CORONADO NURSING CENTER

**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 time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 23 residents (Residents #23, #26, #36, #39, #53, and #62) reviewed for care plans in that:<BR/>1. The facility failed to define measurable objectives on Resident #23's care plan regarding the problems of resisting care, visual function, oral hygiene, pain, mobility, cognitive loss, and daily tasks.<BR/>2. The facility failed to define measurable objectives on Resident #26's care plan regarding the problems of psychotropic drugs, psychosocial well-being, pain, mood, behaviors, activities of daily living and daily tasks. <BR/>3. The facility failed to define measurable objectives on Resident #36's care plan regarding the problems of mobility and daily tasks and failed to address on Resident #36's comprehensive care plan the care areas of visual function and communication triggered on the MDS.<BR/>4. The facility failed to define measurable objectives on Resident #39's care plan regarding the problems of visual function, self-care deficits, decreased cognition, and daily tasks and the care areas of dental care and communication triggered on the MDS.<BR/>5. The facility failed to define measurable objectives on Resident #53's care plan in regard to the problems of daily tasks, pain, ADL function, and impaired cognition.<BR/>6. The facility failed to define measurable objectives on Resident #62's comprehensive care plan regarding the problems of self-care related to mobility and impaired cognition, and daily tasks.<BR/>These failures could affect residents and place them at risk for not having their needs and preferences met.<BR/>Findings included: <BR/>Resident #23<BR/>Review of Resident #23's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes mellitus (non-insulin dependent diabetes), heartburn, enterocolitis (inflammation of the colon), difficulty sleeping, high blood cholesterol, rapid heart rate, swelling, weakness, anxiety, absence of right and left legs below the knees, pancreatitis (inflammation of the pancreas), and high blood pressure. <BR/>Review of Resident #23's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #23 scored 99 indicating the resident was unable to complete the interview. Further review revealed the following care area triggered Section M - Skin Conditions, sub-section M1200. Skin and Ulcer/Injury Treatments: number 16. Pressure Ulcer/Injury indicated item B. Pressure reducing device on bed was selected. MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column revealed 16. Pressure Ulcer was selected.<BR/>Review of Resident #23's Quarterly MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score Resident #23 scored 15 out of 15 indicating cognition was intact. <BR/>Review of Resident #23's care plan reviewed/revised 01/27/25 revealed the following: <BR/>*Problem I resist care resisted taking medications/injections with an objective of I will make an informed choice about the benefits of care, options in care, and possible consequences/outcomes for resisting care. <BR/>*Problem visual function with an objective of Resident will have optimal visual acuity. <BR/>*Problem Oral/Dental Status with an objective of Maintain oral hygiene/status. <BR/>*Problem I am at risk for pain R/T my multiple comorbidities with an objective of I will be as comfortable as possible. <BR/>*Problem ADL Functional/Rehab Potential with an objective of I will achieve maximum functional mobility. <BR/>*Problem I have cognitive loss related to my diagnosis of anxiety with an objective of I will be as alert and oriented as possible. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an objective of The Resident will perform the following tasks at their highest practicable level. Approaches/Interventions included Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is days Once A Day on Mon, Wed, Fri; 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and Weekly skin Observations Flowsheet ADL Once Daily on Mon, Wed, Fri 06:00 AM - 06:00 PM.<BR/>Resident #26<BR/>Review of Resident #26's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of high blood cholesterol, cholecystitis (inflammation of the gall bladder), anxiety, difficulty sleeping, dementia, kidney disease, depression, high blood pressure, chest pain, heart failure, Type 2 diabetes (non-insulin dependent diabetes), ascites (fluid build-up in the abdomen), and constipation (inability to have a bowel movement) <BR/>Review of Resident #26's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #26 scored 11 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #26's care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem Psychotropic Drug Use with an unmeasurable objective of Benefit without side effects. <BR/>*Problem Psychosocial Well-Being with an unmeasurable objective of Resident will express/exhibit satisfaction. <BR/>*Problem I am at risk for pain related to aging process and dx of diabetes with an unmeasurable objective of Resident will be as comfortable as possible. <BR/>*Problem Mood State with an unmeasurable objective of Resident will express/exhibit satisfaction. <BR/>*Problem I have inappropriate verbal outbursts such as yelling out related to my dementia with an unmeasurable objective of I will be encouraged to communicate with the staff for my needs. <BR/>*Problem ADL Functional/Rehab Potential with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approaches/Interventions included Bowel Movement Every Shift; 1 SHIFT 1 06:00 AM - 06:00 PM, SHIFT 1 06:00 PM - 06:00 AM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, HS Snack At Bedtime; 06:00 PM - 06:00 AM, I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and The staff member who does my bath will document skin issues in the POC Once A Day on Mon, Wed, Fri 06:00 AM - 06:00 PM.<BR/>Resident #36<BR/>Review of Resident #36's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), dementia, depression, difficulty walking, pain, high blood pressure, weakness, heart failure, arthritis, paranoid schizophrenia, and swelling.<BR/>Review of Resident #36's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #36 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #36's care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem I have self-care deficits R/T impaired mobility and impaired cognition with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM.<BR/>Review of Resident #36's Care Area Assessment (CAA) list generated from the admission MDS, dated [DATE], revealed the following care areas triggered and selected in MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column, were not addressed on Resident #36's comprehensive care plan: Visual Function triggered by entry in MDS Section B Hearing, Speech, and Vision, sub-section B1000 Vision, Ability to see in adequate light (with glasses or other visual appliances) code 1. Impaired - sees large print, but not regular print in newspapers/books was selected and sub-section B1200 Corrective Lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision code 1. Yes was selected. Communication triggered by entry in MDS Section B Hearing, Speech, and Vision, Sub-section B0200 Hearing - Ability to hear (with hearing aid or hearing appliances if normally used) code 2. Moderate difficulty - speaker has to increase volume and speak distinctly was selected.<BR/>Resident #39 <BR/>Review of Resident #39's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of high blood pressure, dementia, Alzheimer's disease (a brain disorder that destroys memory and thinking skills), weakness, anxiety, high blood cholesterol, macular degeneration (an eye disease that affects central vision), and Vitamin D deficiency. <BR/>Review of Resident #39's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #39 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #39's care plan reviewed/revised 02/04/25 revealed the following:<BR/>*Problem I have decreased Visual Function and require glasses at times with an unmeasurable objective of Resident will have optimal visual ability. <BR/>*Problem I have deficits in self-care. ADL Function/Rehab Potential with an unmeasurable objective of Resident will achieve maximum functional mobility. <BR/>*Problem I have Cognitive Loss related to Dementia with an unmeasurable objective of I will be as alert and oriented as possible. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approach/Interventions included: Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is 6a-6p Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>Review of Resident #39's Care Area Assessment (CAA) list generated from the admission MDS dated [DATE] revealed the following care areas triggered and selected in MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column, were not addressed on Resident #39's comprehensive care plan: Dental Care MDS Section L - Oral/Dental Status, sub-section L0200. Dental A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) and D. Obvious or likely cavity or broken natural teeth were selected. Communication was triggered by entry in MDS Section B Hearing, Speech, and Vision, Sub-section B0200 Hearing - Ability to hear (with hearing aid or hearing appliances if normally used) code 1. Minimal difficulty - difficulty in some environments (e.g. when person speaks softly or setting is noisy) was selected.<BR/>Resident #53<BR/>Review of Resident #53's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), human immunodeficiency virus, myalgia (muscle pain), major depressive disorder, paranoid schizophrenia, chronic obstructive pulmonary disease (a group of lung diseases that cause airway obstruction), cardiac pacemaker, rapid heart rate, atrial fibrillation (irregular beating of upper chamber of the heart), heart failure, high blood cholesterol, cellulitis (bacterial infection affecting the skin and underlying tissues), respiratory disease, chronic leg ulcers, and hemorrhoids.<BR/>Review of Resident #53's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #53 scored 12 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #53's comprehensive care plan, reviewed/revised 12/05/24, revealed the following:<BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approach/Interventions included Bowel Movement Every Shift; SHIFT 1 06:00 AM - 06:00 PM, SHIFT 1 06:00 PM - 06:00 AM. <BR/>*Problem I am at risk for pain with the unmeasurable objective of I will be as comfortable as possible for the next 90 days. Problem ADL Functional/Rehab Potential with an unmeasurable objective of I will achieve maximum functional mobility . <BR/>*Problem I have impaired cognition r/t fluctuations in cognition with an unmeasurable objective of Resident will be as alert and oriented as possible . <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level . and Approach/Interventions of I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is 6a-6p Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, HS Snack At Bedtime; 06:00 PM - 06:00 AM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and weekly skin observation Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>Resident #62 <BR/>Review of Resident #62's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), dementia, depression, difficulty walking, pain, high blood pressure, weakness, heart failure, arthritis, paranoid schizophrenia, and swelling.<BR/>Review of Resident #62's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #62 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #62's comprehensive care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem I have self-care deficits R/T impaired mobility and impaired cognition with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>During an interview on 02/19/2025 at 2:30 PM, the MDS coordinator stated she was responsible for completing the initial comprehensive care plan and the DON and ADON were responsible for updating the care plans. The MDS coordinator stated her expectation was care plans should include resident's diagnosis, medications, diet, physician orders and any resident care needs. The MDS coordinator stated that objectives should be specific and measurable, and interventions should be a specific task for staff and/or residents that accomplishes objectives. <BR/>During an interview on 02/19/25 at 12:07 PM, the Regional Nurse Consultant stated her expectations of care plan were for the care plan to look like the resident. She stated if she were a nurse coming in to provide care, she would want to know what was documented on the care plan. The RNC stated if a resident needed assistance or was a fall risk for example, that information should be on the care plan. The RNC explained the objectives should be based on what a nurse would expect to assess when interventions were followed. She stated the DON was responsible for the initial care plan and the ADON/MDS Coordinator contributed to revisions based on the comprehensive assessment. The RNC stated the CAA's should be addressed on the comprehensive care plan. She stated the DON was ultimately responsible for the accuracy of the care plans. The RNC stated in response to an example of an objective for pain, the RNC stated she did not agree with use of a pain scale because pain was subjective data. She explained staff should be able to identify pain by a resident's facial expressions or behavior. The RNC stated she trained staff to recognize pain or discomfort by being observant.<BR/>Review of the facility policy titled Comprehensive Care Plans, undated, revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives . that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: item 2. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the care plan., and 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment and failed to ensure the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment including both the comprehensive assessment and quarterly review assessments for 4 (Resident #1, #39, #40and #43) of 6 residents were reviewed for comprehensive care plans. <BR/>1. The facility failed to develop a comprehensive care plan within seven days for Resident #1, #39, #40 and #43.<BR/>2. The interdisciplinary team failed to review and revise the plan of care for Resident #1, #39, #40, #43 and #50.<BR/>These failures could affect all 88 residents by placing them at risk for not having their individual needs met. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 02/20/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 11/20/2022 with the following diagnosis: unspecified fracture of left shaft/femur, non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). <BR/>Review of Resident #1's revealed an MDS Significant Change assessment, dated 01/30/2023 section G reflects the following ADL care areas: bed mobility- extensive assistance, transfer- extensive assistance, walk in room- activity occurred only one or twice, walk in corridor- activity occurred only once or twice, dressing- extensive assistance, eating- Supervision, toilet use- extensive assistance, personal hygiene- extensive assistance, bathing- activity did not occur. <BR/>Review of Resident #1's most recent Care Plan , dated 12/07/2023, revealed category: ADL function/rehabilitation potential- ambulation/transfers amount of assist x1, bath hygiene amount of assist x1, Dressing/grooming assist x1. Further review revealed the interdisciplinary team had not reviewed and revised the care plan following the assessment of 12/07/2022.<BR/>Review of Resident #1's Care Conference Schedule revealed a Quarterly Care Conference was conducted on 12/07/2022.<BR/>Record review of Resident #39's face sheet dated 02/20/2023 revealed a [AGE] year-old male admitted on [DATE] with the following diagnosis: chronic pain due to trauma, quadriplegia (paralysis of all 4 limbs), hypertension (high blood pressure), bipolar disorder; current episode severe, mixed with psychotic features (mood disorder), anxiety disorder and neuromuscular of the bladder (person lacks bladder control due to brain, spinal cord or nerve problems). <BR/>Review of Resident #39's revealed an MDS Annual assessment, dated 08/31/2022 section G reflects the following ADL care areas: bed mobility- total dependance, transfer- total dependance, walk in room- activity did not occur, walk in corridor- activity did not occur, dressing- total dependance, eating- Supervision, toilet use- extensive assistance, personal hygiene- extensive assistance, bathing- total dependence. <BR/>Review of Resident #39's Care Plan, dated 01/04/2023 , revealed category: ADL function/rehabilitation potential- Does not have the ADL function or assistance needed care planned. An Annual Care Conference was not documented after the Annual MDS assessment, dated 08/31/2022 was completed.<BR/>Review of Resident #39's Care Conference Schedule revealed a Quarterly Care Conference was conducted on 10/05/2022 and 01/04/2022. An Annual Care Conference was not documented.<BR/>Record review of Resident #40's face sheet dated 02/14/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 01/06/2023 with the following diagnosis: fractured left hip, osteoporosis (disease of bone that makes them brittle), history of falling, Alzheimer's Disease, and Major Depressive disorder (persistent depressed mood).<BR/>Review of Resident #40's revealed an MDS Annual assessment, dated 01/11/2023 section G reflects the following ADL care areas: bed mobility- extensive assistance with 2+ person assist, transfer- extensive assistance with 2+ person assist, walk in room- activity did not occur, walk in corridor- activity did not occur, dressing- extensive assistance with 2+ person assist, eating- Supervision with 1 person assist, toilet use- extensive assistance with 2+ person assist , personal hygiene- extensive assistance with 1 person assist, bathing- personal help in part of bathing with 1 person assist . <BR/>Review of Resident #40's Care Plan dated 02/21/2023 revealed category: ADL function/rehabilitation potential- Provide assistance x1 with bathing/showering, requires x1 assist with bathing, requires x1 assist with eating, requires x1 assist with peri-care, requires x1 assist with toileting. <BR/>Review of Resident #40's Care Conference Schedule revealed a Quarterly Care Conference was conducted on 12/07/2022. An Annual Care Conference was not documented.<BR/>Record review of Resident #43's face sheet dated 02/14/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 01/06/2023 with the following diagnosis: fractured left hip, osteoporosis (disease of bone that makes them brittle), history of falling, Alzheimer's Disease, and major depressive disorder.<BR/>Review of Resident #43's revealed an MDS Annual assessment, dated 12/02/2022 section G reflects the following ADL care areas: bed mobility- supervision with 1 person assist, transfer- extensive assistance with 2+ person assist, walk in room- supervision with set-up, walk in corridor- supervision with set-up, dressing- extensive assistance with 2+ person assist, eating- Supervision with 1 person assist, toilet use- extensive assistance with 2+ person assist , personal hygiene- extensive assistance with 2+ person assist, bathing- personal help in part of bathing with 2+ person assist . Section O reflects the resident was receiving hospice care. <BR/>Review of Resident #43's Care Plan, dated 02/21/2023, revealed category: ADL function/rehabilitation potential- Does not have the ADL function or assistance needed care planned. Hospice has not been care planned. <BR/>Review of Resident #43's Care Conference Schedule revealed a Quarterly Care Conference was conducted on 12/23/2022. A Significant Change Care Conference was not documented.<BR/>In an interview on 02/18/23 at 12:16 a.m. MDS Coordinator DI revealed that the Care plans were behind in the schedule and has not been able to do it in time. She stated she had been out of 6 months due to illness, and they did not have anyone filling in for her. She said that her and RN CCM DH are responsible for making sure they are complete. She said the failure could place the resident at risk for unmet needs. The MDS coordinator said that she was out for 6 months and that they did not have anyone to cover for her. She stated that the Social Worker was planning the care plan conferences and they were not getting done timely. She stated that she was unaware that the Comprehensive Assessment care plans needed to be updated after the MDS was completed. She stated she followed the quarterly care conference and she thought that was how she did it. <BR/>An interview with the MDS Coordinator on 02/22/2023 at 11:00 a.m. revealed she did not revise the care plans or did not conduct the care conferences for (Resident #1, #39, #40 and #43) within the time frame after assessments. She stated the facility was behind on comprehensive care plans and care plan meetings.<BR/>Review of Policy and Procedure for Assessment/Care Plan dated February 2021 revealed:<BR/>3. The resident/representative's right to participate in the development and implementation of his or her care plan of care includes the right to: <BR/>a. participates in the planning process.<BR/>b. identify individuals to be included in the planning process<BR/>c. request meetings<BR/>d. request revisions.<BR/>e. participate in establishing goals.<BR/>f. participate in the type, amount, frequency, and duration of the care.<BR/>g. receiver services/items to be included in the care plan<BR/>h. be informed in advance of changes.<BR/>i. refuse, request changes to and/or discontinue care of treatment offered or proposed.<BR/>j. be informed in advance of the risk and benefits of the care of treatment proposed.<BR/>k. have access to and review care plans.<BR/>l. review and sign the care plan after any significant changes are made. <BR/>4. The care planning process:<BR/>a. facilities the inclusion of the resident's and/or representative.<BR/>b. includes an assessment of the resident's strengths and his/her needs.<BR/>c. incorporates the resident's personal and cultural preferences in establishing goals of care. <BR/>7. A comprehensive care plan is developed within seven days (7) days of completing the resident assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for (Resident #169) 1 of 23 resident's rooms observed for environmental conditions.<BR/>The facility failed to ensure that Resident #169 ' s toilet was free from cracks at the base and was sturdily attached to the floor.<BR/>The facility's failure placed the residents at risk for diminished quality of life, discomfort, and safety.<BR/>The findings included:<BR/>Record review of Resident #169's electronic face sheet dated 02/19/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and most recently on 02/01/2025 with diagnoses to include: right foot drop (difficulty lifting the front part of the right foot and foot might drag on the floor when walking), muscle wasting and atrophy (breakdown of muscle fibers), muscle weakness, and unspecified abnormalities of gait and mobility.<BR/>Record review of Resident #169's admission MDS dated [DATE] revealed: BIMS score of 15 which indicated his cognition was intact. Further review of the MDS Section GG for functional limitation in range of motion revealed he used a wheelchair and was independent with toileting hygiene and transfer.<BR/>Record review of Resident #169's care plan dated 02/04/2025 revealed no evidence that Resident #169 needed assistance with toilet hygiene or transfer.<BR/>Record review of Resident #169's progress notes dated February 2025 revealed on 02/03/2025, 02/07/2025, 02/16/2025, and 02/18/2025 nurse documented Resident #169 needed supervision &ndash; oversight, encouragement or cueing for toilet use.<BR/>During an observation and interview on 02/17/2025 at 2:21 p.m., Resident #169 was sitting up in a wheelchair in his room. He stated he had made a complaint about his toilet being broken when the maintenance man had first started Resident #169 stated he was scared that he was going to fall off the toilet. Toiled observed in resident ' s restroom to have left side of toiled base busted. Toilet moved easily with hands approximately an inch to the left side when pressed down on.<BR/>During an interview on 02/19/2025 at 3:00 PM the MD stated he had been there two weeks. MD stated he remembers talking with Resident # 169 about the toilet but was not sure when. The MD stated after he had been there a week he had cut his finger and had to take a week off. The MD stated the expectation was for residents ' toilets be in working order.<BR/>During an interview and record review on 02/19/2025 at 4:41 PM LVN A stated she was made aware of the broken toilet by the pest control man. LVN A stated she had made a repair request on 2/10/2025 on their electronic system, which she displayed. LVN A stated the new MD did not show up on the electronic system so she had made request to the ADMN. LVN A stated a toilet that was broken at the base could cause Resident to fall if they did not feel secure when they sat on toilet.<BR/>During an interview on 02/19/2025 at 5:11 PM the ADMN stated her expectation was that Residents have a safe and clean environment to reside. The ADMN stated she was not aware of Resident #169 ' s toilet being broken. The ADMN stated she never checked the electronic system and did not know that staff could send them under her name. The ADMN stated affect on residents having broken equipment could cause injury to resident. The ADMN stated what led to failure was the new DM not being at facility because he had been on leave and staff not knowing the ADMN was not checking the electronic reporting system.<BR/>Record review of facility ' s admission agreement dated 02/22/2022 revealed: Resident ' s rights under Texas law .You have a right: .2) to safe, decent and clean conditions.

**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 time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 23 residents (Residents #23, #26, #36, #39, #53, and #62) reviewed for care plans in that:<BR/>1. The facility failed to define measurable objectives on Resident #23's care plan regarding the problems of resisting care, visual function, oral hygiene, pain, mobility, cognitive loss, and daily tasks.<BR/>2. The facility failed to define measurable objectives on Resident #26's care plan regarding the problems of psychotropic drugs, psychosocial well-being, pain, mood, behaviors, activities of daily living and daily tasks. <BR/>3. The facility failed to define measurable objectives on Resident #36's care plan regarding the problems of mobility and daily tasks and failed to address on Resident #36's comprehensive care plan the care areas of visual function and communication triggered on the MDS.<BR/>4. The facility failed to define measurable objectives on Resident #39's care plan regarding the problems of visual function, self-care deficits, decreased cognition, and daily tasks and the care areas of dental care and communication triggered on the MDS.<BR/>5. The facility failed to define measurable objectives on Resident #53's care plan in regard to the problems of daily tasks, pain, ADL function, and impaired cognition.<BR/>6. The facility failed to define measurable objectives on Resident #62's comprehensive care plan regarding the problems of self-care related to mobility and impaired cognition, and daily tasks.<BR/>These failures could affect residents and place them at risk for not having their needs and preferences met.<BR/>Findings included: <BR/>Resident #23<BR/>Review of Resident #23's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes mellitus (non-insulin dependent diabetes), heartburn, enterocolitis (inflammation of the colon), difficulty sleeping, high blood cholesterol, rapid heart rate, swelling, weakness, anxiety, absence of right and left legs below the knees, pancreatitis (inflammation of the pancreas), and high blood pressure. <BR/>Review of Resident #23's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #23 scored 99 indicating the resident was unable to complete the interview. Further review revealed the following care area triggered Section M - Skin Conditions, sub-section M1200. Skin and Ulcer/Injury Treatments: number 16. Pressure Ulcer/Injury indicated item B. Pressure reducing device on bed was selected. MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column revealed 16. Pressure Ulcer was selected.<BR/>Review of Resident #23's Quarterly MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score Resident #23 scored 15 out of 15 indicating cognition was intact. <BR/>Review of Resident #23's care plan reviewed/revised 01/27/25 revealed the following: <BR/>*Problem I resist care resisted taking medications/injections with an objective of I will make an informed choice about the benefits of care, options in care, and possible consequences/outcomes for resisting care. <BR/>*Problem visual function with an objective of Resident will have optimal visual acuity. <BR/>*Problem Oral/Dental Status with an objective of Maintain oral hygiene/status. <BR/>*Problem I am at risk for pain R/T my multiple comorbidities with an objective of I will be as comfortable as possible. <BR/>*Problem ADL Functional/Rehab Potential with an objective of I will achieve maximum functional mobility. <BR/>*Problem I have cognitive loss related to my diagnosis of anxiety with an objective of I will be as alert and oriented as possible. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an objective of The Resident will perform the following tasks at their highest practicable level. Approaches/Interventions included Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is days Once A Day on Mon, Wed, Fri; 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and Weekly skin Observations Flowsheet ADL Once Daily on Mon, Wed, Fri 06:00 AM - 06:00 PM.<BR/>Resident #26<BR/>Review of Resident #26's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of high blood cholesterol, cholecystitis (inflammation of the gall bladder), anxiety, difficulty sleeping, dementia, kidney disease, depression, high blood pressure, chest pain, heart failure, Type 2 diabetes (non-insulin dependent diabetes), ascites (fluid build-up in the abdomen), and constipation (inability to have a bowel movement) <BR/>Review of Resident #26's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #26 scored 11 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #26's care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem Psychotropic Drug Use with an unmeasurable objective of Benefit without side effects. <BR/>*Problem Psychosocial Well-Being with an unmeasurable objective of Resident will express/exhibit satisfaction. <BR/>*Problem I am at risk for pain related to aging process and dx of diabetes with an unmeasurable objective of Resident will be as comfortable as possible. <BR/>*Problem Mood State with an unmeasurable objective of Resident will express/exhibit satisfaction. <BR/>*Problem I have inappropriate verbal outbursts such as yelling out related to my dementia with an unmeasurable objective of I will be encouraged to communicate with the staff for my needs. <BR/>*Problem ADL Functional/Rehab Potential with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approaches/Interventions included Bowel Movement Every Shift; 1 SHIFT 1 06:00 AM - 06:00 PM, SHIFT 1 06:00 PM - 06:00 AM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, HS Snack At Bedtime; 06:00 PM - 06:00 AM, I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and The staff member who does my bath will document skin issues in the POC Once A Day on Mon, Wed, Fri 06:00 AM - 06:00 PM.<BR/>Resident #36<BR/>Review of Resident #36's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), dementia, depression, difficulty walking, pain, high blood pressure, weakness, heart failure, arthritis, paranoid schizophrenia, and swelling.<BR/>Review of Resident #36's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #36 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #36's care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem I have self-care deficits R/T impaired mobility and impaired cognition with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM.<BR/>Review of Resident #36's Care Area Assessment (CAA) list generated from the admission MDS, dated [DATE], revealed the following care areas triggered and selected in MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column, were not addressed on Resident #36's comprehensive care plan: Visual Function triggered by entry in MDS Section B Hearing, Speech, and Vision, sub-section B1000 Vision, Ability to see in adequate light (with glasses or other visual appliances) code 1. Impaired - sees large print, but not regular print in newspapers/books was selected and sub-section B1200 Corrective Lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision code 1. Yes was selected. Communication triggered by entry in MDS Section B Hearing, Speech, and Vision, Sub-section B0200 Hearing - Ability to hear (with hearing aid or hearing appliances if normally used) code 2. Moderate difficulty - speaker has to increase volume and speak distinctly was selected.<BR/>Resident #39 <BR/>Review of Resident #39's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of high blood pressure, dementia, Alzheimer's disease (a brain disorder that destroys memory and thinking skills), weakness, anxiety, high blood cholesterol, macular degeneration (an eye disease that affects central vision), and Vitamin D deficiency. <BR/>Review of Resident #39's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #39 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #39's care plan reviewed/revised 02/04/25 revealed the following:<BR/>*Problem I have decreased Visual Function and require glasses at times with an unmeasurable objective of Resident will have optimal visual ability. <BR/>*Problem I have deficits in self-care. ADL Function/Rehab Potential with an unmeasurable objective of Resident will achieve maximum functional mobility. <BR/>*Problem I have Cognitive Loss related to Dementia with an unmeasurable objective of I will be as alert and oriented as possible. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approach/Interventions included: Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is 6a-6p Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>Review of Resident #39's Care Area Assessment (CAA) list generated from the admission MDS dated [DATE] revealed the following care areas triggered and selected in MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column, were not addressed on Resident #39's comprehensive care plan: Dental Care MDS Section L - Oral/Dental Status, sub-section L0200. Dental A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) and D. Obvious or likely cavity or broken natural teeth were selected. Communication was triggered by entry in MDS Section B Hearing, Speech, and Vision, Sub-section B0200 Hearing - Ability to hear (with hearing aid or hearing appliances if normally used) code 1. Minimal difficulty - difficulty in some environments (e.g. when person speaks softly or setting is noisy) was selected.<BR/>Resident #53<BR/>Review of Resident #53's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), human immunodeficiency virus, myalgia (muscle pain), major depressive disorder, paranoid schizophrenia, chronic obstructive pulmonary disease (a group of lung diseases that cause airway obstruction), cardiac pacemaker, rapid heart rate, atrial fibrillation (irregular beating of upper chamber of the heart), heart failure, high blood cholesterol, cellulitis (bacterial infection affecting the skin and underlying tissues), respiratory disease, chronic leg ulcers, and hemorrhoids.<BR/>Review of Resident #53's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #53 scored 12 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #53's comprehensive care plan, reviewed/revised 12/05/24, revealed the following:<BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approach/Interventions included Bowel Movement Every Shift; SHIFT 1 06:00 AM - 06:00 PM, SHIFT 1 06:00 PM - 06:00 AM. <BR/>*Problem I am at risk for pain with the unmeasurable objective of I will be as comfortable as possible for the next 90 days. Problem ADL Functional/Rehab Potential with an unmeasurable objective of I will achieve maximum functional mobility . <BR/>*Problem I have impaired cognition r/t fluctuations in cognition with an unmeasurable objective of Resident will be as alert and oriented as possible . <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level . and Approach/Interventions of I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is 6a-6p Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, HS Snack At Bedtime; 06:00 PM - 06:00 AM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and weekly skin observation Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>Resident #62 <BR/>Review of Resident #62's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), dementia, depression, difficulty walking, pain, high blood pressure, weakness, heart failure, arthritis, paranoid schizophrenia, and swelling.<BR/>Review of Resident #62's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #62 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #62's comprehensive care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem I have self-care deficits R/T impaired mobility and impaired cognition with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>During an interview on 02/19/2025 at 2:30 PM, the MDS coordinator stated she was responsible for completing the initial comprehensive care plan and the DON and ADON were responsible for updating the care plans. The MDS coordinator stated her expectation was care plans should include resident's diagnosis, medications, diet, physician orders and any resident care needs. The MDS coordinator stated that objectives should be specific and measurable, and interventions should be a specific task for staff and/or residents that accomplishes objectives. <BR/>During an interview on 02/19/25 at 12:07 PM, the Regional Nurse Consultant stated her expectations of care plan were for the care plan to look like the resident. She stated if she were a nurse coming in to provide care, she would want to know what was documented on the care plan. The RNC stated if a resident needed assistance or was a fall risk for example, that information should be on the care plan. The RNC explained the objectives should be based on what a nurse would expect to assess when interventions were followed. She stated the DON was responsible for the initial care plan and the ADON/MDS Coordinator contributed to revisions based on the comprehensive assessment. The RNC stated the CAA's should be addressed on the comprehensive care plan. She stated the DON was ultimately responsible for the accuracy of the care plans. The RNC stated in response to an example of an objective for pain, the RNC stated she did not agree with use of a pain scale because pain was subjective data. She explained staff should be able to identify pain by a resident's facial expressions or behavior. The RNC stated she trained staff to recognize pain or discomfort by being observant.<BR/>Review of the facility policy titled Comprehensive Care Plans, undated, revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives . that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: item 2. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the care plan., and 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitization.<BR/>1. <BR/>The facility failed to ensure ground meat was thawed properly.<BR/>2. <BR/>The facility failed to ensure the cook performed hand hygiene appropriately when preparing food.<BR/>3. <BR/>The facility failed to ensure foods were sealed and/or labeled properly.<BR/>4. <BR/>The facility failed to ensure the foods were not stored past expiration date.<BR/>Thess failures could place residents that eat out of the kitchen at risk for contamination and foodborne illnesses.<BR/>Findings included:<BR/>During an observation of the kitchen on 01/19/2025 between 2:15 p.m. - 2:50 p.m. revealed the following: <BR/>Sink:<BR/>1 plastic dish sitting in a sink with 4 tubes of ground meat sitting vertically in the dish that was filled with water and water running into the container. The ground meat was not submerged in the water with approximately 30% of ground meat outside of the water and water was running in the middle of the 4 tubes and not covering the meat.<BR/>Pantry:<BR/>*1 clear plastic bag not sealed and was open to air held an opened bag of potato chips dated 2-12-25 & 2-25-25.<BR/>*7 expired bottles of Lemon Juice from concentrate with written date of 10/02 on the outside of the bottles. Manufacture date on the bottle lids was 01/24/2025.<BR/>Refrigerator #1:<BR/>*1 clear plastic bag not sealed and was open to air held an opened bag of pink circular meat. There was no description on the bag.<BR/>*1 expired bottle of Lemon Juice from concentrate with written date of 10/02 on the outside of the bottle. Manufacture date on the bottle lid was 01/24/2025. <BR/>Refrigerator #2:<BR/>*1 sealed plastic container of grape jelly with no date on label.<BR/>Freezer # 1:<BR/>*1 box of 3 containers of whipped topping sitting on the floor on its side to the left of freezer door. <BR/>*1 bag of a circular breaded item with no description and no date. <BR/>*2 bags of what appeared to be frozen pancakes with no description and no date.<BR/>During an interview on 02/16/2025 at 2:53 p.m., the cook stated bags of food being stored should be sealed. He stated after opening food item it should be labeled with open date. He stated if foods were not stored in their original container, then they should have item description on them. He stated no food should be stored on the floor. The cook stated meat should be dethawed in the refrigerator, but meat would need to be placed in the refrigerator several days before needed to dethaw in the refrigerator. He stated he had been rotating the meat during the thawing process due to all the meat was not submerged in the water in dish in sink. He stated he had started defrosting the meat about an hour prior. He stated he was responsible for storing, labeling, and preparing foods.<BR/>During an observation on 02/16/2025 at 4:11 p.m., the cook started pureeing foods for diner service. He donned gloves without washing his hands and began pureeing meat entree. He added all ingredients into the blender until food item was appropriate consistency He then moved food into container and covered with foil prior to putting item into the freezer. He took blender to the dish room and removed his gloves. The cook rinsed out blender prior to running through the dish washer and he did not wash hands before touching sanitized blender. He then [NAME] blender back to puree station and put down on counter. He reached into a bucket of water solution and pulled out a rag then wiped down counter under blender and bottom of blender machine. He put blender back together then put gloves on his hands. He did not perform hand hygiene prior to putting on gloves. He then started on pureeing the rest of dinner items. <BR/>During an interview on 02/16/2025 at 6:45 p.m., the cook stated he should have washed his hands when changing out gloves during food preparation. He stated he had just forgotten to do so when being observed. He stated he was a train wreck and nervous. He stated not labeling food items with date and description could cause the wrong food item to be given to residents with allergies to that food item and could cause the residents to get sick. He stated not storing food items appropriately could cause residents to be sick.<BR/>During an interview on 02/17/2025 at 3:29 p.m., the DM stated food stored outside of the original container should be labeled with food description and date. She stated no food should be stored on the floor and should be stored at least 6 inches off of the floor. She stated foods should not be stored in the pantry or in the refrigerator past the manufacture's expiration date and the date the manufacturer had on container was the expiration date. The DM stated she expected for food items to be disposed of when item passed the expiration date. She stated anyone who puts up food items off the delivery truck and during food preparation were responsible for making sure items were stored correctly with appropriate label. She stated she does monitor that food was labeled, stored at least 6 inches off of the floor and not expired. She stated she last monitored the kitchen the week prior. The DM stated packages of food should be stored in sealed containers after opened. She stated ground meat should be thawed submerged under running water. She stated kitchen staff should wash hands with soap and water during glove changes. She stated she expected for HH to be done when moving from one task to another in the kitchen and not performing could lead to cross contamination and bacteria spread. She stated she had been working for the facility for approximately one week and will be monitoring the kitchen at least 2-3 times a week. She stated not labeling food appropriately with description of food item and dates could lead to allergic reaction. She stated she would have thrown food away without date on label because staff would not know when food should be disposed of. The DM stated not thawing out meat correctly could lead to some of the food being in the danger zone for longer than appropriate time and could cause bacteria to grow.<BR/>During a telephone interview on 02/17/2025 at 5:00 p.m., the dietician stated foods stored outside of their original container should be labeled with description and date. She stated foods should be stored 6 inches above the floor. She stated foods should be disposed of and not kept past the expiration date. She stated packages of food items should be sealed so not to expose food to the elements. She stated typically frozen meat was thawed during the cooking process, in the cooler or under cold running water. She stated not submerging frozen meat could more than likely cause it to thaw unevenly and cause foodborne illness. She stated every time gloves were changed during food preparation then HH should be performed in between glove changes. She stated the dietary manager monitors that kitchen staff store, prepare and prepare food appropriately. She stated she was available for training and does observe how staff store and prepare food. She stated the kitchen staff had been changing and there was a new DM which could have led to failures of HH, meat thawing, and food storage or staff may have forgotten their training. She stated she felt more education was needed. She stated that not storing food appropriately and not performing HH correctly could lead to illness from bacteria. <BR/>During an interview on 02/17/2025 at 9:39 a.m., the ADMN stated she expected for kitchen staff to follow policies on food storage, preparation, and hand hygiene. She stated the DM monitored that kitchen staff were following the facility's policy. She stated not storing and preparing food appropriately could cause residents to get sick. <BR/>Record Review of facility's policy titled Food Preparation and Handling dated 2018 revealed: <BR/>Procedure: <BR/>1. General Guidelines a. Use clean, sanitized surfaces, equipment and utensils. b. Wash hands properly before beginning food preparation .<BR/>2. Thawing Foods a. Thaw meat, poultry and fish in a refrigerator at 41&deg;F or less. b. Foods may also be thawed using the following procedures: i. Completely submerged under running water at a temperature of 70&deg;F or below with sufficient water velocity to agitate and float off loosened food particles into the overflow: 1. For a period of time that does not allow thawed portions of ready-to-eat food to rise above 41&deg;F; or 2. For a period of time that does not allow thawed portions of a raw animal food requiring cooking to be above 41&deg;F for more than four hours including the time the food is exposed to the running water and the time needed for preparation for cooking.<BR/>Record Review of facility's policy titled Handwashing/Hand Hygiene dated 01/20/2023 revealed: <BR/>Hand hygiene must be performed prior to donning and after doffing gloves.<BR/>Record Review of facility's policy titled Preventing Foodborne Illness - Food Handling dated April 2022 revealed:<BR/>All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .Potentially hazardous foods held in the danger zone (41&deg;F to 135&deg;F) for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) will be discarded.<BR/>Record Review of facility's policy titled Food Storage dated 2018 revealed:<BR/>1. Dry storage rooms .d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated .2. Refrigerators .d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage .e. Use all leftovers within 72 hours. Discard items that are over 72 hours old .3. Freezers .c. Store all foods on racks or shelves off the floor. <BR/>Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed on 02/19/2025 revealed: <BR/>3-602.11 Food Labels. <BR/>(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. <BR/>(B) Label information shall include: <BR/>(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; <BR/>(2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; <BR/>(3) An accurate declaration of the net quantity of contents; <BR/>(4) The name and place of business of the manufacturer, [NAME], or distributor; and <BR/>(5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf <BR/>(6) Except as exempted in the Federal Food, Drug, and Cosmetic Act &sect; 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. <BR/>Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.<BR/>3-501.13 Thawing.