form or proof that the ombudsman was provided a copy of a 30-day discharge notice.<BR/>During an interview on 8/17/23 at 5:05 p.m., when asked what did the facility policies stated about facility-initiated discharges, the SW stated, Well, like the 30-days [notice], behaviors, non-payment, once they met their needs, and if we're not able to meet their needs. SW stated she typically issued the 30-day discharge notice. The SW stated, I present it to the resident, and then I tell him this is the 30-day discharge and I give him the reason and I tell them I will assist them in finding alternative placement. When asked if a resident was able to appeal the discharge notice, the SW stated, yes. When asked how would a resident appeal a discharge notice, the SW stated, I don't know, but if they [the residents] tell me that they want to appeal, I'm going to find out real fast. The SW stated Resident #1 was discharged because he had already use dup his Medicare days and he had no funding and there was no family member to help him get his financial Medicaid . Medicare pays 100% for the first day to the 20th, and 80% from the 21st to the 100th day. The SW stated a discharge notice was not issued to Resident #1. When asked why a discharge notice wasn't issued to Resident #1, the SW stated, We don't give discharge notices when their [the residents'] therapy had ended. When asked who initiated Resident #1's discharge, the SW stated, I guess I did. I was told [by the Administrator] that 'it's time for him to go and do what you need to do.' When asked how the Administrator made the determination to discharge Resident #1, the SW stated, when he [Resident #1] ran out of his Medicare.<BR/>During an interview on 8/18/23 at 10:56 a.m., the Administrator stated, if it comes down to financial or behaviors, we've had to issue a 30-day notice. When asked what were the state guidelines about facility-initiated discharges, the Administrator stated, I know there's a 30 day notice. If it's an immediate discharge there's a letter than you can set out or write up. That's just kind of brief. When asked when was the decision made to discharge Resident #1, the Administrator stated, maybe the week before. When asked if Resident #1 was discharged because he could not pay for his stay, the Administrator stated, It was part of that, yeah. It was that-in our meetings it was discussed that he was private pay . but I took the fact that he wanted to leave into consideration into it too. When asked if Resident #1 received a 30-day notice, the Administrator stated, You know, I wouldn't say there was a 30-day discharge. The Administrator stated he did not know if the ombudsman was notified of Resident #1's discharge. <BR/>During an interview on 8/18/23 at 9:28 a.m., the facility's Volunteer Ombudsman stated he was not notified of Resident #1's discharge until 8/16/23, the day after Resident #1 had already been discharged on 8/15/23. The Volunteer Ombudsman stated he was notified of the discharge through several phone calls from the facility staff. The Volunteer Ombudsman stated he did not receive a 30 day discharge notice for Resident #1.<BR/>Record review of the facility's admission Packet, dated 11/2022, revealed the following: discharged for Failure to Pay: If you are required to vacate for failure to pay, the facility will provide at least 30 days advance noticed as set forth in the Resident's Rights section of this Agreement.<BR/>Record review of a facility summary titled Transfer or Discharge, Facility-Initiated, October 2022, revealed the following, The resident and his or her representative are given thirty (30)-day advance written notice of an impending transfer or discharge from this facility . a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility for 1 of 3 residents (Resident #1) reviewed for discharge rights, in that:<BR/>The facility failed to ensure Resident #1's legal guardian was sufficiently prepared and oriented for Resident #1's transfer to hospital.<BR/>This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and services and denying them a voice regarding their treatment plan.<BR/>The findings were:<BR/>Record review of Resident #1's admission record, dated 06/29/24, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include dementia (loss of thinking, remembering, and reasoning skills), schizoaffective disorder (a chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors). <BR/>Record review of Resident #1's MDS assessment (Nursing Home Comprehensive), dated 04/25/24, reflected she had a BIMS score of 10 out of 15, indicating moderately impaired cognition. <BR/>Record review of Resident #1's care plan, dated 06/29/24, reflected Resident #1 had impaired cognitive function/dementia or impaired thought processes [related to] schizophrenia, dementia, initiated 04/19/24, with an intervention [Resident #1[ needs supervision/assistance with all decision making.<BR/>Record review of Resident #1's Letter of Guardianship, dated 01/24/24, reflected [Guardianship Program] was appointed as guardian of Resident #1, an incapacitated person. <BR/>There was no record of a written discharge/transfer notice for Resident #1's legal guardian. <BR/>There was no record of the facility making efforts to get an accurate state of the resident's condition while he was in the hospital. <BR/>During an interview on 06/28/24 at 09:03 PM, Resident #1's legal guardian revealed he was not aware Resident #1 was not resident at this nursing home facility anymore. He revealed he was not told Resident #1 was transferred to a hospital so he was unable to follow up with resident. When he came to visit the facility on 06/24/24 at 01:30 PM, he found Resident #1 was not in the facility. He revealed ADON A did not know Resident #1's whereabouts at this time. The legal guardian further revealed he was unable to locate resident and filed a missing person's report to the local Police Department on 06/26/24 at 10:30 AM. <BR/>During an interview on 06/29/24 at 11:15 AM, the Administrator revealed Resident #1 was anticipated to return to the facility and there was no reason for the facility to not take this resident back. She revealed they had communication with the hospital and the case manager there was finding placement for Resident #1. The Administrator revealed she assumed the hospital was working with Resident #1's legal guardian to ensure the guardian knew where Resident #1 would be discharged to, from the hospital. She further revealed another nursing home facility accepted Resident #1 to be admitted to their facility. There was no documentation of any of these actions being done. <BR/>During a record review, interview, and observation on 06/29/24 at 04:18 PM, Resident #1 was observed at a different nursing home facility. He revealed he did not remember anything about the facility he was prior to hospitalization. He revealed he did not have a legal guardian and he was responsible for himself. Record review of his admission record at this second nursing home facility reflected Resident #1 was his own responsible party with no mention of a legal guardian. <BR/>During an interview on 06/29/24 at 04:55 PM, Resident #1's legal guardian revealed he was not notified Resident #1 was discharged to a hospital on [DATE]. He revealed he would have followed up with Resident #1 at the hospital. He further revealed he was not notified Resident #1 was at another facility. <BR/>During an interview and record review on 06/29/24 at 06:26 PM, ADON A confirmed she spoke to the legal guardian about Resident #1 discharging to a hospital on [DATE] at 09:15 PM (per a nursing progress note authored by ADON A). She revealed she sent the hospital all pertinent paperwork, including Resident #1's admission record that listed legal guardian's contact information. She further revealed she expected and assumed the hospital would contact the legal guardian and discharge residents appropriately. <BR/>Record review of grievances since January 2024 revealed no grievances regarding discharges. <BR/>Record Review of facility's policy, Transfer or Discharge, Facility-Initiated, dated October 2022, reflected Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer . and Notice of Facility Bed-Hold and return policies are provided to the resident and representative within 24 hours of emergency transfer.<BR/>4. If the facility determines that the resident cannot return to the facility, the medical record will indicate the facility made efforts to: b. ascertain an accurate status of the resident's condition, which can be accomplished via communication between hospital and facility staff and/or through visits by facility staff to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident had a discharge summary that included a final summary of the resident's status at the time of the discharge for 1 of 5 residents (Resident #1) reviewed for discharge in that:<BR/>The facility failed to ensure Resident #1 had a discharge summary, medication reconciliation, information on Resident #1's permanent medical necessity (PMN) status, and a post-discharge plan of care at the time of his discharge to the local homeless shelter on 8/15/23.<BR/>This deficient practice could place discharged residents at risk for a lack of continued care and services.<BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated 8/17/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy [a chemical imbalance in the blood that causes problems in the brain], thrombocytopenia [a low amount of platelets, which are blood cells that cause clotting, in the blood], unspecified, essential (primary) hypertension, muscle weakness (generalized), and dysphagia [difficulty swallowing], oral phase. Further record review of this face sheet revealed Resident #1 was discharged on 8/15/23 and his length of stay was 20 days.<BR/>Record review of Resident #1's entry MDS, dated [DATE], revealed Resident #1 had a BIMS score of 8, signifying moderate cognitive impairment. <BR/>Record review of Resident #1's MoCA assessment [which is a test used to detect mild cognitive decline and early signs of issues with the ability to remember, think, or make decisions], dated 8/9/23, revealed Resident #1 had a MoCA score of 6 out of 30, signifying severe cognitive deficits. <BR/>Record review of Resident #1's care plan, dated 8/15/23, revealed the following Focus area initiated on 8/8/23: Resident will be assessed for discharge needs, included in the discharge planning process, and educated appropriately to ensure a successful discharge. This Focus area was associated with the following intervention initiated on 8/8/23: Resident's discharge plan will be discussed with physician and orders will be obtained if needed.<BR/>Record review of Care Conference Summary, dated 8/16/23 at 11:01 a.m., revealed no documentation indicating Resident #1 had a discharge summary, medication reconciliation, information on Resident #1's permanent medical necessity (PMN) status, and a post-discharge plan of care when he was discharged to the local homeless shelter. There was no documentation indicating a discharge summary, medication reconciliation, information on Resident #1's permanent medical necessity (PMN) status, and a post-discharge plan of care was sent to the local homeless shelter.<BR/>Record review of Resident #1's Discharge Planning and Summary, dated 8/15/23 at 11:27 a.m., revealed an incomplete and unsigned Discharge Planning and Summary form. There was no documentation indicating Resident #1 had a discharge summary, medication reconciliation, information on Resident #1's permanent medical necessity (PMN) status, and a post-discharge plan of care when he was discharged to the local homeless shelter. There was no documentation indicating a discharge summary, medication reconciliation, information on Resident #1's permanent medical necessity (PMN) status, and a post-discharge plan of care was sent to the local homeless shelter.<BR/>Record review of Resident #1's progress notes from 7/26/23 to 8/17/23, revealed the following progress notes: <BR/>- Nursing Progress Note dated 8/15/23 at 4:17 p.m. and written by LVN G: This nurse was informed that pt was d/c to [local homeless shelter.]<BR/>- Nursing Progress Note dated 8/15/23 at 11:29 a.m. and written by the DON: This nurse with the IDT agreed that this was an unsafe DC.<BR/>- Discharge Plan Update Note dated 8/14/23 at 3:29 p.m. and written by the SW: In anticipation of upcoming discharge of resident, the following agencies were contacted for possible housing for resident: [8 local agencies were listed here, including the local homeless shelter Resident #1 was ultimately discharged to.] SW was informed by agencies ID is required or other forms of identification and would have to register, and resident had no form of ID. Administrator was informed of requirements for housing and that resident had none. SW told Adm. this is an unsafe discharge Adm. responded [Resident #1] had no payor source and would have to be discharged today. Adm. stated he should have been out yesterday because we are not getting paid. SW will continue to follow closely. <BR/>Further record review of these progress notes ranging from 7/26/23 to 8/17/23 revealed no documentation that written records were provided to Resident #1's discharge location: the local homeless shelter. There was no documentation indicating Resident #1 had a discharge summary, medication reconciliation, information on Resident #1's permanent medical necessity (PMN) status, and a post-discharge plan of care when he was discharged to the local homeless shelter. There was no documentation indicating a discharge summary, medication reconciliation, information on Resident #1's permanent medical necessity (PMN) status, and a post-discharge plan of care was sent to the local homeless shelter.<BR/>During an interview on 8/17/23 at 3:36 p.m., the Driver stated he transported Resident #1 to the local homeless shelter on 8/15/23. The Driver stated that his direct supervisor, the Maintenance Director, said he [the Driver] needed to transport Resident #1 to [the local homeless shelter]. The Driver stated he transported Resident #1 to the local homeless shelter's intake area, but did not see if Resident #1 entered the premises. The Driver stated he did not know why Resident #1 was discharged and stated Resident #1 only had the clothes he [Resident #1] was wearing when Resident #1 left the facility.<BR/>During a confidential interview on 8/17/23 on 4:38 p.m., the confidential interviewee stated they worked on 8/15/23. The interviewee stated, if we know the patient is discharged , then we have to do the necessary documentation, like the discharge papers and anything, prepare all of those that needs to be done, like the medications and everything, if they will go with their medications. The interviewee stated she had assisted someone with their lunch meal and thought Resident #1 went to therapy. The interviewee stated, I didn't know he was discharged until someone told me. And I said 'discharged ? Where?' And it was the med aide who told me he was discharged . So I said, 'to where?' And she goes, 'I don't know but he was discharged .' The interviewee stated she did not know who prepared Resident #1 for discharge. <BR/>During an interview on 8/17/23 at 5:05 p.m., the SW stated the discharge planning process started at time of admission. The SW stated, I ask what their [the resident's] plans are once they meet their goals. Well, I follow up with the family and see what the family says and sometimes we have to wait until they [the resident] finish their therapy and see how they're doing if they're going to stay for long term. When asked when a resident was able to discharge, the SW stated, If they [the residents] come in for therapy, once they've met their goals on therapy, and this population, the psychiatric ones, they're long-term. When asked if Resident #1 met criteria for long-term care, the SW stated, Well, this is my conundrum: he could do everything, but his-he was confused. Yet, he could function. When asked if Resident #1 had medical necessity to stay, the SW stated, I personally don't think so. Just because you're confused and a street person, why does that give you medical necessity? Now I may be wrong. When asked what were Resident #1's discharged goals, the SW stated, He wanted to leave . Back to the community. When asked why Resident #1 was discharged , the SW stated, Because he had already used up his Medicare days and he had no funding and there was no family member to help him get his financial Medicaid. I would have said that he has the right to leave. You may want him on Medicaid or think that he's better her, but the man has a right to leave. We can't tell him what's best for him and the way to live. That's my opinion. The SW stated, Medicare pays for 100% for the first day until the 20th day and 80% from the 21st day to the 100th day. When asked who initiated Resident #1's discharge, the SW stated, I guess I did. I was told [by the Administrator] that 'it's time for him to go and do what you need to do.' When asked how the Administrator made the determination to discharge Resident #1, the SW stated, when he [Resident #1] ran out of his Medicare. The SW stated Resident #1 went to the local homeless shelter. The SW stated, I called multiple places but they required an ID, or some sort of ID which he didn't have, or some type of money, so he ended up having to go [the local homeless shelter.] The SW stated she started reaching out to multiple agencies on 8/14/23, the day before Resident #1 was discharged . The SW stated Resident #1 did not leave with any medications or medical records. <BR/>During an interview on 8/18/23 at 9:43 a.m., a representative from the local homeless shelter, Representative E, stated Resident #1 was not at the local homeless shelter. Representative E stated, we have a discharge process for our intake center since we're not a medical facility. We want to make sure that people who are discharged from a medical facility, we have a form that is submitted. We didn't have any records that the form was submitted [for Resident #1.] And we did search for [Resident #1] . we searched by the date of birth and SSN provided and we didn't have anyone there . And then usually the facility, they will transport by non-emergency vehicle or ambulance and they'll usually pull up in front of our intake center and then walk the individual inside, like a 'warm hand-off.' We don't have a record of anyone bringing him into our intake center and that paperwork . [Resident #1] wouldn't have been accepted here, it would have been an inappropriate placement. We do have our [clinic] that will come and look at him, but our ADLs are just different than the standard ADLs. It mainly comes down to how far they can walk on their own and things like that. <BR/>During an interview on 8/18/23 at 10:56 a.m., the Administrator stated typically discharge planning started even before the resident was admitted to the facility. The Administrator stated, There's a process to it. Sometimes they come in long-term but then they become short-term because of the resident's wishes. We have meetings. We talk about discharging if they're going to be short-term or long-term . The social worker helps with the discharge planning. When asked if Resident #1 had medical necessity, the Administrator stated, I do believe he met medical necessity. I want to say he was on skilled services. I don't know if he was all three therapies or just one. When asked what were Resident #1's discharge goals, the Administrator stated, I do recall that he wanted to leave. I know we had an elopement at one point with him. He wanted to leave and I know the [resident's] hospital paperwork