Parklane West Healthcare Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>The facility failed to ensure plastic storage containers used to store dry cereal in the dry storage room of the kitchen were properly sealed.<BR/>This deficient practice could place residents who received meals and snacks from the kitchen at risk for food borne illness.<BR/>The findings included:<BR/>Observation on 02/21/2023 at 10:05 a.m. revealed there were three 6-quart plastic containers used to store dry cereal. One container contained crispy rice dry cereal and was filled to the 2-qt. mark. One container contained corn flakes dry cereal and was filled approximately halfway. One container contained toasted oats dry cereal and was completely full. All three containers had plastic lids that were slightly ajar, revealing an open space at the top of the container.<BR/>Interview with the Dietary Manager (DM) on 02/21/2023 at 10:07 a.m. confirmed that all three containers of dry cereal were not properly sealed. When asked about the risks associated with food containers not being sealed, the DM stated this failure could result in product deterioration and potential rodent infestation. The DM stated that dietary aides are responsible for ensuring all food items that are stored in the dry storage room that had been opened are properly sealed, labeled and dated. The DM trains all new employees for one week and continuously throughout the year, and the consultant dietitian also provides training on food safety and sanitation.<BR/>Record review of facility policy Reusable Food Storage Containers, undated, revealed: Procedure: 1. Leftover foods and foods that cannot be restored in their original containers will be stored in nonporous containers that can be completely sealed.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.1, Food Storage, (A) 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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>The facility failed to ensure plastic storage containers used to store dry cereal in the dry storage room of the kitchen were properly sealed.<BR/>This deficient practice could place residents who received meals and snacks from the kitchen at risk for food borne illness.<BR/>The findings included:<BR/>Observation on 02/21/2023 at 10:05 a.m. revealed there were three 6-quart plastic containers used to store dry cereal. One container contained crispy rice dry cereal and was filled to the 2-qt. mark. One container contained corn flakes dry cereal and was filled approximately halfway. One container contained toasted oats dry cereal and was completely full. All three containers had plastic lids that were slightly ajar, revealing an open space at the top of the container.<BR/>Interview with the Dietary Manager (DM) on 02/21/2023 at 10:07 a.m. confirmed that all three containers of dry cereal were not properly sealed. When asked about the risks associated with food containers not being sealed, the DM stated this failure could result in product deterioration and potential rodent infestation. The DM stated that dietary aides are responsible for ensuring all food items that are stored in the dry storage room that had been opened are properly sealed, labeled and dated. The DM trains all new employees for one week and continuously throughout the year, and the consultant dietitian also provides training on food safety and sanitation.<BR/>Record review of facility policy Reusable Food Storage Containers, undated, revealed: Procedure: 1. Leftover foods and foods that cannot be restored in their original containers will be stored in nonporous containers that can be completely sealed.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.1, Food Storage, (A) 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #72) reviewed for privacy, in that:<BR/>The facility failed to ensure that MA D locked the computer after she walked away and left the computer unattended , which exposed Resident #72's morning medication list . <BR/>This failure could place residents at risk of having their medical information exposed to others and cause residents to feel uncomfortable and disrespected. <BR/>The findings include:<BR/>Record review of Resident #72's face sheet dated 5/14/25 reflected an [AGE] year-old resident who was admitted to the facility on [DATE] with diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), Heart Failure (condition in which the heart isn't pumping as well as it should) and Atrial Fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots). <BR/>Record review of Resident #72's Quarterly MDS assessment, dated 2/26/25, reflected a BIMS score of 9, which indicated moderate cognitive impairment. <BR/>Observation on 5/14/24 at 9:20 AM, revealed MA D prepared Resident's #72's morning medication and, walked away from the computer leaving screen facing fall , MA D did not lock the computer screen and was away from computer for 7 minutes. <BR/>During an interview on 5/14/24 at 9:40 AM, MA D stated she was not aware of the option to lock the computer screen and believed minimizing the screen was sufficient. MA D noted Resident #72's private medical information might have been exposed when she stepped away from the computer.<BR/>During an interview on 05/15/24 at 1:51 PM, the DON stated she was unaware that Resident #72's records had been left open and unattended by MA D. The DON stated her expectation was for the facility nursing staff to uphold HIPAA regulations and lock computer screens when they were away from them. The DON emphasized that all staff members should protect residents' information. The DON expressed concern that leaving residents' charts open and unattended could lead to unauthorized access. The DON also stated that the ADON would be responsible for overseeing compliance with this task, and she would monitor it by conducting random computer screen checks.<BR/>Record review of the facility's undated policy titled HIPAA reflected: Protected health information that identifies a patient/resident or contains information that can be used to determine the patient/resident must be kept safe, confidential, and protected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly for 1 of 5 residents (Resident #4) reviewed for medication storage, in that:<BR/>The facility failed to ensure medications were not left on Resident #4's bed side table. <BR/>This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered.<BR/>The findings were:<BR/>Record review of Resident #4's face sheet, dated 4/4/24, revealed an [AGE] year-old male admitted to the facility on [DATE] with the diagnosis that included Acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), Chronic obstructive pulmonary disease, (refers to a group of diseases that cause airflow blockage and breathing-related problems), and Anxiety disorder (involves a constant feeling of anxiety or fear). <BR/>Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. <BR/>Record review of Resident #4's physician orders for April 2024, reviewed on 4/3/24 did not reveal an order to self-administer medications. <BR/>Observation on 04/03/2024 at 11:47 a.m. of Resident #4's room revealed there was a bottle of Fluticasone nasal spray 50 mcg, extra-strength Tylenol, and Voltaren gel 1 % on the bedside table<BR/>In an interview with Resident #4 on 4/3/24 at 12:05 p.m., the resident stated he purchased the over-the-counter medications from an online store and had them on his bedside table since he was admitted back to the facility sometime in November 2003. The resident further stated no one had given him a self-medication assessment. <BR/>During an interview with CNA B on 04/03/2024 at 12:55 p.m., CNA B stated a bottle of Fluticasone nasal spray 50 mcg, extra-strength Tylenol, and Voltaren gel 1 % were on the bedside table. CNA B stated the medications had been on Resident #4's bedside table for as long as she could recall but did not know why they were there. <BR/>During an Interview with LVN C, on 4/3/24 at 1:05 p.m., LVN C stated she was the assigned nurse for Resident # 4, and that a bottle of Fluticasone nasal spray 50 mcg, extra-strength Tylenol, and Voltaren gel 1 % were on the bedside table of Resident #4, because Resident #4 became upset when he was asked to move them to the medication cart for safe keeping. LVN C stated a self-medication assessment had not been conducted before the surveyor's intervention and medications left on the bedside table of Resident #4 risked possibly taking more medication than was ordered by the physician. <BR/>During an interview with the DON on 04/4/24/ at 9:53 a.m., the DON stated that a bottle of Fluticasone nasal spray 50 mcg, extra-strength Tylenol, and Voltaren gel 1 % were on the bedside table of Resident #4. The DON stated no medication should be left on any resident bedside table without a self-medication assessment, and a signed physician order as lack of risked the resident taking more than the prescribed dosage. <BR/>Record review of the facility's policy titled, Monitoring a Resident who Self-Administers Medications, undated, revealed, residents who self-administer medications will have a signed physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation.<BR/>Resident #'1's electronic medical record did not contain complete and accurate documentation that RN A recorded the resident's vital signs, follow-up on a STAT (immediate) lab request, kept the DON or MD informed on the monitoring of the resident's change of condition for a period of three hours; before the resident expired.<BR/>This failure could result in residents' records not accurately documenting interventions, monitoring, and information provided to the MD or DON during a change of condition that could result in a death.<BR/> Findings included:<BR/>Record review of Resident #1's Face Sheet, dated 01/12/23, and EMR (electronic medical record) revealed, Resident #1 was a male age [AGE], was admitted on [DATE] with diagnoses that included: acute metabolic acidosis (infection), sepsis (infection of the blood), urinary tract infection, kidney failure, hypertension, anemia ( low red blood count), chronic kidney disease and diabetes 2 . Advanced Directive was DNR (do not resuscitate). RP (responsible party) was listed as: the resident. The date of discharge was 01/07/23 due to resident expiring in the facility. <BR/>Record review of Resident#1's Care Plan dated 12/31/22 revealed goals of resident being free of antidepressant side effects, diabetic treatment, improving cognition.<BR/>Record review of Resident #1's Social Services Assessment, dated 12/30/22, revealed resident's BIMS was zero (severely impaired).<BR/>Record review of Resident #1's MD orders dated 01/01/23 read: Lansoprazole Oral Tablet Delayed Release Disintegrating 30 MG (Lansoprazole) Give 1 tablet by mouth one time a day for stress ulcer p (prophylaxis).<BR/>Record review of Resident #1's Change of Condition Nurses Note dated 01/07/23 at 1:09 PM read, Resident noted to be sleepy, unable to tolerate food. 02 (oxygen) 89 (percent) RM (room temperature) , HR (heart rate) 120, lung crackles, cough, afebrile. [Change of Condition Nurse Note was authored by RN A]<BR/>Record review of Resident #1's Physician Progress Note dated 01/07/23 at 9:57 PM read: Earlier in the day [01/07/23] I (MD B) received a text message that (Resident #1) has been asleep since breakfast and his vital signs BP 100/59, HR 120 oxygen sats (saturation) 2L (liters) with 95%. Not in distress. stat labs were ordered and advised to monitor clinically and hold BP meds and sedatives. (8:13 PM) received a text message that pt (patient) had expired .cause of the death is internal upper GI (gastro intestinal) bleeding is more likely even though pt has been taking Lansoprazole for a possible ulcer/prophylaxis ( action taken to prevent a disease) .<BR/>Record review of Resident #1's Nurse Note dated 01/07/23 at 4:11 PM, authored by RN A, revealed the resident's BP was 90/56, HR was 98 and the lab company had arrived to take a blood specimen of the resident.<BR/>Record review of Resident #1's Nurse Note dated 01/07/23 at 5:29 PM, authored by RN A, revealed: Resident's 02 saturation was 96 %. RN did not document any other vital signs that could have included: resident's temperature, BP, HR and respiration.<BR/>Record review of Resident #1's Nurse Notes from 01/07/23 at 5:29 PM to 8:05 PM (time of death) did not document the resident's condition, nursing monitoring or interventions, or follow-up to the lab, MD or DON.<BR/>Record revie of Resident #1's Nurse Note on 01/07/23 authored by RN A revealed: resident vomited blood, was unresponsible, deceased , and the MD and DON were notified. [MD note dated 01/07/23 at 9:57 PM revealed the . cause of death is internal upper GI (gastro intestinal) bleeding is more likely even though pt (patient) has been taking Lansoprazole for a possible ulcer/prophylaxis .]<BR/>Record review of Resident #1's labs dated 01/07/23 revealed: labs for Resident #1 was collected on 01/07/23 at 4:28 PM; the lab received the blood specimen at 9:21 PM; and results were reported at 10:07 PM. WBC (white blood count) was 25.3 H (high) .reference range 4.2-9.1 . <BR/>During a telephone interview on 01/12/23 at 2:59 PM, the MD revealed: (time line) on 01/07/23 at 1:09 PM he was alerted that Resident #1's O2 stats was 89% . The MD ordered stat labs. At 1:25 PM he was informed that Resident (#1)'s BP was 100/59 and heart rate 120 . The MD stated the latter BP was a little low and heart rate a little high . He ordered that the facility monitor the resident and to keep him informed of any change of condition. The MD stated, the last time the facility contacted me by text was at 8:05 PM when he (MD) was informed the resident was deceased . The MD stated, he was told Resident #1 had a little blood on his shirt. The MD recalled that he wrote a physician's note revealing that the resident might have suffered GI bleeding due to ulcer prophylaxis. <BR/>During an interview on 01/13/23 at 8:40 AM, DON revealed: on 01/07/23 at 1:07 PM the MD was contacted because the resident suffered hypotension (BP was 100/59 and heart rate was 120) and the MD ordered stat labs and to monitor the resident. At 4:11 PM Nurse A recorded that Resident #1's BP was 90/56 and heart rate was 98 (assessment by DON: indication that the BP and had heart were lower. At 5:29 PM Nurse A took vital signs which revealed Resident #1's oxygen saturation was 96 % ( assessment by DON; good oxygen intake) BP was not recorded. At 8:05 PM the resident is deceased . The lack of documentation meant per the DON that she and the MD had no information regarding Resident #1's change of condition and current status for 3 hours (5:29 PM to 8:05 PM). The DON revealed she could not answer for Nurse A as to why she (Nurse A) did not document the BP or other vital signs for the time period 5:29 PM to 8:05 PM. The DON described vital signs as BP, heart rate, respiration, O2 saturation and temperature. The DON stated the labs arrived at 10:07 PM after the resident expired; finding was resident had elevated WBC (white blood count).The DON added the system failure by Nurse A was not documenting completely and accurately between the hours 5:29 PM to 8:05 PM. The responsible party for documentation on 01/07/23 was the charge nurse (Nurse A). <BR/>During a telephone interview on 01/13/23 at 9:30 AM, Nurse A revealed: on 01/07/23 at 1:07 PM the MD was contacted because Resident #1 suffered hypotension (BP was 100/59 and heart rate was 120) and MD ordered stat labs and to monitor the resident. At 4:11 PM Nurse A recorded that Resident #1's BP was 90/56 and heart rate was 98 (means BP is low but not critical and 98 heart is high but not requiring MD notification). At 5:29 PM, she (Nurse A) recorded that 02 saturation was at 96 % (normal). Nurse A stated other vital signs were normal (temperature, respiration, BP and heart rate) but not recorded. Last not written by Nurse A was 8:05 PM when resident deceased . Nurse A stated, I observed the resident (#1) at 6 PM, 7 PM, 8 PM and in between and resident was stable .I did not record the vitals because I had other residents to take care .I saw the resident at 7:30 PM and vitals were okay and was waiting on the lab results .but did not record my visit at 7:40 PM . vitals were low but not critical .there was no written policy that I call the MD or DON every two hours .or document visits every 2 hours . Further, Nurse A stated she followed up on the stat labs at 7 PM and did not record the contact .it was my fault for not documenting. <BR/>During a telephone interview on 01/23/23 at 10:46 AM, CNA B revealed: his shift was from 2 PM-10 PM on 01/07/23 and he checked on Resident #1 every 30 minutes to 1 hour. At 7:22 PM, Resident (#1) was asleep, snoring, and not in distress .I did not document my checks with the resident but told Nurse (A) around 8 PM I found resident with a brown substance around his mouth and called the charge nurse .charge nurse said the resident had expired . CNA B stated that Nurse A would document the information he was conveying to her regarding the monitoring of Resident #1. <BR/>During an interview on 01/23/23 at 11:03 AM, DON revealed: Nurse A called the lab at 1:09 PM per MD request and the lab collected the specimen at 4:28 PM. The lab considers a STAT telephone request to fall within a time window of 4-6 hours.<BR/>During a telephone interview on 01/23/23 at 11:14 AM, Lab Representative C revealed the lab's policy was to respond to STAT telephone requests by six hours from time of collection to results. Reference # 1893253 revealed (Resident #1's) labs were collected at 4:28 PM. STAT did not mean the lab would immediately go to the facility rather from time of collection to results within a 6 hour timeframe . Follow-up calls from facility checking on STAT orders were not documented by the lab. <BR/>During an interview on 01/13/23 at 11:40 PM, the Administrator revealed Nurse A forgot to document critical information. He stated, it is a battle we fight on documentation . The Administrator added that complete and accurate documentation would be included in the on-[NAME] in-service training for nursing staff documentation, monitoring, and change of condition. <BR/>Record review of facility's Significant Change in Condition Response dated 01/2022 read, .The Nurse will perform and document an assessment of the resident and identify need for additional interventions .The resident will then be placed on the 24 Hour Report and Nursing will provide no less than three (3) days of observation, documentation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 3 of 11 residents (Resident #1, Resident #2, and Resident #4) reviewed for clinical records. 1. The facility failed to obtain a physician's order to provide Resident #1 with indwelling catheter care and monitoring for 12 of 12 days (06/28/2025 to 07/09/2025) after admission and failed to ensure Resident #1's daily indwelling catheter care was documented in her medical record for 2 of 12 days (07/08/2025 and 07/09/2025). 2. The facility failed to obtain a physician's order to provide Resident #2 with indwelling catheter and monitoring for 2 of 3 days (06/22/2025 and 06/23/2025) after admission. 3. The facility failed to ensure Resident #4's weekly skin assessments were documented in his medical record for 2 of 15 weeks (the weeks of: 05/15/2025 and 05/22/2025). These failures could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided.The findings included: 1. Record review of Resident #1's admission Record, dated 07/16/2025, reflected Resident #1 was admitted on [DATE] and discharged on 07/10/2025. Resident #1 was noted to be [AGE] years old. Record review of Resident #1's Diagnosis Report, undated and accessed 07/14/2025, reflected Resident #1 was diagnosed with other sequelae of cerebral infarction (long-term complications or effects that can occur after a stroke), acute kidney failure (a sudden condition when the kidneys stop working or being able to filter waste products from the blood), and chronic kidney failure, stage 3 (a condition where the kidneys lose their ability to filter blood and remove wastes). Record review of Resident #1's admission MDS assessment, dated 06/30/2025, reflected it had been completed and signed by MDS Coordinator A on 07/12/2025. Resident #1's BIMS score of 12 indicated she was mildly cognitively impaired, and her bowel and bladder appliances noted she had an indwelling catheter (a tube inserted into the body). Record review of Resident #1's hospital transfer documents, dated 06/25/2025, reflected Resident #1 had a foley (an indwelling catheter to drain urine from the bladder) approved for comfort. Record review of Resident #1's LN- Initial admission Record, signed and dated 06/27/2025 at 06:45 p.m. by LPN D, reflected Resident #1 had a urinary indwelling catheter in place. Record review of Resident #1's Order Recap Report, order dates 06/27/2025 to 07/31/2025, did not reflect physician orders for an indwelling catheter or the care and monitoring of an indwelling catheter. Record review of Resident #1's MAR, dated 06/01/2025- 06/30/2025, did not reflect physician orders for an indwelling catheter or the care and monitoring of an indwelling catheter. Record review of Resident #1's MAR, dated 07/01/2025- 07/31/2025, did not reflect physician orders for an indwelling catheter or the care and monitoring of an indwelling catheter. Record review of Resident #1's Nursing Progress Note, by LPN D, effective 06/27/2025 at 05:55 p.m., reflected .She has an indwelling foley catheter. Record review of Resident #1's Daily Skilled Note Progress Note, by LPN E, effective 06/28/2025 at 10:39 a.m., reflected Urine is [sic] pt has indwelling foley cath, urine is yellow and clear, no foul odor noted, no c/o dysuria [painful urination] [sic] Active SX: retention / distension of bladder. GU appliance used is an indwelling catheter. Other observations and interventions include Indwelling [sic] foley cath is drainingwell [sic] via gravity, no sediment noted, pt is tolerating well, no c/o pain or discomfort. Record review of Resident #1's Daily Skilled Note Progress Note, by LPN E, effective 06/29/2025 at 06:00 p.m., reflected Urine is [sic] pt has indwelling foley cath, urine is yellow and clear, no foul odor noted, no c/o dysuria [sic] No active Genitourinary/Renal symptoms observed. Record review of Resident #1's Daily Skilled Note Progress Note, by LPN D, effective 06/30/2025 at 11:31 p.m., reflected Urine is [sic] pt has indwelling foley cath, urine is yellow and clear, no foul odor noted, no c/o dysuria [sic] Other active symptoms or treatments are described below. GU appliance used is an indwelling catheter. Other observations and interventions include Resident [sic] has wounds and rash to perianal [area surrounding the anus] area- foley is to provide relief and promote skin integrity. Resident response to treatment is indweling [sic] foley catheter. Record review of Resident #1's Daily Skilled Note Progress Note, by LPN D, effective 07/01/2025 at 07:00 p.m., reflected Urine is [sic] pt has indwelling foley cath, urine is yellow and clear, no foul odor noted, no c/o dysuria [sic] No active Genitourinary/Renal symptoms observed. GU appliance used is an indwelling catheter. Other observations and interventions include Resident [sic] has wounds and rash to perianal area- foley is to provide relief and promote skin integrity. Resident response to treatment is indweling [sic] foley catheter. Record review of Resident #1's Daily Skilled Note Progress Note, by ADON G, effective 07/01/2025 at 10:53 p.m., reflected Urine is [sic] pt has indwelling foley cath, urine is yellow and clear, no foul odor noted, no c/o dysuria [sic] No active Genitourinary/Renalsymptoms [sic] observed. GU appliance used is an indwelling catheter. Other observations and interventions include Resident [sic] has wounds and rash to perianal area- foley is to provide relief and promote skin integrity. Resident response to treatment is indweling [sic] foley catheter. Record review of Resident #1's Nursing Progress Note, by LPN H, effective 07/02/2025 at 05:09 a.m., reflected Output noted for this shift was 250ml. Record review of Resident #1's Daily Skilled Note Progress Note, by LPN D, effective 07/02/2025 at 06:35 p.m., reflected Urine is [sic] resident has indwelling foley cath, urine is yellow and clear, no foul odor noted, no c/o dysuria [sic] No active Genitourinary/Renal symptoms observed. Resident response to treatment is indweling [sic] foley catheter. Record review of Resident #1's Daily Skilled Note Progress Note, by LPN D, effective 07/03/2025 at 10:28 p.m., reflected Urine is [sic] resident has indwelling foley cath, urine is yellow and clear, no foul odor noted, no c/o dysuria [sic] No active Genitourinary/Renal symptoms observed. GU appliance used is an indwelling catheter. Resident has wounds and rash to perianal area- foley is to provide relief and promote skin integrity. Record review of Resident #1's Daily Skilled Note Progress Note, by LPN I, effective 07/04/2025 at 02:54 p.m., reflected Urine is [sic] resident has indwelling foley cath, urine is yellow and clear, no foul odor noted, no c/o dysuria [sic] No active Genitourinary/Renal symptoms observed. Record review of Resident #1's Daily Skilled Note Progress Note, by LPN E, effective 07/05/2025 at 02:27 p.m., reflected Urine is [sic] resident has indwelling foley cath, urine is yellow and clear, no foul odor noted, no c/o dysuria [sic] Active SX: retention / distention of bladder. GU appliance used is an indwelling catheter. Other observations and interventions include Indwelling foley cath is draining well via gravity, no sediment noted, pt is tolerating well, no c/o pain or discomfort. Record review of Resident #1's Daily Skilled Note Progress Note, by LPN E, effective 07/06/2025 at 05:41 p.m., reflected Urine is [sic] resident has indwelling foley cath, urine is yellow and clear, no foul odor noted, no c/o dysuria [sic] No active Genitourinary/Renal symptoms observed. Record review of Resident #1's Daily Skilled Note Progress Note, by ADON G, effective 07/07/2025 at 06:27 p.m., reflected Urine is [sic] resident has indwelling foley cath, urine is yellow and clear, no foul odor noted, no c/o dysuria [sic] No active Genitourinary/Renal symptoms observed. GU appliance used is an indwelling catheter. Other observations and interventions include Indwelling foley cath is draining well via gravity, no sediment noted, pt is tolerating well, no c/o pain or discomfort. Record review of Resident #1's Progress Notes did not reveal a Daily Skilled Note or mention of indwelling catheter care or monitoring on 07/08/2025, 07/09/2025, or 07/10/2025. Record review of Resident #1's local hospital History and Physical/admission Notes, dated 07/11/2025, reflected Resident #1 presented at the hospital on [DATE] with a chief complaint of altered mental status. She was found to have a urinary tract infection upon arrival. Her history of present illness included she was recently hospitalized , discharged [DATE], for an acute cerebrovascular accident (a stroke) with altered mental status. During an interview on 07/13/2025 at 02:15 p.m., RN K, a local hospital nurse, revealed she had provided care for Resident #1 during her current and most recent prior hospitalization. RN K stated Resident #1 was being treated for a urinary tract infection during her current hospitalization. RN K stated Resident #1 had the foley inserted during her last hospitalization, after Resident #1 had a stroke. During an interview with Resident #1, at a local hospital, on 07/13/2025 at 02:37 p.m., revealed Resident #1 admitted , on 07/10/2025, to a local hospital. Resident #1 stated she did not feel she had consistent catheter care at the nursing facility; however, Resident #1 was noted as a poor historian and was mixing her complaints about her recent nursing facility admission and a prior assisted living admission. Resident #1 ended conversation by stating she only had complaints regarding the assisted living. During an interview on 07/14/2025 at 12:11 p.m., MD L, a local hospital physician, stated she had provided care for Resident #1 during her current and most recent prior hospitalization. MD L stated she did not believe the reason for Resident #1's return to the local hospital was due to the care provided by the nursing facility. During an interview on 07/14/2025 at 01:00 p.m., NP F stated she had assessed and visited with Resident #1 four times while she was at the nursing facility. NP F stated the last time she saw Resident #1 was the day prior to Resident #1's discharge, discharged [DATE]. NP F stated she recalled Resident #1 was admitted to the nursing facility with a foley from a local hospital due to urinary retention. During an interview on 07/14/2025 at 04:12 p.m., LPN D stated she was the admitting and discharging nurse for Resident #1. LPN D stated she recalled Resident #1 admitted with an indwelling catheter. LPN D stated she was unable to complete a full assessment on Resident #1 prior to her discharge, on 07/10/2025, but did note that Resident #1's urine was amber with no sedimentation, there was no odor, and Resident #1's vitals were normal. During an interview on 07/15/2025 at 12:17 p.m., LPN M stated she recalled providing care for Resident #1 and knew Resident #1 had an indwelling catheter. LPN M stated she did not recall Resident #1 having had any symptoms of an infection. She stated the nurses would monitor for changes in mental status and for resident's with foley catheters, monitor the foley bag for changes in urine color and concentration, and for sediment. LPN M stated she did not recall Resident #1 having had any issues with her foley catheter. She recalled Resident #1's urine was yellow, and Resident #1 was up in her wheelchair for lunch during her shift. LPN M stated Resident #1 did not verbalize any concerns or complaints during her shift and she acted normal, within her baseline. LPN M stated she believed she provided Resident #1 with direct care over 5-7 days and over those days, Resident #1's urine was yellow, not amber or any other concerns. LPN M stated she did not recall if Resident #1 had orders or care planned interventions for her foley catheter, however; she would have still known about the catheter by observing it during her rounds. LPN M stated she would have still checked Resident #1's foley catheter even without an order or care planned intervention. During an interview on 07/15/2025 at 02:43 p.m., the DON stated she could not find foley catheter orders for Resident #1. During an interview on 07/15/2025 at 03:41 p.m., LPN N stated she picked up a 02:00 p.m. to 10:00 p.m. shift on 07/09/2025 and worked on a hall that she did not typically work on. She stated provided care to Resident #1 during that shift. She stated she did not recall providing foley catheter care to Resident #1 during that shift, but she typically provided care per the resident's orders. She stated she would not have known Resident #1 had a foley if she did not have orders to provide foley catheter care, if she did not personally see it during her shift, was told about it by another staff member, or was given the resident's outputs to log. During an interview on 07/15/2025 at 04:04 p.m., CNA O stated she provided care for Resident #1 around 2 times. CNA O stated she also assisted other CNAs with Resident #1's care on other days. CNA O stated she would give Resident #1 showers, check and empty her catheter bag, wipe around the catheter insertion site, and provide perineal care (clean around the resident's genital and anal areas). During an interview on 07/15/2025 at 04:21 p.m., ADON G stated she might have provided care for Resident #1 due to covering the floor Resident #1 was on that day or shift. ADON G stated she did not recall providing foley catheter care for Resident #1. She stated she may not have known Resident #1 had a foley unless it was told to her or unless she had a reason to have checked for it. During an interview on 07/17/2025 at 10:40 a.m., LPN I stated he vaguely recalled Resident #1, but did remember checking her catheter during his shift and completing a routine assessment. LPN I stated he checked Resident #1's catheter bag and did not see any signs of issues, no sediment at that time. He stated he did not remember if Resident #1 had orders for foley catheter care, but he still provided care. During an interview on 07/17/2025 at 11:48 a.m., LPN D stated for admissions, the admitting nurse will get a report sheet when the resident arrives and the nurse will call the physician to obtain verification and depending on the physician, enter the orders for them. LPN D stated the admitting nurse will ask the transferring nurse if the admitting resident has wounds and/or ostomies, and if so, would ask the transferring nurse for the diagnoses and treatment orders for them. Upon the resident's admission, the admitting nurse would review the treatment orders with the physician and determine if the physician would want to continue those treatments or start new treatments per facility protocol. LPN D stated she did not recall Resident #1's admitting orders. She stated she believed the ADONs would follow up after a resident was admitted by completing a chart audit and they would often enter batch orders. LPN D stated the indwelling catheter orders were part of the batch orders. During an interview on 07/17/2025 at 12:10 p.m., LPN H stated she remembered providing Resident #1's foley catheter care. She stated Resident #1 came in with a foley catheter and she had provided care to Resident #1 for a couple of overnight shifts. LPN H stated Resident #1's foley was okay, but Resident #1 did complain of pain, in her back and leg. She stated she did not remember if Resident #1 had orders for foley catheter care. During an interview on 07/17/2025 at 02:07 p.m., CNA P stated she provided care for Resident #1 at least once or twice. CNA P stated she remembered Resident #1 had a foley catheter and providing care for the foley. She stated Resident #1 never complained when she provided Resident #1's foley catheter or perineal care. CNA P stated when providing perineal and foley catheter care, she would wipe from top down, look for redness, look for any redness or cloudiness in the urine, and watch for any complaints of pain when changing the resident or transferring her. During an interview on 07/17/2025 at 03:10 p.m., CNA R stated she provided care for Resident #1 for the two weeks Resident #1 was admitted . CNA R stated she remembered proving foley catheter care for Resident #1. She stated she did not observe Resident #1's urine having an unusual color or cloudiness, and Resident #1 would deny pain when she was cleaning her in that area. During an interview on 07/17/2025 at 05:17 p.m., LPN E revealed he recalled providing care for Resident #1 over two weekends. LPN E stated he was scheduled to work double weekends, 06:00 a.m. to 10:00 p.m. He stated he remembered providing foley catheter care for her and did not note any concerns while providing foley catheter care. He stated he did not remember Resident #1 having an order for her foley catheter to be flushed, so he would use disinfectant wipes to clean the area and clean the tubing. 2. Record review of Resident #2's admission Record, dated 07/16/2025, reflected Resident #2 was admitted on [DATE]. Resident #2 was noted to be [AGE] years old. Record review of Resident #2's Diagnosis Report, undated and accessed 07/16/2025, reflected Resident #2 was diagnosed with displaced intertrochanteric fracture of right femur (a break in the hip bone), thrombocytopenia (a low number of platelets, which are blood cells that cause clotting, in the blood), and dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #2's admission MDS assessment, dated 06/23/2025, reflected Resident #2's BIMS score of 02 indicated she was moderately cognitively impaired. She was noted to have an indwelling catheter and always incontinent of bowel. Record review of Resident #2's LN- Initial admission Record, effective date 06/21/2025, reflected Resident #2 had an indwelling urinary catheter in place upon admission for retention. Record review of Resident #2's Order Recap Report, dated 07/17/2025 for order dates 06/20/2025 to 07/31/2025, reflected the following orders:- CATHETER CARE EVERY SHIFT. MONITOR URETHRAL SITE FOR S/S OF SKIN BREAKDOWN, PAIN/DISCOMFORTS [sic], UNUSUAL ODOR, URINE CHARACTERISTIC OR SECREATIONS, CATHETER PULLING CAUSING TENSION every shift, noted as Active, order and start date 06/23/2025. - CATHETER TYPE: 16 FR # 10 ML_TO CLOSED URINARY DRAINAGE SYSTEM- DIAGNOSIS FOR USE: urinary retention, noted as Active, order and start date 06/21/2025.- CHANGE DRAINAGE BAG MONTHLY ON 15 DAY OF EACH MONTH &PRN [sic] one time a day for urinary retention, noted as Discontinued on 06/24/2025, order date 06/21/2025, start date 06/22/2025, and end date 06/24/2025.- CHANGE DRAINAGE BAG MONTHLY ON 15 DAY OF EACH MONTH &PRN [sic] one time a day every 1 month(s) starting on the 15th for 1 day(s), noted as Active, order date 06/23/2025 and start date 07/15/2025.- CHANGE FOLEY CATHETER MONTHLY ON 15 DAY OF EACH MONTH. REINSERT PRN FOR ACCIDENTAL REMOVAL, DISLODGEMENT, OBSTRUCTION OF URINE FLOW one time a day starting on the 15th and ending on the 15th every month, noted as Active, order date 06/21/2025 and start date 07/15/2025.- CHANGE LEG STRAP EVERY WEEK and AS NEEDED as needed AND one time a day every 7 day(s), noted as Active, order and start date 06/23/2025.- DX TO SUPPORT USE OF INDWELLING CATHETER: RETENTION, noted as Active, order date 06/23/2025.- Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: Indwelling Catheter every shift for foley, noted as Active, order and start date 06/21/2025.- MONITOR / RECORD /REPROT TO MD FOR ANY S/S OF UTI: PAIN/DISCOMFORTS [sic], [NAME] BLOOD TINGED URINE, CLOUDINESS, SCANTY OR NO URINARY OUTPUT, DARK URINE COLOR, HIGH TEMP., CHILLS, ALTERED MENTAL STATUS, CHANGES IN BEHAVIOR, CHANGES IN EATING PATTERN, FOUL SMELLING URINE every shift, noted as Active, order and start date 06/23/2025.- Monitor Catheter Output every shift, noted as Active, order and start date 06/23/2025.- POSITION PRIVACY BAG &TUBING [sic] BELOW THE LEVEL OF THE BLADDER every shift, noted as Active, order and start date 06/23/2025.- SECURE CATHETER WITH A LEG STRAP/LEG BAND OR ANCHOR TO MINIMIZE CATHETER RELATED INJURY AND ACCIDENTAL REMOVAL OR OBSTRUCTION OF URINE OUTFLOW, CHECK PLACEMENT as needed AND every shift, noted as Active, order and start date 06/23/2025. Record review of Resident #2's MAR, dated 06/01/2025- 06/30/2025, reflected the following indwelling catheter orders did not start until 06/23/2025 or 06/24/2025:- CHANGE LEG STRAP EVERY WEEK and AS NEEDED as needed AND one time a day every 7 day(s), noted as active, order date 06/23/2025 at 03:10 p.m., noted as Administered once, on 07/24/2025 at AM 07.- CATHETER CARE EVERY SHIFT. MONITOR URETHRAL SITE FOR S/S OF SKIN BREAKDOWN, PAIN/DISCOMFORTS [sic], UNUSUAL ODOR, URINE CHARACTERISTIC OR SECREATIONS, CATHETER PULLING CAUSING TENSION every shift, order date 06/23/2025 at 03:10 p.m., first noted as Administered on 07/23/2025 at NOC2, then noted as Administered three times a day for the remainder of the month.- MONITOR / RECORD /REPROT TO MD FOR ANY S/S OF UTI: PAIN/DISCOMFORTS [sic], [NAME] BLOOD TINGED URINE, CLOUDINESS, SCANTY OR NO URINARY OUTPUT, DARK URINE COLOR, HIGH TEMP., CHILLS, ALTERED MENTAL STATUS, CHANGES IN BEHAVIOR, CHANGES IN EATING PATTERN, FOUL SMELLING URINE every shift, order date 06/23/2025 at 03:10 p.m., first noted as Administered on 07/23/2025 at NOC2, then noted as Administered three times a day for the remainder of the month.- Monitor Catheter Output every shift, order date 06/23/2025 at 03:16 p.m., first noted as Administered on 07/23/2025 at NOC2, then noted as Administered three times a day for the remainder of the month.- POSITION PRIVACY BAG &TUBING [sic] BELOW THE LEVEL OF THE BLADDER every shift, order date 06/23/2025 at 03:10 p.m., first noted as Administered on 07/23/2025 at NOC2, then noted as Administered three times a day for the remainder of the month.- SECURE CATHETER WITH A LEG STRAP/LEG BAND OR ANCHOR TO MINIMIZE CATHETER RELATED INJURY AND ACCIDENTAL REMOVAL OR OSTRUCTION OF URINE OUTFLOW. CHECK PLACEMENT every shift, order date 06/23/2025 at 03:10 p.m., first noted as Administered on 07/23/2025 at NOC2, then noted as Administered three times a day for the remainder of the month.- CHANGE LEG STRAP EVERY WEEK and AS NEEDED as needed, order date 06/23/2025 at 03:10 p.m., noted as scheduled PRN and not noted as Administered. - SECURE CATHETER WITH A LEG STRAP/LEG BAND OR ANCHOR TO MINIMIZE CATHETER RELATED INJURY AND ACCIDENTAL REMOVAL OR OSTRUCTION OF URINE OUTFLOW. CHECK PLACEMENT as needed, order date 06/23/2025 at 03:10 p.m., noted as scheduled PRN and not noted as Administered. Observation and attempted interview with Resident #2 on 07/17/2025 at 09:40 a.m. Resident #2 observed to lying in bed, watching her television. Resident #2 observed to be alert, but her speech was garbled and her response to questions was inconsistent to interview prompt. During an interview on 07/15/2025 at 01:02 p.m., the DON stated the admitting nurse was to put the foley catheter orders in and then the NP or MD would sign off on them. The DON stated if there were not orders, the monitoring orders would not be in place and measuring output wouldn't be triggered for monitoring. She stated the nurses are hands-on, and they continue to monitor even without an order. She stated her expectation was that if a nurse were to observe a foley catheter and identify that there was not an order, the nurse was supposed to put in the order or notify her. During an interview on 07/15/2025 at 02:43 p.m., the DON stated the nurses would have documented the care provided and monitoring of the foley catheter care in their daily skilled note, even if they were not documenting it in the MAR. During an interview on 07/15/2025 at 04:21 p.m., ADON G stated if foley catheter care was not provided per order or care plan intervention, lack of care could result in a larger infection including the development of sepsis. During an interview on 07/17/2025 at 12:17 p.m., NP F stated she deferred to facility protocols for indwelling catheter care unless she identified a need for the orders and care to be changed. NP F stated she expected the facility staff to initiate the orders, generally upon admission. She stated the impact of the facility not putting in the orders could result in the indwelling catheter care was not being done, which could harm the resident. NP F stated she could not necessarily state the degree of harm to a resident if the care was delayed 2-3 days or more; however, she stated that the delay in care would not be best practice. During an interview on 07/17/2025 at 03:34 p.m., the DON stated it was the responsibility of the admitting nurse to put in orders for a resident's foley catheter care. She stated the ADONs or weekend supervisor will then audit the admission the next day; however, for Resident #1 it was missed. The DON stated the orders are patient specific, but even without orders the charge nurses would still see the foley catheter and provide care, including monitoring for signs and symptoms of a urinary tract infection. Record review of facility policy, Indwelling Urinary Catheter Care, dated revised/reviewed April 2025, revealed under Policy, It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 2 of 4 (Residents #1 and #2) reviewed for assessments. 1. The MDS Coordinator failed to complete Resident #1's admission comprehensive assessment within 14 days after admission. MDS Coordinator A verified as complete on 07/12/2025. Resident #1 was admitted on [DATE]. 2. The MDS Coordinator failed to complete Resident #2's admission comprehensive assessment within 14 days after admission. MDS Coordinator A verified as complete on 07/13/2025. Resident #2 was admitted on [DATE]. This failure could affect newly admitted residents and result in residents not receiving the care and services as needed.The findings included: 1. Record review of Resident #1's admission Record, dated 07/16/2025, reflected Resident #1 was admitted on [DATE] and discharged on 07/10/2025. Resident #1 was noted to be [AGE] years old. Record review of Resident #1's Diagnosis Report, undated and accessed 07/14/2025, reflected Resident #1 was diagnosed with other sequelae of cerebral infarction (long-term complications or effects that can occur after a stroke), acute kidney failure (a sudden condition when the kidneys stop working or being able to filter waste products from the blood), and chronic kidney failure, stage 3 (a condition where the kidneys lose their ability to filter blood and remove wastes). Record review of Resident #1's admission MDS assessment, dated 06/30/2025, reflected Resident #1 was admitted on [DATE] and had a BIMS score of 12 indicating she was mildly cognitively impaired. The admission MDS assessment was completed and signed by MDS Coordinator A on 07/12/2025; 15 days after Resident #1's admission. Interview with Resident #1, at a local hospital, on 07/13/2025 at 02:37 p.m., revealed Resident #1 admitted , on 07/10/2025, to a local hospital. Resident #1 stated she did not feel she had consistent care at the nursing facility; however, Resident #1 was noted as a poor historian and was mixing her complaints between the recent nursing facility administration and a prior assisted living administration. Resident #1 ended conversation by stating she only had complaints regarding the assisted living. 2. Record review of Resident #2's admission Record, dated 07/16/2025, reflected Resident #2 was admitted on [DATE]. Resident #2 was noted to be [AGE] years old. Record review of Resident #2's Diagnosis Report, undated and accessed 07/16/2025, reflected Resident #2 was diagnosed with displaced intertrochanteric fracture of right femur (a break in the hip bone), thrombocytopenia (a low number of platelets, which are blood cells that cause clotting, in the blood), and dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #2's EMR (electronic medical record) on 07/16/2025, reflected Resident #2 had four MDS Assessments, an Entry MDS, dated [DATE], and noted as Accepted, an admission - None PPS MDS, dated [DATE], and noted as Accepted, a Medicare- 5 Day MDS, dated [DATE], and noted as Completed, and a Discharge Return NotAnticipated [sic] MDS, dated [DATE], and noted as In Progress. Record review of Resident #2's admission MDS assessment, dated 06/23/2025, reflected Resident #2 was admitted on [DATE] and had a BIMS score of 02 indicating she was moderately cognitively impaired. The admission MDS assessment was completed and signed by MDS Coordinator A on 07/13/2025; 23 days after Resident #2's admission. Observation and attempted interview with Resident #2 on 07/17/2025 at 09:40 a.m. Resident #2 observed to lying in bed, watching her television. Resident #2 observed to be alert, but her speech was garbled and her response to questions was inconsistent to interview prompt. During an interview on 07/16/2025 at 09:26 a.m., MDS Coordinator A stated she worked on a PRN (as needed) basis. She revealed she would review the in-progress list and just complete the MDS Assessments that needed to be done. She stated a late MDS Assessment would impact a resident depending on the specific sections of the MDS Assessment that were not completed. She did not clarify how an assessment signed late could impact a resident. During an interview on 07/16/2025 at 09:41 a.m., MDS Coordinator B stated the assessments were scheduled based on the RAI (Resident Assessment Instrument). MDS Coordinator B stated the facility had herself and another MDS Coordinator, MDS Coordinator C, completing the assessments, but MDS Coordinator C was new and still in training. She stated MDS Coordinator A was working PRN and MDS Coordinator A would review and complete the MDS Assessments that were in-progress. MDS Coordinator B stated Resident #1's admission MDS was probably signed late because the MDS Coordinators were behind and still attempting to get caught up. MDS Coordinator B was not asked about Resident #'2's admission MDS. MDS Coordinator B stated a late MDS Assessment could impact a resident because it could delay triggers for care planning. Record review of facility policy, Resident Assessment and Associated Processes, dated revised/reviewed December 2023, revealed under Procedure, 3. Comprehensive assessments will be conducted within 14 days of admission., 7. Each individual who completes a portion of the assessment will electronically sign and certify the accuracy of that portion of the assessment, as well as the date the data was obtained., and 8. A Registered Nurse will electronically sign and certify that the assessment is completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 3 of 8 residents (Resident #233, Resident #237, and Resident #230) reviewed for a baseline care plan, in that: <BR/>1. The facility failed to ensure Resident #237's baseline care plan, undated, revealed no focus area or interventions for resident #237's use of pain medication [Norco].