<BR/>Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed:<BR/>(A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) <BR/>or less Pf; or <BR/>(B) Completely submerged under running water: <BR/>(1) At a water temperature of 21oC (70oF) or below Pf,<BR/>(2) With sufficient water velocity to agitate and float off loose particles in an overflow Pf, and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 diseases and infections for 1 of 3 residents (Resident #18) observed for infection control. <BR/>1. The facility failed to ensure CNA B used the required PPE for Resident #18, (gown) who was on enhanced barrier precautions due to her Foley Catheter while performing Foley Catheter Care on 02/19/25. <BR/>These failures could place the residents at risk of cross-contamination and development of infection.<BR/>Findings included: <BR/>Record review of Resident #18's face sheet, dated 2/18/25, reflected a [AGE] year-old female with an admission date of 2/15/19. Resident #1 had a diagnosis which included dementia, disorder of urinary system, and type 2 diabetes mellites. <BR/>Record review of Resident #18's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 8, indicating moderate cognitive impairment. <BR/>Record review of Resident #18's Care Plan dated 2/18/25 with ADL's indicated Resident #18 has problem with recurrent urinary tract infections. <BR/>During an observation on 2/18/25 at 9:18 AM, CNA B gathered supplies for Resident #18's catheter care and placed supplies in a plastic bag. CNA B entered room with plastic bag and did not don gown. She performed hand hygiene and put on gloves in the room prior to performing care to the resident. CNA B performed foley catheter care using clean wipe each x 4 and cleaned catheter from the resident's skin, away from the resident. CNA B disposed of each used wipe into disposal bag and performed hand hygiene after care completed and gloves removed. Resident #18's foley catheter bag was suspended to the left side of her bed and in a privacy bag. Resident #18 had sign on door notifying staff of EBP (enhanced barrier precautions). There was no PPE directly outside of room or handing on the door . <BR/>During an interview on 2/19/25 at 04:25 PM LVN A stated Resident #18 was on enhanced barrier precautions due to her having an indwelling foley catheter. she stated that means that any employee that goes into Resident #18's room and performs any kind of patient care associated to the foley, the employee should be wearing all the gear. she stated all the gear includes gown, gloves, and mask.<BR/>During an interview on 2/19/25 at 05:45 PM DON stated that she was the infection preventionist. She stated that enhanced barrier precautions are in place to protect the residents and employees while performing patient care from spreading any bacteria. She stated that an employee that performed foley catheter care should have been wearing the required ppe. She stated the required ppe was mask, gloves, and gown. She stated that CNA B should have been wearing a gown while she performed foley care. She stated that if the proper ppe was not worn, it could put Resident #18 at risk for an infection. <BR/>Attempted to contact CNA B on 2/19/24 at 5:50 pm by phone, no answer, left message. <BR/>Record review of facilities policy titled Enhanced Barrier Precautions dated 4/1/24 indicated: <BR/>Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. <BR/>9. Enhance barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents/resident's representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 2 of 23 residents (Resident #29 and Resident #44) reviewed for antipsychotic consents.<BR/>1. The facility failed to ensure Resident #29 or their representative signed consent for antipsychotic medication Seroquel (quetiapine) (an antipsychotic medication used to treat mental health disorders, such as schizophrenia) prior to administering medication and after dosage increased and prior to administering new dosage ordered by physician.<BR/>2. The facility failed to ensure Resident #44's or their representative signed consent for antipsychotic medication Seroquel (quetiapine) prior to administering medication. <BR/>These failures could affect residents by placing them at risk of not being informed of their health status, to make informed decisions regarding their care.<BR/>Findings included: <BR/>Resident #29<BR/>Record review of Resident #29's electronic face sheet dated 02/19/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and most recently on 08/21/2022 with diagnoses to include: schizoaffective disorder, bipolar type (mental health condition that includes hallucinations and delusions, depression and mania).<BR/>Record review of Resident #29's quarterly MDS dated [DATE] revealed: BIMS score of 09 which indicated moderate cognitive impairment. Further review of the MDS Section N-Medications revealed Resident #29 was taking antipsychotic medication.<BR/>Record review of Resident #29's physician order dated 10/14/2024 revealed: quetiapine tablet 100mg 1 tablet to be administered twice a day orally.<BR/>Record review of Resident #29's MAR dated October 2024 revealed Resident #29 received Seroquel (quetiapine) 100mg twice a day starting the night of 10/14/2024 - 10/31/2024<BR/>Record review of Resident #29's MAR dated November 2024 revealed Resident #29 received Seroquel (quetiapine) 100mg twice a day from 11/01/2024 - 11/30/2024.<BR/>Record review of Resident #29's MAR dated December 2024 revealed Resident #29 received Seroquel (quetiapine) 100mg twice a day from 12/01/2024 - 12/31/2024.<BR/>Record review of Resident #29's MAR dated January 2025 revealed Resident #29 received Seroquel (quetiapine) 100mg twice a day from 01/01/2025 - 01/31/2025.<BR/>Record review of Resident #29's MAR dated February 2025 revealed Resident #29 received Seroquel (quetiapine) 100mg twice a day from 02/01/2025 - 02/19/2025.<BR/>Record review of Resident #29's HHSC Form 3713 Consent for Antipsychotic or Neuroleptic Medication Treatment dated 03/31/2023 for Seroquel revealed no evidence of a signature by Resident #24 or their representative. Further review revealed a verbal consent obtained by CCN on 04/05/2023 for dosage of 50mg in the AM and 100mg in the PM. No evidence that side effects were went over with Resident #29's representative and side effects were not listed on the form.<BR/>Record review of Resident #29's electronic medical chart revealed no evidence Resident #29 or his representative consented to increased dosage of Seroquel on or before 10/14/2024.<BR/>Attempted a telephone interview on 02/17/2025 at 11:10 a.m., Resident #29's representative did not answer phone call and no return call.<BR/>Resident #44<BR/>Record review of Resident #44's electronic face sheet dated 02/19/2025 revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: neurocognitive disorder with Lewy bodies (Protein deposits called Lewy bodies develop in nerve cells in the brain. The protein deposits affect brain regions involved in thinking, memory and movement), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest that affects how people feel, think and behave).<BR/>Record review of Resident #44's quarterly MDS dated [DATE] revealed: BIMS score of 07 which indicated severe cognitive impairment. Further review of the MDS Section N-Medications revealed Resident #44 was taking antipsychotic medication.<BR/>Record review of Resident #44's physician order dated 05/15/2024 revealed: quetiapine tablet 25mg 1 tablet to be administered once a day orally at bedtime. Further review of physician order revealed quetiapine was discontinued on 05/22/2024.<BR/>Record review of Resident #44's physician order dated 08/09/2024 revealed: quetiapine tablet 25mg 1 tablet to be administered once a day orally at bedtime. Further review of physician order revealed quetiapine was discontinued on 08/21/2024.<BR/>Record review of Resident #44's physician order dated 09/12/2024 revealed: quetiapine tablet 25mg 1 tablet to be administered once a day at bedtime.<BR/>Record review of Resident #44's MAR dated May 2024 revealed Resident #44 received Seroquel (quetiapine) 25mg once a day starting the night of 05/15/2024 - 05/21/2024.<BR/>Record review of Resident #44's MAR dated August 2024 revealed Resident #44 received Seroquel (quetiapine) 25mg once a day from 08/09/2024 - 08/31/2024.<BR/>Record review of Resident #44's MAR dated September 2024 revealed Resident #44 received Seroquel (quetiapine) 25mg once a day from 09/01/2024 - 09/30/2024.<BR/>Record review of Resident #44's MAR dated October 2024 revealed Resident #44 received Seroquel (quetiapine) 25mg once a day from 10/01/2024 - 10/24/2024 & 10/26/2024 - 10/31/2024.<BR/>Record review of Resident #44's MAR dated November 2024 revealed Resident #44 received Seroquel (quetiapine) 25mg once a day from 11/01/2024 - 11/30/2025.<BR/>Record review of Resident #44's electronic medical chart revealed no evidence Resident #44, or his representative consented to antipsychotic medication Seroquel on or before 05/15/2024.<BR/>During an interview on 02/19/2025 at 4:20 p.m., LVN A stated that nurses were responsible for obtaining medication consent for psychoactive medications. She stated nurses get the consent prior to giving the medication. She stated sometimes the DON will assist with getting psychoactive medications. LVN A stated there was a form that would be filled in on the electronic medical system under the observations section. She stated after form filled out then the process would be to print the form and get a physical signature on the form. She stated it was okay to get a verbal consent if person not available in person to sign the form and when a verbal was obtained the DON would be notified. She stated as far as she knew, there was not another process for medications like Seroquel that were antipsychotics.<BR/>During an interview on 02/19/2025 at 5:08 p.m., the DON stated it was the nurse's responsibility for getting consents signed for psychoactive medications. She stated those consents should be obtained prior to giving psychoactive medication to the resident. She stated she was not able to find a consent for Seroquel medication on Resident #44. She stated she was unaware that verbal consents were not appropriate for Seroquel medication on Resident #29. She stated she could not find a consent with updated dosage for Resident #29. She verified that the consent for Seroquel on Resident #29 did not have physical signature on the form. She stated what might have led to Resident #44 not having consent on file could be that he had been discontinued from that medication in the past but then restarted back on that medication. The DON stated the effect of not obtaining consent prior to medication administration could cause residents or their representatives not being provided information of the side effects of the medication or not being notified that the resident was ordered that medication. She stated she was responsible for monitoring that the appropriate medications had consents. She stated she had just started monitoring that those consents were completed during the daily morning meetings.<BR/>During an interview on 02/19/2025 at 5:11 p.m., the CCN stated her expectation would be for consents to be obtained by nurses prior to administering Seroquel to a resident. She stated the reason she obtained a verbal consent on Resident #29's Seroquel on 04/05/2023 was because there was not a policy in place for anti-psychotic medications at that time. She stated there was a policy written on July 2024 about anti-psychotic medication consents. She stated she had been instructed on 04/05/2023 that verbal consent was appropriate. She stated consents needed to be done timely. She stated not obtaining consent for over a year was not timely. She stated there were barriers to obtaining the consents such as family not responding to telephone messages, emails, or written letters. She stated she felt representatives and families were scared to respond because representatives were afraid the facility was reaching out for financial reasons. She stated some of the facility's residents do not have guardians that makes the process timelier and more difficult. She stated no negative affect occurred to residents or their representatives from consents not physically being signed. She stated the facility ensures that residents and their representatives make an informed decision to medication by facility sending out information via letters, emails, and attempting to communicate with them verbally over the telephone. She stated the DON was responsible for monitoring medication consents were properly obtained or her designee. She stated she felt staff needed more education on antipsychotic medication consents and lack of knowledge may have led to the failure. <BR/>Record review of facility's admission agreement dated 02/22/2022 revealed: Resident's rights under Texas law .You have a right: . 9) to retain the services of a physician of your choice, at your own expense or through a healthcare plan, and to have a physician explain to you, in language you understand, your complete medical condition, the recommended treatment, and the expected results of the treatment<BR/>Record review of facility policy titled Psychoactive Medications dated July 2024 revealed A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics .9. Consent must be obtained from the resident or resident representative prior to administering a psychotropic medication (excluding an emergency). a. A consent form for antipsychotic/neuroleptic medication utilizing Texas form 3713 must be completed and signed by the resident or resident representative. Consent must be obtained in writing.<BR/>Review of LTCR Provider letter titled Consent for Antipsychotic and Neuroleptic Medications dated May 5, 2022, accessed on 02/19/2025 at https://www.hhs.texas.gov/sites/default/files/documents/pl2022-11.pdf, revealed The prescriber of the medication, the prescriber's designee, or the NF' s medical director must complete Section I of Form 3713. HHSC cannot specify who can be the designee for the prescriber. Prescribers should consult their own board, such as the Texas Medical Board, to determine who can act as their designee. A prescriber can delegate the completion of Form 3713, Section I, if the prescriber's license permits it . The resident or the resident's legally authorized representative must sign Section II of Form 3713 (Consent for Antipsychotic or Neuroleptic Medication Treatment). The rule requires consent in writing by the resident or by a person authorized by law to consent on behalf of the resident. Verbal consent does not meet the rule requirements. NF staff cannot sign on behalf of the resident. <BR/>Review of drugs.com accessed on 02/19/2024 at https://www.drugs.com/seroquel.html, revealed Seroquel .Drug class: Atypical antipsychotics .Seroquel may cause serious side effects. Call your doctor at once if you have: uncontrolled muscle movements in your face (chewing, lip smacking, frowning, tongue movement, blinking or eye movement); breast swelling and tenderness, nipple discharge, impotence, missed menstrual periods; trouble swallowing, severe constipation; painful or difficult urination; high blood pressure, fast, slow or uneven heart rate; a light-headed feeling, sudden numbness or weakness, severe headache; blurred vision, eye pain or redness, seeing halos around lights; a seizure, feeling unusually hot or cold; signs of infection - fever, chills, sore throat, body aches, unusual tiredness, loss of appetite, bruising or bleeding; severe nervous system reaction - very stiff (rigid) muscles, high fever, sweating, confusion, fast or uneven heartbeats, tremors, feeling like you might pass out; underactive thyroid - tiredness, depressed mood, dry skin, thinning hair, decreased sweating, weight gain, puffiness in your face, feeling more sensitive to cold temperatures; high blood sugar - increased thirst, increased urination, dry mouth, fruity breath odor; or low white blood cell counts - fever, mouth sores, skin sores, sore throat, cough. Common Seroquel side effects may include speech problems; dizziness; drowsiness; tiredness; feeling like you might pass out; lack of energy; fast heartbeats; increased appetite; weight gain; upset stomach; vomiting; constipation; stomach pain; nausea; abnormal liver function tests; sore throat; stuffy nose; dry mouth; or difficulty moving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for (Resident #169) 1 of 23 resident's rooms observed for environmental conditions.<BR/>The facility failed to ensure that Resident #169 ' s toilet was free from cracks at the base and was sturdily attached to the floor.<BR/>The facility's failure placed the residents at risk for diminished quality of life, discomfort, and safety.<BR/>The findings included:<BR/>Record review of Resident #169's electronic face sheet dated 02/19/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and most recently on 02/01/2025 with diagnoses to include: right foot drop (difficulty lifting the front part of the right foot and foot might drag on the floor when walking), muscle wasting and atrophy (breakdown of muscle fibers), muscle weakness, and unspecified abnormalities of gait and mobility.<BR/>Record review of Resident #169's admission MDS dated [DATE] revealed: BIMS score of 15 which indicated his cognition was intact. Further review of the MDS Section GG for functional limitation in range of motion revealed he used a wheelchair and was independent with toileting hygiene and transfer.<BR/>Record review of Resident #169's care plan dated 02/04/2025 revealed no evidence that Resident #169 needed assistance with toilet hygiene or transfer.<BR/>Record review of Resident #169's progress notes dated February 2025 revealed on 02/03/2025, 02/07/2025, 02/16/2025, and 02/18/2025 nurse documented Resident #169 needed supervision &ndash; oversight, encouragement or cueing for toilet use.<BR/>During an observation and interview on 02/17/2025 at 2:21 p.m., Resident #169 was sitting up in a wheelchair in his room. He stated he had made a complaint about his toilet being broken when the maintenance man had first started Resident #169 stated he was scared that he was going to fall off the toilet. Toiled observed in resident ' s restroom to have left side of toiled base busted. Toilet moved easily with hands approximately an inch to the left side when pressed down on.<BR/>During an interview on 02/19/2025 at 3:00 PM the MD stated he had been there two weeks. MD stated he remembers talking with Resident # 169 about the toilet but was not sure when. The MD stated after he had been there a week he had cut his finger and had to take a week off. The MD stated the expectation was for residents ' toilets be in working order.<BR/>During an interview and record review on 02/19/2025 at 4:41 PM LVN A stated she was made aware of the broken toilet by the pest control man. LVN A stated she had made a repair request on 2/10/2025 on their electronic system, which she displayed. LVN A stated the new MD did not show up on the electronic system so she had made request to the ADMN. LVN A stated a toilet that was broken at the base could cause Resident to fall if they did not feel secure when they sat on toilet.<BR/>During an interview on 02/19/2025 at 5:11 PM the ADMN stated her expectation was that Residents have a safe and clean environment to reside. The ADMN stated she was not aware of Resident #169 ' s toilet being broken. The ADMN stated she never checked the electronic system and did not know that staff could send them under her name. The ADMN stated affect on residents having broken equipment could cause injury to resident. The ADMN stated what led to failure was the new DM not being at facility because he had been on leave and staff not knowing the ADMN was not checking the electronic reporting system.<BR/>Record review of facility ' s admission agreement dated 02/22/2022 revealed: Resident ' s rights under Texas law .You have a right: .2) to safe, decent and clean conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment were reported immediately but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 16 resident reviewed for abuse or neglect.<BR/>The facility failed to report to the State Survey Agency allegations of Abuse and Neglect when learning of an elopement of Resident #1.<BR/>This failure could affect residents by placing them at risk of not having incidents of abuse and neglect being reviewed and investigated in a timely manner by the facility and State Survey Agency.<BR/>The findings included: <BR/>Record review of Resident #1's face sheet dated 04/24/2024 revealed [AGE] year-old male admitted on [DATE]. Resident #1's diagnoses: Alzheimer's disease, type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), hypertension (high blood pressure), and Major Depressive Disorder. <BR/>Record review of Resident #1's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns Resident #1 had a BIMS score of 7 meaning severe cognitive impairment; Section E- Behavior Resident #1 had not exhibited and wandering; Section GG- Functional Abilities and Goals Resident #1 required supervision or touching assistance for eating, hygiene, dressing, transferring and walking; Section M- Skin Conditions Resident #1 had no skin conditions; <BR/>Record review of Resident #1's Care plan dated 04/18/2024 revealed: <BR/>Problem Start Date 12/19/2023: Behavioral Symptoms<BR/>Goal: Resident will have fewer episodes of Depression and wandering in unsafe places<BR/>Approach: Start Date 12/19/2023 Approach Start Date: 12/19/2023 Always ask for help if resident becomes abusive/resistive; Start Date: 12/19/2023 Convey acceptance of resident during periods of inappropriate behavior; Start Date: 12/19/2023 Encourage diversional activities; Start Date: 12/19/2023 Keep environment calm and relaxed; Start Date: 12/19/2023 Redirect resident as needed; Start Date: 12/19/2023 Remove from public area when behavior is unacceptable <BR/>Problem Start Date: 12/19/2023: Falls/Safety Risk/Elopement Risk <BR/>Goal: Resident will remain free of injuries related to falls and will remain in a safe environment<BR/>Approach: Start Date- 12/19/2023 Assess resident's footwear for proper fit and non skid soles; Start Date: 12/19/2023 Encourage use of call light; Start Date: 12/19/2023 Instruct resident on safety measures; Start Date: 12/19/2023 Keep call light in reach: Start Date: 12/19/2023 Orthostatic hypotension precautions; Start Date: 12/19/2023 PT referral; <BR/>Problem Start Date: 12/19/2023: Delirium<BR/>Goal: Resident will be as alert and oriented as possible.<BR/>Approach: Start Date: 12/19/2023 Assess for constipation; Start Date: 12/19/2023 Assess for Pain; Start Date: 12/19/2023 Minimize distraction; Start Date: 12/19/2023 Orient PRN; Start Date: 12/19/2023 Rule out acute illnesses<BR/>Problem Start Date: 12/19/2023 Category: Cognitive Loss/ Dementia Cognitive Loss-related Alzheimer disease.<BR/>Goal: Resident will be as alert and oriented as possible<BR/>Approach: Approach Start Date: 12/19/2023 Anticipate needs and observe for nonverbal cues; Start Date: 12/19/2023 Approach in calm manner; Start Date: 12/19/2023 Explain what you intend to do while providing care; Introduce self-Created; Start Date: 12/19/2023 Orient PRN to person, place and time.<BR/>Record review of Resident #1's progress notes revealed: Date & Time: 04/18/2024 at 8:00 PM, Documented by LVN B [Recorded as Late Entry on 0411912024 12:36AM] nurse went into resident room to give him his medication. resident wasn't in his. nurse and staff went to all rooms and living area looking for him. nurse notified ADMN and DON that resident couldn't be found. administrator notified police. police came to facility and look in all rooms. nurse notified resident [this resident family member] to report resident left the facility without telling anyone. resident was found at salvation army and bring back to facility. resident was wearing shorts, gray shirt and black shoes and his glasses. resident stated he got upset and took off walking and went a crunch that took him to the salvation army. resident was taking to hospital for eval and treatment. resident [this resident family member] notified he has returned and sent to hospital to get check out and will be moved to room [ROOM NUMBER] in station 2 unit. nurse in unit aware of the transfer and has his medications. waiting for resident return. <BR/>Date & Time: 04/19/2024 at 3:06 AM Documented by LVN U: Resident returned via facility transport staff to secured unit. Assessed resident upon return, no open wounds, lesions, or immediate bruising observed. Resident range of motion WNL. Hand grasps strong, able to push and pull with hands and feet. States nothing happened to him during his departure. Resident denies pain, weakness, or feelings of sickness. Does not appear to be in distress. Resident made comfortable in their new room and offered a tray of food. Resident states that he's going to rest. Plan of care continues.<BR/>Record review of Resident #1's physician orders reviewed on 04/26/2024 revealed: start date 04/18/2024, Admit to secured unit due to high elopement risk and poor safety awareness.<BR/>During an interview on 04/24/2024 at 12:20 PM LVN B stated she worked the night of 04/18/2024. LVN B stated when she starts her shift she will pass medications on Hall 2 and then will pass medications on Hall 1. LVN B stated she went into Resident # 1's room about 7:30 PM to give him his evening medications and discovered he was not in his room and he his meal tray had not been touched. LVN B stated she immediately went to search for Resident #1. LVN B stated she asked staff if they had seen Resident #1 and asked them to look for him. LVN B stated when he was not in his usual places, she then called a CODE PINK, which was the code for missing resident. LVN B stated she then contacted the DON and ADMN and contacted law enforcement. LVN B stated she was not aware of how long resident had been gone.<BR/>During an interview on 04/24/2024 at 1:58 PM the SW stated the ADMN was the abuse/Neglect coordinator. The SW stated elopement was a reportable incident. The SW stated the ADMN was responsible for reporting the elopement. <BR/>During an interview on 0/24/2024 at 2:25 PM, the DON stated elopement was an incident that should have been reported to the State Survey Agency. The DON stated the ADMN was the Abuse/Neglect coordinator and was responsible for reporting and investigating incidents of Abuse and Neglect to the State Survey Agency. The DON stated she thought that the ADMN had reported the incident. The DON stated that residents that required assistance with ADLs and/ or were incontinent were checked every 2-3 hours and it would have been documented. The DON stated residents who were ambulatory were observed when in their room or while sitting in common areas, but there were no set time frames to document the whereabout of ambulatory residents. <BR/>During an interview on 04/24/2024 at 2:45 PM, the ADMN stated she was the Abuse/Neglect Coordinator. The ADMN stated it was her responsibility to investigate and report abuse and neglect. The ADMN stated she had reported the elopement of Resident #1 and that she would not fail to report an incident. The ADMN pulled out a folder and revealed her initial report and the completed PIR. The ADMN stated she knew she had sent the report in an email but was not able to find the email and stated she did not have an intake number. The ADMN stated what led to failure of not reporting the incident was she must have gotten distracted and forgot to send the email. The ADMN stated she had made several reports during that time frame. <BR/>Record review of the facility's policy titled Emergency Procedure-Missing Resident, dated September 1, 2023, revealed: Resident elopement resulting in a missing resident is considered a center emergency . Administrator/Incident Commander Report eh incident to the State Licensing and Certification Agency according to regulation.<BR/>Record review of facility's policy titled Abuse Prevention Program, dated 01/09/20223, revealed: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by Center Administrator, or his/her designee, to the following person or agencies as required: a. The State licensing/certification agency responsible for surveying/licensing the center . An alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but not later than: 2 hours if the alleged violation involves abuse OR has resulted in serious bodily injury; Twenty- four(24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to thoroughly investigate, prevent further potential abuse when allegations of abuse was made for 7 of 7 Residents (Resident #53, Resident #6, Resident #9, Resident #15, Resident #40, Resident #43, and Resident #74) that resided on Station 2/Hall 6 (women's secure locked unit). <BR/>1. The facility failed to thoroughly investigate and prevent further potential abuse involving Resident's #43, #53, #74 that resulted in injuries to Resident's #43 and #53 on 12/03/22.<BR/>2. The facility failed to thoroughly investigate and prevent further potential abuse involving Resident's #40, #53 that resulted in an injury to Resident #40 on 12/21/22. <BR/>3. The facility failed to thoroughly investigate and prevent further potential abuse involving Resident's #9 and #53 that resulted in an injury to Resident #9 on 12/21/22.<BR/>4. The facility failed to thoroughly investigate and prevent further potential abuse involving Resident's #40, #53 and #74 that resulted in an injury to Resident #53 on 01/26/23.<BR/>5. The facility failed to thoroughly investigate and prevent further potential abuse involving Resident's #15 and #53 on 11/26/22.<BR/>6. The facility failed to thoroughly investigate and prevent further potential abuse involving Resident's #6 and #53 to prevent on 12/20/22.<BR/>This failure could place the residents who resided on Station 2/Hall 6 (women's secured unit) at risk of serious injury and emotional distress.<BR/>Findings include:<BR/>Resident #53 <BR/>Record review of Resident #53's electronic face sheet, dated 02/23/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. She was being housed on the women's secured unit (the average age of the residents on the women's secure unit was 76 years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness; epilepsy and epileptic syndromes with seizures of localized onset; restlessness and agitation; post-traumatic stress disorder; repeated falls; muscle weakness (generalized); insomnia due to other mental disorder; major depressive disorder; anxiety disorder; dysphagia (difficulty in swallowing), altered mental status; pain; adult sexual abuse; and victim of crime and terrorism. <BR/>Record review of Resident #53's Quarterly MDS, dated [DATE], revealed the BIMS score was blank. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. None of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavior symptoms directed towards others - behavior of this type occurred 1 to 3 days, B. Verbal behaviors symptoms directed towards others - behavior not exhibited, C. Other behavioral symptoms not directed towards others - behavior of this type occurred 1 to 3 days. E0900: Wandering - 1 (Behavior of this type occurred 1 to 3 days). <BR/>Record review of Resident #53's Care Plan, last edited on 02/13/23 revealed: Problem: I have periods of time where I am in constant motion/movement. Problem: I get frustrated because of my physical condition and may reach out to grab or hit others. Goal. To not hit other residents. Approach. Patient placed on 1:1 observation for at least 72 hours to prevent injury to others, will keep her separated from arms reach from other residents, put gloves on resident to prevent any injury if she reaches out. Problem: I have anxiety related to anoxic brain injury as evidence by I fidget constantly, grab at others, lick my hands and rub it on things and people, sit to stand frequently, stand up rapidly and attempt to walk with no regards to surroundings. Problem: Behavioral Symptoms - licking her hands and trying to touch others, invading others space, grabbing at others, sitting and or lying-in other residents' beds when they are not in them. Goal. Resident will have less than 5 bad outcomes due to grabbing at people and toward staff or other residents over the next 90 days. Approach: 15-minute checks, I will have increased supervision due to my behavior or grabbing at things and swinging my arms, I rest better with a quiet calm environment at night. <BR/>Record review of Resident #53's transfer documentation packet, faxed on 04/19/2023 from previous facility revealed: resident required a locked facility that has more supervision and brain training support. On 04/21/22, Resident #53 was transferred from a sister facility requiring 1:1 supervision due to being threat to herself and others.<BR/>Record review of Nurse Practitioner progress note, dated 06/10/22, revealed Resident #53 was transferred from other facility due to not being able to continually provide the 1:1 care and attention that she requires.<BR/>Record review of Social Worker progress note, dated 09/12/22 at 5:27 pm, revealed: SW expressed to Family Member J, facility is not able to meet resident needs and SW will need to talk with Family Member J regarding plans to transition resident to another facility. <BR/>Record review of Social Worker progress note, dated 10/01/22 at 10:33 am, revealed: SW expressed to Family Member J, facility is not able to meet resident needs.<BR/>Resident #43 <BR/>Record review of Resident #43's face sheet in the electronic medical record, accessed on 02/14/22 revealed a [AGE] year-old female whose most recent admission date was 10/14/22 to the female secured locked unit with diagnosis to include: Alzheimer's Disease, schizoaffective Disorder (a mental health condition), and hypertension (high blood pressure).<BR/>Record review of Resident #43's Significant Change in Status MDS dated [DATE], revealed her BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E0800 Rejection of care: behavior did not occur. Section E0900 Wandering - behavior did not occur. <BR/>Record review of Resident #43's Care Plan revealed the following problems and approaches: Problem: (start date 08/23/21) I have a history of aimless wandering increasing safety concerns. 12/03/22 Behavior from another resident. Goal: I will have less than 2 episodes of wandering into others space over the next 90 days. Approaches: I will be redirected if I walk up to someone and invade their personal space, I will be redirected as needed when wandering to prevent me from going into an unsafe area, I will reside in the secured unit. Problem: for elopement- (start date 01/11/23). Goal - Resident will not wander out of designated secure area over the next 90 days. Approach: Secure Unit Placement. Secure unit evaluation quarterly and PRN, elopement assessment quarterly and PRN Risk related to Alzheimer's /dementia.<BR/>Resident #74 <BR/>Record review of Resident #74's Face Sheet document in the electronic medical record accessed on 02/14/22 revealed an [AGE] year-old female whose most recent admission date was 01/06/23 to the female secured locked unit with diagnosis to include: fractured left hip, osteoporosis (disease that makes the bones brittle), history of falling, Alzheimer's Disease, and major depressive disorder.<BR/>Record review of Resident #74's Annual MDS dated [DATE], revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E0800 Rejection of care: behavior did not occur. Section E0900 Wandering -behavior did not occur. <BR/>Record review of Resident #74's Care Plan revealed the following problems and approaches: Problem: At risk for elopement - (start date 01/11/23). Goal: Resident will be kept safe in surroundings. Approaches: continuous placement in secure unit, elopement assessment quarterly and nail care weekly. Problem: Behavioral symptoms - resident exhibits verbal and physical aggression when other residents invade her space and surroundings. Goal: Resident will not show behaviors of aggression. Approaches: Remove and provide a quiet place, staff will encourage rapport with other residents, staff will encourage redirection when resident exhibiting bouts of verbal/ physical aggression, I will have increased supervision until reviewed by psych services., I will be assisted to a quiet place when things become too loud for me, Keep environment calm and relaxed. <BR/>1. Record review of facility investigation on 12/03/22 at 3:53 pm, Resident #53 slapped the face of Resident #43, and Resident #74 retaliated. A record review of the Provider Investigation Report revealed Resident #43 was sitting in the recliner minding her own business and for no reason Resident #53 slapped Resident #43 in the face. This in turn upset Resident #74 who scratched Resident #53 on the arm. Resident #43 had slight redness noted to the left side of her face. Resident #53 had several scratch marks to her upper right arm. Resident #53 was placed on increased supervision with staff. The facility failed to determine the root cause of the incidence, identify the incident as abuse, and determine corrective action to prevent a reoccurrence. <BR/>Record review of Resident #53's progress note dated 12/03/22 at 4:39 am by LVN-AB, revealed Resident #53 had multiple behaviors throughout the evening and night. Grabbing at residents. Attempting to remove snacks from other residents. Walking on knees and crawling on the floor. Attempting to hit and kick staff during care. Removing clothes and brief and walking down hall. Walks to exit door of secured unit 1 and slaps and then tries to open locked door. No evidence of documentation that resident was on 1:1 supervision included in the note.<BR/>Record review of Resident #53's progress note dated 12/03/22 at 3:53 pm by LVN-T, revealed Resident #53 hit another resident (not identified) across the face. <BR/>Record review of Resident #53's progress note dated 12/03/22 at 5:46pm by LVN-T, revealed another resident was yelling get away, get away. Resident #53 hit another resident in the face and the other resident scratched at Resident #53's upper arm. Residents were separated. Resident #53 then went toward another resident and attempted to hit her, but the LVN intervened. (Other residents were not identified.) <BR/>Record review of Resident #53's progress note dated 12/03/22 at 6:05 pm by LVN-AC, revealed Resident #53 was on 1:1 supervision. <BR/>Record review of Resident #53's progress note dated 12/03/22 at 6:43pm, LVN-T documented in Resident #53's progress notes per DON, resident to be 1:1. If no staff available to be 1:1 then resident can be on Q (every) 15-minute checks.<BR/>Record Review of Resident #53's progress note dated 12/03/22 at 10:15 pm by LVN-AC, revealed Resident #53 was on 15-minute checks. <BR/>During an interview on 02/17/23 at 9:45 am, the Interim Administrator stated she could not provide documentation of who was working on the women's secured unit at that time or documentation of 15-minute checks. She failed to address how to prevent future actions of recurrence by Resident #53 and how to protect the residents on the secured units.<BR/>Resident #40 <BR/>Record review of Resident #40's electronic face sheet accessed on 02/14/22 revealed a [AGE] year-old female whose most recent admission date was 01/06/23 to the female secured locked unit with diagnosis to include: fractured left hip, osteoporosis (disease of bone that makes them brittle), history of falling, Alzheimer's Disease, and major depressive disorder.<BR/>Record review of Resident #40's Annual MDS dated , dated 01/11/23, revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E 0800 Rejection of care: behavior did not occur. Section E 0900 Wandering - behavior did not occur. <BR/>Record review of resident #40's Care Plan revealed the following problems and approaches: Problem: Mood state - start date 01/06/23 resident exhibits socially inappropriately disruptive behavioral symptoms. Resident wanders about without direction and becomes physically aggressive (hitting, kicking etc.) when she gets near other residents or staff in her path as well as being hit by resident's she provokes with her unwanted behavior. Goal: Resident will not harm self or others secondary to socially inappropriate, disruptive behavior of opportunistically hitting or kicking residents who get in her pathway or reach while she wanders. Approach: Assess whether the behavior endangers the resident or others. Intervene, if necessary, by moving resident to a safe area, to wander, avoid over stimulation (noise, crowding and other physically aggressive residents, when resident begins to reach for, hit, kick, or grab others, provide for basic needs pain, hunger toileting, too hot/cold etc. Problem: behavioral symptoms: (start date 09/09/22) I pace up and down the halls frequently with no regards to others in my path. 08/01/22 I walked up behind another resident and got hit in the stomach. 08/17/22 I pushed another resident in the hallway while I was pacing up and down the hall. 08/26/22 I hit another resident in the face while walking in the hallway. 12/04/22 Hit by another resident. Goal: I will have less than 3 episodes of physical aggression with other people in my path over the next 90 days. Approaches: I will be redirected to least crowded areas when pacing. I will have increased monitoring and a referral to a behavioral center.<BR/>2. Record review of facility investigation on 12/21/22 at 11:25 am, Resident #53 scratched Resident #9 on the forehead. A record review of the Provider Investigation Report revealed, Resident #9 was sitting in a chair when Resident #53 approached her and brushed Resident #9 on her forehead, causing a small 2cm X 1cm scratch. The facility stated Resident #53 did not intend to hurt Resident #9 as both residents were acting per their norm. The facility failed to determine the root cause of the incidence, identify the incident as abuse, and determine corrective action to prevent a reoccurrence. <BR/>Record review of Resident #53's progress note, dated 12/21/22 at 5:35 am by LVN-AB, revealed resident #53 had multiple behaviors throughout the shift, including crawling on the floor, pulling and trying to remove the keypad cover, attempting to open doors, removing pants and brief and walking naked in the hallway, pulling a sign off the door, grabbing at residents and attempting to take their snacks, refusing evening medications, and attempting to climb in bed with another resident. Resident received Diazepam 15mg and it was documented it was not effective. <BR/>Record review of Resident #53's progress notes, dated 12/21/22 at 12:09 pm by LVN-R, revealed Resident #53 scratched another resident in the face. Resident also attempted to grab and hit the nurse. <BR/>Resident #9 <BR/>Record review of Resident #9's Annual Assessment MDS, dated [DATE], revealed Resident #9 was admitted to the facility on [DATE]. Diagnosis included dementia, depression, and psychotic disorder (a mental disorder characterized by a disconnection from reality). Resident #9 had a BIMS score of 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E 0800 Rejection of care: behavior did not occur. Section E 0900 Wandering - behavior did not occur. <BR/>3. Record review of facility investigation on 12/21/22 at 1:52 pm, Resident #53 reached out her arm causing a skin tear to Resident #9. A record review of the Provider Investigation Report revealed, Resident #53 was ambulating in the hallway and reached out grabbing Resident #9's arm causing a small 1cm X 2cm skin tear to her forearm. Review of the report revealed it is normal for Resident #53 to reach out and grab objects and people within reach. The facility failed to determine the root cause of the incidence, identify the incident as abuse, and determine corrective action to prevent a reoccurrence. <BR/>Record review of a progress note, dated 12/21/22 at 9:40 pm by LVN-S, revealed Resident #53 was non-stop agitated and should have been on 1:1 observation. Resident #53 scratched and pulled the hair of the LVN on duty. Upon discussion with the ADON, Resident #53 was to be monitored until further notice. Record review revealed no documentation of resident being placed on 1:1 observation. <BR/>4. Record review of facility investigation on 01/26/23 at 7:00 pm, Resident #53 made contact with Resident #40's face and Resident #74 retaliated. A record review of the Provider Investigation Report revealed, Resident #40 walked to close to Resident #53 who flailed her hands making contact with Resident #40's face. Resident #74 intervened and scratched Resident #53 on her elbow. The scratch was visible. Resident #53 was placed on 1:1 observation until she went to sleep. <BR/>Record review of Resident #53's progress note dated 01/26/23 at 7:00 pm by LVN-AB revealed, an unknown resident was sitting in a chair watching TV when Resident #53 walked past the unknown resident and hit her on the jaw with a closed fist. <BR/>Record review of Resident #53's progress note dated 01/26/23 at 7:10 pm by LVN-AB revealed, Resident #53 walked past resident #40 and attempted to slap her. Resident #74 grabbed Resident #53's right elbow causing a 1.5cm X 0.5cm superficial scratch. Resident #53 was already currently on 1:1 monitoring. <BR/>Resident #15 <BR/>Record review of Resident #15's electronic face sheet, dated 02/23/23, revealed an [AGE] year-old female who latest return to the facility was on 11/17/22. She was being housed on the women's secured unit until she moved to a non-secured area of the facility on 01/09/23. Diagnosis included: unspecified dementia with behavioral disturbance, schizoaffective disorder (a mental illness), other lack of coordination, need for assistance with personal care, abnormalities of gait and mobility, and insomnia. <BR/>Record review of Resident #15's Significate Change in Status Assessment MDS, dated [DATE], revealed the BIMS score was blank. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E 0800 Rejection of care: behavior did not occur. <BR/>Record review of Resident #15's Care Plan, last reviewed/revised on 02/15/23 revealed: Problem: I have behavioral symptoms of verbal and physical aggression. Goal: Will not hit others or be hit by other residents. Approach: I do not like a lot of noise; I prefer to remain in my room most of the time where it is quiet. Problem: Falls - I have a history of falls as evidence by while walking in the dining room another resident pushed Resident #15 causing her to fall on the floor. Problem: I have aggressive behaviors at times. <BR/>5. Record review of facility investigation on 11/26/22 at 4:00 pm, Resident #53 pulled the hair of Resident #15 and Resident #74 retaliated. A record review of the Provider Investigation Report revealed, Resident #74 was in the hallway when Resident #53 attempted to hit her, Resident #74 hit Resident #53 on the arm. Resident #15 was sitting at the dining room table and Resident #53 came up and pulled Resident #15's hair. Resident #53 was placed on 15-minute checks. The facility failed to determine the root cause of the incidence, identify the incident as abuse, and determine corrective action to prevent a reoccurrence. <BR/>Record review of Resident #53's progress note dated 11/26/22 at 3:50 pm by RN-U, revealed Resident #53 was walking in the dining room and pulled Resident #15's hair. Resident #74 hit Resident #53 on the right arm after she pull Resident #15's hair. No documentation that Resident #53 was placed on 15-minute checks. <BR/>During an interview on 02/17/23 at 9:45 am, the Interim Administrator stated she could not provide documentation of who was working on the women's secured unit at that time or documentation of 15-minute checks. <BR/>Resident #6 <BR/>Record review of Resident #6's electronic face sheet accessed on 02/14/22 revealed an [AGE] year-old female whose most recent admission date was 12/20/21 to the female secured locked unit with diagnosis to include: Alzheimer's Disease, macular degeneration (deterioration of the retina of the eye that causes vision loss), and hypertension (high blood pressure).