said Resident #1 worked for [the local homeless shelter] and resided there. That was one of the things he wanted. Personally, I wasn't the one who sat down with him and asked him what were his goals. When asked why Resident #1 was discharged , the Administrated stated, He was a short-term resident. When he first got here we saw that he was going to be potentially a long-term but due to him not having co-insurance and things, we looked at that. But he also verbalized to our social worker and the business office manager that he wanted to leave and I was aware the resident was homeless. And during our PDPM meeting it was discussed that the resident had to be discharged after 20 days . The DON and SW, we made that decision to find placement for him. That's when I looked at my SW . for discharge planning and she looked at multiple different facilities and [the local homeless shelter] came up and it seemed like she [the SW] had it under control and taken care of it and I trusted that and that's when we made the decision. When asked when was the decision made to discharge Resident #1, the Administrator stated, Maybe the week before because we had those daily meetings. The Administrator was not sure exactly when the SW began looking for alternative placement for Resident #1. The Administrator stated he was aware Resident #1 was going to the local homeless shelter before Resident #1 was discharged but did not check if arrangements were made for Resident #1 to discharge. The Administrator stated, When my social worker said that [Resident #1] was ready to go to [the local homeless shelter] and we just needed someone to transport him there. Right then and there I was thinking plans had been arranged and we can proceed with this. I didn't question it. When asked what sort of items went with Resident #1, the Administrator stated, he didn't have anything. He didn't have much to begin with. When asked if Resident #1 went with any medications or medical records, the Administrator stated, I wasn't present at the time of his actual discharge. <BR/>During an interview on 8/18/23 at 12:08 p.m., the DON stated the discharge planning process started at the point of admission. When asked when a resident was able to be discharged , the DON stated, they [the residents] can be discharged at their request, but there's safety criteria that we have to meet. When asked what were the state guidelines for facility-initiated discharges, the DON stated, they have to be planned, it has to be a safe discharge, it cannot be not because of funds . It has to be safe. That's why we do PDPM to make sure we're following the plans . You have to give a 30 day [notice] and you have to assist in finding placement. When asked if Resident #1 required 24-hr care, the DON stated, yes, at first. Because of his cognition. When asked if Resident #1 had medical necessity, the DON stated, he had medications that we were giving. Basic ADLs and his food . I know he was hypertensive. He was unsteady on his feet too.And his confusion. He had a lot of queuing to sit down and eat because he'd like to walk. He'd like to go up and down the hall. I know they had to assist him with dressing, but I don't know what level. The DON stated to send a resident to the local homeless shelter, the social worker will reach out to the shelter to see if the shelter can accept the resident. The DON stated she saw Resident #1 just as he was about to leave on 8/15/23 and stated Resident #1 did not have any medications or paperwork. <BR/>Record review of a facility policy titled, Discharge Summary and Plan, dated October 2022, revealed the following: a copy of the following is provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. the post-discharge plan; and c. the discharge summary. <BR/>Record review of a facility policy titled, Transfer of Discharge, Facility-Initiated, dated October 2022, revealed the following: should a resident be transferred or discharged for any reasons, the following information is communicated to the receiving facility or provider: a. the basis for the transfer or discharge . g. all other information necessary to meet the resident's needs, including but not limited to: (1) resident status, including baseline and current mental, behavioral, and functional status; (2) recent vital signs; (3) diagnosis and allergies; (4) medications (including when last received); .(6) a copy of the residents' discharge summary; and (7) any other documentation, as applicable to ensure a safe and effective transition of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #2, #3, #1) reviewed for infection control, in that: <BR/>1. During wound care of Resident #3, LVN D made several passes in multiple directions with the same gauze to clean the wound; she made several passes in multiple directions to dry the wound, and when applying the ointment to the wound, she made several passes with the tongue depressor with ointment on it without discarding the used tongue depressor and using a new one with each new pass. <BR/>2. During incontinent care for Resident #2, CNA C washed her hands before starting care and dried her hands with one soaked paper towel for both hands; after washing her hands, she closed the privacy curtain; she donned gloves without using hand sanitizer. CNA F washed his hands for only 7 seconds and used the same soaked paper towel to dry both hands. CNA C wiped areas multiple times with the same wipe.<BR/>3. During nephrostomy care for Resident #1, LVN E did not change gloves to go from the resident's left nephrostomy to the right nephrostomy; LVN E double gloved her hands before starting care on the resident's right side. <BR/>These failures could place residents at risk of infection due to improper infection control practices.<BR/>Findings include:<BR/>1. Record review of Resident #3's face sheet, dated 2/2/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Bi-polar disorder, Cerebral Palsy, Epilepsy, and anxiety disorder.<BR/>Record review of Resident #3's consolidated physician orders for February 2024 revealed an order for Wound Care: NON-PRESSURE WOUND OF THE LEFT, UPPER FACE-Cleanse site with wound cleanser, pat dry apply anasept, and leave open to air, dated 1/2/2024.<BR/>Record review of Resident #3's Quarterly MDS, dated [DATE], revealed the resident had a BIMS of 99, which indicated the resident was not able to complete the cognitive assessment, and was indicated to have a non pressure ulcer wound for care.<BR/>Record review of Resident #3's Care Plan,dated 1/24/2024, revealed the resident's care plan addressed altered skin integrity non pressure related with a skin abrasion to upper left face.<BR/>Observation on 1/31/2024 at 2:34 PM of wound care for Resident #3 by LVN D revealed that while performing wound care to a wound on the resident's left forehead, LVN D made several passes in multiple directions with the same gauze with wound cleanser without discarding the used gauze. Further observation revealed LVN D patted the wound dry and applied the anasept ointment using a tongue depressor making several passes in multiple directions with the same tongue depressor with the ointment on it without discarding the used tongue depressor and using a new one with each pass.<BR/>During an interview with LVN D and ADON B on 1/31/2024 at 2:34 PM, at the same time as the observation, LVN D stated she understood by saying, oh yeah, I knew what I did wrong. LVN D further stated she had been employeed with the facility for 3 years. ADON B was in the room during observation, and also stated, yes, she [LVN D] wiped for too many times on the wound. ADON B stated the last inservice for infection control was in November 2023.<BR/>2. Record review of Resident #2's face sheet, dated 2/2/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Traumatic brain injury, schizoaffective disorder, and anxiety disorder.<BR/>Record review of Resident #2's consolidated physician orders for February 2024 revealed an order, to have barrier cream applied daily to perineum and buttocks after each incontinent episode, dated 05/10/2023. <BR/>Record reviewof Resident #2's Quarterly MDS, dated [DATE], revealed the resident had a BIMS of 11, which indicated the resident was mildly cognitively impaired, and was indicated to be a two-person assist with all ADLs.<BR/>Record review of Resident #2's Care plan, dated 1/26/2024, revealed the resident's care plan addressed that barrier cream was to be applied after each incontinent episode.<BR/>Observation on 1/31/2024 at 2:46 PM of incontinent care for Resident #2 by CNAs C and F revealed prior to incontinent care for Resident #2 CNA F did not wash his hands according to the facility's infection control policy. CNA F used one water soaked paper towel to dry both hands. CNA C after washing her hands correctly, she used her clean hands to close the privacy curtain, contaminating her hands once more and she did not use hand sanitizer or rewash her hands before donning gloves to perform incontinent care. Further observation revealed CNA C wiped Resident #2's penis shaft multiple time with one wipe, in a back and forth wiping motion. CNA C then used another wipe to clean the glans foreskin and the urethra opening, using a circular motion several times with the same wipe. CNA C got a clean wipe to clean the scrotum. CNA C wiped the scrotum up and down several times with the same cloth.<BR/>During an interview with CNAs C and F on 1/31/2024 at 2:46 PM,at the same time of the observation,CNA F confirmed he did not wash his hands according to the facility's infection control policy. CNA C confirmed she did not use hand sanitizer after touching Resident #2's privacy curtain and did not realize she made the mistake. CNA C further confirmed she wiped Resident #2's penis shaft multiple times with one cloth, in a back and forth wiping motion, then she used another cloth to clean the glans foreskin and the urethra opening, using a circular motion several times with the same cloth; then she got a clean cloth to clean the scrotum and she wiped the scrotum up and down several times with the same cloth.<BR/>3. Record review of Resident #1's face sheet, dated 1/30/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Obstructive and reflux uropathy, chronic systolic heart failure, and spinal stenosis.<BR/>Record review of Resident #1's consolidated physician orders for February 2024 revealed an order for, cleanse nephrostomy sites with normal saline, pat dry with gauze and apply clean dry split gauze and secure with tape daily.<BR/>Record review of Resident #1's Annual MDS, dated [DATE], revealed the resident had a BIMS of 13, which indicated the resident was cognitively intact, required a two-person assisted with ADLs, and required an indwelling catheter.<BR/>Record review of Resident #1's Care Plan, dated 1/12/2024, revealed the resident's care plan addressed that the resident had bilateral nephrostomy tubes related to obstructive uropathy (difficulty passing urine), and pyelonephritis (inflamation of the substance of the kidney as a result of bacterial infection).<BR/>Observation on 1/31/2024 at 3:30 PM of nephrostomy care for Resident #1 by LVN E and assisting her was CNA/Med Aide G revealed LVN E went to right side nephrostomy to do care after completing care on the left side nephrostomy (tube that was placed in the kidney because the person was unable to urinate due to obstruction or other issues preventing them from urinating through the bladder) wearing the same gloves. LVN E proceeded to remove the gloves and then after sanitizing her hands,and she put on two pairs of gloves. LVN E cleaned the site and removed the top layer of gloves and wiped the nephrostomy site to dry with one dry gauze with two motions up and down with the same gauze. <BR/>During an interview with LVN E on 1/31/2024 at 3:30 PM, at the same time as the observation, when asked by the Surveyor about not changing her gloves, LVN E denied wrongdoing of not removing her gloves after nephrostomy care on the left side and going over to the right side to do nephrostomy care. LVNE stated she did not feel she did anything wrong with wearing two pairs of gloves.<BR/>During an interview on 1/31/2024 at 3:55 PM with DON A regarding the observation of nephrostomy care, the surveyor explained the failures of the observations, DON A stated, Oh my God. No, that is not how it should be done. And double gloves should not be worn. No. The surveyor also informed DON A about incontinent care observation and explained the failures, and DON A stated, Oh, no. They know they are to only wipe in one direction and use only one wipe for each area. She stated the last inservice for infection control was done in November of 2023 and it is usually done every 3 months where the staff goes on the computer to do the inservice or they do spot checks where they go and follow a staff member and have them wash their hands or do incontinent care and are signed off on the task. If they fail the task, and in person training would be done with staff for each shift. The ADON is the Infection Control Preventionist but the DON assists her with the task.<BR/>Record review of the facility's policy titled, Handwashing/Hand Hygiene, dated August 2019- Revised, revealed: All employees are to follow the handwashing/ had hygiene procedures to help prevent the spread of infections to personnel, residents, and visitors.<BR/>Record review of the facility's policy titled, Handwashing Competency, (no date), revealed: hands are to be vigorously washed with soap and water, creating friction to all surfaces for a minimum of 20 seconds (or longer) under a moderate stream of running water at a comfortable temperature.<BR/>Record review of the facility's policy titled, Care of Nephrostomy Tube, dated October 2020- Revised, revealed: Nephrostomy care should be done using sterile technique after removing soiled dressing from nephrostomy site. Once removed, wash hands and don sterile gloves and clean area, doffing gloves when done, clean hands and don new gloves to apply dressing.<BR/>Record review of facility's training titled, Incontinent Care, no date, revealed: Peri care is done with one wipe front to back, always away from the urethral opening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents' right to formulate an advance directive for 1 of 13 residents (Resident #9) reviewed for advanced directives, in that:<BR/>Resident #9's Out-of-Hospital Do Not Resuscitate (OOH-DNR) was invalid.<BR/>This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.<BR/>The findings include:<BR/>Record review of Resident #9's face sheet dated [DATE] revealed an original admission date of [DATE] and a most recent admission date of [DATE] with diagnoses that included: hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) and cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, or following directions). Further review of Resident #9's face sheet revealed under the section ADVANCE DIRECTIVE: Do Not Resuscitate - DNR.<BR/>Record review of Resident #9's Quarterly MDS, dated [DATE], revealed a BIMS score of 14, which indicated the resident was cognitively intact.<BR/>Record review of Resident #9's Care Plan, last review date [DATE], revealed a focus: Patient has an advance Directive as evidenced by: Do not Resuscitate. Patient's wishes will be honored. Further review revealed interventions obtain advance directive with physician order and resident/responsible party signature and review code status quarterly.<BR/>Record review of Resident #9's electronic medical record Order Summary Report, Active Orders as of [DATE], revealed an order dated [DATE] for Do Not Resuscitate - DNR. <BR/>Record review of Resident #9's electronic clinical record revealed an OOH-DNR for Resident #9, was signed by the resident at the top of the document on [DATE] and by the physician in the two places required on [DATE]. Further review revealed the resident had not signed at the bottom of the document and the physician had not printed his name in the Physician's statement section. Two witnesses had signed at the bottom of the form however had not printed and signed their names and had not dated the document in the witness section in the upper part of the document.<BR/>In an interview with the DON on [DATE] at 2:02 p.m., the DON confirmed Resident #9's OOH-DNR had only been signed once by Resident #9 and the witnesses. The DON stated the OOH-DNR would not be valid missing the signatures and Resident #9's code status would have to change back to full code.<BR/>In an interview with the Corporate Registered Nurse on [DATE] at 4:10 p.m., the Corporate Nurse revealed the facility staff had just completed an audit for code status and was surprised this had been missed. The Corporate Nurse stated she and the DON had visited with Resident #9 and the resident agreed to sign another OOH-DNR because she wanted to make sure everyone knew her wishes. The Corporate Nurse revealed the new OOH-DNR had been completed with Resident #9 and sent to the physician for his signature. <BR/>Record review of the Texas Health and Human Services webpage, www.dshs.texas.gov/emstraumasystems/dnr.shtm, titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Frequently Asked Questions for DNR: Why does everyone have to sign twice? All persons who have signed the DNR form must sign at the bottom of the page to acknowledge that the document has been properly completed. Further review revealed in the section, Filling out the Out-of-Hospital Do-Not-Resuscitate Form. Signatures: The statute requires that everyone who signed the form MUST sign the form again in the bottom section to acknowledge that the form has been completed.<BR/>Record review of the Texas Health and Safety Code Title 2 Health, Subtitle H Public Health Provisions, Chapter 166 Advance Directives, Section 166.083 Form of Out-Of-Hospital DNR order, effective [DATE], revealed, (a) A written out-of-hospital DNR order shall be in the standard form specified by department rule as recommended by the department. (b) The standard form of an out-of-hospital DNR order specified by department rule must, at a minimum, contain the following: . (6) places for the printed names and signatures of the witnesses or the notary public's acknowledgment and (13) a statement at the bottom of the document, with places for the signature of each person executing the document, acknowledging that the document has been properly completed.<BR/>Record review of the facility's policy titled, Do Not Resuscitate Order, revised [DATE], revealed, 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders follow physician orders and the resident's advance directives for 1 of 14 residents (Resident #1) whose records were reviewed for Full code status. <BR/>The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff provided Resident #1, who had a Full Code in place, CPR, after the resident was found unresponsive with no pulse or respirations, according to professional standards of practice.<BR/>An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:07 p.m. While the IJ was removed on [DATE] at 9:23 p.m., the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated.<BR/>These deficient practices could contribute to a resident's decline in emotional, physical, and psychological health and result in serious injury and or death. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet in her electronic medical record, dated [DATE] revealed a 57-year female who was initially admitted to the facility on [DATE] with diagnoses to include senile degeneration of brain (a term used to describe the mental deterioration that is associated with old age.), impulse behavior(an improvised or unpredicted course of action that's not based on logic.), dysphagia(inability to speak), unspecified dementia(general name for a decline in cognitive abilities that impacts a person's ability to do every day activities.), and need for assistance with personal care.<BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed her BIMS score was 0 reflective of severe cognitive impairment and was rarely or never understood. She required extensive assistance by 2 persons for ADL's. The MDS did not reflect code status.<BR/>Record review of Resident #1's Care Plan, date initiated [DATE], with a revision date of [DATE], revealed Focus: Advanced Directives: Full Code Status, Goal: Resident will maintain their optimal level of comfort, advanced directive will be honored, and resident/family will be advised of Advanced Directive Forms upon admission, annual review, or significant change in status through next review. Interventions: MD and staff to be made aware of code status/treatment decisions. Staff will start CPR should cardiac arrest occurs and/or breathing independently cease, call EMS and transport to hospital as ordered. Staff will maintain all advanced directives in a prominent location in the medical record.<BR/>Record review of Resident #1's active physician orders for [DATE] revealed she had an order for Full code with original date [DATE].<BR/>Record review of Resident #1's Resident admission Agreement, signed by Resident #1 on [DATE],revealed on page 5-6 of 41; section titled: Care Planning, Refusal of Treatment and Issuance of Advance Directive; The Resident may issue an Advance Directive in accordance with state law that describes the Resident's wishes with respect to treatments that may be administered or withheld in the event the Resident becomes unable to make health care decisions for him or herself. Further review of Resident #1's medical record revealed there was no Advance Directive.<BR/>Record review of Resident #1's progress notes, dated [DATE], at 9:00 a.m. authored by Agency LVN A, read as follows: -Resident #1 was found unresponsive by Nurse Aide F and Nurse Aide G. They both informed charge nurse Agency LVN A immediately of Resident #1 not breathing and cold to touch. Agency LVN A went to Resident #1's room immediately, checked Resident #1 finding Resident #1 in semi-Fowler's, with eyes open and fixed, mouth open, cold and stiff to touch with no spontaneous to rigor mortis setting in, did not initiate CPR. Agency LVN A alerted ADON LVN B and was advised to place call to hospice. Hospice was notified at 10:00 a.m. on [DATE].<BR/>During an interview on [DATE] at 1:00 p.m. CNA F revealed he was working during the 6:00 a.m. to 2:00 p.m. shift. He was asked by Agency LVN A to give a bed bath to Resident #1 around 7:30 a.m. as she had an incontinent episode. He stated he provided Resident #1 a bed bath at that time with assistance from CNA G. He further revealed Resident #1 tolerated the bed bath and was resting in bed afterwards. He stated when he returned to check Resident #1 at approximately 9:00 a.m. she was not breathing appeared pale in color and was cool to touch. He stated he immediately told Agency LVN A and she immediately went to Resident #1's room. He stated he did not know the code status of the resident , Agency LVN A left Resident #1's room after checking for pulse respirations. CNA F stated , Agency LVN A stated that Resident #1 did not have any signs of life at that time. He stated she did not do any CPR. When asked if CNA F was CPR certified, he stated yes. When asked if he started CPR on Resident #1, he stated no because he did not know the code status on Resident #1 at the time and he was not directed by Agency LVN A to do any first aide.<BR/>During an interview on [DATE] at 1:07 p.m. CNA G revealed she was working during the 6:00 a.m. to 2:00 p.m. shift. She was asked by Agency LVN A to assist CNA F in giving a bed bath to Resident #1 around 7:30 a.m. as she had an incontinent episode. She stated she provided Resident #1 a bed bath at that time with assistance from CNA F. She further revealed Resident #1 tolerated the bed bath and was resting in bed afterwards. She stated when she returned to check Resident #1, with CNA F at approximately 9:00 a.m. she was not breathing appeared pale in color and was cool to touch. She stated CNA F immediately told Agency LVN A and she immediately went to Resident #1's room. She stated she did not know the code status of the resident, Agency LVN A left Resident #1's room after checking for pulse respirations. CNA G stated, Agency LVN A stated that Resident #1 did not have any signs of life at that time. He stated she did not do any CPR CNA G stated she was not CPR certified and did not perform first aide on Resident #1 because she was not directed by Agency LVN A to do anything.<BR/>During an interview on [DATE] at 1:12 p.m. Hospice RN revealed she was informed via telephone call from Agency LVN A that Resident #1 had expired and would need an RN from hospice to pronounce her. Hospice RN stated she arrived at facility and pronounced Resident #1 at 10:16 a.m. on [DATE]. Hospice RN stated Resident #1 was full code.<BR/>During an interview on [DATE] at 1:21 p.m. Agency LVN A revealed she found Resident #1 in semi-Fowler's position in bed with eyes open and fixed, mouth open, cold and stiff to touch with no spontaneous movement. No respiratory sounds on auscultation, no pulses palpable in carotid or femoral arteries. Agency LVN A stated, due to rigor mortis setting in, she did not initiate CPR even though she was aware that Resident #1 was a Full Code from her medical record. She further revealed she had last seen Resident #1 at 8:30 a.m. and she was in no distress. She stated rigor mortis had set in. When asked if she knew how to determine if rigor mortis is present or how long it would take for rigor mortis to be present, she stated, I just know stiffening occurs with the body, I am not sure how long it actually takes. Agency LVN A stated she then went downstairs to speak with ADON LVN B to ask her for recommendations on what she should do about Resident #1, as she felt that she had expired. She stated ADON LVN B told her to contact hospice, as Resident #1 was under the services of hospice care.<BR/>During an interview on [DATE] at 3:00 p.m. with ADON-LVN B revealed Agency LVN A did not perform CPR after assessment of Resident #1, when she was found unresponsive by CNA F and CNA G. ADON-LVN B stated she was in the management role of ADON and there was no current DON working at the facility. ADON-LVN B further revealed there was no RN in the building at the time of the incident with Resident #1. During an interview on [DATE] at 3:00 p.m. the facility ADON LVN B revealed, if a resident is found to be unresponsive and is a Full Code, the primary nurse should begin CPR and contact 911. She further revealed staff should follow the protocol of a Full code and receive interventions such as CPR. <BR/>During an interview on [DATE] at 3:02 p.m. the facility Administrator stated staff should follow the protocol of a Full code and receive interventions such as CPR.<BR/>Record review of CPR certification status for Agency LVN A revealed she had a current active CPR certification with an issue date of [DATE] and renew by 8/2024 provided by the American Heart Association.<BR/>Record review of facility policy titled, Emergency Procedure- Cardiopulmonary Resuscitation. Section General Guidelines: 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is CPR certified in CPR/BLS shall initiate CPR unless: a: It is known that a Do Not Resuscitate order that specifically prohibits CPR and/or external defibrillation exists for that individual: or b. There are obvious signs of irreversible death (e.g., rigor mortis). <BR/>Review of website: https://www.medicinenet.com/what_are_the_stages_of_rigor_mortis/article.htm, revealed the definition of Rigor Mortis to be in stages: Pallor mortis: The main change that occurs is increased paleness because of the suspension of blood circulation. This is the first sign and occurs quickly, within 15-30 minutes of death.Algor mortis: Humans are warm-blooded creatures, which means that we keep a consistent body temperature, regardless of the external environment. The brain is our temperature regulator, and the circulatory framework is the principal heat dissipator. After death, the brain cells stop signaling, and the heart stops pumping blood, which means the body begins to match the external temperature. Our normal body temperature level is 98.6&deg;F (37&deg;C). Assuming the surrounding temperature around the dead body is not exactly the same, it normally takes somewhere in the range of 18-20 hours for the body's temperature to match the external temperature.<BR/>Rigor mortis: Following death, the body will turn stiff. The muscles become loose and limp, yet the entire body will stiffen after a couple of hours.<BR/>This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 2:07 p.m. and the Administrator was notified at 2:07 p.m. and was provided with the IJ template on [DATE].<BR/>The following Plan of Removal(POR) was accepted on [DATE] at 9:23 p.m. and indicated the following:<BR/>Immediate corrective actions for removal of immediate jeopardy: <BR/>On [DATE], at approximately 3:00 p.m. the following actions were taken:<BR/>Director of Nursing/designee completed immediate education with LVN A, and CNA B who were in attendance on proper response to emergency situation, when to initiate CPR on a resident and including the following steps for emergency response. <BR/>a. Instruct a staff member to activate the emergency response system (code) and call 911. <BR/>b. Instruct a staff member to retrieve the automatic external defibrillator. <BR/>c. Verify or instruct a staff member to verify the DNR or code status of the individual. <BR/>d. Initiate the basic life support (BLS) sequence of events. <BR/>e. LVN role in determining when to initiate CPR. <BR/>o Director of Nursing/designee validated all resident current Code status were up to date and in EHR, including care planned and on direct care [NAME] on [DATE]. <BR/>o The Corporate Clinical Resource completed education with Assistant Director of nursing regarding requirements on Emergency response, including, following policy titled: Emergency Procedure-Cardiopulmonary Resuscitation on [DATE]. <BR/>o Administrator/designee completed sweep of all licensed staff to verify CPR certification status is up to date on [DATE]. <BR/>IDENTIFICATION OF OTHER AFFECTED: <BR/>All residents have the potential to be affected. <BR/>o The Director of nursing/designee validated that all residents had up to date code status in EHR, their code is reflected in both care plan and direct care staff [NAME] care record on [DATE]. <BR/>SYSTEMIC CHANGES AND/OR MEASURES: <BR/>o The Corporate Registered Nurse/Designee will complete education with all staff to include agency staff on proper procedures to follow in case of Emergency, including initiation of emergency response system, validating resident code status in EHR, appropriate initiation of CPR, and designating staff in emergent situations to these tasks. Education will specify that any staff responsibility in performing CPR will be delegated to certified personnel, with additional staff to aid in support areas, such as initiating 911, validating code status, etc. Education will be initiated on [DATE] to ensure that staff have a clear understanding of how they should respond during an emergency once they have established a resident's code status. This education will be ongoing with all staff to include agency prior to working their next scheduled shift. <BR/>o The Corporate Registered Nurse/Designee will complete education regarding initiation of CPR/Emergency response based on resident's code status and wishes, emphasis will be placed on staff understanding of following resident code status indicated in EHR. Education will be initiated on [DATE] and be ongoing will all staff prior to working next scheduled shift. <BR/>o Administrator/Designee will upload policy on Emergency Procedure-Cardiopulmonary resuscitation policy to agency website for new agency staff to review and acknowledge prior to working shift. <BR/>o Ad hoc QAPI meeting held with IDT team and MD to review policy on Emergency Procedure-Cardiopulmonary resuscitation and Plan of removal/response to Immediate Jeopardy Citation on [DATE] @ 4:00 pm <BR/>o The Corporate Registered Nurse/Designee will initiate a process to conduct quarterly Mock Code training with clinical staff beginning the week of [DATE]-[DATE]. <BR/>o The Corporate Registered Nurse/Designee will conduct post code blue debriefing with staff following a code blue events to ensure proper procedures were followed. <BR/>TRACKING AND MONITORING: <BR/>o The Corporate Registered Nurse/Designee will, through record review, monitor resident code status in PCC to validate codes are in place and on plan of care, daily x 7 days, then 5 x per week beginning [DATE]. <BR/>o The Corporate Registered Nurse/Designee will conduct observational rounds and interviews, daily x 7 days, then 5 x per week beginning [DATE], to validate that staff can verbalize understanding of how and where to find resident code status and proper steps for initiating emergency response if needed. Are they keeping a list of staff they have conducted observational rounds and interviews with this is supposed to be post in-service training?<BR/>o The Administrator/designee will monitor that licensed staff are certified and certifications are up to date, to perform CPR, for all current staff, then weekly for all new hires. <BR/>o The Administrator/designee will conduct a monthly audit to ensure staff that have CPR certifications that are going to be expiring soon will be set up to take CPR recertification. <BR/>o Any trends or concerns were/will be addressed with the Quality Assurance Performance Committee and monitoring will continue until a lessor frequency is deemed appropriate. <BR/>The Administrator will be responsible for ensuring the adequate process regarding Emergency Response, including initiation of CPR are followed per policy. The education on process/system was initiated on [DATE].<BR/>Verification: <BR/>Verified; Record review of in-service titled Emergency Procedures - Cardiopulmonary Resuscitation, staff signatures and interviews with ADON and the Corporate Registered Nurse on [DATE] revealed LVN A and CNA B were trained step by step in the emergency response procedure via phone initially on [DATE] to cover immediacy, by the ADON, the Corporate Registered Nurse and Administrator. Upon returning for their next shift, LVN A on [DATE] and CNA B on [DATE], they were brought into the office, provided a copy of the procedure and were able to verbalize understanding of procedure. See in-service sheets attached.<BR/>Verified; Record review of resident's code status in EHR however, surveyor discovered that one OOH-DNR was completed incorrectly/invalid. Interview with ADON and Corporate Registered Nurse on [DATE] acknowledged the deficiency, and this deficient practice will be cited.<BR/>Verified; Record review of an in-service titled Emergency Procedures - Cardiopulmonary Resuscitation, staff signatures and interviews with the Corporate Registered Nurse and ADON on [DATE] revealed the ADON and Treatment Nurse were immediately trained on [DATE] in the emergency response procedures to ensure they were able to train other staff. <BR/>Verified; Record review of the staff schedule dated [DATE] - [DATE] revealed at least one CPR certified staff was scheduled on each shift. CPR cards for each of these staff members were attached to the schedule as well. Interview with the Corporate Registered Nurse on [DATE] verified that all staff not fully certified at this time are scheduled to attend CPR on [DATE] at 10:30 with [name of company]. Record review of a confirmation text from [name of company] verified CPR is scheduled for [DATE] at 10:30 am at the facility. <BR/>Verified; Record review of resident's code status in EHR however, surveyor discovered that one OOH-DNR was completed incorrectly/invalid. Interview with ADON and Corporate Registered Nurse on [DATE] acknowledged the deficiency, and this deficient practice will be cited.<BR/>Verified; Record review of an in-service titled Emergency Procedures - Cardiopulmonary Resuscitation, revealed 44 of 87 staff signatures. Interviews with the Corporate Registered Nurse and ADON on [DATE] revealed all staff training began immediately on [DATE]. The ADON reported she and the Treatment Nurse went to each employee together to instruct in the emergency procedures and make sure they understood the importance of the situation. The ADON added that each staff member had to be able to verbalize understanding of the procedure. Copies of the procedure were provided to each staff member. Staff members who have not worked since the incident have been in-serviced via phone however all will be trained in person on a one-to-one basis before they are allowed to work their next shift. On [DATE], 17 direct care staff members, including RNs, LVNs, CNAs and an Activity Director, to include all shifts at the facility were interviewed and verified they had received inservice training on the facility's Emergency Procedures for CPR.<BR/>Verified; record review of a printout from the [name of agency] website revealed link that agency staff are required to review and acknowledge Emergency Procedure-Cardiopulmonary resuscitation policy prior to being able to choose a shift on the schedule. Interview with Corporate Registered Nurse on [DATE] revealed all staff that had previously read and accepted the previous version must now read and accept the updated policy prior to working.<BR/>Verified; record review of the [name of agency] site (agency website) and interview with Corporate Registered Nurse [DATE] revealed agency staff are required to review and acknowledge Emergency Procedure-Cardiopulmonary resuscitation policy prior to being able to choose a shift on the schedule. <BR/>Verified; Record review of sign-in sheets provided by the Administrator of Ad hoc QAPI meeting on [DATE]. The Administrator in-serviced all managers on emergency procedures for CPR policy and POR for IJ. Medical Director, Physician J attended via phone.<BR/>Verified; Record review Ad hoc QAPI meeting and interview with Corporate Registered Nurse on [DATE] revealed Mock code scheduled for [DATE] (1st shift), [DATE] (2nd shift) and [DATE] (3rd shift). <BR/>Verified; Each mock code packet contains a debriefing sheet that staff will complete following code to discuss what occurred and any improvements that could be made. This will be presented at QA. These sheets are also to be used in the event of an actual code.<BR/>Verified; Interview with Corporate Registered Nurse on [DATE] acknowledged the invalid OOH-DNR and initiated correction of document immediately.<BR/>Verified; record review of Observational Rounds/Interviews CPR logs for [DATE] (13 staff) and [DATE] (14 staff) revealed ADON (the designee) rounded to ensure staff continued to verbalize understanding of content from previous in-service training on [DATE].<BR/>Verified; record review of CPR audit completed on [DATE] and interview with the Corporate Registered Nurse on [DATE] revealed a CPR course is scheduled for [DATE] at 10:30 with [name of company].<BR/>On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying their POR had been initiated and or completed. <BR/>The Administrator was informed the Immediate Jeopardy was removed on [DATE] at . While the IJ was removed the facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy and a scope of isolated, due to the facility was still monitoring the effectiveness of their Plan of Removal .