<BR/>2. The facility failed to ensure that Resident #233's baseline care plan included information related to the resident's diagnosis of diabetes mellitus. <BR/>3. The facility failed to ensure that Resident #230's baseline care plan included information related to the resident's diagnosis of diabetes mellitus and bipolar disorder. <BR/>This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. <BR/>The findings included:<BR/>1. Record review of Resident #237's Face Sheet, dated 02/23/2023, revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses: [Osteomyelitis] is an infection in a bone. [Benign prostatic hyperplasia] is an enlarged prostate, and [Hyperlipidemia] is a medical condition in which you have too much fat in your blood. <BR/>Record review of Resident #237's Baseline Care Plan, undated, revealed no focus area or or instructions for Resident #237's use of pain medication [Norco]. <BR/>Record review of Resident #237's admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated intact cognition. <BR/>Record review of Resident #237's electronic medical record Order Summary Report, dated 02/23/2023, revealed an order on 02/06/2023 for [Norco] to administer every six hours as needed for pain.<BR/>Record review of Resident #237's admission MDS, dated 0204/2023, revealed under section J, pain management, J 0100, B. received PRN pain med or was offered number one was selected, indicating pain medication was administered. <BR/>In an interview with Resident #237 on 02/23/2022 at 9:30 a.m., Resident #237 stated he requested his [Norco] about twice a day since it was ordered on 2/6/2023. The resident said, it makes me feel better because if I don't ask for it, I am in pain.<BR/>2. Record review of Resident #233's face sheet, dated 02/23/2023, revealed a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included: [Type 2 diabetes mellitus] with hyperglycemia (high blood sugar level), [Hyperlipidemia] is a medical condition in which you have too much fat in your blood and [Hypertension], also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure. <BR/>Record review of Resident #233's electronic face sheet, dated 02/23/2023, revealed a diagnosis of diabetes mellitus.<BR/>Record review of Resident #233's admission MDS, dated [DATE], revealed the resident had a BIMS score of 7, which indicated the resident's cognition was severely impaired. Further review revealed under section 1, metabolic, I2900, with an X indicating diabetes mellitus. <BR/>Record review of Resident #233's baseline care plan, undated, revealed no focus area or instructions for the resident's diagnosis of diabetes mellitus. <BR/>In an interview with Resident #233 on 02/24/2023 at 9:25 a.m., Resident #223 stated she had been diabetic for about forty years. <BR/>3. Record review of Resident #230's face sheet, dated 2/23/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: [Type 2 diabetes mellitus] with hyperglycemia (high blood sugar level), [Atrial fibrillation] is irregular. Often very rapid heart rhythm can lead to blood clots in the heart, [Low Blood Pressure] Low blood pressure is generally considered a blood pressure reading lower than 90 millimeters of mercury (mm Hg) for the top number (systolic) or 60 mm Hg for the bottom number (diastolic), and [Bi-Polar]A disorder associated with episodes of mood swings ranging from depressive lows to manic highs.<BR/>Record review of Resident #230's electronic face sheet, dated 02/23/2023, revealed a diagnosis of diabetes mellitus.<BR/>Record review of Resident #230's admission MDS, dated [DATE], revealed the resident had a BIMS score blank, which indicated the resident's cognition was severely impaired and could not complete the interview. Further review revealed blank under section 1, metabolic, I2900, section was left empty, and section was left blank under section I , I500. <BR/>Record review of Resident #230's baseline care plan, undated, revealed no focus area or instructions for the resident's diagnosis of diabetes mellitus or bipolar disorder . <BR/>Record review of Resident #230's electronic medical record Order Summary Report, dated 02/23/2023, revealed an order on 02/14/2023 for Glipizide 2 mg, take daily for diabetes Mellitus. <BR/>In a phone interview with Resident #230's family member on 02/24/2023 at 10:25 a.m., Resident #230's family member revealed that Resident #230 was diabetic and bipolar. <BR/>During an observation and interview with ADON B on 02/24/2023 at 9:47 a.m., ADON B confirmed that the resident's diagnosis of diabetes Mellitus was not included in the baseline care plan for Residents #233 and Resident #230. ADON B also confirmed that there was no baseline care plan to include pain management for Resident #237 ADON B stated that MDS and care plans were not currently in his area of expertise and referred the surveyor to the MDS Coordinator.<BR/>During a record review interview and confirmation with MDS Coordinator on 02/23/2023 at 10:02 a.m., MDS Coordinator confirmed the diagnosis of Diabetes Mellitus was not on the baseline care plan for Residents #233 and #230. The MDS Coordinator also confirmed no baseline care plan for Resident #237, indicating the use of pain medication [Norco]. The MDS Coordinator stated it was his job to complete the baseline care plan along with key interdisciplinary team members. The MDS Coordinator noted that an incomplete baseline care plan could negatively impact communication among nursing home staff, leading to unmet patient needs. The MDS Coordinator stated he did not know why baseline care plans were incomplete but would promptly complete them. <BR/>During an interview and confirmation with the DON on 02/24/2023 at 10:25 a.m., the DON confirmed that Residents #233, #230, and #237 needs should have been addressed on their baseline care plans. The DON stated she did not know why it was not completed but expected baseline care plans to reflect the patient's requirements to care for the first 48 hours completed by the MDS nurse. The DON stated the lack of a complete baseline care plan risk's not having all healthcare team members on the same page with residents leading to possible unmet resident needs. <BR/>Record review of the facility's policy titled, Comprehensive -Person-Centered Care Planning, revised 0/2022, revealed, The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide for a resident who is incontinent of bladder appropriate treatment, and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #5) reviewed for catheter care, in that: <BR/>Resident #5's urinary catheter bag with urine was not anchored to the bed frame and lying on the floor. <BR/>This deficiency could prevent residents on catheter treatment from receiving appropriate services and could lead to blockage in urine flow and infection. <BR/>The findings were:<BR/>Record review of Resident #5's face sheet, dated 2/15/24, and EMR revealed, the resident was admitted on [DATE] with diagnoses that included: hospice, Huntington's disease (a neurological disorder), aphasia (cannot communicate), and stage 4 pressure ulcer (right buttocks).<BR/>Record review of Resident#1's MDS, dated [DATE], revealed the resident had a BIMS score of 0, which indicated the resident was severely cognitively impaired, and for ADLs: bowel and bladder; catheter for bladder function, bowel was listed as always incontinent; transfer was dependent; bed mobility was dependent, and ROM was listed as impairment of upper and lower extremities. <BR/>Record review of Resident# 1's Care Plan, undated, revealed a goal and interventions for catheter treatment which included: Position catheter bag and tubing below the level of the bladder .<BR/>Record review of Resident #5's physician's orders for February 2024 revealed an order for, POSITION PRIVACY BAG & TUBING BELOW THE LEVEL OF THE BLADDER .<BR/>Observation and interview on 2/14/24 at 11:45 AM revealed Resident #5 was in bed, receiving continuous 02; not alert or oriented. Further observations revealed the resident's room gave off the odor of urine, and the resident's catheter was on the floor not anchored to the bed; there was urine in the bag. The resident could not answer any direct questions. <BR/>During an interview with RN E on 2/14/24 at 11:47 AM, RN E stated Resident #5's catheter bag was on the floor and should have been anchored. RN E stated there was an odor in the room. RN E stated the catheter bag on the floor could be an infection control concern.<BR/>During an interview with LVN F on 2/14/24 at 11:50 AM, LVN F stated the resident's catheter bag was on the floor and it could present an infection control concern. LVN F stated the, aides turned the resident and may have forgotten to anchor the bag. LVN F stated the charge nurse [LVN G] on the floor was responsible for checking on nurse aides and there activities around catheter care.<BR/>During an interview with LVN G (charge nurse) on 2/14/24 at 11:55 AM, LVN G (charge nurse) stated Resident #5's catheter bag was on the floor and it could present an infection control concern. LVN G stated it was his/her responsibility to follow-up on nurse aides when they provided catheter services to Resident #5. <BR/>During an interview with the DON on 2/15/24 at 10:31 AM, the DON stated Resident #5's catheter bag should have been anchored and the resident's bed was at the lowest position due to fall risk. The DON Stated the resident's catheter bag should be anchored because if exposed on the floor it could create an infection control issue. The DON stated the wound nurse (LVN H) while re-positioning the resident after wound care on 2/14/24 should have anchored the catheter bag to the bed. The DON stated in lowering the bed to a lowered position the bag may have un-hooked off the bed and laid on the floor. The DON did not offer an explanation as to why LVN H did not check the position of the catheter bag before leaving Resident #5's room. <BR/>Record review of the facility's policy titled, Catheter Care/Indwelling, undated, revealed: It is the policy of this facility that each resident with an indwelling catheter will received catheter care daily .Monitoring of leg strap and level of drainage bag as indicated .Keep tubing below level of bladder .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation.<BR/>Resident #'1's electronic medical record did not contain complete and accurate documentation that RN A recorded the resident's vital signs, follow-up on a STAT (immediate) lab request, kept the DON or MD informed on the monitoring of the resident's change of condition for a period of three hours; before the resident expired.<BR/>This failure could result in residents' records not accurately documenting interventions, monitoring, and information provided to the MD or DON during a change of condition that could result in a death.<BR/> Findings included:<BR/>Record review of Resident #1's Face Sheet, dated 01/12/23, and EMR (electronic medical record) revealed, Resident #1 was a male age [AGE], was admitted on [DATE] with diagnoses that included: acute metabolic acidosis (infection), sepsis (infection of the blood), urinary tract infection, kidney failure, hypertension, anemia ( low red blood count), chronic kidney disease and diabetes 2 . Advanced Directive was DNR (do not resuscitate). RP (responsible party) was listed as: the resident. The date of discharge was 01/07/23 due to resident expiring in the facility. <BR/>Record review of Resident#1's Care Plan dated 12/31/22 revealed goals of resident being free of antidepressant side effects, diabetic treatment, improving cognition.<BR/>Record review of Resident #1's Social Services Assessment, dated 12/30/22, revealed resident's BIMS was zero (severely impaired).<BR/>Record review of Resident #1's MD orders dated 01/01/23 read: Lansoprazole Oral Tablet Delayed Release Disintegrating 30 MG (Lansoprazole) Give 1 tablet by mouth one time a day for stress ulcer p (prophylaxis).<BR/>Record review of Resident #1's Change of Condition Nurses Note dated 01/07/23 at 1:09 PM read, Resident noted to be sleepy, unable to tolerate food. 02 (oxygen) 89 (percent) RM (room temperature) , HR (heart rate) 120, lung crackles, cough, afebrile. [Change of Condition Nurse Note was authored by RN A]<BR/>Record review of Resident #1's Physician Progress Note dated 01/07/23 at 9:57 PM read: Earlier in the day [01/07/23] I (MD B) received a text message that (Resident #1) has been asleep since breakfast and his vital signs BP 100/59, HR 120 oxygen sats (saturation) 2L (liters) with 95%. Not in distress. stat labs were ordered and advised to monitor clinically and hold BP meds and sedatives. (8:13 PM) received a text message that pt (patient) had expired .cause of the death is internal upper GI (gastro intestinal) bleeding is more likely even though pt has been taking Lansoprazole for a possible ulcer/prophylaxis ( action taken to prevent a disease) .<BR/>Record review of Resident #1's Nurse Note dated 01/07/23 at 4:11 PM, authored by RN A, revealed the resident's BP was 90/56, HR was 98 and the lab company had arrived to take a blood specimen of the resident.<BR/>Record review of Resident #1's Nurse Note dated 01/07/23 at 5:29 PM, authored by RN A, revealed: Resident's 02 saturation was 96 %. RN did not document any other vital signs that could have included: resident's temperature, BP, HR and respiration.<BR/>Record review of Resident #1's Nurse Notes from 01/07/23 at 5:29 PM to 8:05 PM (time of death) did not document the resident's condition, nursing monitoring or interventions, or follow-up to the lab, MD or DON.<BR/>Record revie of Resident #1's Nurse Note on 01/07/23 authored by RN A revealed: resident vomited blood, was unresponsible, deceased , and the MD and DON were notified. [MD note dated 01/07/23 at 9:57 PM revealed the . cause of death is internal upper GI (gastro intestinal) bleeding is more likely even though pt (patient) has been taking Lansoprazole for a possible ulcer/prophylaxis .]<BR/>Record review of Resident #1's labs dated 01/07/23 revealed: labs for Resident #1 was collected on 01/07/23 at 4:28 PM; the lab received the blood specimen at 9:21 PM; and results were reported at 10:07 PM. WBC (white blood count) was 25.3 H (high) .reference range 4.2-9.1 . <BR/>During a telephone interview on 01/12/23 at 2:59 PM, the MD revealed: (time line) on 01/07/23 at 1:09 PM he was alerted that Resident #1's O2 stats was 89% . The MD ordered stat labs. At 1:25 PM he was informed that Resident (#1)'s BP was 100/59 and heart rate 120 . The MD stated the latter BP was a little low and heart rate a little high . He ordered that the facility monitor the resident and to keep him informed of any change of condition. The MD stated, the last time the facility contacted me by text was at 8:05 PM when he (MD) was informed the resident was deceased . The MD stated, he was told Resident #1 had a little blood on his shirt. The MD recalled that he wrote a physician's note revealing that the resident might have suffered GI bleeding due to ulcer prophylaxis. <BR/>During an interview on 01/13/23 at 8:40 AM, DON revealed: on 01/07/23 at 1:07 PM the MD was contacted because the resident suffered hypotension (BP was 100/59 and heart rate was 120) and the MD ordered stat labs and to monitor the resident. At 4:11 PM Nurse A recorded that Resident #1's BP was 90/56 and heart rate was 98 (assessment by DON: indication that the BP and had heart were lower. At 5:29 PM Nurse A took vital signs which revealed Resident #1's oxygen saturation was 96 % ( assessment by DON; good oxygen intake) BP was not recorded. At 8:05 PM the resident is deceased . The lack of documentation meant per the DON that she and the MD had no information regarding Resident #1's change of condition and current status for 3 hours (5:29 PM to 8:05 PM). The DON revealed she could not answer for Nurse A as to why she (Nurse A) did not document the BP or other vital signs for the time period 5:29 PM to 8:05 PM. The DON described vital signs as BP, heart rate, respiration, O2 saturation and temperature. The DON stated the labs arrived at 10:07 PM after the resident expired; finding was resident had elevated WBC (white blood count).The DON added the system failure by Nurse A was not documenting completely and accurately between the hours 5:29 PM to 8:05 PM. The responsible party for documentation on 01/07/23 was the charge nurse (Nurse A). <BR/>During a telephone interview on 01/13/23 at 9:30 AM, Nurse A revealed: on 01/07/23 at 1:07 PM the MD was contacted because Resident #1 suffered hypotension (BP was 100/59 and heart rate was 120) and MD ordered stat labs and to monitor the resident. At 4:11 PM Nurse A recorded that Resident #1's BP was 90/56 and heart rate was 98 (means BP is low but not critical and 98 heart is high but not requiring MD notification). At 5:29 PM, she (Nurse A) recorded that 02 saturation was at 96 % (normal). Nurse A stated other vital signs were normal (temperature, respiration, BP and heart rate) but not recorded. Last not written by Nurse A was 8:05 PM when resident deceased . Nurse A stated, I observed the resident (#1) at 6 PM, 7 PM, 8 PM and in between and resident was stable .I did not record the vitals because I had other residents to take care .I saw the resident at 7:30 PM and vitals were okay and was waiting on the lab results .but did not record my visit at 7:40 PM . vitals were low but not critical .there was no written policy that I call the MD or DON every two hours .or document visits every 2 hours . Further, Nurse A stated she followed up on the stat labs at 7 PM and did not record the contact .it was my fault for not documenting. <BR/>During a telephone interview on 01/23/23 at 10:46 AM, CNA B revealed: his shift was from 2 PM-10 PM on 01/07/23 and he checked on Resident #1 every 30 minutes to 1 hour. At 7:22 PM, Resident (#1) was asleep, snoring, and not in distress .I did not document my checks with the resident but told Nurse (A) around 8 PM I found resident with a brown substance around his mouth and called the charge nurse .charge nurse said the resident had expired . CNA B stated that Nurse A would document the information he was conveying to her regarding the monitoring of Resident #1. <BR/>During an interview on 01/23/23 at 11:03 AM, DON revealed: Nurse A called the lab at 1:09 PM per MD request and the lab collected the specimen at 4:28 PM. The lab considers a STAT telephone request to fall within a time window of 4-6 hours.<BR/>During a telephone interview on 01/23/23 at 11:14 AM, Lab Representative C revealed the lab's policy was to respond to STAT telephone requests by six hours from time of collection to results. Reference # 1893253 revealed (Resident #1's) labs were collected at 4:28 PM. STAT did not mean the lab would immediately go to the facility rather from time of collection to results within a 6 hour timeframe . Follow-up calls from facility checking on STAT orders were not documented by the lab. <BR/>During an interview on 01/13/23 at 11:40 PM, the Administrator revealed Nurse A forgot to document critical information. He stated, it is a battle we fight on documentation . The Administrator added that complete and accurate documentation would be included in the on-[NAME] in-service training for nursing staff documentation, monitoring, and change of condition. <BR/>Record review of facility's Significant Change in Condition Response dated 01/2022 read, .The Nurse will perform and document an assessment of the resident and identify need for additional interventions .The resident will then be placed on the 24 Hour Report and Nursing will provide no less than three (3) days of observation, documentation .

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 7 residents (Resident #58) reviewed for infection control, in that:<BR/>While administering medications for Resident #58, RN E touched the light fixture pull cord and power plug and, the bed remote with her gloved hands and did not changed her gloves and washed her hands before touching Resident #58's eyes area and administering eye drops to the resident. <BR/>These failures could place residents at-risk for infection due to improper care practices. <BR/>The findings include:<BR/>Record review of Resident #58's face sheet, dated 04/05/2024, revealed an admission date of 12/24/2021, and a readmission date of 06/28/2023, with diagnoses which included: Dysphagia (Difficulty in swallowing), Insomnia (Difficulty sleeping), Hemiplegia (Paralysis of one side of the body), Cerebral infarction (process that result in an area of dead tissue in the brain), Hypertension (High blood pressure), Vascular dementia (Decline in cognition caused by restricted blood flow).<BR/>Record review of Resident #58's Annual MDS assessment, dated 01/01/2024, revealed the resident had a BIMS score of 5 indicating severe impairment. Resident #58 required extensive assistance to total care.<BR/>Review of Resident #58's physician order, dated 04/05/2024, revealed an order for Artificial Tears Ophthalmic Solution (Artificial Tear Solution) Instill 1 drop in both eyes four times a day for dry eyes<BR/>Observation on 04/05/24 at 08:19 a.m. revealed while administering medications to Resident # 58, RN E did not demonstrate proper use of PPE (personal protective equipment) and hand hygiene. She washed her hands and donned gloves then, prior to administer eye drops to the resident, she touched the lights pull cord, the power cord and plug behind the bed on the wall and the bed remote. She did not change her gloves or sanitize her hands and administered the drops to Resident #58 and touched the resident face and eyes areas. <BR/>During an interview on 04/05/2024 at 8:58 a.m., RN E confirmed the environment around Resident #58 was considered contaminated. She confirmed she should have changed her gloves after touching the pull cord, power cord and the bed remote and before administering the eye drops and touching the resident's face. She confirmed receiving infection control training within the year. <BR/>During an interview with the DON on 04/05/2024 at 2:00 p.m., the DON confirmed the staff should have changed her gloves after touching the environment and before touching the eyes of the resident. She confirmed Infection control training was provided to the staff yearly and as needed if problem with infection control were noted . The facility checked skills yearly and spot check were by the ADONS. The facility had an infection preventionist overseeing infection control. <BR/>Review of annual skills check for RN E revealed RN E passed competency for hand hygiene and infection control during medications administration on 03/12/2024.<BR/>Review of facility policy, titled Hand hygiene, dated 10/2022, revealed Use an alcohol-based hand rub [ .] before preparing or handling medications [ .] after contact with objects in the immediate vicinity of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure each resident received food prepared in a form designed to meet individual needs, for 1 of 8 residents (Resident #1) reviewed for nutritional needs.<BR/>The facility failed to provide a fortified meal plan from 1/4/2025 to 4/24/2025 for Resident #1 as ordered by the physician and the dietician. <BR/>This failure could place residents at risk for harm by weight loss.<BR/>The findings included:<BR/>A record review of Resident #1's admission record, dated 4/23/2025, revealed an admission date of 11/9/2024 with diagnoses which included vascular dementia (a group of symptoms affecting memory, thinking and social abilities caused by strokes), cerebral infarction (strokes), and chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood well). <BR/>A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 7, out of a possible score of 15, which indicated severe cognitive impairment. Further review revealed Resident #1 was assessed as having a therapeutic diet while a resident within the last seven days from the assessment completed 3/7/2025. <BR/>A record review of Resident #1's physician's order dated 1/2/2025 revealed the physician prescribed Resident #1 to receive a FMP (fortified meal plan).<BR/>A record review of Resident #1's care plan dated 1/4/2025 revealed (Resident #1) has potential nutritional problem related to therapeutic diet . following cerebral infarction . diet as ordered by the physician: FMP <BR/>A record review of a progress note dated 2/17/2025 authored by LVN B revealed Resident #1 had lost weight and was assessed with a low albumin level (a blood protein, malnutrition can lead to decreased albumin); Patient has had a gradual weight decline and labs reviewed which were completed on 01/07/25 with abnormal values and reflecting low albumin <BR/>A record review of Resident #1's breakfast meal ticket dated 4/24/2025 revealed no indication to alert staff for Resident #1's prescribed fortified meal plan. <BR/>A record review of Resident #1's medical records from 1/2/2025 to 4/25/2025 revealed Resident #1 had triggered for weight loss as documented by the physician's order dated 1/2/2025 for a FMP however, Resident #1 was assessed by the RD on 1/15/2025 to weight 122.1 lbs. with a BMI of 27.4 which indicated her to be 20% overweight for her height. Further review revealed Resident #1 had no further weight loss throughout the period reviewed. <BR/>During an observation on 4/24/2025 at 8:30 AM revealed Resident #1 seated in the dining room eating her breakfast. The breakfast served was pancakes served with sugar free syrup, bacon, oatmeal, coffee, and juice. <BR/>During an interview on 4/24/2025 at 8:33 LVN A stated she had reviewed Resident #1's physician's orders and recognized Resident #1 was prescribed by the physician to receive a FMP, however her meal ticket did not reflect the FMP order. LVN A stated the meal ticket guides staff as to what to serve residents. LVN A stated she had reviewed Resident #1's meal ticket prior to serving Resident #1 her breakfast and did not recognize from the meal ticket Resident #1 was to be served a FMP meal. <BR/>During an interview on 4/24/2025 at 8:40 AM the ADON stated she reviewed Resident #1's physician's order which included a fortified meal plan. The ADON stated the FMP would alert the nurses who would review the meal prior to serving the meal to review the meal for extra calories such as extra servings of fats and carbohydrates, butter, and breads. The ADON stated if the meal ticket did not state FMP then the staff would not know the resident needed to be served a FMP meal. The ADON stated the process would be for the nursing staff to communicate the FMP order to the dietary manager. The ADON stated she reviewed Resident #1's weight status and Resident #1 has gained and maintained her weight since January 2025 and the nursing staff and cooperating registered dietician had been having the nursing staff administer extra calories during Resident #1's medication administration. <BR/>During an interview on 4/24/2025 at 8:50 AM the Food Service Manager (FSM) stated he had received communication from the nursing department that Resident #1 was prescribed a FMP. The FSM stated a FMP consisted of serving the meal as approved by the registered dietician and to the add extra calories, fats, and carbohydrates to the resident's meal; for example, extra butter, and extra bread, and gravy. The FSM stated he reviewed the dietary resident database and recognized Resident #1's was documented as needing a FMP and could not explain why her meal ticket would print out without the direction for the FMP. The FSM stated the meal tickets would be printed out prior to the serving of the meals and would guide the cook as how to plate the meal and in this case to serve extra calories to the meal, without the FMP on the ticket my staff would not know to add extras.<BR/>During an interview on 4/25/2025 at 11:00 AM the DON stated her expectation was for the FSM to accurately serve the residents meals per the physician and nursing dietary communications and for the staff to review the residents' meal tickets to their orders after there was a change in the resident's meal plan. The DON stated the risk to residents was they may not have received their meal as prescribed by the physician. <BR/> A record review of the facility's Dietary Services Meals and Food policy dated 6/2027, revealed, It is the policy of this facility to ensure dietary services are provided to our residents operating within the confines of Texas state regulations.<BR/>PROCEDURE:<BR/>I. A dietary manager is responsible for the total food service of this facility . 5. <BR/>Therapeutic diets as ordered by the resident's physician are provided according to the service plan

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for 2 of 3 residents (Resident #1 and #2) reviewed for pressure injuries.<BR/>1. The facility nurses did not provide wound care to Resident #1 on 03/20/2025 and 03/24/2025. However, the physician order indicated Cleanse left glute, lateral malleolus, medial calf, and right plantar with wound cleanser, gently pat dry with gauze, apply skin prep to peri wound, apply medi-honey, cover with calcium alginate and secure with dry dressing daily - every day.<BR/>2. The facility nurses did not provide wound care to Resident #2 on 03/25/2025. However, the physician order indicated Cleanse third digit right toe with wound cleanser, gently pat dry with gauze, apply betadine and LOTA (leave open to air) daily - every day. <BR/>This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain.<BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet, dated 03/26/2025, revealed the resident was [AGE] years old, male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with the diagnosis of cellulitis of left lower limb (skin infection), abnormity of gait and mobility, cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 2 diabetes mellitus (uncontrolled blood sugars), and edema (swelling caused by fluid). <BR/>Record review of Resident #1's Medicare 5 days MDS assessment, dated 02/21/2025, revealed the resident's BIMS was 15 out of 15, indicated the resident's cognition was intact and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) to sit-to-stand, chair-to-bed, and toilet transfer. <BR/>Record review of Resident #1's comprehensive care plan, dated 03/18/2025, revealed [Resident #1] has pressure ulcer left buttock-stage 4, left malleolus (ankle)-stage 3, right plantar (bottom of foot)-unstageable, and left medical calf related to vascular ulceration. For interventions - Administered medications as ordered.<BR/>Record review of Resident #1's physician orders, dated 03/13/2025, revealed the resident had the orders of cleanse left glute (buttock) with wound cleanser, gently pat dry with gauze, apply skin prep to peri wound, apply medi-honey, cover with calcium alginate and secure with dressing daily, cleanse left lateral malleolus (ankle) with wound cleanser, gently pat dry with gauze, apply skin prep to peri wound, apply medi-honey, cover with calcium alginate and secure with dressing daily, cleanse left medial calf (side of lower leg) with wound cleanser, gently pat dry with gauze, apply skin prep to peri wound, apply medi-honey, cover with calcium alginate and secure with dressing daily, and cleanse right plantar (bottom of foot) with wound cleanser, gently pat dry with gauze, apply skin prep to peri wound, apply medi-honey, cover with calcium alginate and secure with dressing wrap with kerlix and secure with tape daily. <BR/>Record review of Resident #1's treatment administration record, from 03/01/2025 to 03/31/2025, revealed there were empty blanks (no nurses' initials) on 03/20/2025 and 03/24/2025 for wound care to Resident #1's left glute (buttock), lateral malleolus (ankle), medial calf (lower leg), and right plantar (bottom of foot) daily - once a day. <BR/>Observation on 03/26/2025 at 9:53 a.m. revealed wound care nurse was providing wound care to Resident #1 as ordered. The resident had wounds to his left buttock, left lower leg, left ankle, and right bottom of foot. The all wounds were very clean, no signs and symptoms related to infection such as redness, hot, and swelling, and no discharge from all wounds were noted.<BR/>Interview on 03/26/2025 at 9:55 a.m. with Resident #1 stated he did not have any pain and received wound care from nurses, but sometimes the facility nurses missed his wound care. <BR/>Interview on 03/26/2025 at 10:00 a.m. with wound care nurse stated wound care nurse started working at the facility as wound care nurse on 03/25/2025, and before the nurse worked as a wound care nurse, the charge nurse provided wound care to Resident #1. <BR/>Interview on 03/25/2025 at 1:40 p.m. with Resident #1's charge nurse RN-A stated she worked on 03/20/2025 and 03/24/2025 from 6 am to 2 pm and did not provide wound care to Resident #1 because she was very busy at those dates. The RN-A said she did not remember if she passed the information regarding needing Resident #1's wound care to evening shift (2 pm to 10 pm) and might forget telling it to the nurses of evening shift. That was why the resident did not receive wound care on 03/20/2025 and 03/24/2025. Further interview on the RN-A said she should have ensured the resident received wound care as ordered on 03/20/2025 and 03/24/2025 by providing wound care or telling the resident needed to have wound care to nurses of evening shift, so the evening nurses might provide wound care to Resident #1. Resident #1 might have wound infection if he did not receive proper wound care. <BR/>Interview on 03/26/2025 at 10:52 a.m. with Resident #1's provider NP stated Resident #1 was under the NP's care, and the NP assessed the resident at least two times a week. The latest assessment the NP conducted was 03/25/2025. Further interview with the NP said Resident #1 did not have infection, and his blood sugars were controlled very well; therefore, only two days for missing wound care did not affect any negative outcomes to Resident #1. <BR/>Interview on 03/26/2025 at 1:27 p.m. with DON stated facility nurses should have provided wound cares to Resident #1 as ordered, which was every day no matter what situation nurses had. Resident #1 did not have any negative effects, such as wound infection, but the resident might have wound infection if nurses did not provide wound care as ordered. <BR/>2. Record review of Resident #2's face sheet, dated 03/26/2025, revealed the resident was [AGE] years old, male, and admitted to the facility on [DATE] with diagnosis of hyperkalemia (high level of potassium in the blood), type 2 diabetes mellitus (uncontrolled blood sugars), atrial flutter (heart's upper chambers beat too quickly), hyperlipidemia (high level of fat in the blood), and hypertension (high blood pressure). <BR/>Record review of Resident #2's admission MDS revealed the resident's MDS was still in progress because he was admitted to the facility on [DATE]. <BR/>Record review of Resident #2's admission BIMS assessment, dated 03/18/2025, revealed the resident's BIMS was 15 out of 15, indicated the resident's cognitive was intact. <BR/>Record review of Resident #2's baseline care plan, dated 03/19/2025, revealed [Resident #2] admitted with skin impairment to lower extremities - right middle toe (3rd toe). For intervention - clean right third digit with wound cleanser, gently pat dry with gauze, apply betadine, and leave open to air daily - every day. <BR/>Record review of Resident #2's physician order, dated 03/18/2025, revealed Wound care: Cleanse third digit right toe with wound cleanser, gently pat dry with gauze, apply betadine and leave open to air daily. Every day for diabetic ulcer. <BR/>Record review of Resident #2's treatment administration record, from 03/01/2025 to 03/31/2025, revealed wound care nurse documented on 03/25/2025 as 7, which indicated the wound care nurse document to nursing progress note, and the progress note indicted the wound care nurse did not provide the wound care on 03/25/2025 because the nurse could not find the resident at the facility.<BR/>Observation on 03/26/2025 at 9:27 a.m. revealed wound care nurse was providing wound care to Resident #2 as ordered. The resident had wound to third toe of his right foot with one cent size. No signs and symptoms of infection and no discharge was noted. Wound was very clean. <BR/>Interview on 03/26/2025 at 9:37 a.m. with Resident #2 stated he did not have any pain, and facility nurses provided wound care every day, but only yesterday (03/25/2025) he did not receive wound care. Further interview with the resident denied any neglect. <BR/>Interview on 03/26/2025 at 9:47 a.m. with wound care nurse said she tried to find Resident #2 to provide wound care, but the wound care nurse could not find the resident at the facility. The wound care nurse wrote Resident #2 needs to have wound care when he was available to 24-hour nursing shift report to make sure evening or night charge nurse would provide wound care to the resident, but due to lack of communication between the wound care nurse to the charge nurses, the nurses wound not provide the wound care to Resident #2 on 03/25/2025. To prevent wound infection, the nurses should have provided wound care to the resident every day as ordered. <BR/>Interview on 03/26/2025 at 1:27 p.m. with DON stated she tried to call evening charge nurses or night charge nurses who worked on 03/25/2025 to find out what reason they did not provide the wound care to Resident #2, but nobody answered the phone calls. However, facility nurses should have provided wound cares to Resident #2 as ordered, which was every day and no matter what situation nurses had. Resident #2 did not have any negative effects, such as wound infection at this time, but the resident might have wound infection if nurses did not provide wound care as ordered. <BR/>Record review of the facility's policy, titled Skin and Wound Monitoring and Management, revised 12/2023, revealed A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation.<BR/>Resident #'1's electronic medical record did not contain complete and accurate documentation that RN A recorded the resident's vital signs, follow-up on a STAT (immediate) lab request, kept the DON or MD informed on the monitoring of the resident's change of condition for a period of three hours; before the resident expired.<BR/>This failure could result in residents' records not accurately documenting interventions, monitoring, and information provided to the MD or DON during a change of condition that could result in a death.<BR/> Findings included:<BR/>Record review of Resident #1's Face Sheet, dated 01/12/23, and EMR (electronic medical record) revealed, Resident #1 was a male age [AGE], was admitted on [DATE] with diagnoses that included: acute metabolic acidosis (infection), sepsis (infection of the blood), urinary tract infection, kidney failure, hypertension, anemia ( low red blood count), chronic kidney disease and diabetes 2 . Advanced Directive was DNR (do not resuscitate). RP (responsible party) was listed as: the resident. The date of discharge was 01/07/23 due to resident expiring in the facility. <BR/>Record review of Resident#1's Care Plan dated 12/31/22 revealed goals of resident being free of antidepressant side effects, diabetic treatment, improving cognition.<BR/>Record review of Resident #1's Social Services Assessment, dated 12/30/22, revealed resident's BIMS was zero (severely impaired).<BR/>Record review of Resident #1's MD orders dated 01/01/23 read: Lansoprazole Oral Tablet Delayed Release Disintegrating 30 MG (Lansoprazole) Give 1 tablet by mouth one time a day for stress ulcer p (prophylaxis).<BR/>Record review of Resident #1's Change of Condition Nurses Note dated 01/07/23 at 1:09 PM read, Resident noted to be sleepy, unable to tolerate food. 02 (oxygen) 89 (percent) RM (room temperature) , HR (heart rate) 120, lung crackles, cough, afebrile. [Change of Condition Nurse Note was authored by RN A]<BR/>Record review of Resident #1's Physician Progress Note dated 01/07/23 at 9:57 PM read: Earlier in the day [01/07/23] I (MD B) received a text message that (Resident #1) has been asleep since breakfast and his vital signs BP 100/59, HR 120 oxygen sats (saturation) 2L (liters) with 95%. Not in distress. stat labs were ordered and advised to monitor clinically and hold BP meds and sedatives. (8:13 PM) received a text message that pt (patient) had expired .cause of the death is internal upper GI (gastro intestinal) bleeding is more likely even though pt has been taking Lansoprazole for a possible ulcer/prophylaxis ( action taken to prevent a disease) .<BR/>Record review of Resident #1's Nurse Note dated 01/07/23 at 4:11 PM, authored by RN A, revealed the resident's BP was 90/56, HR was 98 and the lab company had arrived to take a blood specimen of the resident.<BR/>Record review of Resident #1's Nurse Note dated 01/07/23 at 5:29 PM, authored by RN A, revealed: Resident's 02 saturation was 96 %. RN did not document any other vital signs that could have included: resident's temperature, BP, HR and respiration.<BR/>Record review of Resident #1's Nurse Notes from 01/07/23 at 5:29 PM to 8:05 PM (time of death) did not document the resident's condition, nursing monitoring or interventions, or follow-up to the lab, MD or DON.<BR/>Record revie of Resident #1's Nurse Note on 01/07/23 authored by RN A revealed: resident vomited blood, was unresponsible, deceased , and the MD and DON were notified. [MD note dated 01/07/23 at 9:57 PM revealed the . cause of death is internal upper GI (gastro intestinal) bleeding is more likely even though pt (patient) has been taking Lansoprazole for a possible ulcer/prophylaxis .]<BR/>Record review of Resident #1's labs dated 01/07/23 revealed: labs for Resident #1 was collected on 01/07/23 at 4:28 PM; the lab received the blood specimen at 9:21 PM; and results were reported at 10:07 PM. WBC (white blood count) was 25.3 H (high) .reference range 4.2-9.1 . <BR/>During a telephone interview on 01/12/23 at 2:59 PM, the MD revealed: (time line) on 01/07/23 at 1:09 PM he was alerted that Resident #1's O2 stats was 89% . The MD ordered stat labs. At 1:25 PM he was informed that Resident (#1)'s BP was 100/59 and heart rate 120 . The MD stated the latter BP was a little low and heart rate a little high . He ordered that the facility monitor the resident and to keep him informed of any change of condition. The MD stated, the last time the facility contacted me by text was at 8:05 PM when he (MD) was informed the resident was deceased . The MD stated, he was told Resident #1 had a little blood on his shirt. The MD recalled that he wrote a physician's note revealing that the resident might have suffered GI bleeding due to ulcer prophylaxis. <BR/>During an interview on 01/13/23 at 8:40 AM, DON revealed: on 01/07/23 at 1:07 PM the MD was contacted because the resident suffered hypotension (BP was 100/59 and heart rate was 120) and the MD ordered stat labs and to monitor the resident. At 4:11 PM Nurse A recorded that Resident #1's BP was 90/56 and heart rate was 98 (assessment by DON: indication that the BP and had heart were lower. At 5:29 PM Nurse A took vital signs which revealed Resident #1's oxygen saturation was 96 % ( assessment by DON; good oxygen intake) BP was not recorded. At 8:05 PM the resident is deceased . The lack of documentation meant per the DON that she and the MD had no information regarding Resident #1's change of condition and current status for 3 hours (5:29 PM to 8:05 PM). The DON revealed she could not answer for Nurse A as to why she (Nurse A) did not document the BP or other vital signs for the time period 5:29 PM to 8:05 PM. The DON described vital signs as BP, heart rate, respiration, O2 saturation and temperature. The DON stated the labs arrived at 10:07 PM after the resident expired; finding was resident had elevated WBC (white blood count).The DON added the system failure by Nurse A was not documenting completely and accurately between the hours 5:29 PM to 8:05 PM. The responsible party for documentation on 01/07/23 was the charge nurse (Nurse A). <BR/>During a telephone interview on 01/13/23 at 9:30 AM, Nurse A revealed: on 01/07/23 at 1:07 PM the MD was contacted because Resident #1 suffered hypotension (BP was 100/59 and heart rate was 120) and MD ordered stat labs and to monitor the resident. At 4:11 PM Nurse A recorded that Resident #1's BP was 90/56 and heart rate was 98 (means BP is low but not critical and 98 heart is high but not requiring MD notification). At 5:29 PM, she (Nurse A) recorded that 02 saturation was at 96 % (normal). Nurse A stated other vital signs were normal (temperature, respiration, BP and heart rate) but not recorded. Last not written by Nurse A was 8:05 PM when resident deceased . Nurse A stated, I observed the resident (#1) at 6 PM, 7 PM, 8 PM and in between and resident was stable .I did not record the vitals because I had other residents to take care .I saw the resident at 7:30 PM and vitals were okay and was waiting on the lab results .but did not record my visit at 7:40 PM . vitals were low but not critical .there was no written policy that I call the MD or DON every two hours .or document visits every 2 hours . Further, Nurse A stated she followed up on the stat labs at 7 PM and did not record the contact .it was my fault for not documenting. <BR/>During a telephone interview on 01/23/23 at 10:46 AM, CNA B revealed: his shift was from 2 PM-10 PM on 01/07/23 and he checked on Resident #1 every 30 minutes to 1 hour. At 7:22 PM, Resident (#1) was asleep, snoring, and not in distress .I did not document my checks with the resident but told Nurse (A) around 8 PM I found resident with a brown substance around his mouth and called the charge nurse .charge nurse said the resident had expired . CNA B stated that Nurse A would document the information he was conveying to her regarding the monitoring of Resident #1. <BR/>During an interview on 01/23/23 at 11:03 AM, DON revealed: Nurse A called the lab at 1:09 PM per MD request and the lab collected the specimen at 4:28 PM. The lab considers a STAT telephone request to fall within a time window of 4-6 hours.