<BR/>Record review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. Other behavioral symptoms not directed toward others - behavior not exhibited. E0800 Rejection of care - behavior did not occur, E0900 Wandering - behavior occurred 1-3 days. <BR/>Record review of Resident's #6's Care Plan dated 11/02/22 revealed the following problems and approaches: At risk for elopement - (problem start date 01/12/23) Requires secure unit placement. Attempted to take out of the secure unit. She started to wander aimlessly throughout all halls and rooms placing her at risk for other residents becoming aggressive towards her. Goal: Resident will be safe throughout her surroundings for 90 days. Approaches: Secure unit placement evaluation quarterly and prn. Elopement assessment quarterly and prn, Problem: (start date 01/05/23) Resident has physically abusive behavioral symptoms. Resident was hit by another resident and in return hit the other resident several times in defense. Goal resident will not harm self or others secondary to physically abusive behavior. Approach: avoid over stimulation, noise, crowding, and other physically aggressive residents), Avoid power struggles with resident, divert resident's behavior by encouraging resident to move to another common area away from distraction and other potentially aggressive residents who might provoke an unwanted response from resident #6 such as aggression, maintain a calm environment and approach<BR/>6. Record review of a facility investigation report on 12/20/22 at 1:15 pm, Resident #53 reached out towards Resident #6 and Resident #6 reached out toward #53 swiping her in the face. A record review of the Provider Investigation Report revealed, Resident #53 unknowingly/unintentionally reached out (per her norm) toward Resident #6 brushing her face, in return Resident #6 swatted at Resident #53 in reaction and was instructed to not do that anymore. No injury noted. The facility failed to determine the root cause of the incidence, identify the incident as abuse, and determine corrective action to prevent a reoccurrence. <BR/>Record review of Resident #53's nursing progress note dated 12/20/22 at 3:07 pm, revealed Resident #53 was in the dining room reaching out towards Resident #6. Resident #6 slapped Resident #53 in the face on the right cheek. No injury. Residents were separated. <BR/>In an interview on 02/14/23 at 9:00 AM, the Interim DON stated she called Resident #53's responsible family member earlier this morning to discuss her behavior and the need to transfer her to another facility as they were not able to care for her. She stated Resident #53 was a harm to herself and harm to others. She said the Social Worker was going to (work on it). <BR/>In an observation on 02/14/23 at 11:00 am, Station 2/Hall 6 had 6 residents with known behaviors with CNA-E was observed on the hall and a rehab staff who left shortly after arrival. <BR/>In an interview on 12/14/23 at 11:00 am, CNA-E said she worked 6am to 6pm and worked 12 hours by herself on the women's secured unit, with 1 resident requiring 1:1 supervision. A staff member would come in every 2 hours to check on her. She said she did not feel safe working alone and was unable to prevent resident to resident altercations. <BR/>In an interview on 02/14/22 at 3:00 pm, the Corporate Regional Resource Nurse-J, said on January 10th, 2023, the facility moved 3 residents off of the Women's Secured Unit and moved 1 CNA to the general population. She stated I move staff to where they are needed, there were less residents on the women's locked secure unit after I moved the residents off the unit, therefore we needed less staff. I'm not cutting staff no matter what they tell you. They might tell you they are short staffed, but they are not. She had there was an aid that went to the unit whenever the CNA needed to give a resident a bath. When asked about how staff calls for help, she said staff can use their personal cell phone to call for help. <BR/>In an interview on 02/15/23 at 9:15 am, CNA-E stated there was not enough staff to provide adequate supervision for the residents on the female locked unit. She stated it was not safe with one person in the unit. She stated that the acuity was high due to behaviors, but Administration says that it was not. She said that Administration had told her that she sits the residents too close together, but she had nowhere for the residents to be as the unit was small. She said that during meals she was often by herself on the unit. She sat Resident #53 next to her because Resident #53 constantly required assistance and redirection. <BR/>In an interview on 02/15/23 at 11:00 am, with the Interim DON and Corporate Regional Resource Nurse-J, the Interim DON stated she talked to the Social Worker and Administrator earlier that same morning and told them they were not equipped to deal with Resident #53's behaviors. She stated, We are not a behavior unit, can we deal with these behaviors, yes, but it requires 1:1, 2:1, and sometimes even 3:1. The Interim DON stated that 1 staff on the Women's Secured Unit was enough as the residents are a low acuity level and just custodial care, and the census was 6 residents. The Interim DON defined acuity level as medical needs only and stated she did not consider behaviors when determining a resident's acuity. <BR/>In an interview on 02/15/23 at 4:00 pm, the Social Worker stated she has been employed at the facility since April 2022 and came on after Resident #53 was admitted . She stated she had told the responsible family member the facility was not able to meet her needs due to her behaviors, but she had not found a facility that would accept her. She stated she had not documented her attempts to find alternate placement for Resident #53. She stated due to the facility's continual documentation of behaviors, the facilities she contacts reject her. She stated had tried the state school, MHMR, state hospital, and all refused. When asked for documentation of the referrals, she was not able to produce any documentation that referrals had been completed.<BR/>In an interview on 02/16/23 at 11:40 am, CNA-E stated: It's not safe for the other residents with only one CNA working on the women's locked unit alone and there's always only one CNA scheduled. There has been 2 CNAs for the last few days only because the state surveyors are in the building. CNA-E said, we tell the DON all the time that we don't feel safe, and we need at least 2 CNAs back there, but they don't listen to us, and we're told to work it out. We have had some training, but no training ever received on how to provide care for residents who are aggressive or residents that have behavior problems.<BR/>On 02/16/23 at 4:00 pm, CNA-AA stated there have been issues with Resident #53's behavior for a long time as she hit, scratched, bit, and kicked staff and residents. <BR/>Record review of the facility policy Resident-to-Resident Altercations, dated as revised December 2016, revealed the following [in part]:<BR/>Policy Statement: All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator.<BR/>Policy Interpretation and Implementation: <BR/>1. Facility staff will monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator.<BR/>2. If two residents are involved in an altercation, staff will:<BR/>A. Separate the residents, and institute measures to calm the situation;<BR/>B. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation;<BR/>C. Notify each resident's representative and Attending Physician of the incident; <BR/>D. Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents; <BR/>F. Make any necessary changes in the care plan approaches to any or all of the involved individuals;<BR/>G. Document in the resident's clinical record all interventions and their effectiveness;<BR/>J. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident.<BR/>Record review of the facility policy, Abuse Prevention Program, dated as revised June 2021, revealed the following [in part]:<BR/>Policy Statements:<BR/>2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. <BR/>4. Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. <BR/>9. All occurrences of abuse, neglect, mistreatment, injuries of unknown source and theft or misappropriation of resident property will be analyzed by the Quality Assurance and Performance Improvement (QAPI) Committee to determine if system changes need to be made.<BR/>Response: Treatment/Managemen[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 diseases and infections for 1 of 3 residents (Resident #18) observed for infection control. <BR/>1. The facility failed to ensure CNA B used the required PPE for Resident #18, (gown) who was on enhanced barrier precautions due to her Foley Catheter while performing Foley Catheter Care on 02/19/25. <BR/>These failures could place the residents at risk of cross-contamination and development of infection.<BR/>Findings included: <BR/>Record review of Resident #18's face sheet, dated 2/18/25, reflected a [AGE] year-old female with an admission date of 2/15/19. Resident #1 had a diagnosis which included dementia, disorder of urinary system, and type 2 diabetes mellites. <BR/>Record review of Resident #18's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 8, indicating moderate cognitive impairment. <BR/>Record review of Resident #18's Care Plan dated 2/18/25 with ADL's indicated Resident #18 has problem with recurrent urinary tract infections. <BR/>During an observation on 2/18/25 at 9:18 AM, CNA B gathered supplies for Resident #18's catheter care and placed supplies in a plastic bag. CNA B entered room with plastic bag and did not don gown. She performed hand hygiene and put on gloves in the room prior to performing care to the resident. CNA B performed foley catheter care using clean wipe each x 4 and cleaned catheter from the resident's skin, away from the resident. CNA B disposed of each used wipe into disposal bag and performed hand hygiene after care completed and gloves removed. Resident #18's foley catheter bag was suspended to the left side of her bed and in a privacy bag. Resident #18 had sign on door notifying staff of EBP (enhanced barrier precautions). There was no PPE directly outside of room or handing on the door . <BR/>During an interview on 2/19/25 at 04:25 PM LVN A stated Resident #18 was on enhanced barrier precautions due to her having an indwelling foley catheter. she stated that means that any employee that goes into Resident #18's room and performs any kind of patient care associated to the foley, the employee should be wearing all the gear. she stated all the gear includes gown, gloves, and mask.<BR/>During an interview on 2/19/25 at 05:45 PM DON stated that she was the infection preventionist. She stated that enhanced barrier precautions are in place to protect the residents and employees while performing patient care from spreading any bacteria. She stated that an employee that performed foley catheter care should have been wearing the required ppe. She stated the required ppe was mask, gloves, and gown. She stated that CNA B should have been wearing a gown while she performed foley care. She stated that if the proper ppe was not worn, it could put Resident #18 at risk for an infection. <BR/>Attempted to contact CNA B on 2/19/24 at 5:50 pm by phone, no answer, left message. <BR/>Record review of facilities policy titled Enhanced Barrier Precautions dated 4/1/24 indicated: <BR/>Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. <BR/>9. Enhance barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment were reported immediately but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 16 resident reviewed for abuse or neglect.<BR/>The facility failed to report to the State Survey Agency allegations of Abuse and Neglect when learning of an elopement of Resident #1.<BR/>This failure could affect residents by placing them at risk of not having incidents of abuse and neglect being reviewed and investigated in a timely manner by the facility and State Survey Agency.<BR/>The findings included: <BR/>Record review of Resident #1's face sheet dated 04/24/2024 revealed [AGE] year-old male admitted on [DATE]. Resident #1's diagnoses: Alzheimer's disease, type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), hypertension (high blood pressure), and Major Depressive Disorder. <BR/>Record review of Resident #1's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns Resident #1 had a BIMS score of 7 meaning severe cognitive impairment; Section E- Behavior Resident #1 had not exhibited and wandering; Section GG- Functional Abilities and Goals Resident #1 required supervision or touching assistance for eating, hygiene, dressing, transferring and walking; Section M- Skin Conditions Resident #1 had no skin conditions; <BR/>Record review of Resident #1's Care plan dated 04/18/2024 revealed: <BR/>Problem Start Date 12/19/2023: Behavioral Symptoms<BR/>Goal: Resident will have fewer episodes of Depression and wandering in unsafe places<BR/>Approach: Start Date 12/19/2023 Approach Start Date: 12/19/2023 Always ask for help if resident becomes abusive/resistive; Start Date: 12/19/2023 Convey acceptance of resident during periods of inappropriate behavior; Start Date: 12/19/2023 Encourage diversional activities; Start Date: 12/19/2023 Keep environment calm and relaxed; Start Date: 12/19/2023 Redirect resident as needed; Start Date: 12/19/2023 Remove from public area when behavior is unacceptable <BR/>Problem Start Date: 12/19/2023: Falls/Safety Risk/Elopement Risk <BR/>Goal: Resident will remain free of injuries related to falls and will remain in a safe environment<BR/>Approach: Start Date- 12/19/2023 Assess resident's footwear for proper fit and non skid soles; Start Date: 12/19/2023 Encourage use of call light; Start Date: 12/19/2023 Instruct resident on safety measures; Start Date: 12/19/2023 Keep call light in reach: Start Date: 12/19/2023 Orthostatic hypotension precautions; Start Date: 12/19/2023 PT referral; <BR/>Problem Start Date: 12/19/2023: Delirium<BR/>Goal: Resident will be as alert and oriented as possible.<BR/>Approach: Start Date: 12/19/2023 Assess for constipation; Start Date: 12/19/2023 Assess for Pain; Start Date: 12/19/2023 Minimize distraction; Start Date: 12/19/2023 Orient PRN; Start Date: 12/19/2023 Rule out acute illnesses<BR/>Problem Start Date: 12/19/2023 Category: Cognitive Loss/ Dementia Cognitive Loss-related Alzheimer disease.<BR/>Goal: Resident will be as alert and oriented as possible<BR/>Approach: Approach Start Date: 12/19/2023 Anticipate needs and observe for nonverbal cues; Start Date: 12/19/2023 Approach in calm manner; Start Date: 12/19/2023 Explain what you intend to do while providing care; Introduce self-Created; Start Date: 12/19/2023 Orient PRN to person, place and time.<BR/>Record review of Resident #1's progress notes revealed: Date & Time: 04/18/2024 at 8:00 PM, Documented by LVN B [Recorded as Late Entry on 0411912024 12:36AM] nurse went into resident room to give him his medication. resident wasn't in his. nurse and staff went to all rooms and living area looking for him. nurse notified ADMN and DON that resident couldn't be found. administrator notified police. police came to facility and look in all rooms. nurse notified resident [this resident family member] to report resident left the facility without telling anyone. resident was found at salvation army and bring back to facility. resident was wearing shorts, gray shirt and black shoes and his glasses. resident stated he got upset and took off walking and went a crunch that took him to the salvation army. resident was taking to hospital for eval and treatment. resident [this resident family member] notified he has returned and sent to hospital to get check out and will be moved to room [ROOM NUMBER] in station 2 unit. nurse in unit aware of the transfer and has his medications. waiting for resident return. <BR/>Date & Time: 04/19/2024 at 3:06 AM Documented by LVN U: Resident returned via facility transport staff to secured unit. Assessed resident upon return, no open wounds, lesions, or immediate bruising observed. Resident range of motion WNL. Hand grasps strong, able to push and pull with hands and feet. States nothing happened to him during his departure. Resident denies pain, weakness, or feelings of sickness. Does not appear to be in distress. Resident made comfortable in their new room and offered a tray of food. Resident states that he's going to rest. Plan of care continues.<BR/>Record review of Resident #1's physician orders reviewed on 04/26/2024 revealed: start date 04/18/2024, Admit to secured unit due to high elopement risk and poor safety awareness.<BR/>During an interview on 04/24/2024 at 12:20 PM LVN B stated she worked the night of 04/18/2024. LVN B stated when she starts her shift she will pass medications on Hall 2 and then will pass medications on Hall 1. LVN B stated she went into Resident # 1's room about 7:30 PM to give him his evening medications and discovered he was not in his room and he his meal tray had not been touched. LVN B stated she immediately went to search for Resident #1. LVN B stated she asked staff if they had seen Resident #1 and asked them to look for him. LVN B stated when he was not in his usual places, she then called a CODE PINK, which was the code for missing resident. LVN B stated she then contacted the DON and ADMN and contacted law enforcement. LVN B stated she was not aware of how long resident had been gone.<BR/>During an interview on 04/24/2024 at 1:58 PM the SW stated the ADMN was the abuse/Neglect coordinator. The SW stated elopement was a reportable incident. The SW stated the ADMN was responsible for reporting the elopement. <BR/>During an interview on 0/24/2024 at 2:25 PM, the DON stated elopement was an incident that should have been reported to the State Survey Agency. The DON stated the ADMN was the Abuse/Neglect coordinator and was responsible for reporting and investigating incidents of Abuse and Neglect to the State Survey Agency. The DON stated she thought that the ADMN had reported the incident. The DON stated that residents that required assistance with ADLs and/ or were incontinent were checked every 2-3 hours and it would have been documented. The DON stated residents who were ambulatory were observed when in their room or while sitting in common areas, but there were no set time frames to document the whereabout of ambulatory residents. <BR/>During an interview on 04/24/2024 at 2:45 PM, the ADMN stated she was the Abuse/Neglect Coordinator. The ADMN stated it was her responsibility to investigate and report abuse and neglect. The ADMN stated she had reported the elopement of Resident #1 and that she would not fail to report an incident. The ADMN pulled out a folder and revealed her initial report and the completed PIR. The ADMN stated she knew she had sent the report in an email but was not able to find the email and stated she did not have an intake number. The ADMN stated what led to failure of not reporting the incident was she must have gotten distracted and forgot to send the email. The ADMN stated she had made several reports during that time frame. <BR/>Record review of the facility's policy titled Emergency Procedure-Missing Resident, dated September 1, 2023, revealed: Resident elopement resulting in a missing resident is considered a center emergency . Administrator/Incident Commander Report eh incident to the State Licensing and Certification Agency according to regulation.<BR/>Record review of facility's policy titled Abuse Prevention Program, dated 01/09/20223, revealed: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by Center Administrator, or his/her designee, to the following person or agencies as required: a. The State licensing/certification agency responsible for surveying/licensing the center . An alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but not later than: 2 hours if the alleged violation involves abuse OR has resulted in serious bodily injury; Twenty- four(24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for 1 (Resident #2) of 3 residents reviewed for discharge requirements. <BR/>1. The facility failed to ensure Resident #2 was provided a discharge in writing <BR/>2. The facility failed to document a discharge summary. <BR/>This failure placed residents at risk of not receiving necessary care and services. <BR/>Findings included: <BR/>Record review of Resident #2 electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnosis Anxiety, Type II Diabetes Mellitus, Dysuria , Hypertension, Altered Mental Status, acquired absence of right leg below knee, Acquired absence of left leg below knee.<BR/>Record review of Resident's #2 Discharge MDS assessment dated [DATE] revealed: Section C Cognitive Patterns #2's BIMS Score was 12 indicating moderate cognitive impairment. Section E Wandering behavior was not exhibited. Section GG Functional Abilities and Goals Resident #2 required supervision with Eating, Toileting and Dressing. Section M Skin Conditions Resident #2 had no skin conditions.<BR/>Record review of Resident #2's progress notes dated 04/12/2024 at 1:53 PM documented by the SW revealed, Resident has been advised that he is to have alternate residence placement by 3:30 PM<BR/>Record review of Resident #2's medical chart reviewed on 04/20/2024 revealed no evidence of discharge paperwork completed. <BR/>During an interview on 04/21/2024 at 6:24 PM, Resident # 2 stated the facility had told him he had to leave because he tested positive for illegal substances . Resident # 2 stated honest truth I signed myself out and went to the convenience store and bout Delta- 8 . He stated it was legalized Marijuana. Resident #2 stated he did not do meth because that is what caused him to lose his legs. Resident #2 stated when he returned to facility that he was told he had to pee in a cup or he would be discharged . Resident #2 stated he did not feel like he had a choice to take the drug test. Resident #2 stated the facility had called the emergency medical services because he was unresponsive. Resident #2 stated his blood sugar had gotten too low. Resident stated he declined to go to the hospital with them. Resident # 2 stated that after the emergency medical services left he was told he had to leave the facility that day, and he only had a few hours to leave due to his positive drug test. Resident #2 stated the facility told him they were going to discharge him to a local homeless shelter. Resident #2 stated he did not want to go to the local homeless shelter because it was not a permanent place. He could only stay 3 nights , and he needed help with his medications. Resident #2 stated he did not how it was safe to kick him out after he had been unresponsive that morning. Resident # 2 stated he would have gone somewhere else but he would not have gone to the local homeless shelter. Resident # 2 stated the facility did not provide him any paperwork or give him his medications at the time. Resident # 2 stated he was not doing good and he had been to the emergency room 4 times because he had blacked out and did not have his medications. He stated that he went to the facility today and that he had gotten his medications but there are so many scripts he was not sure what he was supposed to take.<BR/>During an interview on 04/29/2024 at 11:59 AM, the ADMN stated their policy had changed recently and that she had talked with Resident #2 prior to incident on 04/12/2024. The ADMN stated their new policy was that if you tested positive for an illegal substance, it was an immediate discharge. The ADMN stated that Resident # 2 had not signed any confirmation of the immediate discharge policy. The ADMN stated he was not given a written discharge, because he refused to go to the local homeless shelter. The ADMN stated herself, the SW and the DON were responsible to ensure that discharges were done correctly . The ADMN stated what led to the failure of giving Resident # 2 an immediate discharge was because she followed the corporate policy. <BR/>Record review of facility policy titled , Transfer or Discharge Notice dated March 2021, revealed Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge . Residents are permitted to stay in the facility and not be transferred or discharged unless: the transfer is necessary for the resident' s welfare and the resident' s needs cannot be met in the facility. the transfer or discharge is appropriate because the resident' s health has improved sufficient! so the resident no longer needs the services provided by the facility. the resident has failed, after reasonable and appropriate notice, to pay for (or to have pai under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility will only charge a resident allowable charge under Medicaid. the facility ceases to operate. Except as specified below, the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: The safety of individuals in the facility would be endangered; The health of individuals in the facility would be endangered; The resident' s health improves sufficiently to allow a more immediate transfer or discharge; An immediate transfer or discharge is required by the resident' s urgent medical needs; and/or The resident has not resided in the facility for thirty (30) days. The resident and representative are notified in writing of the following information: The specific reason for the transfer or discharge&middot; The effective date of the transfer or discharge; The location to which the resident is being transferred or discharged .<BR/>Record review of facility policy titled, Resident Possession and Use of Illegal Substances, dated March 2024, revealed: Possession of illegal substances and/or being under the influence of illegal substances is grounds for immediate discharge.

**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 time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 23 residents (Residents #23, #26, #36, #39, #53, and #62) reviewed for care plans in that:<BR/>1. The facility failed to define measurable objectives on Resident #23's care plan regarding the problems of resisting care, visual function, oral hygiene, pain, mobility, cognitive loss, and daily tasks.<BR/>2. The facility failed to define measurable objectives on Resident #26's care plan regarding the problems of psychotropic drugs, psychosocial well-being, pain, mood, behaviors, activities of daily living and daily tasks. <BR/>3. The facility failed to define measurable objectives on Resident #36's care plan regarding the problems of mobility and daily tasks and failed to address on Resident #36's comprehensive care plan the care areas of visual function and communication triggered on the MDS.<BR/>4. The facility failed to define measurable objectives on Resident #39's care plan regarding the problems of visual function, self-care deficits, decreased cognition, and daily tasks and the care areas of dental care and communication triggered on the MDS.<BR/>5. The facility failed to define measurable objectives on Resident #53's care plan in regard to the problems of daily tasks, pain, ADL function, and impaired cognition.<BR/>6. The facility failed to define measurable objectives on Resident #62's comprehensive care plan regarding the problems of self-care related to mobility and impaired cognition, and daily tasks.<BR/>These failures could affect residents and place them at risk for not having their needs and preferences met.<BR/>Findings included: <BR/>Resident #23<BR/>Review of Resident #23's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes mellitus (non-insulin dependent diabetes), heartburn, enterocolitis (inflammation of the colon), difficulty sleeping, high blood cholesterol, rapid heart rate, swelling, weakness, anxiety, absence of right and left legs below the knees, pancreatitis (inflammation of the pancreas), and high blood pressure. <BR/>Review of Resident #23's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #23 scored 99 indicating the resident was unable to complete the interview. Further review revealed the following care area triggered Section M - Skin Conditions, sub-section M1200. Skin and Ulcer/Injury Treatments: number 16. Pressure Ulcer/Injury indicated item B. Pressure reducing device on bed was selected. MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column revealed 16. Pressure Ulcer was selected.<BR/>Review of Resident #23's Quarterly MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score Resident #23 scored 15 out of 15 indicating cognition was intact. <BR/>Review of Resident #23's care plan reviewed/revised 01/27/25 revealed the following: <BR/>*Problem I resist care resisted taking medications/injections with an objective of I will make an informed choice about the benefits of care, options in care, and possible consequences/outcomes for resisting care. <BR/>*Problem visual function with an objective of Resident will have optimal visual acuity. <BR/>*Problem Oral/Dental Status with an objective of Maintain oral hygiene/status. <BR/>*Problem I am at risk for pain R/T my multiple comorbidities with an objective of I will be as comfortable as possible. <BR/>*Problem ADL Functional/Rehab Potential with an objective of I will achieve maximum functional mobility. <BR/>*Problem I have cognitive loss related to my diagnosis of anxiety with an objective of I will be as alert and oriented as possible. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an objective of The Resident will perform the following tasks at their highest practicable level. Approaches/Interventions included Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is days Once A Day on Mon, Wed, Fri; 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and Weekly skin Observations Flowsheet ADL Once Daily on Mon, Wed, Fri 06:00 AM - 06:00 PM.<BR/>Resident #26<BR/>Review of Resident #26's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of high blood cholesterol, cholecystitis (inflammation of the gall bladder), anxiety, difficulty sleeping, dementia, kidney disease, depression, high blood pressure, chest pain, heart failure, Type 2 diabetes (non-insulin dependent diabetes), ascites (fluid build-up in the abdomen), and constipation (inability to have a bowel movement) <BR/>Review of Resident #26's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #26 scored 11 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #26's care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem Psychotropic Drug Use with an unmeasurable objective of Benefit without side effects. <BR/>*Problem Psychosocial Well-Being with an unmeasurable objective of Resident will express/exhibit satisfaction. <BR/>*Problem I am at risk for pain related to aging process and dx of diabetes with an unmeasurable objective of Resident will be as comfortable as possible. <BR/>*Problem Mood State with an unmeasurable objective of Resident will express/exhibit satisfaction. <BR/>*Problem I have inappropriate verbal outbursts such as yelling out related to my dementia with an unmeasurable objective of I will be encouraged to communicate with the staff for my needs. <BR/>*Problem ADL Functional/Rehab Potential with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approaches/Interventions included Bowel Movement Every Shift; 1 SHIFT 1 06:00 AM - 06:00 PM, SHIFT 1 06:00 PM - 06:00 AM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, HS Snack At Bedtime; 06:00 PM - 06:00 AM, I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and The staff member who does my bath will document skin issues in the POC Once A Day on Mon, Wed, Fri 06:00 AM - 06:00 PM.<BR/>Resident #36<BR/>Review of Resident #36's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), dementia, depression, difficulty walking, pain, high blood pressure, weakness, heart failure, arthritis, paranoid schizophrenia, and swelling.<BR/>Review of Resident #36's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #36 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #36's care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem I have self-care deficits R/T impaired mobility and impaired cognition with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM.<BR/>Review of Resident #36's Care Area Assessment (CAA) list generated from the admission MDS, dated [DATE], revealed the following care areas triggered and selected in MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column, were not addressed on Resident #36's comprehensive care plan: Visual Function triggered by entry in MDS Section B Hearing, Speech, and Vision, sub-section B1000 Vision, Ability to see in adequate light (with glasses or other visual appliances) code 1. Impaired - sees large print, but not regular print in newspapers/books was selected and sub-section B1200 Corrective Lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision code 1. Yes was selected. Communication triggered by entry in MDS Section B Hearing, Speech, and Vision, Sub-section B0200 Hearing - Ability to hear (with hearing aid or hearing appliances if normally used) code 2. Moderate difficulty - speaker has to increase volume and speak distinctly was selected.<BR/>Resident #39 <BR/>Review of Resident #39's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of high blood pressure, dementia, Alzheimer's disease (a brain disorder that destroys memory and thinking skills), weakness, anxiety, high blood cholesterol, macular degeneration (an eye disease that affects central vision), and Vitamin D deficiency. <BR/>Review of Resident #39's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #39 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #39's care plan reviewed/revised 02/04/25 revealed the following:<BR/>*Problem I have decreased Visual Function and require glasses at times with an unmeasurable objective of Resident will have optimal visual ability. <BR/>*Problem I have deficits in self-care. ADL Function/Rehab Potential with an unmeasurable objective of Resident will achieve maximum functional mobility. <BR/>*Problem I have Cognitive Loss related to Dementia with an unmeasurable objective of I will be as alert and oriented as possible. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approach/Interventions included: Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is 6a-6p Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>Review of Resident #39's Care Area Assessment (CAA) list generated from the admission MDS dated [DATE] revealed the following care areas triggered and selected in MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column, were not addressed on Resident #39's comprehensive care plan: Dental Care MDS Section L - Oral/Dental Status, sub-section L0200. Dental A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) and D. Obvious or likely cavity or broken natural teeth were selected. Communication was triggered by entry in MDS Section B Hearing, Speech, and Vision, Sub-section B0200 Hearing - Ability to hear (with hearing aid or hearing appliances if normally used) code 1. Minimal difficulty - difficulty in some environments (e.g. when person speaks softly or setting is noisy) was selected.<BR/>Resident #53<BR/>Review of Resident #53's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), human immunodeficiency virus, myalgia (muscle pain), major depressive disorder, paranoid schizophrenia, chronic obstructive pulmonary disease (a group of lung diseases that cause airway obstruction), cardiac pacemaker, rapid heart rate, atrial fibrillation (irregular beating of upper chamber of the heart), heart failure, high blood cholesterol, cellulitis (bacterial infection affecting the skin and underlying tissues), respiratory disease, chronic leg ulcers, and hemorrhoids.<BR/>Review of Resident #53's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #53 scored 12 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #53's comprehensive care plan, reviewed/revised 12/05/24, revealed the following:<BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approach/Interventions included Bowel Movement Every Shift; SHIFT 1 06:00 AM - 06:00 PM, SHIFT 1 06:00 PM - 06:00 AM. <BR/>*Problem I am at risk for pain with the unmeasurable objective of I will be as comfortable as possible for the next 90 days. Problem ADL Functional/Rehab Potential with an unmeasurable objective of I will achieve maximum functional mobility . <BR/>*Problem I have impaired cognition r/t fluctuations in cognition with an unmeasurable objective of Resident will be as alert and oriented as possible . <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level . and Approach/Interventions of I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is 6a-6p Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, HS Snack At Bedtime; 06:00 PM - 06:00 AM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and weekly skin observation Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>Resident #62 <BR/>Review of Resident #62's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), dementia, depression, difficulty walking, pain, high blood pressure, weakness, heart failure, arthritis, paranoid schizophrenia, and swelling.<BR/>Review of Resident #62's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #62 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #62's comprehensive care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem I have self-care deficits R/T impaired mobility and impaired cognition with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>During an interview on 02/19/2025 at 2:30 PM, the MDS coordinator stated she was responsible for completing the initial comprehensive care plan and the DON and ADON were responsible for updating the care plans. The MDS coordinator stated her expectation was care plans should include resident's diagnosis, medications, diet, physician orders and any resident care needs. The MDS coordinator stated that objectives should be specific and measurable, and interventions should be a specific task for staff and/or residents that accomplishes objectives. <BR/>During an interview on 02/19/25 at 12:07 PM, the Regional Nurse Consultant stated her expectations of care plan were for the care plan to look like the resident. She stated if she were a nurse coming in to provide care, she would want to know what was documented on the care plan. The RNC stated if a resident needed assistance or was a fall risk for example, that information should be on the care plan. The RNC explained the objectives should be based on what a nurse would expect to assess when interventions were followed. She stated the DON was responsible for the initial care plan and the ADON/MDS Coordinator contributed to revisions based on the comprehensive assessment. The RNC stated the CAA's should be addressed on the comprehensive care plan. She stated the DON was ultimately responsible for the accuracy of the care plans. The RNC stated in response to an example of an objective for pain, the RNC stated she did not agree with use of a pain scale because pain was subjective data. She explained staff should be able to identify pain by a resident's facial expressions or behavior. The RNC stated she trained staff to recognize pain or discomfort by being observant.<BR/>Review of the facility policy titled Comprehensive Care Plans, undated, revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives . that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: item 2. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the care plan., and 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident's environment remained free of accident and hazards, and each resident's received adequate supervision to prevent accidents and altercations for 2 of 14 residents (Resident #36 and Resident #45) reviewed for accidents and supervision. <BR/>The facility failed to ensure there was adequate supervision on Station 2/Hall 2 (men secured locked unit) to prevent a resident-to-resident physical altercation between Resident #36 and Resident #45 on 02/19/23. <BR/>These failures placed residents at risk for injury and undue psychosocial distress due to lack of supervision provided by the facility. <BR/>Findings include:<BR/>Station 2 Hall 1 (Men's Secured Unit)<BR/>In an observation on 02/14/23 at 11:47 am, revealed Station 2 Hall 1 had 14 residents with known behaviors. 1 agency CNA, ADON, and LVN-PH were observed on the hall. <BR/>In an interview on 02/14/23 at 11:00 am, CNA-JF said she worked 6am to 6pm and worked 12 hours by herself on the women's secured unit, with 1 resident requiring 1:1 supervision. A staff member would come in every 2 hours to check on her. She said she did not feel safe working alone and was unable to prevent resident to resident altercations. CNA-JF stated she had received training in the past for Alzheimer's/dementia but not for residents with behaviors. <BR/>In an interview on 02/14/23 at 11:47 am, LVN-PH said the facility usually had 2 staff on the men's secured unit and 1 staff on the women's secured unit during the day shift. She floated between the 2 units but spent the majority of her time on the men's unit as that was where her desk as. She said 1 staff on the women's secured unit was not enough to protect the residents. She said staff was cut back from 2 staff to 1 staff on the women's unit about a month ago. <BR/>Resident #36<BR/>Record review of Resident #36's undated face sheet revealed he was a [AGE] year old male admitted on [DATE] with the following diagnoses: Moderate psychological disability, <BR/>unspecific dementia without behavioral disturbances, personality change due to unknown psychological condition, and intermittent explosive disorder (explosive eruptions that occur suddenly, with little or no warning). <BR/>Record review of Resident #36's Quarterly MDS assessment, dated 11/21/22, revealed a BIMS score of 00 which indicated severe cognitive impairment. Further review of MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. None of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavior symptoms directed towards others behavior did not occur, B. Verbal behaviors symptoms directed towards others behavior did not occur, C. Other behavioral symptoms not directed towards others behavior <BR/>did not occur. Section G: Functional Status. G0110. Activities of Daily Living Assistance: H. Eating: 1 (supervision oversight, encouragement or cueing). G0120 Bathing: Self Performance: 3 (Physical help in part of bathing activity). G0300: Balance during transitions and walking: A. Moving from seated to standing position 1 (not steady, but able to stabilize without human assistance. B. Walking (with assistive device if used) 1 (not steady, but able to stabilize without human <BR/>assistance).<BR/>Review of Resident #36 Care Plan dated 01/18/2023 (Last Care Conference) revealed the following: Problem I have behavioral symptoms at times tearing up/destroying the mini blinds in my room. I wander at times that is why I am on a secure unit. I am not usually aggressive. On 02/24/23 I Wandered in another resident's room space, and he hit me on the chest, I hit his arm as a reaction to being stuck. This is not my normal behavior, and I was remorseful that this happened. Goal: Privacy will be maintained via alternate means (drape and or privacy curtains) mini blinds will not be hung. On 02/14/23 I will not strike out at any other Resident in the next 90 <BR/>days. Approach: Always ask for help if resident becomes abusive/resistive. Ask assistance from staff If placed in an uncomfortable situation.<BR/>Resident #45<BR/>Record review of Resident #45's Annual MDS assessment, dated 11/21/22, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Diagnosis Diagnoses included dementia, Epilepsy (seizure disorder), and schizophrenia (a mental disorder in which people interpret reality abnormally). Resident #45 had a BIMS score of 00 which indicated severe cognitive impairment. Further review of MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. None of the above (psychosis). E0200. Behavioral Symptoms: A. Physical behavior symptoms directed towards others - behavior did not occur, B. Verbal behaviors symptoms directed towards others - behavior did not occur, C. Other behavioral symptoms not directed towards others - behavior did not occur. Section G: Functional Status. G0110. Activities of Daily Living Assistance: H. Eating: 1 (supervision-oversight, encouragement or cueing). G0120 Bathing: Self-Performance: 3 (Physical help in part of bathing activity). G0300: Balance during transitions and walking: A. Moving from seated to standing position - 1 (not steady, but able to stabilize without human assistance. B. Walking (with assistive device if used) - 1 (not steady, but able to stabilize without human assistance).<BR/>During an observation on 02/19/23 at 11:00 AM, Surveyor witnessed a physical altercation between Resident #36 and Resident #45 on the men's secured locked unit. Resident #36 was standing in the dayroom area approximately 10 feet away from the doorway and as Resident #45 entered through the doorway, Resident #36 went up to him and hit him in the chest with a closed fist. Resident #45 fell into a chair, and he immediately got up and continued on his way. <BR/>In an interview on 02/22/23 at 10:10 AM, the Interim Administrator said she had spoken to SW-EJJ about Resident #36's behavior. She said Resident #36 had an Intellectual Developmental Disability and did not qualify to be sent to a psychiatric hospital. She also said his Guardian refuses to allow him to be sent to one. She said Resident #36's Guardian was a social worker at the group home he was previously staying at and said Resident #36 would be inappropriate for that care option. The Interim Administrator said she was not aware of the altercation between Resident #36 and Resident #45 on 02/19/23. She said Resident #36 should be on one-on-one monitoring to protect the other residents. <BR/>In an interview on 02/23/23 at 11:17 AM, CNA-JG and TNA-AL said they were never informed Resident #36 needed one-on-one monitoring. When asked how the other residents react when there are altercations between residents, they said the other residents get upset.<BR/>In an interview on 02/23/23 at 10:30 AM, SW-EJJ was asked why two residents were sent to a psychiatric hospital when there were behaviors related to physical altercation and Resident #36 continues to remain in the men's locked unit. SW-EJJ said Resident 36 had been in a group home all his life and his behaviors were mostly yelling and acting out. Usually going outside and walking around helps his behaviors and smoking calms him down. When asked, how do staff monitor his behaviors, she said we just monitor him, he sits and eats with another resident who keeps him calm. When asked about his history of previous altercations and behaviors hitting residents and it upsetting other residents, per staff. She said she personally had not witnessed any behaviors with altercations. When brought to her attention the altercation recorded in progress notes she said, she had not personally seen Resident #36 hit anyone. When asked how the facility protects residents from being hit by Resident #36, she said we monitor him. She said he could be sitting across from someone and reach over and punch someone, how can you anticipate what is going to happen.<BR/>In an interview on 02/23/23 at 12:37 PM, NP-KR said Resident #36 was difficult because he does not speak and was not able to express himself. She said, Resident #36's primary doctor had discontinued his Seroquel and his behaviors increased and she put him back on the Seroquel which seems to have help calm him down. As far as protecting the other residents from his behaviors, that is up to the facility. She said she was not aware he hit another resident on 02/19/23.<BR/>Record review of Resident #36's progress notes from 12/02/23 until 02/19/23 revealed the following behaviors related to altercations:<BR/>A. 12/02/2022 at 2:56 PM, Resident #36 was showing aggressive behavior to staff taking off shirt and yelling at staff.<BR/>B. 12/03/2022 at 3:39 AM, .Resident yelling, hitting his head and hit the exit door with his fist then ate a cigarette. <BR/>C. 12/04/2022 at 11:55 AM, CNA (unidentified) reported Resident #36 was standing in the living area when another resident was ambulating by him (Resident #36). Resident #36 let (Resident #40 - female) walk by him then hit her with closed fist (no location of where she was hit was identified). Residents were separated and taken out to smoke. No redness to resident who was hit noted at this time. <BR/>D. 12/08/2022 at 3:37 AM, After returning from smoke break resident (Resident #36) ate a cigarette. Staff tried to get cigarette from resident, he (Resident #36) began swinging fist and yelling. Quickly calmed and walked to room. <BR/>E. 01/09/2023 at 11:32 AM Resident (Resident #36) went out to have a cigarette and when he came inside, he was standing by the door and another resident (unidentified) walking fast came by him and he hit her on the left shoulder with his left hand. <BR/>F. 01/10/2023 at 12:31 PM, CNA (unidentified) reports, her, and another CNA (unidentified) had resident (Resident #36) in bathroom attempting to change brief when he (Resident #36) became combative.<BR/>G. 01/13/2023 at 5:12 PM, Resident cries and occasionally threatens staff with fist.<BR/>H. 02/19/2023 at 12:46 PM: Resident (#36) was standing up by the outside door and hit a Resident (identified as Resident #45 by staff (HA-LB who witnessed the event) when he came into the Unit from outside. He (Resident #36) hit him (Resident #45) in the chest. Residents were separated. (Progress notes did not indicate who separated the residents).<BR/>In an interview on 02/14/22 at 3:00 pm, the Corporate Regional Resource Nurse, said on January 10th, 2023, the facility moved 3 residents off the of Women's Secured Unit and moved 1 CNA to the general population which leaves only 1 staff on the unit (The census of the women's secured unit on 02/14/23, were a total of 6 residents with behavioral issues that required close supervision.) She stated I move staff to where they are needed, I'm not cutting staff no matter what they tell you. They might tell you they are short staffed, but they are not. She had an aide that goes to the unit whenever the CNA needs to give a resident a bath. When asked about how staff calls for help, she said they had walkie-talkies but they didn't work. Staff can use their personal cell phone to call for help. <BR/>In an interview on 02/15/23 at 9:15 am, CNA-JF stated there was not enough staff to provide adequate supervision for the residents on the female locked unit. She stated it was not safe with one person in the unit. She stated that the acuity was high due to behaviors, but Administration says that it was not. She stated that at times, they send staff who are not certified or aides such as the activity person to help. She said she usually worked by herself for the entire 12-hour shift. She said that if she needed help, she would have to go down the hallway, enter the keycode to unlock the door, open the door and call for help all while leaving the residents unsupervised as it is a long hallway. She said that she had permission to use her personal cell phone to call for help but no one will answer when she called. She said that Administration had told her that she sits the residents too close together, but she had nowhere for the residents to be as the unit was small. She said that during meals she was often by herself on the unit. She sat Resident #53 next to her because Resident #53 constantly required assistance and redirection. All the while she had to assist the other residents to eat and prevent another resident from constantly getting up and taking other residents drinks. She said it as a lot for one person to do. She also said she will only take a break or go to the bathroom when the LVN comes to administer medications or sometimes when the activity person comes into the unit. <BR/>In an interview on 02/15/23 at 11:00 am, with the Interim DON and Corporate Regional Resource Nurse, the Interim DON stated she talked to the Social Worker and Administrator that morning and told them they were not equipped to deal with Resident #53's behaviors. She stated, We are not a behavior unit, can we deal with these behaviors, yes, but it requires 1:1, 2:1, and sometimes even 3:1. When asked if she felt 1 staff on the Women's Secured Unit was sufficient, the Interim DON stated that 1 staff on the Women's Secured Unit was enough as the residents are a low acuity level and just custodial care. The Interim DON defined acuity level as medical needs only and stated she did not take into account behaviors when determining resident acuity. <BR/>In an observation on 02/15/23 at 3:50pm, Resident #53 was observed crawling on the floor with gait belt around her waist on the women's secured unit. The Interim DON was observed pulling on the gait belt to move the resident back.