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 facility, in that:<BR/>The facility failed to store non-refrigerated food in a manner that protected it from contamination.<BR/>This deficient practice could place residents who received meals and snacks from the facility at risk for food borne illness.<BR/>The findings included:<BR/>Observation on 03/15/2023 at 10:20 a.m. revealed there were nine cases of food stored on the floor in a closet located inside the facility's conference room. None of the cases were marked with dates indicating when were received by the facility. The cases of food were:<BR/>- Two cases, each containing six #10 cans*, of Pineapple Tidbits<BR/>- One case of six #10 cans of Unsweetened Applesauce<BR/>- One case of six #10 cans of Chunk Light Tuna in Water<BR/>- Four cases, each containing six #10 cans of Deluxe Pulled Chicken<BR/>- One case of six #10 cans of Pinto Beans<BR/>*The #10 can is the standard size can for commercial food service, measuring approximately 6 3/16 x 7 inches with a volume capacity of 104-117 fluid ounces. <BR/>Further observation 03/15/2023 at 10:20 a.m. inside the closet where the food was stored revealed there were cobwebs in the right front corner of the room, approximately 2 - 3 from where the cases of food were stored on the floor. The cobwebs had small insects trapped in them that were too numerous to count.<BR/>Interview on 03/16/2023 at 12:40 p.m. with the Dietary Manager (DM) revealed she confirmed there were cases of food on the floor in the closet in the conference room, and that they should not have been there. The DM stated she was unaware the cases of food were there and that she had been in the position for four months. The DM stated that when she was a Dietary Aide, she would put cases of food on the rack in that area, but never on the floor. The DM also stated the cans and cases were not dated with the date they were received and should have been, and that there were cobwebs in the corner of the closet that had trapped many small insects and that could potentially lead to the contamination of the food on the floor.<BR/>Interview on 03/16/2023 at 4:25 p.m. with the Administrator and DON revealed they confirmed the presence of the cases of food on the floor. The Administrator stated that this food was for emergency purposes, and that it should not have been on the floor. The administrator also confirmed that the room where the food was stored was not climate controlled, and the presence of the cobwebs and insects trapped inside the cobwebs.<BR/>Review of facility policy Food Receiving and Storage revised October 2017 revealed, Food shall be received and stored in a manner that complies with safe food handling practices. 5. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.11, Food Storage, (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Food in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling equipment as specified under &sect; 4-204.122.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents had the right to personal privacy during personal care for 1 of 3 residents (Resident #3) reviewed for privacy, in that:<BR/>CNA E and CNA J did not maintain privacy while providing incontinent care for Resident #3.<BR/>This failure could place residents who require assistance with incontinent care at risk of being exposed. <BR/>Findings included:<BR/>Record review of Resident #3's undated face sheet revealed Resident #3 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (occurs when your brain loses oxygen and could cause serious, permanent brain damage), schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), bipolar disorder (a mental illness characterized by alternating periods of elation and depression), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 11/26/2024, revealed a BIMS score of 5, indicating severe cognitive impairment. Section GG - Functional Abilities revealed Resident #2 required substantial to maximum assistance with toileting hygiene, bathing and dressing, and Resident #3 was dependent on staff for transfers. Section H- Bladder and Bowel revealed Resident #3 was always incontinent of bowel and bladder.<BR/>Record review of Resident #3's comprehensive care plan revealed a care plan that stated, Resident will be treated with dignity and respect while at the facility, date initiated 09/11/2024. <BR/>During an observation by Surveyor L on 01/09/2025 at 1:40 p.m., Surveyor L observed incontinent care provided to Resident #3 by CNA J and CNA E. Resident #3 was observed lying in the middle bed, Bed B, of a room with 3 residents. CNA J and CNA E were observed pulling the privacy curtain closed for bed A and for bed C to provide privacy for Resident #3 from her roommates. Surveyor L observed that Resident #3 did not have a privacy curtain on the track above her bed that would have provided Resident #3 privacy if a person opened Resident #3's bedroom door during care. <BR/>During an interview with CNA J on 01/09/2025 at 2:01 p.m., CNA J told Surveyor L that CNA E made sure the other curtains were closed all the way during incontinent care and stated there was no curtain available for Resident #3. <BR/>During an interview with CNA E on 01/09/2025 at 2:02 p.m., CNA E told Surveyor L that the windows and privacy curtains should be closed when providing incontinent care to residents. <BR/>During an interview with the Housekeeping Director on 01/09/2025 at 2:43 p.m., the Housekeeping Director told Surveyor K that he ordered privacy curtains and stated every resident room and bed should have a privacy curtain. The Housekeeping Director stated he made rounds daily to make sure privacy curtains were in place. The Housekeeping Director and Surveyor K entered Resident #3's room on 01/09/2025 at 2:46 p.m., and the Housekeeping Director observed Resident #3's privacy curtain was missing and stated, I have been trying to order more hooks for the track. The Housekeeping Director stated the curtain had been down for about a month. The Housekeeping Director stated he would check the housekeeping and maintenance work order system to see if there was a work order for the missing privacy curtain. The Housekeeping Director stated it was important for each resident to have a privacy curtain to maintain their privacy. <BR/>During an interview with the Housekeeping Director on 01/09/2025 at 3:15 p.m., the Housekeeping Director provided a work order and stated, based on the work order, the privacy curtain had been missing from Resident #3's bed since 2022. He stated, if anyone would have told me I would have added it and stated he had the parts and was going to install the privacy curtain. <BR/>During an interview with the Administrator on 01/10/2025 at 1:48 p.m., the Administrator stated each resident should have a privacy curtain and the privacy curtain should be used to provide privacy to the resident during care and at the resident's request. The Administrator stated the use of privacy curtains were important so the residents felt dignified in their personal care and space and stated staff were trained on privacy during new hire orientation, competency checks, and resident rights training. <BR/>During an interview with the DON on 01/10/2025 at 2:28 p.m., the DON stated the expectation for staff was to use the resident privacy curtain when providing incontinent care and the staff should have reported any issues with the privacy curtain to the Housekeeping Director. The DON stated it was important that each resident had a privacy curtain because we can provide the resident privacy during any treatment or care and so they have a curtain to close if they want the privacy in their own space. The DON stated staff were trained on resident privacy. <BR/>During an interview with Resident #3 on 01/10/2025 at 2:50 p.m., Resident #3 stated she was happy with her new privacy curtain.<BR/>Record review of a facility document titled CNA/Nurse Aide Orientation/Annual Sills Competency Checklist revealed a Skill/Task listed on the competency check off that stated Promotes and protects participant's dignity and privacy (knocks on doors, pulls curtains during care, and speaks respectfully to participants).<BR/>Record review of a facility policy titled Resident Rights, 2001 MED-PASS, Inc. (Revised February 2021), revealed a policy statement that stated, Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation stated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; t. privacy and confidentiality.<BR/>Record review of a facility policy titled Dignity, 2001 MED-PASS, Inc. (Revised February 2021), revealed a policy statement that stated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation stated, 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident was provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for three of eight residents (Residents #8, #54 and #48) reviewed for quality of life. <BR/>1. The facility failed to ensure the environment in and around Residents #8 and #54's room was free of unpleasant odors.<BR/>2. The facility failed to ensure Resident #48 was able to spend time outside per his preferences and care plan.<BR/>These failures could place residents at risk of a diminished quality of life, indignity, and depression.<BR/>Findings include:<BR/>1. Record review of Resident #8's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included cellulitis (bacterial skin infection), cerebral ischemia (brain injury from impaired blood flow) memory deficits, need for assistance with personal care, type two diabetes mellitus (condition which affects the way the body processes sugar), anxiety disorder, and schizoaffective disorder (mental illness including symptoms of schizophrenia and mood disorder).<BR/>Record review of the quarterly MDS for Resident #8, dated 03/22/23, reflected a BIMS score of 13, which indicated a mild cognitive impairment. It also reflected she required the extensive assistance of one person for toileting. <BR/>Record review of the care plan for Resident #8, dated 09/14/22, reflected the following: [Resident #8] has an ADL self-care performance deficit related impaired mobility, obesity. [Resident #8] will maintain current level of function through the review date. Toilet Use: The resident requires limited to extensive assist x 1 staff for toileting. [Resident #8] is resistive to care r/t schizophrenia. At times will refuse to shower, follow diet as recommended, follow fluid restriction as recommended. Resident will participate in her plan of care daily and ongoing. Allow the resident to make decisions about treatment regime, to provide sense of control. o Encourage as much participation/interaction by the resident as possible during care activities. o Give clear explanation of all care activities prior to an as they occur during each contact. o If possible, negotiate a time for ADLs so that the resident participates in the decision making process. Return at the agreed upon time. o If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. o Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. o psych services as ordered.<BR/>Record review of POC (CNA) tasks for Resident #8, from 03/15/23 to 04/13/23, reflected provision of incontinent care twice a day for eight days, three times per day for 17 days, four times per day for three days, and one time per day for two days.<BR/>Record review of Resident #54's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, insomnia, cognitive communication deficit, and recurrent depressive disorders.<BR/>Record review of the quarterly MDS for Resident #54, dated 01/09/23, reflected a BIMS score of 11, which indicated a mild cognitive impairment. <BR/>Record review of the care plan for Resident #54, dated 11/11/22, reflected the following: Resident will be treated with dignity and respect while at the facility. Resident will be treated with dignity and respect. Staff will treat resident with dignity and respect. Resident will be able to have visitors in their room or common areas.<BR/>Observations on 04/12/23 at 09:41 AM, 12:03 PM, and 02:24 PM revealed a strong unpleasant odor in the hall surrounding and inside the room of Resident #8.<BR/>Observation and interview on 04/13/23 at 08:36 AM revealed Resident #8 was in her room, and the unpleasant odor was still strong. There was a sign on the bathroom with the title Toileting Schedule and one X: written for Tuesday 9:00 AM with dry erase marker. There were no dates or year on the schedule. Resident #8 stated staff sometimes helped her get to the toilet and sometimes did not. Resident #8 stated she had not been changed today and was in a diaper. Resident #8 stated she did not remember when she last had her brief changed, but she did not need a change. <BR/>Observation on 04/14/23 at 08:11 AM revealed a strong unpleasant odor lingered in the hall outside and inside the room for Resident #8.<BR/>During an interview on 04/14/23 at 09:13 AM, Resident #54 stated she was aware of the bad smell in her room and it was horrible. She stated she had tried to tell them at the facility, but they did not do anything about it. She stated she could not remember exactly who she told but thought it was probably a nurse. She stated the smell was because her roommate peed everywhere.<BR/>During an interview on 04/14/23 at 08:25 AM, CNA G stated he smelled the foul odor and knew it was urine. He stated housekeeping had a closet right near Resident #8's room and maybe that was the source of the odor. He stated he thought there could be an old mattress in the closet or something. CNA G stated he walked in the building thought something smelled really bad, and he guessed it could be one or more of the residents producing the odor, but he was not sure. <BR/>During observation and interview on 04/14/23 at 08:43 AM, the DON stated she did sometimes smell the foul odor in the hall near Resident #8's room, and she wondered if it was the janitorial closet. The DON had the housekeeping supervisor open the closet, and the foul odor was not stronger or present inside. The DON stated the odor might be Resident #8, and there may have been some issues with incontinent care. The DON stated the CNAs who usually worked in that area were not in that day. <BR/>During an interview on 04/14/23 at 08:59 AM, CNA F stated her opinion was the foul odor, which she could detect, was Resident #8. CNA F stated Resident #8 urinated a lot and would soak four to five briefs in one shift and would still be soaking wet. CNA F stated they got the size 3X briefs for Resident #8, but it was still hard to ensure they worked properly, but the bigger problem was Resident #8 would receive incontinent care but not get her clothes changed, so the soaked clothing stayed on her and created the odor. CNA F stated the CNAs tried everything they knew to do to help with the situation. CNA F stated it was an obvious problem, and management knew about it and had not provided the CNAs with any specific guidance. CNA F stated she was not sure what management had come up with to try to help Resident #8. CNA F stated Resident #8's roommate complained about the odor. CNA F stated Resident #8's roommate was very neat and tidy. <BR/>During an interview on 04/14/23 at 11:03 AM, LVN C stated she noticed the foul odor in the hall and in Resident #8's room since she began working at the facility three months prior. LVN C stated she was not sure why it happened, but she thought it might be because housekeeping was not cleaning the bed when they changed the sheets. LVN C stated Resident #8 wet her brief very heavily during the night, and every morning it reeked of urine. LVN C stated they had a toileting schedule for Resident #8, and it should be followed, but a lot of times Resident #8 would say she did not need to go. LVN C stated there were also times when Resident #8 would not let them know ahead of time. LVN C stated she suggested a bedside commode but she did not know if Resident #8 would make the effort. LVN C stated Resident #8 needed to be checked and changed more often at night, but she could not say exactly how often would be enough. LVN C stated her opinion was Resident #8 was probably changed only three times each night and probably needed more frequent changes. LVN C stated Resident #8 did not have skin breakdown currently, but potential negative impacts of the failure were skin issues, excoriation, and it could have become worse and developed ulcers. LVN C stated she had never had anyone complain about the odor, but she was sure it bothered anyone who came down the hall. <BR/>During an interview on 04/14/23 at 12:32 PM, the ADON stated she had been at the facility since December 2022. The ADON stated she noticed the odor in the hallway around Resident #8's room. She stated she assumed the odor was residents using the toilet. The ADON stated the residents who lived on the hall could use the toilet, including Resident #8. The ADON stated she and the other managers went down each hall to make sure they were clean. The ADON stated she had not specifically looked into why there was always an odor of urine around Resident #8's room. The ADON stated she had never had any residents, staff, or visitors complain about the odor. The ADON stated she did not have any knowledge of Resident #8 being on a toileting program. She stated her expectation was for incontinent residents to be checked and changed every two hours and then as needed. The ADON stated potential negative impacts were skin breakdown, infections, and wounds. The ADON stated other residents could feel frustrated and morale could go down. <BR/>During an interview on 04/14/23 at 01:49 PM, the DON stated if Resident #8 refused to change clothes or refused to use the toilet, what should have been happening was they should be getting the nurse on duty. The DON stated when she went looking for the source of the odor, she thought it was possible that it might be the floor and that urine may have soaked in. The DON stated she told the staff to document in the progress notes and the nurse to let them know in the morning meeting if there were refusals or issues. The DON stated the nurses checked the shower sheets for refusals and they tried to do in-services and talked about it with staff to help them learn how to approach refusals. The DON stated potential negative impacts were unpleasant smells, UTIs, rashes, and chafing. <BR/>During an interview on 04/14/23 at 02:24 PM, the ADM stated he never perceived the smell of urine or other foul odors in the facility. He stated a strong unpleasant odor could have a negative impact on residents and staff alike. <BR/>2. Record review of Resident #48's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included post-traumatic stress disorder, panic disorder, radiculopathy, intervertebral, disc, degeneration, spinal stenosis, vascular, dementia, need for assistance with personal care, difficulty walking, depression, reduced mobility, frontal, lobe and executive function, deficits, following cerebrovascular disease, and pain in both knees.<BR/>Record review of the annual MDS for Resident #48, dated 11/17/22, reflected a BIMS score of 10, which indicated a moderate cognitive impairment. <BR/>Record review of the care plan for Resident #48, dated 09/14/22, reflected the following: am dependent on staff for meeting emotional, intellectual, physical, and social needs r/t Intervertebral disc degeneration, Vascular dementia, depression, and PTSD. [Resident #48's] preferred activities are: listening to old country music, watching western movies, going out doors for fresh air, snacking.<BR/>During an interview on 04/12/23 at 03:53 PM, Resident #48 stated he was in the military when he was younger and then was a fishing guide and a steel guitarist for a country music band as his career. Resident #48 stated he did not get to go outside at all in the facility. He stated he could go outside if staff escorted him but there was hardly ever anyone to do that, and he could not remember the last time he went outside. He stated it was incredibly important to him to get outside and just sit and listen to the birds and the wind in the trees. He stated this was the only thing he did not like about the facility. Resident #48 stated he would like to go outside with the smokers when they smoked so he could just get some outside time and would not mind the smell of smoke at all.