<BR/>During a telephone interview on 01/23/23 at 11:14 AM, Lab Representative C revealed the lab's policy was to respond to STAT telephone requests by six hours from time of collection to results. Reference # 1893253 revealed (Resident #1's) labs were collected at 4:28 PM. STAT did not mean the lab would immediately go to the facility rather from time of collection to results within a 6 hour timeframe . Follow-up calls from facility checking on STAT orders were not documented by the lab. <BR/>During an interview on 01/13/23 at 11:40 PM, the Administrator revealed Nurse A forgot to document critical information. He stated, it is a battle we fight on documentation . The Administrator added that complete and accurate documentation would be included in the on-[NAME] in-service training for nursing staff documentation, monitoring, and change of condition. <BR/>Record review of facility's Significant Change in Condition Response dated 01/2022 read, .The Nurse will perform and document an assessment of the resident and identify need for additional interventions .The resident will then be placed on the 24 Hour Report and Nursing will provide no less than three (3) days of observation, documentation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment ans supports for daily living safely for 4 of 30 rooms (Rooms #309, #316, #328, and #330) on the third floor of the facility and 1 of 3 halls (Hall C) on the third floor of the facility, in that: <BR/>1. The facility failed to repair a wall scrape behind a resident bed in room [ROOM NUMBER]. <BR/>2. The facility failed to repair a wall scrape behind a resident bed in room [ROOM NUMBER].<BR/>3. There were 2 of 3 light bulbs burnt in room [ROOM NUMBER]. <BR/>4. The wall between Rooms #328 and #330 showed signs of water damaged. <BR/>These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. <BR/>The findings included: <BR/>During an observation tour on 04/05/2024 from 10:45-10:50 a.m. with the Maintenance Director and the Administrator the following was noted: <BR/>1. Resident room [ROOM NUMBER] which was occupied had a scrap on the wall which measured 4x1 feet and included paint removal and was located behind the resident's bed. <BR/>2. Resident room [ROOM NUMBER] which was occupied had a scrap on the wall which measured 4x1 feet and included paint removal and was located behind the resident's bed. <BR/>During an interview with the Maintenance Director and Administrator on 04/05/24 at 11:00 a.m. the Administrator stated that staff uses the TELS work order notification system to alert the Maintenance Director of needed repairs. The Maintenance Director stated that he was not aware of a work order that was placed for wall repair on these two rooms. <BR/>Record review of facility work orders provided by the Maintenance Director for the time period of 6/6/23 through 3/30/24 did not reveal a work order placed for wall repair in room [ROOM NUMBER] and 316.<BR/>3. Observation on 04/04/2024 at 01:29 p.m., revealed that in room [ROOM NUMBER] 2 of the 3 light fixtures on top of the resident sink had bulbs that were burnt out and one had a bulb that was very dim. <BR/>Interview on 04/04/2024 at 1:35 p.m. CNA F and CNA G confirmed 2 of the bulbs were burnt out and the third one was probably going to burn out soon. They confirmed they could electronically report any issue with maintenance. They were not sure how long the bulbs had been burnt <BR/>Interview on 04/04/2024 at 1:40 p.m. with the resident in room [ROOM NUMBER] revealed she did not have concerns about the bulbs being burnt and revealed that the lights were very dim even with fully functional bulbs. She revealed the bulbs had been burn for 4 to 5 days. <BR/>Interview with the Administrator on 04/05/2024 at 8:30 a.m. confirmed lights bulbs should not be burnt in residents' rooms and that the staff could report directly to maintenance. <BR/>4. Observation on 04/04/2024 at 1:38 p.m. revealed the wall between Rooms #330 and #328 was showing sign of water infiltration. The paint was missing toward the middle of the wall by two power plugs. There was a small open area were the ceiling tiles and wall meet.<BR/>Interview with the Administrator on 04/05/2024 at 8:30 a.m. confirmed he knew about the damage on the wall between Rooms #328 and #330 and the damages had been there for a few weeks. The Administrator revealed there was a problem overtime it rained and the condensation of the air conditioning was also a problem. <BR/>Record review of the facility's preventative Maintenance and Inspections Policy dated 05/2007 stated that inspections by the Maintenance Director which include resident rooms are to be completed on a regular basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to ensure the MDS assessments accurately reflected the resident's status for 1 of 8 residents (Resident #230) reviewed for accuracy of assessments. <BR/>1. The facility failed to ensure the MDS assessment reflected Resident #230's diagnosis of diabetes Mellitus. <BR/>2. The facility failed to ensure the MDS assessment reflected Resident #230's diagnosis of bipolar disorder. <BR/>These deficient practices could place the residents at risk of not receiving the necessary care and services.<BR/>The findings included: <BR/>1. Record review of Resident #230's face sheet, dated 2/23/2023, revealed a 93- year old male admitted to the facility on [DATE] with diagnoses that included: [Type 2 diabetes mellitus] with hyperglycemia (high blood sugar level), [Atrial fibrillation] is irregular. Often very rapid heart rhythm can lead to blood clots in the heart. [Low Blood Pressure] Low blood pressure is generally considered a blood pressure reading lower than 90 millimeters of mercury (mm Hg) for the top number (systolic) or 60 mm Hg for the bottom number (diastolic) and [Bi-Polar] condition marked by alternating periods of elation and depression.<BR/>Record review of Resident #230's electronic face sheet, dated 02/23/2023, revealed a diagnosis of diabetes mellitus and bipolar disorder. <BR/>Record review of Resident #230's baseline care plan, undated, revealed no focus area or instructions for residents diagnosis of diabetes or bipolar disorder. <BR/>Record review of Resident's #230's electronic medical record Order Summary Report, dated 02/23/2023, revealed an order on 02/14/2023 for Glipizade 2 mg taken daily for diabetes mellitus. <BR/>Record review of Resident #230's admission MDS, dated [DATE], revealed the resident had a BIMS score blank, which indicated the resident's cognition was severely impaired and could not complete the interview. Further review revealed blank under section 1, metabolic, I2900, section was left unmarked, and section I, Psychiatric / Mood disorder, I5900, was left unmarked. <BR/>In a phone interview with Resident #230's family member on 02/24/2023 at 10:25 a.m., Resident #230's family member confirmed that Resident #230 was diabetic and bipolar. <BR/>During an interview and record review on 02/23/23 at 10:58 a.m., The MDS nurse stated it was a collaborative effort between him and the staff nurses to accurately assess residents, which then in turn produced an accurate MDS. the MDS nurse did not know why Resident #230 diagnoses were not included in the admission MDS. <BR/>During an interview and record review on 02/23/23 at 11:43 a.m., the Administrator stated the lack of documentation risked potential residents' negative outcomes for not accurately completing the MDS. The Administrator stated the expectation was for the MDS nurse to complete the MDS assessments accurately, reflecting the care patients are receiving. <BR/>Record review of the facility's policy titled, Electronic Transmission of the MDS, revised September 2017, revealed in part, All MDS assessments .will be completed and electronically encoded into our facility's MDS information system .6. The MDS Coordinator is responsible for ensuring that appropriate edits are made before transmitting MDS data .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 3 of 3 residents (Resident #34 , Resident #55, and Resident #74) whose records were reviewed for PASRR services.<BR/>The facility failed to recognize during the Level I PASRR screening that Resident #34 and Resident #55 were diagnosed with major depressive disorder, while Resident #74 was diagnosed with schizoaffective disorder and bipolar disorder. <BR/>This deficient practice could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnosis.<BR/>The findings included:<BR/>1. Record review of Resident #34's admission sheet, dated 5/14/25, noted a [AGE] year-old resident admitted to the facility on [DATE] with a diagnoses of major depressive disorder.<BR/>Record review of Resident #34's quarterly MDS assessment, dated 2/5/25, noted that the resident's BIMS was 15, indicating intact cognition. The MDS reflected psychiatric / mood disorder , depression other than bipolar was selected. <BR/>Record review of Resident #34's order summary from May 2025 indicated the resident received fluvoxamine 50mg for major depressive disorder at bedtime. <BR/>Record review of Resident #34's care plan, revised on 11/01/24, revealed the resident is on antidepressant medication, one approach was to monitor and document targeted behavior. <BR/>Record review of Resident #34's PASRR 1 screening dated 1/24/20, revealed an answer of 0 (No) in section C0100 Mental Illness in response to the question, Is there evidence or an indicator this is an individual with a Mental Illness? <BR/>2. Record review of Resident #55's admission sheet, dated 5/14/25, noted a [AGE] year-old resident admitted to the facility on [DATE] with a diagnosis of major depressive disorder. <BR/>Record review of Resident #55's quarterly MDS assessment, dated 3/22/25, noted the resident's BIMS was 06, indicating severe cognitive impairment. The MDS reflected psychiatric/mood disorder, depression other than bipolar, selected.<BR/>Record review of Resident #55's order summary from May 2025 indicated the resident received paroxetine 30 mg at bedtime for major depressive disorder. <BR/>Record review of Resident #55's care plan, revised on 11/01/24, revealed the resident had Potential for mood problem related to disease process with interventions to administer medications as ordered. <BR/>Record review of Resident #55's, PASRR 1 screening dated 12/18/23, revealed an answer of 0 (No) in section C0100 Mental Illness in response to the question, Is there evidence or an indicator this is an individual with a Mental Illness?<BR/>3. Record review of Resident #74's face sheet, dated 5/16/25, revealed the [AGE] year old resident was admitted to the facility on [DATE] with diagnoses including: schizoaffective disorder (a mental health condition that is marked by a mix of symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression) and bipolar disorder (mental disorder that includes bouts of hypomania or mania and sometimes major depression). <BR/>Record review of Resident #74's Quarterly MDS assessment , dated 03/31/25, revealed a BIMS score of 5, which indicated a low level of cognitive impairment. <BR/>Record review of the quarterly MDS for Resident #74 revealed a diagnosis of schizoaffective disorder and bipolar disorder.<BR/>Record review of Resident #74's monthly physician order's for May 2025 revealed Resident #74 was taking an anti-psychotic medication, Seroquel 100mg, each day and at bedtime, for a schizoaffective disorder.<BR/>Record review of Resident #74's PASRR 1 screening form dated 12/31/23 revealed an answer of 0 (No) in section C0100 Mental Illness in response to the question, Is there evidence or an indicator this is an individual with a Mental Illness?<BR/>In an interview on 05/16/25 at 12:55 PM, the MDS nurse stated, When residents come here, they should have their PASRR included with their admission paperwork. The MDS coordinator explained that the facility uploads it and sends a copy to the local authority. If the level one screening is negative, the local authority acknowledges receipt. If it is positive, they assess the resident and attend care plan meetings; if negative, there is no follow-up. Regarding whether the PASRR assessment should be left as 'No' for residents with bipolar disorder, major depressive disorder, or schizoaffective disorder, the coordinator stated, Most of the time the PASRR says 'No', and they submit the hospital PASRR to the local authority and the MDS assessment. When asked about the risk of putting 'No' on the level one screening for residents with mental illness, the MDS Coordinator said she has never experienced a negative effect if they answer 'No', as behaviors lead to mental screenings. Lastly, she noted no issues arise from not marking 'Yes' for mental illness, as psych services are available on-site. <BR/>In an interview on 05/16/25 at 1:20 PM with the DON, she stated she would consult with corporate leadership about training for the MDS nurse because the residents have a mental illness diagnosis on admission. Still, the hospital PASRR assessment is negative. It is not getting updated before being sent to the local authority, who is not coming out to evaluate the resident. The DON stated she would educate them on getting the PASRR fixed moving forward, especially if the residents are on mental illness medications. The DON stated, All residents get assessed for psych services, but moving forward they will make sure they take care of the PASRR correctly. The DON stated she wasn't sure what the risk to the resident was of a negative level one PASRR with evidence of a mental illness diagnosis, but noted, The purpose of PASRR is to get residents services if they have a diagnosis of mental illness.<BR/>Record review of the facility undated, policy titled PASRR Policy , revealed the facility staff will coordinate with the local Intellectual/Development Disability and/or Local Mental Health Authority to ensure a PASSAR level 2 evaluation is conducted when an individual's PASSAR level 1 screening indicated the individual may have an ID,DD, or MI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 3 of 8 residents (Resident #233, Resident #237, and Resident #230) reviewed for a baseline care plan, in that: <BR/>1. The facility failed to ensure Resident #237's baseline care plan, undated, revealed no focus area or interventions for resident #237's use of pain medication [Norco].<BR/>2. The facility failed to ensure that Resident #233's baseline care plan included information related to the resident's diagnosis of diabetes mellitus. <BR/>3. The facility failed to ensure that Resident #230's baseline care plan included information related to the resident's diagnosis of diabetes mellitus and bipolar disorder. <BR/>This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. <BR/>The findings included:<BR/>1. Record review of Resident #237's Face Sheet, dated 02/23/2023, revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses: [Osteomyelitis] is an infection in a bone. [Benign prostatic hyperplasia] is an enlarged prostate, and [Hyperlipidemia] is a medical condition in which you have too much fat in your blood. <BR/>Record review of Resident #237's Baseline Care Plan, undated, revealed no focus area or or instructions for Resident #237's use of pain medication [Norco]. <BR/>Record review of Resident #237's admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated intact cognition. <BR/>Record review of Resident #237's electronic medical record Order Summary Report, dated 02/23/2023, revealed an order on 02/06/2023 for [Norco] to administer every six hours as needed for pain.<BR/>Record review of Resident #237's admission MDS, dated 0204/2023, revealed under section J, pain management, J 0100, B. received PRN pain med or was offered number one was selected, indicating pain medication was administered. <BR/>In an interview with Resident #237 on 02/23/2022 at 9:30 a.m., Resident #237 stated he requested his [Norco] about twice a day since it was ordered on 2/6/2023. The resident said, it makes me feel better because if I don't ask for it, I am in pain.<BR/>2. Record review of Resident #233's face sheet, dated 02/23/2023, revealed a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included: [Type 2 diabetes mellitus] with hyperglycemia (high blood sugar level), [Hyperlipidemia] is a medical condition in which you have too much fat in your blood and [Hypertension], also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure. <BR/>Record review of Resident #233's electronic face sheet, dated 02/23/2023, revealed a diagnosis of diabetes mellitus.<BR/>Record review of Resident #233's admission MDS, dated [DATE], revealed the resident had a BIMS score of 7, which indicated the resident's cognition was severely impaired. Further review revealed under section 1, metabolic, I2900, with an X indicating diabetes mellitus. <BR/>Record review of Resident #233's baseline care plan, undated, revealed no focus area or instructions for the resident's diagnosis of diabetes mellitus. <BR/>In an interview with Resident #233 on 02/24/2023 at 9:25 a.m., Resident #223 stated she had been diabetic for about forty years. <BR/>3. Record review of Resident #230's face sheet, dated 2/23/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: [Type 2 diabetes mellitus] with hyperglycemia (high blood sugar level), [Atrial fibrillation] is irregular. Often very rapid heart rhythm can lead to blood clots in the heart, [Low Blood Pressure] Low blood pressure is generally considered a blood pressure reading lower than 90 millimeters of mercury (mm Hg) for the top number (systolic) or 60 mm Hg for the bottom number (diastolic), and [Bi-Polar]A disorder associated with episodes of mood swings ranging from depressive lows to manic highs.<BR/>Record review of Resident #230's electronic face sheet, dated 02/23/2023, revealed a diagnosis of diabetes mellitus.<BR/>Record review of Resident #230's admission MDS, dated [DATE], revealed the resident had a BIMS score blank, which indicated the resident's cognition was severely impaired and could not complete the interview. Further review revealed blank under section 1, metabolic, I2900, section was left empty, and section was left blank under section I , I500. <BR/>Record review of Resident #230's baseline care plan, undated, revealed no focus area or instructions for the resident's diagnosis of diabetes mellitus or bipolar disorder . <BR/>Record review of Resident #230's electronic medical record Order Summary Report, dated 02/23/2023, revealed an order on 02/14/2023 for Glipizide 2 mg, take daily for diabetes Mellitus. <BR/>In a phone interview with Resident #230's family member on 02/24/2023 at 10:25 a.m., Resident #230's family member revealed that Resident #230 was diabetic and bipolar. <BR/>During an observation and interview with ADON B on 02/24/2023 at 9:47 a.m., ADON B confirmed that the resident's diagnosis of diabetes Mellitus was not included in the baseline care plan for Residents #233 and Resident #230. ADON B also confirmed that there was no baseline care plan to include pain management for Resident #237 ADON B stated that MDS and care plans were not currently in his area of expertise and referred the surveyor to the MDS Coordinator.<BR/>During a record review interview and confirmation with MDS Coordinator on 02/23/2023 at 10:02 a.m., MDS Coordinator confirmed the diagnosis of Diabetes Mellitus was not on the baseline care plan for Residents #233 and #230. The MDS Coordinator also confirmed no baseline care plan for Resident #237, indicating the use of pain medication [Norco]. The MDS Coordinator stated it was his job to complete the baseline care plan along with key interdisciplinary team members. The MDS Coordinator noted that an incomplete baseline care plan could negatively impact communication among nursing home staff, leading to unmet patient needs. The MDS Coordinator stated he did not know why baseline care plans were incomplete but would promptly complete them. <BR/>During an interview and confirmation with the DON on 02/24/2023 at 10:25 a.m., the DON confirmed that Residents #233, #230, and #237 needs should have been addressed on their baseline care plans. The DON stated she did not know why it was not completed but expected baseline care plans to reflect the patient's requirements to care for the first 48 hours completed by the MDS nurse. The DON stated the lack of a complete baseline care plan risk's not having all healthcare team members on the same page with residents leading to possible unmet resident needs. <BR/>Record review of the facility's policy titled, Comprehensive -Person-Centered Care Planning, revised 0/2022, revealed, The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 4 of 24 residents (Residents #58, #35, #74, and #233) reviewed for care plans, in that:<BR/>1. The facility failed to develop a comprehensive care plan that addressed Residents #58's anti-coagulant therapy.<BR/>2. The facility failed to develop a comprehensive care plan that addressed Resident #74's anti-coagulant therapy.<BR/>3. The facility failed to develop a comprehensive care plan that addressed Resident #233's anti-coagulant therapy.<BR/>4. The facility failed to develop a comprehensive care plan that addressed Resident #35's cognitive communication deficit.<BR/>These deficient practices could place residents at risk of receiving inadequate interventions that are not individualized to their care needs. <BR/>The findings included:<BR/>1. Record review of Resident #58's face sheet, dated 2/22/2023, revealed the [AGE] year old resident was admitted to the facility on [DATE] with diagnoses including: cerebral infarction (a condition caused by disrupted blood flow to the brain), vascular dementia (a condition in which there is brain damage caused by multiple strokes), and primary hypertension (a condition involving abnormally high blood pressure).<BR/>Record review of Resident #58's MDS, dated [DATE], revealed a BIMS score of 8, indicating moderate cognitive impairment.<BR/>Record review of Resident #58's Physician Summary Report, dated 2/22/23, revealed a prescription order for the medication Eliquis, an anticoagulant, with a start date of 9/30/2022.<BR/>Record review of Resident #58's care plan record on 2/22/23 revealed there was not a care plan for the anticoagulant medication order.<BR/>During an interview with the MDS Coordinator on 2/23/23 at 3:55 p.m., the MDS Coordinator stated that Resident #58's care plan for alteration in hematological status-thrombosis, dated 10/15/22, addressed the anticoagulant medication order. The MDS Coordinator stated that if the anticoagulant medication order was not care planned, the staff would not be aware of a potential health problem.<BR/>During an interview with the DON on 2/23/23 at 4:25 p.m. stated that Resident #58's care plan for alteration in hematological status-thrombosis was not a care plan that addressed an anticoagulant medication order. The DON stated that there was not a care plan in place that would address the Physician's anticoagulant order. The DON stated that having an anticoagulant care plan was important to address the resident's overall treatment.<BR/>2. Record review of Resident #74's face sheet dated 2/22/2023 revealed the [AGE] year-old Resident admitted on [DATE] with diagnoses that included Thrombocytopenia (a condition in which you have a low blood platelet count), cardiac arrhythmia, (an irregular heartbeat), and atrial fibrillation (arrhythmia occurs when the heart beats too slowly, fast, or irregularly).<BR/>Record review of Resident #74's admission MDS assessment, dated 01/23/23, revealed BIMS of 12, suggesting moderately impaired cognition.<BR/>Record review of Resident #74's Physician Orders for February 2023 revealed the order Apixaban with an order date of 01/21/2023 and no end date. <BR/>Record review of Resident #74's comprehensive person-centered care plan, revision date 02/20/2023, revealed Resident #74 had no care plan to address the use of Apixaban.<BR/>Record review of Resident #74's MAR (Medication Administration Record) for February 2023 revealed medication Apixaban was given daily in the morning. <BR/>During an interview on 2/23/2023 at 8:39 a.m., Resident #74 stated, Due to my Atrial Fibrillation, I must take a blood thinner daily. <BR/>3. Record review of Resident #233's face sheet, dated 02/23/2023, revealed the [AGE] year old resident admitted to the facility on [DATE], with diagnoses that included: Type 2 diabetes mellitus with hyperglycemia (high blood sugar level), Hyperlipidemia (a medical condition in which you have too much fat in your blood) and Hypertension (also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure). <BR/>Record review of Resident #233's admission MDS, dated [DATE], revealed the resident had a BIMS score of seven, which indicated the resident's cognition was severely impaired.<BR/>Record review of Resident #233's Physician Orders for February 2023 revealed the order Eliquis with an order date of 02/02/2023 and no end date. <BR/>Record review of Resident #233's comprehensive person-centered care plan, revision date 02/20/2023, revealed Resident #74 had no care plan to address the use of Eliquis.<BR/>Record review of Resident #233's MAR (Medication Administration Record) for February 2023 revealed medication Eliquis was given daily in the morning.<BR/>In an interview with Resident #233 on 02/24/2023 at 9:25 a.m., Resident #223 stated, I know I take a blood thinner but can't recall why. <BR/>During an interview with ADON B on 2/23/2023 at 1:20 p.m., he stated that at this facility, the charge nurse must administer blood thinners to include Residents #74 and #233. ADON B noted that this was done so the licensed nurse could monitor residents for bleeding. ADON B confirmed that this medication should be carefully planned and does not know why it was not done. ADON B stated that care plans were not currently in his area of expertise and referred the surveyor to the MDS Coordinator. <BR/>During a record review interview and confirmation with MDS Coordinator on 02/23/2023 at 10:02 a.m., MDS Coordinator confirmed that no comprehensive care plan was available to address the blood thinner use of Residents #74 and #233 was completed. MDS Coordinator stated that an incomplete comprehensive plan could negatively impact communication among nursing home staff, leading to unmet patient needs. MDS Coordinator did not know why comprehensive care plans were incomplete but would promptly complete them. <BR/>During an interview on 2/23/2023 at 3:00 p.m., the DON stated that all residents on blood thinners should be carefully monitored for bleeding precautions; not care planning a resident on a blood thinner was not best practice. The DON did not know why this was not care planned, but lack of care planning risked not everyone being on the same page. The DON stated the comprehensive person-centered care plan gave a true picture of how the resident was cared for.<BR/>4. Record review of Resident #35's electronic face sheet, dated 02/24/2023, revealed the [AGE] year-old resident admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (a condition caused by disrupted blood flow to the brain), aphasia (a comprehension and communication disorder resulting from damage or injury to the specific area in the brain), type II diabetes mellitus, cognitive communication deficit, and chronic kidney disease. <BR/>Record review of Resident #35's comprehensive care plan, updated 11/23/2022, revealed there was no focus area addressing Resident #35's cognitive communication deficit.<BR/>Record review of Resident #35's MDS (5-day scheduled assessment) dated 12/22/2022 revealed a BIMS of 3, indicating severe cognitive impairment. Record review of this MDS and also the Resident #35's admission MDS dated [DATE] revealed both included under Section I Active Diagnoses, I8000, Additional Diagnoses, E. Cognitive Communication Deficit.<BR/>Record review of Resident #35's admission physician's orders, dated 05/08/2022, revealed an order for Speech Therapy (ST) effective 05/08/2022. Review of Resident #35's EHR indicated he had received ST 4x/week.<BR/>An interview attempt on 02/02/21/2023 at 12:45 p.m. with Resident #35 located in the resident's room revealed he had difficulty speaking. The resident became tearful twice while attempting to speak. The surveyor stated, It must be frustrating to not be able to express what you want to say. Resident #35 nodded his head up and down in an affirmative manner. <BR/>Another interview attempt on 02/24/2023 at 8:20 p.m. with Resident #35 located in the dining room revealed Resident #35 again had difficulty speaking and used hand gestures to attempt to convey displeasure with meal items on his breakfast tray. Resident #35 again expressed distress over his inability to speak.<BR/>Interview on 02/23/2023 at 3:00 p.m. with the MDS Coordinator revealed when conducted the speech portion of the assessment, asked yes/no questions and understood Resident #35 when he responded, yes or no. The MDS Coordinator confirmed Resident #35 had a diagnosis of Communication Deficit, had an order for ST since 05/08/2022 and was receiving ST 4x/week. The MDS Coordinator further confirmed that there was no mention of a communication deficit in the resident's care plan. When asked why it was not there, the MDS Coordinator stated that he was still in the process of learning.<BR/>Interview with the MDS Coordinator on 02/24/20223 at 2:30 p.m., the MDS Coordinator stated that Resident #35 triggered for communication deficit during admission and subsequently during his assessments, so communication deficit should have been a focus area in his care plan. <BR/>Interview on 02/24/2023 at 2:40 p.m. with the ADON for long term care residents revealed that both she and another staff member completed the initial MDS for Resident #35, the resident triggered for Communication Deficit, and We definitely missed this as a team.<BR/>Interview with the facility's DON on 02/24/2023 at 2:55 p.m. revealed the DON confirmed that communication deficit was not in Resident #35's comprehensive care plan and should have been a focus area in this care plan.<BR/>Record review of the facility's policy titled Comprehensive -Person-Centered Care Planning, revised 1/2022, revealed, The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly for 1 of 5 residents (Resident #4) reviewed for medication storage, in that:<BR/>The facility failed to ensure medications were not left on Resident #4's bed side table. <BR/>This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered.<BR/>The findings were:<BR/>Record review of Resident #4's face sheet, dated 4/4/24, revealed an [AGE] year-old male admitted to the facility on [DATE] with the diagnosis that included Acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), Chronic obstructive pulmonary disease, (refers to a group of diseases that cause airflow blockage and breathing-related problems), and Anxiety disorder (involves a constant feeling of anxiety or fear). <BR/>Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. <BR/>Record review of Resident #4's physician orders for April 2024, reviewed on 4/3/24 did not reveal an order to self-administer medications. <BR/>Observation on 04/03/2024 at 11:47 a.m. of Resident #4's room revealed there was a bottle of Fluticasone nasal spray 50 mcg, extra-strength Tylenol, and Voltaren gel 1 % on the bedside table<BR/>In an interview with Resident #4 on 4/3/24 at 12:05 p.m., the resident stated he purchased the over-the-counter medications from an online store and had them on his bedside table since he was admitted back to the facility sometime in November 2003. The resident further stated no one had given him a self-medication assessment. <BR/>During an interview with CNA B on 04/03/2024 at 12:55 p.m., CNA B stated a bottle of Fluticasone nasal spray 50 mcg, extra-strength Tylenol, and Voltaren gel 1 % were on the bedside table. CNA B stated the medications had been on Resident #4's bedside table for as long as she could recall but did not know why they were there. <BR/>During an Interview with LVN C, on 4/3/24 at 1:05 p.m., LVN C stated she was the assigned nurse for Resident # 4, and that a bottle of Fluticasone nasal spray 50 mcg, extra-strength Tylenol, and Voltaren gel 1 % were on the bedside table of Resident #4, because Resident #4 became upset when he was asked to move them to the medication cart for safe keeping. LVN C stated a self-medication assessment had not been conducted before the surveyor's intervention and medications left on the bedside table of Resident #4 risked possibly taking more medication than was ordered by the physician. <BR/>During an interview with the DON on 04/4/24/ at 9:53 a.m., the DON stated that a bottle of Fluticasone nasal spray 50 mcg, extra-strength Tylenol, and Voltaren gel 1 % were on the bedside table of Resident #4. The DON stated no medication should be left on any resident bedside table without a self-medication assessment, and a signed physician order as lack of risked the resident taking more than the prescribed dosage. <BR/>Record review of the facility's policy titled, Monitoring a Resident who Self-Administers Medications, undated, revealed, residents who self-administer medications will have a signed physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual religious and cultural nutritional needs for 1 of 8 residents (Resident #200) reviewed for religious and cultural dietary needs.<BR/>The facility failed to provide Resident #200 with a no pork Kosher diet (a diet which follows Jewish dietary laws, which has as a core principate that meat and dairy cannot be consumed together and only certain animals and birds are considered kosher) for the first 5 days after her admission on [DATE].<BR/>This deficient practice could place residents at risk for poor food intake, weight loss, and not having their religious nutritional preferences met.<BR/>The findings included:<BR/>Record review of Resident #200's admission Record, dated 05/14/2025 revealed the resident was admitted on [DATE] with diagnoses which included: Fracture of unspecified part of neck of right femur (thigh) and irritable bowel syndrome (intestinal disorder causing pain, gas, diarrhea and constipation. <BR/>Record review of Resident #200's Order Summary dated 5/14//2025 revealed an order for REGULAR Diet REGULAR texture, THIN LIQUIDS consistency, no pork-kosher diet religious preference . Date of order was 05/05/2025.<BR/>Record review of Resident #200's Care Plan initiated 05/03/2025 shows an intervention for .no pork-kosher diet religious preference . initiated 05/05/2025. <BR/>During an interview with Resident #200 on 05/13/2025 at 10:31a.m., Resident #200 stated she was Jewish and was upset that she was still receiving bacon and other pork products on her food trays even though she informed them when she was admitted that she can't eat pork and needs a Kosher diet. She stated that the last time she received bacon on her plate for breakfast, she complained to the CNA who brought her breakfast tray, so the CNA just removed the bacon from her plate. Resident #200 stated that did not solve the problem, as the juices from the bacon had touched her plate and her roll, and thus she could not eat the roll or anything on the plate.<BR/>Observation of the lunch meal and tray card provided to Resident #200 on 05/14/2025 at 12:11 p.m. revealed she was provided a turkey sandwich, sweet potatoes and applesauce for lunch - no pork. The menu for that day included sliced pork with gravy. Her tray card did not say Kosher diet, but listed pork as a dislike.<BR/>Interview on with Resident #20 on 05/14/2025 at 12:15 p.m. revealed Resident #200 stated the dietary manager visited her that morning and reviewed her meal preferences and appropriate substitutes. She told him no pork, and she stated he seemed unaware of other parts of Kosher diet when they discussed substitutes, such as not mixing meats with milk (or milk products like cheese) Resident #200 also stated that when pork was taken away, the facility seemed unable to provide her other suitable sources of protein she liked such as cottage cheese and yogurt, which she stated the Dietary Manager did provide to her after he met with her this morning. Resident #200 stated she was happy that today for lunch she was provided a Kosher diet with appropriate substitutes for pork, but stated it should not have taken 5 days after she was admitted to finally receive the correct diet.<BR/>Interview on 05/15/2025 at 3:21 p.m. with the Dietary Supervisor revealed that he or the admission coordinator try to meet with all new admissions within 48 hours of their admission for food preferences, and he obtains diet slips from the Nurse's regarding dietary orders. He stated he did not know why Resident #200 kept receiving pork products even though it was listed as a dislike on her tray card, other than he checks all trays leaving the kitchen, but notes on some days like the day before when he had 3 staff call-in, he is not always able to check all the meal trays before they leave the kitchen. The Dietary Supervisor stated he does not have a thorough knowledge of Kosher diets, and stated Resident #200 has been the first resident since he has worked at facility to request a Kosher diet, and he was going to research and learn more about Kosher diets to meet the special needs of residents on this diet. He stated it was not acceptable that Resident #200 did not receive a Kosher diet for the first 5 days after she was admitted , because it was matter of respect to honor her religious beliefs about food. He stated that the facility did not have a policy regarding the provision of specialized diets.<BR/>Interview on 05/15/2025 at 05:19 p.m. with the DON, Administrator and Clinical Resource Nurse revealed that the process for new admissions was for original diet orders to come from documents and verbal report from the transferring hospital or facility or from the family, and then diet orders are updated following physician and dietician assessments. The DON stated it was important for Residents to receive the correct diet and texture and to have their religious dietary preferences honored. <BR/>Telephone interview on 05/16/2025 at 5:19 p.m. with the Dietician revealed that she was able to meet with Resident #200 this week, and obtained all her information on diet and food preferences. She stated that the facility does not get many requests for Kosher diets, so most of the staff would be unfamiliar with this diet. The Dietician stated she has information regarding Kosher diets that she has provided to the Dietary Supervisor, and stated no one called her after Resident #200's admission to obtain more specific information on Kosher diets. The Dietician stated that not providing the diet that follows a Resident's religious and cultural beliefs could result in the Resident not eating, weight loss and feeling disrespected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation.<BR/>Resident #'1's electronic medical record did not contain complete and accurate documentation that RN A recorded the resident's vital signs, follow-up on a STAT (immediate) lab request, kept the DON or MD informed on the monitoring of the resident's change of condition for a period of three hours; before the resident expired.<BR/>This failure could result in residents' records not accurately documenting interventions, monitoring, and information provided to the MD or DON during a change of condition that could result in a death.<BR/> Findings included:<BR/>Record review of Resident #1's Face Sheet, dated 01/12/23, and EMR (electronic medical record) revealed, Resident #1 was a male age [AGE], was admitted on [DATE] with diagnoses that included: acute metabolic acidosis (infection), sepsis (infection of the blood), urinary tract infection, kidney failure, hypertension, anemia ( low red blood count), chronic kidney disease and diabetes 2 . Advanced Directive was DNR (do not resuscitate). RP (responsible party) was listed as: the resident. The date of discharge was 01/07/23 due to resident expiring in the facility. <BR/>Record review of Resident#1's Care Plan dated 12/31/22 revealed goals of resident being free of antidepressant side effects, diabetic treatment, improving cognition.<BR/>Record review of Resident #1's Social Services Assessment, dated 12/30/22, revealed resident's BIMS was zero (severely impaired).<BR/>Record review of Resident #1's MD orders dated 01/01/23 read: Lansoprazole Oral Tablet Delayed Release Disintegrating 30 MG (Lansoprazole) Give 1 tablet by mouth one time a day for stress ulcer p (prophylaxis).<BR/>Record review of Resident #1's Change of Condition Nurses Note dated 01/07/23 at 1:09 PM read, Resident noted to be sleepy, unable to tolerate food. 02 (oxygen) 89 (percent) RM (room temperature) , HR (heart rate) 120, lung crackles, cough, afebrile. [Change of Condition Nurse Note was authored by RN A]<BR/>Record review of Resident #1's Physician Progress Note dated 01/07/23 at 9:57 PM read: Earlier in the day [01/07/23] I (MD B) received a text message that (Resident #1) has been asleep since breakfast and his vital signs BP 100/59, HR 120 oxygen sats (saturation) 2L (liters) with 95%. Not in distress. stat labs were ordered and advised to monitor clinically and hold BP meds and sedatives. (8:13 PM) received a text message that pt (patient) had expired .cause of the death is internal upper GI (gastro intestinal) bleeding is more likely even though pt has been taking Lansoprazole for a possible ulcer/prophylaxis ( action taken to prevent a disease) .<BR/>Record review of Resident #1's Nurse Note dated 01/07/23 at 4:11 PM, authored by RN A, revealed the resident's BP was 90/56, HR was 98 and the lab company had arrived to take a blood specimen of the resident.<BR/>Record review of Resident #1's Nurse Note dated 01/07/23 at 5:29 PM, authored by RN A, revealed: Resident's 02 saturation was 96 %. RN did not document any other vital signs that could have included: resident's temperature, BP, HR and respiration.<BR/>Record review of Resident #1's Nurse Notes from 01/07/23 at 5:29 PM to 8:05 PM (time of death) did not document the resident's condition, nursing monitoring or interventions, or follow-up to the lab, MD or DON.<BR/>Record revie of Resident #1's Nurse Note on 01/07/23 authored by RN A revealed: resident vomited blood, was unresponsible, deceased , and the MD and DON were notified. [MD note dated 01/07/23 at 9:57 PM revealed the . cause of death is internal upper GI (gastro intestinal) bleeding is more likely even though pt (patient) has been taking Lansoprazole for a possible ulcer/prophylaxis .]<BR/>Record review of Resident #1's labs dated 01/07/23 revealed: labs for Resident #1 was collected on 01/07/23 at 4:28 PM; the lab received the blood specimen at 9:21 PM; and results were reported at 10:07 PM. WBC (white blood count) was 25.3 H (high) .reference range 4.2-9.1 . <BR/>During a telephone interview on 01/12/23 at 2:59 PM, the MD revealed: (time line) on 01/07/23 at 1:09 PM he was alerted that Resident #1's O2 stats was 89% . The MD ordered stat labs. At 1:25 PM he was informed that Resident (#1)'s BP was 100/59 and heart rate 120 . The MD stated the latter BP was a little low and heart rate a little high . He ordered that the facility monitor the resident and to keep him informed of any change of condition. The MD stated, the last time the facility contacted me by text was at 8:05 PM when he (MD) was informed the resident was deceased . The MD stated, he was told Resident #1 had a little blood on his shirt. The MD recalled that he wrote a physician's note revealing that the resident might have suffered GI bleeding due to ulcer prophylaxis. <BR/>During an interview on 01/13/23 at 8:40 AM, DON revealed: on 01/07/23 at 1:07 PM the MD was contacted because the resident suffered hypotension (BP was 100/59 and heart rate was 120) and the MD ordered stat labs and to monitor the resident. At 4:11 PM Nurse A recorded that Resident #1's BP was 90/56 and heart rate was 98 (assessment by DON: indication that the BP and had heart were lower. At 5:29 PM Nurse A took vital signs which revealed Resident #1's oxygen saturation was 96 % ( assessment by DON; good oxygen intake) BP was not recorded. At 8:05 PM the resident is deceased . The lack of documentation meant per the DON that she and the MD had no information regarding Resident #1's change of condition and current status for 3 hours (5:29 PM to 8:05 PM). The DON revealed she could not answer for Nurse A as to why she (Nurse A) did not document the BP or other vital signs for the time period 5:29 PM to 8:05 PM. The DON described vital signs as BP, heart rate, respiration, O2 saturation and temperature. The DON stated the labs arrived at 10:07 PM after the resident expired; finding was resident had elevated WBC (white blood count).The DON added the system failure by Nurse A was not documenting completely and accurately between the hours 5:29 PM to 8:05 PM. The responsible party for documentation on 01/07/23 was the charge nurse (Nurse A). <BR/>During a telephone interview on 01/13/23 at 9:30 AM, Nurse A revealed: on 01/07/23 at 1:07 PM the MD was contacted because Resident #1 suffered hypotension (BP was 100/59 and heart rate was 120) and MD ordered stat labs and to monitor the resident. At 4:11 PM Nurse A recorded that Resident #1's BP was 90/56 and heart rate was 98 (means BP is low but not critical and 98 heart is high but not requiring MD notification). At 5:29 PM, she (Nurse A) recorded that 02 saturation was at 96 % (normal). Nurse A stated other vital signs were normal (temperature, respiration, BP and heart rate) but not recorded. Last not written by Nurse A was 8:05 PM when resident deceased . Nurse A stated, I observed the resident (#1) at 6 PM, 7 PM, 8 PM and in between and resident was stable .I did not record the vitals because I had other residents to take care .I saw the resident at 7:30 PM and vitals were okay and was waiting on the lab results .but did not record my visit at 7:40 PM . vitals were low but not critical .there was no written policy that I call the MD or DON every two hours .or document visits every 2 hours . Further, Nurse A stated she followed up on the stat labs at 7 PM and did not record the contact .it was my fault for not documenting. <BR/>During a telephone interview on 01/23/23 at 10:46 AM, CNA B revealed: his shift was from 2 PM-10 PM on 01/07/23 and he checked on Resident #1 every 30 minutes to 1 hour. At 7:22 PM, Resident (#1) was asleep, snoring, and not in distress .I did not document my checks with the resident but told Nurse (A) around 8 PM I found resident with a brown substance around his mouth and called the charge nurse .charge nurse said the resident had expired . CNA B stated that Nurse A would document the information he was conveying to her regarding the monitoring of Resident #1. <BR/>During an interview on 01/23/23 at 11:03 AM, DON revealed: Nurse A called the lab at 1:09 PM per MD request and the lab collected the specimen at 4:28 PM. The lab considers a STAT telephone request to fall within a time window of 4-6 hours.<BR/>During a telephone interview on 01/23/23 at 11:14 AM, Lab Representative C revealed the lab's policy was to respond to STAT telephone requests by six hours from time of collection to results. Reference # 1893253 revealed (Resident #1's) labs were collected at 4:28 PM. STAT did not mean the lab would immediately go to the facility rather from time of collection to results within a 6 hour timeframe . Follow-up calls from facility checking on STAT orders were not documented by the lab. <BR/>During an interview on 01/13/23 at 11:40 PM, the Administrator revealed Nurse A forgot to document critical information. He stated, it is a battle we fight on documentation . The Administrator added that complete and accurate documentation would be included in the on-[NAME] in-service training for nursing staff documentation, monitoring, and change of condition. <BR/>Record review of facility's Significant Change in Condition Response dated 01/2022 read, .The Nurse will perform and document an assessment of the resident and identify need for additional interventions .The resident will then be placed on the 24 Hour Report and Nursing will provide no less than three (3) days of observation, documentation .