<BR/>In an interview on 02/16/23 at 11:40 am, CNA-JG stated: It's not safe for the other residents with only one CNA working on the women's locked unit alone and there's always only one CNA scheduled. There has been 2 CNAs for the last few days only because the state surveyors are in the building. CNA-JG said, we tell the DON all the time that we don't feel safe, and we need at least 2 CNAs back there, but they don't listen to us, and we're told to work it out. We have had some training, but no training ever received on how to provide care for residents who are aggressive or residents that have behavior problems.<BR/>In an observation and interview on 02/16/23 at 11:50 am, TNA-BM stated, I'm here on this unit today sitting 1:1 with Resident #53 because y'all (State Surveyors) are in the building, there's usually is only one CNA assigned. She stated it would be almost impossible for one person to care for the residents on the secure unit. We asked the DON and ADON all the time for more help, but we don't get any, and the residents suffer. TNA-BM stated, We have trainings, but I don't remember getting training on how to provide care for residents who are aggressive or residents that have behavior problems. TNA-BM was observed utilizing the gait belt around Resident #53's waist to restrict her movement and guide her away from other resident's multiple times.<BR/>In an interview on 02/16/23 at 3:00 pm, TNA-ML said she had been employed for 1 year at the facility and floated from unit to unit. She stated it is impossible to know the residents on different units if you don't get a report. She said, you just have to figure out the residents on all of the different units likes and dislikes as you go along. She stated there was supposed to be a Get to Know Me Book on each unit, but it usually was not in the place it is supposed to be, and if it was the staff are not given time to review it. The showers on the female locked unit are very difficult to complete if a resident was having behaviors when you arrive at work as there is only 1 CNA to deal with the situation. She also stated, I don't feel safe working alone on the female lock unit. Resident #53's mood and behaviors dictate the type of day every resident and staff on the unit are going to have. She stated she does not remember receiving training on how to provide care for residents who are aggressive and have behavior problems. She said concerning Resident #53, we were told to keep the other residents away from her utilizing the gait belt. <BR/>In an interview on 02/16/23 at 4:00 pm, CNA-DS stated there have been issues with Resident #53's behavior for a long time as she hit, scratched, bit, and kicked staff and residents. <BR/>In an interview with the Interim Administrator on 02/17/23 at 9:45 am, she stated she was aware there was a problem with staff scheduling and she had recently taken over the scheduling. She stated she scheduled the number of people to work. The charge nurses would assign the employees what hall they will be working on. She stated the facility did not write these assignments down and said she could not produce historic staffing sheets with assignments for each shift. She stated she could not tell where staff worked a week ago. <BR/>In an interview with the Interim Administrator 02/19/23 at 2:55 PM, she said the time clock does not always work properly. She said if the time clock does not work, the staff were expected to complete a paper time sheet and they were collected and put into the system within a day or two. She said the facility did not have records of staffing sheets with assigned halls for each shift worked. She denied any major incidents that had been attributed to staffing shortage, but stated it was possible that something could happen. <BR/>In an interview on 02/19/23 at 4:30 PM, the DON stated there was no way to tell which staff worked in which area of the facility on any given date. She stated the facility had recognized this being a concern and had put a new scheduling sheet in place that should make it easier to track this information. The DON stated if there was an allegation of abuse and neglect, there was no system in place to determine which staff was working in that area.<BR/>Record review of employee files revealed the facility was unable to produce evidence of training for staff on accidents, hazards, supervision, and performance evaluations to ensure the continuing competency of nurse's aides. <BR/>Record review of the facility policy Resident-to-Resident Altercations, dated as revised December 2016, revealed the following [in part]:<BR/>Policy Statement: All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator.<BR/>Policy Interpretation and Implementation: <BR/>1. Facility staff will monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator.<BR/>2. If two residents are involved in an altercation, staff will:<BR/>A. Separate the residents, and institute measures to calm the situation;<BR/>B. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation;<BR/>C. Notify each resident's representative and Attending Physician of the incident; <BR/>D. Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents; <BR/>F. Make any necessary changes in the care plan approaches to any or all of the involved individuals;<BR/>G. Document in the resident's clinical record all interventions and their effectiveness;<BR/>J. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident.<BR/>The facility failed to provide a policy relating to accidents/hazards/supervision by the time of exit on 02/24/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the nessary care and services to attain the highest practicable, physicial, mental, and psychosocial well-being consisted for 2 (Resident #10 and Resident #12) of 12 residents reviewed for quality of life<BR/>The facility failed to ensure Resident #10 received showers per resident's request.<BR/>The facility failed to ensure Resident #12 transferred from bed to chair per resident's request.<BR/>This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.<BR/>Findings included:<BR/>Resident #10<BR/>Record review of Resident #10's face sheet dated 04/09/2024 revealed [AGE] year-old female originally admitted on [DATE] with most recent readmission on [DATE] and the following diagnoses: candida stomatitis (yeast causing inflammation inside the mouth), cough, acute upper respiratory infection, pneumonia, osteoarthritis (degenerative joint disease) right ankle and foot, nicotine dependence (smokes cigarettes), alcohol dependence, bipolar disorder (mental illness that causes unusual shifts in a person's mood), abnormalities of gait and mobility, difficulty in walking, dependence on supplemental oxygen, lack of coordination, weakness, chronic obstructive pulmonary disease (chronic lung disease interfering with airflow), and heart failure (chronic heart disease interfering with blood flow).<BR/>Record review of Resident #10's quarterly MDS dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 9 (moderate cognitive impairment); Section GG- Functional Abilities and Goals revealed: resident required partial to moderate assistance meaning helper does more than half the effort to shower/bathe self.<BR/>Record review of Resident #10's care plan dated 04/09/2024 revealed: resident had a problem with ADLs functional status / rehabilitation potential with start date of 06/23/2023 .goal: Maintain current functional status .approach: I require supervision with dressing .I require supervision with locomotion on and off the unit .I require supervision with transfers; problem The following tasks will be documented with start date of 07/30/2022 .goal: The Resident will perform the following tasks at their highest practicable level; approach: I prefer to take my bath/shower on T/T/S My preferred time to Bath/Shower is 6a-6p.<BR/>Record review of Resident #10's Point of Care history dated 4/9/2024 revealed no evidence that resident received assistance for showering on the following dates: 03/09/2024, 3/14/2024, 3/16/2024, 3/26/2024, 3/28/2024, 3/30/2024, 04/02/2024, and 04/04/2024.<BR/>During an interview on 04/09/2024 at 2:35 p.m., Resident #10 stated she had not had a shower in 3 weeks and felt that the facility was short staffed. She stated she preferred to get showers <BR/>Resident #12<BR/>Record review of Resident #12's face sheet dated 04/09/2024 revealed [AGE] year-old female originally admitted on [DATE] and the following diagnoses: Parkinson's disease (brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), abnormal posture, edema (swelling), acute lower respiratory infection, lack of coordination, pain, malignant neoplasm of unspecified site of unspecified female breast (breast cancer), epilepsy (seizure disorder), gastro-esophageal reflux disease (disorder that allows stomach contents to leak back into esophagus and irritate it), and depression.<BR/>Record review of Resident #12's other payment assessment MDS dated [DATE] revealed: Section C- Cognitive Behavior BIMS score of 14 (cognition is intact); Section G- Functional Status revealed: resident involved in activity, but staff provide weight-bearing support with bed mobility and transfers.<BR/>Record review of Resident #12's care plan dated 04/09/2024 revealed: I prefer to get out of bed and up in my chair at after breakfast on M/W/F and on T/Th/Sa after breakfast for my shower and then put back to bed by 330pm. I prefer to only get up on Sundays by my own choice. With start date of 06/20/2023 .goal: Get resident up as requested; approach Assist resident in getting up as stated.<BR/>During an observation and interview on 04/08/2024 at 4:02 p.m., Resident #12 was lying in her bed working with yarn. She voiced she felt facility did not have enough staff and called the Ombudsman. She stated she had requested a meeting with the ADMN to review her care plan on Thursday 04/11/2024 because she felt the facility was not paying attention to her wants. She stated most of the time, she was not transferred out of bed and into motorized chair when she wanted to be or not at all. She stated the staff told her they would be back to assist her when she asked about it and it will be a while before they come to assist her. She stated there are times when other resident entered her room, and it would take staff time to answer her call light and remove him. She stated it upsets her when she was not assisted with transfers as she had requested or was not able to answer her call light when other resident was wondering around in her room. She stated that she knew how to file a grievance but had not filed one.<BR/>During an interview on 04/09/2024 at 10:10 a.m., the ADMN stated the facility summary tool was used for figuring staffing to resident ratios. She stated HPPD stood for hours per patient day. She stated the facility multiplies the resident total from census by the HPPD to get the hours needed for direct care staff per resident in a 24-hour period. She stated the facility had started allowing agency nurses and CNAs to be contracted to help with staffing. The ADMN stated the facility continued to have issues with agency staff signing up for shifts then taking themselves off the schedule later making it more difficult to staff facility appropriately. She stated she knew the facility was understaffed. <BR/>Record review of facility document titled Facility Assessment Tool last updated on 04/02/2024 revealed: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility, at least annually, per the above requirement. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being .Direct Care Staff plan 24 hour nursing, to include licensed staff, med aides when available, CNA staffing based off of care needs with an Average HPPD 2.85 .Staffing assignments are based off of acuity and needs, resident physical and psychological needs which are part of the admission assessments. Assessments are not only completed on admission, quarterly and prn with sig changes and as requested.<BR/>Record review of facility policy titled Resident Rights dated February 2021 revealed: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing care to attain or maintain the highest practicable physical, mental, and psychosocial well-being for # of # Residents reviewed for sufficient staffing.<BR/>1. <BR/>The facility failed to ensure there was sufficient staffing for 02/17/2023 6:00pm-6:00am shift with a facility census of 91 residents where 4 residents were total dependent on transfers.<BR/>2. <BR/>The Assistant Administrator was assisting Resident #645 to eat lunch meal in her room. The Assistant Administrator had no training on assisting resident with eating.<BR/>These failures could place residents at risk of not receiving care and services to meet their needs<BR/>Findings include:<BR/>Review of facility times sheets for 02/17/2023 revealed only two staff (CNA-AG and LVN-AC) were the only staff working in the facility with census of 91 residents where 4 residents were total dependent on transfers from 6:00 PM until 6:00 AM.<BR/>Review of Resident #645's Face Sheet, dated 2/23/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: systemic lupus erythematosus (autoimmune disease where the body attacks itself); gastro-esophageal reflux disease without esophagitis (heartburn that burns the throat); rheumatoid arthritis, unspecified (autoimmune arthritis that affects the joints); essential (primary) hypertension (high blood pressure); heart failure, unspecified (failure of the heart to function properly); venous insufficiency (poor circulation of extremities); pain, unspecified; and generalized anxiety disorder. <BR/>Review of Resident #645's admission MDS Assessment, dated 2/13/23, revealed a BIMS had not been completed. The resident was assessed as having short-term and long-term memory problems, moderately impaired decision-making skills, required supervision while eating, was 64 inches tall and weighed 147 pounds, and did not receive a therapeutic diet or mechanically altered diet.<BR/>Review of Resident #645's current physician orders, dated 2/22/23, revealed an order dated 2/04/23 for a regular diet with regular texture with thin consistency fluids.<BR/>In an interview on 2/18/23 at 10:27 AM, the family members of Resident #645 stated the facility seemed to be short staffed. They stated they had arrived one evening to visit about one week ago and there was food all over the floor in the resident's room. They stated the food was from the lunch meal. The family stated Resident #645 fed herself and her hand was not too steady. They stated she spilled food while trying to eat.<BR/>Observation on 2/19/23 at 12:53 PM revealed Resident #645 was seated in the armchair in her room and was being fed the lunch meal by the Assistant Administrator. Resident #645 was served a regular diet consisting of chili, cornbread, Mexican style corn, and peach parfait for dessert. She was served 2 glasses with iced tea of thin consistency. Resident #645 drank 1 glass of iced tea and ate almost 100% of her meal with the Assistant Administrator's assistance. <BR/>In an interview on 2/22/23 at 9:45 AM, the Assistant Administrator stated she had not ever been a C.N.A. When asked if she had fed Resident #645 at times other than on Sunday 2/19/23 at lunch time, she stated no, she had not fed Resident #645 before that meal, but she had fed other residents. When asked about the other residents she had fed, the Assistant Administrator stated she had probably fed 5 other residents off and on over the course of the year she had worked in the facility. She stated she usually just helped pass meal trays. She stated she helped Resident #645 eat the lunch meal on 2/19/23 because they needed aides. When asked if she had ever been trained to feed residents and been evaluated with a skills test or if she had taken a paid feeding assistant course, she stated no, I have not. The Assistant Administrator inquired how she could be trained to assist residents with eating and asked if it could be done by computer-based training or by the DON. <BR/>In an interview on 2/23/23 at 9:22 AM, RN Corporate Clinical Company Leader-H stated the facility did not use paid feeding assistants. When asked how the facility trained staff to assist residents to eat or with feeding, she stated the CNAs were taught that during nurse aide training. When asked how non-nursing staff and office staff were trained for assisting residents with eating or feeding, RN Corporate Clinical Company Leader-H stated other staff should not be feeding residents. When asked if the facility had a policy and procedure for staff assistance with resident eating and feeding, she stated she would look for a policy and procedure.<BR/>In an interview on 02/23/23 at 10:00am, the DON stated that non-nursing staff should not assist residents with eating unless they have been trained.<BR/>During an interview at 02/18/2023 at 11:35am, Resident #90 stated that it takes forever for someone to respond to a call light. She stated the nursing staff never explain the delay in answering. <BR/>During observation and interview on 02/18/2023 at 12:14pm, Resident #13's call light was activated at 11:25am while surveyor was in the room interviewing her. Nursing staff did not answer the activated call light until 12:14pm, total of 49 minutes, while surveyor was still in the room. Resident #13 stated that staff do not care about the residents and the call lights. <BR/>Resident #79<BR/>Review of Resident #79's electronic Face Sheet dated revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis, pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus, major depressive disorder, dependence on renal dialysis, dependence on supplemental oxygen, chronic atrial fibrillation, Methicillin resistant Staphylococcus aureus, and Type 2 diabetes mellitus.<BR/>Review of Resident #79's admission Assessment MDS dated [DATE] revealed that he scored 15 on his mental status exam indicating that he was cognitively intact. He required extensive or total dependence on staff for all ADLs except for eating, for which he only required setup. He used a wheelchair for mobility. He was always incontinent of bowel and bladder. <BR/>During an interview on 02/18/2023 at 3:30pm, Resident #79 stated there was not enough manpower in the facility. He stated that during the night shift on 02/17/2023, the facility was only staffed with two people. He stated he turned on his call light at 6:30pm for assistance to change incontinent brief and it was 12:30 AM before the staff got around to it. He said the staff came in a couple of times to tell him that they were busy and had to wait for help and they would be back as soon as they could. He stated that was not the first time that had happened. He stated he hasn't found any staff that don't want to help him, they just can't because there aren't enough of them. He believes it is because of poor management. He stated that call lights never get answered quickly. He stated he has only had 2 showers since he has been here, everything else had been quick bed baths because the staff tell him they don't have enough people to do proper showers.<BR/>During an interview and observation on 02/19/2023 at 1:27pm, Resident #51 stated she activated her call light at 12:15pm because she spilled tea on her bed shortly after getting her lunch tray. She stated that several people had come in to ask what she needed and said they would go get help and never returned. Staff was observed answering the light at 12:57 PM, leaving the room then returning at 1:08 PM with 3 other staff members to assist in changing her linens and cleaning her up. She stated that her indwelling catheter tubing and bag were leaking on 02/16/2023. She stated she reported to the day shift nurse who just placed a towel under the leaking bag. She stated it was not changed until 02/18/2023. She stated that since she has been placed on Hospice, she felt as if the facility staff were somewhat letting my care slide. She stated if it wasn't for Hospice nursing staff, she would not be bathed. She stated she has to contact Hospice nursing staff for issues for constipation.<BR/>During an interview 02/19/2023 at 2:55pm, Interim Administrator stated she was aware of the facility concerns with providing staff for the facility. She stated the concern had been going from way back. She stated the facility had a big turnover in administration and she believed this contributed to the staffing concern. She stated she had a meeting every week with corporate to discuss the staffing concerns and several things have been put into place to attempt to correct the concern, including placing ads, offering sign on bonuses, etc. She stated that compensation was also a concern because the staff could make more money if worked at the hospital. She stated the facility was short staffed, especially on the weekends. She stated it was specifically every other weekend that they do not have staffing coverage. She stated they used agency staff, when they show up, or pull from facility administrative staff to provide coverage. She stated it was possible for major incidents to be attributed to the staffing shortage. <BR/>In an interview on 2/20/23 at 1:47 PM TNA-W stated the facility was always short staffed. TNA-W stated that Administration knows that we are short staffed and say they try to get us extra help, but we don't really know if they do or how they do it.<BR/>During an interview on 02/20/2023 at 4:34 pm, RN-V stated the facility was short staffed on 02/19/2023 and she was behind on her nursing tasks. She stated the facility is often short staffed or without staff.<BR/>During an interview on 02/22/2023 at 1:02pm, MDS-LVN stated she was the only nurse in the facility completing MDS Assessments. She stated that the workload was very heavy, and it was easy to miss things on the assessments. She stated that the other MDS-RN completes some care plans but has no MDS experience, so it falls on the MDS-LVN to complete.<BR/>During an interview on 02/22/2023 at 6:30 pm, TNA-W stated the facility is routinely short-staffed. She stated that she had expressed her concerns with administration including the Corporate Regional Resource Nurse-J. She stated that she is just told they are working on getting staff. <BR/>Record review of facility assessment dated [DATE] Part 3 titled Facility Resourced Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies revealed: <BR/>Station 1: Days (6:00am to 6:00pm)<BR/>LVN/RN Days = 1<BR/>Med Aide Day = 1<BR/>CNAs = 4<BR/>Station 2: Days (6:00am to 6:00pm)<BR/>LVN/RN Days = 2<BR/>CNAs = 6<BR/>Station 1: Nights (6:00pm to 6:00am)<BR/>LVN/RN Days = 1<BR/>Med Aide Day = 1<BR/>CNAs = 2<BR/>Station 2: Days (6:00am to 6:00pm)<BR/>LVN/RN Days = 2<BR/>CNAs = 4<BR/>We will review censes and add or cancel staff as census and needs increase.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete an assessment that accurately reflected the resident's status for 3 of 44 sampled residents (Residents #1, Resident #40, Resident #79) whose records were reviewed for MDS accuracy, in that:<BR/>The facility failed to ensure Resident #1's MDS accurately reflected weight changes and falls.<BR/>Resident #40's MDS dated [DATE], 07/06/2022 and 10/05/2022 did not reflect the resident's weight accurately.<BR/>Resident #79's MDS did not accurately reflect his dependence on dialysis or his chronic pain.<BR/>These failures could place residents at risk for not receiving care and services to meet their needs.<BR/>Findings include:<BR/>Resident #1<BR/>Record review of Resident #1 face sheet dated 02/20/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 11/20/2022 with the following diagnosis: Unspecified fracture of left shaft/femur (upper leg bone), Non ST elevation myocardial infraction (heart attach due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). <BR/>Record review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed on Section K a weight of 199; whereas Resident #1's significant change Minimum Data Set (MDS) dated [DATE] revealed on Section K a weight of 126 and on K0300 Weight Loss was no reported for a weight loss of 5% or more in the last month and 10% more for the last 6 months.<BR/>Record review of Resident #1 Quarterly Minimum Data Set (MDS) dated [DATE] revealed in section J1700 that the resident had a fracture fall prior to admission. J1900 number of falls since admission or prior assessment was not coded in any area. J2100 was checked yes recent surgery requiring SNF care. <BR/>Record review of Resident #1 most recent significant change Minimum Data Set (MDS) dated [DATE] revealed she had the ability to express ideas and wants and was able to understand others clearly. Resident #1 had a Brief Interview for Mental Status (BIMS) of 14 out of score of 15 which indicated an intact cognition. Resident #1 was extensive assistance for activities of daily living (ADL) except for eating where she required supervision.<BR/>Resident #40 <BR/>Record review of Resident #40's electronic face sheet accessed on 02/14/2022 revealed a [AGE] year-old female whose most recent admission date was 1/06/2023 to the female secured locked unit with diagnosis to include: fractured left hip, osteoporosis, history of falling, Alzheimer's Disease, and unspecified protein calorie malnutrition (a condition that occurs when you do not consume enough protein and calories).<BR/>Record review of Resident #40's Annual MDS dated , dated 01/11/2023, revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of MDS, revealed: Section G: Functional Status indicated one-person physical assistance for supervision for eating; Section K Swallowing/Nutritional Status indicated no signs and symptoms of possible swallowing disorder and weight of 144 lbs., no weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. <BR/>Record review of Resident #40's weight records revealed the following: <BR/>-on 8/26/2022 the resident weighed 144 pounds <BR/>-on 01/02/2023, the resident weighed 111 pounds. <BR/>-on 02/03/2023, the resident weighed 110 pounds<BR/>Resident #79<BR/>Review of Resident #79's electronic Face Sheet dated revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis, pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus, major depressive disorder, dependence on renal dialysis, dependence on supplemental oxygen, chronic atrial fibrillation, Methicillin resistant Staphylococcus aureus, and Type 2 diabetes mellitus.<BR/>Review of Resident #79's admission Assessment MDS dated [DATE] revealed: Section C Cognitive Patterns BIMS score of 15 indicated cognitively intake; Section O Special Treatment and Programs indicated oxygen therapy and dialysis prior to admission and since being admitted to the facility; and Section V Care Area Assessment for pain was not triggered on this assessment.<BR/>Review of Resident #79's Quarterly MDS assessment dated [DATE] revealed: Section C Cognitive Patterns BIMS Score of 11 indicating moderate cognitive impairment; Section O Special Treatment and Programs indicated oxygen therapy and IV medications in the facility, and Section V Care Area Assessment indicated no triggered areas. Resident #79's dialysis was not documented on the Quarterly MDS Assessment. Section V: No CAAs were marked as triggered or addressed in care plan on this assessment.<BR/>Review of Resident #79's physician orders revealed: Hemodialysis performed M-F in-house dialysis suite between 0900-0930. Once a Day on Monday, Tuesday, Wednesdays, Thursdays, Fridays.<BR/>In an interview on 02/18/23 at 12:16 PM, MDS-LVN stated that Resident #1's weight loss on the last MDS was coded wrong and should have been a coded as a significant weight loss in Section K0300. She stated this failure could place the resident at risk for not having her needs met due to not accurately coding an assessment. When asked if Resident #1's recent hospital stay and return should have been a significant change assessment, she stated that, yes, it should have. She stated she did not realize that it had been done as a quarterly. MDS-LVN contacted her regional nurse who told her that all hospital stays where there is a decline should have a significant change MDS assessment done upon the resident's return to the facility. The MDS-LVN stated this failure could place the resident at risk for inadequate assessments due to not triggering Section V for a comprehensive assessment, which results in the care plan not being updated. <BR/>In an interview on 2/22/23 at 11:30 AM the MDS-LVN stated she was the only nurse in the facility doing MDS assessments. She stated Section K of Resident #40's Annual MDS dated [DATE] was not accurate. She stated a weight of 144 pounds should have been documented as a significant weight gain. She stated she was responsible for completing all resident's MDS, and most of the care plans. She stated that the error occurred because the workload was so heavy, and it was too easy to miss things on the assessments and care plans. She stated she was responsible for the accuracy of the MDS. She stated an inaccuracy on the residents MDS could lead to the resident not receiving necessary care and services.<BR/>In an interview on 2/22/23 at 1:02 PM MDS-LVN stated that Resident #79's dialysis was not checked on quarterly MDS by mistake, she had the dx code written down she just forgot to check the box. She stated that CAAs are triggered by how questions in the MDS are answered, the pain questions for Resident #79 should have triggered the pain CAA, she was not sure why it did not, especially with his diagnoses. She stated that she was able to manually trigger CAAs for residents when she was completing an assessment and if she had noticed that the CAA for pain had not triggered for Resident #79, she would have done it herself. She stated that she was the only nurse in the facility who did MDS assessments at that time and she was responsible for all residents' MDSs and most care plans. She stated that the workload was very heavy, and it was too easy to miss things on the assessments. She stated that the other CCM did some care plans, but he did not have any MDS experience, so they all fell to her to complete. She stated that the inaccuracies on Resident #79's assessment could result in his care plan not being up to date which could lead to him not receiving proper care.<BR/>In an interview on 2/24/23 at 4:47 PM, MDS-LVN stated she referred to MDS 3.0 RAI Manual provided by CMS for instructions on how and when to complete assessments. The facility did not provide a written policy regarding resident assessment.<BR/>Review of CMS'S RAI Version 3.0 Manual version 1.17.1 dated October 2019 revealed:<BR/>The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that<BR/>(1) the assessment accurately reflects the resident's status<BR/>(2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals<BR/>(3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.<BR/>Nursing homes are left to determine<BR/>(1) who should participate in the assessment process<BR/>(2) how the assessment process is completed<BR/>(3) how the assessment information is documented while remaining in compliance with the requirements of the Federal regulations and the instructions contained within this manual.

**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 time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 23 residents (Residents #23, #26, #36, #39, #53, and #62) reviewed for care plans in that:<BR/>1. The facility failed to define measurable objectives on Resident #23's care plan regarding the problems of resisting care, visual function, oral hygiene, pain, mobility, cognitive loss, and daily tasks.<BR/>2. The facility failed to define measurable objectives on Resident #26's care plan regarding the problems of psychotropic drugs, psychosocial well-being, pain, mood, behaviors, activities of daily living and daily tasks. <BR/>3. The facility failed to define measurable objectives on Resident #36's care plan regarding the problems of mobility and daily tasks and failed to address on Resident #36's comprehensive care plan the care areas of visual function and communication triggered on the MDS.<BR/>4. The facility failed to define measurable objectives on Resident #39's care plan regarding the problems of visual function, self-care deficits, decreased cognition, and daily tasks and the care areas of dental care and communication triggered on the MDS.<BR/>5. The facility failed to define measurable objectives on Resident #53's care plan in regard to the problems of daily tasks, pain, ADL function, and impaired cognition.<BR/>6. The facility failed to define measurable objectives on Resident #62's comprehensive care plan regarding the problems of self-care related to mobility and impaired cognition, and daily tasks.<BR/>These failures could affect residents and place them at risk for not having their needs and preferences met.<BR/>Findings included: <BR/>Resident #23<BR/>Review of Resident #23's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes mellitus (non-insulin dependent diabetes), heartburn, enterocolitis (inflammation of the colon), difficulty sleeping, high blood cholesterol, rapid heart rate, swelling, weakness, anxiety, absence of right and left legs below the knees, pancreatitis (inflammation of the pancreas), and high blood pressure. <BR/>Review of Resident #23's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #23 scored 99 indicating the resident was unable to complete the interview. Further review revealed the following care area triggered Section M - Skin Conditions, sub-section M1200. Skin and Ulcer/Injury Treatments: number 16. Pressure Ulcer/Injury indicated item B. Pressure reducing device on bed was selected. MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column revealed 16. Pressure Ulcer was selected.<BR/>Review of Resident #23's Quarterly MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score Resident #23 scored 15 out of 15 indicating cognition was intact. <BR/>Review of Resident #23's care plan reviewed/revised 01/27/25 revealed the following: <BR/>*Problem I resist care resisted taking medications/injections with an objective of I will make an informed choice about the benefits of care, options in care, and possible consequences/outcomes for resisting care. <BR/>*Problem visual function with an objective of Resident will have optimal visual acuity. <BR/>*Problem Oral/Dental Status with an objective of Maintain oral hygiene/status. <BR/>*Problem I am at risk for pain R/T my multiple comorbidities with an objective of I will be as comfortable as possible. <BR/>*Problem ADL Functional/Rehab Potential with an objective of I will achieve maximum functional mobility. <BR/>*Problem I have cognitive loss related to my diagnosis of anxiety with an objective of I will be as alert and oriented as possible. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an objective of The Resident will perform the following tasks at their highest practicable level. Approaches/Interventions included Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is days Once A Day on Mon, Wed, Fri; 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and Weekly skin Observations Flowsheet ADL Once Daily on Mon, Wed, Fri 06:00 AM - 06:00 PM.<BR/>Resident #26<BR/>Review of Resident #26's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of high blood cholesterol, cholecystitis (inflammation of the gall bladder), anxiety, difficulty sleeping, dementia, kidney disease, depression, high blood pressure, chest pain, heart failure, Type 2 diabetes (non-insulin dependent diabetes), ascites (fluid build-up in the abdomen), and constipation (inability to have a bowel movement) <BR/>Review of Resident #26's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #26 scored 11 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #26's care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem Psychotropic Drug Use with an unmeasurable objective of Benefit without side effects. <BR/>*Problem Psychosocial Well-Being with an unmeasurable objective of Resident will express/exhibit satisfaction. <BR/>*Problem I am at risk for pain related to aging process and dx of diabetes with an unmeasurable objective of Resident will be as comfortable as possible. <BR/>*Problem Mood State with an unmeasurable objective of Resident will express/exhibit satisfaction. <BR/>*Problem I have inappropriate verbal outbursts such as yelling out related to my dementia with an unmeasurable objective of I will be encouraged to communicate with the staff for my needs. <BR/>*Problem ADL Functional/Rehab Potential with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approaches/Interventions included Bowel Movement Every Shift; 1 SHIFT 1 06:00 AM - 06:00 PM, SHIFT 1 06:00 PM - 06:00 AM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, HS Snack At Bedtime; 06:00 PM - 06:00 AM, I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and The staff member who does my bath will document skin issues in the POC Once A Day on Mon, Wed, Fri 06:00 AM - 06:00 PM.<BR/>Resident #36<BR/>Review of Resident #36's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), dementia, depression, difficulty walking, pain, high blood pressure, weakness, heart failure, arthritis, paranoid schizophrenia, and swelling.<BR/>Review of Resident #36's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #36 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #36's care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem I have self-care deficits R/T impaired mobility and impaired cognition with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM.<BR/>Review of Resident #36's Care Area Assessment (CAA) list generated from the admission MDS, dated [DATE], revealed the following care areas triggered and selected in MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column, were not addressed on Resident #36's comprehensive care plan: Visual Function triggered by entry in MDS Section B Hearing, Speech, and Vision, sub-section B1000 Vision, Ability to see in adequate light (with glasses or other visual appliances) code 1. Impaired - sees large print, but not regular print in newspapers/books was selected and sub-section B1200 Corrective Lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision code 1. Yes was selected. Communication triggered by entry in MDS Section B Hearing, Speech, and Vision, Sub-section B0200 Hearing - Ability to hear (with hearing aid or hearing appliances if normally used) code 2. Moderate difficulty - speaker has to increase volume and speak distinctly was selected.<BR/>Resident #39 <BR/>Review of Resident #39's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of high blood pressure, dementia, Alzheimer's disease (a brain disorder that destroys memory and thinking skills), weakness, anxiety, high blood cholesterol, macular degeneration (an eye disease that affects central vision), and Vitamin D deficiency. <BR/>Review of Resident #39's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #39 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #39's care plan reviewed/revised 02/04/25 revealed the following:<BR/>*Problem I have decreased Visual Function and require glasses at times with an unmeasurable objective of Resident will have optimal visual ability. <BR/>*Problem I have deficits in self-care. ADL Function/Rehab Potential with an unmeasurable objective of Resident will achieve maximum functional mobility. <BR/>*Problem I have Cognitive Loss related to Dementia with an unmeasurable objective of I will be as alert and oriented as possible. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approach/Interventions included: Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is 6a-6p Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>Review of Resident #39's Care Area Assessment (CAA) list generated from the admission MDS dated [DATE] revealed the following care areas triggered and selected in MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column, were not addressed on Resident #39's comprehensive care plan: Dental Care MDS Section L - Oral/Dental Status, sub-section L0200. Dental A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) and D. Obvious or likely cavity or broken natural teeth were selected. Communication was triggered by entry in MDS Section B Hearing, Speech, and Vision, Sub-section B0200 Hearing - Ability to hear (with hearing aid or hearing appliances if normally used) code 1. Minimal difficulty - difficulty in some environments (e.g. when person speaks softly or setting is noisy) was selected.<BR/>Resident #53<BR/>Review of Resident #53's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), human immunodeficiency virus, myalgia (muscle pain), major depressive disorder, paranoid schizophrenia, chronic obstructive pulmonary disease (a group of lung diseases that cause airway obstruction), cardiac pacemaker, rapid heart rate, atrial fibrillation (irregular beating of upper chamber of the heart), heart failure, high blood cholesterol, cellulitis (bacterial infection affecting the skin and underlying tissues), respiratory disease, chronic leg ulcers, and hemorrhoids.<BR/>Review of Resident #53's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #53 scored 12 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #53's comprehensive care plan, reviewed/revised 12/05/24, revealed the following:<BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approach/Interventions included Bowel Movement Every Shift; SHIFT 1 06:00 AM - 06:00 PM, SHIFT 1 06:00 PM - 06:00 AM. <BR/>*Problem I am at risk for pain with the unmeasurable objective of I will be as comfortable as possible for the next 90 days. Problem ADL Functional/Rehab Potential with an unmeasurable objective of I will achieve maximum functional mobility . <BR/>*Problem I have impaired cognition r/t fluctuations in cognition with an unmeasurable objective of Resident will be as alert and oriented as possible . <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level . and Approach/Interventions of I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is 6a-6p Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, HS Snack At Bedtime; 06:00 PM - 06:00 AM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and weekly skin observation Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>Resident #62 <BR/>Review of Resident #62's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), dementia, depression, difficulty walking, pain, high blood pressure, weakness, heart failure, arthritis, paranoid schizophrenia, and swelling.<BR/>Review of Resident #62's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #62 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #62's comprehensive care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem I have self-care deficits R/T impaired mobility and impaired cognition with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>During an interview on 02/19/2025 at 2:30 PM, the MDS coordinator stated she was responsible for completing the initial comprehensive care plan and the DON and ADON were responsible for updating the care plans. The MDS coordinator stated her expectation was care plans should include resident's diagnosis, medications, diet, physician orders and any resident care needs. The MDS coordinator stated that objectives should be specific and measurable, and interventions should be a specific task for staff and/or residents that accomplishes objectives. <BR/>During an interview on 02/19/25 at 12:07 PM, the Regional Nurse Consultant stated her expectations of care plan were for the care plan to look like the resident. She stated if she were a nurse coming in to provide care, she would want to know what was documented on the care plan. The RNC stated if a resident needed assistance or was a fall risk for example, that information should be on the care plan. The RNC explained the objectives should be based on what a nurse would expect to assess when interventions were followed. She stated the DON was responsible for the initial care plan and the ADON/MDS Coordinator contributed to revisions based on the comprehensive assessment. The RNC stated the CAA's should be addressed on the comprehensive care plan. She stated the DON was ultimately responsible for the accuracy of the care plans. The RNC stated in response to an example of an objective for pain, the RNC stated she did not agree with use of a pain scale because pain was subjective data. She explained staff should be able to identify pain by a resident's facial expressions or behavior. The RNC stated she trained staff to recognize pain or discomfort by being observant.<BR/>Review of the facility policy titled Comprehensive Care Plans, undated, revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives . that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: item 2. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the care plan., and 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment and failed to ensure the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment including both the comprehensive assessment and quarterly review assessments for 4 (Resident #1, #39, #40and #43) of 6 residents were reviewed for comprehensive care plans. <BR/>1. The facility failed to develop a comprehensive care plan within seven days for Resident #1, #39, #40 and #43.<BR/>2. The interdisciplinary team failed to review and revise the plan of care for Resident #1, #39, #40, #43 and #50.<BR/>These failures could affect all 88 residents by placing them at risk for not having their individual needs met. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 02/20/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 11/20/2022 with the following diagnosis: unspecified fracture of left shaft/femur, non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). <BR/>Review of Resident #1's revealed an MDS Significant Change assessment, dated 01/30/2023 section G reflects the following ADL care areas: bed mobility- extensive assistance, transfer- extensive assistance, walk in room- activity occurred only one or twice, walk in corridor- activity occurred only once or twice, dressing- extensive assistance, eating- Supervision, toilet use- extensive assistance, personal hygiene- extensive assistance, bathing- activity did not occur. <BR/>Review of Resident #1's most recent Care Plan , dated 12/07/2023, revealed category: ADL function/rehabilitation potential- ambulation/transfers amount of assist x1, bath hygiene amount of assist x1, Dressing/grooming assist x1. Further review revealed the interdisciplinary team had not reviewed and revised the care plan following the assessment of 12/07/2022.<BR/>Review of Resident #1's Care Conference Schedule revealed a Quarterly Care Conference was conducted on 12/07/2022.<BR/>Record review of Resident #39's face sheet dated 02/20/2023 revealed a [AGE] year-old male admitted on [DATE] with the following diagnosis: chronic pain due to trauma, quadriplegia (paralysis of all 4 limbs), hypertension (high blood pressure), bipolar disorder; current episode severe, mixed with psychotic features (mood disorder), anxiety disorder and neuromuscular of the bladder (person lacks bladder control due to brain, spinal cord or nerve problems). <BR/>Review of Resident #39's revealed an MDS Annual assessment, dated 08/31/2022 section G reflects the following ADL care areas: bed mobility- total dependance, transfer- total dependance, walk in room- activity did not occur, walk in corridor- activity did not occur, dressing- total dependance, eating- Supervision, toilet use- extensive assistance, personal hygiene- extensive assistance, bathing- total dependence. <BR/>Review of Resident #39's Care Plan, dated 01/04/2023 , revealed category: ADL function/rehabilitation potential- Does not have the ADL function or assistance needed care planned. An Annual Care Conference was not documented after the Annual MDS assessment, dated 08/31/2022 was completed.<BR/>Review of Resident #39's Care Conference Schedule revealed a Quarterly Care Conference was conducted on 10/05/2022 and 01/04/2022. An Annual Care Conference was not documented.<BR/>Record review of Resident #40's face sheet dated 02/14/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 01/06/2023 with the following diagnosis: fractured left hip, osteoporosis (disease of bone that makes them brittle), history of falling, Alzheimer's Disease, and Major Depressive disorder (persistent depressed mood).<BR/>Review of Resident #40's revealed an MDS Annual assessment, dated 01/11/2023 section G reflects the following ADL care areas: bed mobility- extensive assistance with 2+ person assist, transfer- extensive assistance with 2+ person assist, walk in room- activity did not occur, walk in corridor- activity did not occur, dressing- extensive assistance with 2+ person assist, eating- Supervision with 1 person assist, toilet use- extensive assistance with 2+ person assist , personal hygiene- extensive assistance with 1 person assist, bathing- personal help in part of bathing with 1 person assist . <BR/>Review of Resident #40's Care Plan dated 02/21/2023 revealed category: ADL function/rehabilitation potential- Provide assistance x1 with bathing/showering, requires x1 assist with bathing, requires x1 assist with eating, requires x1 assist with peri-care, requires x1 assist with toileting. <BR/>Review of Resident #40's Care Conference Schedule revealed a Quarterly Care Conference was conducted on 12/07/2022. An Annual Care Conference was not documented.