<BR/>During an interview on 04/14/23 at 09:13 AM, CNA F stated Resident #48 was really confused when he first moved in, and she thought they did not want him to go out by himself. CNA F stated he had to be accompanied by somebody when outside, and sometimes when he had the opportunity to go outside for a few minutes, he would say he was worried it would be too much trouble and take the person who monitored him away from the other residents. CNA F stated the last time she offered to take him outside was a week ago, and she might have five minutes to sit with him if they went outside. She stated it was not cool to be stuck inside 24/7. <BR/>During an interview on 04/14/23 at 09:23 AM, the AD stated she did not know the last time Resident #48 went outside and did not know the last time he was offered to go outside. The AD stated the weekend activity assistant took residents out on Saturdays, and if she took Resident #48 outside, it would be documented on their activity log. She stated they should do everything they could to help him get outside, because she knew that was important to him. The AD stated she took several residents out for a walk on Wednesday 04/12/23, but she did not invite Resident #48 and did not have a reason. <BR/>During an interview on 04/14/23 at 02:01 PM, the DON stated she occasionally took Resident #48 outside with a root beer. She stated she thought the last time she took him outside was two and a half weeks ago onto the front porch, and she thought it was probably for a few minutes. <BR/>During an interview on 04/14/23 at 02:14 PM, the ADM stated he felt it was important to carry over former life to current nursing facility life, especially because if residents had behaviors, it helped to understand them better. The ADM stated it could also help with dementia or Alzheimer's symptoms to some extent. The ADM stated he tried to remember Resident #48 going outside, but he was sure he had seen it. The ADM stated Resident #48 did not spend a lot of time outside. The ADM stated he would have a problem if it were him, because he loved being outside. The ADM stated as the administrator, he ensured quality of life for residents, and he monitored quality of life by doing a root cause analysis into problems, hiring a social worker, and speaking about the issue in morning meetings. <BR/>Record review of the facility policy titled Quality of life- Accommodation of Needs, dated 2018, reflected the following: Our facilities, environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being. The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. In order to accommodate individual needs and preferences, staff, attitudes, and behaviors must be directed towards assisting the residents and maintaining independence, dignity and well-being to the extent possible, and in accordance with the resident's wishes.<BR/>Record review of the facility policy titled Quality of Life- Homelike Environment, dated 2018, reflected the following: Residents are provided with a safe, clean, comfortable and home like environment and encouraged to use their personal belongings to the extent possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 5 residents (Residents #6, 8, 9, 14, and 27) reviewed for ADLS.<BR/>The facility failed to ensure Residents #6, #8, #9, #14, and #27's fingernails were trimmed, smooth, and clean. <BR/>This failure could place residents at risk of scratches, infection, and indignity.<BR/>Findings included: <BR/>1. Record review of Resident #8's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included cellulitis (infection of the deeper layers of skin most commonly caused by bacteria that normally live on the skins surface), cerebral ischemia (impaired blood flow to the brain) memory deficits, need for assistance with personal care, type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities) and schizoaffective disorder (cycles of severe symptoms that may include delusions, hallucinations, depressed episodes, and manic periods of high energy).<BR/>Record review of the quarterly MDS for Resident #8, dated 03/22/2023, reflected a BIMS score of 13, which indicated a mild cognitive impairment. It also reflected she required the extensive assistance of one person for activities of personal hygiene. <BR/>Record review of the care plan for Resident #8, dated 09/14/2022, reflected the following: [Resident #8] has an ADL self-care performance deficit related to impaired mobility, obesity. [Resident #8] will maintain current level of function through the review date. Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse.<BR/>Observation and interview on 04/13/2023 at 01:07 PM revealed Resident #8's fingernails were long and jagged with very chipped nail polish. Resident #8 stated she liked to have her fingernails done but she had not gotten them done. When asked if she had talked to any staff in the facility about having them done, she shrugged her shoulders.<BR/>2. Record review of Resident #6's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), need for assistance with personal care, cellulitis (infection of the deeper layers of skin most commonly caused by bacteria that normally live on the skins surface), dementia (a group of thinking and social symptoms that interfere with daily functioning), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and spastic quadriplegic cerebral palsy (a developmental disorder caused by damage to the brain before birth, during delivery or within the first few years of life that prevents the normal development of motor function affecting all four limbs, characterized by jerky movements, muscle tightness and joint stiffness).<BR/>Record review of the annual MDS for Resident #6, dated 12/22/2022, reflected a BIMS of 3, which indicated a severe cognitive impairment. It also reflected he required the extensive assistance of one person for activities of personal hygiene. <BR/>Record review of the care plan for Resident #6, dated 10/19/2022, reflected the following: [Resident #6) has an ADL self-care performance deficit r/t guillian (sic) barre syndrome, quadriplegia, depression, Parkinson's. I will maintain current level of function in w/c [wheelchair] mobility through the review date. Keep resident's nail trimmed and cleaned d/t [due to] resident will scratch himself to point of bleeding.<BR/>Observation on 04/13/2023 at 01:40 PM revealed Resident #6's fingernails were long with a dark brown substance underneath all of them. He was scratching his arms and had scratched scabs off in some places which were now lightly bleeding. When asked if he liked to have his fingernails cut and cleaned, he said yes. He did not answer any follow up questions. <BR/>3. Record review of Resident #27's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included unspecified injury of head, drug-induced subacute dyskinesia (involuntary movement disorder), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities), need for assistance with personal care, schizoaffective disorder (cycles of severe symptoms that may include delusions, hallucinations, depressed episodes, and manic periods of high energy), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors).<BR/>Record review of the quarterly MDS for Resident #27, dated 01/20/2023, reflected a BIMS of 5, which indicated a severe cognitive impairment. It also reflected he required limited assistance of one person for activities of personal hygiene. <BR/>Record review of the care plan for Resident #27, dated, reflected the following: [Resident #27] has an ADL self-care performance deficit r/t Parkinson's and general weakness. Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. It also reflected the following item, dated 06/07/21,: [Resident #27] has potential/actual impairment to skin integrity due to venous insuffenciey (sic) and atherosclerosis BLE. [Resident #27) will maintain or develop clean and intact skin by the review date. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short.<BR/>Observation and interview on 04/12/2023 at 02:26 PM revealed Resident #27's fingernails were long, jagged, and dirty. Resident #27 said he liked them trimmed, and the staff did cut them sometimes. He stated he could not remember when they last cut them. <BR/>4 Record review of Resident #9's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included age related to cataract (medical condition in which the lens of the eye becomes progressively opaque [not able to be seen through] resulting in blurred vision), left hand contracture (a condition of shortening and hardening of muscles, tendons or other tissue often leading to deformity and rigidity of joints), dementia (a group of thinking and social symptoms that interferes with daily functioning), need for assistance with personal care, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), schizophrenia (disorder that is characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior and decreased participation in daily activities), pain in right arm, pain in left shoulder, severe intellectual disabilities (difficulty thinking and understanding).<BR/>Record review of the quarterly MDS for Resident #9, dated 01/26/2023, reflected she required the extensive assistance of one person for activities of personal hygiene. <BR/>Record review of the care plan for Resident #9, dated 06/21/26, reflected the following: [Resident #]) has an ADL self-care performance deficit r/t Confusion, Fatigue, Impaired balance, Pain. Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse.<BR/>Observation on 04/12/2023 at 02:55 PM revealed Resident #9's hands were contracted, and her fingernails were long and dirty. When asked if the staff ever helped her clean and trim her fingernails, she smiled broadly but did not answer. <BR/>5. Record review of the Resident #14's, undated, face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #14 had diagnoses which included schizophrenia (disorder that is characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior and decreased participation in daily activities), unsteadiness on feet, altered mental status, contracture (a condition of shortening and hardening of the muscles, often leading to deformity and rigidity of joints) of muscle right forearm, gastro-esophageal reflux disease without esophagitis (digestive disease in which stomach acid or bile flows into the food pipe, esophagus, without causing inflammation of the food pipe), bradycardia (slower than expected heart rate, fewer than 60 beats per minute), atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fats, cholesterol and other substances in and on the artery walls without causing pain in the chest due to inadequate blood supply to the heart), and need for assistance with personal care. <BR/>Record review of the care clan for Resident #14, dated 11/16/2022, reflected the following: Focus: potential impairment to skin integrity. Goal: maintain or develop clean and intact skin by the review date, target date 06/19/23. Interventions: Avoid scratching and keep hands and body parts for excessive moisture. Keep fingernails short.<BR/>Record review of the quarterly MDS for Resident #14, dated 01/29/2023, reflected he had a BIMS score of 7, which indicated severe cognitive impairment. It also reflected he required the limited assistance of one person for activities of personal hygiene. <BR/>Observation on 04/12/2023 at 10:10 AM of Resident #14 in his room revealed his fingernails were &frac34; to 1-inch long with a brown substance under them. His hair was disheveled looking, and he had a blue sock on his right foot with an unknown brown substance streaked down the side. <BR/>During an interview on 04/14/2023 at 08:25 AM, CNA G stated the staff were responsible for nail care. CNA G stated the procedure was when they showered the residents, they were supposed to check fingernails, and if time permitted, they cleaned and trimmed nails. CNA G stated if there was not time on the regular shower days, they did fingernails on Sundays when no showers were scheduled. CNA G stated if you saw grime or dirt under the fingernails, they needed to get it out right then. CNA G stated there was a supply closet upstairs that had all the materials they needed for nail care. CNA G stated a great many of the residents refused, but they had plans to work with the refusals. CNA G stated the aides should have consulted the nurses if residents refused nail care. CNA G stated he did not usually work with Residents #8, #6, #27, or #9, but Resident #14 refused a lot of care. CNA G stated Resident #14 would usually allow care from certain people or if you gave him a few minutes. CNA G stated it was important to clean and trim resident fingernails, because they could scratch themselves.<BR/>During an interview on 04/14/2023 at 08:59 AM, CNA F stated the procedure for nail care was it should be done every day. CNA F stated the CNA job was to wash and clean the nails, and if the resident did not have diabetes, the CNAs should also cut the nails. CNA F stated only nurses could cut diabetic nails. CNA F stated it was important to offer and provide nail care every day in the same way she cleaned the dried mucus out of resident eyes and helped them brush their teeth. CNA F stated there were materials for nail care in the supply closet which included clippers and sticks to clean nails, and the nurse on duty always had a key. CNA F stated she did not have any residents who refused nail care. She stated Resident #6 complied with nail care, and it was important to provide it as he scratched his body. She stated she had not provided him nail care, because she did not know his fingernails were long and dirty. CNA F stated Resident #27 did sometimes refuse nail and other care due to his feelings of dignity and manliness. CNA F stated they were supposed to notify the nurse if the resident refused nail care, and she notified the nurse about Resident #27. CNA F stated Resident #8 enjoyed getting her nails and hair done and never refused. NA F stated she did not know why Resident #8's nails were long and jagged. <BR/>During an interview on 04/14/2023 at 11:03 AM, LVN C stated she had worked at the facility for three months. LVN C stated fingernail care was the responsibility of the CNAs. LVN C stated the schedule was usually to perform nail care on Sundays, but it was also PRN. LVN C stated she would sometimes do nail care herself if needed. LVN C stated she monitored for compliance with nail care procedure by spot checking that her CNAs did nails, especially with Resident #6 because his nails needed to be kept short so he would not scratch his skin off. LVN C stated she made rounds for the residents and checked their nails. LVN C stated if a resident refused nail care, they charted it, left it alone for an hour, and came back. LVN C stated a potential negative impact of not providing nail care was infection, cross contamination, or itching and scratching. <BR/>During an interview on 04/14/2023 at 12:32 PM, the ADON said she had been working at the facility since December 2022. She stated part of her duties was to oversee the floor staff. She stated she monitored by rounding, talking to residents, talking to nurses, and checking paperwork. The ADON stated nail care should have been on Sundays, and CNAs did it for most residents who did not have diabetes. She stated the podiatrist clipped nails for residents with diabetes, but the CNAs still made sure the nails were clean. The ADON stated she monitored to make sure the residents' nails were trimmed and cleaned by following up if anything was brought to her attention. The ADON stated she did not have a system in place for ensuring nail care was completed. The ADON stated the staff were supposed to report to her if residents refused, and to her knowledge, nobody had been brought to her attention. The ADON stated a potential negative impact for residents not getting their fingernails cleaned and trimmed was an increased risk of infection and tearing skin. <BR/>During an interview on 04/14/2023 at 01:56 PM, the DON stated nail care should happen every time each resident had a shower and on Sundays. The DON stated nurses did the diabetic nail trimming. The DON stated when a resident refused nail care, staff tried it again and came back later in the day. The DON stated it was the resident's right to refuse, but they should have encouraged and used interventions to get compliance. The DON stated interventions for Resident #27 were to give him a cigarette or a sweet snack. For Resident #6, bringing him to visit his female friend in the facility was an incentive. The DON stated Resident #14 might respond to sodas or yogurt as an intervention. The DON stated a potential impact of not providing nail care was infection. <BR/>During an interview on 04/14/2023 at 02:32 PM, the ADM stated his expectation for the provision of nail care was it should be provided and followed through. The ADM stated nurses should have done the care for diabetics and should have met with and educate residents who refused nail care. The ADM stated some of the residents became a little defensive about nail care, and staff could not force them but they documented if the resident insisted on the refusal. The ADM stated he monitored nail care each morning by reading progress notes and seeing documentation to see if there were behaviors and interventions were being done. He stated they talked about it in their morning clinical meetings. <BR/>Record review of the facility policy titled Activities of Daily Living, dated 2018, reflected the following: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care, and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility; c. elimination (toileting): d. dining: e. and communication.<BR/>Record review of the facility policy titled Fingernails/Toenails, Care of, dated 2018, reflected the following: The purposes of this procedure are to clean the nail bed, to keep nails, trimmed, and to prevent infections. General Guidelines 1. Nail care includes cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 residents (Resident #10 and Resident #8) reviewed for incontinence care. <BR/>1. The facility failed to ensure Resident #10's urinary catheter bag was emptied and not backing up into the catheter tubing. <BR/>2. The facility failed to ensure Resident #8 received timely incontinent care, which led to a strong foul odor about her person. <BR/>This failure could place residents at risk of urinary tract infections.<BR/>Findings include:<BR/>1. Record review of Resident #10's, undated, face sheet reflected a [AGE] year-old male resident who was admitted to the facility on [DATE] with diagnoses which included Congenital and Developmental Myasthenia (inherited disorder that usually develops at or near birth and involves muscle weakness and fatigue), Type 2 Diabetes Mellitus (chronic condition that affects the way body processes blood sugar), Schizoaffective Disorder, Depressive type (chronic mental health condition characterized by symptoms of schizophrenia such as hallucinations or delusions with symptoms of mood disorder), low back pain, Essential Hypertension (high blood pressure), Neuromuscular dysfunction of bladder (lack of bladder control due to a brain, spinal cord or nerve problem) and need for assistance with personal care. <BR/>Record review of Resident #10's Care Plan reflected he had an indwelling catheter related to neuromuscular dysfunction bladder. Goal: (He) will show no signs/symptoms of urinary function through review date 06/22/2023. Interventions: none were noted regarding emptying the urinary catheter bag. <BR/>Record review of Resident #10's Comprehensive MDS assessment, dated 03/20/2023, reflected a BIMS score of 14, which indicated intact cognitive status. <BR/>Observation and interview on 04/12/2023 at 9:35 AM in Resident #10's room revealed his urinary catheter bag totally full, stretched out like a blown-up balloon with urine backing up into the catheter tubing. The resident complained that no one would empty his catheter bag and he had to empty it himself. He stated when he was admitted to the facility, he had an E-coli (type of bacteria) infection in his urine and had received intravenous antibiotics at the hospital for a urinary tract infection. He stated sometimes the urine backed up into his bladder, leaked out and wet his bed. <BR/>Interview on 4/12/2023 at 9:40 AM, the MDSN observed Resident #10's full urinary catheter bag and stated it could cause him discomfort, and a urinary tract infection by urine backing up into bladder. <BR/>Interview on 04/12/2023 at 9:45 AM, LVN A stated she came to work at the facility at 6:10 am. She observed the full, stretched tight urinary catheter bag for Resident #10, and stated the aides were supposed to empty the bags. She stated the urine could back up into his bladder and cause infections. She stated he had finished his oral antibiotic for a urinary tract infection. <BR/>Interview on 04/14/2023 at 9:44 AM, CNA E stated she had been at the facility since February 2022. She stated she emptied the catheter bags by the end of her shift because she did not want them to fill up and bust. She stated the resident could get an infection because there was a lot of bacteria in the bag. <BR/>Interview on 04/14/2023 at 9:49 AM, CNA F stated she emptied the urinary catheter bags first thing in the morning and at the end of the shift. She stated if the urinary catheter bag got too full it could backflow into the bladder and cause an infection. She stated urine could end up on the floor and a resident could slip on it. She stated most CNAs checked the bags during the shift and at the end of the shift and it was rare to see them totally full.<BR/>Interview on 04/14/2023 at 10:14 AM, the DON stated the CNAs were responsible for emptying urinary catheters at the end of the shift and the nurses should make sure they were doing it. She stated the potential risk to the resident if they were too full was a urinary tract infection.<BR/>Interview on 04/14/2023 at 2:40 PM, the ADM stated if urinary catheter bags were not being emptied the urine could get on the floor and the resident could get a urinary tract infection. He stated his expectation was for the staff to empty the catheters.