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 7 residents (Resident #58) reviewed for infection control, in that:<BR/>While administering medications for Resident #58, RN E touched the light fixture pull cord and power plug and, the bed remote with her gloved hands and did not changed her gloves and washed her hands before touching Resident #58's eyes area and administering eye drops to the resident. <BR/>These failures could place residents at-risk for infection due to improper care practices. <BR/>The findings include:<BR/>Record review of Resident #58's face sheet, dated 04/05/2024, revealed an admission date of 12/24/2021, and a readmission date of 06/28/2023, with diagnoses which included: Dysphagia (Difficulty in swallowing), Insomnia (Difficulty sleeping), Hemiplegia (Paralysis of one side of the body), Cerebral infarction (process that result in an area of dead tissue in the brain), Hypertension (High blood pressure), Vascular dementia (Decline in cognition caused by restricted blood flow).<BR/>Record review of Resident #58's Annual MDS assessment, dated 01/01/2024, revealed the resident had a BIMS score of 5 indicating severe impairment. Resident #58 required extensive assistance to total care.<BR/>Review of Resident #58's physician order, dated 04/05/2024, revealed an order for Artificial Tears Ophthalmic Solution (Artificial Tear Solution) Instill 1 drop in both eyes four times a day for dry eyes<BR/>Observation on 04/05/24 at 08:19 a.m. revealed while administering medications to Resident # 58, RN E did not demonstrate proper use of PPE (personal protective equipment) and hand hygiene. She washed her hands and donned gloves then, prior to administer eye drops to the resident, she touched the lights pull cord, the power cord and plug behind the bed on the wall and the bed remote. She did not change her gloves or sanitize her hands and administered the drops to Resident #58 and touched the resident face and eyes areas. <BR/>During an interview on 04/05/2024 at 8:58 a.m., RN E confirmed the environment around Resident #58 was considered contaminated. She confirmed she should have changed her gloves after touching the pull cord, power cord and the bed remote and before administering the eye drops and touching the resident's face. She confirmed receiving infection control training within the year. <BR/>During an interview with the DON on 04/05/2024 at 2:00 p.m., the DON confirmed the staff should have changed her gloves after touching the environment and before touching the eyes of the resident. She confirmed Infection control training was provided to the staff yearly and as needed if problem with infection control were noted . The facility checked skills yearly and spot check were by the ADONS. The facility had an infection preventionist overseeing infection control. <BR/>Review of annual skills check for RN E revealed RN E passed competency for hand hygiene and infection control during medications administration on 03/12/2024.<BR/>Review of facility policy, titled Hand hygiene, dated 10/2022, revealed Use an alcohol-based hand rub [ .] before preparing or handling medications [ .] after contact with objects in the immediate vicinity of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 8 wheelchairs reviewed for essential equipment. <BR/>The facility failed to ensure Resident #198's wheelchair brakes were functioning correctly on 05/13/2025. <BR/>These failures could place residents at risk of not having functional and safe mode of mobility. <BR/>Findings include:<BR/>Record review of Resident #198's admission Record dated 05/16/2025 revealed a [AGE] year-old resident admitted on [DATE] with diagnoses which included: Fracture of part of neck of unspecified femur (break in part of thigh bone that connects to hip joint); repeated falls; and unsteadiness on feet.<BR/>Record review of Resident #198's admission MDS assessment dated [DATE] revealed a BIMS score of 14, indicating normal cognition. She was assessed as using a wheelchair for mobility and needing partial/moderate assistance for bed to chair transfers.<BR/>Record review of Resident #198's Care Plan revealed a focus area for ADL Self Care Performance Deficit r/t weakness with interventions that included staff assistance for wheelchair transfers.<BR/>During an interview with Resident #198 on 05/13/2025 at 12:36 p.m., Resident #198 stated that she was at facility for rehabilitation following a hip replacement, and was happy with the therapy she was receiving, but had a concern about the brake on the loaner wheelchair the facility provided to her to use. She stated the right brake on the wheelchair was broken, would not close down sufficiently to stop movement in that tire, so it would move a little on the right side when she was transferred into and out of the wheelchair. Resident #198 stated she informed the therapist the day before (05/12/2025), and the therapist stated she would call to get the wheelchair fixed. <BR/>Observation on 05/13/2025 at 12:40 p.m. of Resident #198's loaner wheelchair. The right-side brake did not engage completely, providing some, but not complete braking function to keep the tires from moving. <BR/>During an interview with PT-I on 05/14/2025 at 2:57 p.m., PT-I stated that Resident #198 had her own wheelchair at home, but the wheelchair she was currently using at the facility was a loaner from the facility. She stated that Resident #198 cannot self-transfer, and requires one-person assist for transfers with some weight bearing restrictions. PT-I stated one of the therapists told her about the wheelchair first thing this morning, and she had arranged for their maintenance person to fix the brake, and in the meantime the DOR had requested another replacement loaner wheelchair from one of their sister facilities that was just delivered. PT-I stated that not having both brakes on her wheelchair in good functioning order could increase the risk for falls, especially during transfers.<BR/>During an interview with COTA-J on 05/14/2025 at 03:02 p.m., COTA-J stated that Resident #198 had told her about the loose wheelchair brake late yesterday afternoon, and she tried to tighten it herself, but did not have the right tools, so informed the DOR this morning. COTA-J stated that she had not noticed the right brake to be loose on the wheelchair when she worked with Resident #198 during previous therapy. <BR/>Interview on 05/14/2025 at 3:50 p.m. with the DOR, revealed the DOR was in the gym, assisting maintenance to fix the brake on the loaner wheelchair. The DOR stated that they follow the same procedures for broken equipment as the rest of the facility and that was to submit a work order with their maintenance department in TELS, and if it required more specialized intervention could send for repairs with manufacturer or specialty companies as needed. The DOR stated she immediately contacted maintenance when she was told of the loose brake on Resident #198's wheelchair and made arrangements to borrow another wheelchair from one of their nearby sister facilities. The DOR stated they do not have a specific policy regarding wheelchair maintenance, but would refer to the facility maintenance policy.<BR/>During an interview with the Administrator and DON on 05/15/2025 at 5:25 p.m., the Administrator stated their maintenance department could do repairs on wheelchairs, and although they currently do not have a maintenance supervisor, their regional and sister facility maintenance supervisors were covering maintenance needs. <BR/>Record review of the facility's policy entitled Equipment Inspection and Maintenance dated 07/2018 revealed It is the policy of this community to maintain all equipment provided by the facility, in good working order to ensure the safety and wellbeing of all residents and staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 4 of 24 residents (Residents #58, #35, #74, and #233) reviewed for care plans, in that:<BR/>1. The facility failed to develop a comprehensive care plan that addressed Residents #58's anti-coagulant therapy.<BR/>2. The facility failed to develop a comprehensive care plan that addressed Resident #74's anti-coagulant therapy.<BR/>3. The facility failed to develop a comprehensive care plan that addressed Resident #233's anti-coagulant therapy.<BR/>4. The facility failed to develop a comprehensive care plan that addressed Resident #35's cognitive communication deficit.<BR/>These deficient practices could place residents at risk of receiving inadequate interventions that are not individualized to their care needs. <BR/>The findings included:<BR/>1. Record review of Resident #58's face sheet, dated 2/22/2023, revealed the [AGE] year old resident was admitted to the facility on [DATE] with diagnoses including: cerebral infarction (a condition caused by disrupted blood flow to the brain), vascular dementia (a condition in which there is brain damage caused by multiple strokes), and primary hypertension (a condition involving abnormally high blood pressure).<BR/>Record review of Resident #58's MDS, dated [DATE], revealed a BIMS score of 8, indicating moderate cognitive impairment.<BR/>Record review of Resident #58's Physician Summary Report, dated 2/22/23, revealed a prescription order for the medication Eliquis, an anticoagulant, with a start date of 9/30/2022.<BR/>Record review of Resident #58's care plan record on 2/22/23 revealed there was not a care plan for the anticoagulant medication order.<BR/>During an interview with the MDS Coordinator on 2/23/23 at 3:55 p.m., the MDS Coordinator stated that Resident #58's care plan for alteration in hematological status-thrombosis, dated 10/15/22, addressed the anticoagulant medication order. The MDS Coordinator stated that if the anticoagulant medication order was not care planned, the staff would not be aware of a potential health problem.<BR/>During an interview with the DON on 2/23/23 at 4:25 p.m. stated that Resident #58's care plan for alteration in hematological status-thrombosis was not a care plan that addressed an anticoagulant medication order. The DON stated that there was not a care plan in place that would address the Physician's anticoagulant order. The DON stated that having an anticoagulant care plan was important to address the resident's overall treatment.<BR/>2. Record review of Resident #74's face sheet dated 2/22/2023 revealed the [AGE] year-old Resident admitted on [DATE] with diagnoses that included Thrombocytopenia (a condition in which you have a low blood platelet count), cardiac arrhythmia, (an irregular heartbeat), and atrial fibrillation (arrhythmia occurs when the heart beats too slowly, fast, or irregularly).<BR/>Record review of Resident #74's admission MDS assessment, dated 01/23/23, revealed BIMS of 12, suggesting moderately impaired cognition.<BR/>Record review of Resident #74's Physician Orders for February 2023 revealed the order Apixaban with an order date of 01/21/2023 and no end date. <BR/>Record review of Resident #74's comprehensive person-centered care plan, revision date 02/20/2023, revealed Resident #74 had no care plan to address the use of Apixaban.<BR/>Record review of Resident #74's MAR (Medication Administration Record) for February 2023 revealed medication Apixaban was given daily in the morning. <BR/>During an interview on 2/23/2023 at 8:39 a.m., Resident #74 stated, Due to my Atrial Fibrillation, I must take a blood thinner daily. <BR/>3. Record review of Resident #233's face sheet, dated 02/23/2023, revealed the [AGE] year old resident admitted to the facility on [DATE], with diagnoses that included: Type 2 diabetes mellitus with hyperglycemia (high blood sugar level), Hyperlipidemia (a medical condition in which you have too much fat in your blood) and Hypertension (also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure). <BR/>Record review of Resident #233's admission MDS, dated [DATE], revealed the resident had a BIMS score of seven, which indicated the resident's cognition was severely impaired.<BR/>Record review of Resident #233's Physician Orders for February 2023 revealed the order Eliquis with an order date of 02/02/2023 and no end date. <BR/>Record review of Resident #233's comprehensive person-centered care plan, revision date 02/20/2023, revealed Resident #74 had no care plan to address the use of Eliquis.<BR/>Record review of Resident #233's MAR (Medication Administration Record) for February 2023 revealed medication Eliquis was given daily in the morning.<BR/>In an interview with Resident #233 on 02/24/2023 at 9:25 a.m., Resident #223 stated, I know I take a blood thinner but can't recall why. <BR/>During an interview with ADON B on 2/23/2023 at 1:20 p.m., he stated that at this facility, the charge nurse must administer blood thinners to include Residents #74 and #233. ADON B noted that this was done so the licensed nurse could monitor residents for bleeding. ADON B confirmed that this medication should be carefully planned and does not know why it was not done. ADON B stated that care plans were not currently in his area of expertise and referred the surveyor to the MDS Coordinator. <BR/>During a record review interview and confirmation with MDS Coordinator on 02/23/2023 at 10:02 a.m., MDS Coordinator confirmed that no comprehensive care plan was available to address the blood thinner use of Residents #74 and #233 was completed. MDS Coordinator stated that an incomplete comprehensive plan could negatively impact communication among nursing home staff, leading to unmet patient needs. MDS Coordinator did not know why comprehensive care plans were incomplete but would promptly complete them. <BR/>During an interview on 2/23/2023 at 3:00 p.m., the DON stated that all residents on blood thinners should be carefully monitored for bleeding precautions; not care planning a resident on a blood thinner was not best practice. The DON did not know why this was not care planned, but lack of care planning risked not everyone being on the same page. The DON stated the comprehensive person-centered care plan gave a true picture of how the resident was cared for.<BR/>4. Record review of Resident #35's electronic face sheet, dated 02/24/2023, revealed the [AGE] year-old resident admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (a condition caused by disrupted blood flow to the brain), aphasia (a comprehension and communication disorder resulting from damage or injury to the specific area in the brain), type II diabetes mellitus, cognitive communication deficit, and chronic kidney disease. <BR/>Record review of Resident #35's comprehensive care plan, updated 11/23/2022, revealed there was no focus area addressing Resident #35's cognitive communication deficit.<BR/>Record review of Resident #35's MDS (5-day scheduled assessment) dated 12/22/2022 revealed a BIMS of 3, indicating severe cognitive impairment. Record review of this MDS and also the Resident #35's admission MDS dated [DATE] revealed both included under Section I Active Diagnoses, I8000, Additional Diagnoses, E. Cognitive Communication Deficit.<BR/>Record review of Resident #35's admission physician's orders, dated 05/08/2022, revealed an order for Speech Therapy (ST) effective 05/08/2022. Review of Resident #35's EHR indicated he had received ST 4x/week.<BR/>An interview attempt on 02/02/21/2023 at 12:45 p.m. with Resident #35 located in the resident's room revealed he had difficulty speaking. The resident became tearful twice while attempting to speak. The surveyor stated, It must be frustrating to not be able to express what you want to say. Resident #35 nodded his head up and down in an affirmative manner. <BR/>Another interview attempt on 02/24/2023 at 8:20 p.m. with Resident #35 located in the dining room revealed Resident #35 again had difficulty speaking and used hand gestures to attempt to convey displeasure with meal items on his breakfast tray. Resident #35 again expressed distress over his inability to speak.<BR/>Interview on 02/23/2023 at 3:00 p.m. with the MDS Coordinator revealed when conducted the speech portion of the assessment, asked yes/no questions and understood Resident #35 when he responded, yes or no. The MDS Coordinator confirmed Resident #35 had a diagnosis of Communication Deficit, had an order for ST since 05/08/2022 and was receiving ST 4x/week. The MDS Coordinator further confirmed that there was no mention of a communication deficit in the resident's care plan. When asked why it was not there, the MDS Coordinator stated that he was still in the process of learning.<BR/>Interview with the MDS Coordinator on 02/24/20223 at 2:30 p.m., the MDS Coordinator stated that Resident #35 triggered for communication deficit during admission and subsequently during his assessments, so communication deficit should have been a focus area in his care plan. <BR/>Interview on 02/24/2023 at 2:40 p.m. with the ADON for long term care residents revealed that both she and another staff member completed the initial MDS for Resident #35, the resident triggered for Communication Deficit, and We definitely missed this as a team.<BR/>Interview with the facility's DON on 02/24/2023 at 2:55 p.m. revealed the DON confirmed that communication deficit was not in Resident #35's comprehensive care plan and should have been a focus area in this care plan.<BR/>Record review of the facility's policy titled Comprehensive -Person-Centered Care Planning, revised 1/2022, revealed, The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 5 residents reviewed for pharmacy services.<BR/>The facility failed to transcribe Resident #1's discharge orders and failed to follow-up to ensure Resident #1's hospital discharge orders were implemented timely, which caused him to miss getting his medications for four (4) to five (5) days. <BR/>This failure could cause a delay in appropriate medical care and worsening in symptoms, condition, or illness. <BR/>The findings included:<BR/>Record review of Resident #1's admission Record, dated 07/30/2024, indicated he was a [AGE] year-old male admitted on [DATE]. <BR/>Record review of Resident #1's Medical Diagnosis list in the facility's EMR included: COVID-19 (An illness that can affect a person's lungs and airways caused by a virus called the Coronavirus), Pneumonia due to Coronavirus Disease 2019 (a lung infection caused by the coronavirus), muscle weakness, unsteadiness on feet, need for assistance with personal care, type 2 diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), paroxysmal atrial fibrillation (a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days), and hypothyroidism (when the thyroid does not produce enough hormones).<BR/>Record review of Resident #1's BIMS (Brief Interview for Mental Status) indicated Resident #1's mental status was moderately impaired (BIMS score 12). <BR/>Record review on 07/30/2024 of Resident #1's hospital records uploaded to his facility EMR did not reveal a discharge medication list. <BR/>Record review of an email dated 07/24/2024 at 11:18 p.m. sent by [local hospital] staff member to the ADON included Resident #1's Discharge Medication List dated 07/24/2024 indicated This med [medication] list indicates the medications you should continue taking and new medications you should start taking. The list included: <BR/> - Amoxicillin/Clavulanate Potassium (Augmentin; a combination antibiotic used to treat various bacterial infections) 875 MG, oral, twice a day through 07/27/2024<BR/> - Apixaban (Eliquis; used to prevent serious blood clots) 5 MG, oral, twice a day<BR/> - Aspirin EC (Ecotrin; used to prevent heart problems) 81 MG, oral, daily<BR/> - Guaifenesin/DM 100-10 MG/5ML (Robitussin-DM 100-10 MG/5ML; used to thin mucus and relieve coughing) 200 MG, oral, every 4 hours as needed<BR/> - Levothyroxine Sodium (used to treat underactive thyroid) 175 MCG, oral, daily<BR/> - Losartan Potassium (used to treat high blood pressure) 25 MG, oral, daily<BR/> - Metformin HCl (used to lower the amount of sugar the body makes or absorbs) 500 MG, oral, daily<BR/> - Metoprolol Succinate (Toprol XL; used to treat chest pain, heart failure, and high blood pressure) 25 MG, oral, daily<BR/> - Rosuvastatin Calcium (used to lower cholesterol and fats in blood) 5 MG, oral, at bedtime <BR/>Record review of Resident #1's Order Summary Report, active orders, dated 07/30/2024, reflected: <BR/> - Blood sugar checks QAM (every morning) and HSQ (every evening) in the morning for BS (blood sugar) monitoring, order date 07/29/2024 and start date 07/30/2024. Ordered five (5) days after admission and started six (6) days after admission.<BR/> - Document Temp (temperature) / O2 sats (oxygen saturation) and monitor for the following symptoms: Fever, Cough, New shortness of breath or difficulty breathing, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell, congestion, runny nose. GI (Gastrointestinal) symptoms: Diarrhea/Nausea/Vomiting every shift, order and start date 07/24/2024. Ordered and started the day of admission.<BR/> - Monitor for signs and symptoms of hypo/hyperglycemia (low or high blood pressure) hunger, thirst, sweating, dizziness, changes in vision, headache, irritability, nausea, fatigue, frequent urination q (every) shift, order and start date 07/24/2024. Ordered and started the day of admission.<BR/> - Amoxicillin-Pot Clavulanate Oral Tablet 875-125 MG, give 1 tablet by mouth every 12 hours for UTI (urinary tract infection), order and start date 07/29/2024. Ordered and started five (5) days after admission and three (3) days after expected end date for treatment per the hospital discharge medication list. <BR/> - Apixaban Oral Tablet 5 MG, give 1 tablet by mouth two times a day for Afib (atrial fibrillation), order and start date 07/29/2024. Ordered and started five (5) days after admission.<BR/> - Aspirin 81 Oral Tablet Delayed Release, give 1 tablet by mouth one time a day for heart health, order date 07/29/2024 and start date 07/30/2024. Ordered five (5) days after admission and started six (6) days after admission.<BR/> - Atorvastatin Calcium 10 MG Tablet, give 1 tablet by mouth at bedtime for HLD (hyperlipidemia; high fat levels in the blood), order and start date 07/29/2024. Ordered and started five (5) days after admission.<BR/> - Levothyroxine Sodium Oral Tablet 175 MCG, give 1 tablet by mouth in the morning for hypothyroidism, order date 07/29/2024 and start date 07/30/2024. Ordered five (5) days after admission and started six (6) days after admission.<BR/> - Losartan Potassium Oral Tablet 25 MG, give 1 tablet by mouth one time a day for Hypertension, order date 07/29/2024 and start date 07/30/2024. The order included to hold if SBP (systolic blood pressure) was less than 110 or if DBP (diastolic blood pressure) was less than 60. Ordered five (5) days after admission and started six (6) days after admission. <BR/> - Metformin HCl Oral Tablet 500 MG, give 1 tablet by mouth one time a day for DM (diabetes mellitus), order date 07/29/2024 and start date 07/30/2024. Ordered five (5) days after admission and started six (6) days after admission. <BR/> - Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG, give 1 tablet by mouth one time a day for hypertension, order date 07/29/2024 and start date 07/30/2024. The order included to hold if SBP (systolic blood pressure) was less than 110, if DBP (diastolic blood pressure) was less than 60, or if HR (heart rate or pulse) was less than 60. Ordered five (5) days after admission and started six (6) days after admission. <BR/>Record review of Resident #1's July 2024 CMA (Certified Medication Assistant) MAR (Medication Administration Record), accessed on 07/30/2024 at 03:10 p.m., indicated:<BR/> - Aspirin 81 Oral Tablet was first administered on 07/30/2024.<BR/> - Atorvastatin Calcium 10 MG Tablet was first administered on 07/29/2024.<BR/> - Levothyroxine Sodium Oral Tablet 175 MCG was first administered on 07/30/2024.<BR/> - Losartan Potassium Oral Tablet 25 MG was first administered on 07/30/2024 with blood pressure level documented as 124/83.<BR/> - Metformin HCl Oral Tablet 500 MG was first administered on 07/30/2024.<BR/> - Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG was first administered on 07/30/2024 with blood pressure level documented as 124/83 and pulse documented as 84.<BR/> - Rosuvastatin Calcium Oral Tablet 5 MG was documented as discontinued on 07/29/2024 at 04:19 p.m. and was not documented as administered.<BR/>Record review of Resident #1's July 2024 MAR, accessed on 07/30/2024 at 03:10 p.m., indicated:<BR/> - Blood Sugar Checks QAM (every morning) and QHS (every night) was first collected on 07/30/2024 with blood sugar level documented as 137 mg/dL (considered normal at 140 or lower). <BR/> - Amoxicillin-Pot Clavulanate Oral Tablet 875-125 MG was first administered on 07/29/2024 and administered a second time on 07/30/2024.<BR/> - Apixaban Oral Tablet 5 MG was first administered on 07/29/2024 and administered a second time on 07/30/2024.<BR/> - Document Temp/O2 Sats (oxygen saturation) and monitor for the following symptoms: Fever, Cough . was first collected and monitored on 07/25/2024. The 11 (eleven) shifts documented:<BR/> - N for no symptoms, <BR/> - systolic blood pressures ranging from 114 to 155 (considered normal below 120, elevated from 120 to 129, hypertension stage 1 from 130 to 139, hypertension stage 2 when 140 or more, and hypertensive crisis if 180 or more), <BR/> - diastolic blood pressure ranging from 71 to 95 (considered normal when lower than 80, stage 1 hypertension from 80 to 89, stage 2 hypertension from 90 or more, and hypertensive crisis if 120 or more), <BR/> - temperatures ranging from 97.3- 98.3 degrees Fahrenheit (considered normal when between 97.5 to 99.5 degrees Fahrenheit), <BR/> - pulses ranging from 67 to 103 beats per minute (considered normal when between 60 to 100 beats per minute), <BR/> - respirations ranging from 14 to 18 breaths per minute (considered normal when between 12 to 20 breaths per minute), <BR/> - and O2 Sats ranging from 91 to 99 % (percent; considered normal when between 95% to 100%).<BR/> - Monitor for signs and symptoms of hypo/hyperglycemia (low or high blood pressure) was first monitored on 07/24/2024 during the night shift and continued to be monitored the 16 following shifts with a total of 17 shifts having had monitored. <BR/>Record review of Resident #1's nursing progress note, dated 07/24/2024 at 06:22 p.m., completed by LVN B indicated Patient has arrived, COVID positive . paperwork did not arrive with patient, called hospital twice to have it faxed over.<BR/>During an interview on 07/31/2024 at 01:25 p.m., Resident #1 stated that he felt that the facility took a while to get his medications but that he was receiving them now. Resident #1 stated that he didn't know why there was a delay with his medications and that he had told them that he was missing his mediations, but he felt it was a different group he told each time and that they didn't seem to coordinate with each other. Resident #1 stated he did not experience any side effects or complications due to the delay in receiving his medications. <BR/>During an interview on 07/31/2024 at 01:46 p.m., LVN A stated that the process for admitting a new resident when they came to the facility without a hospital admission packet would be to obtain the hospital floor number (phone number for the nurses' station at the hospital which the resident came from) and to request that they fax the resident's discharge medication list. LVN A stated he was not working the night of Resident #1's admission, but he was made aware that the resident did not receive medications for several days. LVN A stated that the procedural mistake was that the hospital was not called again the next day if the admitting nurse did not receive the discharge medication list on the night of admission. <BR/>During an interview on 07/31/2024 at 02:51 p.m., the ADON stated Resident #1 arrived from the hospital during the evening shift (of 07/24/2024) and did not arrive with a medication list from the hospital. The ADON stated she was aware that LVN B had called the nurse at the hospital multiple times, but since he had been unsuccessful, she also called the house supervisor for the hospital to obtain the finalized discharge medication list. The ADON stated that the hospital staff tried to fax the medication list a couple of times, but it didn't go through. Around 08:00 p.m., she reached out to the DON about not obtaining the medication list. The DON recommended requesting the house supervisor to email the mediation list to her (the ADON). The ADON stated she received the email with the finalized discharge medication list around 11:00 p.m. The ADON stated she forwarded the medication list to the DON and that she assumed the DON would take the next steps from there. The ADON stated that she would have typically completed a chart review the next day (Thursday, 07/25/2024), which was part of her process following a new admission, but she was scheduled off the next two days (Thursday and Friday, 07/25/2024 and 07/26/2024) due to being scheduled as the weekend supervisor which required working doubles on Saturday and Sunday (07/27/2024 and 07/28/2024). The ADON stated she did come in on her scheduled off days (Thursday and Friday, 07/25/2024 and 07/26/2024) for a few hours but did not follow up with the admission , which was what she would have typically done as part of her process following an admission. The ADON stated she was not sure what happened after she had forwarded the documentation from the hospital to the DON. The ADON stated that her understanding was that the DON was going to take over the next steps with the medication list that night. The ADON stated that the DON was expected to be out of town on Thursday, 07/25/2024, and scheduled off on Friday, 07/26/2024. The ADON stated the DON worked remotely a lot of the time. The ADON stated that due to her belief that the DON took over with the medication list, and because she did not receive any concerns from the staff [nursing staff working Thursday through Sunday (07/25/2024 through 07/28/2024), 6 shifts], she had thought everything was good. The ADON stated that on Monday, 07/29/2024, a nurse notified her that Resident #1 did not have any medications ordered. The ADON stated that she notified the DON and Resident #1's physician. Resident #1's physician requested lab work following the report. The ADON stated Resident #1 had been assessed and his vitals had been reviewed since the medication error was identified but no adverse effects had been found. The ADON stated she had been notified the RP (Responsible Party) had sent an email with concerns, but the email had been forwarded to the wrong [first name of the ADON] resulting in her not receiving it until after the error was identified. <BR/>During an interview on 08/01/2024 at 03:00 p.m., LVN B stated he was the receiving and admitting nurse for Resident #1. LVN B stated that when Resident #1 arrived for admission, the admitting paperwork only consisted of one page and the transport services staff stated that the one document was all that they received from the hospital. LVN B stated that he called the hospital and requested the discharge paperwork to be faxed over but after several attempts he discovered that the 1st, 2nd, and 3rd floor fax machines were having connection issues. LVN B stated he notified the ADON of the status and passed it over to her due to it being passed his end of shift. LVN B stated the ADON told him that she would email the discharge medication list to the DON and that the DON would email it to the night shift (next shift). He stated the on-call physician was notified when Resident #1 arrived for admission that the discharge medication list was missing, and that they were having difficulties getting the medication list routed to them. LVN B did not state that the physician made any actions following his notification of a lack of medication list. LVN B stated he ended up leaving that night around 11:38 p.m. or a little over an hour and half after the end of his scheduled shift. He stated that he gave a verbal report to the oncoming night shift nurse, reported to her that Resident #1 had pending medications. He stated that he also reported or documented about Resident #1's pending medications on the 24-hour report and on the facility's encrypted administration group chat, which went to every nurse, the DON, both ADONs, and the coordinator for admissions and discharges. LVN B stated that the DON was involved in his chat with the ADON and was constantly monitoring stuff but from home, not within the facility. LVN B stated he did not work again until Saturday (3 days later) and at that time, did not follow up because he did not see how it would not have been resolved over the last two (2) days. LVN B stated that due to residents having medications on either the CMA MAR, the regular MAR, or both; he did not notice that Resident #1 did not have medications ordered on either. LVN B stated it was not unusual to not have a resident listed on the CMA MAR, if all their orders were on the MAR, or for a resident to have all their medications on the CMA MAR and not have any medications on the MAR. LVN B stated that though he distributed both the CMA MAR medications and the MAR medications over the weekend, he was moving non-stop and didn't notice that Resident #1 was on neither MAR, thus not receiving any medications. LVN B stated that no one had mentioned to him that Resident #1 did not have medications orders, it was not brought to his attention. <BR/>During an interview on 08/01/2024 at 04:16 p.m., the NP stated he had seen Resident #1 on Friday, 07/26/2024 and early in the week of 07/29/2024. The NP stated that Resident #1 was COVID positive but doing okay. The NP stated the medical team had communicated with the discharging hospital prior to Resident #1's discharge to the nursing facility and had received his labs. The NP stated LVN B had notified him upon admission that Resident #1 admitted without a discharge medication list. The NP stated he received another call from the ADON on Tuesday, 07/30/2024 to notify him that she was working on the error. The NP stated that he felt the facility staff could have done more, that they could have gotten more attention on it and done work on it over the weekend. The NP stated he had not received any reports of any issues that were caused by the delay in medications. The NP stated that the facility and resident were fortunate that Resident #1 was stable. The NP stated that the 4-day day (if given on day of discharge from the hospital) in Resident #1's Amoxicillin/Clavulanate Potassium was not detrimental and was mostly prescribed as a preventative measure but could have caused harm. The 4-day gap in Apixaban (Eliquis) could have been significant if Resident #1's blood pressure and pulse were not so stable. The NP stated that the 5-day delay in Resident #1's Aspirin EC 81 MG would have been beneficial for Resident #1 due him having had COVID and could have been serious. The 5-day gap in receiving the Levothyroxine Sodium was okay to have been missed due to the medication's slow breakdown in the body, so Resident #1 would have been fine missing it up to two weeks. The 5-day gap in receiving the Losartan Potassium could have been detrimental, but Resident #1's blood pressures were surprisingly okay during the time that the medication was missed. The 5-day gap in receiving Metformin did not reveal any physical signs for the short-term and Resident #1's labs were not outstanding during this time. The 5-day gap in receiving Metoprolol Succinate did not appear to cause harm with Resident #1 having had his blood pressure and pulse monitored which were okay. The 5-day delay in receiving the Rosuvastatin Calcium which was changed to Atorvastatin Sodium did not cause harm since the delay was a short period of time and this medication was prescribed for managing long-term heart disease. <BR/>During an interview on 08/01/2024 at 04:50 p.m., the DON stated that Resident #1 was admitted on Wednesday, and she was notified via an encrypted thread (text message chain) set up to go to the facility administration. The DON stated that as far as she knew, the ADON had reported to her that she (the ADON) was having problems getting the discharge medications list that night. The DON stated that she had seen in the EMR that Resident #1 was admitted on Wednesday night and that his diet and code status were entered but that was about all she checked. The DON stated that she did not touch the chart after that and had left to go out of town on Thursday morning. The DON denied receiving an email from the hospital and stated that she may have received something from the ADON, but the ADON was still at the facility late. The DON stated that she did not receive any notifications from Thursday to over the weekend from staff regarding concerns about Resident #1's medications. The DON stated that Resident #1 having missed his prescribed Amoxicillin/Clavulanate Potassium for four (4) days could have made him sick and that there was no excuse for the error. The DON stated that Resident #1 having missed his Apixaban for four (4) days could have resulted in Resident #1 having atrial fibrillation. The DON stated that Resident #1's missed five (5) doses of Aspirin were prophylactic (a measure or substance intended to prevent or protect against undesired effects), meaning it was prescribed as a preventative medication. The DON stated that Resident #1's five (5) missed doses of Metformin does not seem to have been impactful since Resident #1's blood sugars don't indicate that missing the medication changed his blood sugars. The DON stated that Resident #1's vitals seem to indicate that missing five (5) doses of his Metoprolol Succinate was not impactful since Resident #1's vitals were okay. The DON stated that she wouldn't be able to say that Resident #1 missing his statin (Rosuvastatin Calcium and then prescribed Atorvastatin Sodium) was impactful but would say that Resident #1 should have gotten his medications. <BR/>Record review of facility's policy, Policy / Procedure- Nursing Administration, dated as revised 05/2007, indicated Procedures: .Licensed Nurse Procedure .2. Initiate any required treatments (oxygen, intravenous) necessary at time of admission per transfer orders .4. Inform physician of administration and verify transfer and admission orders. 5. Order medications from resident's pharmacy of choice .9. Note and initiate physician orders. Initiate medications and treatment sheets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation.<BR/>Resident #'1's electronic medical record did not contain complete and accurate documentation that RN A recorded the resident's vital signs, follow-up on a STAT (immediate) lab request, kept the DON or MD informed on the monitoring of the resident's change of condition for a period of three hours; before the resident expired.<BR/>This failure could result in residents' records not accurately documenting interventions, monitoring, and information provided to the MD or DON during a change of condition that could result in a death.<BR/> Findings included:<BR/>Record review of Resident #1's Face Sheet, dated 01/12/23, and EMR (electronic medical record) revealed, Resident #1 was a male age [AGE], was admitted on [DATE] with diagnoses that included: acute metabolic acidosis (infection), sepsis (infection of the blood), urinary tract infection, kidney failure, hypertension, anemia ( low red blood count), chronic kidney disease and diabetes 2 . Advanced Directive was DNR (do not resuscitate). RP (responsible party) was listed as: the resident. The date of discharge was 01/07/23 due to resident expiring in the facility. <BR/>Record review of Resident#1's Care Plan dated 12/31/22 revealed goals of resident being free of antidepressant side effects, diabetic treatment, improving cognition.<BR/>Record review of Resident #1's Social Services Assessment, dated 12/30/22, revealed resident's BIMS was zero (severely impaired).<BR/>Record review of Resident #1's MD orders dated 01/01/23 read: Lansoprazole Oral Tablet Delayed Release Disintegrating 30 MG (Lansoprazole) Give 1 tablet by mouth one time a day for stress ulcer p (prophylaxis).<BR/>Record review of Resident #1's Change of Condition Nurses Note dated 01/07/23 at 1:09 PM read, Resident noted to be sleepy, unable to tolerate food. 02 (oxygen) 89 (percent) RM (room temperature) , HR (heart rate) 120, lung crackles, cough, afebrile. [Change of Condition Nurse Note was authored by RN A]<BR/>Record review of Resident #1's Physician Progress Note dated 01/07/23 at 9:57 PM read: Earlier in the day [01/07/23] I (MD B) received a text message that (Resident #1) has been asleep since breakfast and his vital signs BP 100/59, HR 120 oxygen sats (saturation) 2L (liters) with 95%. Not in distress. stat labs were ordered and advised to monitor clinically and hold BP meds and sedatives. (8:13 PM) received a text message that pt (patient) had expired .cause of the death is internal upper GI (gastro intestinal) bleeding is more likely even though pt has been taking Lansoprazole for a possible ulcer/prophylaxis ( action taken to prevent a disease) .<BR/>Record review of Resident #1's Nurse Note dated 01/07/23 at 4:11 PM, authored by RN A, revealed the resident's BP was 90/56, HR was 98 and the lab company had arrived to take a blood specimen of the resident.<BR/>Record review of Resident #1's Nurse Note dated 01/07/23 at 5:29 PM, authored by RN A, revealed: Resident's 02 saturation was 96 %. RN did not document any other vital signs that could have included: resident's temperature, BP, HR and respiration.<BR/>Record review of Resident #1's Nurse Notes from 01/07/23 at 5:29 PM to 8:05 PM (time of death) did not document the resident's condition, nursing monitoring or interventions, or follow-up to the lab, MD or DON.<BR/>Record revie of Resident #1's Nurse Note on 01/07/23 authored by RN A revealed: resident vomited blood, was unresponsible, deceased , and the MD and DON were notified. [MD note dated 01/07/23 at 9:57 PM revealed the . cause of death is internal upper GI (gastro intestinal) bleeding is more likely even though pt (patient) has been taking Lansoprazole for a possible ulcer/prophylaxis .]