<BR/>Record review of Resident #43's face sheet dated 02/14/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 01/06/2023 with the following diagnosis: fractured left hip, osteoporosis (disease of bone that makes them brittle), history of falling, Alzheimer's Disease, and major depressive disorder.<BR/>Review of Resident #43's revealed an MDS Annual assessment, dated 12/02/2022 section G reflects the following ADL care areas: bed mobility- supervision with 1 person assist, transfer- extensive assistance with 2+ person assist, walk in room- supervision with set-up, walk in corridor- supervision with set-up, dressing- extensive assistance with 2+ person assist, eating- Supervision with 1 person assist, toilet use- extensive assistance with 2+ person assist , personal hygiene- extensive assistance with 2+ person assist, bathing- personal help in part of bathing with 2+ person assist . Section O reflects the resident was receiving hospice care. <BR/>Review of Resident #43's Care Plan, dated 02/21/2023, revealed category: ADL function/rehabilitation potential- Does not have the ADL function or assistance needed care planned. Hospice has not been care planned. <BR/>Review of Resident #43's Care Conference Schedule revealed a Quarterly Care Conference was conducted on 12/23/2022. A Significant Change Care Conference was not documented.<BR/>In an interview on 02/18/23 at 12:16 a.m. MDS Coordinator DI revealed that the Care plans were behind in the schedule and has not been able to do it in time. She stated she had been out of 6 months due to illness, and they did not have anyone filling in for her. She said that her and RN CCM DH are responsible for making sure they are complete. She said the failure could place the resident at risk for unmet needs. The MDS coordinator said that she was out for 6 months and that they did not have anyone to cover for her. She stated that the Social Worker was planning the care plan conferences and they were not getting done timely. She stated that she was unaware that the Comprehensive Assessment care plans needed to be updated after the MDS was completed. She stated she followed the quarterly care conference and she thought that was how she did it. <BR/>An interview with the MDS Coordinator on 02/22/2023 at 11:00 a.m. revealed she did not revise the care plans or did not conduct the care conferences for (Resident #1, #39, #40 and #43) within the time frame after assessments. She stated the facility was behind on comprehensive care plans and care plan meetings.<BR/>Review of Policy and Procedure for Assessment/Care Plan dated February 2021 revealed:<BR/>3. The resident/representative's right to participate in the development and implementation of his or her care plan of care includes the right to: <BR/>a. participates in the planning process.<BR/>b. identify individuals to be included in the planning process<BR/>c. request meetings<BR/>d. request revisions.<BR/>e. participate in establishing goals.<BR/>f. participate in the type, amount, frequency, and duration of the care.<BR/>g. receiver services/items to be included in the care plan<BR/>h. be informed in advance of changes.<BR/>i. refuse, request changes to and/or discontinue care of treatment offered or proposed.<BR/>j. be informed in advance of the risk and benefits of the care of treatment proposed.<BR/>k. have access to and review care plans.<BR/>l. review and sign the care plan after any significant changes are made. <BR/>4. The care planning process:<BR/>a. facilities the inclusion of the resident's and/or representative.<BR/>b. includes an assessment of the resident's strengths and his/her needs.<BR/>c. incorporates the resident's personal and cultural preferences in establishing goals of care. <BR/>7. A comprehensive care plan is developed within seven days (7) days of completing the resident assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to attempt to use alternatives prior to installing a side or bed rail and assess the resident for risk of entrapment from bed rails prior to installation for 3 of 3 residents (Resident #7, Resident #10, and Resident #13) reviewed for bed rails. <BR/>The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails.<BR/>These failures could place residents at risk for injury.<BR/>The findings include:<BR/>Resident #7<BR/>Record review of Resident #7's undated electronic face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease (a brain disorder that causes unintended and uncontrollable body movements), left shoulder pain, lack of coordination, and weakness. <BR/>Record review of Resident #7's quarterly MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS assessment revealed a score of 14 meaning cognitively intact; Section GG (Functional Abilities) revealed Resident #7 needed partial to moderate assistance to roll left to right; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. <BR/>Record review of Resident #7's comprehensive care plan reviewed on 12/21/2023 revealed the resident was at risk for falls due to unsteady gait (walking), decreased balance, medications, poor safety awareness, and suffered a recent fall which resulted in a broken hip. Resident #7's care plan noted the resident required extensive assistance with bed mobility. There was no evidence of interventions for placement and/or use of bed rails. <BR/>Record review of Resident #7's electronic physician orders revealed no order for the use of bed rails.<BR/>Record review of Resident #7's electronic records on 12/21/2023 revealed no evidence of an attempt to use alternatives to bed rails or assessment for the risk of entrapment.<BR/>During an observation and interview on 12/18/2023 at 2:47 p.m., Resident #7's bed had quarter rails on both sides. Resident #7 stated that the rails help her with bed mobility. <BR/>Resident #10<BR/>Record review of Resident #10's undated electronic face sheet revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnoses which included intellectual disabilities, dementia, atrophy (muscle loss), unsteadiness on feet, and reduced mobility.<BR/>Record review of Resident #10's quarterly MDS dated [DATE] Section C (Cognitive Patterns) BIMS assessment revealed a score of 9 indicated moderately impaired and Section G (Functional Status) revealed Resident #10 needed extensive assistance with bed mobility. <BR/>Record review of Resident #10's comprehensive care plan reviewed on 12/21/2023 revealed the resident preferred to have grab bars on both sides of bed to increase mobility on 12/21/2023 and resident at risk for falls related to history of fall with major injury on 03/06/2019. <BR/>Record review of Resident #10's electronic physician orders revealed order for left and right positioning bars for increased mobility with start date of 12/21/2023.<BR/>Record review of Resident #10's electronic records on 12/21/2023 revealed no evidence of an attempt to use alternatives to bed rails or assessment for the risk of entrapment. <BR/>During an observation of Resident #10's room on 12/18/23 at 2:17 p.m., Resident #10 had quarter rails present to the head of bed.<BR/>Resident #13<BR/>Record review of Resident #13's undated electronic face sheet revealed an [AGE] year-old female was originally admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnoses which included unsteadiness on feet, mild cognitive impairment, lack of coordination, abnormalities of gait and mobility, atrophy (muscle wasting) and muscle weakness.<BR/>Record review of Resident #13's quarterly MDS dated [DATE] Section C (Cognitive Patterns) BIMS assessment revealed a score of 8 meaning moderately impaired and Section GG (Functional Abilities) revealed Resident #13 needed partial to moderate assistance with rolling left to right. <BR/>Record review of Resident #13's comprehensive care plan reviewed on 12/21/2023 revealed the resident preferred to have grab bars to bilateral sides of the bed to increase mobility starting on 12/21/2023 and resident at risk for falls related to poor safety awareness, weakness, and medications starting on 11/22/2020 with interventions listed not including placement and/or use of bed rails. <BR/>Record review of Resident #13's electronic physician orders revealed order for grab bars to bilateral upper sides of bed with start date of 12/21/2023.<BR/>Record review of Resident #13's electronic records on 12/21/2023 revealed no evidence of an attempt to use alternatives to bed rails or assessment for the risk of entrapment. <BR/>During an observation of Resident #13's room on 12/18/23 at 2:29 p.m., Resident #13 had quarter rails present on bed. <BR/>During an interview on 12/21/2023 at 10:50 a.m., DON stated her expectation would be that entrapment risk assessment be performed, order received from physician, consent be signed by resident or responsible party, and care plan be updated prior to bed rails being installed on a resident's bed. DON stated that she was unsure what led to entrapment risk assessment not being performed, order not received, consent not signed, and care plan not updated prior to bed rails being installed for the 3 residents listed above and charts are being audited at this time to correct any missed steps. DON could not provide any documentation at this time that entrapment risk assessment had been performed. She stated that it was her responsibility for making sure assessments were performed, orders were obtained, and consents were signed prior to bed rail installation.<BR/>During an interview on 12/21/2023 at 11:00 a.m., CNA E stated that bed rails are used to help residents be mobile and for fall prevention. CNA E stated that facility does not use bed rails to keep residents in bed. <BR/>During an interview on 12/21/2023 at 11:03 a.m., LVN F stated that physician's order needed to be obtained and DON notified prior to bed rails being installed on a resident's bed. LVN F stated that she did not know who was responsible for completing entrapment risk assessment. LVN F stated that if no assessment were performed, resident could be at risk for getting entangled in bed rail and staff unaware. LVN F stated that she had no residents with half or full bed rails and that facility uses rails to help with mobility and not as a restraint. <BR/>During an interview and record review on 12/21/2023 at 1:54 p.m., DON stated that all entrapment risk assessments had been performed for the residents requiring bed rails. She provided what assessment had been performed titled Physical Restraint/Adaptive Equipment Consent for Resident #7. Surveyor reviewed form provided by DON for Resident #7's assessment and no documentation was observed of an attempt to use alternatives to bed rails or assessment for the risk of entrapment on the form. DON stated that she would reach out to corporate to see if they had another assessment form available. <BR/>During an interview on 12/21/2023 at 2:38 p.m., DON stated that if entrapment risk assessments were not performed, bed rails being used inappropriately would put residents at risk of injury or harm from becoming trapped in bed rails. <BR/>Record review of the facility's policy titled Proper Use of Side Rails revision date of December 2016 revealed Purpose: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms .General Guidelines:<BR/>1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.)<BR/>2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents.<BR/>3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's:<BR/>a. Bed mobility;<BR/>b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet;<BR/>c. Risk of entrapment from the use of side rails; and<BR/>d. That the bed's dimensions are appropriate for the resident's size and weight.<BR/>4. The use of side rails as an assistive device will be addressed in the resident care plan.<BR/>5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol.<BR/>6. Less restrictive interventions that will be incorporated in care planning include:<BR/>a. Providing restorative care to enhance abilities to stand safely and to walk;<BR/>b. Providing a trapeze to increase bed mobility;<BR/>c. Placing the bed lower to the floor and surrounding the bed with a soft mat;<BR/>d. Equipping the resident with a device that monitors attempts to arise;<BR/>e. Providing staff monitoring at night with periodic assisted toileting for residents attempting to arise to use the bathroom; and/or<BR/>f. Furnishing visual and verbal reminders to use the call bell for residents who can comprehend this information.<BR/>7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails.<BR/>8. The risks and benefits of side rails will be considered for each resident.<BR/>9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. (Note: Federal regulations do not require written consent for using restraints. Signed consent forms do not relieve the facility from meeting the requirements for restraint use, including<BR/>10. Manufacturer instructions for the operation of side rails will be adhered to.<BR/>11. The resident will be checked periodically for safety relative to side rail use.<BR/>12. If side rail use is associated with symptoms of distress, such as screaming or agitation, the resident's needs, and use of side rails will be reassessed.<BR/>13. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used).<BR/>14. Side rails with padding may be used to prevent resident injury in situations of uncontrollable movement disorders but are still restraints if they meet the definition of a restraint.<BR/>15. Facility staff, in conjunction with the Attending Physician, will assess and document the resident's risk for injury due to neurological disorders or other medical conditions.<BR/>Record review of the facility's policy titled Bed Safety revision date of October 2023 revealed Purpose: <BR/>It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails .<BR/>Resident Assessment: <BR/>1. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with<BR/>the Attending Physician, and input from the resident and/or legal representative.<BR/>2. As part of the resident's comprehensive assessment, the following components will be considered<BR/>when determining the resident's needs, and whether or not the use of bed rails meets those needs:<BR/>a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms<BR/>b. Size and weight<BR/>c. Sleep habits<BR/>d. Medication(s)<BR/>e. Acute medical or surgical interventions<BR/>f. Underlying medical conditions<BR/>g. Existence of delirium<BR/>h. Ability to toilet self safely<BR/>i. Cognition<BR/>j. Communication<BR/>k. Mobility (in and out of bed)<BR/>l. Risk of falling<BR/>3. The resident assessment must include an evaluation of the alternatives that were attempted prior to<BR/>the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed<BR/>needs.<BR/>4. The resident assessment must also assess the resident's risk from using bed rails. Examples of the<BR/>potential risks with the use of bed rails include:<BR/>a. Accident hazards (e.g., falls, entrapment, and other injuries sustained from attempts to climb<BR/>over, around, between, or through the rails, or over the footboard)<BR/>b. Barrier to residents from safely getting out of bed<BR/>c. Physical restraint (e.g., hinders residents from independently getting out of bed or performing<BR/>routine activities)<BR/>d. Decline in resident function, such as muscle functioning/balance<BR/>e. Skin integrity issues<BR/>f. Decline in other areas of activities of daily living such as using the bathroom, continence, eating,<BR/>hydration, walking and mobility<BR/>g. Other potential negative psychosocial outcomes such as an undignified self-image, altered self esteem,<BR/>feelings of isolation, or agitation/anxiety.<BR/>5. The resident assessment should assess the resident's risk of entrapment between the mattress and<BR/>bed rail or in the bed rail itself.<BR/>6. The facility will assess to determine if the bed rail meets the definition of a restraint. A bed rail is a<BR/>restraint if the bed rail keeps a resident from voluntarily getting out of bed in a safe manner due to<BR/>his/her physical or cognitive inability to lower the bed rail independently. If it is determined to be a<BR/>restraint, the facility will follow their procedures related to physical restraints .<BR/>Informed Consent<BR/>7. Informed consent from the resident or resident representative must be obtained after appropriate<BR/>alternatives have been attempted prior to installation and use of bed rails. This information should<BR/>be presented in an understandable manner, and consent given voluntarily, free from coercion.<BR/>8. The information that the facility should provide to the resident, or resident representative includes,<BR/>but is not limited to:<BR/>a. What assessed medical needs would be addressed by the use of bed rails;<BR/>b. The resident's benefits from the use of bed rails and the likelihood of these benefits;<BR/>c. The resident's risks from the use of bed rails and how these risks will be mitigated; and<BR/>d. Alternatives attempted that failed to meet the resident's needs and alternatives considered<BR/>but not attempted because they were considered to be inappropriate.<BR/>9. Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified<BR/>bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail.<BR/>Appropriate Alternatives<BR/>10. The facility will attempt to use appropriate alternatives prior to installing or using bed rails.<BR/>Alternatives include, but are not limited to:<BR/>a. Roll guards<BR/>b. Foam bumpers<BR/>c. Lowering the bed<BR/>d. Concave mattresses<BR/>11. Alternatives that are attempted should be appropriate for the resident, safe and address the<BR/>medical conditions, symptoms, or behavioral patterns for which a bed rail was considered.<BR/>12. If no appropriate alternatives are identified, the medical record should include evidence of the<BR/>following:<BR/>a. Purpose for which the bed rail was intended and evidence that alternatives were tried<BR/>and were not successful;<BR/>b. Assessment of the resident, the bed, the mattress, and rail for entrapment risk (which<BR/>would include ensuring bed dimensions are appropriate for resident size/weight); and<BR/>c. Risks and benefits were reviewed with the resident or resident representative, and<BR/>informed consent was given before installation or use.<BR/>Ongoing Monitoring and Supervision<BR/>13. The facility will continue to provide necessary treatment and care to the resident who has bed rails<BR/>in accordance with professional standards of practice and the resident's choices. This should be<BR/>evidenced in the resident's records, including their care plan, including, but not limited to, the<BR/>following information:<BR/>a. The type of specific direct monitoring and supervision provided during the use of the bed<BR/>rails, including documentation of the monitoring;<BR/>b. The identification of how needs will be met during use of the bed rails, such as for repositioning,<BR/>hydration, meals, use of the bathroom and hygiene;<BR/>c. Ongoing assessment to assure that the bed rail is used to meet the resident's needs;<BR/>d. Ongoing evaluation of risks;<BR/>e. The identification of who may determine when the bed rail will be discontinued; and<BR/>f. The identification and interventions to address any residual effects of the bed rail (e.g.,<BR/>generalized weakness, skin breakdown).<BR/>14. Responsibilities of ongoing monitoring and supervision are specified as follows:<BR/>b. Direct care staff will be responsible for care and treatment in accordance with the plan of<BR/>care.<BR/>c. A nurse assigned to the resident will complete reassessments in accordance with the<BR/>facility's assessment schedule, but not less than quarterly, upon a significant change in<BR/>status, or a change in the type of bed/mattress/rail.<BR/>d. The interdisciplinary team will make decisions regarding when the bed rail will be used or<BR/>discontinued, or when to revise the care plan to address any residual effects of the bed<BR/>rail.<BR/>e. The maintenance director, or designee, is responsible for adhering to a routine<BR/>maintenance and inspection schedule for all bed frames, mattresses, and bed rails.<BR/>f. The facility's education and training activities will include instruction about risk factors for<BR/>resident injury due to beds, and strategies for reducing risk factors for injury, including<BR/>entrapment.<BR/>15. The staff shall report to the Director of Nursing and Administrator any deaths, serious illnesses and/or<BR/>injuries resulting from a problem associated with a bed and related equipment including the bed<BR/>frame, bedside rails, and mattresses. The Administrator shall ensure that reports are made to the<BR/>Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and<BR/>regulations including the Safe Medical Devices Act.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week, for 10 of 12 months (January, March, April, May- August, October-December 2022) reviewed for RN coverage 60 days between 01/2022 to 12/2022. <BR/>The facility failed to ensure a RN coverage for 8 consecutive hours for 60 days between 01/2022 to 12/2022.<BR/>These failures could place all residents at risk of care and clinical needs not being met. <BR/>Findings include:<BR/>Record review of Facility's RN coverage reporting system (PBJ) reviewed between 01/01/2022 to 12/31/2023 revealed no evidence of RN coverage for 60 of 365 days:<BR/>1. <BR/>*1/1/2022 with no RN coverage<BR/>2. <BR/>*1/2/2022 with no RN coverage<BR/>3. <BR/>*1/8/2022 with no RN coverage<BR/>4. <BR/>*1/9/2022 with no RN coverage<BR/>5. <BR/>*3/27/2022 with no RN coverage<BR/>6. <BR/>*4/9/2022 with no RN coverage<BR/>7. <BR/>*4/10/2022 with no RN coverage<BR/>8. <BR/>*4/23/2022 with no RN coverage<BR/>9. <BR/>*4/24/2022 with no RN coverage<BR/>10. <BR/>*5/7/2022 with no RN coverage<BR/>11. <BR/>*5/8/2022 with no RN coverage<BR/>12. <BR/>*5/14/2022 with no RN coverage<BR/>13. <BR/>*5/15/2022 with no RN coverage<BR/>14. <BR/>*5/21/2022 with no RN coverage<BR/>15. <BR/>*5/22/2022 with no RN coverage<BR/>16. <BR/>*6/4/2022 with no RN coverage<BR/>17. <BR/>*6/5/2022 with no RN coverage<BR/>18. <BR/>*6/18/2022 with no RN coverage<BR/>19. <BR/>*6/19/2022 with no RN coverage<BR/>20. <BR/>*7/1/2022 with no RN coverage<BR/>21. <BR/>*7/2/2022 with no RN coverage<BR/>22. <BR/>*7/3/2022 with no RN coverage<BR/>23. <BR/>*7/16/2022 with no RN coverage<BR/>24. <BR/>*7/17/2022 with no RN coverage<BR/>25. <BR/>*7/22/2022 with no RN coverage<BR/>26. <BR/>*7/23/2022 with no RN coverage<BR/>27. <BR/>*7/24/2022 with no RN coverage<BR/>28. <BR/>*7/31/2022 with no RN coverage<BR/>29. <BR/>*7/30/2022 with no RN coverage<BR/>30. <BR/>*8/6/2022 with no RN coverage<BR/>31. <BR/>*8/7/2022 with no RN coverage<BR/>32. <BR/>*8/13/2022 with no RN coverage<BR/>33. <BR/>*8/14/2022 with no RN coverage<BR/>34. <BR/>*10/8/2022 with no RN coverage<BR/>35. <BR/>*10/09/2022 with no RN coverage<BR/>36. <BR/>*10/15/2022 with no RN coverage<BR/>37. <BR/>*10/16/2022 with no RN coverage<BR/>38. <BR/>*10/27/2022 with no RN coverage<BR/>39. <BR/>*10/28/2022 with no RN coverage<BR/>40. <BR/>*11/10/2022 with no RN coverage<BR/>41. <BR/>*11/11/2022 with no RN coverage<BR/>42. <BR/>*11/19/2022 with no RN coverage<BR/>43. <BR/>*11/20/2022 with no RN coverage<BR/>44. <BR/>*11/21/2022 with no RN coverage<BR/>45. <BR/>*11/24/2022 with no RN coverage<BR/>46. <BR/>*11/25/2022 with no RN coverage<BR/>47. <BR/>*11/29/2022 with no RN coverage<BR/>48. <BR/>*12/3/2022 with no RN coverage<BR/>49. <BR/>*12/4/2022 with no RN coverage<BR/>50. <BR/>*12/5/2022 with no RN coverage<BR/>51. <BR/>*12/8/2022 with no RN coverage<BR/>52. <BR/>*12/9/2022 with no RN coverage<BR/>53. <BR/>*12/13/2022 with no RN coverage<BR/>54. <BR/>*12/14/2022 with no RN coverage<BR/>55. <BR/>*12/17/2022 with no RN coverage<BR/>56. <BR/>*12/18/2022 with no RN coverage<BR/>57. <BR/>*12/19/2022 with no RN coverage<BR/>58. <BR/>*12/22/2022 with no RN coverage<BR/>59. <BR/>*12/27/2022 with no RN coverage, and<BR/>60. <BR/>*12/31/2022 with no RN coverage<BR/>During an interview on 02/24/23 at 01:46 PM, the Admin stated, the negative effects for no RN coverage were that the residents may not have gotten good care deserved and needed. She stated herself (Admin) and the DON should monitor the staff they need with coverage. The failures, she felt were due to the turnover of staff which were excessive. Her expectations for RN coverage were for the facility to have good care for the residents in all staffing and care areas . <BR/>During an interview on 02/24/23 at 02:00 PM, the DON stated the reasoning for having RN's were to have higher levels of skills and recourse for residents with the care needed. She added, she could not state why there was a failure being she was new to this position and facility, but guessed it was most likely due to staff overturn. The DON stated RN's were very important to have on staff for assessing resident's needs. The negative impact to residents, if a serious change of condition were not to be acted on immediately, it could have serious outcomes. She felt the failure were not having made working staff schedules, or on call staff available. Her expectations were for the DON and Admin to monitor RN coverage appropriately seeing fit where needed. <BR/>During exit conference on 02/24/2023 at 7:00pm, the facility administration could did not provide evidence of policies or procedures regarding utilization of RNs for 8 consecutive hours a day/7 days a week.

Based on observation, interview, and record review, the facility failed to provide foods at a safe and appetizing temperature for 1 of 1 meal reviewed for palatable temperatures.<BR/>Facility failed to serve food that retained safe palatable temperature for lunch service.<BR/>These failures placed 90 of 92 residents at risk for foodborne illnesses due to food temperatures.<BR/>Findings included:<BR/>During an interview on 02/18/23 at 10:58AM with Resident #85, she complained that the food was usually cold.<BR/>During an interview on 02/18/23 at 2:45PM with Resident # 5, he said the food was always cold. <BR/>During an interview on 02/18/23 at 2:55PM with Resident #59, he said the food was always cold. <BR/>During an observation and interview on 02/19/23 at 12:40PM with Resident #59, he was visibly upset and yelling and cursing, LVN CD was assisting resident with meal. Resident #59 loudly complained that his food was late and that it was cold. <BR/>During an interview on 02/19/23 at 01:07PM with LVN CD, she said Resident #59 always complained that his food was late and /or cold.<BR/>During an observation on 02/22/23 from 11:30AM to 12:30PM, <BR/>the service line meal item temperatures included:<BR/>Beef Roast 180 degrees F<BR/>Sliced Carrots 200 degrees F<BR/>Red Potatoes 180 degrees F.<BR/>11:40AM-Kitchen staff began preparing meal trays for residents.<BR/>11:44AM-First meal cart out to dining room on Unit 1. No staff in dining room, DM had to go tell nursing staff that meal trays were ready.<BR/>11:54AM-Nursing staff entered the dining room on Unit 1 and began to look at resident meal trays and compare them to the resident meal cards. 1 nursing staff asked the DM for a tea pitcher and began making drinks for the meal trays on the cart. DM said there was usually more staff in the dining room prior to meal trays coming out of kitchen. She said the kitchen staff responsibility was to make the meal trays and get them out of the kitchen for nursing to serve to the residents. She said it was the responsibility of the nursing staff to make the resident drinks. DM said after the meal trays left the kitchen it was no longer the responsibility of kitchen staff to serve the meals to the residents. <BR/>12:02PM-Nursing staff began serving residents in dining room for Unit 1 from the first meal cart.<BR/>12:04PM-First meal cart out to dining room on Unit 2. 1 staff in the dining room began making iced tea for the meals.<BR/>12:10PM-The drinks had been made and 2 staff members began serving residents in the dining room for Unit 2 their meals.<BR/>12:16PM-Final cart with surveyor sample tray out of the kitchen.<BR/>12:21PM-Nursing staff preparing resident drinks for meal trays on the final cart and began serving hall trays.<BR/>12:26PM-Sample tray provided after all residents served their meal. Food temperature of meal tray as followed:<BR/>Beef Roast-95 degrees F<BR/>Sliced Carrots- 120 degrees F<BR/>Red Potatoes-110 degrees F<BR/>Surveyor team sample of tray indicated the food temperature was cool. DM said that the temperatures had been a drop of almost 100 degrees for some food items and that waiting for nursing staff to pass out trays could be some of the reason for the food being cold. She said that a Resident Council meeting last year, (unable to remember which month), indicated that residents complained about their tea being warm and the ice melted. She said the facility decided that their solution would be to no longer have the kitchen be responsible for resident drinks on meal trays. DM said it would be the responsibility of nursing staff to make resident drinks for meal trays fresh, so that the ice would not be melted in the tea. RVPO sampled meal and said that the food was cold. <BR/>During an interview on 02/22/23 at 3:35PM with TNA GM, she said she had been working day shift since October of 2022 and meals had been served on a hall cart with no drinks from the kitchen since at least that time. She said it was the responsibility of the nursing staff to make resident drinks before serving the meals to the residents. TNA GM said she did not know the exact reason for that, but that it had something to do with previously the ice was melted in the tea and residents didn't like that, so the nurses and aides had to make the drinks with fresh ice and tea before they were placed on the meal trays after the kitchen made the trays and right before they were served to the residents. She said there would usually be a resident smoke break right before lunch time, so it would be difficult for the nursing staff to get back and start preparing the drinks prior to the kitchen getting the meal trays out for the nursing staff to pass out to the residents. <BR/>During an interview on 02/22/23 at 3:40PM with the Activity Director, she said that she remembered last year having a resident council meeting that the residents complained about their ice being melted in their tea and it being warm when they got their lunch and supper. She said she wrote a grievance from that council meeting, and it was discussed with administration. Activity Director said the solution that administration came up with was that the nursing department would be responsible for making the drinks fresh after the kitchen made meal trays, so that the tea would have fresh ice and it would not be melted. Activity Director provided the Resident Council meeting minutes and grievance form that she filled out that was for April of 2022.<BR/>During an interview on 02/23/23 at 3:20PM, ADM said that it was usually a responsibility of the kitchen staff to make the drinks for the residents. She said it did not make sense that the former administration would make a decision for nursing to make the drinks as a solution for ice being melted in tea.<BR/>During an interview on 02/24/23 at 6:45PM, ADM said she had no additional evidence to provide. <BR/>Record review of Facility Resident Council Meeting and Grievance form dated 04/29/2022 revealed: residents state that when they receive meals lunch and supper the ice is always melted, they would like to have ice in their drinks <BR/>Record review of Facility policy labeled Food and Nutrition Services revised 09/2021 revealed: . And nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.<BR/>Record review of CMS form 672 dated 02/19/23 revealed a census of 92 with 2 residents that received enteral nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitization.<BR/>1. <BR/>The facility failed to ensure ground meat was thawed properly.<BR/>2. <BR/>The facility failed to ensure the cook performed hand hygiene appropriately when preparing food.<BR/>3. <BR/>The facility failed to ensure foods were sealed and/or labeled properly.<BR/>4. <BR/>The facility failed to ensure the foods were not stored past expiration date.<BR/>Thess failures could place residents that eat out of the kitchen at risk for contamination and foodborne illnesses.<BR/>Findings included:<BR/>During an observation of the kitchen on 01/19/2025 between 2:15 p.m. - 2:50 p.m. revealed the following: <BR/>Sink:<BR/>1 plastic dish sitting in a sink with 4 tubes of ground meat sitting vertically in the dish that was filled with water and water running into the container. The ground meat was not submerged in the water with approximately 30% of ground meat outside of the water and water was running in the middle of the 4 tubes and not covering the meat.<BR/>Pantry:<BR/>*1 clear plastic bag not sealed and was open to air held an opened bag of potato chips dated 2-12-25 & 2-25-25.<BR/>*7 expired bottles of Lemon Juice from concentrate with written date of 10/02 on the outside of the bottles. Manufacture date on the bottle lids was 01/24/2025.<BR/>Refrigerator #1:<BR/>*1 clear plastic bag not sealed and was open to air held an opened bag of pink circular meat. There was no description on the bag.<BR/>*1 expired bottle of Lemon Juice from concentrate with written date of 10/02 on the outside of the bottle. Manufacture date on the bottle lid was 01/24/2025. <BR/>Refrigerator #2:<BR/>*1 sealed plastic container of grape jelly with no date on label.<BR/>Freezer # 1:<BR/>*1 box of 3 containers of whipped topping sitting on the floor on its side to the left of freezer door. <BR/>*1 bag of a circular breaded item with no description and no date. <BR/>*2 bags of what appeared to be frozen pancakes with no description and no date.<BR/>During an interview on 02/16/2025 at 2:53 p.m., the cook stated bags of food being stored should be sealed. He stated after opening food item it should be labeled with open date. He stated if foods were not stored in their original container, then they should have item description on them. He stated no food should be stored on the floor. The cook stated meat should be dethawed in the refrigerator, but meat would need to be placed in the refrigerator several days before needed to dethaw in the refrigerator. He stated he had been rotating the meat during the thawing process due to all the meat was not submerged in the water in dish in sink. He stated he had started defrosting the meat about an hour prior. He stated he was responsible for storing, labeling, and preparing foods.<BR/>During an observation on 02/16/2025 at 4:11 p.m., the cook started pureeing foods for diner service. He donned gloves without washing his hands and began pureeing meat entree. He added all ingredients into the blender until food item was appropriate consistency He then moved food into container and covered with foil prior to putting item into the freezer. He took blender to the dish room and removed his gloves. The cook rinsed out blender prior to running through the dish washer and he did not wash hands before touching sanitized blender. He then [NAME] blender back to puree station and put down on counter. He reached into a bucket of water solution and pulled out a rag then wiped down counter under blender and bottom of blender machine. He put blender back together then put gloves on his hands. He did not perform hand hygiene prior to putting on gloves. He then started on pureeing the rest of dinner items. <BR/>During an interview on 02/16/2025 at 6:45 p.m., the cook stated he should have washed his hands when changing out gloves during food preparation. He stated he had just forgotten to do so when being observed. He stated he was a train wreck and nervous. He stated not labeling food items with date and description could cause the wrong food item to be given to residents with allergies to that food item and could cause the residents to get sick. He stated not storing food items appropriately could cause residents to be sick.<BR/>During an interview on 02/17/2025 at 3:29 p.m., the DM stated food stored outside of the original container should be labeled with food description and date. She stated no food should be stored on the floor and should be stored at least 6 inches off of the floor. She stated foods should not be stored in the pantry or in the refrigerator past the manufacture's expiration date and the date the manufacturer had on container was the expiration date. The DM stated she expected for food items to be disposed of when item passed the expiration date. She stated anyone who puts up food items off the delivery truck and during food preparation were responsible for making sure items were stored correctly with appropriate label. She stated she does monitor that food was labeled, stored at least 6 inches off of the floor and not expired. She stated she last monitored the kitchen the week prior. The DM stated packages of food should be stored in sealed containers after opened. She stated ground meat should be thawed submerged under running water. She stated kitchen staff should wash hands with soap and water during glove changes. She stated she expected for HH to be done when moving from one task to another in the kitchen and not performing could lead to cross contamination and bacteria spread. She stated she had been working for the facility for approximately one week and will be monitoring the kitchen at least 2-3 times a week. She stated not labeling food appropriately with description of food item and dates could lead to allergic reaction. She stated she would have thrown food away without date on label because staff would not know when food should be disposed of. The DM stated not thawing out meat correctly could lead to some of the food being in the danger zone for longer than appropriate time and could cause bacteria to grow.<BR/>During a telephone interview on 02/17/2025 at 5:00 p.m., the dietician stated foods stored outside of their original container should be labeled with description and date. She stated foods should be stored 6 inches above the floor. She stated foods should be disposed of and not kept past the expiration date. She stated packages of food items should be sealed so not to expose food to the elements. She stated typically frozen meat was thawed during the cooking process, in the cooler or under cold running water. She stated not submerging frozen meat could more than likely cause it to thaw unevenly and cause foodborne illness. She stated every time gloves were changed during food preparation then HH should be performed in between glove changes. She stated the dietary manager monitors that kitchen staff store, prepare and prepare food appropriately. She stated she was available for training and does observe how staff store and prepare food. She stated the kitchen staff had been changing and there was a new DM which could have led to failures of HH, meat thawing, and food storage or staff may have forgotten their training. She stated she felt more education was needed. She stated that not storing food appropriately and not performing HH correctly could lead to illness from bacteria. <BR/>During an interview on 02/17/2025 at 9:39 a.m., the ADMN stated she expected for kitchen staff to follow policies on food storage, preparation, and hand hygiene. She stated the DM monitored that kitchen staff were following the facility's policy. She stated not storing and preparing food appropriately could cause residents to get sick. <BR/>Record Review of facility's policy titled Food Preparation and Handling dated 2018 revealed: <BR/>Procedure: <BR/>1. General Guidelines a. Use clean, sanitized surfaces, equipment and utensils. b. Wash hands properly before beginning food preparation .<BR/>2. Thawing Foods a. Thaw meat, poultry and fish in a refrigerator at 41&deg;F or less. b. Foods may also be thawed using the following procedures: i. Completely submerged under running water at a temperature of 70&deg;F or below with sufficient water velocity to agitate and float off loosened food particles into the overflow: 1. For a period of time that does not allow thawed portions of ready-to-eat food to rise above 41&deg;F; or 2. For a period of time that does not allow thawed portions of a raw animal food requiring cooking to be above 41&deg;F for more than four hours including the time the food is exposed to the running water and the time needed for preparation for cooking.<BR/>Record Review of facility's policy titled Handwashing/Hand Hygiene dated 01/20/2023 revealed: <BR/>Hand hygiene must be performed prior to donning and after doffing gloves.<BR/>Record Review of facility's policy titled Preventing Foodborne Illness - Food Handling dated April 2022 revealed:<BR/>All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .Potentially hazardous foods held in the danger zone (41&deg;F to 135&deg;F) for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) will be discarded.<BR/>Record Review of facility's policy titled Food Storage dated 2018 revealed:<BR/>1. Dry storage rooms .d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated .2. Refrigerators .d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage .e. Use all leftovers within 72 hours. Discard items that are over 72 hours old .3. Freezers .c. Store all foods on racks or shelves off the floor. <BR/>Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed on 02/19/2025 revealed: <BR/>3-602.11 Food Labels. <BR/>(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. <BR/>(B) Label information shall include: <BR/>(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; <BR/>(2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; <BR/>(3) An accurate declaration of the net quantity of contents; <BR/>(4) The name and place of business of the manufacturer, [NAME], or distributor; and <BR/>(5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf <BR/>(6) Except as exempted in the Federal Food, Drug, and Cosmetic Act &sect; 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. <BR/>Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.<BR/>3-501.13 Thawing.<BR/>Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed:<BR/>(A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) <BR/>or less Pf; or <BR/>(B) Completely submerged under running water: <BR/>(1) At a water temperature of 21oC (70oF) or below Pf,<BR/>(2) With sufficient water velocity to agitate and float off loose particles in an overflow Pf, and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 diseases and infections for 1 of 3 residents (Resident #18) observed for infection control. <BR/>1. The facility failed to ensure CNA B used the required PPE for Resident #18, (gown) who was on enhanced barrier precautions due to her Foley Catheter while performing Foley Catheter Care on 02/19/25. <BR/>These failures could place the residents at risk of cross-contamination and development of infection.<BR/>Findings included: <BR/>Record review of Resident #18's face sheet, dated 2/18/25, reflected a [AGE] year-old female with an admission date of 2/15/19. Resident #1 had a diagnosis which included dementia, disorder of urinary system, and type 2 diabetes mellites. <BR/>Record review of Resident #18's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 8, indicating moderate cognitive impairment. <BR/>Record review of Resident #18's Care Plan dated 2/18/25 with ADL's indicated Resident #18 has problem with recurrent urinary tract infections. <BR/>During an observation on 2/18/25 at 9:18 AM, CNA B gathered supplies for Resident #18's catheter care and placed supplies in a plastic bag. CNA B entered room with plastic bag and did not don gown. She performed hand hygiene and put on gloves in the room prior to performing care to the resident. CNA B performed foley catheter care using clean wipe each x 4 and cleaned catheter from the resident's skin, away from the resident. CNA B disposed of each used wipe into disposal bag and performed hand hygiene after care completed and gloves removed. Resident #18's foley catheter bag was suspended to the left side of her bed and in a privacy bag. Resident #18 had sign on door notifying staff of EBP (enhanced barrier precautions). There was no PPE directly outside of room or handing on the door . <BR/>During an interview on 2/19/25 at 04:25 PM LVN A stated Resident #18 was on enhanced barrier precautions due to her having an indwelling foley catheter. she stated that means that any employee that goes into Resident #18's room and performs any kind of patient care associated to the foley, the employee should be wearing all the gear. she stated all the gear includes gown, gloves, and mask.<BR/>During an interview on 2/19/25 at 05:45 PM DON stated that she was the infection preventionist. She stated that enhanced barrier precautions are in place to protect the residents and employees while performing patient care from spreading any bacteria. She stated that an employee that performed foley catheter care should have been wearing the required ppe. She stated the required ppe was mask, gloves, and gown. She stated that CNA B should have been wearing a gown while she performed foley care. She stated that if the proper ppe was not worn, it could put Resident #18 at risk for an infection. <BR/>Attempted to contact CNA B on 2/19/24 at 5:50 pm by phone, no answer, left message. <BR/>Record review of facilities policy titled Enhanced Barrier Precautions dated 4/1/24 indicated: <BR/>Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. <BR/>9. Enhance barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Based on observation, interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation in that:<BR/>The facility failed to dispose of and have procedures for handling drugs and biologicals according to federal, state, and local laws. <BR/>The facility failed to make sure that a resident's medications are returned to him/her to the new facility, or to the family, only if the attending physician approves it. <BR/>These failures could result in decreased medication effectiveness or increased risk of medication errors.<BR/>Finding include:<BR/>During observation on 02/18/2023 at 04:04 PM, LVN-R stated to the DON that there was a basket of keys in her office to the medication destruction box. The DON did not know where the drug destruction box was stating, at and stated, I literally do not know. <BR/>During an interview on 02/18/2023 at 04:30 PM, the DON stated she did not know where the drug destruction logbook would be and would be looking for it. She stated it should have been in her office previously along with the destroyed meds.<BR/>Record Review on 02/19/2022 of facility's medication disposition record revealed 3 months of documented logs (November, December, January). <BR/>During observation and interview on 02/23/2023 at 10:50, the RN-U of med with Med Cart #2 revealed:<BR/>2 bottles of nasal spray and 4 blister packs of hydrocodone 7.5-325, 234 tabs. This resident was transferred to another facility on 02/19/2023 . RN-U stated these meds had been discharged with no documentation in the narcotic book. <BR/>During an interview on 02/23/2023 at 11:50 AM, the Admin stated the facility had not previously had anyone to take the discharged medications from the carts. They are supposed to have turned them in to the DON but there had not been one. <BR/>During an interview on 02/23/2023 at11:52 AM, the DON stated, she is new to LTC and will only answer to what she thinks is right. She did not know how long the logs should be kept. If the Resident was transferred, all medications should had been sent with them. <BR/>During an interview on 02/23/2023 at 12:00 PM, Corporate Clinical Company Leader RN-H stated the current DON has had no orientation and the discharged meds should have gone with the resident when transferred. If the nurses did not send all medications with resident and had not discharged those medications with the proper paperwork, there could be a drug diversion. Corporate Clinical Company Leader RN-H stated the risk to residents was running out before the prescription is ready to be re-filled. Her expectations were for the residents to not go without their medication with the DON monitoring that. The staff failures were where the medications had not been monitored. <BR/>Record review of the facility policy Discarding and Destroying Medications revised 10/2014, revealed;<BR/>Policy Statement: Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances.<BR/>Policy Interpretation and Implementation <BR/> 3. Unless otherwise prohibited under applicable federal or state laws, individual resident medication supplied and sealed unopened containers may be returned to the issuing pharmacy for disposition provided that: <BR/>b. Oh such medications are identified as to what or control number; and<BR/>c. The receiving Pharmacist and the Registered Nurse employed by the facility sign a separate log that lists the residents name; the name, strength, prescription number (if applicable) and amount of the medication returned; and the date the medication was returned <BR/> 5. c. Disposal of controlled substances must take place immediately) no longer than three days) after discontinuation of youth by the resident <BR/> 10. The medication disposition record will contain the following information:<BR/>a. <BR/>The residents name; <BR/>b. <BR/>Date medication disposed;<BR/>c. <BR/> The name and strength of the medication; <BR/>d. <BR/>The name of the dispensing pharmacy;<BR/>e. <BR/>The quantity disposed;<BR/>f. <BR/>Method of disposition; <BR/>g. <BR/>Reason for disposition; and<BR/>h. <BR/>The signature of witnesses.<BR/>11. Completed medication disposition records shall be kept on file in the facility for at least two (2) years, or as mandated by state law governing the retention and storage of such records.