<BR/>Record review of the facility policy and procedure titled Catheter care, Urinary, dated Quarter 3, 2018, stated The purpose of this procedure is to prevent catheter-associated urinary tract infections. Infection control: Empty the collection bag at least every eight (8) hours.<BR/>2. Record review of Resident #8's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included cellulitis, cerebral ischemia memory deficits, need for assistance with personal care, type two diabetes mellitus, anxiety disorder, and schizoaffective disorder.<BR/>Record review of the quarterly MDS for Resident #8, dated 03/22/23, reflected a BIMS score of 13, which indicated mild cognitive impairment. It also reflected she required extensive assistance of one person for toileting. <BR/>Record review of the care plan for Resident #8, dated 09/14/22, reflected the following: [Resident #8] has an ADL self-care performance deficit related impaired mobility, obesity. [Resident #8] will maintain current level of function through the review date. Toilet Use: The resident requires limited to extensive assist x 1 staff for toileting. [Resident #8] is resistive to care r/t schizophrenia. At times will refuse to shower, follow diet a recommended, follow fluid restriction as recommended. Resident will participate in her plan of care daily and ongoing. Allow the resident to make decisions about treatment regime, to provide sense of control. o Encourage as much participation/interaction by the resident as possible during care activities. o Give clear explanation of all care activities prior to an as they occur during each contact. o If possible, negotiate a time for ADLs so that the resident participates in the decision making process. Return at the agreed upon time. o If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. o Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. o psych services as ordered.<BR/>Record review of POC (CNA) tasks for Resident #8 from 03/15/23 to 04/13/23 reflected provision of incontinent care twice a day for eight days, three times per day for 17 days, four times per day for three days, and one time per day for two days.<BR/>Observations on 04/12/23 at 09:41 AM, 12:03 PM, and 02:24 PM revealed a strong unpleasant odor in the hall surrounding and inside the room of Resident #8.<BR/>Observation and interview on 04/13/23 at 08:36 AM revealed Resident #8 was in her room, and the unpleasant odor was still strong. There was a sign on the bathroom with the title Toileting Schedule and one X: written for Tuesday 9:00 AM with dry erase marker. There were no dates or year on the schedule. When asked if the staff were helping her get to the toilet, Resident #8 stated they sometimes did and sometimes did not. Resident #8 stated she had not been changed today and was in a diaper. Resident #8 stated she did not remember when she last had her brief changed, but she did not need a change. <BR/>Observation on 04/14/23 at 08:11 AM revealed a strong unpleasant odor lingered in the hall outside and inside the room for Resident #8.<BR/>During an interview on 04/14/23 at 08:25 AM, CNA G stated he smelled the foul odor and knew it was urine. He stated housekeeping had a closet right near Resident #8's room and maybe that was the source of the odor. He stated he thought there could be an old mattress in the closet or something. CAN G stated he had walked int the building thought something smelled really bad, and he guessed it could be one or more of the residents producing the odor, but he was not sure. <BR/>During observation and interview on 04/14/23 at 08:43 AM, the DON stated she did sometimes smell the foul odor in the hall near Resident #8's room, and she wondered if it was the janitorial closet. The DON had the housekeeping supervisor open the closet, and the foul odor was not stronger or present inside. The DON stated the odor might be Resident #8, and there may have been some issues with incontinent care. The DON stated the CNAs who usually work in that area were not in that day. <BR/>During an interview on 04/14/23 at 08:59 AM, CNA F stated her opinion was that the foul odor, which she could detect, was Resident #8. CNA F stated Resident #8 urinated a lot and will soak four to five briefs in one shift and will still be soaking wet. CNA F stated they get the size 3X briefs for Resident #8, but it is still hard to ensure they work properly, but the bigger problem is that Resident #8 will receive incontinent care but not get her clothes changes, so the soaked clothing stays on her and creates the odor. CNA F stated the CNAs were trying everything they knew to do to help with the situation. CNA F stated it was an obvious problem, and management knew about it and had not provided the CNAs with any specific guidance about it. CNA F stated she was not sure what management had come up with to try to help Resident #8. CNA F stated Resident #8's roommate complained about the odor. CNA F stated Resident #8's roommate was very neat and tidy. <BR/>During an interview on 04/14/23 at 11:03 AM, LVN C stated she has noticed the foul odor in the hall and in Resident #8's room since she began working there three months prior. LVN C stated she was not sure why it happened, but she thought it might be because housekeeping was not cleaning the bed when they changed the sheets. LVN C stated Resident #8 wet her brief very heavily during the night, and every morning it reeked of urine. LVN C stated they have a toileting schedule for Resident #8, and it should be followed, but a lot of times Resident #8 would say she did not need to go. LVN C stated there were also times when Resident #8 would not let them know ahead of time. LVN C stated she had suggested a bedside commode but she did not know if Resident #8 would make the effort. LCN C stated Resident #8 needed to be checked and changed more often at night, but she could not say exactly how often would be enough. LVN C stated her opinion was Resident #8 was probably changed only three times each night and probably needed more frequent changes. LVN C stated Resident #8 did not have skin breakdown currently, but potential negative impacts of the failure were skin issues, excoriation, and it could have become worse and developed ulcers. LVN C stated she had never had anyone complain about the odor, but she was sure it bothered anyone who came down the hall. <BR/>During an interview on 04/14/23 at 12:32 PM, the ADON stated she had been at the facility since December 2022. The ADON stated she had noticed the odor in the hallway around Resident #8's room. When asked what she thought was causing the odor, she stated she assumed it was residents using the toilet. The ADON stated the residents who lived on this hall could use the toilet, including Resident #8. The ADON stated she and the other managers went down each hall to make sure they were clean. The ADON stated she had not specifically looked into why there was always an odor of urine around Resident #8's room. The ADON stated she had never had any residents, staff, or visitors complain about the odor. The ADON stated she did not have any knowledge of Resident #8 being on a toileting program. She stated her expectation was for incontinent residents to be checked and changed every two hours and then as needed. The ADON stated potential negative impacts were skin breakdown, infections, and wounds. The ADON stated other residents could feel frustrated and morale could go down. <BR/>During an interview on 04/14/23 at 01:49 PM, the DON stated if Resident #8 was refusing to change clothes or refusing to use the toilet, what should have been happening was they should be getting the nurse on duty. The [NAME] stated when she went looking for the source of the odor, she thought it was possible that it might be the floor and that urine may have soaked in. The DON stated she told the staff to document in the progress notes and the nurse to let them know in the morning meeting if there were refusals or issues. The DON stated the nurses checked the shower sheets for refusals and they tried to do in-services and talk about it with staff to help them learn how to approach refusals. The DON stated potential negative impacts were unpleasant smells, UTIs, rashes, and chafing. <BR/>During an interview on 04/14/23 at 02:24 PM, the ADM stated he had never perceived the smell of urine or other foul odors in the facility. He stated a strong unpleasant odor could have a negative impact on residents and staff alike. <BR/>Record review of the facility policy titled Activities of Daily Living, dated 2018, reflected the following: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care, and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility; c. elimination (toileting): d. dining: e. and communication.

Based on observation, interview and record review the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition for one of two ovens (oven #1 and oven #2) reviewed in the facility's only kitchen for essential equipment <BR/>1. The facility failed to ensure oven #2 was maintained, and the griddle grease can was properly cleaned in accordance with manufacturer's instructions. <BR/>2. The facility failed to ensure that one of the two ovens in the kitchen could be safely operated after the griddle grease can was welded to the oven and can't be removed.<BR/>These failures could place residents at risk of not having their food send out timely. <BR/>The findings include:<BR/>Observation on 04/12/2023 at 9:40 AM revealed a Vulcan brand oven. The oven was one unit with two ovens side by side. The larger unit on the right had a griddle on the top and a grease can that caught grease below the griddle. The grease can was extended approximately 4 -6 inches from the front of the larger oven on the right that had the griddle on top. The grease can was frozen, it could not be pulled out or pushed into the oven to close. The can permanently extended from the top of the right oven. The grease can contained a layer of approximately 1.5 inches of grease. On the floor surrounding the right side of the oven were 3 to 4 white cotton towels stained with intermittent spattering of a brown grease like substance. Inside of the right oven about halfway up revealed a small puncture to the inside in the metal material of the oven. The oven interior was saturated with grease on the interior door opening, on the bottom tray that was covered with aluminum foil and on the elongated metal strip directly under the grease can. The oven was not in use. There was no signage that indicated the right oven should not be used. Oven #2 was observed on four different occasions and at no time was it observed that Oven #2 was in use. <BR/>Interview and observation on 04/13/2023 at 1:15 PM with DS stated she was aware of the issue with the grease can on the right oven. The DS stated that because they could not remove the grease can entirely, she had a cleaning schedule that included using a long utiensil and parer towels to scrape out the grease. She stated the inside of the grease can could not get sparkling clean, but the process prevented build up from occuring. The DS demonstrated the process on the grease can, which was already empty of any standing grease or food particles. The DS stated the grease did drip into the back of the oven as a result of the grease can not being in place, but they never turned on that oven. The DS stated she had been working at the facility for many years, and the oven had been this way for at least four months, and there had never been a fire or any smoking, ebcause they did not use the right oven. <BR/>Interview on 04/14/2023 at 10:05 AM with MAINT revealed prior to her position as the facility the grease can was stuck and could not be moved forward or backwards. She did not have the service records and was unable to confirm the dates of the service and was not present at the time the grease can was serviced. She understood from the kitchen staff the company hired to repair the grease can used a blow torch to soften the metal and then pull the grease can lose but instead soldered the grease can permanently to the oven rendering it immobile in its current position. MAINT revealed because the grease can could not be removed, the grease cavity (the area that the grease can is slid into and out from) could not be cleaned. She said she inspected the kitchen once a week for safety and looked at the oven and asked the kitchen staff if they had any problems with the oven. She felt the oven was safe because, even though they were using the griddle on top of the oven that created the grease that was caught in the grease can, they were not using the oven itself. She revealed the kitchen staff cleaned the grease can every day by scooping out as much grease as they could with a small cup and then inserting a towel into the space to absorb as much of the grease as possible. She revealed the grease can was not being cleaned according to the manufacturer's instructions because the grease can could not be removed and washed with soap and water then be reinserted into its space. <BR/>Interview on 04/14/2023 with DC I at 1:51 PM revealed he was the cook. He said the grease can could not be removed from the right oven under the griddle because it was stuck. He said the grease cavity could not be cleaned because the grease can could not be removed. He was not present at the time, but it was his understanding, that a company was called to remove the grease can when it was originally stuck to the oven. A blow torch was used to soften the metal to remove the grease can however the can became permanently adhered to the oven. The can was jutted approximately 4 - 6 inches out from the oven. The can was unable to be pushed in further or removed. DC I revealed there were towels under the right oven because the oven leaks grease. He understood when the company used a blow torch to remove the grease can, a hole was poked in the right side of the right oven about halfway up and the towels were placed to catch the grease. He revealed they do not use the right oven. When they had tried to use it, it smoked. He said he cleaned the grease can at the end of his workday. He did it at the end of the day to give the grease time to cool. He used a small plastic cup and scooped out as much grease as possible. He then used napkins to make sure, all the gunk is out. He revealed the maintenance person came to the kitchen about once a week, looked at the grease can and oven and asked if there had been any concerns. DC I said the oven was safe if you do not use the oven. DC I said you couldn't get all the grease out of the grease can because you can't remove the grease can from the oven and wash it with soap and water, dry it and return it to it to its space. DC I said it was messy and dirty and wished they could get another oven. He said he was not concerned about the safety because they did not use the oven that has the grease can and even though they couldn't remove the grease can clean it, most of the grease was removed with the napkins. <BR/>Interview and observation on 04/14/2023 with ADM at 2:15 PM revealed he did not know when the right oven was turned on, it began smoking, and the kitchen staff did not use it for this reason. The ADM revealed the oven was not maintained according to manufacturer's recommendations because it smoked when it was used, and it was not maintained in a safe operating condition because the right oven could not be used. Observed the ADM attempt to pull the grease can out from the oven and it would not move. The ADM revealed because the grease can could not be removed from the oven it could not be washed with soap and water, dried, and returned to its place in the oven. The ADM revealed because towels were placed at the bottom of the oven #2 to catch grease that leaked from the oven #2 because oven #2 was not maintained according to manufactures instructions. <BR/>Record review of the, undated, Installation & Manual of Vulcan Endurance gas restaurant ranges, revealed under cleaning instructions to daily clean and empty grease can as needed throughout the day and regularly clean at least once daily. Remove, empty, and wash grease can in the same manner as an ordinary cooking utensil. In addition to grease can cleaning, inspect and clean grease can cavity weekly, or as needed. Once the unit is cool, use an appropriate brush, towel, or cleaning device to endure all visible surfaces are wiped clean and that any buildup is removed from the cavity. This includes the cavity top and around the griddle chute. <BR/>Record review of the facility policy for maintenance service, revised December 2009, revealed the maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Maintenance personnel shall follow the manufacturer's recommended maintenance schedule. The maintenance directors are responsible for maintaining the following records/reports warranties and guarantees. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.

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 facility, in that:<BR/>The facility failed to store non-refrigerated food in a manner that protected it from contamination.<BR/>This deficient practice could place residents who received meals and snacks from the facility at risk for food borne illness.<BR/>The findings included:<BR/>Observation on 03/15/2023 at 10:20 a.m. revealed there were nine cases of food stored on the floor in a closet located inside the facility's conference room. None of the cases were marked with dates indicating when were received by the facility. The cases of food were:<BR/>- Two cases, each containing six #10 cans*, of Pineapple Tidbits<BR/>- One case of six #10 cans of Unsweetened Applesauce<BR/>- One case of six #10 cans of Chunk Light Tuna in Water<BR/>- Four cases, each containing six #10 cans of Deluxe Pulled Chicken<BR/>- One case of six #10 cans of Pinto Beans<BR/>*The #10 can is the standard size can for commercial food service, measuring approximately 6 3/16 x 7 inches with a volume capacity of 104-117 fluid ounces. <BR/>Further observation 03/15/2023 at 10:20 a.m. inside the closet where the food was stored revealed there were cobwebs in the right front corner of the room, approximately 2 - 3 from where the cases of food were stored on the floor. The cobwebs had small insects trapped in them that were too numerous to count.<BR/>Interview on 03/16/2023 at 12:40 p.m. with the Dietary Manager (DM) revealed she confirmed there were cases of food on the floor in the closet in the conference room, and that they should not have been there. The DM stated she was unaware the cases of food were there and that she had been in the position for four months. The DM stated that when she was a Dietary Aide, she would put cases of food on the rack in that area, but never on the floor. The DM also stated the cans and cases were not dated with the date they were received and should have been, and that there were cobwebs in the corner of the closet that had trapped many small insects and that could potentially lead to the contamination of the food on the floor.<BR/>Interview on 03/16/2023 at 4:25 p.m. with the Administrator and DON revealed they confirmed the presence of the cases of food on the floor. The Administrator stated that this food was for emergency purposes, and that it should not have been on the floor. The administrator also confirmed that the room where the food was stored was not climate controlled, and the presence of the cobwebs and insects trapped inside the cobwebs.<BR/>Review of facility policy Food Receiving and Storage revised October 2017 revealed, Food shall be received and stored in a manner that complies with safe food handling practices. 5. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.11, Food Storage, (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Food in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling equipment as specified under &sect; 4-204.122.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview and record review the facility failed to ensure resident rooms measured at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in single resident rooms for 8 of 59 resident rooms (Rooms 8, 9, 10, 33, 40, 41, 42 and 43) reviewed for square footage.<BR/>The facility failed to ensure resident rooms 8, 9, 10, 33, 40, 41, 42, and 43 were the required 80 square feet per resident. <BR/>This failure could place residents at-risk for problems in residents' activities of daily living and could compromise resident's privacy.<BR/>The findings include:<BR/>Observation on 04/12/23 at 10:00AM revealed room measurements for the following rooms:<BR/>- room [ROOM NUMBER] - 20.778 x 11.25 = 77.915 (approximately 77.915 square feet for each resident).<BR/>- room [ROOM NUMBER] - 20.789 x 11.265 feet = 234.175 (approximately 76.61 square feet for each resident).<BR/>- room [ROOM NUMBER] - 15.072 x 15.831 = 238.606 (approximately 79.535 square feet for each resident).<BR/>- room [ROOM NUMBER] - 20.644 x 11.217 = 231.553 (approximately 77.184 square feet for each resident).<BR/>- room [ROOM NUMBER] - 20.672 x 11.240 = 232.357 (approximately 77.452 square feet for each resident).<BR/>- room [ROOM NUMBER] - 20.737 x 11.270 = 233.707 (approximately 77.902 square feet for each resident).