<BR/>Record review of Resident #1's labs dated 01/07/23 revealed: labs for Resident #1 was collected on 01/07/23 at 4:28 PM; the lab received the blood specimen at 9:21 PM; and results were reported at 10:07 PM. WBC (white blood count) was 25.3 H (high) .reference range 4.2-9.1 . <BR/>During a telephone interview on 01/12/23 at 2:59 PM, the MD revealed: (time line) on 01/07/23 at 1:09 PM he was alerted that Resident #1's O2 stats was 89% . The MD ordered stat labs. At 1:25 PM he was informed that Resident (#1)'s BP was 100/59 and heart rate 120 . The MD stated the latter BP was a little low and heart rate a little high . He ordered that the facility monitor the resident and to keep him informed of any change of condition. The MD stated, the last time the facility contacted me by text was at 8:05 PM when he (MD) was informed the resident was deceased . The MD stated, he was told Resident #1 had a little blood on his shirt. The MD recalled that he wrote a physician's note revealing that the resident might have suffered GI bleeding due to ulcer prophylaxis. <BR/>During an interview on 01/13/23 at 8:40 AM, DON revealed: on 01/07/23 at 1:07 PM the MD was contacted because the resident suffered hypotension (BP was 100/59 and heart rate was 120) and the MD ordered stat labs and to monitor the resident. At 4:11 PM Nurse A recorded that Resident #1's BP was 90/56 and heart rate was 98 (assessment by DON: indication that the BP and had heart were lower. At 5:29 PM Nurse A took vital signs which revealed Resident #1's oxygen saturation was 96 % ( assessment by DON; good oxygen intake) BP was not recorded. At 8:05 PM the resident is deceased . The lack of documentation meant per the DON that she and the MD had no information regarding Resident #1's change of condition and current status for 3 hours (5:29 PM to 8:05 PM). The DON revealed she could not answer for Nurse A as to why she (Nurse A) did not document the BP or other vital signs for the time period 5:29 PM to 8:05 PM. The DON described vital signs as BP, heart rate, respiration, O2 saturation and temperature. The DON stated the labs arrived at 10:07 PM after the resident expired; finding was resident had elevated WBC (white blood count).The DON added the system failure by Nurse A was not documenting completely and accurately between the hours 5:29 PM to 8:05 PM. The responsible party for documentation on 01/07/23 was the charge nurse (Nurse A). <BR/>During a telephone interview on 01/13/23 at 9:30 AM, Nurse A revealed: on 01/07/23 at 1:07 PM the MD was contacted because Resident #1 suffered hypotension (BP was 100/59 and heart rate was 120) and MD ordered stat labs and to monitor the resident. At 4:11 PM Nurse A recorded that Resident #1's BP was 90/56 and heart rate was 98 (means BP is low but not critical and 98 heart is high but not requiring MD notification). At 5:29 PM, she (Nurse A) recorded that 02 saturation was at 96 % (normal). Nurse A stated other vital signs were normal (temperature, respiration, BP and heart rate) but not recorded. Last not written by Nurse A was 8:05 PM when resident deceased . Nurse A stated, I observed the resident (#1) at 6 PM, 7 PM, 8 PM and in between and resident was stable .I did not record the vitals because I had other residents to take care .I saw the resident at 7:30 PM and vitals were okay and was waiting on the lab results .but did not record my visit at 7:40 PM . vitals were low but not critical .there was no written policy that I call the MD or DON every two hours .or document visits every 2 hours . Further, Nurse A stated she followed up on the stat labs at 7 PM and did not record the contact .it was my fault for not documenting. <BR/>During a telephone interview on 01/23/23 at 10:46 AM, CNA B revealed: his shift was from 2 PM-10 PM on 01/07/23 and he checked on Resident #1 every 30 minutes to 1 hour. At 7:22 PM, Resident (#1) was asleep, snoring, and not in distress .I did not document my checks with the resident but told Nurse (A) around 8 PM I found resident with a brown substance around his mouth and called the charge nurse .charge nurse said the resident had expired . CNA B stated that Nurse A would document the information he was conveying to her regarding the monitoring of Resident #1. <BR/>During an interview on 01/23/23 at 11:03 AM, DON revealed: Nurse A called the lab at 1:09 PM per MD request and the lab collected the specimen at 4:28 PM. The lab considers a STAT telephone request to fall within a time window of 4-6 hours.<BR/>During a telephone interview on 01/23/23 at 11:14 AM, Lab Representative C revealed the lab's policy was to respond to STAT telephone requests by six hours from time of collection to results. Reference # 1893253 revealed (Resident #1's) labs were collected at 4:28 PM. STAT did not mean the lab would immediately go to the facility rather from time of collection to results within a 6 hour timeframe . Follow-up calls from facility checking on STAT orders were not documented by the lab. <BR/>During an interview on 01/13/23 at 11:40 PM, the Administrator revealed Nurse A forgot to document critical information. He stated, it is a battle we fight on documentation . The Administrator added that complete and accurate documentation would be included in the on-[NAME] in-service training for nursing staff documentation, monitoring, and change of condition. <BR/>Record review of facility's Significant Change in Condition Response dated 01/2022 read, .The Nurse will perform and document an assessment of the resident and identify need for additional interventions .The resident will then be placed on the 24 Hour Report and Nursing will provide no less than three (3) days of observation, documentation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 5 residents reviewed for pharmacy services.<BR/>The facility failed to transcribe Resident #1's discharge orders and failed to follow-up to ensure Resident #1's hospital discharge orders were implemented timely, which caused him to miss getting his medications for four (4) to five (5) days. <BR/>This failure could cause a delay in appropriate medical care and worsening in symptoms, condition, or illness. <BR/>The findings included:<BR/>Record review of Resident #1's admission Record, dated 07/30/2024, indicated he was a [AGE] year-old male admitted on [DATE]. <BR/>Record review of Resident #1's Medical Diagnosis list in the facility's EMR included: COVID-19 (An illness that can affect a person's lungs and airways caused by a virus called the Coronavirus), Pneumonia due to Coronavirus Disease 2019 (a lung infection caused by the coronavirus), muscle weakness, unsteadiness on feet, need for assistance with personal care, type 2 diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), paroxysmal atrial fibrillation (a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days), and hypothyroidism (when the thyroid does not produce enough hormones).<BR/>Record review of Resident #1's BIMS (Brief Interview for Mental Status) indicated Resident #1's mental status was moderately impaired (BIMS score 12). <BR/>Record review on 07/30/2024 of Resident #1's hospital records uploaded to his facility EMR did not reveal a discharge medication list. <BR/>Record review of an email dated 07/24/2024 at 11:18 p.m. sent by [local hospital] staff member to the ADON included Resident #1's Discharge Medication List dated 07/24/2024 indicated This med [medication] list indicates the medications you should continue taking and new medications you should start taking. The list included: <BR/> - Amoxicillin/Clavulanate Potassium (Augmentin; a combination antibiotic used to treat various bacterial infections) 875 MG, oral, twice a day through 07/27/2024<BR/> - Apixaban (Eliquis; used to prevent serious blood clots) 5 MG, oral, twice a day<BR/> - Aspirin EC (Ecotrin; used to prevent heart problems) 81 MG, oral, daily<BR/> - Guaifenesin/DM 100-10 MG/5ML (Robitussin-DM 100-10 MG/5ML; used to thin mucus and relieve coughing) 200 MG, oral, every 4 hours as needed<BR/> - Levothyroxine Sodium (used to treat underactive thyroid) 175 MCG, oral, daily<BR/> - Losartan Potassium (used to treat high blood pressure) 25 MG, oral, daily<BR/> - Metformin HCl (used to lower the amount of sugar the body makes or absorbs) 500 MG, oral, daily<BR/> - Metoprolol Succinate (Toprol XL; used to treat chest pain, heart failure, and high blood pressure) 25 MG, oral, daily<BR/> - Rosuvastatin Calcium (used to lower cholesterol and fats in blood) 5 MG, oral, at bedtime <BR/>Record review of Resident #1's Order Summary Report, active orders, dated 07/30/2024, reflected: <BR/> - Blood sugar checks QAM (every morning) and HSQ (every evening) in the morning for BS (blood sugar) monitoring, order date 07/29/2024 and start date 07/30/2024. Ordered five (5) days after admission and started six (6) days after admission.<BR/> - Document Temp (temperature) / O2 sats (oxygen saturation) and monitor for the following symptoms: Fever, Cough, New shortness of breath or difficulty breathing, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell, congestion, runny nose. GI (Gastrointestinal) symptoms: Diarrhea/Nausea/Vomiting every shift, order and start date 07/24/2024. Ordered and started the day of admission.<BR/> - Monitor for signs and symptoms of hypo/hyperglycemia (low or high blood pressure) hunger, thirst, sweating, dizziness, changes in vision, headache, irritability, nausea, fatigue, frequent urination q (every) shift, order and start date 07/24/2024. Ordered and started the day of admission.<BR/> - Amoxicillin-Pot Clavulanate Oral Tablet 875-125 MG, give 1 tablet by mouth every 12 hours for UTI (urinary tract infection), order and start date 07/29/2024. Ordered and started five (5) days after admission and three (3) days after expected end date for treatment per the hospital discharge medication list. <BR/> - Apixaban Oral Tablet 5 MG, give 1 tablet by mouth two times a day for Afib (atrial fibrillation), order and start date 07/29/2024. Ordered and started five (5) days after admission.<BR/> - Aspirin 81 Oral Tablet Delayed Release, give 1 tablet by mouth one time a day for heart health, order date 07/29/2024 and start date 07/30/2024. Ordered five (5) days after admission and started six (6) days after admission.<BR/> - Atorvastatin Calcium 10 MG Tablet, give 1 tablet by mouth at bedtime for HLD (hyperlipidemia; high fat levels in the blood), order and start date 07/29/2024. Ordered and started five (5) days after admission.<BR/> - Levothyroxine Sodium Oral Tablet 175 MCG, give 1 tablet by mouth in the morning for hypothyroidism, order date 07/29/2024 and start date 07/30/2024. Ordered five (5) days after admission and started six (6) days after admission.<BR/> - Losartan Potassium Oral Tablet 25 MG, give 1 tablet by mouth one time a day for Hypertension, order date 07/29/2024 and start date 07/30/2024. The order included to hold if SBP (systolic blood pressure) was less than 110 or if DBP (diastolic blood pressure) was less than 60. Ordered five (5) days after admission and started six (6) days after admission. <BR/> - Metformin HCl Oral Tablet 500 MG, give 1 tablet by mouth one time a day for DM (diabetes mellitus), order date 07/29/2024 and start date 07/30/2024. Ordered five (5) days after admission and started six (6) days after admission. <BR/> - Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG, give 1 tablet by mouth one time a day for hypertension, order date 07/29/2024 and start date 07/30/2024. The order included to hold if SBP (systolic blood pressure) was less than 110, if DBP (diastolic blood pressure) was less than 60, or if HR (heart rate or pulse) was less than 60. Ordered five (5) days after admission and started six (6) days after admission. <BR/>Record review of Resident #1's July 2024 CMA (Certified Medication Assistant) MAR (Medication Administration Record), accessed on 07/30/2024 at 03:10 p.m., indicated:<BR/> - Aspirin 81 Oral Tablet was first administered on 07/30/2024.<BR/> - Atorvastatin Calcium 10 MG Tablet was first administered on 07/29/2024.<BR/> - Levothyroxine Sodium Oral Tablet 175 MCG was first administered on 07/30/2024.<BR/> - Losartan Potassium Oral Tablet 25 MG was first administered on 07/30/2024 with blood pressure level documented as 124/83.<BR/> - Metformin HCl Oral Tablet 500 MG was first administered on 07/30/2024.<BR/> - Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG was first administered on 07/30/2024 with blood pressure level documented as 124/83 and pulse documented as 84.<BR/> - Rosuvastatin Calcium Oral Tablet 5 MG was documented as discontinued on 07/29/2024 at 04:19 p.m. and was not documented as administered.<BR/>Record review of Resident #1's July 2024 MAR, accessed on 07/30/2024 at 03:10 p.m., indicated:<BR/> - Blood Sugar Checks QAM (every morning) and QHS (every night) was first collected on 07/30/2024 with blood sugar level documented as 137 mg/dL (considered normal at 140 or lower). <BR/> - Amoxicillin-Pot Clavulanate Oral Tablet 875-125 MG was first administered on 07/29/2024 and administered a second time on 07/30/2024.<BR/> - Apixaban Oral Tablet 5 MG was first administered on 07/29/2024 and administered a second time on 07/30/2024.<BR/> - Document Temp/O2 Sats (oxygen saturation) and monitor for the following symptoms: Fever, Cough . was first collected and monitored on 07/25/2024. The 11 (eleven) shifts documented:<BR/> - N for no symptoms, <BR/> - systolic blood pressures ranging from 114 to 155 (considered normal below 120, elevated from 120 to 129, hypertension stage 1 from 130 to 139, hypertension stage 2 when 140 or more, and hypertensive crisis if 180 or more), <BR/> - diastolic blood pressure ranging from 71 to 95 (considered normal when lower than 80, stage 1 hypertension from 80 to 89, stage 2 hypertension from 90 or more, and hypertensive crisis if 120 or more), <BR/> - temperatures ranging from 97.3- 98.3 degrees Fahrenheit (considered normal when between 97.5 to 99.5 degrees Fahrenheit), <BR/> - pulses ranging from 67 to 103 beats per minute (considered normal when between 60 to 100 beats per minute), <BR/> - respirations ranging from 14 to 18 breaths per minute (considered normal when between 12 to 20 breaths per minute), <BR/> - and O2 Sats ranging from 91 to 99 % (percent; considered normal when between 95% to 100%).<BR/> - Monitor for signs and symptoms of hypo/hyperglycemia (low or high blood pressure) was first monitored on 07/24/2024 during the night shift and continued to be monitored the 16 following shifts with a total of 17 shifts having had monitored. <BR/>Record review of Resident #1's nursing progress note, dated 07/24/2024 at 06:22 p.m., completed by LVN B indicated Patient has arrived, COVID positive . paperwork did not arrive with patient, called hospital twice to have it faxed over.<BR/>During an interview on 07/31/2024 at 01:25 p.m., Resident #1 stated that he felt that the facility took a while to get his medications but that he was receiving them now. Resident #1 stated that he didn't know why there was a delay with his medications and that he had told them that he was missing his mediations, but he felt it was a different group he told each time and that they didn't seem to coordinate with each other. Resident #1 stated he did not experience any side effects or complications due to the delay in receiving his medications. <BR/>During an interview on 07/31/2024 at 01:46 p.m., LVN A stated that the process for admitting a new resident when they came to the facility without a hospital admission packet would be to obtain the hospital floor number (phone number for the nurses' station at the hospital which the resident came from) and to request that they fax the resident's discharge medication list. LVN A stated he was not working the night of Resident #1's admission, but he was made aware that the resident did not receive medications for several days. LVN A stated that the procedural mistake was that the hospital was not called again the next day if the admitting nurse did not receive the discharge medication list on the night of admission. <BR/>During an interview on 07/31/2024 at 02:51 p.m., the ADON stated Resident #1 arrived from the hospital during the evening shift (of 07/24/2024) and did not arrive with a medication list from the hospital. The ADON stated she was aware that LVN B had called the nurse at the hospital multiple times, but since he had been unsuccessful, she also called the house supervisor for the hospital to obtain the finalized discharge medication list. The ADON stated that the hospital staff tried to fax the medication list a couple of times, but it didn't go through. Around 08:00 p.m., she reached out to the DON about not obtaining the medication list. The DON recommended requesting the house supervisor to email the mediation list to her (the ADON). The ADON stated she received the email with the finalized discharge medication list around 11:00 p.m. The ADON stated she forwarded the medication list to the DON and that she assumed the DON would take the next steps from there. The ADON stated that she would have typically completed a chart review the next day (Thursday, 07/25/2024), which was part of her process following a new admission, but she was scheduled off the next two days (Thursday and Friday, 07/25/2024 and 07/26/2024) due to being scheduled as the weekend supervisor which required working doubles on Saturday and Sunday (07/27/2024 and 07/28/2024). The ADON stated she did come in on her scheduled off days (Thursday and Friday, 07/25/2024 and 07/26/2024) for a few hours but did not follow up with the admission , which was what she would have typically done as part of her process following an admission. The ADON stated she was not sure what happened after she had forwarded the documentation from the hospital to the DON. The ADON stated that her understanding was that the DON was going to take over the next steps with the medication list that night. The ADON stated that the DON was expected to be out of town on Thursday, 07/25/2024, and scheduled off on Friday, 07/26/2024. The ADON stated the DON worked remotely a lot of the time. The ADON stated that due to her belief that the DON took over with the medication list, and because she did not receive any concerns from the staff [nursing staff working Thursday through Sunday (07/25/2024 through 07/28/2024), 6 shifts], she had thought everything was good. The ADON stated that on Monday, 07/29/2024, a nurse notified her that Resident #1 did not have any medications ordered. The ADON stated that she notified the DON and Resident #1's physician. Resident #1's physician requested lab work following the report. The ADON stated Resident #1 had been assessed and his vitals had been reviewed since the medication error was identified but no adverse effects had been found. The ADON stated she had been notified the RP (Responsible Party) had sent an email with concerns, but the email had been forwarded to the wrong [first name of the ADON] resulting in her not receiving it until after the error was identified. <BR/>During an interview on 08/01/2024 at 03:00 p.m., LVN B stated he was the receiving and admitting nurse for Resident #1. LVN B stated that when Resident #1 arrived for admission, the admitting paperwork only consisted of one page and the transport services staff stated that the one document was all that they received from the hospital. LVN B stated that he called the hospital and requested the discharge paperwork to be faxed over but after several attempts he discovered that the 1st, 2nd, and 3rd floor fax machines were having connection issues. LVN B stated he notified the ADON of the status and passed it over to her due to it being passed his end of shift. LVN B stated the ADON told him that she would email the discharge medication list to the DON and that the DON would email it to the night shift (next shift). He stated the on-call physician was notified when Resident #1 arrived for admission that the discharge medication list was missing, and that they were having difficulties getting the medication list routed to them. LVN B did not state that the physician made any actions following his notification of a lack of medication list. LVN B stated he ended up leaving that night around 11:38 p.m. or a little over an hour and half after the end of his scheduled shift. He stated that he gave a verbal report to the oncoming night shift nurse, reported to her that Resident #1 had pending medications. He stated that he also reported or documented about Resident #1's pending medications on the 24-hour report and on the facility's encrypted administration group chat, which went to every nurse, the DON, both ADONs, and the coordinator for admissions and discharges. LVN B stated that the DON was involved in his chat with the ADON and was constantly monitoring stuff but from home, not within the facility. LVN B stated he did not work again until Saturday (3 days later) and at that time, did not follow up because he did not see how it would not have been resolved over the last two (2) days. LVN B stated that due to residents having medications on either the CMA MAR, the regular MAR, or both; he did not notice that Resident #1 did not have medications ordered on either. LVN B stated it was not unusual to not have a resident listed on the CMA MAR, if all their orders were on the MAR, or for a resident to have all their medications on the CMA MAR and not have any medications on the MAR. LVN B stated that though he distributed both the CMA MAR medications and the MAR medications over the weekend, he was moving non-stop and didn't notice that Resident #1 was on neither MAR, thus not receiving any medications. LVN B stated that no one had mentioned to him that Resident #1 did not have medications orders, it was not brought to his attention. <BR/>During an interview on 08/01/2024 at 04:16 p.m., the NP stated he had seen Resident #1 on Friday, 07/26/2024 and early in the week of 07/29/2024. The NP stated that Resident #1 was COVID positive but doing okay. The NP stated the medical team had communicated with the discharging hospital prior to Resident #1's discharge to the nursing facility and had received his labs. The NP stated LVN B had notified him upon admission that Resident #1 admitted without a discharge medication list. The NP stated he received another call from the ADON on Tuesday, 07/30/2024 to notify him that she was working on the error. The NP stated that he felt the facility staff could have done more, that they could have gotten more attention on it and done work on it over the weekend. The NP stated he had not received any reports of any issues that were caused by the delay in medications. The NP stated that the facility and resident were fortunate that Resident #1 was stable. The NP stated that the 4-day day (if given on day of discharge from the hospital) in Resident #1's Amoxicillin/Clavulanate Potassium was not detrimental and was mostly prescribed as a preventative measure but could have caused harm. The 4-day gap in Apixaban (Eliquis) could have been significant if Resident #1's blood pressure and pulse were not so stable. The NP stated that the 5-day delay in Resident #1's Aspirin EC 81 MG would have been beneficial for Resident #1 due him having had COVID and could have been serious. The 5-day gap in receiving the Levothyroxine Sodium was okay to have been missed due to the medication's slow breakdown in the body, so Resident #1 would have been fine missing it up to two weeks. The 5-day gap in receiving the Losartan Potassium could have been detrimental, but Resident #1's blood pressures were surprisingly okay during the time that the medication was missed. The 5-day gap in receiving Metformin did not reveal any physical signs for the short-term and Resident #1's labs were not outstanding during this time. The 5-day gap in receiving Metoprolol Succinate did not appear to cause harm with Resident #1 having had his blood pressure and pulse monitored which were okay. The 5-day delay in receiving the Rosuvastatin Calcium which was changed to Atorvastatin Sodium did not cause harm since the delay was a short period of time and this medication was prescribed for managing long-term heart disease. <BR/>During an interview on 08/01/2024 at 04:50 p.m., the DON stated that Resident #1 was admitted on Wednesday, and she was notified via an encrypted thread (text message chain) set up to go to the facility administration. The DON stated that as far as she knew, the ADON had reported to her that she (the ADON) was having problems getting the discharge medications list that night. The DON stated that she had seen in the EMR that Resident #1 was admitted on Wednesday night and that his diet and code status were entered but that was about all she checked. The DON stated that she did not touch the chart after that and had left to go out of town on Thursday morning. The DON denied receiving an email from the hospital and stated that she may have received something from the ADON, but the ADON was still at the facility late. The DON stated that she did not receive any notifications from Thursday to over the weekend from staff regarding concerns about Resident #1's medications. The DON stated that Resident #1 having missed his prescribed Amoxicillin/Clavulanate Potassium for four (4) days could have made him sick and that there was no excuse for the error. The DON stated that Resident #1 having missed his Apixaban for four (4) days could have resulted in Resident #1 having atrial fibrillation. The DON stated that Resident #1's missed five (5) doses of Aspirin were prophylactic (a measure or substance intended to prevent or protect against undesired effects), meaning it was prescribed as a preventative medication. The DON stated that Resident #1's five (5) missed doses of Metformin does not seem to have been impactful since Resident #1's blood sugars don't indicate that missing the medication changed his blood sugars. The DON stated that Resident #1's vitals seem to indicate that missing five (5) doses of his Metoprolol Succinate was not impactful since Resident #1's vitals were okay. The DON stated that she wouldn't be able to say that Resident #1 missing his statin (Rosuvastatin Calcium and then prescribed Atorvastatin Sodium) was impactful but would say that Resident #1 should have gotten his medications. <BR/>Record review of facility's policy, Policy / Procedure- Nursing Administration, dated as revised 05/2007, indicated Procedures: .Licensed Nurse Procedure .2. Initiate any required treatments (oxygen, intravenous) necessary at time of admission per transfer orders .4. Inform physician of administration and verify transfer and admission orders. 5. Order medications from resident's pharmacy of choice .9. Note and initiate physician orders. Initiate medications and treatment sheets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide the necessary services to maintain good personal hygiene for 4 of 5 residents (Residents #1, #2, #3, and #4,) reviewed for activities of daily living.<BR/>1. Resident #1 had no showers between dates of 12/29/2023-1/7/2024. <BR/>2. Resident #2 had 3 showers between dates of 12/25/2023-1/7/2024.<BR/>3. Resident #3 had 2 showers between dates of 12/25/2023-1/7/2024.<BR/>4. Resident #4 had 2 showers between dates of 12/25/2023-1/7/2024.<BR/>This failure could affect residents and contributed to feelings of hopelessness and frustration.<BR/>The findings were:<BR/>Review of Resident # 1's face sheet dated 1/6/2024 revealed admission into facility on 12/29/2023 with diagnoses to include chronic kidney disease, stage 3(mild to moderate loss of kidney function.),vascular dementia without behavioral disturbance(A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.), major depressive disorder recurrent (a mood disorder that causes a persistent feeling of sadness and loss of interest.) and repeated falls.<BR/>Review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 13 indicating minimal cognitive impairment. ADLs not yet determined for assistance on MDS.<BR/>Record review of Resident #1's EMR for bathing dated 12/29/23- 1/6/2024 revealed dates were marked as not applicable for bathing activity. There was no indication of Resident #1 receiving showers or bed baths on the above dates.<BR/>Observation/interview on 1/8/2024 at 9:00 a.m. revealed Resident #1 lying in bed in low position. Resident #1 presented as being alert and oriented. He stated he had not had a shower since he had been admitted , until this morning. He further stated, I don't like not having a shower every day. Since I cannot control my bladder, I feel I need to be clean. <BR/>Phone interview on 1/8/2024 at 9:05 a.m. with Resident #1's RP revealed Resident #1 had not had a shower until this am since he had been admitted to the facility on [DATE]. She further stated, I expect him to be taken better care of than he has been, and he should get a shower every day if not three times a week as the facility told me. She revealed her likes to be groomed and dressed every day. She stated, it makes him depressed if he is not clean.<BR/>Interview on 1/8/2024 at 9:40 am with CNA E confirmed Resident #1 told her he had not had a shower since he had been admitted . She revealed she had been off and did not know why he had not had a shower as he was scheduled for Monday, Wednesday, and Fridays on the 6:00 am to 2:00pm shift.<BR/>Review of Resident # 2's face sheet dated 1/6/2024 revealed an original admission date of 12/18/2019 with recent re-admission date of 4/17/2022 into facility with diagnosis to include unspecified dementia without behaviors, Diabetes Mellitus type 2, overflow urinary incontinence, chronic gout, major depressive disorder recurrent, and anxiety disorder.<BR/>Review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating minimal cognitive impairment and that she required extensive assistance by 2 staff for most ADS's including showers.<BR/>Record review of Resident #2's EMR for bathing dated 12/29/23-1/6/2024 revealed dates were marked as not applicable for bathing activity. There was as indication of Resident #2 receiving 3 showers on the above dates.<BR/>Observation/interview on 1/6/2024 at 9:00 a.m. revealed Resident #2 sitting in wheelchair in room beside bed. She was watching TV Resident #2 presented as being alert and oriented. She revealed she required assistance from staff for her care. She further revealed she had not had a shower but twice in the last 14 days. When asked why she had not had a shower, she stated because the staff said they did not have enough of help. She further stated, I like to have a shower every other day. Since I cannot control my bladder. I do not want to stink. That embarrass me.<BR/>Interview on 1/6/2024 at 9:30 am with CNA D confirmed Resident #2 told her she had not had a shower for 2 weeks. CNA D further stated she told Resident #2 that she would be getting a shower on Monday on the 6 am-PM shift as this was her regular day.<BR/>Interview on 1/6/2024 at 9:50 am with LVN B revealed resident #2 had not had showers as she should have during the past 2 weeks. She further stated, we have been short staffed, so some residents have not gotten their showers like they should . <BR/>Review of Resident # 3's face sheet dated 1/6/2024 revealed an initial admission date of 11/16/2022 with readmission of 1/24/2023 with diagnosis to include fracture of base of skull right side, dysphagia, Diabetes Mellitus Type 2, depression and anxiety disorder.<BR/>Review of Resident #3's comprehensive MDS dated [DATE] revealed a BIMS score of 11 indicating minimal cognitive impairment and that she required extensive assistance by 1 or 2 staff for most ADS's including toileting. <BR/>Observation/Interview on 1/6/2024 at 10:00 am revealed Resident #3 lying down in bed. She presented as being alert and oriented. <BR/>When asked if she was receiving any showers at the facility by staff , she stated no not really. She stated, I I believe I only have had 2 maybe in the last few weeks. When asked why she had not received more showers. Resident #2 stated, the staff says they are short staff or do not have time to shower me. Resident #2 further revealed she felt she needed to be showered more often because she was incontinent and wanted to be clean. Resident #2 stated it is embarrassing to not have showers and be clean.<BR/>Interview on 1/6/2024 at 10:10 am CNA E revealed if it is not marked in the residents record as being done on the shower section, then the resident did not get a shower. She further revealed she did not know why Resident #3 did not get a shower on her regular shower days. CNA E stated , we are short staffed sometimes and cannot get to everybody. <BR/>Record review of Resident #4's face sheet revealed a [AGE] year-old male with an admission date of 6/28/2023 revealed diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, and Diabetes Mellitus type 2.<BR/>Record review of Resident #4 quarterly MDS (minimum data sheet) assessment dated [DATE], revealed he had a BIMS score of 15, which indicated moderately cognitively impaired. Section G mobility revealed he required 1-person physical assist.<BR/>During an observation/interview on 1/6/2023 at 10:15 a.m. revealed Resident #4 was in the hallway in his wheelchair. When asked by surveyor how he was doing, he stated I am mad. Resident #4 revealed he was mad because he did not get showers like he should. He revealed he should get showers by the staff 3 times a week but only had 2 or 3 in the last 2 weeks. Resident #4 further revealed he feels mad and dirty when he is not helped. When asked why he had not had showers , he revealed the staff tells him they are short or do not have time to shower him.<BR/>During an interview on 1/6/2023 at 10:20 a.m. LVN B confirmed Resident #4 required assistance with showers. LVN B further revealed the nurse aides have a shower schedule for the residents. She said sometimes the nurse aides may be short staffed and cannot give all the residents their showers.<BR/>Interview on 1/8/2024 at 2:50 p.m. with facility ADON revealed nurse aides document in residents EMR when a shower or bed bath occurs. She revealed if there was no documentation in the EMR or on shower sheets then the resident did not receive a bath. She further revealed she did not know why residents did not receive a bath/shower. She stated all residents should receive a bed bath or shower on the assigned dates and shift. She stated this was for the resident's dignity and health to be clean and cared for. <BR/>Interview on 1/8/2024 at 3:00 p.m. with facility DON revealed nurse aides document in residents EMR when a shower or bed bath occurs. She revealed it was her expectation that all residents should receive a bed bath or shower on the assigned dates and shift. She stated this was for the resident's dignity and health to be clean.<BR/>Record review of facility policy, titled; Routine procedures, Subject: Bath, Shower: It is the policy of the facility to promote cleanliness, stimulate circulation and assist in relaxation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide for a resident who is incontinent of bladder appropriate treatment, and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #5) reviewed for catheter care, in that: <BR/>Resident #5's urinary catheter bag with urine was not anchored to the bed frame and lying on the floor. <BR/>This deficiency could prevent residents on catheter treatment from receiving appropriate services and could lead to blockage in urine flow and infection. <BR/>The findings were:<BR/>Record review of Resident #5's face sheet, dated 2/15/24, and EMR revealed, the resident was admitted on [DATE] with diagnoses that included: hospice, Huntington's disease (a neurological disorder), aphasia (cannot communicate), and stage 4 pressure ulcer (right buttocks).<BR/>Record review of Resident#1's MDS, dated [DATE], revealed the resident had a BIMS score of 0, which indicated the resident was severely cognitively impaired, and for ADLs: bowel and bladder; catheter for bladder function, bowel was listed as always incontinent; transfer was dependent; bed mobility was dependent, and ROM was listed as impairment of upper and lower extremities. <BR/>Record review of Resident# 1's Care Plan, undated, revealed a goal and interventions for catheter treatment which included: Position catheter bag and tubing below the level of the bladder .<BR/>Record review of Resident #5's physician's orders for February 2024 revealed an order for, POSITION PRIVACY BAG & TUBING BELOW THE LEVEL OF THE BLADDER .<BR/>Observation and interview on 2/14/24 at 11:45 AM revealed Resident #5 was in bed, receiving continuous 02; not alert or oriented. Further observations revealed the resident's room gave off the odor of urine, and the resident's catheter was on the floor not anchored to the bed; there was urine in the bag. The resident could not answer any direct questions. <BR/>During an interview with RN E on 2/14/24 at 11:47 AM, RN E stated Resident #5's catheter bag was on the floor and should have been anchored. RN E stated there was an odor in the room. RN E stated the catheter bag on the floor could be an infection control concern.<BR/>During an interview with LVN F on 2/14/24 at 11:50 AM, LVN F stated the resident's catheter bag was on the floor and it could present an infection control concern. LVN F stated the, aides turned the resident and may have forgotten to anchor the bag. LVN F stated the charge nurse [LVN G] on the floor was responsible for checking on nurse aides and there activities around catheter care.<BR/>During an interview with LVN G (charge nurse) on 2/14/24 at 11:55 AM, LVN G (charge nurse) stated Resident #5's catheter bag was on the floor and it could present an infection control concern. LVN G stated it was his/her responsibility to follow-up on nurse aides when they provided catheter services to Resident #5. <BR/>During an interview with the DON on 2/15/24 at 10:31 AM, the DON stated Resident #5's catheter bag should have been anchored and the resident's bed was at the lowest position due to fall risk. The DON Stated the resident's catheter bag should be anchored because if exposed on the floor it could create an infection control issue. The DON stated the wound nurse (LVN H) while re-positioning the resident after wound care on 2/14/24 should have anchored the catheter bag to the bed. The DON stated in lowering the bed to a lowered position the bag may have un-hooked off the bed and laid on the floor. The DON did not offer an explanation as to why LVN H did not check the position of the catheter bag before leaving Resident #5's room. <BR/>Record review of the facility's policy titled, Catheter Care/Indwelling, undated, revealed: It is the policy of this facility that each resident with an indwelling catheter will received catheter care daily .Monitoring of leg strap and level of drainage bag as indicated .Keep tubing below level of bladder .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodations of residents needs and preferences for 3 of 6 residents (Residents #1 #2, and #4) reviewed for accommodations of needs.<BR/>The facility failed to ensure Residents (#1, #2, and #4,) call lights were answered in a timely manner when they needed assistance. <BR/>This failure could place residents at risk of not receiving care or attention needed.<BR/>The findings were:<BR/>Record review of Resident #1's face sheet dated 1/6/2024 revealed an [AGE] year-old male with an admission date of 12/29/2023. His diagnosis included chronic kidney disease stage 3(your kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood.), vascular dementia(is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage), polyneuropathy(is when multiple peripheral nerves become damaged. Symptoms include problems with sensation, coordination, or other body functions.), major depressive disorder recurrent, and repeated falls.<BR/>Record review of Resident #1's admission MDS assessment, dated 1/2/2024, revealed Resident #1's had a BIMS score of 13, which indicated cognitively alert. Section G functional status revealed Resident #1 required one-person physical assist for transfers, bed mobility, and dressing.<BR/>During an observation/interview on 1/6/2024 at 9:10 a.m. revealed Resident #1 was in his room in bed. He was in a hospital gown. <BR/>During an interview he stated, the staff do not answer my call light when I need help. It takes them along time. I am unable to get myself dressed, and I need help being changed. He further stated, I don't not like to be wet, or unclean, it makes me sad. Surveyor was in room with call light on for 35 minutes until staff answered it.<BR/>During an interview on 1/6/2024 at 9:45 a.m. LVN B confirmed Resident #1 was in bed and call light had not been answered by staff. She stated, the nurse aides are very busy, and we try to answer the call lights as quick as we can, but sometimes we do not have enough staff, or we the nurses are passing medications. She further revealed residents call light should be answered by staff within 15 minutes of them turning it on.<BR/>During an interview on 1/6/2024 at 9:50 am CNA D stated, we answer the call lights as quick as we can. When we are giving residents care, the nurses should answer the residents call lights. <BR/>During a telephone interview on 1/8/2024 at 9:20 am Resident #1's responsible party, revealed he needed assistance by staff and would turn his call light on, but it would take sometimes an hour for them to answer it. She further revealed that Resident #1 did not like to be unclean as he had always been very conscientious of his appearance and cleanliness.<BR/>Record review of Resident #2's face sheet revealed a [AGE] year-old female with an original admission date of 12/19/2019 and a recent readmission date of 4/17/2022 with diagnoses of unspecified dementia, Diabetes Mellitus type 2, overflow incontinence, and major depressive disorder recurrent. <BR/>Record review of Resident #2's Quarterly MDS assessment dated [DATE], revealed she had a BIMS score of 15, which indicated moderately cognitively impaired. Section G mobility revealed she required 2-person physical assist.<BR/>During an observation/interview on 1/6/2024 at 10:00 a.m. revealed Resident #2 was in her room in her wheelchair. She was alert and oriented. She revealed she was incontinent of bladder and required staff to assist her. She further revealed most of the time it will take at least an hour for the call light to be answer. She stated, I turn my call light on when I need help like changing my brief and it will stay on for an hour and has even stayed on as long as two hours. She stated it makes me mad, because they are here to help me, they need more staff. <BR/>During an interview on 1/6/2024 at 10:05 a.m. LVN B confirmed Resident #2 would use her call light. She further revealed if the nurse aides are busy with other residents any staff can answer a call light.<BR/>Record review of Resident #4's face sheet revealed a [AGE] year-old male with an admission date of 6/28/2023 revealed diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia(difficulty with speech), and Diabetes Mellitus type 2.<BR/>Record review of Resident #4's quarterly MDS assessment dated [DATE], revealed he had a BIMS score of 15, which indicated moderately cognitively impaired. Section G mobility revealed he required 1-person physical assist.<BR/>During an observation/interview on 1/6/2024 at 10:15 a.m. revealed Resident #4 was in the hallway in his wheelchair. When asked by surveyor how he was doing, he stated I am mad. Resident #4 revealed he was mad because his call light had not been answered the morning of 1/6/2024 for over 3 hours. He stated, if they come in, they turn it off and then say they will come back, but don't. I need help having my brief changed. Resident #4 further revealed he feels sad and dirty when he is not helped. <BR/>During an interview on 1/6/2024 at 10:20 a.m. LVN B confirmed Resident #4 required assistance with incontinent care. LVN B revealed a residents call light should be answered by staff within 15-30 minutes of them turning it on. LVN B further revealed if the nurse aides were taking care of other residents, we help them if we can and she did not know why his call light had not been answered.