Based on observation, interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation in that:<BR/>The facility failed to dispose of and have procedures for handling drugs and biologicals according to federal, state, and local laws. <BR/>The facility failed to make sure that a resident's medications are returned to him/her to the new facility, or to the family, only if the attending physician approves it. <BR/>These failures could result in decreased medication effectiveness or increased risk of medication errors.<BR/>Finding include:<BR/>During observation on 02/18/2023 at 04:04 PM, LVN-R stated to the DON that there was a basket of keys in her office to the medication destruction box. The DON did not know where the drug destruction box was stating, at and stated, I literally do not know. <BR/>During an interview on 02/18/2023 at 04:30 PM, the DON stated she did not know where the drug destruction logbook would be and would be looking for it. She stated it should have been in her office previously along with the destroyed meds.<BR/>Record Review on 02/19/2022 of facility's medication disposition record revealed 3 months of documented logs (November, December, January). <BR/>During observation and interview on 02/23/2023 at 10:50, the RN-U of med with Med Cart #2 revealed:<BR/>2 bottles of nasal spray and 4 blister packs of hydrocodone 7.5-325, 234 tabs. This resident was transferred to another facility on 02/19/2023 . RN-U stated these meds had been discharged with no documentation in the narcotic book. <BR/>During an interview on 02/23/2023 at 11:50 AM, the Admin stated the facility had not previously had anyone to take the discharged medications from the carts. They are supposed to have turned them in to the DON but there had not been one. <BR/>During an interview on 02/23/2023 at11:52 AM, the DON stated, she is new to LTC and will only answer to what she thinks is right. She did not know how long the logs should be kept. If the Resident was transferred, all medications should had been sent with them. <BR/>During an interview on 02/23/2023 at 12:00 PM, Corporate Clinical Company Leader RN-H stated the current DON has had no orientation and the discharged meds should have gone with the resident when transferred. If the nurses did not send all medications with resident and had not discharged those medications with the proper paperwork, there could be a drug diversion. Corporate Clinical Company Leader RN-H stated the risk to residents was running out before the prescription is ready to be re-filled. Her expectations were for the residents to not go without their medication with the DON monitoring that. The staff failures were where the medications had not been monitored. <BR/>Record review of the facility policy Discarding and Destroying Medications revised 10/2014, revealed;<BR/>Policy Statement: Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances.<BR/>Policy Interpretation and Implementation <BR/> 3. Unless otherwise prohibited under applicable federal or state laws, individual resident medication supplied and sealed unopened containers may be returned to the issuing pharmacy for disposition provided that: <BR/>b. Oh such medications are identified as to what or control number; and<BR/>c. The receiving Pharmacist and the Registered Nurse employed by the facility sign a separate log that lists the residents name; the name, strength, prescription number (if applicable) and amount of the medication returned; and the date the medication was returned <BR/> 5. c. Disposal of controlled substances must take place immediately) no longer than three days) after discontinuation of youth by the resident <BR/> 10. The medication disposition record will contain the following information:<BR/>a. <BR/>The residents name; <BR/>b. <BR/>Date medication disposed;<BR/>c. <BR/> The name and strength of the medication; <BR/>d. <BR/>The name of the dispensing pharmacy;<BR/>e. <BR/>The quantity disposed;<BR/>f. <BR/>Method of disposition; <BR/>g. <BR/>Reason for disposition; and<BR/>h. <BR/>The signature of witnesses.<BR/>11. Completed medication disposition records shall be kept on file in the facility for at least two (2) years, or as mandated by state law governing the retention and storage of such records.

**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 time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 23 residents (Residents #23, #26, #36, #39, #53, and #62) reviewed for care plans in that:<BR/>1. The facility failed to define measurable objectives on Resident #23's care plan regarding the problems of resisting care, visual function, oral hygiene, pain, mobility, cognitive loss, and daily tasks.<BR/>2. The facility failed to define measurable objectives on Resident #26's care plan regarding the problems of psychotropic drugs, psychosocial well-being, pain, mood, behaviors, activities of daily living and daily tasks. <BR/>3. The facility failed to define measurable objectives on Resident #36's care plan regarding the problems of mobility and daily tasks and failed to address on Resident #36's comprehensive care plan the care areas of visual function and communication triggered on the MDS.<BR/>4. The facility failed to define measurable objectives on Resident #39's care plan regarding the problems of visual function, self-care deficits, decreased cognition, and daily tasks and the care areas of dental care and communication triggered on the MDS.<BR/>5. The facility failed to define measurable objectives on Resident #53's care plan in regard to the problems of daily tasks, pain, ADL function, and impaired cognition.<BR/>6. The facility failed to define measurable objectives on Resident #62's comprehensive care plan regarding the problems of self-care related to mobility and impaired cognition, and daily tasks.<BR/>These failures could affect residents and place them at risk for not having their needs and preferences met.<BR/>Findings included: <BR/>Resident #23<BR/>Review of Resident #23's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes mellitus (non-insulin dependent diabetes), heartburn, enterocolitis (inflammation of the colon), difficulty sleeping, high blood cholesterol, rapid heart rate, swelling, weakness, anxiety, absence of right and left legs below the knees, pancreatitis (inflammation of the pancreas), and high blood pressure. <BR/>Review of Resident #23's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #23 scored 99 indicating the resident was unable to complete the interview. Further review revealed the following care area triggered Section M - Skin Conditions, sub-section M1200. Skin and Ulcer/Injury Treatments: number 16. Pressure Ulcer/Injury indicated item B. Pressure reducing device on bed was selected. MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column revealed 16. Pressure Ulcer was selected.<BR/>Review of Resident #23's Quarterly MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score Resident #23 scored 15 out of 15 indicating cognition was intact. <BR/>Review of Resident #23's care plan reviewed/revised 01/27/25 revealed the following: <BR/>*Problem I resist care resisted taking medications/injections with an objective of I will make an informed choice about the benefits of care, options in care, and possible consequences/outcomes for resisting care. <BR/>*Problem visual function with an objective of Resident will have optimal visual acuity. <BR/>*Problem Oral/Dental Status with an objective of Maintain oral hygiene/status. <BR/>*Problem I am at risk for pain R/T my multiple comorbidities with an objective of I will be as comfortable as possible. <BR/>*Problem ADL Functional/Rehab Potential with an objective of I will achieve maximum functional mobility. <BR/>*Problem I have cognitive loss related to my diagnosis of anxiety with an objective of I will be as alert and oriented as possible. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an objective of The Resident will perform the following tasks at their highest practicable level. Approaches/Interventions included Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is days Once A Day on Mon, Wed, Fri; 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and Weekly skin Observations Flowsheet ADL Once Daily on Mon, Wed, Fri 06:00 AM - 06:00 PM.<BR/>Resident #26<BR/>Review of Resident #26's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of high blood cholesterol, cholecystitis (inflammation of the gall bladder), anxiety, difficulty sleeping, dementia, kidney disease, depression, high blood pressure, chest pain, heart failure, Type 2 diabetes (non-insulin dependent diabetes), ascites (fluid build-up in the abdomen), and constipation (inability to have a bowel movement) <BR/>Review of Resident #26's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #26 scored 11 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #26's care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem Psychotropic Drug Use with an unmeasurable objective of Benefit without side effects. <BR/>*Problem Psychosocial Well-Being with an unmeasurable objective of Resident will express/exhibit satisfaction. <BR/>*Problem I am at risk for pain related to aging process and dx of diabetes with an unmeasurable objective of Resident will be as comfortable as possible. <BR/>*Problem Mood State with an unmeasurable objective of Resident will express/exhibit satisfaction. <BR/>*Problem I have inappropriate verbal outbursts such as yelling out related to my dementia with an unmeasurable objective of I will be encouraged to communicate with the staff for my needs. <BR/>*Problem ADL Functional/Rehab Potential with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approaches/Interventions included Bowel Movement Every Shift; 1 SHIFT 1 06:00 AM - 06:00 PM, SHIFT 1 06:00 PM - 06:00 AM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, HS Snack At Bedtime; 06:00 PM - 06:00 AM, I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and The staff member who does my bath will document skin issues in the POC Once A Day on Mon, Wed, Fri 06:00 AM - 06:00 PM.<BR/>Resident #36<BR/>Review of Resident #36's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), dementia, depression, difficulty walking, pain, high blood pressure, weakness, heart failure, arthritis, paranoid schizophrenia, and swelling.<BR/>Review of Resident #36's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #36 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #36's care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem I have self-care deficits R/T impaired mobility and impaired cognition with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM.<BR/>Review of Resident #36's Care Area Assessment (CAA) list generated from the admission MDS, dated [DATE], revealed the following care areas triggered and selected in MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column, were not addressed on Resident #36's comprehensive care plan: Visual Function triggered by entry in MDS Section B Hearing, Speech, and Vision, sub-section B1000 Vision, Ability to see in adequate light (with glasses or other visual appliances) code 1. Impaired - sees large print, but not regular print in newspapers/books was selected and sub-section B1200 Corrective Lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision code 1. Yes was selected. Communication triggered by entry in MDS Section B Hearing, Speech, and Vision, Sub-section B0200 Hearing - Ability to hear (with hearing aid or hearing appliances if normally used) code 2. Moderate difficulty - speaker has to increase volume and speak distinctly was selected.<BR/>Resident #39 <BR/>Review of Resident #39's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of high blood pressure, dementia, Alzheimer's disease (a brain disorder that destroys memory and thinking skills), weakness, anxiety, high blood cholesterol, macular degeneration (an eye disease that affects central vision), and Vitamin D deficiency. <BR/>Review of Resident #39's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #39 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #39's care plan reviewed/revised 02/04/25 revealed the following:<BR/>*Problem I have decreased Visual Function and require glasses at times with an unmeasurable objective of Resident will have optimal visual ability. <BR/>*Problem I have deficits in self-care. ADL Function/Rehab Potential with an unmeasurable objective of Resident will achieve maximum functional mobility. <BR/>*Problem I have Cognitive Loss related to Dementia with an unmeasurable objective of I will be as alert and oriented as possible. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approach/Interventions included: Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is 6a-6p Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>Review of Resident #39's Care Area Assessment (CAA) list generated from the admission MDS dated [DATE] revealed the following care areas triggered and selected in MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column, were not addressed on Resident #39's comprehensive care plan: Dental Care MDS Section L - Oral/Dental Status, sub-section L0200. Dental A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) and D. Obvious or likely cavity or broken natural teeth were selected. Communication was triggered by entry in MDS Section B Hearing, Speech, and Vision, Sub-section B0200 Hearing - Ability to hear (with hearing aid or hearing appliances if normally used) code 1. Minimal difficulty - difficulty in some environments (e.g. when person speaks softly or setting is noisy) was selected.<BR/>Resident #53<BR/>Review of Resident #53's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), human immunodeficiency virus, myalgia (muscle pain), major depressive disorder, paranoid schizophrenia, chronic obstructive pulmonary disease (a group of lung diseases that cause airway obstruction), cardiac pacemaker, rapid heart rate, atrial fibrillation (irregular beating of upper chamber of the heart), heart failure, high blood cholesterol, cellulitis (bacterial infection affecting the skin and underlying tissues), respiratory disease, chronic leg ulcers, and hemorrhoids.<BR/>Review of Resident #53's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #53 scored 12 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #53's comprehensive care plan, reviewed/revised 12/05/24, revealed the following:<BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approach/Interventions included Bowel Movement Every Shift; SHIFT 1 06:00 AM - 06:00 PM, SHIFT 1 06:00 PM - 06:00 AM. <BR/>*Problem I am at risk for pain with the unmeasurable objective of I will be as comfortable as possible for the next 90 days. Problem ADL Functional/Rehab Potential with an unmeasurable objective of I will achieve maximum functional mobility . <BR/>*Problem I have impaired cognition r/t fluctuations in cognition with an unmeasurable objective of Resident will be as alert and oriented as possible . <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level . and Approach/Interventions of I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is 6a-6p Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, HS Snack At Bedtime; 06:00 PM - 06:00 AM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and weekly skin observation Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>Resident #62 <BR/>Review of Resident #62's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), dementia, depression, difficulty walking, pain, high blood pressure, weakness, heart failure, arthritis, paranoid schizophrenia, and swelling.<BR/>Review of Resident #62's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #62 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #62's comprehensive care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem I have self-care deficits R/T impaired mobility and impaired cognition with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>During an interview on 02/19/2025 at 2:30 PM, the MDS coordinator stated she was responsible for completing the initial comprehensive care plan and the DON and ADON were responsible for updating the care plans. The MDS coordinator stated her expectation was care plans should include resident's diagnosis, medications, diet, physician orders and any resident care needs. The MDS coordinator stated that objectives should be specific and measurable, and interventions should be a specific task for staff and/or residents that accomplishes objectives. <BR/>During an interview on 02/19/25 at 12:07 PM, the Regional Nurse Consultant stated her expectations of care plan were for the care plan to look like the resident. She stated if she were a nurse coming in to provide care, she would want to know what was documented on the care plan. The RNC stated if a resident needed assistance or was a fall risk for example, that information should be on the care plan. The RNC explained the objectives should be based on what a nurse would expect to assess when interventions were followed. She stated the DON was responsible for the initial care plan and the ADON/MDS Coordinator contributed to revisions based on the comprehensive assessment. The RNC stated the CAA's should be addressed on the comprehensive care plan. She stated the DON was ultimately responsible for the accuracy of the care plans. The RNC stated in response to an example of an objective for pain, the RNC stated she did not agree with use of a pain scale because pain was subjective data. She explained staff should be able to identify pain by a resident's facial expressions or behavior. The RNC stated she trained staff to recognize pain or discomfort by being observant.<BR/>Review of the facility policy titled Comprehensive Care Plans, undated, revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives . that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: item 2. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the care plan., and 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 of 3 residents (Resident #645) reviewed for accommodation of needed assistance, in that: <BR/>1. Resident #645 was observed in her room from the hallway and was wearing only a hospital gown and disposable brief.<BR/>2. The room call light was activated for staff assistance on behalf of Resident #645 at 10:50 AM. The MDS-RN entered Resident #245's room at 11:17 AM, 27 minutes after the call light was activated, and asked if the resident needed something. <BR/>These failures placed the resident at risk for physical exposure to the public and a delay in assessment for need and care assistance.<BR/>The findings included:<BR/>Review of Resident #645's Face Sheet, not dated, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: systemic lupus erythematosus (autoimmune disease where the body attacks itself); gastro-esophageal reflux disease without esophagitis (heartburn that burns the throat); rheumatoid arthritis, unspecified (autoimmune arthritis that affects the joints); chronic post-rheumatic arthropathy [Jaccoud] (problems with the joints due to rheumatic fever when younger); essential (primary) hypertension (high blood pressure); venous insufficiency (poor circulation of extremities); pain, unspecified; and generalized anxiety disorder. <BR/>Review of Resident #645's admission MDS Assessment, dated 2/13/23, revealed a BIMS had not been completed. The resident was assessed as having short-term and long-term memory problems, moderately impaired decision-making skills, required extensive assistance with transfers, and required supervision while eating.<BR/>Observation on 2/18/23 at 12:24 PM revealed the door was open to Resident #645's room. The resident was seated on the side of bed and was slumped over toward the right with her face down on the mattress. Resident #645 was wearing a hospital gown with the back open and a disposable brief. The resident's feet and legs were bare. A mattress was on the floor at the bedside. The room call light was laying on the mattress near the foot of the bed. No drinking water was observed in the room. Resident #645 responded to the knocking on the room door and her name being called. She was able to sit upright on the side of the bed. She did not have a roommate.<BR/>Observation on 2/18/23 at 3:46 PM revealed Resident #645 was seated in a wheelchair in her room. She was holding an empty plastic clothes basket on her lap. Resident #645 was alert, made eye contact, and was able to respond verbally to a simple greeting. She did not reply when asked why she was holding the empty clothes basket. The television was on in the room and was programmed to a channel with music videos. The resident was moving and swaying to the beat of the music.<BR/>Observation on 2/19/23 at 10:50 AM revealed Resident #645's room door was open to the hallway. The resident had spilled the ice water from her drink cup onto her bed and the floor mattress at the bedside. Her bare feet were in a puddle of ice water on the floor mattress. She was holding the empty drink cup and was trying to drink from it. She stated she would like to have some water. Resident #645 tried to stand up and her feet began sliding in the puddle of ice water. The surveyor intervened and asked her to sit on the side of the bed and wait until staff came to help her. The room call light was clipped to the end of Resident #645's hospital gown. She was unable to locate it and did not know how to activate it. The surveyor activated the call light in the resident's behalf. The light above the room door in the hallway lighted up. No staff were observed working in the hallway at that time.<BR/>Observation on 2/19/23 at 10:56 AM revealed Resident #645 continued to sit on the side of her bed, which was located near the room door. There was a privacy curtain against the wall, which was not used and allowed Resident #645 to be viewed from the hallway. The male resident in the room located diagonally across the hall was able to look directly into Resident #645's room and see her. <BR/>Observation on 2/19/23 at 11:03 AM revealed a male resident in a wheelchair propelled himself in the hallway toward his room located at the end of the hallway. He passed by Resident #645's room, where she remained seated on the side of her bed wearing a disposable brief and a hospital gown which was open in the back. Resident #645's room door was open, and she was visible to others passing by in the hallway. <BR/>Observation on 2/19/23 at 11:07 AM revealed a pair of gray colored sweatpants and a matching gray colored shirt were on top of the dresser in Resident #645's room. The resident consented for the surveyor to look inside her closet, where a cardigan sweater was hanging and two small plastic bags with a few items of personal clothes were on the floor. <BR/>Observation on 2/19/23 at 11:12 AM revealed Resident #645's room call light, which was activated at 10:50 AM, remained on and unanswered. Resident #645 continued to sit on the side of the bed and was tapping her empty drink cup.<BR/>Observation on 2/19/23 at 12:17 PM revealed MDS-RN came down the hallway with a male resident who wanted to show the RN his mattress. MDS-RN then went to Resident #645's room and asked if she needed something. MDS-RN asked her if she would like some more water and she stated, I would love some. The male resident from the room located diagonally across the hall entered Resident #645's room and gave her a can of cola flavored soda. Resident #645 opened the soda and started drinking it. MDS-RN instructed the Assistant ADM to fill the resident's drink cup with ice, which she did and brought to room. The drink cup was filled to the top with ice and did not contain any water. MDS-RN instructed the Administrative ADM to add water to the cup and she left the room with the drink cup. MDS-RN left the room and returned with bath towels. He wiped up the water on the floor mattress with towels and dried Resident #645's feet. MDS-RN took hold of Resident #645's hands and pulled her up to a standing position on the floor mattress. She was unsteady standing on the soft mattress. MDS-RN instructed the resident to shimmy to her left and to step off the end of the mattress to the floor. He instructed the resident to take a few steps and sit down in the armchair located a few steps away from the foot of her bed.<BR/>Observation on 2/20/23 at 12:20 PM revealed Resident #645 was seated in the armchair in her room. She was wearing a hospital gown and had bare feet. The resident was alert and was holding a spoon to feed herself the lunch meal. A Hospice nurse was in the room and was preparing to leave.<BR/>In an interview on 2/18/23 at 10:27 AM, the family members of Resident #645 stated the resident had end-stage lupus and was more confused now. The family stated Resident #645 was in the hospital and came to the facility about two weeks ago and was receiving Hospice care services. The family stated the facility seemed to be short staffed. They stated they had arrived one evening to visit about one week ago and there was food all over the floor in the resident's room. They stated the food was from the lunch meal. The family stated Resident #645 fed herself and her hand was not too steady and she spilled food while trying to eat. The family stated the resident was in her chair that morning and they had just assisted her into bed. The family stated Resident #645 wore a disposable brief and was currently soiled. They stated they did not change her brief and were on their way to the desk to tell the charge nurse. <BR/>In a telephone interview on 2/20/23 at 11:56 AM, Resident #645's representative stated the family had taken a few items of personal clothing to the resident. She stated she thought the Hospice aide put the hospital gowns on Resident #645 and she did not know why. The representative voiced concern that the resident no longer knew how to feed herself, needed assistance to eat and was not being fed by staff. She stated she thought the resident had lost weight.<BR/>In an interview on 2/20/23 at 12:22 PM, the Hospice RN stated the Hospice primary nurse came two times per week and the Hospice aide came two times per week. The RN stated Resident #645 refused to wear her own personal clothes and would not keep on non-skid socks or shoes. She stated the resident preferred hospital gowns. The RN stated Resident #645 can walk pretty good once she gets going. <BR/>Review of the State Ombudsman Long Term Care Nursing Facility Residents' Rights, dated November 2021, revealed the following [in part]:<BR/>Dignity and Respect<BR/>You have the right to:<BR/>o Live in safe, decent and clean conditions<BR/>o Be free from abuse, neglect and exploitation.<BR/>o Be treated with dignity, courtesy, consideration and respect.<BR/>o Keep and use personal property, and have it secured from<BR/>theft or loss.<BR/>o Choose and wear your own clothes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect the resident's right to be free from abuse and neglect for 4 of 4 residents (Resident #1, Resident #79, Resident #53, Resident #57) reviewed for abuse and neglect. <BR/>1. The facility failed to follow physician's orders to prevent Resident #1 who had an indwelling catheter received appropriate treatment and services to prevent a urinary tract infection and complications associated with an indwelling catheter. <BR/>2. The facility failed to follow physician's orders to prevent Resident #79's stage 4 pressure ulcer to his sacrum from developing osteomyelitis, and his right heel pressure ulcer to deteriorate from a stage 3 to a stage 4. <BR/>3. The facility failed to have sufficient staff with necessary competencies and failed to have interventions in place to provide resident care with aggressive with physical behaviors. R53 assaulted residents on multiple occasions on Station 2/Hall 6 (women secured locked unit), that led to resident injuries that required medical treatment. <BR/>4. The facility failed to have interventions in place to prevent Resident #57 from being abused by other residents on Station 2/Hall 2 (men secured locked unit), due to lack of staff with competencies to provide care with resident with aggressive behaviors int he locked unit. <BR/>An Immediate Jeopardy (IJ) was identified on 02/22/23. While the IJ was removed on 02/24/23, the facility remained out of compliance at a pattern of actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions.<BR/>These failures could place residents at risk of infections, worsening of wounds, injuries, emotional distress, and even death. <BR/>Findings include:<BR/>1. Resident #1<BR/>Record review of Resident #1 face sheet dated 02/20/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 11/20/2022 with the following diagnosis: Unspecified fracture of left shaft/femur, Non-ST elevation myocardial infarction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). <BR/>Review of Resident #1 physician orders dated 10/13/2022 revealed Foley Catheter: Size (10cc) FR (16) Diagnosis: Neurogenic bladder (lack bladder control due to brain, spine, or nerve problems)<BR/>Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: May obtain urine sample via Foley Catheter Port as needed when a Urine Analysis is ordered. (If Foley Catheter has been in place greater than 14 days, change Foley Catheter before obtaining urine.) <BR/>Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: Provide catheter care every shift. <BR/>Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: Change catheter and drainage bag as needed for indications of blockage, increased sediment, infection, displacement as needed.<BR/>Record review of Resident #1 Discharge MDS Section C dated 09/19/2022 revealed in Section H (bladder and bowel) that she was frequently incontinent, 7 or more times episodes of incontinent, but 1 episode of continent). <BR/>Record review of Resident #1 Quarterly MDS dated [DATE] revealed in Section C (Cognitive Patterns) a BIMS Score of 15 indicating no cognitive impairment and in Section H (bladder and bowel) that resident had an indwelling catheter. <BR/>Record review of Resident #1 electronic care plan accessed on 02/20/2022 revealed the following: Problem - Resident #1 has Indwelling Foley Catheter: Goal - Resident will not show signs of urinary infection or urethral trauma. Interventions - Change catheter every per MD order, document urinary output; record the amount, type, color and odor, observe for leakage, keep catheter system a closed system as much as possible, position bag below level of bladder, provide catheter care as scheduled and PRN. Problem- Resident #1 has a urinary tract infection. Goal- resident will not exhibit signs of a urinary tract infection. Interventions- Administer Bactrim DS (antibiotic), encourage fluids, keep perineal area clean and dry and report signs or UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back pain/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine and blood in urine). Initiated date of 10/15/2022 and revised date of 01/31/2023.<BR/>Record review of Resident #1 most recent significant change MDS Section C dated 01/30/2023 revealed she had the ability to express ideas and wants and was able to understand others clearly. Resident #1 had a BIMS of 14 out of score of 15 which indicated an intact cognition. Resident #1 was extensive assistance for activities of daily living (ADL) except for eating where she required supervision.<BR/>Record review of Resident #1 significant change MDS on 01/30/2023 revealed Resident #1 had an indwelling catheter reported in section H: Bladder and Bowel. <BR/>Observation and interview on 02/18/2023 at 10:15 AM, Resident #1's catheter bag was full and overflowing with urine and backflowing up the tubing. The catheter bag was leaking on the floor. Resident reported that it had not been drained in 2 days. The resident's urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. <BR/>Observation and interview on 02/18/2023 at 10:16 AM, with the DON present Resident #1's catheter tubing and bag was visualized. The DON said that the thick cloudy substance in the resident's catheter bag and tubing appeared to be a puss like substance. She said that she was going to have it changed immediately. <BR/>Interview on 02/18/2023 at 1:20pm, DON stated indwelling catheter bags should always be covered. She also stated catheter bags that are full of urine backflowing in the catheter tubing placed the resident at risk for infections. She stated she did not know the reason for Resident #1's overflowing catheter bag with urine backflowing into the catheter tubing.<BR/>Observation on 02/18/2023 at 3:58pm, Resident #1 continued to have an indwelling catheter with an overfilled catheter bag with urine backflowing in the catheter tubing. The bag continued to be leaking urine onto the floor. The urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. This observation was reported to the Corporate Regional Resource Nurse-J.<BR/>Observation and interview on 02/19/2023 at 8:35 am, Resident #1's catheter bag had been emptied; however, the Foley catheter and tubing had not been changed and was observed to be crusted with sediment and puss like substance visible in the tubing. There was a trash bag on the floor under the uncovered catheter bag. Resident #1 stated that the trash bag was placed to catch leaking urine from the catheter bag.<BR/>Interview on 02/19/2023 at 9:45 am, RN-V stated she had not gone to Resident #1's catheter bag to check if it had been drained or changed during previous day's shift. She reported it was delegated to her, but she was busy and had not had a chance to do it. <BR/>Interview on 02/19/2023 at 10:02 am, Corporate Regional Resource Nurse-J-J stated she had instructed RN-V to change Resident #1's catheter bag. She stated that RN-V reported that it had been changed. She collected a UA sample while changing it and would notify the physician. She stated that the catheter should have been changed due to the sediment. She said that she could see where there was an issue for concern. <BR/>Interview on 02/19/2023 at 11:04 am, DON stated she asked LVN-O and RN-V to change Resident #1's catheter, tubing and bag yesterday afternoon. She could not remember the exact time, but it was after lunch. She said she went back to Resident #1's rooms yesterday afternoon and it continue to not be completed. She then asked them again to complete the task. She stated this failure placed the residents at risk for an infection.<BR/>Interview on 02/19/2023 at 3:10pm, RN-V said she did not change Resident #1's catheter tubing but only changed the bag. She said she obtained a urine sample for an ordered UA from the catheter tubing that continued to have sediment and puss like substance but not from the bag. <BR/>Interview and observation on 02/19/23 03:15 PM, Corporate Regional Resource Nurse-J-J stated she instructed RN-V to change Resident #1's entire catheter on 02/18/2023.<BR/>Observation and interview on 02/19/2023 at 11:20 am, Resident #1 was speaking with surveyor without any distress. <BR/>Observation on 02/19/2023 at 2:57 pm, with Corporate Clinical Company Leader RN-I present, Resident #1 was observed unresponsiveness with emesis on chest . Corporate Clinical Company Leader RN-I stated she had to check Resident #1's pulse because she wasn't sure if she was alive. <BR/>Interview on 02/19/2023 about 3:00pm, Resident #56 (Resident #1's roommate) said Resident #1 received her lunch tray about 12:00 pm and almost immediately started to throw up. Resident #56 then called for help, but no one came until about 2:00 pm. Resident #56 said she told the staff that Resident #1 needed assistance, the staff was Assistant Administrator in Training who removed Resident #1's tray and stated, I can't help you and left the room. <BR/>Review of Resident #56's quarterly MDS dated [DATE] revealed Section C Cognitive Patterns BIMS Score of 15 indicating no cognitive impairment.<BR/>Observation on 02/19/2023 at 3:25pm, Resident #1 was transferred to a local hospital via EMS.<BR/>Interview on 02/19/2023 at 4:34pm, the DON said she looked at Resident #1's catheter yesterday (02/18/2023) and it appeared to have puss and sediment in the catheter tubing and catheter bag entry hub. She said it was her expectation that it was to be changed. She made an additional request for the catheter to be changed this morning by RN-V. DON stated she discovered Resident #1 left the facility (to the hospital) without a changed catheter tubing but only a changed catheter bag. It was her expectation that it was changed yesterday. <BR/>Interview on 02/20/2023 at 3:57pm, CNA-Z stated Resident #1 had puss in her catheter tubing when she drained the catheter bag and performed incontinent care about 2 weeks ago. She stated she notified RN-V of the puss in resident's catheter tubing at that time. <BR/>Interview on 02/20/2023 at 04:04 PM, Resident #56 (Resident #1's roommate) said she pressed the call light frequently and it takes a while to answer. She said the lady who came to answer the call light after two hours had long dark hair and was part of administration but did not work the floor. Resident #56 (Resident #1's roommate) said that this staff went to the Resident #1 and said Oh, My God, when she saw the resident. Resident #56 (Resident #1's roommate) said that the staff stated she could not help Resident #1 and left the room. Resident #56 (Resident #1's roommate) said she thought the staff was coming back but never did. Resident #56 (Resident #1's roommate) said she could hear Resident #1 throwing up and gurgling. Resident #56 (Resident #1's roommate) said no one changed their catheters. She said yesterday (02/19/2023) the staff just changed the bag. Resident #56 (Resident #1's roommate) said the regional nurse did in fact tell the nurse to just change the bag until she got caught up and that she could change it later. Resident #56 (Resident #1's roommate) said it was the same nurse who told her in Spanish to butt out and put her hand to her mouth as in telling her to hush and she cut her eyes. <BR/>Interview on 02/20/23 04:34 PM, RN-V stated while in Resident's room that she was short of staff 02/19/2023 and behind. She said when the regional nurse came, she told her to change the catheter bag only. She said she was often short staffed or without staff and can do what she can do. She said she is trying hard and stays for the residents.<BR/>Interview on 02/21/2023 at 4:46 PM, with Resident #1's Family Members A and B revealed when they would come to see her, she would look malnourished, and her catheter bag was always full. <BR/>Record review of Resident #1's vital reports, dated 02/21/2023, provided by Corporate Clinical Leader RN-H revealed no evidence of catheter care, drainage of catheter bag and amount of urine obtained during drainage on 48 occasions between 01/18/23 and 02/19/23. <BR/>Record review of Resident #1's hospital record History and Physical dated 02/19/2023 at 8:48pm, revealed the following physician's notes- We sent her to the ICU Again, clinically it just seems to be a very ill patient, who was sent from the nursing home for an honestly a bogus reason at this point. At any rate from what I can gather she had left sided weakness from a prior stroke, but today currently it seems like she is not moving the right side, so we will get MRI of the brain. She does have a UTI in her labs, which will be treated. <BR/>Record review of Resident #1's hospital records dated 02/19/2023 revealed Resident #1 was admitted into the hospital's ICU with diagnosis of UTI & rule out stroke.<BR/>Record reviewed on Resident #1's hospital records labs, assessment and plan dated 02/19/2022 revealed, Resident #1 had a primary diagnosis of Urinary Tract Infection, with orders to check cultures, place her on ceftriaxone (antibiotic) <BR/>Record review of Resident #1's hospital records dated 02/21/2023 revealed Resident #1 had a diagnosis of Sepsis (A life threatening complication or infection. Sepsis occurs when chemicals released in the bloodstream to fight an infection throughout the body. This can result in multi organ system failure and even death). <BR/>Records review of Resident #1's hospital records dated 02/21/2023 Assessment and Plan revealed:<BR/>1. UTI in the setting on chronic indwelling foley catheter. Urine culture grew E coli. Blood cultures grew gram positive cocci. Start IV Vancomycin and Rocephin for empiric treatment. <BR/>2. Bacteremia: Blood culture grew gram positive cocci. Start IV Vancomycin (antibiotic) and Rocephin (antibiotic) for empiric treatment.<BR/>2. Resident #79 <BR/>Review of Resident #79's electronic Face Sheet dated revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis (infection of the bone caused by bacteria), pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus (inflammatory disease caused when the immune system attacks its own tissues causing fatigue and pain), major depressive disorder, dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), dependence on supplemental oxygen, chronic atrial fibrillation (irregular heart beat), Methicillin resistant Staphylococcus aureus (certain type of bacteria resistant to treatment by many common antibiotics), and Type 2 diabetes mellitus .<BR/>Review of Resident #79's admission MDS dated [DATE] revealed:<BR/>Section C: Cognitive Patterns BIMS Score of 15 indicating no cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated one Stage 3 pressure ulcer present upon admission and one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar present upon admission.<BR/>Review of Resident #79's Quarterly MDS dated [DATE] revealed:<BR/>Section M: Skin Conditions indicated two Stage 4 pressure ulcers present upon admission, and one Unstageable pressure ulcer that was not present upon admission.<BR/>Review of Resident #79's Care Plan last revised 1/30/23 revealed: <BR/>Problem: Resident has a pressure ulcer to sacrum r/t immobility. Goal: Resident's ulcer will heal without complications. Approach: use cushion provided by family for pressure reduction when resident is in chair; conduct a systematic skin inspection daily during treatment ; Problem: Pressure Sores/Skin Care. Goal: Prevent/Heal pressure sores and skin breakdown. Approach: follow facility skin care protocol; preventative measures use cushioned boots for heels while in bed as tolerated, off load heels while in bed; report to charge nurse any redness or skin breakdown immediately; treatment as ordered; turn and reposition every 2 hours and PRN; Problem: Resident has a pressure ulcer to right heel r/t immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection. Approach: . conduct a systematic skin inspection during treatment .<BR/>Review of Resident #79's electronic orders revealed:<BR/>Multivitamin plus Minerals 1 tablet by mouth daily (start date 11/15/22)<BR/>Left heel cleanse with ns or wound cleanser and apply sure-prep two times daily for preventative (start date 11/25/22)<BR/>Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved (start date 11/25/22)<BR/>Cleanse right heel with normal saline or wound cleanser, apply sure-prep to heel two times daily for preventative (start date 11/25/22)<BR/>Ascorbic acid (vitamin c) 500mg 1 tablet by mouth daily (start date 11/29/22)<BR/>Pro-Stat AWC (amino acids-protein hydrolys) 17-100 gram-kcal/30ml give 30ml by mouth twice a day (start date 11/29/22)<BR/>Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved (twice a day - PRN, morning, bedtime) (start date 11/29/22)<BR/>Cleanse right heel with normal saline or wound cleanser apply anasept to wound and secure with a bordered dressing daily (start date 12/29/22)<BR/>Use cushioned boots while in bed as tolerated (start date 1/3/23)<BR/>Ertapenem 1 gram intravenously daily for 42 days r/t osteomyelitis (start date 1/13/23 end date 2/24/23)<BR/>Site 1: Sacrum<BR/>Review of Resident #79's Wound Management Wound History dated 11/15/2022 at 8:08 am revealed: Pressure Ulcer to Sacrum present on admission.<BR/>Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed:<BR/>Stage 4 Pressure Wound Sacrum Full Thickness measured 1.7cm in length by 0.7cm in width with 1.2cm in depth.<BR/>Review of Resident #79's Wound Care Physician Progress Note dated 01/12/2023 revealed:<BR/>The histology report from the biopsy of the sacrum taken on 01/05/2023 indicates acute osteomyelitis.<BR/>Review of Resident #79's physicians orders dated 11/25/2022 revealed:<BR/>Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved. <BR/>Review of Resident #79's physicians orders dated 11/29/2022 revealed:<BR/>Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved.<BR/>Review of Resident #79's Treatment Administration Record from November 2022 to February 2023 revealed no evidence of treatments on 12/02/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023<BR/>Review of Resident #79's electronic record revealed no evidence of reposition every 2 hours and as needed and conduction of systematic skin inspection daily between 11/25/2022 and 12/29/2022.<BR/>Site 2: Right Heel<BR/>Review of Resident #79's Wound Management Detail Report dated 11/15/2022 at 8:11am by LVN-AE revealed: Stage 3 pressure ulcer to right heel measured 0.3cm in length by 0.3cm in width with 0.1cm in depth.<BR/>Review of Resident #79's Wound Management Wound History dated 11/25/2022 at 7:33am revealed: Pressure Ulcer to right heel present on admission and healed.<BR/>Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Unstageable due to necrosis (death of cells in body tissues) of the Right Heel measured 1cm in length by 1.1cm in width with no measurable depth. <BR/>Review of Resident #79's Wound Care Physician Progress Notes dated 12/29/2022 revealed deterioration to a Stage 4 Pressure Wound of the Right Heel.<BR/>Review of Resident #79's Wound Management Wound History dated 12/29/2022 at 2:31am revealed: Pressure Ulcer to right heel present on admission.<BR/>Review of Resident #79's Wound Management Detail Report dated 02/23/2023 at 7:11pm by Corporate Clinical Company Leader RN-I revealed: Stage 4 Pressure Ulcer to right heel measured 0.5cm in length by 0.6cm in width with unmeasurable depth. The wound had necrotic tissue type.<BR/>Review of Resident #79's skin assessment records revealed no evidence of systematic skin inspection during treatment between 11/25/2022 and 12/29/2022.<BR/>During an observation on 02/20/23 at 3:25 PM of Resident #79's wound care revealed RN-V completed wound care with the assistance of MDS-RN and LVN Q. RN-V failed to change gloves after removing sacrum dirty wound dressing and beginning to apply treatment and clean dressing to sacrum. RN-V also failed to perform hand hygiene before applying new gloves to begin treatment to right heel. Following the treatment, RN-V was unable to be located for an interview.