<BR/>- room [ROOM NUMBER] - 20.715 x 11.234 = 232.711 (approximately 77.570 square feet for each resident).<BR/>During an interview on 04/12/23 at 9:30 a.m., the ADM stated he was new to the facility and was not aware there was a room waiver in place, but he understood a room waiver was needed for the rooms in the building with less than 80 square feet per resident. He stated rooms 9, 10, 33, 40, 41, 42 and 43 had less than 80 square feet per resident and required the room size waiver. The ADM requested a room size waiver.<BR/>Record review of the facility census, dated 04/12/23, reflected rooms 9, 10, 33, 40, 41, 42 and 43 had three beds in each room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for 3 of 37 residents (Residents #3, #6, and #8) reviewed for reasonable accommodations, in that:<BR/>1. Resident #3 had no access to her call light that was observed on the floor approximately four feet away from Resident #3.<BR/>2. Resident # 6 had no access to his call light that was observed on the floor behind the headboard of Resident #6's bed.<BR/>3. Resident #8 had no access to his call light that was observed on the floor approximately five feet away from Resident #8.<BR/>This deficient practice could place residents not being able to use call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being. <BR/>Findings included:<BR/>1. Record review of Resident #3's undated face sheet revealed Resident #3 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (occurs when your brain loses oxygen and could cause serious, permanent brain damage), schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), bipolar disorder (a mental illness characterized by alternating periods of elation and depression), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 11/26/2024, revealed a BIMS score of 5, indicating severe cognitive impairment. Section GG - Functional Abilities revealed Resident #2 required substantial to maximum assistance with toileting hygiene, bathing and dressing, and Resident #3 was dependent on staff for transfers. Section GG also revealed Resident #3 required partial to moderate assistance from staff for bed mobility. Section H- Bladder and Bowel revealed Resident #3 was always incontinent of bowel and bladder indicating Resident #1 would have required assistance from staff for incontinent care. <BR/>Record review of Resident #3's comprehensive care plan revealed a care plan that stated, Resident will be treated with dignity and respect while at the facility, date initiated 09/11/2024. <BR/>During an observation of Resident #3 on 01/08/2025 at 12:00 p.m., Resident #3 was lying in her bed asleep and Resident #3's call light was observed on the ground approximately four feet away from Resident #3 in front of her dresser. <BR/>During an interview with PTA, 01/08/2025 at 12:02 p.m., PTA confirmed that he observed Resident #3's call light out of the reach of Resident #3. <BR/>During an interview with CNA A on 01/08/2025 at 12:03 p.m., CNA A stated CNA A and CNA D were working B and C hall and stated resident call lights should be placed within reach of the resident when a resident was in their room. CNA A stated she had received training on call lights. CNA A stated she rounded on her patients at least every 2 hours.<BR/>During an interview with CNA D on 01/08,2025 at 12:20 p.m., CNA D stated it was his second day working on the 1st floor and stated call lights should be within reach of the residents. He stated he made rounds during his shift by going up and down the halls checking on people and CNA D stated he had been answering call lights that morning when he was making rounds.<BR/>During an interview with Resident #3 on 01/10/2025 at 2:50 p.m., Resident #3 stated that she used her call light to call for assistance and indicated that her call light was usually placed on her chest by pointing to her chest and stated here. <BR/>2. Record review of Resident #6's face sheet revealed Resident #6 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included lymphedema, (swelling due to the build-up of fluid in the body due to a problem with the lymphatic system, which is a network of tubes throughout the body that drains fluid), schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities). <BR/>Record review of Resident #6's quarterly MDS assessment, dated 11/07/2024, revealed a BIMS score of 14, indicating no cognitive impairment. Section GG- Functional Abilities revealed Resident #6 was ambulatory and was independent with ADL's and transfers. Section H - Bladder and Bowel indicated Resident #6 had frequent bowel incontinence. <BR/>Record review of Resident #6's comprehensive care plan revealed the following care plans: 1) [Resident #6] is at risk for falls r/t medications, occasional incontinence, insomnia, impaired cognition-schizophrenia, psych meds and psychosis, date initiated 03/15/2023. An intervention listed was be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, date initiated 06/12/2021. 2) [Resident #6] has an ADL self-care performance deficit medication, psychological dx and needs set up to limited assist at times, date initiated 06/12/2021. An intervention listed was encourage the resident to use bell to call for assistance, date initiated 06/12/2021. <BR/>During an observation and interview with Resident #6 on 01/08/2025 at 12:35 p.m., Resident #6's was observed sitting on the side of his bed eating lunch and Resident #6's call light was observed to be on the floor behind the head of Resident #6's bed. Resident #6 stated he did not place the call light behind his bed and stated staff usually place his call light on his bed. Resident #6 stated he did use his call light at times to call for assistance and stated he could not reach his call light from his seated position while eating lunch. <BR/>3. Record review of Resident #8's undated face sheet revealed Resident #8 was an [AGE] year old male who had an initial admission date of 02/16/2001, admission date of 04/12/2018, and admitted with diagnoses that included senile degeneration of brain (a term used to describe a cognitive decline, memory loss and difficulty learning, and problem solving in older adults), Alzheimer's disease (a progressive disease that affects memory and other important mental functions), legal blindness (a specific level of visual impairment that includes both people who are totally blind and those who have some vision but with significant limitations), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities), and disorganized schizophrenia (disorganization of thought processes, behavior, and emotions).<BR/>Record review of Resident #8's quarterly MDS assessment, dated 12/09/2024, revealed a BIMS score of 02, which indicated the resident was severely cognitively impaired. Section B- Hearing, Speech, and Vision revealed Resident #8 was sometimes able to make himself understood and express his ideas and wants and sometimes able to understand others. Section B also revealed Resident #8 had severely impaired vision. Section GG - Functional Abilities revealed Resident #8 required partial/moderate assistance with bathing and dressing and required supervision or touching assistance with bed mobility and transfers. Section H -Bladder and Bowel revealed Resident #8 was frequently incontinent of his bowel and bladder indicating Resident #8 would require staff assistance with incontinent care. <BR/>Record review of Resident #8's comprehensive care plan revealed the following care plans: 1. [Resident #8] has an ADL self-care performance deficit r/t cognition and blindness, dated initiated 9/19/2017 and revised 6/07/2021. An intervention listed was encourage the resident to use bell to call for assistance, dated initiated 6/07/2021 and revised 6/15/2023. 2. [Resident #8 is at risk for falls r/t blindness, incontinence, medications, unsteady gait, and Parkinson's, date initiated 6/07/2021 and revised 9/09/2021. An intervention listed was be sure the resident's call light is within reach and encourage the resident to use it to call for assistance as needed. The resident needs prompt response to all requests for assistance, date initiated 6/07/2021.<BR/>During an observation on 01/08/2025 at 1:16 p.m., Resident #8 was observed lying in bed asleep and Resident #8's call light was observed lying on the floor underneath a wheelchair approximately five feet away from Resident #8's bed. <BR/>During an interview with RN C on 01/08/2025 at 2:35 p.m., RN C stated he was the Charge Nurse on the first floor and stated, I educate my staff about keeping the call lights in reach at all times.<BR/>During an interview with the Administrator on 01/10/2025 at 1:48 p.m., the Administrator stated call lights should have been within reach of a resident when the resident was in their room. He stated it was important for the call light to be in reach so the resident can access the light whenever they need to meet their needs. The Administrator stated the facility staff had received training on call light placement and would receive additional training during an in-service scheduled for 1/17/2025. <BR/>During an interview with the DON on 01/10/2025 at 2:28 p.m., the DON stated she ensured call lights were in reach of facility residents by rounding and made sure call lights were attached to the resident bed or wheelchair. The DON stated the call light should have been in reach of each resident and it was important for the call light to be in reach so the resident could call for help when needed. The DON stated when she started in her role 2 weeks ago, the DON rounded with staff in resident rooms to demonstrate observations each staff member should have made when rounding in rooms and that included call light placement. The DON also stated call light placement was a part of the skills competency check off trainings completed by direct care staff. <BR/>Record review of a facility policy titled Call System, Resident, MED-PASS, Inc. (September 2022), revealed a policy heading that stated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Listed under, Policy Interpretation and Implementation, the policy stated, 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

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 facility, in that:<BR/>The facility failed to store non-refrigerated food in a manner that protected it from contamination.<BR/>This deficient practice could place residents who received meals and snacks from the facility at risk for food borne illness.<BR/>The findings included:<BR/>Observation on 03/15/2023 at 10:20 a.m. revealed there were nine cases of food stored on the floor in a closet located inside the facility's conference room. None of the cases were marked with dates indicating when were received by the facility. The cases of food were:<BR/>- Two cases, each containing six #10 cans*, of Pineapple Tidbits<BR/>- One case of six #10 cans of Unsweetened Applesauce<BR/>- One case of six #10 cans of Chunk Light Tuna in Water<BR/>- Four cases, each containing six #10 cans of Deluxe Pulled Chicken<BR/>- One case of six #10 cans of Pinto Beans<BR/>*The #10 can is the standard size can for commercial food service, measuring approximately 6 3/16 x 7 inches with a volume capacity of 104-117 fluid ounces. <BR/>Further observation 03/15/2023 at 10:20 a.m. inside the closet where the food was stored revealed there were cobwebs in the right front corner of the room, approximately 2 - 3 from where the cases of food were stored on the floor. The cobwebs had small insects trapped in them that were too numerous to count.<BR/>Interview on 03/16/2023 at 12:40 p.m. with the Dietary Manager (DM) revealed she confirmed there were cases of food on the floor in the closet in the conference room, and that they should not have been there. The DM stated she was unaware the cases of food were there and that she had been in the position for four months. The DM stated that when she was a Dietary Aide, she would put cases of food on the rack in that area, but never on the floor. The DM also stated the cans and cases were not dated with the date they were received and should have been, and that there were cobwebs in the corner of the closet that had trapped many small insects and that could potentially lead to the contamination of the food on the floor.<BR/>Interview on 03/16/2023 at 4:25 p.m. with the Administrator and DON revealed they confirmed the presence of the cases of food on the floor. The Administrator stated that this food was for emergency purposes, and that it should not have been on the floor. The administrator also confirmed that the room where the food was stored was not climate controlled, and the presence of the cobwebs and insects trapped inside the cobwebs.<BR/>Review of facility policy Food Receiving and Storage revised October 2017 revealed, Food shall be received and stored in a manner that complies with safe food handling practices. 5. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.11, Food Storage, (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Food in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling equipment as specified under &sect; 4-204.122.

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of two medication carts (2nd floor cart) reviewed for medication storage. <BR/>The facility failed to ensure the Medication Aide cart for the 2nd floor was locked and supervised. <BR/>This failure could place residents at risk of ingesting unprescribed and/or expired medications resulting in adverse health consequences. <BR/>Findings included:<BR/>Observation on 04/13/2023 at 7:16 AM revealed MA D left the medication cart unlocked while she administered medications to Resident #58. <BR/>Interview on 04/13/2023 at 7:35 AM, MA D stated she had been a Medication Aide for 9 years but had worked at the facility for 1 &frac12; months. She stated she should not have left the medication cart unlocked and unattended as it was a safety issue and someone could come along and get into it, ingest the medications, and make them sick, or they could have an allergic reaction.<BR/>Interview on 4/14/2023 at 9:34 AM, LVN A stated they were trained to lock the medication carts. <BR/>Interview on 4/14/2023 at 10:14 AM, the DON stated if the medication cart was left unlocked someone can could get pills off the cart, take the pills, sell them, swallow them, and overdose. She stated they could get sick and have an allergic reaction.<BR/>Interview on 4/14/2023 at 12:50 PM, the ADON stated the medication cart should be locked because people could walk off with medications, take them, and have an adverse reaction. <BR/>Interview on 4/14/2023 at 2:40 PM, the ADM stated if the medication cart was left unlocked the resident could open the cart, get medications out, take them and get sick. He stated they could overdose. He stated staff could take the medications. <BR/>Record review of the facility policy and procedure titled Administering Medications, dated 2001 and revised December 2012, reflected During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aid.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 Maintenance and Housekeeping Office reviewed, in that:<BR/>The Maintenance and Housekeeping Office, in which were stored tools and cleaning equipment, was observed with the door ajar and no staff in attendance. <BR/>This deficient practice could result in residents, staff, or the public coming into contact with tools and cleaning equipment that were unsafe. <BR/>The findings were: <BR/>Observation on 05/21/2025 at 9:15 a.m. revealed the Maintenance and Housekeeping Office was located on the facility's second floor, was the first room of a hallway with resident room, was adjacent from the nurses' desk, and across the hall from a resident room. Further observation revealed the office door was ajar and no staff were in the office. Further observation revealed Housekeeper E was in the hallway between the Maintenance and Housekeeping Office and a resident's room. <BR/>During an interview with Housekeeper E on 05/21/2025 at 9:15 a.m., Housekeeper E confirmed the office was unlocked and the door was ajar. She stated that the office was usually kept locked because it contained tools and cleaning equipment which were potentially unsafe for residents to handle. <BR/>During an interview with the Maintenance Director on 05/21/2025 at 11:30 a.m., the Maintenance Director confirmed he had left the Maintenance and Housekeeping Office open and unattended. He stated that he had seen Housekeeper E in the hallway outside the office and believed it was safe to leave the office open due to her presence. The Maintenance Director confirmed that the office contained tools and cleaning equipment which were potentially unsafe for residents to handle. <BR/>During an interview with the DON on 05/23/2025 at 3:30 p.m. the DON stated that her expectation was for the Maintenance and Housekeeping Office to be secured at all times when not in use by staff. The DON confirmed that was was potentially unsafe for residents to have access to tools and cleaning supplies. <BR/> Record review of the facility policy, Hazardous Areas, Devices, and Equipment, revised July 2017, revealed, All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.

Based on observation, interview, and record review, the facility failed to protect the residents' right to reside in a safe, clean, comfortable, and homelike environment for 2 residents (Residents #14 and #33), in that: <BR/>1. Barrels of soiled linens and trash were stored in the shower area of Resident #14's restroom. <BR/>2. Resident #33's shower chair and the floor of the shower area in her restroom were soiled with a dark brown substance which appeared to be mud or feces. <BR/>These deficient practices could lead to diminished quality of life and psychosocial harm. <BR/>The findings were: <BR/>1. Observation of Resident #14's restroom on 06/10/2024 at 1:00 p.m., revealed the presence of two wheeled barrels, one with soiled linen and the other with trash. <BR/>During an interview with the Director of Housekeeping on 06/10/2024 at 1:04 p.m., the Director of Housekeeping confirmed the presence of two wheeled barrels, one with soiled linen and the other with trash in Resident #14's restroom and stated, I keep telling them not to do that.<BR/>2. Observation of Resident #33's restroom on 06/10/2024 at 1:12 p.m., revealed Resident #33's shower chair and the floor of the shower area in her restroom were soiled with a dark brown substance which appeared to be mud or feces. <BR/>During an interview with the ADON on 06/10/2024 at 1:15 p.m., the ADON confirmed Resident #33's shower chair and the floor of the shower area in her restroom were soiled with a dark brown substance which appeared to be mud or feces and should not have been. <BR/>During an interview with the Administrator on 06/13/2024 at 3:36 p.m., the Administrator stated that her expectation is for resident living spaces to be clean, well-kept, and free of debris. <BR/>Record review of the facility's policy titled, Resident Rights, dated 2/20/2021, revealed, 8. Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports of daily living safely.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 Maintenance and Housekeeping Office reviewed, in that:<BR/>The Maintenance and Housekeeping Office, in which were stored tools and cleaning equipment, was observed with the door ajar and no staff in attendance. <BR/>This deficient practice could result in residents, staff, or the public coming into contact with tools and cleaning equipment that were unsafe. <BR/>The findings were: <BR/>Observation on 05/21/2025 at 9:15 a.m. revealed the Maintenance and Housekeeping Office was located on the facility's second floor, was the first room of a hallway with resident room, was adjacent from the nurses' desk, and across the hall from a resident room. Further observation revealed the office door was ajar and no staff were in the office. Further observation revealed Housekeeper E was in the hallway between the Maintenance and Housekeeping Office and a resident's room. <BR/>During an interview with Housekeeper E on 05/21/2025 at 9:15 a.m., Housekeeper E confirmed the office was unlocked and the door was ajar. She stated that the office was usually kept locked because it contained tools and cleaning equipment which were potentially unsafe for residents to handle. <BR/>During an interview with the Maintenance Director on 05/21/2025 at 11:30 a.m., the Maintenance Director confirmed he had left the Maintenance and Housekeeping Office open and unattended. He stated that he had seen Housekeeper E in the hallway outside the office and believed it was safe to leave the office open due to her presence. The Maintenance Director confirmed that the office contained tools and cleaning equipment which were potentially unsafe for residents to handle. <BR/>During an interview with the DON on 05/23/2025 at 3:30 p.m. the DON stated that her expectation was for the Maintenance and Housekeeping Office to be secured at all times when not in use by staff. The DON confirmed that was was potentially unsafe for residents to have access to tools and cleaning supplies. <BR/> Record review of the facility policy, Hazardous Areas, Devices, and Equipment, revised July 2017, revealed, All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.