<BR/>During an observation on 1/8/2024 at 9:30 a.m., Resident #4's call light was on. Surveyor knocked on door and asked to enter. Resident #4 was standing by his bedside. He revealed he had his call light on for an hour. He stated, I have had my call light on and off this morning since 7:00 am, someone will come in and say they will be back but did not come back. <BR/>During an interview on 1/8/2024 at 9:35 a.m. CNA E stated she was assisting other residents this am and giving showers to residents and could not answer Resident #4's call light. She stated, I am here now to help him. She further revealed if she was busy with other residents the nurses should answer call lights.<BR/>During an interview on 1/6/2024 at 1:30 p.m. the facility Administrator stated all residents should have call lights answered in a timely manner. He further revealed 30 minutes or less should be the time frame to be answered by staff when a resident calls for assistance. Administrator further revealed we have enough staff working each shift to take care of the current census of residents.<BR/>During an interview on 1/8/2024 at 3:00 p.m. the facility ADON stated all residents should have call lights answered in a timely manner. She further revealed her expectation was 30 minutes or less to be answered by staff when a resident calls for assistance. <BR/>During an interview on 1/8/2024 at 3:10 p.m. the facility DON stated all residents should have call lights answered in a timely manner. She further revealed her expectation was 30 minutes or less to be answered by staff when a resident calls for assistance.<BR/>Record review of facility policy undated, titled: Routine procedures. Subject: Call lights/Bell. It is the policy of this facility to provide the resident a means of communication with nursing staff. 1. Answer the light/bell within a reasonable time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide the necessary services to maintain good personal hygiene for 4 of 5 residents (Residents #1, #2, #3, and #4,) reviewed for activities of daily living.<BR/>1. Resident #1 had no showers between dates of 12/29/2023-1/7/2024. <BR/>2. Resident #2 had 3 showers between dates of 12/25/2023-1/7/2024.<BR/>3. Resident #3 had 2 showers between dates of 12/25/2023-1/7/2024.<BR/>4. Resident #4 had 2 showers between dates of 12/25/2023-1/7/2024.<BR/>This failure could affect residents and contributed to feelings of hopelessness and frustration.<BR/>The findings were:<BR/>Review of Resident # 1's face sheet dated 1/6/2024 revealed admission into facility on 12/29/2023 with diagnoses to include chronic kidney disease, stage 3(mild to moderate loss of kidney function.),vascular dementia without behavioral disturbance(A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.), major depressive disorder recurrent (a mood disorder that causes a persistent feeling of sadness and loss of interest.) and repeated falls.<BR/>Review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 13 indicating minimal cognitive impairment. ADLs not yet determined for assistance on MDS.<BR/>Record review of Resident #1's EMR for bathing dated 12/29/23- 1/6/2024 revealed dates were marked as not applicable for bathing activity. There was no indication of Resident #1 receiving showers or bed baths on the above dates.<BR/>Observation/interview on 1/8/2024 at 9:00 a.m. revealed Resident #1 lying in bed in low position. Resident #1 presented as being alert and oriented. He stated he had not had a shower since he had been admitted , until this morning. He further stated, I don't like not having a shower every day. Since I cannot control my bladder, I feel I need to be clean. <BR/>Phone interview on 1/8/2024 at 9:05 a.m. with Resident #1's RP revealed Resident #1 had not had a shower until this am since he had been admitted to the facility on [DATE]. She further stated, I expect him to be taken better care of than he has been, and he should get a shower every day if not three times a week as the facility told me. She revealed her likes to be groomed and dressed every day. She stated, it makes him depressed if he is not clean.<BR/>Interview on 1/8/2024 at 9:40 am with CNA E confirmed Resident #1 told her he had not had a shower since he had been admitted . She revealed she had been off and did not know why he had not had a shower as he was scheduled for Monday, Wednesday, and Fridays on the 6:00 am to 2:00pm shift.<BR/>Review of Resident # 2's face sheet dated 1/6/2024 revealed an original admission date of 12/18/2019 with recent re-admission date of 4/17/2022 into facility with diagnosis to include unspecified dementia without behaviors, Diabetes Mellitus type 2, overflow urinary incontinence, chronic gout, major depressive disorder recurrent, and anxiety disorder.<BR/>Review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating minimal cognitive impairment and that she required extensive assistance by 2 staff for most ADS's including showers.<BR/>Record review of Resident #2's EMR for bathing dated 12/29/23-1/6/2024 revealed dates were marked as not applicable for bathing activity. There was as indication of Resident #2 receiving 3 showers on the above dates.<BR/>Observation/interview on 1/6/2024 at 9:00 a.m. revealed Resident #2 sitting in wheelchair in room beside bed. She was watching TV Resident #2 presented as being alert and oriented. She revealed she required assistance from staff for her care. She further revealed she had not had a shower but twice in the last 14 days. When asked why she had not had a shower, she stated because the staff said they did not have enough of help. She further stated, I like to have a shower every other day. Since I cannot control my bladder. I do not want to stink. That embarrass me.<BR/>Interview on 1/6/2024 at 9:30 am with CNA D confirmed Resident #2 told her she had not had a shower for 2 weeks. CNA D further stated she told Resident #2 that she would be getting a shower on Monday on the 6 am-PM shift as this was her regular day.<BR/>Interview on 1/6/2024 at 9:50 am with LVN B revealed resident #2 had not had showers as she should have during the past 2 weeks. She further stated, we have been short staffed, so some residents have not gotten their showers like they should . <BR/>Review of Resident # 3's face sheet dated 1/6/2024 revealed an initial admission date of 11/16/2022 with readmission of 1/24/2023 with diagnosis to include fracture of base of skull right side, dysphagia, Diabetes Mellitus Type 2, depression and anxiety disorder.<BR/>Review of Resident #3's comprehensive MDS dated [DATE] revealed a BIMS score of 11 indicating minimal cognitive impairment and that she required extensive assistance by 1 or 2 staff for most ADS's including toileting. <BR/>Observation/Interview on 1/6/2024 at 10:00 am revealed Resident #3 lying down in bed. She presented as being alert and oriented. <BR/>When asked if she was receiving any showers at the facility by staff , she stated no not really. She stated, I I believe I only have had 2 maybe in the last few weeks. When asked why she had not received more showers. Resident #2 stated, the staff says they are short staff or do not have time to shower me. Resident #2 further revealed she felt she needed to be showered more often because she was incontinent and wanted to be clean. Resident #2 stated it is embarrassing to not have showers and be clean.<BR/>Interview on 1/6/2024 at 10:10 am CNA E revealed if it is not marked in the residents record as being done on the shower section, then the resident did not get a shower. She further revealed she did not know why Resident #3 did not get a shower on her regular shower days. CNA E stated , we are short staffed sometimes and cannot get to everybody. <BR/>Record review of Resident #4's face sheet revealed a [AGE] year-old male with an admission date of 6/28/2023 revealed diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, and Diabetes Mellitus type 2.<BR/>Record review of Resident #4 quarterly MDS (minimum data sheet) assessment dated [DATE], revealed he had a BIMS score of 15, which indicated moderately cognitively impaired. Section G mobility revealed he required 1-person physical assist.<BR/>During an observation/interview on 1/6/2023 at 10:15 a.m. revealed Resident #4 was in the hallway in his wheelchair. When asked by surveyor how he was doing, he stated I am mad. Resident #4 revealed he was mad because he did not get showers like he should. He revealed he should get showers by the staff 3 times a week but only had 2 or 3 in the last 2 weeks. Resident #4 further revealed he feels mad and dirty when he is not helped. When asked why he had not had showers , he revealed the staff tells him they are short or do not have time to shower him.<BR/>During an interview on 1/6/2023 at 10:20 a.m. LVN B confirmed Resident #4 required assistance with showers. LVN B further revealed the nurse aides have a shower schedule for the residents. She said sometimes the nurse aides may be short staffed and cannot give all the residents their showers.<BR/>Interview on 1/8/2024 at 2:50 p.m. with facility ADON revealed nurse aides document in residents EMR when a shower or bed bath occurs. She revealed if there was no documentation in the EMR or on shower sheets then the resident did not receive a bath. She further revealed she did not know why residents did not receive a bath/shower. She stated all residents should receive a bed bath or shower on the assigned dates and shift. She stated this was for the resident's dignity and health to be clean and cared for. <BR/>Interview on 1/8/2024 at 3:00 p.m. with facility DON revealed nurse aides document in residents EMR when a shower or bed bath occurs. She revealed it was her expectation that all residents should receive a bed bath or shower on the assigned dates and shift. She stated this was for the resident's dignity and health to be clean.<BR/>Record review of facility policy, titled; Routine procedures, Subject: Bath, Shower: It is the policy of the facility to promote cleanliness, stimulate circulation and assist in relaxation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly for 1 of 5 residents (Resident #4) reviewed for medication storage, in that:<BR/>The facility failed to ensure medications were not left on Resident #4's bed side table. <BR/>This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered.<BR/>The findings were:<BR/>Record review of Resident #4's face sheet, dated 4/4/24, revealed an [AGE] year-old male admitted to the facility on [DATE] with the diagnosis that included Acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), Chronic obstructive pulmonary disease, (refers to a group of diseases that cause airflow blockage and breathing-related problems), and Anxiety disorder (involves a constant feeling of anxiety or fear). <BR/>Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. <BR/>Record review of Resident #4's physician orders for April 2024, reviewed on 4/3/24 did not reveal an order to self-administer medications. <BR/>Observation on 04/03/2024 at 11:47 a.m. of Resident #4's room revealed there was a bottle of Fluticasone nasal spray 50 mcg, extra-strength Tylenol, and Voltaren gel 1 % on the bedside table<BR/>In an interview with Resident #4 on 4/3/24 at 12:05 p.m., the resident stated he purchased the over-the-counter medications from an online store and had them on his bedside table since he was admitted back to the facility sometime in November 2003. The resident further stated no one had given him a self-medication assessment. <BR/>During an interview with CNA B on 04/03/2024 at 12:55 p.m., CNA B stated a bottle of Fluticasone nasal spray 50 mcg, extra-strength Tylenol, and Voltaren gel 1 % were on the bedside table. CNA B stated the medications had been on Resident #4's bedside table for as long as she could recall but did not know why they were there. <BR/>During an Interview with LVN C, on 4/3/24 at 1:05 p.m., LVN C stated she was the assigned nurse for Resident # 4, and that a bottle of Fluticasone nasal spray 50 mcg, extra-strength Tylenol, and Voltaren gel 1 % were on the bedside table of Resident #4, because Resident #4 became upset when he was asked to move them to the medication cart for safe keeping. LVN C stated a self-medication assessment had not been conducted before the surveyor's intervention and medications left on the bedside table of Resident #4 risked possibly taking more medication than was ordered by the physician. <BR/>During an interview with the DON on 04/4/24/ at 9:53 a.m., the DON stated that a bottle of Fluticasone nasal spray 50 mcg, extra-strength Tylenol, and Voltaren gel 1 % were on the bedside table of Resident #4. The DON stated no medication should be left on any resident bedside table without a self-medication assessment, and a signed physician order as lack of risked the resident taking more than the prescribed dosage. <BR/>Record review of the facility's policy titled, Monitoring a Resident who Self-Administers Medications, undated, revealed, residents who self-administer medications will have a signed physician order.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 7 residents (Resident #58) reviewed for infection control, in that:<BR/>While administering medications for Resident #58, RN E touched the light fixture pull cord and power plug and, the bed remote with her gloved hands and did not changed her gloves and washed her hands before touching Resident #58's eyes area and administering eye drops to the resident. <BR/>These failures could place residents at-risk for infection due to improper care practices. <BR/>The findings include:<BR/>Record review of Resident #58's face sheet, dated 04/05/2024, revealed an admission date of 12/24/2021, and a readmission date of 06/28/2023, with diagnoses which included: Dysphagia (Difficulty in swallowing), Insomnia (Difficulty sleeping), Hemiplegia (Paralysis of one side of the body), Cerebral infarction (process that result in an area of dead tissue in the brain), Hypertension (High blood pressure), Vascular dementia (Decline in cognition caused by restricted blood flow).<BR/>Record review of Resident #58's Annual MDS assessment, dated 01/01/2024, revealed the resident had a BIMS score of 5 indicating severe impairment. Resident #58 required extensive assistance to total care.<BR/>Review of Resident #58's physician order, dated 04/05/2024, revealed an order for Artificial Tears Ophthalmic Solution (Artificial Tear Solution) Instill 1 drop in both eyes four times a day for dry eyes<BR/>Observation on 04/05/24 at 08:19 a.m. revealed while administering medications to Resident # 58, RN E did not demonstrate proper use of PPE (personal protective equipment) and hand hygiene. She washed her hands and donned gloves then, prior to administer eye drops to the resident, she touched the lights pull cord, the power cord and plug behind the bed on the wall and the bed remote. She did not change her gloves or sanitize her hands and administered the drops to Resident #58 and touched the resident face and eyes areas. <BR/>During an interview on 04/05/2024 at 8:58 a.m., RN E confirmed the environment around Resident #58 was considered contaminated. She confirmed she should have changed her gloves after touching the pull cord, power cord and the bed remote and before administering the eye drops and touching the resident's face. She confirmed receiving infection control training within the year. <BR/>During an interview with the DON on 04/05/2024 at 2:00 p.m., the DON confirmed the staff should have changed her gloves after touching the environment and before touching the eyes of the resident. She confirmed Infection control training was provided to the staff yearly and as needed if problem with infection control were noted . The facility checked skills yearly and spot check were by the ADONS. The facility had an infection preventionist overseeing infection control. <BR/>Review of annual skills check for RN E revealed RN E passed competency for hand hygiene and infection control during medications administration on 03/12/2024.<BR/>Review of facility policy, titled Hand hygiene, dated 10/2022, revealed Use an alcohol-based hand rub [ .] before preparing or handling medications [ .] after contact with objects in the immediate vicinity of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment ans supports for daily living safely for 4 of 30 rooms (Rooms #309, #316, #328, and #330) on the third floor of the facility and 1 of 3 halls (Hall C) on the third floor of the facility, in that: <BR/>1. The facility failed to repair a wall scrape behind a resident bed in room [ROOM NUMBER]. <BR/>2. The facility failed to repair a wall scrape behind a resident bed in room [ROOM NUMBER].<BR/>3. There were 2 of 3 light bulbs burnt in room [ROOM NUMBER]. <BR/>4. The wall between Rooms #328 and #330 showed signs of water damaged. <BR/>These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. <BR/>The findings included: <BR/>During an observation tour on 04/05/2024 from 10:45-10:50 a.m. with the Maintenance Director and the Administrator the following was noted: <BR/>1. Resident room [ROOM NUMBER] which was occupied had a scrap on the wall which measured 4x1 feet and included paint removal and was located behind the resident's bed. <BR/>2. Resident room [ROOM NUMBER] which was occupied had a scrap on the wall which measured 4x1 feet and included paint removal and was located behind the resident's bed. <BR/>During an interview with the Maintenance Director and Administrator on 04/05/24 at 11:00 a.m. the Administrator stated that staff uses the TELS work order notification system to alert the Maintenance Director of needed repairs. The Maintenance Director stated that he was not aware of a work order that was placed for wall repair on these two rooms. <BR/>Record review of facility work orders provided by the Maintenance Director for the time period of 6/6/23 through 3/30/24 did not reveal a work order placed for wall repair in room [ROOM NUMBER] and 316.<BR/>3. Observation on 04/04/2024 at 01:29 p.m., revealed that in room [ROOM NUMBER] 2 of the 3 light fixtures on top of the resident sink had bulbs that were burnt out and one had a bulb that was very dim. <BR/>Interview on 04/04/2024 at 1:35 p.m. CNA F and CNA G confirmed 2 of the bulbs were burnt out and the third one was probably going to burn out soon. They confirmed they could electronically report any issue with maintenance. They were not sure how long the bulbs had been burnt <BR/>Interview on 04/04/2024 at 1:40 p.m. with the resident in room [ROOM NUMBER] revealed she did not have concerns about the bulbs being burnt and revealed that the lights were very dim even with fully functional bulbs. She revealed the bulbs had been burn for 4 to 5 days. <BR/>Interview with the Administrator on 04/05/2024 at 8:30 a.m. confirmed lights bulbs should not be burnt in residents' rooms and that the staff could report directly to maintenance. <BR/>4. Observation on 04/04/2024 at 1:38 p.m. revealed the wall between Rooms #330 and #328 was showing sign of water infiltration. The paint was missing toward the middle of the wall by two power plugs. There was a small open area were the ceiling tiles and wall meet.<BR/>Interview with the Administrator on 04/05/2024 at 8:30 a.m. confirmed he knew about the damage on the wall between Rooms #328 and #330 and the damages had been there for a few weeks. The Administrator revealed there was a problem overtime it rained and the condensation of the air conditioning was also a problem. <BR/>Record review of the facility's preventative Maintenance and Inspections Policy dated 05/2007 stated that inspections by the Maintenance Director which include resident rooms are to be completed on a regular basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 4 of 24 residents (Residents #58, #35, #74, and #233) reviewed for care plans, in that:<BR/>1. The facility failed to develop a comprehensive care plan that addressed Residents #58's anti-coagulant therapy.<BR/>2. The facility failed to develop a comprehensive care plan that addressed Resident #74's anti-coagulant therapy.<BR/>3. The facility failed to develop a comprehensive care plan that addressed Resident #233's anti-coagulant therapy.<BR/>4. The facility failed to develop a comprehensive care plan that addressed Resident #35's cognitive communication deficit.<BR/>These deficient practices could place residents at risk of receiving inadequate interventions that are not individualized to their care needs. <BR/>The findings included:<BR/>1. Record review of Resident #58's face sheet, dated 2/22/2023, revealed the [AGE] year old resident was admitted to the facility on [DATE] with diagnoses including: cerebral infarction (a condition caused by disrupted blood flow to the brain), vascular dementia (a condition in which there is brain damage caused by multiple strokes), and primary hypertension (a condition involving abnormally high blood pressure).<BR/>Record review of Resident #58's MDS, dated [DATE], revealed a BIMS score of 8, indicating moderate cognitive impairment.<BR/>Record review of Resident #58's Physician Summary Report, dated 2/22/23, revealed a prescription order for the medication Eliquis, an anticoagulant, with a start date of 9/30/2022.<BR/>Record review of Resident #58's care plan record on 2/22/23 revealed there was not a care plan for the anticoagulant medication order.<BR/>During an interview with the MDS Coordinator on 2/23/23 at 3:55 p.m., the MDS Coordinator stated that Resident #58's care plan for alteration in hematological status-thrombosis, dated 10/15/22, addressed the anticoagulant medication order. The MDS Coordinator stated that if the anticoagulant medication order was not care planned, the staff would not be aware of a potential health problem.<BR/>During an interview with the DON on 2/23/23 at 4:25 p.m. stated that Resident #58's care plan for alteration in hematological status-thrombosis was not a care plan that addressed an anticoagulant medication order. The DON stated that there was not a care plan in place that would address the Physician's anticoagulant order. The DON stated that having an anticoagulant care plan was important to address the resident's overall treatment.<BR/>2. Record review of Resident #74's face sheet dated 2/22/2023 revealed the [AGE] year-old Resident admitted on [DATE] with diagnoses that included Thrombocytopenia (a condition in which you have a low blood platelet count), cardiac arrhythmia, (an irregular heartbeat), and atrial fibrillation (arrhythmia occurs when the heart beats too slowly, fast, or irregularly).<BR/>Record review of Resident #74's admission MDS assessment, dated 01/23/23, revealed BIMS of 12, suggesting moderately impaired cognition.<BR/>Record review of Resident #74's Physician Orders for February 2023 revealed the order Apixaban with an order date of 01/21/2023 and no end date. <BR/>Record review of Resident #74's comprehensive person-centered care plan, revision date 02/20/2023, revealed Resident #74 had no care plan to address the use of Apixaban.<BR/>Record review of Resident #74's MAR (Medication Administration Record) for February 2023 revealed medication Apixaban was given daily in the morning. <BR/>During an interview on 2/23/2023 at 8:39 a.m., Resident #74 stated, Due to my Atrial Fibrillation, I must take a blood thinner daily. <BR/>3. Record review of Resident #233's face sheet, dated 02/23/2023, revealed the [AGE] year old resident admitted to the facility on [DATE], with diagnoses that included: Type 2 diabetes mellitus with hyperglycemia (high blood sugar level), Hyperlipidemia (a medical condition in which you have too much fat in your blood) and Hypertension (also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure). <BR/>Record review of Resident #233's admission MDS, dated [DATE], revealed the resident had a BIMS score of seven, which indicated the resident's cognition was severely impaired.<BR/>Record review of Resident #233's Physician Orders for February 2023 revealed the order Eliquis with an order date of 02/02/2023 and no end date. <BR/>Record review of Resident #233's comprehensive person-centered care plan, revision date 02/20/2023, revealed Resident #74 had no care plan to address the use of Eliquis.<BR/>Record review of Resident #233's MAR (Medication Administration Record) for February 2023 revealed medication Eliquis was given daily in the morning.<BR/>In an interview with Resident #233 on 02/24/2023 at 9:25 a.m., Resident #223 stated, I know I take a blood thinner but can't recall why. <BR/>During an interview with ADON B on 2/23/2023 at 1:20 p.m., he stated that at this facility, the charge nurse must administer blood thinners to include Residents #74 and #233. ADON B noted that this was done so the licensed nurse could monitor residents for bleeding. ADON B confirmed that this medication should be carefully planned and does not know why it was not done. ADON B stated that care plans were not currently in his area of expertise and referred the surveyor to the MDS Coordinator. <BR/>During a record review interview and confirmation with MDS Coordinator on 02/23/2023 at 10:02 a.m., MDS Coordinator confirmed that no comprehensive care plan was available to address the blood thinner use of Residents #74 and #233 was completed. MDS Coordinator stated that an incomplete comprehensive plan could negatively impact communication among nursing home staff, leading to unmet patient needs. MDS Coordinator did not know why comprehensive care plans were incomplete but would promptly complete them. <BR/>During an interview on 2/23/2023 at 3:00 p.m., the DON stated that all residents on blood thinners should be carefully monitored for bleeding precautions; not care planning a resident on a blood thinner was not best practice. The DON did not know why this was not care planned, but lack of care planning risked not everyone being on the same page. The DON stated the comprehensive person-centered care plan gave a true picture of how the resident was cared for.<BR/>4. Record review of Resident #35's electronic face sheet, dated 02/24/2023, revealed the [AGE] year-old resident admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (a condition caused by disrupted blood flow to the brain), aphasia (a comprehension and communication disorder resulting from damage or injury to the specific area in the brain), type II diabetes mellitus, cognitive communication deficit, and chronic kidney disease. <BR/>Record review of Resident #35's comprehensive care plan, updated 11/23/2022, revealed there was no focus area addressing Resident #35's cognitive communication deficit.<BR/>Record review of Resident #35's MDS (5-day scheduled assessment) dated 12/22/2022 revealed a BIMS of 3, indicating severe cognitive impairment. Record review of this MDS and also the Resident #35's admission MDS dated [DATE] revealed both included under Section I Active Diagnoses, I8000, Additional Diagnoses, E. Cognitive Communication Deficit.<BR/>Record review of Resident #35's admission physician's orders, dated 05/08/2022, revealed an order for Speech Therapy (ST) effective 05/08/2022. Review of Resident #35's EHR indicated he had received ST 4x/week.<BR/>An interview attempt on 02/02/21/2023 at 12:45 p.m. with Resident #35 located in the resident's room revealed he had difficulty speaking. The resident became tearful twice while attempting to speak. The surveyor stated, It must be frustrating to not be able to express what you want to say. Resident #35 nodded his head up and down in an affirmative manner. <BR/>Another interview attempt on 02/24/2023 at 8:20 p.m. with Resident #35 located in the dining room revealed Resident #35 again had difficulty speaking and used hand gestures to attempt to convey displeasure with meal items on his breakfast tray. Resident #35 again expressed distress over his inability to speak.<BR/>Interview on 02/23/2023 at 3:00 p.m. with the MDS Coordinator revealed when conducted the speech portion of the assessment, asked yes/no questions and understood Resident #35 when he responded, yes or no. The MDS Coordinator confirmed Resident #35 had a diagnosis of Communication Deficit, had an order for ST since 05/08/2022 and was receiving ST 4x/week. The MDS Coordinator further confirmed that there was no mention of a communication deficit in the resident's care plan. When asked why it was not there, the MDS Coordinator stated that he was still in the process of learning.<BR/>Interview with the MDS Coordinator on 02/24/20223 at 2:30 p.m., the MDS Coordinator stated that Resident #35 triggered for communication deficit during admission and subsequently during his assessments, so communication deficit should have been a focus area in his care plan. <BR/>Interview on 02/24/2023 at 2:40 p.m. with the ADON for long term care residents revealed that both she and another staff member completed the initial MDS for Resident #35, the resident triggered for Communication Deficit, and We definitely missed this as a team.<BR/>Interview with the facility's DON on 02/24/2023 at 2:55 p.m. revealed the DON confirmed that communication deficit was not in Resident #35's comprehensive care plan and should have been a focus area in this care plan.<BR/>Record review of the facility's policy titled Comprehensive -Person-Centered Care Planning, revised 1/2022, revealed, The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident received food that was served at a safe and appetizing temperature for 2 (Residents #1 and #77) of 22 Residents reviewed for palatable food in that:<BR/>Residents #1 and #77 reported receiving cold food at mealtimes.<BR/>This failure could place residents at risk of not being satisfied with their food or encouraged to increase their personal food intake with an outcome of weight loss and a diminished quality of life.<BR/>The findings were:<BR/>1. Record review of Resident #1's face sheet, dated 4/5/24, revealed the resident was last admitted to the facility on [DATE] with diagnoses including cerebral palsy ( a congenital disorder of movement, muscle tone, or posture), generalized anxiety disorder ( a condition of severe ongoing anxiety that interferes with daily activities), and hypertension( a condition of elevated blood pressure).<BR/>Record review of Resident # 1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. <BR/>During an interview with Resident #1 on 4/4/24 at 4:10 p.m., he stated that he had received a number of meals recently that had been cold. Resident #1 stated sometimes the staff offered to heat up the meals and sometimes they did not do so. The resident stated that if he was hungry enough he would just eat the food when it was cold.<BR/>2. Record review of Resident #77's face sheet, dated 4/5/24, revealed the resident was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease ( a condition in which the heart's major blood vessels are damaged), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), and hyperlipidemia ( a condition in which there are high levels of fat particles in the blood)<BR/>Record review of Resident #77's admission MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. <BR/>During an interview with Resident #77 on 4/4/24 at 4:30 p.m. he stated that before the meals served today, in the last three weeks, he had only had 3 meals that were not cold. The resident stated he would just eat the meals cold but he did not like them served that way.<BR/>During an interview with CNA D on 4/4/24 at 12:45 p.m., CNA D stated she had offered heat up meals in the micro-wave when residents stated that their breakfast or lunch was cold .<BR/>During an interview with LVN C on 4/4/24 at 1:50 p.m., she stated that some residents had complained about their breakfast and lunch meals being cold. LVN C stated the CNA staff could heat the meals up in the dining room microwave, or an alternative could be offered. LVN C stated she had gone to the kitchen at times to replace the meal when it was cold.<BR/>During an observation of breakfast meal service on 4/4/24 at 8:25 a.m. revealed six resident trays were noted to be placed on the top of the closed food cart that was brought to the second floor.<BR/>During an interview with HR Director who was assisting with passing out the trays, on 4/4/24 at 8:26 a.m., the HR Director stated some of the resident meal trays were placed on top of the food cart to better separate the trays which needed to go into the dining room.<BR/>During an observation on 4/4/24 at 8:35 a.m. the food temperature taken from one of the trays placed on top of the food cart revealed a temperature of 99.5 for sausage and 116.1 for the egg portion. On another resident's tray which had been on top of the food cart revealed regular sausage with a temp of 102.4 and eggs with a temperature of 122.8.<BR/>During an observation on 4/4/24 at 8:59 a.m. on the second floor food cart a temperature was taken from a resident's tray noting temperature for sausage of 120.4 and for the egg portion of 119.3<BR/>During an interview on 04/05/24 at 7:45 a.m. with the Activity Director she stated that the food being cold had been a voiced concern of the residents for the last several months.<BR/>Record review of FDA Food Code 2022 Annex 2. Reference 3-501.16-Time/Temperature Control for Safety Food Hot and Cold Holding. Referenced the temperature (165 degrees) that hot foods such as eggs and (155 degrees) for sausage should be served at in a long- term care setting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 15 residents (Resident #5) and for 1 of 1 facility in that:<BR/>The facility failed to adequately clean a resident dining room following meal service, clean a table over a two-day period, clean a spilled liquid area in cabinet holding the juice machine pump, repair broken shelving in a kitchen cabinet, repair a broken piece of kitchen cabinet surface, repair a broken kitchen cabinet door hinge, replace three missing ceiling tiles, and repair a resident's broken window blind.<BR/>This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.<BR/>The findings included:<BR/>Record review of Resident #5's face sheet, dated 11/8/23, revealed a [AGE] year old resident who was originally admitted to the facility on [DATE] with diagnoses which included: cerebral infarction (a condition in which the blood flow to the brain was disrupted) and spinal stenosis (a condition of the narrowing of the spinal canal).<BR/>Record review of the facility's Weekly Menu revealed on 11/06/2023 residents were served Assorted Juice, Cereal of Choice, Egg of choice, Bacon or Sausage, Pancake, Margarine, Syrup, Milk and Beverage.<BR/>During an observation of the dining room on the second-floor on 11/07/2023 at 10:18 a.m., revealed two masks and crumpled napkins on the floor, uncovered trays and drinks on tables, and a brown sticky substance spilled across a large area of one of the tables.<BR/>During an observation on 11/7/23 from 1040am until 1055am the following was noted:<BR/>1. The second floor dining room had a cabinet holding the juice machine and underneath the cabinet there was a 20'' by 20 middle compartment holding an air pump for the juice machine with spilled liquids on the floor surface and numerous live gnats were observed.<BR/>2. The left underneath section of the cabinet had two shelving units that were broken with spilled liquid noted underneath the broken shelves. <BR/>3. The top surface of the cabinet holding the juice machine had a broken piece of ceramic tile on the front surface which measured 3 in length. <BR/>4. On the third-floor dining room the cabinet holding the juice machine had a lower right cabinet door measured 20'' by 20 '' with a broken door hinge.<BR/>5. On the second floor in front of room [ROOM NUMBER] there was a missing ceiling tile which measured 2 ' by 2'.<BR/>6. On the third floor between rooms [ROOM NUMBERS] there were two missing ceiling tiles which measured 1' by 2' and 2' by 2'<BR/>During an observation on 11/08/2023 at 7:06 a.m., revealed the brown sticky substance to still be on the table in the second-floor dining room.<BR/>During an observation on 11/8/2023 at 2:25 pm., revealed the window blind in the room of Resident #5 was broken and was not able to adjust the individual window vents.<BR/>During an interview with the ADON on 11/07/2023 at 10:22 a.m., the ADON revealed the CNAs were responsible for clearing tables and housekeeping staff are responsible for the floors after every meal.<BR/>During an interview on 11/7/23 at 11:00 a.m., the Maintenance Director stated that he was not aware of the dining room cabinets on the second floor having underneath compartments with spilled liquids, the presence of gnats, broken shelving, and the third-floor dining room cabinet with a broken door hinge. He stated that he was aware of the missing ceiling tiles on the second and third floor which were removed due to leakage from a rainstorm. He stated that a roofing contractor will be addressing the roof leakage in the coming week.<BR/>During an interview on 11/7/23 at 11:10 a.m., the Housekeeping Supervisor stated that she was not aware of liquid spillage in the second-floor dining room cabinets holding the juice machine. She stated housekeeping was responsible for cleaning the area.<BR/>During an interview with the ADON on 11/08/2023 at 7:11 a.m., the ADON confirmed the substance to still be on the table and stated, this was very disappointing. The ADON attempted to scrub the substance off however revealed it was too thick to wipe away and she would contact housekeeping for a cleaner and disinfectant. The ADON confirmed this table was used for all meals and at least two meals had been served since discovered yesterday. The ADON further confirmed the potential risk to be infection control or food-borne illnesses.<BR/>During an interview with LVN A on 11/08/2023 at 7:13 a.m., LVN A revealed housekeeping cleaned the dining room following every meal.<BR/>During an interview with the Administrator on 11/08/2023 at 8:00 a.m., the Administrator revealed housekeeping is responsible for cleaning the floors in the dining room after meals. The Administrator further revealed the dietary staff and CNAs are responsible for the tables. The Administrator stated all staff are expected to work together to provide a clean environment for the residents and confirmed the potential risk for infection control.<BR/>During an interview with Housekeeper C on 11/08/2023 at 8:03 a.m., Housekeeper C revealed she cleaned the floors, walls, and employee lounge in the second-floor dining room.<BR/>During an interview with the DS on 11/08/2023 at 11:11 a.m., the DS revealed dietary staff are responsible for cleaning tables after every meal and added, we should have taken care of that. The DS revealed the department had been short staffed but stated that to be no excuse. The DS identified the substance to have likely been pancake syrup since the residents had been served pancakes the day before.<BR/>During an interview on 11/8/23 at 2:25p.m., family member of Resident #5 stated that the window blind was broken. She stated that he had spoken with several maintenance staff about the issue and was frustrated that it was not repaired.<BR/>During an interview on 11/9/23 at 9:25am the Maintenance Director noted the window blind for Resident #5 did not allow for the individual window vents to be easily adjusted. He stated that the window blind repair was on his to do list.<BR/>Review of the facility's policy for Preventative Maintenance and Inspection dated 05/2007 stated a preventative maintenance program was implemented which included inspections to promote safety and keep equipment in good operating order.<BR/>Record review of the facility's policy titled, Dietary, Sanitation in revised 10/2007, revealed, It is the policy of this facility that the food service area shall be maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects.<BR/>Record review of the facility's policy titled, Housekeeping Services/Cleanliness, revised 10/2007, revealed, It is the policy of this facility that the facility shall be maintained in a clean and sanitary manner. All rooms, living spaces, kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to coordinate the PASRR assessment for specialized services for 1 of 1 resident (Resident #1) reviewed for PASRR coordination and assessment, in that: <BR/>The facility failed to submit a NFSS (Nursing Facility Specialized Services) request for nursing facility specialized services in the LTC Online Portal for Resident #1's customized manual wheelchair (CMWC) by a specific deadline. <BR/>This failure could place residents with intellectual and developmental disabilities at risk for not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to a decline in physical, mental, psychosocial well-being and quality of life. <BR/>Findings included:<BR/>Record review of Resident #1's undated face sheet reflected Resident #1 was a [AGE] year old male resident who was originally admitted to the facility on [DATE] with diagnoses that included: generalized idiopathic epilepsy and epileptic syndromes (a group of epileptic disorders that are believed to have a strong underlying genetic basis and are prone to have cognitive dysfunctions), vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory), cognitive communication deficit, and muscle weakness. <BR/>Record review of Resident #1's quarterly MDS assessment, dated 03/02/23, reflected Resident #1 was cognitively intact with a BIMS score of 14/15. Further review revealed the resident required extensive assistance with bed mobility, transfer, dressing and toilet use; supervision with locomotion on and off unit and personal hygiene; limited assistance for eating. <BR/>Record review of Resident #1's care plan, initiated on 2/22/2023, reflected Resident #1 had a positive PASRR status related to DD. Further review revealed interventions included, IDT (Interdisciplinary team) meeting to be completed as required. PASRR evaluation to be completed by local authority. Specialized services will be provided as determined by IDT meeting. Therapy services as ordered.<BR/>Record review of Resident #1's initial PCSP form, dated 01/24/2023, reflected Resident #1 required a new CMWC. <BR/>Review of a PASRR Compliance Call Report for Feb. 2023 spreadsheet for Resident #1's DD services PASRR Unit indicated the following: <BR/>*IDT meeting was held on 01/24/2023, <BR/>*PCSP was created on 01/24/2023, <BR/>*IDT date plus 30 days was 02/23/2023,<BR/>*NF contacted 05/04/2023,<BR/>*Due date for NF to submit NFSS form in LTC portal for therapies was 05/10/2023. <BR/>Further review of the spreadsheet indicated Resident #1 needed a CMWC. <BR/>Record review of the undated Simple LTC PASRR NFSS Activity Portal History, for Resident #1, reflected services requested for CMWC indicated portal history #7, date 7/11/2023 revealed NFSS form request for CMWC/DME was not submitted within 30 calendar days of the IDT meeting. <BR/>Interview with the Administrator on 07/11/2023 at 12:08 pm revealed he was not aware of the resident's need for the CMWC, but he would connect the surveyor with their DOR as she would have more insight of the situation.