<BR/>Interview on 2/24/23 at 4:48 PM, LVN-Q stated wound care with Resident #79 on 2/20/23 performed by RN-V went badly. She stated she did not see RN-V wash hands or use sanitizer at any time before or during the dressing changes, but she did see her change her gloves in between each wound. LVN-Q stated that was not the correct procedure for hand hygiene during wound care and could lead to recontamination of the wound. She stated that RN-V was feeling overwhelmed but that was not an excuse. She stated that it was just overall not good. <BR/>In an interview on 2/21/23 at 11:35 AM, Corporate Clinical Company Leader RN-H stated Resident #79 was admitted to facility on 11/15/22 with stage 3 to sacrum and stage 3 to right heel and that both wounds were documented on admission. Corporate Clinical Company Leader RN-H stated that in her investigation of the Resident #79's chart, it appeared that the wound care/treatment nurse at the time documented the right heel wound was healed on 11/25/22 even though the wound was never healed. She stated the right heel wound was re-identified as a stage 4 on 12/29/22. She stated that because the wound was documented as healed it went one month without treatment or observation leading to it decline to a stage 4. She stated that Resident #79's sacral wound was a stage 3 on admission but had declined to a stage 4. She stated the documentation stating the wound was improving even with the presence of osteomyelitis was strictly referring to the wound bed appearance from her understanding. Corporate Clinical Company Leader RN-H stated the resident was diagnosed with osteomyelitis at the site of the sacral wound by the wound care physician. She stated the staff was supposed to do skin sweeps weekly to check wounds and get measurements and the wound care doctor saw residents weekly as well. The staff did their checks on the residents that the doctor did not see. The measurements were documented in the wound management section of the chart. Corporate Clinical Company Leader RN-H stated wound care was documented on the treatment administration record only unless something was wrong or there were changes. If there was something different with a wound, she stated a prudent nurse would document in a focused observation note or progress note what was observed, notify the doctor of the change in the resident's condition, then document that the doctor was notified. She stated the wound care physician's progress notes were uploaded into the resident's EMR electronically and that he was able to put his own orders in remotely. She stated if someone did transcribe orders for him it would be the nurse who did rounds with him while he was in the building seeing residents, normally the wound care/treatment nurse when the facility had one or the DON. If the resident was a new admission and the wound care physician was giving orders, the admitting nurse would be responsible for transcribing the orders and verifying everything was in the resident's chart correctly. Corporate Clinical Company Leader RN-H stated when an order was put into the facility's charting program it went directly onto the MAR. She stated during the morning meeting, the staff should have been going over all new orders received to make sure all orders had been signed and verified and that nothing had been missed during rounds. Corporate Clinical Company Leader RN-H stated all information regarding wounds had been provided or would be found in focused observation notes.<BR/>In an interview on 02/22/23 at 09:57 AM , LVN-AE the former wound care nurse for the facility, stated that on weekends RN-V would not do wound care for the residents on Station 1. When LVN-AE would ask RN-V why it was not being done, RN-V would say it was because she would be frustrated and that she was one person and could not get them (treatments) done. LVN-AE did not understand why because RN-V always had a med aide, so that would have left her free to do the treatments. LVN-AE stated that the wounds would have the same dressing on them on Monday that she put on the residents on Friday. LVN-AE stated she worked Monday through Friday as the treatment/wound care nurse. LVN-AE reported RN-V to the DON and the former Administrator, then later reported it to Regional Nurse Consultant and others who no longer work for the company. She was told by all of them that they would talk to RN-V. LVN-AE stated it never got corrected. LVN-AW felt the residents did not receive wound care as ordered by the physician when she was not in building. LVN-AE stated that every Thursday the wound care physician would see residents but by the time he arrived, she had a week to make them look better, so he did not make comments that the residents' wounds were worse. LVN-AE stated she got conflicting information from DON's regarding skin assessments. LVN-AE stated at first, she would do skin assessments on wound care residents, then was told the nurses were supposed to do skin assessments and she was only supposed to do the wound management (measurements, wound descriptions). LVN-AE said she left the facility because the facility was not willing to change and hold RN-V accountable for wound care, and she was afraid of losing her license due to the wounds in the facility.<BR/>In an interview on 2/22/23 at 10:25 AM, LVN-P stated since the wound care nurse quit whoever was working the floor was responsible for wound care for the residents. She stated typically, there was a charge nurse and a med nurse on the day shift, and they helped each other out with the residents. LVN-P stated Station 1 had 6 residents getting wound care at that time. When wound care was done, she stated she only signed off on the TAR and she never put a progress note in just to state the wound care had been done. She stated if there were changes to the wound it was documented in a progress note, the doctor was notified, she would notify the family and continue the treatment or write orders if any new orders were given. She stated a nurse always rounded with the wound care doctor when he saw the residents. She stated he was in the facility weekly, and she rounded with him last week because there was no one else to do it. LVN-P stated until the facility hired a new wound care nurse, she believed the DON was going to take over rounding with him.<BR/>In an interview on 2/22/23 at 10:49 AM, Corporate Clinical Company Leader RN-H stated that she was not aware skin assessments were not being done accurately and treatments were not being done until surveyors arrived at the facility. She stated the facility was currently in the process of revising their wound care program to address wound care management, assessments, treatments, and care planning issues the facility had been experiencing.<BR/>In an interview on 2/23/23 at 11:35 AM, the Wound Care Physician stated that his expectation was that his orders would be followed and the wound care for the residents would be done. Wound Care Physician stated that if a resident's wound care was not done as ordered over the weekend that when he came to the facility on Thursday, the wounds would have time for improvement by the time he saw them again if the treatments were started back up on Monday. He stated he did rounds with the floor nurses when he saw the residents.<BR/>3. Resident #53 <BR/>Record review of Resident #53's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. She resided on Station 1 Hall 6 which was a Woman's secured unit (the average age of the women residents on Station 1 Hall 6 was 76 years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness; epilepsy and epileptic syndromes with seizures of localized onset; restlessness and agitation; post-traumatic stress disorder; repeated falls; muscle weakness (generalized); insomnia due to other mental disorder; major depressive disorder; anxiety disorder; dysphagia (difficulty in swallowing), altered mental status; pain; adult sexual abuse. <BR/>Record review of Resident #53's Quarterly MDS, dated [DATE], revealed the BIMS score was blank indicating inability to obtain a Brief Interview for Mental Status; Section E: Behavior indicated no psychosis, presence of physician behavior symptoms directed toward others, significant risk for physical illness or injury on self and others, rejection of care, wandering that places resident at significant risk of getting to a potentially dangerous place and intrusion on privacy of activity of others.<BR/>Record review of Resident #53's Care Plan, last edited on 02/13/23 revealed: Problem: I have periods of time where I am in constant motion/movement. Problem: I get frustrated because of my physical condition and may reach out to grab or hit others. Goal. To not hit other residents. Approach. Patient placed on 1:1 observation for at least 72 hours to prevent injury to others, will keep her separated from arms reach from other residents, put gloves on resident to prevent any injury if she reaches out. Problem: I have anxiety related to anoxic brain injury as evidence by I fidget constantly, grab at others, lick my hands and rub it on things and people, sit to stand frequently, stand up rapidly and attempt to walk with no regards to surroundings. Problem: Behavioral Symptoms - licking her hands and trying to touch others, invading others space, grabbing at others, sitting and or lying-in other residents' beds when they are not in them. Goal. Resident will have less than 5 bad outcomes due to grabbing at people and toward staff or other residents over the next 90 days. Approach: 15-minute checks, I will have increased supervision due to my behavior or grabbing at things and swinging my arms, I rest better with a quiet calm environment at night, Problem: Falls. Approach. Ordered an oversize bean bag for positioning. <BR/>Review of Resident #53's electronic record from April 2022 to February 2023 revealed no evidence of documented 15-minute checks and no evidence of physician's order for 1:1 level of supervision.<BR/>Record review of Resident #53's transfer documentation packet, faxed on 04/19/2022 from previous facility revealed: resident required a locked facility that has more supervision and brain training support. On 04/21/22, Resident #53 was transferred from a sister facility requiring 1:1 supervision due to being threat to herself and others.<BR/>Record review of Nurse Practitioner progress not[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 8 residents (Resident #53) reviewed for freedom from physical restraints, in that:<BR/>The facility failed to obtain consent, physician's order, and care plan for Resident #53's gait belt in which staff restricted her freedom of movement and was not required to treat her medical symptoms.<BR/>This failure could put residents at risk of unnecessary restriction of their freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control). <BR/>Findings include:<BR/>Record review of the State Operations Manual Appendix PP, (Rev. 208, 10-21-22), F604 defined Physical restraint as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria:<BR/>o Is attached or adjacent to the resident's body;<BR/>o Cannot be removed easily by the resident; and<BR/>o Restricts the resident's freedom of movement or normal access to his/her body.<BR/>Resident #53 <BR/>Record review of Resident #53's electronic face sheet, dated 02/23/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. She was being housed on the women's secured unit (the average age of the residents was 76 years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness; epilepsy and epileptic syndromes with seizures of localized onset; restlessness and agitation; repeated falls; muscle weakness (generalized); insomnia due to other mental disorder; major depressive disorder; anxiety disorder; and pain.<BR/>Record review of Resident #53's Quarterly MDS, dated [DATE], revealed the BIMS score was blank. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. None of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavior symptoms directed towards others - behavior of this type occurred 1 to 3 days, B. Verbal behaviors symptoms directed towards others - behavior not exhibited, C. Other behavioral symptoms not directed towards others - behavior of this type occurred 1 to 3 days. E0900: Wandering - 1 (Behavior of this type occurred 1 to 3 days). Section G: Functional Status. G0300: Balance during transitions and walking: A. Moving from seated to standing position - 1 (not steady, but able to stabilize without human assistance). B. Walking (with assistive device is used) - 1 (Not steady, but able to stabilize without human assistance). Section P0100: Physical Restraints: Not used. <BR/>Record review of Resident #53's Care Plan, last edited on 02/13/23 revealed: Problem: I have periods of time where I am in constant motion/movement. Problem: I get frustrated because of my physical condition and may reach out to grab or hit others. Goal. To not hit other residents. Approach. Patient placed on 1:1 observation for at least 72 hours to prevent injury to others, will keep her separated from arms reach from other residents, put gloves on resident to prevent any injury if she reaches out. Problem: I have anxiety related to anoxic brain injury as evidence by I fidget constantly, grab at others, lick my hands and rub it on things and people, sit to stand frequently, stand up rapidly and attempt to walk with no regards to surroundings. Problem: Psychosocial Well-Being: Approach: I like to go outside or sit in my bean bag. Sometimes I wear gloves to keep me from harming others when they get into my vicinity. Sometimes I am medicated so I do not harm myself or others. Falls. Approach: Ordered an oversize bean bag for positioning. Problem: Skin. Approach: Preventative Measures, use gait belt with handles to help me walk. <BR/>In an observation and interview on 02/14/23 at 11:00 am, Resident #53 was observed with a gait belt around her waist. Resident #53 was sitting in a chair and was constantly attempted to stand up, CNA-JF was observed grabbing with her hand the back loop of the gait belt, pulling Resident #52's back down into her chair restricting her movement. CNA-JF stated the staff used the gait belt to control Resident #53's movements. <BR/>In an observation and interview on 02/14/23 at 11:30 am, the Administrator in Training was sitting 1:1 with Resident #53. The Administrator in Training utilized the gait belt to pull Resident #53 back down in her chair, restricting her movement when she attempted to approach other residents, and restricted her movement while she was crawling on the floor by pulling backwards on the gait belt. The Administrator in Training stated she had not received any training on dealing with aggressive residents. She said that gait belt was used to direct Resident #53. <BR/>In an observation on 02/15/23 at 9:30 am, the Interim DON was observed 1:1 with Resident #53. She was utilizing the gait belt to control the movements of Resident #53. <BR/>In an observation on 02/15/23 at 3:50 pm, the Interim DON was 1:1 with Resident #53. She was observed utilizing Resident #53's gait belt to restrict and control her movement while she was walking and crawling on the floor by pulling back on the gait belt to redirect her from other residents. <BR/>In an interview with the Interim DON and the Corporate Regional Resource Nurse-J on 02/15/23 at 11:00 AM, the Interim DON said she did not consider Resident #53's gait belt a restraint. She said it was being used as an assistive device to keep Resident #53 from falling so there was no need for a physician's order, consent, or care plan addressing the gait belt. When she was informed about observations of staff restricting Resident #53's movements, she said she would consult therapy about the use of the gait belt. The Interim DON said she would obtain consent, update the MDS and the Care Plan. <BR/>In an interview with the Corporate Regional Resource Nurse-J on 02/15/23 at 3:11 pm, she stated consent for the use of the gait belt was obtained on this date.<BR/>In an interview on 02/16/23 at 3:00 pm, the Director of Rehab said Resident #53 was admitted to the facility with a gait belt. She stated she considers Resident #53's gait belt as an enabler to be used for guidance to keep the resident from falling. She did not agree that pulling on the gait belt forcing a resident in their chair would be consider a restraint. She stated, I guess we have a different way of looking at it, but to me it is not a restraint. She stated she had not personally evaluated the resident for a gait belt but would do so. <BR/>In an interview on 02/15/2023 at 5:04 PM, the Corporate Clinical Company Leader RN stated Resident #53's Representative gave consent for the gait belt with loops to be used out of bed. <BR/>In an observation on 02/16/23 at 11:50 am, TNA-BM was observed utilizing Resident #53's gait belt to restrict her movements by moving her away from other resident's multiple times. <BR/>In an observation and interview on 02/16/2023 at 3:00 pm, TNA-LA was observed multiple times pulling on Resident #53's gait belt restricting her movements. She stated we were told by Administration to use the gait belt to keep Resident #53 away from the other residents. <BR/>In an interview on 02/22/23 at 11:45 AM, the Corporate Clinical Company Leader RN, stated there was no consent for the use of a gait belt for Resident #53. She said the Interim DON got verbal consent from the Resident #53 Representative on 02/15/23 and the form was sent by mail. <BR/>A record review of Resident #53's progress note, dated 09/18/22, revealed Resident constantly bucking in wheelchair with gait belt used to assist staff in returning resident to wheelchair when she attempts to take off walking with her highly unsteady gait.<BR/>Record review of Resident #53's electronic health record, accessed on 02/14/23, revealed there was no physician's order, no consent, and no care plan for using the gait belt as a restraint or redirection. <BR/>Record review of the facility policy Abuse Prevention Program, dated as revised 01/09/2023, revealed the following [in part]:<BR/>Policy Statements:<BR/>2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. <BR/>During interview on 02/24/2023 at 7:00pm, Interim Administrator, Corporate Survey Resource Personnel, Corporate Regional [NAME] President of Operations, and two (2) Corporate Clinical Company Leader RNs did not provide a requested policy for restraints as requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to thoroughly investigate, prevent further potential abuse when allegations of abuse was made for 7 of 7 Residents (Resident #53, Resident #6, Resident #9, Resident #15, Resident #40, Resident #43, and Resident #74) that resided on Station 2/Hall 6 (women's secure locked unit). <BR/>1. The facility failed to thoroughly investigate and prevent further potential abuse involving Resident's #43, #53, #74 that resulted in injuries to Resident's #43 and #53 on 12/03/22.<BR/>2. The facility failed to thoroughly investigate and prevent further potential abuse involving Resident's #40, #53 that resulted in an injury to Resident #40 on 12/21/22. <BR/>3. The facility failed to thoroughly investigate and prevent further potential abuse involving Resident's #9 and #53 that resulted in an injury to Resident #9 on 12/21/22.<BR/>4. The facility failed to thoroughly investigate and prevent further potential abuse involving Resident's #40, #53 and #74 that resulted in an injury to Resident #53 on 01/26/23.<BR/>5. The facility failed to thoroughly investigate and prevent further potential abuse involving Resident's #15 and #53 on 11/26/22.<BR/>6. The facility failed to thoroughly investigate and prevent further potential abuse involving Resident's #6 and #53 to prevent on 12/20/22.<BR/>This failure could place the residents who resided on Station 2/Hall 6 (women's secured unit) at risk of serious injury and emotional distress.<BR/>Findings include:<BR/>Resident #53 <BR/>Record review of Resident #53's electronic face sheet, dated 02/23/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. She was being housed on the women's secured unit (the average age of the residents on the women's secure unit was 76 years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness; epilepsy and epileptic syndromes with seizures of localized onset; restlessness and agitation; post-traumatic stress disorder; repeated falls; muscle weakness (generalized); insomnia due to other mental disorder; major depressive disorder; anxiety disorder; dysphagia (difficulty in swallowing), altered mental status; pain; adult sexual abuse; and victim of crime and terrorism. <BR/>Record review of Resident #53's Quarterly MDS, dated [DATE], revealed the BIMS score was blank. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. None of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavior symptoms directed towards others - behavior of this type occurred 1 to 3 days, B. Verbal behaviors symptoms directed towards others - behavior not exhibited, C. Other behavioral symptoms not directed towards others - behavior of this type occurred 1 to 3 days. E0900: Wandering - 1 (Behavior of this type occurred 1 to 3 days). <BR/>Record review of Resident #53's Care Plan, last edited on 02/13/23 revealed: Problem: I have periods of time where I am in constant motion/movement. Problem: I get frustrated because of my physical condition and may reach out to grab or hit others. Goal. To not hit other residents. Approach. Patient placed on 1:1 observation for at least 72 hours to prevent injury to others, will keep her separated from arms reach from other residents, put gloves on resident to prevent any injury if she reaches out. Problem: I have anxiety related to anoxic brain injury as evidence by I fidget constantly, grab at others, lick my hands and rub it on things and people, sit to stand frequently, stand up rapidly and attempt to walk with no regards to surroundings. Problem: Behavioral Symptoms - licking her hands and trying to touch others, invading others space, grabbing at others, sitting and or lying-in other residents' beds when they are not in them. Goal. Resident will have less than 5 bad outcomes due to grabbing at people and toward staff or other residents over the next 90 days. Approach: 15-minute checks, I will have increased supervision due to my behavior or grabbing at things and swinging my arms, I rest better with a quiet calm environment at night. <BR/>Record review of Resident #53's transfer documentation packet, faxed on 04/19/2023 from previous facility revealed: resident required a locked facility that has more supervision and brain training support. On 04/21/22, Resident #53 was transferred from a sister facility requiring 1:1 supervision due to being threat to herself and others.<BR/>Record review of Nurse Practitioner progress note, dated 06/10/22, revealed Resident #53 was transferred from other facility due to not being able to continually provide the 1:1 care and attention that she requires.<BR/>Record review of Social Worker progress note, dated 09/12/22 at 5:27 pm, revealed: SW expressed to Family Member J, facility is not able to meet resident needs and SW will need to talk with Family Member J regarding plans to transition resident to another facility. <BR/>Record review of Social Worker progress note, dated 10/01/22 at 10:33 am, revealed: SW expressed to Family Member J, facility is not able to meet resident needs.<BR/>Resident #43 <BR/>Record review of Resident #43's face sheet in the electronic medical record, accessed on 02/14/22 revealed a [AGE] year-old female whose most recent admission date was 10/14/22 to the female secured locked unit with diagnosis to include: Alzheimer's Disease, schizoaffective Disorder (a mental health condition), and hypertension (high blood pressure).<BR/>Record review of Resident #43's Significant Change in Status MDS dated [DATE], revealed her BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E0800 Rejection of care: behavior did not occur. Section E0900 Wandering - behavior did not occur. <BR/>Record review of Resident #43's Care Plan revealed the following problems and approaches: Problem: (start date 08/23/21) I have a history of aimless wandering increasing safety concerns. 12/03/22 Behavior from another resident. Goal: I will have less than 2 episodes of wandering into others space over the next 90 days. Approaches: I will be redirected if I walk up to someone and invade their personal space, I will be redirected as needed when wandering to prevent me from going into an unsafe area, I will reside in the secured unit. Problem: for elopement- (start date 01/11/23). Goal - Resident will not wander out of designated secure area over the next 90 days. Approach: Secure Unit Placement. Secure unit evaluation quarterly and PRN, elopement assessment quarterly and PRN Risk related to Alzheimer's /dementia.<BR/>Resident #74 <BR/>Record review of Resident #74's Face Sheet document in the electronic medical record accessed on 02/14/22 revealed an [AGE] year-old female whose most recent admission date was 01/06/23 to the female secured locked unit with diagnosis to include: fractured left hip, osteoporosis (disease that makes the bones brittle), history of falling, Alzheimer's Disease, and major depressive disorder.<BR/>Record review of Resident #74's Annual MDS dated [DATE], revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E0800 Rejection of care: behavior did not occur. Section E0900 Wandering -behavior did not occur. <BR/>Record review of Resident #74's Care Plan revealed the following problems and approaches: Problem: At risk for elopement - (start date 01/11/23). Goal: Resident will be kept safe in surroundings. Approaches: continuous placement in secure unit, elopement assessment quarterly and nail care weekly. Problem: Behavioral symptoms - resident exhibits verbal and physical aggression when other residents invade her space and surroundings. Goal: Resident will not show behaviors of aggression. Approaches: Remove and provide a quiet place, staff will encourage rapport with other residents, staff will encourage redirection when resident exhibiting bouts of verbal/ physical aggression, I will have increased supervision until reviewed by psych services., I will be assisted to a quiet place when things become too loud for me, Keep environment calm and relaxed. <BR/>1. Record review of facility investigation on 12/03/22 at 3:53 pm, Resident #53 slapped the face of Resident #43, and Resident #74 retaliated. A record review of the Provider Investigation Report revealed Resident #43 was sitting in the recliner minding her own business and for no reason Resident #53 slapped Resident #43 in the face. This in turn upset Resident #74 who scratched Resident #53 on the arm. Resident #43 had slight redness noted to the left side of her face. Resident #53 had several scratch marks to her upper right arm. Resident #53 was placed on increased supervision with staff. The facility failed to determine the root cause of the incidence, identify the incident as abuse, and determine corrective action to prevent a reoccurrence. <BR/>Record review of Resident #53's progress note dated 12/03/22 at 4:39 am by LVN-AB, revealed Resident #53 had multiple behaviors throughout the evening and night. Grabbing at residents. Attempting to remove snacks from other residents. Walking on knees and crawling on the floor. Attempting to hit and kick staff during care. Removing clothes and brief and walking down hall. Walks to exit door of secured unit 1 and slaps and then tries to open locked door. No evidence of documentation that resident was on 1:1 supervision included in the note.<BR/>Record review of Resident #53's progress note dated 12/03/22 at 3:53 pm by LVN-T, revealed Resident #53 hit another resident (not identified) across the face. <BR/>Record review of Resident #53's progress note dated 12/03/22 at 5:46pm by LVN-T, revealed another resident was yelling get away, get away. Resident #53 hit another resident in the face and the other resident scratched at Resident #53's upper arm. Residents were separated. Resident #53 then went toward another resident and attempted to hit her, but the LVN intervened. (Other residents were not identified.) <BR/>Record review of Resident #53's progress note dated 12/03/22 at 6:05 pm by LVN-AC, revealed Resident #53 was on 1:1 supervision. <BR/>Record review of Resident #53's progress note dated 12/03/22 at 6:43pm, LVN-T documented in Resident #53's progress notes per DON, resident to be 1:1. If no staff available to be 1:1 then resident can be on Q (every) 15-minute checks.<BR/>Record Review of Resident #53's progress note dated 12/03/22 at 10:15 pm by LVN-AC, revealed Resident #53 was on 15-minute checks. <BR/>During an interview on 02/17/23 at 9:45 am, the Interim Administrator stated she could not provide documentation of who was working on the women's secured unit at that time or documentation of 15-minute checks. She failed to address how to prevent future actions of recurrence by Resident #53 and how to protect the residents on the secured units.<BR/>Resident #40 <BR/>Record review of Resident #40's electronic face sheet accessed on 02/14/22 revealed a [AGE] year-old female whose most recent admission date was 01/06/23 to the female secured locked unit with diagnosis to include: fractured left hip, osteoporosis (disease of bone that makes them brittle), history of falling, Alzheimer's Disease, and major depressive disorder.<BR/>Record review of Resident #40's Annual MDS dated , dated 01/11/23, revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E 0800 Rejection of care: behavior did not occur. Section E 0900 Wandering - behavior did not occur. <BR/>Record review of resident #40's Care Plan revealed the following problems and approaches: Problem: Mood state - start date 01/06/23 resident exhibits socially inappropriately disruptive behavioral symptoms. Resident wanders about without direction and becomes physically aggressive (hitting, kicking etc.) when she gets near other residents or staff in her path as well as being hit by resident's she provokes with her unwanted behavior. Goal: Resident will not harm self or others secondary to socially inappropriate, disruptive behavior of opportunistically hitting or kicking residents who get in her pathway or reach while she wanders. Approach: Assess whether the behavior endangers the resident or others. Intervene, if necessary, by moving resident to a safe area, to wander, avoid over stimulation (noise, crowding and other physically aggressive residents, when resident begins to reach for, hit, kick, or grab others, provide for basic needs pain, hunger toileting, too hot/cold etc. Problem: behavioral symptoms: (start date 09/09/22) I pace up and down the halls frequently with no regards to others in my path. 08/01/22 I walked up behind another resident and got hit in the stomach. 08/17/22 I pushed another resident in the hallway while I was pacing up and down the hall. 08/26/22 I hit another resident in the face while walking in the hallway. 12/04/22 Hit by another resident. Goal: I will have less than 3 episodes of physical aggression with other people in my path over the next 90 days. Approaches: I will be redirected to least crowded areas when pacing. I will have increased monitoring and a referral to a behavioral center.<BR/>2. Record review of facility investigation on 12/21/22 at 11:25 am, Resident #53 scratched Resident #9 on the forehead. A record review of the Provider Investigation Report revealed, Resident #9 was sitting in a chair when Resident #53 approached her and brushed Resident #9 on her forehead, causing a small 2cm X 1cm scratch. The facility stated Resident #53 did not intend to hurt Resident #9 as both residents were acting per their norm. The facility failed to determine the root cause of the incidence, identify the incident as abuse, and determine corrective action to prevent a reoccurrence. <BR/>Record review of Resident #53's progress note, dated 12/21/22 at 5:35 am by LVN-AB, revealed resident #53 had multiple behaviors throughout the shift, including crawling on the floor, pulling and trying to remove the keypad cover, attempting to open doors, removing pants and brief and walking naked in the hallway, pulling a sign off the door, grabbing at residents and attempting to take their snacks, refusing evening medications, and attempting to climb in bed with another resident. Resident received Diazepam 15mg and it was documented it was not effective. <BR/>Record review of Resident #53's progress notes, dated 12/21/22 at 12:09 pm by LVN-R, revealed Resident #53 scratched another resident in the face. Resident also attempted to grab and hit the nurse. <BR/>Resident #9 <BR/>Record review of Resident #9's Annual Assessment MDS, dated [DATE], revealed Resident #9 was admitted to the facility on [DATE]. Diagnosis included dementia, depression, and psychotic disorder (a mental disorder characterized by a disconnection from reality). Resident #9 had a BIMS score of 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E 0800 Rejection of care: behavior did not occur. Section E 0900 Wandering - behavior did not occur. <BR/>3. Record review of facility investigation on 12/21/22 at 1:52 pm, Resident #53 reached out her arm causing a skin tear to Resident #9. A record review of the Provider Investigation Report revealed, Resident #53 was ambulating in the hallway and reached out grabbing Resident #9's arm causing a small 1cm X 2cm skin tear to her forearm. Review of the report revealed it is normal for Resident #53 to reach out and grab objects and people within reach. The facility failed to determine the root cause of the incidence, identify the incident as abuse, and determine corrective action to prevent a reoccurrence. <BR/>Record review of a progress note, dated 12/21/22 at 9:40 pm by LVN-S, revealed Resident #53 was non-stop agitated and should have been on 1:1 observation. Resident #53 scratched and pulled the hair of the LVN on duty. Upon discussion with the ADON, Resident #53 was to be monitored until further notice. Record review revealed no documentation of resident being placed on 1:1 observation. <BR/>4. Record review of facility investigation on 01/26/23 at 7:00 pm, Resident #53 made contact with Resident #40's face and Resident #74 retaliated. A record review of the Provider Investigation Report revealed, Resident #40 walked to close to Resident #53 who flailed her hands making contact with Resident #40's face. Resident #74 intervened and scratched Resident #53 on her elbow. The scratch was visible. Resident #53 was placed on 1:1 observation until she went to sleep. <BR/>Record review of Resident #53's progress note dated 01/26/23 at 7:00 pm by LVN-AB revealed, an unknown resident was sitting in a chair watching TV when Resident #53 walked past the unknown resident and hit her on the jaw with a closed fist. <BR/>Record review of Resident #53's progress note dated 01/26/23 at 7:10 pm by LVN-AB revealed, Resident #53 walked past resident #40 and attempted to slap her. Resident #74 grabbed Resident #53's right elbow causing a 1.5cm X 0.5cm superficial scratch. Resident #53 was already currently on 1:1 monitoring. <BR/>Resident #15 <BR/>Record review of Resident #15's electronic face sheet, dated 02/23/23, revealed an [AGE] year-old female who latest return to the facility was on 11/17/22. She was being housed on the women's secured unit until she moved to a non-secured area of the facility on 01/09/23. Diagnosis included: unspecified dementia with behavioral disturbance, schizoaffective disorder (a mental illness), other lack of coordination, need for assistance with personal care, abnormalities of gait and mobility, and insomnia. <BR/>Record review of Resident #15's Significate Change in Status Assessment MDS, dated [DATE], revealed the BIMS score was blank. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E 0800 Rejection of care: behavior did not occur. <BR/>Record review of Resident #15's Care Plan, last reviewed/revised on 02/15/23 revealed: Problem: I have behavioral symptoms of verbal and physical aggression. Goal: Will not hit others or be hit by other residents. Approach: I do not like a lot of noise; I prefer to remain in my room most of the time where it is quiet. Problem: Falls - I have a history of falls as evidence by while walking in the dining room another resident pushed Resident #15 causing her to fall on the floor. Problem: I have aggressive behaviors at times. <BR/>5. Record review of facility investigation on 11/26/22 at 4:00 pm, Resident #53 pulled the hair of Resident #15 and Resident #74 retaliated. A record review of the Provider Investigation Report revealed, Resident #74 was in the hallway when Resident #53 attempted to hit her, Resident #74 hit Resident #53 on the arm. Resident #15 was sitting at the dining room table and Resident #53 came up and pulled Resident #15's hair. Resident #53 was placed on 15-minute checks. The facility failed to determine the root cause of the incidence, identify the incident as abuse, and determine corrective action to prevent a reoccurrence. <BR/>Record review of Resident #53's progress note dated 11/26/22 at 3:50 pm by RN-U, revealed Resident #53 was walking in the dining room and pulled Resident #15's hair. Resident #74 hit Resident #53 on the right arm after she pull Resident #15's hair. No documentation that Resident #53 was placed on 15-minute checks. <BR/>During an interview on 02/17/23 at 9:45 am, the Interim Administrator stated she could not provide documentation of who was working on the women's secured unit at that time or documentation of 15-minute checks. <BR/>Resident #6 <BR/>Record review of Resident #6's electronic face sheet accessed on 02/14/22 revealed an [AGE] year-old female whose most recent admission date was 12/20/21 to the female secured locked unit with diagnosis to include: Alzheimer's Disease, macular degeneration (deterioration of the retina of the eye that causes vision loss), and hypertension (high blood pressure).<BR/>Record review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. Other behavioral symptoms not directed toward others - behavior not exhibited. E0800 Rejection of care - behavior did not occur, E0900 Wandering - behavior occurred 1-3 days. <BR/>Record review of Resident's #6's Care Plan dated 11/02/22 revealed the following problems and approaches: At risk for elopement - (problem start date 01/12/23) Requires secure unit placement. Attempted to take out of the secure unit. She started to wander aimlessly throughout all halls and rooms placing her at risk for other residents becoming aggressive towards her. Goal: Resident will be safe throughout her surroundings for 90 days. Approaches: Secure unit placement evaluation quarterly and prn. Elopement assessment quarterly and prn, Problem: (start date 01/05/23) Resident has physically abusive behavioral symptoms. Resident was hit by another resident and in return hit the other resident several times in defense. Goal resident will not harm self or others secondary to physically abusive behavior. Approach: avoid over stimulation, noise, crowding, and other physically aggressive residents), Avoid power struggles with resident, divert resident's behavior by encouraging resident to move to another common area away from distraction and other potentially aggressive residents who might provoke an unwanted response from resident #6 such as aggression, maintain a calm environment and approach<BR/>6. Record review of a facility investigation report on 12/20/22 at 1:15 pm, Resident #53 reached out towards Resident #6 and Resident #6 reached out toward #53 swiping her in the face. A record review of the Provider Investigation Report revealed, Resident #53 unknowingly/unintentionally reached out (per her norm) toward Resident #6 brushing her face, in return Resident #6 swatted at Resident #53 in reaction and was instructed to not do that anymore. No injury noted. The facility failed to determine the root cause of the incidence, identify the incident as abuse, and determine corrective action to prevent a reoccurrence. <BR/>Record review of Resident #53's nursing progress note dated 12/20/22 at 3:07 pm, revealed Resident #53 was in the dining room reaching out towards Resident #6. Resident #6 slapped Resident #53 in the face on the right cheek. No injury. Residents were separated. <BR/>In an interview on 02/14/23 at 9:00 AM, the Interim DON stated she called Resident #53's responsible family member earlier this morning to discuss her behavior and the need to transfer her to another facility as they were not able to care for her. She stated Resident #53 was a harm to herself and harm to others. She said the Social Worker was going to (work on it). <BR/>In an observation on 02/14/23 at 11:00 am, Station 2/Hall 6 had 6 residents with known behaviors with CNA-E was observed on the hall and a rehab staff who left shortly after arrival. <BR/>In an interview on 12/14/23 at 11:00 am, CNA-E said she worked 6am to 6pm and worked 12 hours by herself on the women's secured unit, with 1 resident requiring 1:1 supervision. A staff member would come in every 2 hours to check on her. She said she did not feel safe working alone and was unable to prevent resident to resident altercations. <BR/>In an interview on 02/14/22 at 3:00 pm, the Corporate Regional Resource Nurse-J, said on January 10th, 2023, the facility moved 3 residents off of the Women's Secured Unit and moved 1 CNA to the general population. She stated I move staff to where they are needed, there were less residents on the women's locked secure unit after I moved the residents off the unit, therefore we needed less staff. I'm not cutting staff no matter what they tell you. They might tell you they are short staffed, but they are not. She had there was an aid that went to the unit whenever the CNA needed to give a resident a bath. When asked about how staff calls for help, she said staff can use their personal cell phone to call for help. <BR/>In an interview on 02/15/23 at 9:15 am, CNA-E stated there was not enough staff to provide adequate supervision for the residents on the female locked unit. She stated it was not safe with one person in the unit. She stated that the acuity was high due to behaviors, but Administration says that it was not. She said that Administration had told her that she sits the residents too close together, but she had nowhere for the residents to be as the unit was small. She said that during meals she was often by herself on the unit. She sat Resident #53 next to her because Resident #53 constantly required assistance and redirection. <BR/>In an interview on 02/15/23 at 11:00 am, with the Interim DON and Corporate Regional Resource Nurse-J, the Interim DON stated she talked to the Social Worker and Administrator earlier that same morning and told them they were not equipped to deal with Resident #53's behaviors. She stated, We are not a behavior unit, can we deal with these behaviors, yes, but it requires 1:1, 2:1, and sometimes even 3:1. The Interim DON stated that 1 staff on the Women's Secured Unit was enough as the residents are a low acuity level and just custodial care, and the census was 6 residents. The Interim DON defined acuity level as medical needs only and stated she did not consider behaviors when determining a resident's acuity. <BR/>In an interview on 02/15/23 at 4:00 pm, the Social Worker stated she has been employed at the facility since April 2022 and came on after Resident #53 was admitted . She stated she had told the responsible family member the facility was not able to meet her needs due to her behaviors, but she had not found a facility that would accept her. She stated she had not documented her attempts to find alternate placement for Resident #53. She stated due to the facility's continual documentation of behaviors, the facilities she contacts reject her. She stated had tried the state school, MHMR, state hospital, and all refused. When asked for documentation of the referrals, she was not able to produce any documentation that referrals had been completed.<BR/>In an interview on 02/16/23 at 11:40 am, CNA-E stated: It's not safe for the other residents with only one CNA working on the women's locked unit alone and there's always only one CNA scheduled. There has been 2 CNAs for the last few days only because the state surveyors are in the building. CNA-E said, we tell the DON all the time that we don't feel safe, and we need at least 2 CNAs back there, but they don't listen to us, and we're told to work it out. We have had some training, but no training ever received on how to provide care for residents who are aggressive or residents that have behavior problems.<BR/>On 02/16/23 at 4:00 pm, CNA-AA stated there have been issues with Resident #53's behavior for a long time as she hit, scratched, bit, and kicked staff and residents. <BR/>Record review of the facility policy Resident-to-Resident Altercations, dated as revised December 2016, revealed the following [in part]:<BR/>Policy Statement: All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator.<BR/>Policy Interpretation and Implementation: <BR/>1. Facility staff will monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator.<BR/>2. If two residents are involved in an altercation, staff will:<BR/>A. Separate the residents, and institute measures to calm the situation;<BR/>B. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation;<BR/>C. Notify each resident's representative and Attending Physician of the incident; <BR/>D. Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents; <BR/>F. Make any necessary changes in the care plan approaches to any or all of the involved individuals;<BR/>G. Document in the resident's clinical record all interventions and their effectiveness;<BR/>J. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident.<BR/>Record review of the facility policy, Abuse Prevention Program, dated as revised June 2021, revealed the following [in part]:<BR/>Policy Statements:<BR/>2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. <BR/>4. Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property that is appropriate and effective, as determined by staff need and the Center assessment. <BR/>9. All occurrences of abuse, neglect, mistreatment, injuries of unknown source and theft or misappropriation of resident property will be analyzed by the Quality Assurance and Performance Improvement (QAPI) Committee to determine if system changes need to be made.<BR/>Response: Treatment/Managemen[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that each resident who experiences a significant change in status is comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process for 1 of 44 sampled residents (Residents #86) whose records were reviewed for significant change.