Based on observation, interview, and record review, the facility failed to maintain the garbage storage area in a manner to prevent the harborage of pests for 1 of 1 facility.<BR/>The facility failed to close a garbage bin lid on a separate garbage disposal unit on two separate occasions.<BR/>This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment. <BR/>Findings included:<BR/>An observation with the Dietary Director on 06/11/24 at 11:15a.m, revealed that one of the two garbage bins used by the facility had a side-lid covering which measured 35x23 inches which was left open exposing bags of garbage.<BR/>An observation with the Dietary Director on 6/12/24 at 11:00a.m., revealed that one of the two garbage bins used by the facility had a side-lid covering which was left open exposing bags of garbage.<BR/>During an interview with the Dietary Director on 06/12/24 at 11:00a.m., she stated that she was aware that the garbage bin lids had to stay closed at all times to prevent problems with pests.<BR/>During an interview with the Administrator on 6/12/24 at 4:30 p.m., she stated that she understood the regulation that the garbage bins had to remain closed to prevent problems with pests. <BR/>Record review of the facility's policy on Food-Related Garbage and Refuse Disposal revealed that all garbage and refuse containers must be kept covered with a tight-fitted lid when stored and not in continuous use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1of 6 residents (Resident #55) reviewed for accidents and hazards. <BR/>The facility failed to ensure Resident #55 did not have access to an electronic cigarette.<BR/>This failure could place residents at risk of injury or harm, as well as contribute to avoidable accidents.<BR/>Findings included:<BR/>Record review of Resident #55's face sheet, dated 6/11/24, revealed a [AGE] year-old male admitted to the facility on [DATE] readmitted on [DATE] with the diagnosis that included Muscle weakness (a decrease in muscle strength and the ability to move your body), Insomnia (a sleep disorder in which you have trouble falling and/or staying asleep) and Type II Diabetes (a disease that occurs when your blood glucose, is too high). <BR/>Record review of Resident #55 Quarterly MDS assessment, dated 2/20/24, revealed a BIMS score of 14, indicating intact cognition.<BR/>Record review of Resident #55's care plan, dated 2/6/23, revealed [Name of Resident] was a supervised smoker Instruct resident on smoking locations. <BR/>Observation of an interview with Resident #55 on 06/10/24 at 9:30 AM revealed Resident #55 lying in bed while smoking an electronic cigarette. He stated that he makes his own rules and smokes in his room. <BR/>Interview with RN C on 6/11/24 at 10:15 a.m. RN C confirmed she was the assigned nurse for Resident #55 and he was assessed to be a supervised smoker and sometimes did not comply. <BR/>Interview with the Administrator on 06/12/24 at 7:22 AM revealed facility staff were responsible for taking supervised smokers out side. She stated her DON was responsible for overseeing that, and she monitored it daily. The Administrator stated that Resident #55 risked a possible fire hazard if he was to continue using his electronic cigarette in the room. <BR/>Review of the facility's policy titled, Safety and Supervision of Residents, dated 2001, revised July 2017, revealed, Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated smoking areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 (refrigerator in resident room [ROOM NUMBER]B) of 3 residents' reviewed in that: <BR/> The facilty failed to ensure the personal refrigerators in one residents' rooms contained food items which were unlabeled and undated. <BR/>This deficient practice could place residents at risk of foodborne illness due to consuming spoiled foods. <BR/>The findings were: <BR/>Observation on 06/11/24 at 9:02 a.m. revealed the personal refrigerator in resident room [ROOM NUMBER] B contained open lunch meat undated. <BR/>Further observation on 06/11/2024 at 10:36 a.m. revealed a container with lunch meat undated . <BR/>During an interview with CNA A on 06/11/2024 at 10:45 a.m., CNA A confirmed that the personal refrigerator in resident room [ROOM NUMBER]B contained an open package of lunch meat which was unlabeled and undated.<BR/>During an interview with the DON and ADON on 06/11/2024 at 1:47 p.m., the DON and ADON confirmed that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled foods. The DON stated the night shift nurses were responsible for overseeing this and at thtat time it this was not being monitore . <BR/>Record review of the facility's policy titled, Foods Brought by Family/Visitors, dated 2001 and revised March 2022, revealed, .Food brought to the facility by visitors and family is permitted. The nursing staff will discard perishable foods on or before the use by date .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 3 residents (Resident #20) reviewed for unnecessary medications, in that: <BR/>The facility failed to ensure Resident #20 was prescribed a psychotropic drug for anxiety no longer than 14 days PRN . <BR/>This deficient practice could place residents at risk of receiving unnecessary psychotropic medications. <BR/>The findings were: <BR/>Record review of Resident #20's face sheet dated 6/11/24, revealed a [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included: Congestive heart failure (is a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), Chronic Pain Syndrome (long-standing pain that persists beyond the usual recovery period), and Muscle Weakness (a decrease in muscle strength or a reduced ability to move your body, even when you try hard). <BR/>Record review of Resident #20's Quarterly MDS assessment, dated 4/13/24, revealed a BIMS score of 12, which indicated cognition was moderately impaired. <BR/>Record review of Resident #20 care plan, dated 5/24/24, revealed, Potential for drug related complication associated with antianxiety medication.<BR/>Record review of Resident #20 order summary, dated June 2024, revealed an order for Xanax oral tablet 2 mg, Give one tablet by mouth every 8 hours as needed for anxiety indefinite. <BR/>During an Interview with the DON on 6/12/24 at 10:25 a.m., the DON confirmed that Resident # 20 had an order for Xanax 2 mg every 8 hours PRN indefinite, and the order should have only been for 14 days. She did not know why the order was written over 14 days as overuse can place Resident # 20 at risk for respiratory depression. The DON confirmed that ADON was responsible for overseeing this task daily and she currently monitors this at random which is why the deficient practice was an oversight. <BR/>Record review of the facility's policy titled, Psychotropic Medication Use Policy, dated 2001 revised July 2022, revealed, .PRN orders for psychotropic medication are limited to 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1of 6 residents (Resident #55) reviewed for accidents and hazards. <BR/>The facility failed to ensure Resident #55 did not have access to an electronic cigarette.<BR/>This failure could place residents at risk of injury or harm, as well as contribute to avoidable accidents.<BR/>Findings included:<BR/>Record review of Resident #55's face sheet, dated 6/11/24, revealed a [AGE] year-old male admitted to the facility on [DATE] readmitted on [DATE] with the diagnosis that included Muscle weakness (a decrease in muscle strength and the ability to move your body), Insomnia (a sleep disorder in which you have trouble falling and/or staying asleep) and Type II Diabetes (a disease that occurs when your blood glucose, is too high). <BR/>Record review of Resident #55 Quarterly MDS assessment, dated 2/20/24, revealed a BIMS score of 14, indicating intact cognition.<BR/>Record review of Resident #55's care plan, dated 2/6/23, revealed [Name of Resident] was a supervised smoker Instruct resident on smoking locations. <BR/>Observation of an interview with Resident #55 on 06/10/24 at 9:30 AM revealed Resident #55 lying in bed while smoking an electronic cigarette. He stated that he makes his own rules and smokes in his room. <BR/>Interview with RN C on 6/11/24 at 10:15 a.m. RN C confirmed she was the assigned nurse for Resident #55 and he was assessed to be a supervised smoker and sometimes did not comply. <BR/>Interview with the Administrator on 06/12/24 at 7:22 AM revealed facility staff were responsible for taking supervised smokers out side. She stated her DON was responsible for overseeing that, and she monitored it daily. The Administrator stated that Resident #55 risked a possible fire hazard if he was to continue using his electronic cigarette in the room. <BR/>Review of the facility's policy titled, Safety and Supervision of Residents, dated 2001, revised July 2017, revealed, Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated smoking areas.

Based on observation, interview, and record review, the facility failed to maintain the garbage storage area in a manner to prevent the harborage of pests for 1 of 1 facility.<BR/>The facility failed to close a garbage bin lid on a separate garbage disposal unit on two separate occasions.<BR/>This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment. <BR/>Findings included:<BR/>An observation with the Dietary Director on 06/11/24 at 11:15a.m, revealed that one of the two garbage bins used by the facility had a side-lid covering which measured 35x23 inches which was left open exposing bags of garbage.<BR/>An observation with the Dietary Director on 6/12/24 at 11:00a.m., revealed that one of the two garbage bins used by the facility had a side-lid covering which was left open exposing bags of garbage.<BR/>During an interview with the Dietary Director on 06/12/24 at 11:00a.m., she stated that she was aware that the garbage bin lids had to stay closed at all times to prevent problems with pests.<BR/>During an interview with the Administrator on 6/12/24 at 4:30 p.m., she stated that she understood the regulation that the garbage bins had to remain closed to prevent problems with pests. <BR/>Record review of the facility's policy on Food-Related Garbage and Refuse Disposal revealed that all garbage and refuse containers must be kept covered with a tight-fitted lid when stored and not in continuous use.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 Maintenance and Housekeeping Office reviewed, in that:<BR/>The Maintenance and Housekeeping Office, in which were stored tools and cleaning equipment, was observed with the door ajar and no staff in attendance. <BR/>This deficient practice could result in residents, staff, or the public coming into contact with tools and cleaning equipment that were unsafe. <BR/>The findings were: <BR/>Observation on 05/21/2025 at 9:15 a.m. revealed the Maintenance and Housekeeping Office was located on the facility's second floor, was the first room of a hallway with resident room, was adjacent from the nurses' desk, and across the hall from a resident room. Further observation revealed the office door was ajar and no staff were in the office. Further observation revealed Housekeeper E was in the hallway between the Maintenance and Housekeeping Office and a resident's room. <BR/>During an interview with Housekeeper E on 05/21/2025 at 9:15 a.m., Housekeeper E confirmed the office was unlocked and the door was ajar. She stated that the office was usually kept locked because it contained tools and cleaning equipment which were potentially unsafe for residents to handle. <BR/>During an interview with the Maintenance Director on 05/21/2025 at 11:30 a.m., the Maintenance Director confirmed he had left the Maintenance and Housekeeping Office open and unattended. He stated that he had seen Housekeeper E in the hallway outside the office and believed it was safe to leave the office open due to her presence. The Maintenance Director confirmed that the office contained tools and cleaning equipment which were potentially unsafe for residents to handle. <BR/>During an interview with the DON on 05/23/2025 at 3:30 p.m. the DON stated that her expectation was for the Maintenance and Housekeeping Office to be secured at all times when not in use by staff. The DON confirmed that was was potentially unsafe for residents to have access to tools and cleaning supplies. <BR/> Record review of the facility policy, Hazardous Areas, Devices, and Equipment, revised July 2017, revealed, All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of two medication carts (2nd floor cart) reviewed for medication storage. <BR/>The facility failed to ensure the Medication Aide cart for the 2nd floor was locked and supervised. <BR/>This failure could place residents at risk of ingesting unprescribed and/or expired medications resulting in adverse health consequences. <BR/>Findings included:<BR/>Observation on 04/13/2023 at 7:16 AM revealed MA D left the medication cart unlocked while she administered medications to Resident #58. <BR/>Interview on 04/13/2023 at 7:35 AM, MA D stated she had been a Medication Aide for 9 years but had worked at the facility for 1 &frac12; months. She stated she should not have left the medication cart unlocked and unattended as it was a safety issue and someone could come along and get into it, ingest the medications, and make them sick, or they could have an allergic reaction.<BR/>Interview on 4/14/2023 at 9:34 AM, LVN A stated they were trained to lock the medication carts. <BR/>Interview on 4/14/2023 at 10:14 AM, the DON stated if the medication cart was left unlocked someone can could get pills off the cart, take the pills, sell them, swallow them, and overdose. She stated they could get sick and have an allergic reaction.<BR/>Interview on 4/14/2023 at 12:50 PM, the ADON stated the medication cart should be locked because people could walk off with medications, take them, and have an adverse reaction. <BR/>Interview on 4/14/2023 at 2:40 PM, the ADM stated if the medication cart was left unlocked the resident could open the cart, get medications out, take them and get sick. He stated they could overdose. He stated staff could take the medications. <BR/>Record review of the facility policy and procedure titled Administering Medications, dated 2001 and revised December 2012, reflected During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aid.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 Maintenance and Housekeeping Office reviewed, in that:<BR/>The Maintenance and Housekeeping Office, in which were stored tools and cleaning equipment, was observed with the door ajar and no staff in attendance. <BR/>This deficient practice could result in residents, staff, or the public coming into contact with tools and cleaning equipment that were unsafe. <BR/>The findings were: <BR/>Observation on 05/21/2025 at 9:15 a.m. revealed the Maintenance and Housekeeping Office was located on the facility's second floor, was the first room of a hallway with resident room, was adjacent from the nurses' desk, and across the hall from a resident room. Further observation revealed the office door was ajar and no staff were in the office. Further observation revealed Housekeeper E was in the hallway between the Maintenance and Housekeeping Office and a resident's room. <BR/>During an interview with Housekeeper E on 05/21/2025 at 9:15 a.m., Housekeeper E confirmed the office was unlocked and the door was ajar. She stated that the office was usually kept locked because it contained tools and cleaning equipment which were potentially unsafe for residents to handle. <BR/>During an interview with the Maintenance Director on 05/21/2025 at 11:30 a.m., the Maintenance Director confirmed he had left the Maintenance and Housekeeping Office open and unattended. He stated that he had seen Housekeeper E in the hallway outside the office and believed it was safe to leave the office open due to her presence. The Maintenance Director confirmed that the office contained tools and cleaning equipment which were potentially unsafe for residents to handle. <BR/>During an interview with the DON on 05/23/2025 at 3:30 p.m. the DON stated that her expectation was for the Maintenance and Housekeeping Office to be secured at all times when not in use by staff. The DON confirmed that was was potentially unsafe for residents to have access to tools and cleaning supplies. <BR/> Record review of the facility policy, Hazardous Areas, Devices, and Equipment, revised July 2017, revealed, All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.

Based on observation, interview, and record review, the facility failed to protect the residents' right to reside in a safe, clean, comfortable, and homelike environment for 2 residents (Residents #14 and #33), in that: <BR/>1. Barrels of soiled linens and trash were stored in the shower area of Resident #14's restroom. <BR/>2. Resident #33's shower chair and the floor of the shower area in her restroom were soiled with a dark brown substance which appeared to be mud or feces. <BR/>These deficient practices could lead to diminished quality of life and psychosocial harm. <BR/>The findings were: <BR/>1. Observation of Resident #14's restroom on 06/10/2024 at 1:00 p.m., revealed the presence of two wheeled barrels, one with soiled linen and the other with trash. <BR/>During an interview with the Director of Housekeeping on 06/10/2024 at 1:04 p.m., the Director of Housekeeping confirmed the presence of two wheeled barrels, one with soiled linen and the other with trash in Resident #14's restroom and stated, I keep telling them not to do that.<BR/>2. Observation of Resident #33's restroom on 06/10/2024 at 1:12 p.m., revealed Resident #33's shower chair and the floor of the shower area in her restroom were soiled with a dark brown substance which appeared to be mud or feces. <BR/>During an interview with the ADON on 06/10/2024 at 1:15 p.m., the ADON confirmed Resident #33's shower chair and the floor of the shower area in her restroom were soiled with a dark brown substance which appeared to be mud or feces and should not have been. <BR/>During an interview with the Administrator on 06/13/2024 at 3:36 p.m., the Administrator stated that her expectation is for resident living spaces to be clean, well-kept, and free of debris. <BR/>Record review of the facility's policy titled, Resident Rights, dated 2/20/2021, revealed, 8. Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports of daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 2 of 3 the residents (Residents #4 and #56) reviewed for oxygen in that:<BR/>The facility faield to ensure Residents #4 and #56 did not have an empty oxygen humidifier bottle on the oxygen concentrator dated 5/12/24 while in use. <BR/>This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications.<BR/>The findings were:<BR/>1. Record review of Resident #4's face sheet, dated 6/10/24, revealed a [AGE] year old male admitted to the facility on [DATE] with the diagnosis that included: Acute Kidney Failure (when your kidneys suddenly become unable to filter waste products from your blood), Respiratory Failure (a serious condition that makes it difficult to breathe on your own), and Atrial Fibrillation (an irregular and often very rapid heart rhythm). <BR/>Record review of Resident #4's Physician's monthly orders, dated June 2024, revealed an order with a start date of 03/22/24, Oxygen at 2 liters per nasal cannula as needed for Shortness of breath. <BR/>Record review of Resident #4's Quarterly MDS assessment, dated 4/12/24, revealed a BIMS score of 15, indicating intact cognition. <BR/>Observation on 6/10/24 at 10:55 a.m. revealed Resident #4 oxygen concentrator at the bedside, with the humidifier bottle empty, dated 5/12/24. <BR/>2. Record review of Resident #56's face sheet, dated 6/10/24, revealed a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included: Respiratory Failure (a serious condition that makes it difficult to breathe on your own), Cirrhosis of the Liver (permanent scarring that damages your liver and interferes with its functioning), and Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). <BR/>Record review of Resident #56's Quarterly MDS, dated [DATE], revealed a BIMS score of 7, indicating severe cognitive impairment. <BR/>Observation on 6/10/24 at 9:50 a.m. revealed Resident #56's oxygen concentrator at the bedside, with the humidifier bottle empty, dated 5/12/24. <BR/>During an interview with RN C on 6/10/24 at 10:58 a.m., it was revealed that oxygen tubing and humidifier bottles for Residents #4 and #56 were changed and dated by the night shift. <BR/>An interview with the DON on 6/10/24 at 11:20 AM revealed Residents #4 and #56 oxygen concentrator bottles should have been changed by the night shift weekly. The DON was unaware of why the humidifier bottles were not changed for Residents #4 and #56. She added that the ADON oversaw this task and that she would be monitoring it for compliance. The DON stated that residents risked possible dry nasal passages by having their oxygen humidifier bottles emptied for Residents #4 and #56. <BR/>Record review of the facility's policy titled, Departmental (Respiratory Therapy)-Prevention of Infection, dated 2001 and revised November 2011, revealed, Mark Bottle with date/initials upon opening and discard.