<BR/>Interview with the DOR and the MDS Coordinator on 7/11/2023 at 2:41 pm revealed the DOR was unaware of the resident needing a CMWC under PASRR as Resident #1 already have a wheelchair that he utilized daily. When asked who would be responsible for making sure PASRR positive residents got their specialized services or DME the DOR said their facility did not have many PASRR residents. The DOR stated the last one they had was around 5 years ago, so they did not have a designated person for the oversight, and sometimes she would look at the request MDS would look at the request. The Surveyor specifically inquired about the IDT meeting held on 01/24/2023, and that was when the DOR found the PCSP dated 01/24/2023 which indicated the resident had added a new request for a CMWC and the DOR said she did not attend the IDT meeting. The DOR stated the MDS Coordinator was listed on the form, so the MDS Coordinator was added to the phone interview. The MDS Coordinator confirmed he attended the IDT meeting on 01/24/2023 for Resident #1. The MDS Coordinator confirmed the CMWC was discussed and added to the resident's PCSP. When asked if he was the person making sure the resident got their PASRR specialized services or DME, the MDS Coordinator stated the facility did not have a designated person but going forward the MDS should be monitoring the process. When asked what could be the adverse effect on the resident if they did not get their specialized services or DME or getting them late, the DOR said the risk would be the residents not getting the services and impact to their health condition. The MDS Coordinator confirmed the NFSS for the CMWC was submitted on 07/11/2023 to the LTC portal. <BR/>Record review of the facility policy dated 11/2016, and revision date 01/2022, titled, PASRR POLICY AND PROCEDURE, reflected in part: The facility will designate an individual to follow up on ALL residents have received a PASRR Level I screening. If facility serves a resident with a positive PASRR Level I screening, the facility MUST have obtained A PASRR Level II evaluation from the Local Authority or have documented attempts to follow up with the Local Authority to obtain the PASRR Level II evaluation . C. Coordinate with the local authority to ensure that the individual is properly assessed for any specialized services recommended in the Level II evaluation as being needed when a determination of ID, DD, or MI is made. (Under 40 TAC Chapter 19, the NF is responsible for assessing the individual for PT, OT, and ST needs and for Durable Medical Equipment. D. Convene the IDT meeting within 14 days. E. Provide nursing facility specialized services agreed to in the IDT meeting within 30 days after IDT meeting. F. Coordinate and cooperate with the LIDDA/LMHA Service Planning Team (SPT)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to ensure the MDS assessments accurately reflected the resident's status for 1 of 8 residents (Resident #230) reviewed for accuracy of assessments. <BR/>1. The facility failed to ensure the MDS assessment reflected Resident #230's diagnosis of diabetes Mellitus. <BR/>2. The facility failed to ensure the MDS assessment reflected Resident #230's diagnosis of bipolar disorder. <BR/>These deficient practices could place the residents at risk of not receiving the necessary care and services.<BR/>The findings included: <BR/>1. Record review of Resident #230's face sheet, dated 2/23/2023, revealed a 93- year old male admitted to the facility on [DATE] with diagnoses that included: [Type 2 diabetes mellitus] with hyperglycemia (high blood sugar level), [Atrial fibrillation] is irregular. Often very rapid heart rhythm can lead to blood clots in the heart. [Low Blood Pressure] Low blood pressure is generally considered a blood pressure reading lower than 90 millimeters of mercury (mm Hg) for the top number (systolic) or 60 mm Hg for the bottom number (diastolic) and [Bi-Polar] condition marked by alternating periods of elation and depression.<BR/>Record review of Resident #230's electronic face sheet, dated 02/23/2023, revealed a diagnosis of diabetes mellitus and bipolar disorder. <BR/>Record review of Resident #230's baseline care plan, undated, revealed no focus area or instructions for residents diagnosis of diabetes or bipolar disorder. <BR/>Record review of Resident's #230's electronic medical record Order Summary Report, dated 02/23/2023, revealed an order on 02/14/2023 for Glipizade 2 mg taken daily for diabetes mellitus. <BR/>Record review of Resident #230's admission MDS, dated [DATE], revealed the resident had a BIMS score blank, which indicated the resident's cognition was severely impaired and could not complete the interview. Further review revealed blank under section 1, metabolic, I2900, section was left unmarked, and section I, Psychiatric / Mood disorder, I5900, was left unmarked. <BR/>In a phone interview with Resident #230's family member on 02/24/2023 at 10:25 a.m., Resident #230's family member confirmed that Resident #230 was diabetic and bipolar. <BR/>During an interview and record review on 02/23/23 at 10:58 a.m., The MDS nurse stated it was a collaborative effort between him and the staff nurses to accurately assess residents, which then in turn produced an accurate MDS. the MDS nurse did not know why Resident #230 diagnoses were not included in the admission MDS. <BR/>During an interview and record review on 02/23/23 at 11:43 a.m., the Administrator stated the lack of documentation risked potential residents' negative outcomes for not accurately completing the MDS. The Administrator stated the expectation was for the MDS nurse to complete the MDS assessments accurately, reflecting the care patients are receiving. <BR/>Record review of the facility's policy titled, Electronic Transmission of the MDS, revised September 2017, revealed in part, All MDS assessments .will be completed and electronically encoded into our facility's MDS information system .6. The MDS Coordinator is responsible for ensuring that appropriate edits are made before transmitting MDS data .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 3 of 8 residents (Resident #233, Resident #237, and Resident #230) reviewed for a baseline care plan, in that: <BR/>1. The facility failed to ensure Resident #237's baseline care plan, undated, revealed no focus area or interventions for resident #237's use of pain medication [Norco].<BR/>2. The facility failed to ensure that Resident #233's baseline care plan included information related to the resident's diagnosis of diabetes mellitus. <BR/>3. The facility failed to ensure that Resident #230's baseline care plan included information related to the resident's diagnosis of diabetes mellitus and bipolar disorder. <BR/>This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. <BR/>The findings included:<BR/>1. Record review of Resident #237's Face Sheet, dated 02/23/2023, revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses: [Osteomyelitis] is an infection in a bone. [Benign prostatic hyperplasia] is an enlarged prostate, and [Hyperlipidemia] is a medical condition in which you have too much fat in your blood. <BR/>Record review of Resident #237's Baseline Care Plan, undated, revealed no focus area or or instructions for Resident #237's use of pain medication [Norco]. <BR/>Record review of Resident #237's admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated intact cognition. <BR/>Record review of Resident #237's electronic medical record Order Summary Report, dated 02/23/2023, revealed an order on 02/06/2023 for [Norco] to administer every six hours as needed for pain.<BR/>Record review of Resident #237's admission MDS, dated 0204/2023, revealed under section J, pain management, J 0100, B. received PRN pain med or was offered number one was selected, indicating pain medication was administered. <BR/>In an interview with Resident #237 on 02/23/2022 at 9:30 a.m., Resident #237 stated he requested his [Norco] about twice a day since it was ordered on 2/6/2023. The resident said, it makes me feel better because if I don't ask for it, I am in pain.<BR/>2. Record review of Resident #233's face sheet, dated 02/23/2023, revealed a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included: [Type 2 diabetes mellitus] with hyperglycemia (high blood sugar level), [Hyperlipidemia] is a medical condition in which you have too much fat in your blood and [Hypertension], also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure. <BR/>Record review of Resident #233's electronic face sheet, dated 02/23/2023, revealed a diagnosis of diabetes mellitus.<BR/>Record review of Resident #233's admission MDS, dated [DATE], revealed the resident had a BIMS score of 7, which indicated the resident's cognition was severely impaired. Further review revealed under section 1, metabolic, I2900, with an X indicating diabetes mellitus. <BR/>Record review of Resident #233's baseline care plan, undated, revealed no focus area or instructions for the resident's diagnosis of diabetes mellitus. <BR/>In an interview with Resident #233 on 02/24/2023 at 9:25 a.m., Resident #223 stated she had been diabetic for about forty years. <BR/>3. Record review of Resident #230's face sheet, dated 2/23/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: [Type 2 diabetes mellitus] with hyperglycemia (high blood sugar level), [Atrial fibrillation] is irregular. Often very rapid heart rhythm can lead to blood clots in the heart, [Low Blood Pressure] Low blood pressure is generally considered a blood pressure reading lower than 90 millimeters of mercury (mm Hg) for the top number (systolic) or 60 mm Hg for the bottom number (diastolic), and [Bi-Polar]A disorder associated with episodes of mood swings ranging from depressive lows to manic highs.<BR/>Record review of Resident #230's electronic face sheet, dated 02/23/2023, revealed a diagnosis of diabetes mellitus.<BR/>Record review of Resident #230's admission MDS, dated [DATE], revealed the resident had a BIMS score blank, which indicated the resident's cognition was severely impaired and could not complete the interview. Further review revealed blank under section 1, metabolic, I2900, section was left empty, and section was left blank under section I , I500. <BR/>Record review of Resident #230's baseline care plan, undated, revealed no focus area or instructions for the resident's diagnosis of diabetes mellitus or bipolar disorder . <BR/>Record review of Resident #230's electronic medical record Order Summary Report, dated 02/23/2023, revealed an order on 02/14/2023 for Glipizide 2 mg, take daily for diabetes Mellitus. <BR/>In a phone interview with Resident #230's family member on 02/24/2023 at 10:25 a.m., Resident #230's family member revealed that Resident #230 was diabetic and bipolar. <BR/>During an observation and interview with ADON B on 02/24/2023 at 9:47 a.m., ADON B confirmed that the resident's diagnosis of diabetes Mellitus was not included in the baseline care plan for Residents #233 and Resident #230. ADON B also confirmed that there was no baseline care plan to include pain management for Resident #237 ADON B stated that MDS and care plans were not currently in his area of expertise and referred the surveyor to the MDS Coordinator.<BR/>During a record review interview and confirmation with MDS Coordinator on 02/23/2023 at 10:02 a.m., MDS Coordinator confirmed the diagnosis of Diabetes Mellitus was not on the baseline care plan for Residents #233 and #230. The MDS Coordinator also confirmed no baseline care plan for Resident #237, indicating the use of pain medication [Norco]. The MDS Coordinator stated it was his job to complete the baseline care plan along with key interdisciplinary team members. The MDS Coordinator noted that an incomplete baseline care plan could negatively impact communication among nursing home staff, leading to unmet patient needs. The MDS Coordinator stated he did not know why baseline care plans were incomplete but would promptly complete them. <BR/>During an interview and confirmation with the DON on 02/24/2023 at 10:25 a.m., the DON confirmed that Residents #233, #230, and #237 needs should have been addressed on their baseline care plans. The DON stated she did not know why it was not completed but expected baseline care plans to reflect the patient's requirements to care for the first 48 hours completed by the MDS nurse. The DON stated the lack of a complete baseline care plan risk's not having all healthcare team members on the same page with residents leading to possible unmet resident needs. <BR/>Record review of the facility's policy titled, Comprehensive -Person-Centered Care Planning, revised 0/2022, revealed, The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 4 of 24 residents (Residents #58, #35, #74, and #233) reviewed for care plans, in that:<BR/>1. The facility failed to develop a comprehensive care plan that addressed Residents #58's anti-coagulant therapy.<BR/>2. The facility failed to develop a comprehensive care plan that addressed Resident #74's anti-coagulant therapy.<BR/>3. The facility failed to develop a comprehensive care plan that addressed Resident #233's anti-coagulant therapy.<BR/>4. The facility failed to develop a comprehensive care plan that addressed Resident #35's cognitive communication deficit.<BR/>These deficient practices could place residents at risk of receiving inadequate interventions that are not individualized to their care needs. <BR/>The findings included:<BR/>1. Record review of Resident #58's face sheet, dated 2/22/2023, revealed the [AGE] year old resident was admitted to the facility on [DATE] with diagnoses including: cerebral infarction (a condition caused by disrupted blood flow to the brain), vascular dementia (a condition in which there is brain damage caused by multiple strokes), and primary hypertension (a condition involving abnormally high blood pressure).<BR/>Record review of Resident #58's MDS, dated [DATE], revealed a BIMS score of 8, indicating moderate cognitive impairment.<BR/>Record review of Resident #58's Physician Summary Report, dated 2/22/23, revealed a prescription order for the medication Eliquis, an anticoagulant, with a start date of 9/30/2022.<BR/>Record review of Resident #58's care plan record on 2/22/23 revealed there was not a care plan for the anticoagulant medication order.<BR/>During an interview with the MDS Coordinator on 2/23/23 at 3:55 p.m., the MDS Coordinator stated that Resident #58's care plan for alteration in hematological status-thrombosis, dated 10/15/22, addressed the anticoagulant medication order. The MDS Coordinator stated that if the anticoagulant medication order was not care planned, the staff would not be aware of a potential health problem.<BR/>During an interview with the DON on 2/23/23 at 4:25 p.m. stated that Resident #58's care plan for alteration in hematological status-thrombosis was not a care plan that addressed an anticoagulant medication order. The DON stated that there was not a care plan in place that would address the Physician's anticoagulant order. The DON stated that having an anticoagulant care plan was important to address the resident's overall treatment.<BR/>2. Record review of Resident #74's face sheet dated 2/22/2023 revealed the [AGE] year-old Resident admitted on [DATE] with diagnoses that included Thrombocytopenia (a condition in which you have a low blood platelet count), cardiac arrhythmia, (an irregular heartbeat), and atrial fibrillation (arrhythmia occurs when the heart beats too slowly, fast, or irregularly).<BR/>Record review of Resident #74's admission MDS assessment, dated 01/23/23, revealed BIMS of 12, suggesting moderately impaired cognition.<BR/>Record review of Resident #74's Physician Orders for February 2023 revealed the order Apixaban with an order date of 01/21/2023 and no end date. <BR/>Record review of Resident #74's comprehensive person-centered care plan, revision date 02/20/2023, revealed Resident #74 had no care plan to address the use of Apixaban.<BR/>Record review of Resident #74's MAR (Medication Administration Record) for February 2023 revealed medication Apixaban was given daily in the morning. <BR/>During an interview on 2/23/2023 at 8:39 a.m., Resident #74 stated, Due to my Atrial Fibrillation, I must take a blood thinner daily. <BR/>3. Record review of Resident #233's face sheet, dated 02/23/2023, revealed the [AGE] year old resident admitted to the facility on [DATE], with diagnoses that included: Type 2 diabetes mellitus with hyperglycemia (high blood sugar level), Hyperlipidemia (a medical condition in which you have too much fat in your blood) and Hypertension (also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure). <BR/>Record review of Resident #233's admission MDS, dated [DATE], revealed the resident had a BIMS score of seven, which indicated the resident's cognition was severely impaired.<BR/>Record review of Resident #233's Physician Orders for February 2023 revealed the order Eliquis with an order date of 02/02/2023 and no end date. <BR/>Record review of Resident #233's comprehensive person-centered care plan, revision date 02/20/2023, revealed Resident #74 had no care plan to address the use of Eliquis.<BR/>Record review of Resident #233's MAR (Medication Administration Record) for February 2023 revealed medication Eliquis was given daily in the morning.<BR/>In an interview with Resident #233 on 02/24/2023 at 9:25 a.m., Resident #223 stated, I know I take a blood thinner but can't recall why. <BR/>During an interview with ADON B on 2/23/2023 at 1:20 p.m., he stated that at this facility, the charge nurse must administer blood thinners to include Residents #74 and #233. ADON B noted that this was done so the licensed nurse could monitor residents for bleeding. ADON B confirmed that this medication should be carefully planned and does not know why it was not done. ADON B stated that care plans were not currently in his area of expertise and referred the surveyor to the MDS Coordinator. <BR/>During a record review interview and confirmation with MDS Coordinator on 02/23/2023 at 10:02 a.m., MDS Coordinator confirmed that no comprehensive care plan was available to address the blood thinner use of Residents #74 and #233 was completed. MDS Coordinator stated that an incomplete comprehensive plan could negatively impact communication among nursing home staff, leading to unmet patient needs. MDS Coordinator did not know why comprehensive care plans were incomplete but would promptly complete them. <BR/>During an interview on 2/23/2023 at 3:00 p.m., the DON stated that all residents on blood thinners should be carefully monitored for bleeding precautions; not care planning a resident on a blood thinner was not best practice. The DON did not know why this was not care planned, but lack of care planning risked not everyone being on the same page. The DON stated the comprehensive person-centered care plan gave a true picture of how the resident was cared for.<BR/>4. Record review of Resident #35's electronic face sheet, dated 02/24/2023, revealed the [AGE] year-old resident admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (a condition caused by disrupted blood flow to the brain), aphasia (a comprehension and communication disorder resulting from damage or injury to the specific area in the brain), type II diabetes mellitus, cognitive communication deficit, and chronic kidney disease. <BR/>Record review of Resident #35's comprehensive care plan, updated 11/23/2022, revealed there was no focus area addressing Resident #35's cognitive communication deficit.<BR/>Record review of Resident #35's MDS (5-day scheduled assessment) dated 12/22/2022 revealed a BIMS of 3, indicating severe cognitive impairment. Record review of this MDS and also the Resident #35's admission MDS dated [DATE] revealed both included under Section I Active Diagnoses, I8000, Additional Diagnoses, E. Cognitive Communication Deficit.<BR/>Record review of Resident #35's admission physician's orders, dated 05/08/2022, revealed an order for Speech Therapy (ST) effective 05/08/2022. Review of Resident #35's EHR indicated he had received ST 4x/week.<BR/>An interview attempt on 02/02/21/2023 at 12:45 p.m. with Resident #35 located in the resident's room revealed he had difficulty speaking. The resident became tearful twice while attempting to speak. The surveyor stated, It must be frustrating to not be able to express what you want to say. Resident #35 nodded his head up and down in an affirmative manner. <BR/>Another interview attempt on 02/24/2023 at 8:20 p.m. with Resident #35 located in the dining room revealed Resident #35 again had difficulty speaking and used hand gestures to attempt to convey displeasure with meal items on his breakfast tray. Resident #35 again expressed distress over his inability to speak.<BR/>Interview on 02/23/2023 at 3:00 p.m. with the MDS Coordinator revealed when conducted the speech portion of the assessment, asked yes/no questions and understood Resident #35 when he responded, yes or no. The MDS Coordinator confirmed Resident #35 had a diagnosis of Communication Deficit, had an order for ST since 05/08/2022 and was receiving ST 4x/week. The MDS Coordinator further confirmed that there was no mention of a communication deficit in the resident's care plan. When asked why it was not there, the MDS Coordinator stated that he was still in the process of learning.<BR/>Interview with the MDS Coordinator on 02/24/20223 at 2:30 p.m., the MDS Coordinator stated that Resident #35 triggered for communication deficit during admission and subsequently during his assessments, so communication deficit should have been a focus area in his care plan. <BR/>Interview on 02/24/2023 at 2:40 p.m. with the ADON for long term care residents revealed that both she and another staff member completed the initial MDS for Resident #35, the resident triggered for Communication Deficit, and We definitely missed this as a team.<BR/>Interview with the facility's DON on 02/24/2023 at 2:55 p.m. revealed the DON confirmed that communication deficit was not in Resident #35's comprehensive care plan and should have been a focus area in this care plan.<BR/>Record review of the facility's policy titled Comprehensive -Person-Centered Care Planning, revised 1/2022, revealed, The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager (DM) reviewed for qualified dietary staff, in that: <BR/>The DM failed to ensure there were recipes for all pureed menu items in the kitchen.<BR/>This failure could place residents prescribed a pureed diet at risk for not receiving adequate nutrition and/or weight loss.<BR/>The findings included:<BR/>Review on 02/23/2023 at 10:45 am of the recipe binder in the facility's only kitchen revealed did not contain recipes with instructions on how to prepare pureed menu items for residents prescribed a pureed diet.<BR/>Review of the menu for the pureed diet for Day 3, Week 2 of the menu cycle revealed it was: Pureed fried chicken (1/2 cup); cream gravy, 1/4 cup; pureed mashed potatoes, 1/2 cup; pureed honey-glazed carrots, 3/8 cup; pureed roll, 3/8 cup; margarine, 1 each; pureed lemon bar, 1/4 cup.<BR/>Review of the Resident Diet Roster provided by the facility on 02/21/2023 revealed there were seven residents receiving a pureed diet, comprising 10% of the residents eating meals from the kitchen. Further review of the Resident Diet Roster revealed that six of the seven residents prescribed a pureed diet sustained weight loss over a 6-month period. The weight loss ranged from 4 lbs. - 11 lbs. <BR/>Interview on 02/23/2023 at 10:45 a.m. with [NAME] A revealed that [NAME] A prepared the pureed chicken for the lunch meal and did not follow a recipe to prepare the pureed chicken. When asked about the method of preparation, [NAME] A stated he used the juices from the pan of the baked chicken to achieve the pureed consistency. [NAME] A stated that he'd worked at the facility for 6 years and had been trained on using recipes from the former DM.<BR/>Interview on 02/23/2023 at 10:50 a.m. with the DM revealed that she searched thoroughly through the binder of recipes provided by their food supplier and in her office, and she could not find recipes for any of the pureed menu items on the five-week menu cycle. When asked why there were no recipes instructing cooks how to properly prepare pureed food, the DM stated that she'd taken over the position of DM two months prior and did not realize they were missing. The DM stated she understood the importance of providing recipes to the cooks, especially for pureed items, to ensure they are prepared correctly, preserve nutritional adequacy, and result in the appropriate consistency.<BR/>Interview with the facility's contract registered dietitian (RD) on 02/23/2023 at 11:39 a.m. revealed that the facility did not have the pureed recipes in the kitchen and they should have been present in the kitchen for cooks to use. The RD stated that while the 6 residents on a pureed diet who had lost weight did not sustain a significant weight loss, It is a pattern.<BR/>Record review of Consulting Dietitian Report dated 01/27/2023 revealed that during this RD visit, the RD had done the following: Planned/revised/reviewed and signed menus; planned and discussed therapeutic diets; designed/revised and reviewed dietary records; observed meal preparation; observed meal service; discussed personnel administration and discussed general dietary department administration.<BR/>Review of facility policy Dietary Supervision, undated, revealed, Policy: The Dietary Manager is appointed by the Administrator and is responsible for the total Dietary program in the facility. Procedure: All dietary personnel work under the direction of, and are responsible to the dietary manager. The Manager is responsible, either directly or indirectly, for the preparation and serving of all diets; maintenance of acceptable standards of food preparation and service; work assignments, schedules and records; selection, orientation, training and supervision of all dietary employees in the use and care of all equipment. The Dietary manager receives regularly scheduled consultation from a Registered Dietitian. Written reports of visits and recommendations are submitted by the dietitian to the Administrator, Dietary Manager and the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodations of residents needs and preferences for 3 of 6 residents (Residents #1 #2, and #4) reviewed for accommodations of needs.<BR/>The facility failed to ensure Residents (#1, #2, and #4,) call lights were answered in a timely manner when they needed assistance. <BR/>This failure could place residents at risk of not receiving care or attention needed.<BR/>The findings were:<BR/>Record review of Resident #1's face sheet dated 1/6/2024 revealed an [AGE] year-old male with an admission date of 12/29/2023. His diagnosis included chronic kidney disease stage 3(your kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood.), vascular dementia(is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage), polyneuropathy(is when multiple peripheral nerves become damaged. Symptoms include problems with sensation, coordination, or other body functions.), major depressive disorder recurrent, and repeated falls.<BR/>Record review of Resident #1's admission MDS assessment, dated 1/2/2024, revealed Resident #1's had a BIMS score of 13, which indicated cognitively alert. Section G functional status revealed Resident #1 required one-person physical assist for transfers, bed mobility, and dressing.<BR/>During an observation/interview on 1/6/2024 at 9:10 a.m. revealed Resident #1 was in his room in bed. He was in a hospital gown. <BR/>During an interview he stated, the staff do not answer my call light when I need help. It takes them along time. I am unable to get myself dressed, and I need help being changed. He further stated, I don't not like to be wet, or unclean, it makes me sad. Surveyor was in room with call light on for 35 minutes until staff answered it.<BR/>During an interview on 1/6/2024 at 9:45 a.m. LVN B confirmed Resident #1 was in bed and call light had not been answered by staff. She stated, the nurse aides are very busy, and we try to answer the call lights as quick as we can, but sometimes we do not have enough staff, or we the nurses are passing medications. She further revealed residents call light should be answered by staff within 15 minutes of them turning it on.<BR/>During an interview on 1/6/2024 at 9:50 am CNA D stated, we answer the call lights as quick as we can. When we are giving residents care, the nurses should answer the residents call lights. <BR/>During a telephone interview on 1/8/2024 at 9:20 am Resident #1's responsible party, revealed he needed assistance by staff and would turn his call light on, but it would take sometimes an hour for them to answer it. She further revealed that Resident #1 did not like to be unclean as he had always been very conscientious of his appearance and cleanliness.<BR/>Record review of Resident #2's face sheet revealed a [AGE] year-old female with an original admission date of 12/19/2019 and a recent readmission date of 4/17/2022 with diagnoses of unspecified dementia, Diabetes Mellitus type 2, overflow incontinence, and major depressive disorder recurrent. <BR/>Record review of Resident #2's Quarterly MDS assessment dated [DATE], revealed she had a BIMS score of 15, which indicated moderately cognitively impaired. Section G mobility revealed she required 2-person physical assist.<BR/>During an observation/interview on 1/6/2024 at 10:00 a.m. revealed Resident #2 was in her room in her wheelchair. She was alert and oriented. She revealed she was incontinent of bladder and required staff to assist her. She further revealed most of the time it will take at least an hour for the call light to be answer. She stated, I turn my call light on when I need help like changing my brief and it will stay on for an hour and has even stayed on as long as two hours. She stated it makes me mad, because they are here to help me, they need more staff. <BR/>During an interview on 1/6/2024 at 10:05 a.m. LVN B confirmed Resident #2 would use her call light. She further revealed if the nurse aides are busy with other residents any staff can answer a call light.<BR/>Record review of Resident #4's face sheet revealed a [AGE] year-old male with an admission date of 6/28/2023 revealed diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia(difficulty with speech), and Diabetes Mellitus type 2.<BR/>Record review of Resident #4's quarterly MDS assessment dated [DATE], revealed he had a BIMS score of 15, which indicated moderately cognitively impaired. Section G mobility revealed he required 1-person physical assist.<BR/>During an observation/interview on 1/6/2024 at 10:15 a.m. revealed Resident #4 was in the hallway in his wheelchair. When asked by surveyor how he was doing, he stated I am mad. Resident #4 revealed he was mad because his call light had not been answered the morning of 1/6/2024 for over 3 hours. He stated, if they come in, they turn it off and then say they will come back, but don't. I need help having my brief changed. Resident #4 further revealed he feels sad and dirty when he is not helped. <BR/>During an interview on 1/6/2024 at 10:20 a.m. LVN B confirmed Resident #4 required assistance with incontinent care. LVN B revealed a residents call light should be answered by staff within 15-30 minutes of them turning it on. LVN B further revealed if the nurse aides were taking care of other residents, we help them if we can and she did not know why his call light had not been answered.<BR/>During an observation on 1/8/2024 at 9:30 a.m., Resident #4's call light was on. Surveyor knocked on door and asked to enter. Resident #4 was standing by his bedside. He revealed he had his call light on for an hour. He stated, I have had my call light on and off this morning since 7:00 am, someone will come in and say they will be back but did not come back. <BR/>During an interview on 1/8/2024 at 9:35 a.m. CNA E stated she was assisting other residents this am and giving showers to residents and could not answer Resident #4's call light. She stated, I am here now to help him. She further revealed if she was busy with other residents the nurses should answer call lights.<BR/>During an interview on 1/6/2024 at 1:30 p.m. the facility Administrator stated all residents should have call lights answered in a timely manner. He further revealed 30 minutes or less should be the time frame to be answered by staff when a resident calls for assistance. Administrator further revealed we have enough staff working each shift to take care of the current census of residents.<BR/>During an interview on 1/8/2024 at 3:00 p.m. the facility ADON stated all residents should have call lights answered in a timely manner. She further revealed her expectation was 30 minutes or less to be answered by staff when a resident calls for assistance. <BR/>During an interview on 1/8/2024 at 3:10 p.m. the facility DON stated all residents should have call lights answered in a timely manner. She further revealed her expectation was 30 minutes or less to be answered by staff when a resident calls for assistance.<BR/>Record review of facility policy undated, titled: Routine procedures. Subject: Call lights/Bell. It is the policy of this facility to provide the resident a means of communication with nursing staff. 1. Answer the light/bell within a reasonable time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review failed to ensure that it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident for 4 of 6(Residents #1, #2,#3,#4,) residents.<BR/>1. The Administrator failed to ensure nursing staff were performing showers on Residents (1,2,3,4) causing the residents to receive no showers or only 3 showers in a two week period.<BR/>2. The Administrator failed to ensure all staff were answering resident call lights in a timely manner when they needed assistance.<BR/>This could place residents at risk of not receiving care or attention needed.<BR/>The findings were:<BR/>Record review of Resident #1's face sheet dated 1/6/2024 of an [AGE] year-old male with an admission date of 12/29/2023 revealed diagnoses of chronic kidney disease stage 3(your kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood.), vascular dementia(is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage), polyneuropathy(is when multiple peripheral nerves become damaged. Symptoms include problems with sensation, coordination, or other body functions.), major depressive disorder recurrent, and repeated falls.<BR/>Record review of Resident #1's admission MDS assessment, dated 1/2/2024, revealed Resident #1's had a BIMS score of 13, which indicated cognitively alert. Section G functional status revealed Resident #1 required one-person physical assist for transfers, bed mobility, and dressing.<BR/>During an observation/interview on 1/6/2024 at 9:10 a.m. revealed Resident #1 was in his room in bed. He was in a hospital gown. <BR/>During an interview he stated, the staff do not answer my call light when I need help. It takes them along time. I am unable to get myself dressed, and I need help being changed. He further stated, I don't not like to be wet, or unclean, it makes me sad. Surveyor was in room with call light on for 35 minutes until staff answered it.<BR/>During an interview on 1/6/2024 at 9:45 a.m. LVN B confirmed Resident #1 was in bed and call light had not been answered by staff. She stated, the nurse aides are very busy, and we try to answer the call lights as quick as we can, but sometimes we do not have enough staff, or we the nurses are passing medications. She further revealed residents call light should be answered by staff within 15 minutes of them turning it on.<BR/>During an interview on1/6/2024 at 9:50 am CNA D stated, we answer the call lights as quick as we can. When we are giving residents care, the nurses should answer the residents call lights. <BR/>During a telephone interview on 1/8/2024 at 9:20 am Resident #1's responsible party, revealed her father needed assistance by staff and would turn his call light on, but it would take sometimes an hour for them to answer it. She further revealed that Resident #1 did not like to be unclean as he had always been very conscientious of his appearance and cleanliness.<BR/>Record review of Resident #2's face sheet revealed a [AGE] year-old female with an original admission date of 12/19/2019 and a recent readmission date of 4/17/2022 with diagnoses of unspecified dementia, Diabetes Mellitus type 2, overflow incontinence, and major depressive disorder recurrent. <BR/>Record review of Resident #2 Quarterly MDS (minimum data sheet) assessment dated [DATE], revealed she had a BIMS score of 15, which indicated moderately cognitively impaired. Section G mobility revealed she required 2-person physical assist.<BR/>During an observation/interview on 1/6/2024 at 10:00 a.m. revealed Resident #2 was in her room in her wheelchair. Alert and oriented. She revealed she was incontinent of bladder and required staff to assist her. She further revealed most of the time it will take at least an hour for the call light to be answer. She stated, I turn my call light on when I need help like changing my brief and it will stay on for an hour and has even stayed on as long as two hours. When asked how that made her feel, she stated it makes me mad, because they are here to help me, they need more staff. <BR/>During an interview on 1/6/2024 at 10:05 a.m. LVN B confirmed Resident #2 will use her call light. She further revealed if the nurse aides are busy with other residents any staff can answer a call light.<BR/>Record review of Resident #4's face sheet revealed a [AGE] year-old male with an admission date of 6/28/2023 revealed diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia(difficulty with speech), and Diabetes Mellitus type 2.<BR/>Record review of Resident #4 quarterly MDS (minimum data sheet) assessment dated [DATE], revealed he had a BIMS score of 15, which indicated moderately cognitively impaired. Section G mobility revealed he required 1-person physical assist.<BR/>During an observation/interview on 1/6/2023 at 10:15 a.m. revealed Resident #4 was in the hallway in his wheelchair. When asked by surveyor how he was doing, he stated I am mad. Resident #4 revealed he was mad because his call light had not been answered the morning of 1/6/2024 for over 3 hours. He stated, if they come in, they turn it off and then say they will come back, but don't. I need help having my brief changed. Resident #4 further revealed he feels sad and dirty when he is not helped. <BR/>During an interview on 1/6/2023 at 10:20 a.m. LVN B confirmed Resident #4 required assistance with incontinent care. LVN B revealed a residents call light should be answered by staff within 15-30 minutes of them turning it on. LVN B further revealed if the nurse aides are taking care of other residents, we help them if we can and she did not know why his call light had not been answered.<BR/>During an observation on 1/8/2024 at 9:30 a.m., Resident #4's call light was on. Surveyor knocked on door and asked to enter. Resident #4 was standing by his bedside. He revealed he had his call light on for an hour. He stated, I have had my call light on and off this morning since 7:00am, someone will come in and say they will be back but did not come back. <BR/>During an interview on 1/8/2024 at 9:35 a.m. CNA E stated she was assisting other residents this am and giving showers to residents and could not answer Resident #4's call light. She stated, I am here now to help him. She further revealed if she is busy with other residents the nurses should answer call lights.<BR/>During an interview on 1/6/2024 at 1:30 p.m. the facility Administrator stated all residents should have call lights answered in a timely manner. He further revealed 30 minutes or less should be the time frame to be answered by staff when a resident calls for assistance.<BR/>During an interview on 1/8/2024 at 3:00 p.m. the facility ADON stated all residents should have call lights answered in a timely manner. She further revealed her expectation is 30 minutes or less to be answered by staff when a resident calls for assistance. <BR/>During an interview on 1/8/2024 at 3:10 p.m. the facility DON stated all residents should have call lights answered in a timely manner. She further revealed her expectation is 30 minutes or less to be answered by staff when a resident calls for assistance.<BR/>1. Resident #1 had no showers between dates of 12/29/2023-1/7/2024 <BR/>2. Resident #2 had 3 showers between dates of 12/25/2023-1/7/2024<BR/>3. Resident #3 had 2 showers between dates of 12/25/2023-1/7/2024<BR/>4. Resident #4 had 2 showers between dates of 12/25/2023-1/7/2024<BR/>Review of Resident # 1's face sheet dated 1/6/2024 revealed admission into facility on 12/29/2023 with diagnosis to include chronic kidney disease, stage 3(mild to moderate loss of kidney function.),vascular dementia without behavioral disturbance(A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.), major depressive disorder recurrent (a mood disorder that causes a persistent feeling of sadness and loss of interest.) and repeated falls.<BR/>Review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 13 indicating minimal cognitive impairment. ADLs not yet determined for assistance on MDS.<BR/>Record review of Resident #1's EMR for bathing dated 12/29/23- 1/6/2024 revealed dates were marked as not applicable for bathing activity. There was no indication of Resident #1 receiving showers or bed baths on the above dates.<BR/>Observation/interview on 1/8/2024 at 9:00 a.m. revealed Resident #1 lying in bed in low position. Resident #1 presented as being alert and oriented. He stated he had not had a shower since he had been admitted , until this morning. He further stated, I don't like not having a shower every day. Since I cannot control my bladder, I feel I need to be clean. <BR/>Phone interview on 1/8/2024 at 9:05 a.m. with Resident #1's responsible party revealed resident #1 had not had a shower until this am since he had been admitted to the facility on [DATE]. She further stated, I expect him to be taken better care of than he has been, and he should get a shower every day if not three times a week as the facility told me. She revealed her father likes to be groomed and dressed every day. She stated, it makes him depressed if he is not clean.<BR/>Interview on 1/8/2024 at 9:40 am with CNA E confirmed Resident #1 told her he had not had a shower since he had been admitted . She revealed she had been off and did not know why he had not had a shower as he was scheduled for Monday, Wednesday, and Fridays on the 6:00 am to 2:00pm shift.<BR/>Review of Resident # 2's face sheet dated 1/6/2024 revealed an original admission date of 12/18/2019 with recent re-admission date of 4/17/2022 into facility with diagnosis to include unspecified dementia without behaviors, Diabetes Mellitus type 2, overflow urinary incontinence, chronic gout, major depressive disorder recurrent, and anxiety disorder.<BR/>Review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating minimal cognitive impairment and that she required extensive assistance by 2 staff for most ADS's including showers.<BR/>Record review of Resident #2's EMR for bathing dated revealed dates were marked as not applicable for bathing activity. There was as indication of Resident #2 receiving 3 showers on the above dates.<BR/>Observation/interview on 1/6/2024 at 9:00 a.m. revealed Resident #2 sitting in wheelchair in room beside bed. She was watching T.V. Resident #2 presented as being alert and oriented. She revealed she required assistance from staff for her care. She further revealed she had not had a shower but twice in the last 14 days. When asked why she had not had a shower, she stated because the staff said they did not have enough of help. She further stated, I like to have a shower every other day. Since I cannot control my bladder. I do not want to stink. That embarrass me.<BR/>Interview on 1/6/2024 at 9:30 am with CNA D confirmed Resident #2 told her she had not had a shower for 2 weeks. CNA D further stated she told Resident #2 that she would be getting a shower on Monday on the 6am-2pm shift as this was her regular day.<BR/>Interview on 1/6/2024 at 9:50 am with LVN B revealed resident #2 had not had showers as she should have during the past 2 weeks. She further stated, we have been short staffed, so some residents have not gotten their showers like they should . <BR/>Review of Resident # 3's face sheet dated 1/6/2024 revealed an initial admission date of 11/16/2022 with readmission of 1/24/2023 with diagnosis to include fracture of base of skull right side, dysphagia, Diabetes Mellitus Type 2, depression and anxiety disorder.<BR/>Review of Resident #3's comprehensive MDS dated [DATE] revealed a BIMS score of 11 indicating minimal cognitive impairment and that she required extensive assistance by 1 or 2 staff for most ADS's including toileting. <BR/>Observation/Interview on 1/6/2024 at 10:00 am revealed Resident #3 lying down in bed. She presented as being alert and oriented. When asked if she was receiving any showers at the facility by staff , she stated no not really. She stated, I I believe I only have had 2 maybe in the last few weeks. When asked why she had not received more showers. Resident #2 stated, the staff says they are short staff or do not have time to shower me. Resident #2 further revealed she felt she needed to be showered more often because she was incontinent and wanted to be clean. Resident #2 stated it is embarrassing to not have showers and be clean.<BR/>Interview on 1/6/2024 at 10:10 am CNA E revealed if it is not marked in the residents record as being done on the shower section, then the resident did not get a shower. She further revealed she did not know why Resident #3 did not get a shower on her regular shower days. CNA E stated , we are short staffed sometimes and cannot get to everybody. <BR/>Record review of Resident #4's face sheet revealed a [AGE] year-old male with an admission date of 6/28/2023 revealed diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, and Diabetes Mellitus type 2.<BR/>Record review of Resident #4 quarterly MDS (minimum data sheet) assessment dated [DATE], revealed he had a BIMS score of 15, which indicated moderately cognitively impaired. Section G mobility revealed he required 1-person physical assist.<BR/>During an observation/interview on 1/6/2023 at 10:15 a.m. revealed Resident #4 was in the hallway in his wheelchair. When asked by surveyor how he was doing, he stated I am mad. Resident #4 revealed he was mad because he did not get showers like he should. He revealed he should get showers by the staff 3 times a week but only had 2 or 3 in the last 2 weeks. Resident #4 further revealed he feels mad and dirty when he is not helped. When asked why he had not had showers , he revealed the staff tells him they are short or do not have time to shower him.<BR/>During an interview on 1/6/2023 at 10:20 a.m. LVN B confirmed Resident #4 required assistance with showers. LVN B further revealed the nurse aides have a shower schedule for the residents. She said sometimes the nurse aides may be short staffed and cannot give all the residents their showers.<BR/>Interview on 1/8/2024 at 2:50 p.m. with facility ADON revealed nurse aides document in residents EMR when a shower or bed bath occurs. She revealed if there is no documentation in the EMR or on shower sheets then the resident did not receive a bath. She further revealed she did not know why residents did not receive a bath/shower. She stated all residents should receive a bed bath or shower on the assigned dates and shift. She stated this is for the resident's dignity and health to be clean and cared for. <BR/>Interview on 1/8/2024 at 3:00 p.m. with facility DON revealed nurse aides document in residents EMR when a shower or bed bath occurs. She revealed it is her expectation that all residents should receive a bed bath or shower on the assigned dates and shift. She stated this is for the resident's dignity and health to be clean.<BR/>Record review of Resident Council meeting held on 11/21/23 attended by 10 residents, residents stated that staff come to turn off call light and they never come back. Another resident revealed that staff come to turn off call light and leave without providing assistance. <BR/>Record review of Resident Council meeting held on 12/5/2023 attended by 7 residents and Administrator, revealed residents state that staff come to turn off call light and they never come back. <BR/>Record review of Resident Council meeting held on 1/2/2024 attended by 12 residents, revealed one resident said he had not had a shower in 4 days. Staff stated he did not get a shower because there were no staff. A family member attended meeting and revealed staff come turn call light off and they take a long time to come back.<BR/>Record review of facility policy, titled; Routine procedures, Subject: Bath, Shower: It is the policy of the facility to promote cleanliness, stimulate circulation and assist in relaxation.<BR/>Record review of facility policy titled: Routine procedures. Subject: Call lights/Bell. It is the policy of this facility to provide the resident a means of communication with nursing staff. 1. Answer the light/bell within a reasonable time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 (Resident #28) of 33 residents reviewed for advanced directives, in that:<BR/>Resident #28's OOH-DNR was missing a physician's signature and was therefore invalid. <BR/>This deficient practice could place residents at-risk of having their end of life wishes dishonored and of having CPR performed against their will. <BR/>The findings were:<BR/>Record review of Resident #28's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis. <BR/>Record review of Resident #28's Quarterly MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. <BR/>Record review of Resident #28's care plan, revised [DATE], revealed, [Resident #28] has elected DNR status.<BR/>Record review of Resident #28's OOH-DNR form, revealed the resident signed the form on [DATE]. Further review revealed the physician signed the upper portion of the form on [DATE] but failed to sign the lower portion of the form. <BR/>During an interview with the Social Worker on [DATE] at 4:42 p.m., the Social Worker confirmed that two signatures were required for all parties who sign an OOH-DNR form, confirmed the physician signature was missing from the lower portion of the form, and confirmed the missing signature rendered the form invalid. The Social Worker stated it was her responsibility to ensure OOH-DNR forms were correctly executed and stated the invalid form was an oversight. <BR/>During an interview with the DON on [DATE] at 12:16 p.m., the DON stated that she expected all advance directives, including OOH-DNR forms to be correctly executed so that the residents' end of life wishes would be honored. <BR/>Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly.<BR/>Record review of the facility policy, Advanced Directives and Associated Documentation, reviewed [DATE], revealed, It is the policy of this facility that a resident's choice about advanced directives will be recognized and respected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodations of residents needs and preferences for 3 of 6 residents (Residents #1 #2, and #4) reviewed for accommodations of needs.<BR/>The facility failed to ensure Residents (#1, #2, and #4,) call lights were answered in a timely manner when they needed assistance. <BR/>This failure could place residents at risk of not receiving care or attention needed.<BR/>The findings were:<BR/>Record review of Resident #1's face sheet dated 1/6/2024 revealed an [AGE] year-old male with an admission date of 12/29/2023. His diagnosis included chronic kidney disease stage 3(your kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood.), vascular dementia(is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage), polyneuropathy(is when multiple peripheral nerves become damaged. Symptoms include problems with sensation, coordination, or other body functions.), major depressive disorder recurrent, and repeated falls.<BR/>Record review of Resident #1's admission MDS assessment, dated 1/2/2024, revealed Resident #1's had a BIMS score of 13, which indicated cognitively alert. Section G functional status revealed Resident #1 required one-person physical assist for transfers, bed mobility, and dressing.<BR/>During an observation/interview on 1/6/2024 at 9:10 a.m. revealed Resident #1 was in his room in bed. He was in a hospital gown. <BR/>During an interview he stated, the staff do not answer my call light when I need help. It takes them along time. I am unable to get myself dressed, and I need help being changed. He further stated, I don't not like to be wet, or unclean, it makes me sad. Surveyor was in room with call light on for 35 minutes until staff answered it.<BR/>During an interview on 1/6/2024 at 9:45 a.m. LVN B confirmed Resident #1 was in bed and call light had not been answered by staff. She stated, the nurse aides are very busy, and we try to answer the call lights as quick as we can, but sometimes we do not have enough staff, or we the nurses are passing medications. She further revealed residents call light should be answered by staff within 15 minutes of them turning it on.<BR/>During an interview on 1/6/2024 at 9:50 am CNA D stated, we answer the call lights as quick as we can. When we are giving residents care, the nurses should answer the residents call lights. <BR/>During a telephone interview on 1/8/2024 at 9:20 am Resident #1's responsible party, revealed he needed assistance by staff and would turn his call light on, but it would take sometimes an hour for them to answer it. She further revealed that Resident #1 did not like to be unclean as he had always been very conscientious of his appearance and cleanliness.<BR/>Record review of Resident #2's face sheet revealed a [AGE] year-old female with an original admission date of 12/19/2019 and a recent readmission date of 4/17/2022 with diagnoses of unspecified dementia, Diabetes Mellitus type 2, overflow incontinence, and major depressive disorder recurrent. <BR/>Record review of Resident #2's Quarterly MDS assessment dated [DATE], revealed she had a BIMS score of 15, which indicated moderately cognitively impaired. Section G mobility revealed she required 2-person physical assist.<BR/>During an observation/interview on 1/6/2024 at 10:00 a.m. revealed Resident #2 was in her room in her wheelchair. She was alert and oriented. She revealed she was incontinent of bladder and required staff to assist her. She further revealed most of the time it will take at least an hour for the call light to be answer. She stated, I turn my call light on when I need help like changing my brief and it will stay on for an hour and has even stayed on as long as two hours. She stated it makes me mad, because they are here to help me, they need more staff. <BR/>During an interview on 1/6/2024 at 10:05 a.m. LVN B confirmed Resident #2 would use her call light. She further revealed if the nurse aides are busy with other residents any staff can answer a call light.<BR/>Record review of Resident #4's face sheet revealed a [AGE] year-old male with an admission date of 6/28/2023 revealed diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia(difficulty with speech), and Diabetes Mellitus type 2.<BR/>Record review of Resident #4's quarterly MDS assessment dated [DATE], revealed he had a BIMS score of 15, which indicated moderately cognitively impaired. Section G mobility revealed he required 1-person physical assist.<BR/>During an observation/interview on 1/6/2024 at 10:15 a.m. revealed Resident #4 was in the hallway in his wheelchair. When asked by surveyor how he was doing, he stated I am mad. Resident #4 revealed he was mad because his call light had not been answered the morning of 1/6/2024 for over 3 hours. He stated, if they come in, they turn it off and then say they will come back, but don't. I need help having my brief changed. Resident #4 further revealed he feels sad and dirty when he is not helped. <BR/>During an interview on 1/6/2024 at 10:20 a.m. LVN B confirmed Resident #4 required assistance with incontinent care. LVN B revealed a residents call light should be answered by staff within 15-30 minutes of them turning it on. LVN B further revealed if the nurse aides were taking care of other residents, we help them if we can and she did not know why his call light had not been answered.<BR/>During an observation on 1/8/2024 at 9:30 a.m., Resident #4's call light was on. Surveyor knocked on door and asked to enter. Resident #4 was standing by his bedside. He revealed he had his call light on for an hour. He stated, I have had my call light on and off this morning since 7:00 am, someone will come in and say they will be back but did not come back. <BR/>During an interview on 1/8/2024 at 9:35 a.m. CNA E stated she was assisting other residents this am and giving showers to residents and could not answer Resident #4's call light. She stated, I am here now to help him. She further revealed if she was busy with other residents the nurses should answer call lights.<BR/>During an interview on 1/6/2024 at 1:30 p.m. the facility Administrator stated all residents should have call lights answered in a timely manner. He further revealed 30 minutes or less should be the time frame to be answered by staff when a resident calls for assistance. Administrator further revealed we have enough staff working each shift to take care of the current census of residents.<BR/>During an interview on 1/8/2024 at 3:00 p.m. the facility ADON stated all residents should have call lights answered in a timely manner. She further revealed her expectation was 30 minutes or less to be answered by staff when a resident calls for assistance. <BR/>During an interview on 1/8/2024 at 3:10 p.m. the facility DON stated all residents should have call lights answered in a timely manner. She further revealed her expectation was 30 minutes or less to be answered by staff when a resident calls for assistance.<BR/>Record review of facility policy undated, titled: Routine procedures. Subject: Call lights/Bell. It is the policy of this facility to provide the resident a means of communication with nursing staff. 1. Answer the light/bell within a reasonable time.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>The facility failed to ensure plastic storage containers used to store dry cereal in the dry storage room of the kitchen were properly sealed.<BR/>This deficient practice could place residents who received meals and snacks from the kitchen at risk for food borne illness.<BR/>The findings included:<BR/>Observation on 02/21/2023 at 10:05 a.m. revealed there were three 6-quart plastic containers used to store dry cereal. One container contained crispy rice dry cereal and was filled to the 2-qt. mark. One container contained corn flakes dry cereal and was filled approximately halfway. One container contained toasted oats dry cereal and was completely full. All three containers had plastic lids that were slightly ajar, revealing an open space at the top of the container.<BR/>Interview with the Dietary Manager (DM) on 02/21/2023 at 10:07 a.m. confirmed that all three containers of dry cereal were not properly sealed. When asked about the risks associated with food containers not being sealed, the DM stated this failure could result in product deterioration and potential rodent infestation. The DM stated that dietary aides are responsible for ensuring all food items that are stored in the dry storage room that had been opened are properly sealed, labeled and dated. The DM trains all new employees for one week and continuously throughout the year, and the consultant dietitian also provides training on food safety and sanitation.<BR/>Record review of facility policy Reusable Food Storage Containers, undated, revealed: Procedure: 1. Leftover foods and foods that cannot be restored in their original containers will be stored in nonporous containers that can be completely sealed.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.1, Food Storage, (A) 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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>The facility failed to ensure plastic storage containers used to store dry cereal in the dry storage room of the kitchen were properly sealed.<BR/>This deficient practice could place residents who received meals and snacks from the kitchen at risk for food borne illness.<BR/>The findings included:<BR/>Observation on 02/21/2023 at 10:05 a.m. revealed there were three 6-quart plastic containers used to store dry cereal. One container contained crispy rice dry cereal and was filled to the 2-qt. mark. One container contained corn flakes dry cereal and was filled approximately halfway. One container contained toasted oats dry cereal and was completely full. All three containers had plastic lids that were slightly ajar, revealing an open space at the top of the container.<BR/>Interview with the Dietary Manager (DM) on 02/21/2023 at 10:07 a.m. confirmed that all three containers of dry cereal were not properly sealed. When asked about the risks associated with food containers not being sealed, the DM stated this failure could result in product deterioration and potential rodent infestation. The DM stated that dietary aides are responsible for ensuring all food items that are stored in the dry storage room that had been opened are properly sealed, labeled and dated. The DM trains all new employees for one week and continuously throughout the year, and the consultant dietitian also provides training on food safety and sanitation.<BR/>Record review of facility policy Reusable Food Storage Containers, undated, revealed: Procedure: 1. Leftover foods and foods that cannot be restored in their original containers will be stored in nonporous containers that can be completely sealed.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.1, Food Storage, (A) 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation.<BR/>Resident #'1's electronic medical record did not contain complete and accurate documentation that RN A recorded the resident's vital signs, follow-up on a STAT (immediate) lab request, kept the DON or MD informed on the monitoring of the resident's change of condition for a period of three hours; before the resident expired.<BR/>This failure could result in residents' records not accurately documenting interventions, monitoring, and information provided to the MD or DON during a change of condition that could result in a death.<BR/> Findings included:<BR/>Record review of Resident #1's Face Sheet, dated 01/12/23, and EMR (electronic medical record) revealed, Resident #1 was a male age [AGE], was admitted on [DATE] with diagnoses that included: acute metabolic acidosis (infection), sepsis (infection of the blood), urinary tract infection, kidney failure, hypertension, anemia ( low red blood count), chronic kidney disease and diabetes 2 . Advanced Directive was DNR (do not resuscitate). RP (responsible party) was listed as: the resident. The date of discharge was 01/07/23 due to resident expiring in the facility. <BR/>Record review of Resident#1's Care Plan dated 12/31/22 revealed goals of resident being free of antidepressant side effects, diabetic treatment, improving cognition.<BR/>Record review of Resident #1's Social Services Assessment, dated 12/30/22, revealed resident's BIMS was zero (severely impaired).<BR/>Record review of Resident #1's MD orders dated 01/01/23 read: Lansoprazole Oral Tablet Delayed Release Disintegrating 30 MG (Lansoprazole) Give 1 tablet by mouth one time a day for stress ulcer p (prophylaxis).<BR/>Record review of Resident #1's Change of Condition Nurses Note dated 01/07/23 at 1:09 PM read, Resident noted to be sleepy, unable to tolerate food. 02 (oxygen) 89 (percent) RM (room temperature) , HR (heart rate) 120, lung crackles, cough, afebrile. [Change of Condition Nurse Note was authored by RN A]<BR/>Record review of Resident #1's Physician Progress Note dated 01/07/23 at 9:57 PM read: Earlier in the day [01/07/23] I (MD B) received a text message that (Resident #1) has been asleep since breakfast and his vital signs BP 100/59, HR 120 oxygen sats (saturation) 2L (liters) with 95%. Not in distress. stat labs were ordered and advised to monitor clinically and hold BP meds and sedatives. (8:13 PM) received a text message that pt (patient) had expired .cause of the death is internal upper GI (gastro intestinal) bleeding is more likely even though pt has been taking Lansoprazole for a possible ulcer/prophylaxis ( action taken to prevent a disease) .<BR/>Record review of Resident #1's Nurse Note dated 01/07/23 at 4:11 PM, authored by RN A, revealed the resident's BP was 90/56, HR was 98 and the lab company had arrived to take a blood specimen of the resident.<BR/>Record review of Resident #1's Nurse Note dated 01/07/23 at 5:29 PM, authored by RN A, revealed: Resident's 02 saturation was 96 %. RN did not document any other vital signs that could have included: resident's temperature, BP, HR and respiration.<BR/>Record review of Resident #1's Nurse Notes from 01/07/23 at 5:29 PM to 8:05 PM (time of death) did not document the resident's condition, nursing monitoring or interventions, or follow-up to the lab, MD or DON.<BR/>Record revie of Resident #1's Nurse Note on 01/07/23 authored by RN A revealed: resident vomited blood, was unresponsible, deceased , and the MD and DON were notified. [MD note dated 01/07/23 at 9:57 PM revealed the . cause of death is internal upper GI (gastro intestinal) bleeding is more likely even though pt (patient) has been taking Lansoprazole for a possible ulcer/prophylaxis .]<BR/>Record review of Resident #1's labs dated 01/07/23 revealed: labs for Resident #1 was collected on 01/07/23 at 4:28 PM; the lab received the blood specimen at 9:21 PM; and results were reported at 10:07 PM. WBC (white blood count) was 25.3 H (high) .reference range 4.2-9.1 . <BR/>During a telephone interview on 01/12/23 at 2:59 PM, the MD revealed: (time line) on 01/07/23 at 1:09 PM he was alerted that Resident #1's O2 stats was 89% . The MD ordered stat labs. At 1:25 PM he was informed that Resident (#1)'s BP was 100/59 and heart rate 120 . The MD stated the latter BP was a little low and heart rate a little high . He ordered that the facility monitor the resident and to keep him informed of any change of condition. The MD stated, the last time the facility contacted me by text was at 8:05 PM when he (MD) was informed the resident was deceased . The MD stated, he was told Resident #1 had a little blood on his shirt. The MD recalled that he wrote a physician's note revealing that the resident might have suffered GI bleeding due to ulcer prophylaxis. <BR/>During an interview on 01/13/23 at 8:40 AM, DON revealed: on 01/07/23 at 1:07 PM the MD was contacted because the resident suffered hypotension (BP was 100/59 and heart rate was 120) and the MD ordered stat labs and to monitor the resident. At 4:11 PM Nurse A recorded that Resident #1's BP was 90/56 and heart rate was 98 (assessment by DON: indication that the BP and had heart were lower. At 5:29 PM Nurse A took vital signs which revealed Resident #1's oxygen saturation was 96 % ( assessment by DON; good oxygen intake) BP was not recorded. At 8:05 PM the resident is deceased . The lack of documentation meant per the DON that she and the MD had no information regarding Resident #1's change of condition and current status for 3 hours (5:29 PM to 8:05 PM). The DON revealed she could not answer for Nurse A as to why she (Nurse A) did not document the BP or other vital signs for the time period 5:29 PM to 8:05 PM. The DON described vital signs as BP, heart rate, respiration, O2 saturation and temperature. The DON stated the labs arrived at 10:07 PM after the resident expired; finding was resident had elevated WBC (white blood count).The DON added the system failure by Nurse A was not documenting completely and accurately between the hours 5:29 PM to 8:05 PM. The responsible party for documentation on 01/07/23 was the charge nurse (Nurse A). <BR/>During a telephone interview on 01/13/23 at 9:30 AM, Nurse A revealed: on 01/07/23 at 1:07 PM the MD was contacted because Resident #1 suffered hypotension (BP was 100/59 and heart rate was 120) and MD ordered stat labs and to monitor the resident. At 4:11 PM Nurse A recorded that Resident #1's BP was 90/56 and heart rate was 98 (means BP is low but not critical and 98 heart is high but not requiring MD notification). At 5:29 PM, she (Nurse A) recorded that 02 saturation was at 96 % (normal). Nurse A stated other vital signs were normal (temperature, respiration, BP and heart rate) but not recorded. Last not written by Nurse A was 8:05 PM when resident deceased . Nurse A stated, I observed the resident (#1) at 6 PM, 7 PM, 8 PM and in between and resident was stable .I did not record the vitals because I had other residents to take care .I saw the resident at 7:30 PM and vitals were okay and was waiting on the lab results .but did not record my visit at 7:40 PM . vitals were low but not critical .there was no written policy that I call the MD or DON every two hours .or document visits every 2 hours . Further, Nurse A stated she followed up on the stat labs at 7 PM and did not record the contact .it was my fault for not documenting. <BR/>During a telephone interview on 01/23/23 at 10:46 AM, CNA B revealed: his shift was from 2 PM-10 PM on 01/07/23 and he checked on Resident #1 every 30 minutes to 1 hour. At 7:22 PM, Resident (#1) was asleep, snoring, and not in distress .I did not document my checks with the resident but told Nurse (A) around 8 PM I found resident with a brown substance around his mouth and called the charge nurse .charge nurse said the resident had expired . CNA B stated that Nurse A would document the information he was conveying to her regarding the monitoring of Resident #1. <BR/>During an interview on 01/23/23 at 11:03 AM, DON revealed: Nurse A called the lab at 1:09 PM per MD request and the lab collected the specimen at 4:28 PM. The lab considers a STAT telephone request to fall within a time window of 4-6 hours.<BR/>During a telephone interview on 01/23/23 at 11:14 AM, Lab Representative C revealed the lab's policy was to respond to STAT telephone requests by six hours from time of collection to results. Reference # 1893253 revealed (Resident #1's) labs were collected at 4:28 PM. STAT did not mean the lab would immediately go to the facility rather from time of collection to results within a 6 hour timeframe . Follow-up calls from facility checking on STAT orders were not documented by the lab. <BR/>During an interview on 01/13/23 at 11:40 PM, the Administrator revealed Nurse A forgot to document critical information. He stated, it is a battle we fight on documentation . The Administrator added that complete and accurate documentation would be included in the on-[NAME] in-service training for nursing staff documentation, monitoring, and change of condition. <BR/>Record review of facility's Significant Change in Condition Response dated 01/2022 read, .The Nurse will perform and document an assessment of the resident and identify need for additional interventions .The resident will then be placed on the 24 Hour Report and Nursing will provide no less than three (3) days of observation, documentation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (excessive dose and duplicative therapy) for 1 of 6 residents (Resident #72) reviewed for unnecessary medicines, in that:<BR/>The facility failed when in May 2025 Resident #72 received buspirone 5 mg twice a day for depression and Resident #72 received escitalopram 10 mg once a day for depression , reflecting a duplication of therapy when Psychotropic medications will not be given in excessive dosage. <BR/>This failure could place residents at risk for adverse drug consequences and receiving unnecessary medications.<BR/>The findings included :<BR/>Record review of Resident #72's face sheet dated 5/14/25 reflected an [AGE] year-old resident who was admitted to the facility on [DATE] with diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), Heart Failure (condition in which the heart isn't pumping as well as it should) and Depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest )<BR/>Record review of Resident #72's Quarterly MDS assessment, dated 2/26/25, reflected a BIMS score of 9, which indicated moderate cognitive impairment<BR/>Record review of Resident #72 's comprehensive physician orders, dated 5/15/25, revealed orders for the following : <BR/>- Buspirone 5 mg two times a day orally for depression. There was no documentation indicating the need for duplication of therapy. Further review revealed Resident #72 had been on the medication since 12/13/24. <BR/>- Escitalopram 10 mg once a day orally for depression. There was no documentation indicating the need for duplication therapy. Further review revealed Resident #72 had been on medication since 12/13/24. <BR/>Record review of Resident #72's comprehensive care plan, dated 12/16/24, revealed a care plan for Depression with interventions to administer medications as ordered. <BR/>Record review of Resident #72's Medication Administration Record for May 2025 revealed the resident had received Buspirone 5 mg two times a day for depression and Escitalopram 10 mg once a day for depression. <BR/>Record review of Resident #72's Pharmacy Consultant's Drug Regimen Reviews from 12/01/24 to 04/01/25 revealed no recommendation for Buspirone or Escitalopram, indicating an issue.<BR/>During an interview with the DON on 05/16/2025 at 11:10 a.m., the DON stated she was unaware Resident #72 was on Buspirone 5 mg two times a day orally for depression and Escitalopram 10 mg once a day orally for depression. The DON stated these medications could be considered a duplication of therapy and could cause possible side effects when used concurrently. <BR/>Record review of the facility policy dated 12/19, revised 12/23, revealed Psychotropic medications will not be in excessive dosage.

Based on observation, interview, and record review, the facility failed to provide a resident environment that was free of pests for 1 of 1 facility reviewed for effective pest control in that:<BR/>The facility failed to provide a resident environment that was free of pests as live roaches were observed in Resident #9's bathroom and in the facility conference room <BR/>This deficient practice could result in illness and/or psychosocial harm for residents living in areas with insects. <BR/>The findings included: <BR/>Observation on 05/13/2025 at 11:15 a.m. in Resident #9's bathroom, revealed a live roach crawling on the bathroom wall near a vent in the wall.<BR/>Observation on 05/13/2025 at 3:40 p.m. revealed a live roach crawling on the surveyor's bag in the facility's first-floor conference room. <BR/>During an interview with Resident #9 on 05/13/2025 at 11:15 a.m., Resident #9 stated that he had seen roaches coming out of the vents in his shower room and had one crawl on him in bed 2 nights prior. He stated that he has seen the pest control company come out to spray in his room, but did not feel it was effective.<BR/>During an interview with HSK G on 05/13/2025 at 11:23 a.m., she stated she had worked as a housekeeper at the facility for 2 months and while cleaning has observed roaches under beds, in the breakroom, laundry room and has seen their droppings in some of the bathrooms. She stated she usually sees them when she first walks into a room and turns on the light.<BR/>Interview with the Administrator on 05/13/2025 at 3:45 p.m. revealed that he has received reports of roaches in the facility, most of those reports coming from residents living on the second floor, and that the facility has a contract with a pest control company which were scheduled to come out to exterminate today. The Administrator stated the pest control company comes out regularly to treat for pests, and compared to other places he has been, he does not feel the pest problem at this facility was a big, big problem. <BR/>Record review of the facility policy, Maintain Effective Pest Control Program, undated, revealed, Policy: Maintain and effective pest control program so that the facility is free of pests and rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident representative for 1 of 1 resident (Resident #1) reviewed for changes in condition. <BR/>The facility failed to notify the Resident's # 1 's family member of a positive pneumonia diagnosis. <BR/>This deficient practice could result in denial of resident rights of family to be notified with any change of status criteria.<BR/>Failure to notify family members of significant change of status could affect any resident at risk for hospitalization. <BR/>Findings Included:<BR/>Record review of Resident #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] diagnosis that included: [Dementia] a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, [Chronic obstructive pulmonary disease] a chronic inflammatory lung disease that causes obstructed airflow from the lungs, and [Type 2 diabetes] a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel. The face sheet also recorded the Resident's emergency contact and contact information.<BR/>Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS of 2, suggesting severe cognitive impairment. <BR/>Record review of Resident #1's progress notes, dated 9/8/2023 at 11:29 a.m. and written by the DON, revealed Abnormal Lung Sounds. <BR/>Record review of physician's consolidated orders dated September 2023, revealed an order for Chest X - Ray, 2 view on 9/8/2023 . <BR/>Record review of Resident #1's Chest X-ray results for 9/8/2023 at 12:17 p.m. revealed the impression of Bilateral Pneumonia.<BR/>Record review of Resident #1's progress notes, dated 9/8/2023 at 12:30 p.m., revealed Resident # 1 Doctor was notified of pneumonia diagnoses, and new orders for incentive spirometer use every 2 hours x 14 days was received. on 9/8/2023 . <BR/>Record review of Resident #1's progress notes, dated 9/8/2023, did not reveal Resident #1's family was notified of the resident's change of condition.<BR/>Interview with Resident #1's Responsible Party on 11/8/2023 at 1:00 p.m. did not reveal that Resident #1's family was notified of change of conditon pnumonia diagnosis. <BR/>Interview with the DON on 11/8/23 at 1:33 PM revealed: When should responsible staff call the family when the change of condition occurs? DON responded Right away. Staff should contact the responsible party listed on the face sheet and document. <BR/>Interview with the DON on 11/8/2023 at 4:20 p.m. revealed: Staff should conctact the responsiable party listed on face sheet, Right away, and docuemnt - when the resident had a change of condition. <BR/>Record Review of Facility Policy Titled, Significant Change of Condition, 5/2007 revised 1/2022, revealed: The resident representative will be notified of the change in condition and any changes in the resident's medical or nursing care.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 facility.<BR/>The facility failed to maintain the garbage storage area in a sanitary condition to prevent the harborage and feeding of pests.<BR/>This failure could place residents at risk of having contact with pests from an unsanitary garbage storage area.<BR/>The findings included: <BR/>During an observation tour of the facility's garbage disposal area on 04/04/2024 at 3:50 p.m., with the Food Service Director noted that the facility's garbage disposal unit had a top attached lid which measured 40x 20 inches and was left open exposing stacked bags of garbage inside the unit.<BR/>During an interview with the Food Service Director on 4/4/24 at 4:00 p.m., the Food Service Directorstated the top lid of the garbage disposal unit should have remained closed to prevent, varmits, from entering the facility.<BR/>During an interview with the Administrator on 4/4/24 at 4:45 p.m., the Administrator stated there was only one garbage receptacle used by the facility. The Administrator stated the garbage lid was to remain closed at all times to prevent rodent intrusion into the facility.<BR/>Record review of the facility's policy titled, Dietary Infection Control Policy/Procedure, dated 05/2007, revealed, food waste may be disposed of in garbage disposal or covered waste cans.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess each resident using the quarterly review instrument specified by the State and approved by CMS in a timely manner for 3 (Resident #54, #40, and #81), of 33 residents reviewed for timely assessment, in that: <BR/>1. Resident #54's Quarterly MDS, dated [DATE] and Annual MDS, dated [DATE] had been initiated but not completed. <BR/>2. Resident #40's Quarterly MDS, dated [DATE] and Quarterly MDS, dated [DATE] had been initiated but not completed.<BR/>3. Resident #81's Quarterly MDS, dated [DATE] had been initiated but not completed. <BR/>This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information. <BR/>The findings were: <BR/>1. Record review of Resident #54's face sheet, dated 05/16/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia and Muscle Weakness. <BR/>Record review of Resident #54's clinical record, as of 05/14/2025, revealed a list of MDS assessments beginning with the resident's admission. <BR/>Review of Resident #54's MDS assessments list revealed his Quarterly MDS, dated [DATE] and Annual MDS, dated [DATE] had both been initiated but were not completed. <BR/>2. Record review of Resident #40's face sheet, dated 05/16/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side and Other Speech and Language Deficits Following Cerebral Infarction. <BR/>Record review of Resident #40's clinical record, as of 05/14/2025, revealed a list of MDS assessments beginning with the resident's admission.<BR/>Review of Resident #40's MDS assessments list revealed his Quarterly MDS, dated [DATE] and Quarterly MDS, dated [DATE] had both been initiated but were not completed. <BR/>3. Record review of Resident #81's face sheet, dated 05/16/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including Fracture of Unspecified Part of Neck of Right Femur and Type 2 Diabetes Mellitus Without Complications. <BR/>Record review of Resident #81's clinical record, as of 05/14/2025, revealed a list of MDS assessments beginning with the resident's admission.<BR/>Review of Resident #81's MDS assessments list revealed her Quarterly MDS dated [DATE], had been initiated but was not complete. <BR/>During an interview with MDS C on 05/15/2025 at 2:54 p.m., MDS C confirmed the MDS assessments had been initiated but not completed and stated this was due to an oversight. MDS C stated that MDS assessments should be completed and exported to CMS so that residents may receive services and to aid in the care planning process and confirmed this duty was her responsibility. <BR/>During an interview with the DON on 05/16/2025 at 12:16 p.m., the DON stated that she expected MDS assessments to be initiated, completed, and exported to CMS in a timely manner. <BR/>Record review of the facility policy, Resident Assessment and Associated Processes reviewed January 2022, revealed, The facility will electronically transmit encoded, accurate, and complete MDS data to the CMS system .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to encode and transmit resident assessments in a timely manner for 3 (Residents #200, #57, and #33) of 33 reviewed for resident assessments, in that: <BR/>1. Resident #57's Quarterly MDS, dated [DATE], was completed but not transmitted to CMS as of 05/14/2025. <BR/>2. Resident #33's Quarterly MDS, dated [DATE], was completed but not transmitted to CMS as of 05/14/2025.<BR/>3. Resident #200's Entry MDS, dated [DATE] was completed, but not transmitted to CMS within 14 days of completion. <BR/>These deficient practices placed residents at risk of not having assessments completed and submitted in a timely manner as required. <BR/>The findings were: <BR/>1. Record review of Resident #57's face sheet, dated 05/16/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Lupus Anticoagulant Syndrome. <BR/>Record review of Resident #57's clinical record, as of 05/14/2025, revealed a list of MDS assessments beginning with the resident's admission.<BR/>Review of Resident #57's MDS assessments list revealed his Quarterly MDS, dated [DATE] has been completed but not transmitted to CMS and had a status of export ready. <BR/>2. Record review of Resident #33's face sheet, dated 05/16/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy and Unspecified Sequelae of Cerebral Infarction. <BR/>Record review of Resident #33's clinical record, as of 05/14/2025, revealed a list of MDS assessments beginning with the resident's admission.<BR/>Review of Resident #33's MDS assessments list revealed his Quarterly MDS, dated [DATE] has been completed but not transmitted to CMS and had a status of export ready.<BR/>3. Record review of Resident #200's face sheet dated 05/14/2025 revealed an admission date of 04/30/2025 with diagnoses which included Fracture of neck of right femur (a break in the thigh bone); aftercare following joint replacement surgery and essential hypertension (high blood pressure).<BR/>Record review of Resident #200's Entry MDS assessment revealed it was completed on 04/30/2025, but its status as of 05/16/2025 was noted as export ready.<BR/>During an interview with MDS C on 05/15/2025 at 2:54 p.m., MDS C confirmed the MDS assessments had been completed but not transmitted to CMS and stated this was due to an oversight. MDS C stated that MDS assessments should be completed and exported to CMS so that residents may receive services and to aid in the care planning process and confirmed this duty was her responsibility. <BR/>During an interview with the DON on 05/16/2025 at 12:16 p.m., the DON stated that she expected MDS assessments to be initiated, completed, and exported to CMS in a timely manner. <BR/>During an interview with the DON and Administrator on 05/16/2025 at 12:16 p.m., the DON stated that the Entry MDS needed to be transmitted within 14 days of admission and stated Resident #200's Entry MDS was export ready, meaning it was complete but had not been transmitted yet. The DON stated it was the MDS Nurse's responsibility for transmitting the MDS assessments, however she stated they were short an MDS Nurse right now, and that the delay in transmitting was due to them having only have one MDS Nurse right now. She stated she used to be the second MDS Nurse, but that position has been vacant since she was promoted to the DON position, but noted the position has been posted. The DON stated that by not transmitting the MDS entry assessment within the 14 days, it could hinder monitoring changes in the resident's status and affects reimbursement. <BR/>Record review of the facility policy, Resident Assessment and Associated Processes reviewed January 2022, revealed, The facility will electronically transmit encoded, accurate, and complete MDS data to the CMS system .