<BR/>Resident #51 had no Significant Change Assessment completed after her admission to hospice.<BR/>This failure could contribute to providing an inaccurate assessment of resident's most current medical condition and could lead to failure to not provide necessary care. <BR/>Findings include:<BR/>Resident #51<BR/>Review of Resident #51' electronic Face Sheet revealed she was a [AGE] year-old female admitted to the facility 7/27/22. She had diagnoses which included chronic respiratory failure with hypoxia, chronic atrial fibrillation, Type 2 diabetes mellitus, hypertension, morbid obesity, depression, urinary tract infection, and gastro-esophageal reflux disease.<BR/>Review of Resident #51's admission MDS assessment dated [DATE] revealed that she scored a 15 out of 15 on her mental status exam indicating she was cognitively intact, and she showed no signs of delirium. She had no reported behaviors. She required at least one person assistance with all ADLs except eating. She used a wheelchair for mobility. She was always incontinent of bowel. She had been on a scheduled pain medication regimen in the last 5 days, but she denied pain at the time of the assessment. It was documented that she had received oxygen therapy prior to admission and after admission to the facility.<BR/>Review of Resident #51's Quarterly MDS assessment dated [DATE] revealed she scored a 15 out of 15 on her mental status exam indicating she was cognitively intact and showed no signs of delirium. She had no reported behaviors. She required extensive assistance or was totally dependent on staff with all ADLs except eating. She used a wheelchair for mobility. She was frequently incontinent of bowel. She had been on a scheduled pain medication regimen and had received PRN pain medication. She reported pain at the time of the assessment and occasionally at a rating of 4/10. Her use of oxygen was not documented in the assessment.<BR/>Review of Resident #51's orders revealed:<BR/>Admit to X Hospice under the care of Dr. X (start date 1/11/23)<BR/>In an interview on 2/22/23 at 1:02 PM MDS-LVN stated that Resident #51 was admitted to the hospital on [DATE] and came back to the facility on 1/10/23. She stated that at first it was unclear whether she admitted back to the facility already on hospice or admitted back into the facility and then was admitted to hospice because of some of the paperwork from the hospital. Once it was clarified, it was determined that she was admitted back to the facility and then admitted to hospice. Resident #51 was hospitalized for 7 days, and MDS-LVN stated she opted to only do the MDS Entry Tracking and not do a full quarterly assessment because she was going into hospice. She stated she decided not to do the significant change assessment either because the hospice admission was within 24 hours of her retuning to the facility. MDS-LVN stated at the time that Resident #51 returned to the facility she had already signed the hospice paperwork but had not been formally admitted as hospice, but her (MDS-LVN) understanding that if the resident was admitted to hospice outside of the facility that the significant change did not count for the facility, and she was not required to do a significant change assessment. She stated that she was the only nurse in the facility doing MDS assessments at that time and she was responsible for all residents MDSs and most care plans. She stated that the workload was very heavy, and it was too easy to miss things on the assessments. <BR/>In an interview on 02/23/2023 at 10:54 AM MDS-LVN stated On all of the care plans we have just not been following the MDS Schedules, and we know that we are supposed to, I did not do significant changes when the residents went to the hospital, psychiatric facilities, or had other changes, I should have, I was just overwhelmed there was so many care plans and MDSs.<BR/>In an interview on 02/23/2023 at 10:54 AM MDS-RN, he acknowledged that significant changes should have been done for several residents and the MDS schedule had not been followed. He stated, I signed off on all of the Care Plans we just have so many that I was overwhelmed. <BR/>The facility did not provide a written policy regarding resident assessment. MDS-LVN stated she referred to MDS 3.0 RAI Manual provided by CMS for instructions on how and when to complete assessments.<BR/>Review of CMS'S RAI Version 3.0 Manual version 1.17.1 dated October 2019 revealed:<BR/>The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that<BR/>(1) the assessment accurately reflects the resident's status<BR/>(2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals<BR/>(3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.<BR/>Nursing homes are left to determine<BR/>(1) who should participate in the assessment process<BR/>(2) how the assessment process is completed<BR/>(3) how the assessment information is documented while remaining in compliance with the requirements of the Federal regulations and the instructions contained within this manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete an assessment that accurately reflected the resident's status for 3 of 44 sampled residents (Residents #1, Resident #40, Resident #79) whose records were reviewed for MDS accuracy, in that:<BR/>The facility failed to ensure Resident #1's MDS accurately reflected weight changes and falls.<BR/>Resident #40's MDS dated [DATE], 07/06/2022 and 10/05/2022 did not reflect the resident's weight accurately.<BR/>Resident #79's MDS did not accurately reflect his dependence on dialysis or his chronic pain.<BR/>These failures could place residents at risk for not receiving care and services to meet their needs.<BR/>Findings include:<BR/>Resident #1<BR/>Record review of Resident #1 face sheet dated 02/20/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 11/20/2022 with the following diagnosis: Unspecified fracture of left shaft/femur (upper leg bone), Non ST elevation myocardial infraction (heart attach due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). <BR/>Record review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed on Section K a weight of 199; whereas Resident #1's significant change Minimum Data Set (MDS) dated [DATE] revealed on Section K a weight of 126 and on K0300 Weight Loss was no reported for a weight loss of 5% or more in the last month and 10% more for the last 6 months.<BR/>Record review of Resident #1 Quarterly Minimum Data Set (MDS) dated [DATE] revealed in section J1700 that the resident had a fracture fall prior to admission. J1900 number of falls since admission or prior assessment was not coded in any area. J2100 was checked yes recent surgery requiring SNF care. <BR/>Record review of Resident #1 most recent significant change Minimum Data Set (MDS) dated [DATE] revealed she had the ability to express ideas and wants and was able to understand others clearly. Resident #1 had a Brief Interview for Mental Status (BIMS) of 14 out of score of 15 which indicated an intact cognition. Resident #1 was extensive assistance for activities of daily living (ADL) except for eating where she required supervision.<BR/>Resident #40 <BR/>Record review of Resident #40's electronic face sheet accessed on 02/14/2022 revealed a [AGE] year-old female whose most recent admission date was 1/06/2023 to the female secured locked unit with diagnosis to include: fractured left hip, osteoporosis, history of falling, Alzheimer's Disease, and unspecified protein calorie malnutrition (a condition that occurs when you do not consume enough protein and calories).<BR/>Record review of Resident #40's Annual MDS dated , dated 01/11/2023, revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of MDS, revealed: Section G: Functional Status indicated one-person physical assistance for supervision for eating; Section K Swallowing/Nutritional Status indicated no signs and symptoms of possible swallowing disorder and weight of 144 lbs., no weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. <BR/>Record review of Resident #40's weight records revealed the following: <BR/>-on 8/26/2022 the resident weighed 144 pounds <BR/>-on 01/02/2023, the resident weighed 111 pounds. <BR/>-on 02/03/2023, the resident weighed 110 pounds<BR/>Resident #79<BR/>Review of Resident #79's electronic Face Sheet dated revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis, pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus, major depressive disorder, dependence on renal dialysis, dependence on supplemental oxygen, chronic atrial fibrillation, Methicillin resistant Staphylococcus aureus, and Type 2 diabetes mellitus.<BR/>Review of Resident #79's admission Assessment MDS dated [DATE] revealed: Section C Cognitive Patterns BIMS score of 15 indicated cognitively intake; Section O Special Treatment and Programs indicated oxygen therapy and dialysis prior to admission and since being admitted to the facility; and Section V Care Area Assessment for pain was not triggered on this assessment.<BR/>Review of Resident #79's Quarterly MDS assessment dated [DATE] revealed: Section C Cognitive Patterns BIMS Score of 11 indicating moderate cognitive impairment; Section O Special Treatment and Programs indicated oxygen therapy and IV medications in the facility, and Section V Care Area Assessment indicated no triggered areas. Resident #79's dialysis was not documented on the Quarterly MDS Assessment. Section V: No CAAs were marked as triggered or addressed in care plan on this assessment.<BR/>Review of Resident #79's physician orders revealed: Hemodialysis performed M-F in-house dialysis suite between 0900-0930. Once a Day on Monday, Tuesday, Wednesdays, Thursdays, Fridays.<BR/>In an interview on 02/18/23 at 12:16 PM, MDS-LVN stated that Resident #1's weight loss on the last MDS was coded wrong and should have been a coded as a significant weight loss in Section K0300. She stated this failure could place the resident at risk for not having her needs met due to not accurately coding an assessment. When asked if Resident #1's recent hospital stay and return should have been a significant change assessment, she stated that, yes, it should have. She stated she did not realize that it had been done as a quarterly. MDS-LVN contacted her regional nurse who told her that all hospital stays where there is a decline should have a significant change MDS assessment done upon the resident's return to the facility. The MDS-LVN stated this failure could place the resident at risk for inadequate assessments due to not triggering Section V for a comprehensive assessment, which results in the care plan not being updated. <BR/>In an interview on 2/22/23 at 11:30 AM the MDS-LVN stated she was the only nurse in the facility doing MDS assessments. She stated Section K of Resident #40's Annual MDS dated [DATE] was not accurate. She stated a weight of 144 pounds should have been documented as a significant weight gain. She stated she was responsible for completing all resident's MDS, and most of the care plans. She stated that the error occurred because the workload was so heavy, and it was too easy to miss things on the assessments and care plans. She stated she was responsible for the accuracy of the MDS. She stated an inaccuracy on the residents MDS could lead to the resident not receiving necessary care and services.<BR/>In an interview on 2/22/23 at 1:02 PM MDS-LVN stated that Resident #79's dialysis was not checked on quarterly MDS by mistake, she had the dx code written down she just forgot to check the box. She stated that CAAs are triggered by how questions in the MDS are answered, the pain questions for Resident #79 should have triggered the pain CAA, she was not sure why it did not, especially with his diagnoses. She stated that she was able to manually trigger CAAs for residents when she was completing an assessment and if she had noticed that the CAA for pain had not triggered for Resident #79, she would have done it herself. She stated that she was the only nurse in the facility who did MDS assessments at that time and she was responsible for all residents' MDSs and most care plans. She stated that the workload was very heavy, and it was too easy to miss things on the assessments. She stated that the other CCM did some care plans, but he did not have any MDS experience, so they all fell to her to complete. She stated that the inaccuracies on Resident #79's assessment could result in his care plan not being up to date which could lead to him not receiving proper care.<BR/>In an interview on 2/24/23 at 4:47 PM, MDS-LVN stated she referred to MDS 3.0 RAI Manual provided by CMS for instructions on how and when to complete assessments. The facility did not provide a written policy regarding resident assessment.<BR/>Review of CMS'S RAI Version 3.0 Manual version 1.17.1 dated October 2019 revealed:<BR/>The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that<BR/>(1) the assessment accurately reflects the resident's status<BR/>(2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals<BR/>(3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.<BR/>Nursing homes are left to determine<BR/>(1) who should participate in the assessment process<BR/>(2) how the assessment process is completed<BR/>(3) how the assessment information is documented while remaining in compliance with the requirements of the Federal regulations and the instructions contained within this manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission for 1 of 2 residents (Resident #645) reviewed for new admission baseline care plans, in that: <BR/>1. A baseline care plan was not developed for Resident #645 within 48 hours following her admission to the facility on 2/04/23. <BR/>2. Resident #645's representative was not notified regarding the development and implementation of the baseline care plan.<BR/>The facility's failure placed the resident at risk for not receiving necessary basic care and services to meet her needs following her admission to the facility.<BR/>The findings included:<BR/>Review of Resident #645's Face Sheet, dated 2/23/2023, revealed a [AGE] year-old female admitted to the facility on [DATE] (Saturday). The resident's diagnoses included: <BR/>- systemic lupus erythematosus (autoimmune disease where the body attacks itself) <BR/>- gastro-esophageal reflux disease without esophagitis (heartburn that burns the throat) <BR/>- rheumatoid arthritis, unspecified (autoimmune arthritis that affects the joints)<BR/>- chronic post-rheumatic arthropathy [Jaccoud] (problems with the joints due to rheumatic fever when younger)<BR/>- chronic viral hepatitis B without delta-agent (viral disease of the liver)<BR/>- essential (primary) hypertension (high blood pressure) <BR/>- heart failure, unspecified (failure of the heart to function properly)<BR/>- venous insufficiency (poor circulation of extremities)<BR/>- nicotine dependence<BR/>- pain, unspecified <BR/>- generalized anxiety disorder. <BR/>Review of Resident #645's care plan history revealed a care plan dated 2/04/23 for an actual fall had been initiated by MDS-LVN. A comprehensive care plan was dated as initiated on 2/07/23. There was no documented evidence of a baseline care plan being developed and implemented.<BR/>Review of Resident #645's admission MDS Assessment, dated 2/13/23, revealed the resident was assessed as not having any falls prior to admission or since being admitted to the facility.<BR/>Review of Resident #645's electronic health record progress notes revealed no documented evidence the resident had an incident of falling following admission to the facility on 2/04/23.<BR/>Review of the Care Conference Report, dated 2/06/23, revealed the staff who attended were the RN and LVN Clinical Case Managers, Social Worker, and Activity Director. There was no documented evidence that the resident or resident's representative were included or had participated in the conference. The Care Conference report documented IDT meeting about resident. Up for discussion were diet, health problems, medications, as well as diagnosis, the fact that she is on Hospice, current weight was 165 lbs.<BR/>In a telephone interview on 2/20/23 at 11:39 AM, Resident #645's representative stated she had not been invited to a care plan conference with the staff. <BR/>In an interview on 2/22/23 at 11:47 AM, MDS-LVN stated she and the MDS-RN completed the baseline care plans for the new admission residents. When asked about Resident <BR/>#645's baseline care plan being completed and only having a care plan dated 2/04/23 for an actual fall, MDS-LVN stated the resident did fall. When asked about the remainder of Resident #645's baseline care plan, and the comprehensive care plan dated 2/07/23 being completed prior to the admission MDS Assessment on 2/13/23, MDS-LVN did not reply.<BR/>Review of the facility's policy and procedures Care Planning and Care Plan Workflow, not dated, revealed the following [in part]:<BR/>Baseline/admission Care Plan<BR/>The Baseline care plan is added on all new admissions or re-admissions discharged greater than 30 days. The Baseline care plan is to be completed within 24 hours of admission.

**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 time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 23 residents (Residents #23, #26, #36, #39, #53, and #62) reviewed for care plans in that:<BR/>1. The facility failed to define measurable objectives on Resident #23's care plan regarding the problems of resisting care, visual function, oral hygiene, pain, mobility, cognitive loss, and daily tasks.<BR/>2. The facility failed to define measurable objectives on Resident #26's care plan regarding the problems of psychotropic drugs, psychosocial well-being, pain, mood, behaviors, activities of daily living and daily tasks. <BR/>3. The facility failed to define measurable objectives on Resident #36's care plan regarding the problems of mobility and daily tasks and failed to address on Resident #36's comprehensive care plan the care areas of visual function and communication triggered on the MDS.<BR/>4. The facility failed to define measurable objectives on Resident #39's care plan regarding the problems of visual function, self-care deficits, decreased cognition, and daily tasks and the care areas of dental care and communication triggered on the MDS.<BR/>5. The facility failed to define measurable objectives on Resident #53's care plan in regard to the problems of daily tasks, pain, ADL function, and impaired cognition.<BR/>6. The facility failed to define measurable objectives on Resident #62's comprehensive care plan regarding the problems of self-care related to mobility and impaired cognition, and daily tasks.<BR/>These failures could affect residents and place them at risk for not having their needs and preferences met.<BR/>Findings included: <BR/>Resident #23<BR/>Review of Resident #23's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes mellitus (non-insulin dependent diabetes), heartburn, enterocolitis (inflammation of the colon), difficulty sleeping, high blood cholesterol, rapid heart rate, swelling, weakness, anxiety, absence of right and left legs below the knees, pancreatitis (inflammation of the pancreas), and high blood pressure. <BR/>Review of Resident #23's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #23 scored 99 indicating the resident was unable to complete the interview. Further review revealed the following care area triggered Section M - Skin Conditions, sub-section M1200. Skin and Ulcer/Injury Treatments: number 16. Pressure Ulcer/Injury indicated item B. Pressure reducing device on bed was selected. MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column revealed 16. Pressure Ulcer was selected.<BR/>Review of Resident #23's Quarterly MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score Resident #23 scored 15 out of 15 indicating cognition was intact. <BR/>Review of Resident #23's care plan reviewed/revised 01/27/25 revealed the following: <BR/>*Problem I resist care resisted taking medications/injections with an objective of I will make an informed choice about the benefits of care, options in care, and possible consequences/outcomes for resisting care. <BR/>*Problem visual function with an objective of Resident will have optimal visual acuity. <BR/>*Problem Oral/Dental Status with an objective of Maintain oral hygiene/status. <BR/>*Problem I am at risk for pain R/T my multiple comorbidities with an objective of I will be as comfortable as possible. <BR/>*Problem ADL Functional/Rehab Potential with an objective of I will achieve maximum functional mobility. <BR/>*Problem I have cognitive loss related to my diagnosis of anxiety with an objective of I will be as alert and oriented as possible. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an objective of The Resident will perform the following tasks at their highest practicable level. Approaches/Interventions included Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is days Once A Day on Mon, Wed, Fri; 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and Weekly skin Observations Flowsheet ADL Once Daily on Mon, Wed, Fri 06:00 AM - 06:00 PM.<BR/>Resident #26<BR/>Review of Resident #26's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of high blood cholesterol, cholecystitis (inflammation of the gall bladder), anxiety, difficulty sleeping, dementia, kidney disease, depression, high blood pressure, chest pain, heart failure, Type 2 diabetes (non-insulin dependent diabetes), ascites (fluid build-up in the abdomen), and constipation (inability to have a bowel movement) <BR/>Review of Resident #26's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #26 scored 11 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #26's care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem Psychotropic Drug Use with an unmeasurable objective of Benefit without side effects. <BR/>*Problem Psychosocial Well-Being with an unmeasurable objective of Resident will express/exhibit satisfaction. <BR/>*Problem I am at risk for pain related to aging process and dx of diabetes with an unmeasurable objective of Resident will be as comfortable as possible. <BR/>*Problem Mood State with an unmeasurable objective of Resident will express/exhibit satisfaction. <BR/>*Problem I have inappropriate verbal outbursts such as yelling out related to my dementia with an unmeasurable objective of I will be encouraged to communicate with the staff for my needs. <BR/>*Problem ADL Functional/Rehab Potential with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approaches/Interventions included Bowel Movement Every Shift; 1 SHIFT 1 06:00 AM - 06:00 PM, SHIFT 1 06:00 PM - 06:00 AM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, HS Snack At Bedtime; 06:00 PM - 06:00 AM, I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and The staff member who does my bath will document skin issues in the POC Once A Day on Mon, Wed, Fri 06:00 AM - 06:00 PM.<BR/>Resident #36<BR/>Review of Resident #36's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), dementia, depression, difficulty walking, pain, high blood pressure, weakness, heart failure, arthritis, paranoid schizophrenia, and swelling.<BR/>Review of Resident #36's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #36 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #36's care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem I have self-care deficits R/T impaired mobility and impaired cognition with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM.<BR/>Review of Resident #36's Care Area Assessment (CAA) list generated from the admission MDS, dated [DATE], revealed the following care areas triggered and selected in MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column, were not addressed on Resident #36's comprehensive care plan: Visual Function triggered by entry in MDS Section B Hearing, Speech, and Vision, sub-section B1000 Vision, Ability to see in adequate light (with glasses or other visual appliances) code 1. Impaired - sees large print, but not regular print in newspapers/books was selected and sub-section B1200 Corrective Lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision code 1. Yes was selected. Communication triggered by entry in MDS Section B Hearing, Speech, and Vision, Sub-section B0200 Hearing - Ability to hear (with hearing aid or hearing appliances if normally used) code 2. Moderate difficulty - speaker has to increase volume and speak distinctly was selected.<BR/>Resident #39 <BR/>Review of Resident #39's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of high blood pressure, dementia, Alzheimer's disease (a brain disorder that destroys memory and thinking skills), weakness, anxiety, high blood cholesterol, macular degeneration (an eye disease that affects central vision), and Vitamin D deficiency. <BR/>Review of Resident #39's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #39 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #39's care plan reviewed/revised 02/04/25 revealed the following:<BR/>*Problem I have decreased Visual Function and require glasses at times with an unmeasurable objective of Resident will have optimal visual ability. <BR/>*Problem I have deficits in self-care. ADL Function/Rehab Potential with an unmeasurable objective of Resident will achieve maximum functional mobility. <BR/>*Problem I have Cognitive Loss related to Dementia with an unmeasurable objective of I will be as alert and oriented as possible. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approach/Interventions included: Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is 6a-6p Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>Review of Resident #39's Care Area Assessment (CAA) list generated from the admission MDS dated [DATE] revealed the following care areas triggered and selected in MDS Section V - Care Area Assessment (CAA) Summary B. Care Planning Decision column, were not addressed on Resident #39's comprehensive care plan: Dental Care MDS Section L - Oral/Dental Status, sub-section L0200. Dental A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) and D. Obvious or likely cavity or broken natural teeth were selected. Communication was triggered by entry in MDS Section B Hearing, Speech, and Vision, Sub-section B0200 Hearing - Ability to hear (with hearing aid or hearing appliances if normally used) code 1. Minimal difficulty - difficulty in some environments (e.g. when person speaks softly or setting is noisy) was selected.<BR/>Resident #53<BR/>Review of Resident #53's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), human immunodeficiency virus, myalgia (muscle pain), major depressive disorder, paranoid schizophrenia, chronic obstructive pulmonary disease (a group of lung diseases that cause airway obstruction), cardiac pacemaker, rapid heart rate, atrial fibrillation (irregular beating of upper chamber of the heart), heart failure, high blood cholesterol, cellulitis (bacterial infection affecting the skin and underlying tissues), respiratory disease, chronic leg ulcers, and hemorrhoids.<BR/>Review of Resident #53's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #53 scored 12 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #53's comprehensive care plan, reviewed/revised 12/05/24, revealed the following:<BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level. Approach/Interventions included Bowel Movement Every Shift; SHIFT 1 06:00 AM - 06:00 PM, SHIFT 1 06:00 PM - 06:00 AM. <BR/>*Problem I am at risk for pain with the unmeasurable objective of I will be as comfortable as possible for the next 90 days. Problem ADL Functional/Rehab Potential with an unmeasurable objective of I will achieve maximum functional mobility . <BR/>*Problem I have impaired cognition r/t fluctuations in cognition with an unmeasurable objective of Resident will be as alert and oriented as possible . <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of The Resident will perform the following tasks at their highest practicable level . and Approach/Interventions of I prefer to take my Bath/Shower on M/W/F My preferred time to Bath/Shower is 6a-6p Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, HS Snack At Bedtime; 06:00 PM - 06:00 AM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, and weekly skin observation Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>Resident #62 <BR/>Review of Resident #62's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes (non-insulin dependent diabetes), dementia, depression, difficulty walking, pain, high blood pressure, weakness, heart failure, arthritis, paranoid schizophrenia, and swelling.<BR/>Review of Resident #62's admission MDS dated [DATE] in Section C - Cognitive Patterns, sub-section C0500 BIMS Summary Score, Resident #62 scored 10 out of 15 indicating moderate cognitive impairment. <BR/>Review of Resident #62's comprehensive care plan, reviewed/revised 02/04/25, revealed the following:<BR/>*Problem I have self-care deficits R/T impaired mobility and impaired cognition with an unmeasurable objective of I will achieve maximum functional mobility. <BR/>*Problem The following Tasks will be documented in POC CareAssist with an unmeasurable objective of I prefer to take my Bath/Shower on Monday Wednesday Friday My preferred time to Bath/Shower is 6a-6p Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM, Breakfast (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Dinner (Percentage Eaten) Once A Day: 02:00 AM - 10:00 PM, Lunch (Percentage Eaten) Once A Day: 06:00 AM - 06:00 PM, Nail Care Once A Day on Mon, Wed, Fri; 06:00 AM -06:00 PM, Oral Care Twice A Day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, weekly skin observation during showers Flowsheet: ADL Once A Day on Mon, Wed, Fri, 06:00 AM - 06:00 PM. <BR/>During an interview on 02/19/2025 at 2:30 PM, the MDS coordinator stated she was responsible for completing the initial comprehensive care plan and the DON and ADON were responsible for updating the care plans. The MDS coordinator stated her expectation was care plans should include resident's diagnosis, medications, diet, physician orders and any resident care needs. The MDS coordinator stated that objectives should be specific and measurable, and interventions should be a specific task for staff and/or residents that accomplishes objectives. <BR/>During an interview on 02/19/25 at 12:07 PM, the Regional Nurse Consultant stated her expectations of care plan were for the care plan to look like the resident. She stated if she were a nurse coming in to provide care, she would want to know what was documented on the care plan. The RNC stated if a resident needed assistance or was a fall risk for example, that information should be on the care plan. The RNC explained the objectives should be based on what a nurse would expect to assess when interventions were followed. She stated the DON was responsible for the initial care plan and the ADON/MDS Coordinator contributed to revisions based on the comprehensive assessment. The RNC stated the CAA's should be addressed on the comprehensive care plan. She stated the DON was ultimately responsible for the accuracy of the care plans. The RNC stated in response to an example of an objective for pain, the RNC stated she did not agree with use of a pain scale because pain was subjective data. She explained staff should be able to identify pain by a resident's facial expressions or behavior. The RNC stated she trained staff to recognize pain or discomfort by being observant.<BR/>Review of the facility policy titled Comprehensive Care Plans, undated, revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives . that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: item 2. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the care plan., and 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment and failed to ensure the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment including both the comprehensive assessment and quarterly review assessments for 4 (Resident #1, #39, #40and #43) of 6 residents were reviewed for comprehensive care plans. <BR/>1. The facility failed to develop a comprehensive care plan within seven days for Resident #1, #39, #40 and #43.<BR/>2. The interdisciplinary team failed to review and revise the plan of care for Resident #1, #39, #40, #43 and #50.<BR/>These failures could affect all 88 residents by placing them at risk for not having their individual needs met. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 02/20/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 11/20/2022 with the following diagnosis: unspecified fracture of left shaft/femur, non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). <BR/>Review of Resident #1's revealed an MDS Significant Change assessment, dated 01/30/2023 section G reflects the following ADL care areas: bed mobility- extensive assistance, transfer- extensive assistance, walk in room- activity occurred only one or twice, walk in corridor- activity occurred only once or twice, dressing- extensive assistance, eating- Supervision, toilet use- extensive assistance, personal hygiene- extensive assistance, bathing- activity did not occur. <BR/>Review of Resident #1's most recent Care Plan , dated 12/07/2023, revealed category: ADL function/rehabilitation potential- ambulation/transfers amount of assist x1, bath hygiene amount of assist x1, Dressing/grooming assist x1. Further review revealed the interdisciplinary team had not reviewed and revised the care plan following the assessment of 12/07/2022.<BR/>Review of Resident #1's Care Conference Schedule revealed a Quarterly Care Conference was conducted on 12/07/2022.<BR/>Record review of Resident #39's face sheet dated 02/20/2023 revealed a [AGE] year-old male admitted on [DATE] with the following diagnosis: chronic pain due to trauma, quadriplegia (paralysis of all 4 limbs), hypertension (high blood pressure), bipolar disorder; current episode severe, mixed with psychotic features (mood disorder), anxiety disorder and neuromuscular of the bladder (person lacks bladder control due to brain, spinal cord or nerve problems). <BR/>Review of Resident #39's revealed an MDS Annual assessment, dated 08/31/2022 section G reflects the following ADL care areas: bed mobility- total dependance, transfer- total dependance, walk in room- activity did not occur, walk in corridor- activity did not occur, dressing- total dependance, eating- Supervision, toilet use- extensive assistance, personal hygiene- extensive assistance, bathing- total dependence. <BR/>Review of Resident #39's Care Plan, dated 01/04/2023 , revealed category: ADL function/rehabilitation potential- Does not have the ADL function or assistance needed care planned. An Annual Care Conference was not documented after the Annual MDS assessment, dated 08/31/2022 was completed.<BR/>Review of Resident #39's Care Conference Schedule revealed a Quarterly Care Conference was conducted on 10/05/2022 and 01/04/2022. An Annual Care Conference was not documented.<BR/>Record review of Resident #40's face sheet dated 02/14/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 01/06/2023 with the following diagnosis: fractured left hip, osteoporosis (disease of bone that makes them brittle), history of falling, Alzheimer's Disease, and Major Depressive disorder (persistent depressed mood).<BR/>Review of Resident #40's revealed an MDS Annual assessment, dated 01/11/2023 section G reflects the following ADL care areas: bed mobility- extensive assistance with 2+ person assist, transfer- extensive assistance with 2+ person assist, walk in room- activity did not occur, walk in corridor- activity did not occur, dressing- extensive assistance with 2+ person assist, eating- Supervision with 1 person assist, toilet use- extensive assistance with 2+ person assist , personal hygiene- extensive assistance with 1 person assist, bathing- personal help in part of bathing with 1 person assist . <BR/>Review of Resident #40's Care Plan dated 02/21/2023 revealed category: ADL function/rehabilitation potential- Provide assistance x1 with bathing/showering, requires x1 assist with bathing, requires x1 assist with eating, requires x1 assist with peri-care, requires x1 assist with toileting. <BR/>Review of Resident #40's Care Conference Schedule revealed a Quarterly Care Conference was conducted on 12/07/2022. An Annual Care Conference was not documented.<BR/>Record review of Resident #43's face sheet dated 02/14/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 01/06/2023 with the following diagnosis: fractured left hip, osteoporosis (disease of bone that makes them brittle), history of falling, Alzheimer's Disease, and major depressive disorder.<BR/>Review of Resident #43's revealed an MDS Annual assessment, dated 12/02/2022 section G reflects the following ADL care areas: bed mobility- supervision with 1 person assist, transfer- extensive assistance with 2+ person assist, walk in room- supervision with set-up, walk in corridor- supervision with set-up, dressing- extensive assistance with 2+ person assist, eating- Supervision with 1 person assist, toilet use- extensive assistance with 2+ person assist , personal hygiene- extensive assistance with 2+ person assist, bathing- personal help in part of bathing with 2+ person assist . Section O reflects the resident was receiving hospice care. <BR/>Review of Resident #43's Care Plan, dated 02/21/2023, revealed category: ADL function/rehabilitation potential- Does not have the ADL function or assistance needed care planned. Hospice has not been care planned. <BR/>Review of Resident #43's Care Conference Schedule revealed a Quarterly Care Conference was conducted on 12/23/2022. A Significant Change Care Conference was not documented.<BR/>In an interview on 02/18/23 at 12:16 a.m. MDS Coordinator DI revealed that the Care plans were behind in the schedule and has not been able to do it in time. She stated she had been out of 6 months due to illness, and they did not have anyone filling in for her. She said that her and RN CCM DH are responsible for making sure they are complete. She said the failure could place the resident at risk for unmet needs. The MDS coordinator said that she was out for 6 months and that they did not have anyone to cover for her. She stated that the Social Worker was planning the care plan conferences and they were not getting done timely. She stated that she was unaware that the Comprehensive Assessment care plans needed to be updated after the MDS was completed. She stated she followed the quarterly care conference and she thought that was how she did it. <BR/>An interview with the MDS Coordinator on 02/22/2023 at 11:00 a.m. revealed she did not revise the care plans or did not conduct the care conferences for (Resident #1, #39, #40 and #43) within the time frame after assessments. She stated the facility was behind on comprehensive care plans and care plan meetings.<BR/>Review of Policy and Procedure for Assessment/Care Plan dated February 2021 revealed:<BR/>3. The resident/representative's right to participate in the development and implementation of his or her care plan of care includes the right to: <BR/>a. participates in the planning process.<BR/>b. identify individuals to be included in the planning process<BR/>c. request meetings<BR/>d. request revisions.<BR/>e. participate in establishing goals.<BR/>f. participate in the type, amount, frequency, and duration of the care.<BR/>g. receiver services/items to be included in the care plan<BR/>h. be informed in advance of changes.<BR/>i. refuse, request changes to and/or discontinue care of treatment offered or proposed.<BR/>j. be informed in advance of the risk and benefits of the care of treatment proposed.<BR/>k. have access to and review care plans.<BR/>l. review and sign the care plan after any significant changes are made. <BR/>4. The care planning process:<BR/>a. facilities the inclusion of the resident's and/or representative.<BR/>b. includes an assessment of the resident's strengths and his/her needs.<BR/>c. incorporates the resident's personal and cultural preferences in establishing goals of care. <BR/>7. A comprehensive care plan is developed within seven days (7) days of completing the resident assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews and record review, the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 4 residents (Resident # 1, Resident #79) reviewed for pressure ulcers.<BR/>The facility failed to prevent Resident #1 from developing 5 new pressure ulcers (Stage IV to right ischium, Stage IV to left Ischium, Stage IV to Left Heel, Stage IV to right heel, and Not Stage to sacrum) while she resided in the facility.<BR/>The facility failed to promote healing and prevent Resident #79's Stage IV pressure ulcer to his sacrum from developing osteomyelitis (an infection in the bone caused by bacteria) <BR/>The facility failed to promote healing and prevent Resident #79's right heel pressure ulcer from deteriorating from Stage III to Stage IV.<BR/>An Immediate Jeopardy (IJ) was identified on 2/22/2023 at 4:58 PM. While the IJ was removed on 2/24/2023 at 6:48 PM, the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of pattern due to the facility's need to monitor the implementation and effectiveness of its plan of removal.<BR/>These failures placed residents at risk of pain, worsening of wounds, wound infection, emotional distress, harm or even death.<BR/>The findings were:<BR/>Review of The National Pressure Injury Advisory Panel (NPIAP) accessed on 03/14/2023 https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf revealed:<BR/>Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.<BR/>Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar<BR/>obscures the extent of tissue loss this is an Unstageable Pressure Injury. <BR/>Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.<BR/>Resident #1<BR/>Review of Resident #1's electronic face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a most recent admission date of 11/20/2022 with the following diagnosis: Unspecified fracture of left shaft of the femur (long, straight portion of the upper leg bone), Non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system).<BR/>Review of Resident #1's admission MDS, dated [DATE], revealed:<BR/> Section C: Cognitive Patterns BIMS Score of 9 indicating moderate cognitive impairment; Section G: Functional Status limited/one-person assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions of no pressure ulcers. <BR/>Review of Resident #1's Significant Change MDS dated [DATE], revealed:<BR/> Section C: Cognitive Patterns BIMS Score of 14 indicating cognitively intact; Section G: Functional Status: extensive/two + persons assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated two Stage III pressure ulcers, one Stage IV pressure ulcer, and two Unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. <BR/>Site 1: Right buttock/ischium<BR/>Review of Resident #1's Wound Management Detail Report dated 07/28/2022 at 4:08pm by LVN-AD revealed: <BR/>Pressure Ulcer to Right Buttock, not present on admission. Unstageable measured 2.8cm in length by 2.8cm in width with unmeasurable depth. <BR/>Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:44pm by LVN-Q revealed: <BR/>Stage IV measured 4cm in length by 6cm in width with 2.5 measurable depth. <BR/>Review of Resident #1's wound care physician progress notes revealed the following:<BR/>7/28/22 Initial exam of Right Ischium: Unstageable Pressure Ulcer 2.8cm x 2.8cm x unmeasurable depth; surgical debridement performed<BR/>11/24/22 Change of staging Right Ischium: Stage IV 4.6cm x 6.0cm x 2.0cm; surgical debridement performed<BR/>2/16/23 Last available progress note Right Ischium: 4cm x 6cm x 2.5cm; surgical debridement performed<BR/>Site 2: Left buttock/ischium<BR/>Review of Resident #1's Wound Management Detail Report dated 08/04/22 at 3:24pm by LVN-AD revealed: <BR/>Unstageable Pressure Ulcer to Left Buttock, not present on admission. Measured 4.5cm in length by 4cm in width with no measurable depth.<BR/>Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:50pm by LVN-Q revealed: <BR/>Stage III measured 1.7cm in length by 4.2cm in width with 0.5cm measurable depth.<BR/>Review of Resident #1's wound care physician progress notes revealed the following:<BR/>8/04/22 Initial exam of Left Ischium: Stage II Pressure Ulcer 4.5cm x 4.0cm x unmeasurable depth; no debridement done<BR/>8/11/22 Change of Staging of Left Ischium: Unstageable Pressure Ulcer: 3.2cm x 1.5cm x 0.2cm; surgical debridement performed<BR/>11/10/22 Change of Staging of Left Ischium: Stage III 4.5cm x 2.5cm x 1cm; surgical debridement performed<BR/>2/16/23 Change of Staging of Left Ischium: Stage IV 1.7cm x 4.2cm x 0.5cm; surgical debridement performed<BR/>Site 3: Left heel<BR/>Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:17am by LVN-AE revealed: Unstageable - Deep Tissue Pressure Ulcer left heel not present on admission measured 5.5cm in length by 5cm in width with no measurable depth.<BR/>Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:54pm by LVN-Q revealed: Stage IV measured 3cm in length by 4cm in width with no measurable depth.<BR/>Review of Resident #1's wound care physician progress notes revealed the following:<BR/>11/17/22 Initial exam of Left Heel: Unstageable DTI Pressure Injury 5.5cm x 5.0cm x unmeasurable depth; no debridement done<BR/>12/8/22 Change in Staging of Left Heel: Unstageable Pressure Ulcer 5.5cm x 5.0cm x unmeasurable depth; no debridement done<BR/>2/16/23 last available progress note for Left Heel: Unstageable Pressure Ulcer 3cm x 4cm x unmeasurable depth; no debridement done<BR/>Site 4: Right heel<BR/>Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:15am by LVN-AE revealed: Pressure Ulcer Right Heel not present on admission measured 5cm in length by 7cm in width and no measurable depth.<BR/>Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:52pm by LVN-Q revealed: Stage IV measured 2.7cm in length by 3.8cm in width and no measurable depth.<BR/>Review of Resident #1's wound care physician progress notes revealed the following:<BR/>11/17/22 Initial exam of Right Heel: Unstageable DTI Pressure Injury 5cm x 7cm x unmeasurable depth; no debridement done<BR/>12/8/22 Change in Staging of Right Heel: Unstageable Pressure Ulcer 5cm x 7cm x unmeasurable depth; no debridement done<BR/>12/29/22 Change in Staging of Right Heel: Stage IV Pressure Ulcer 5.5cm x 5cm x unmeasurable depth; surgical debridement performed<BR/>2/16/23 last available progress note for Right Heel: Stage IV 2.7cm x 3.8cm x unmeasurable depth; no debridement done<BR/>Site 5: Sacrum<BR/>Review of Resident #1's Wound Management Detail Report dated 11/09/22 at 12:50 PM by LVN-AE revealed: Pressure Ulcer Sacrum not present on admission measured 10cm in length by 8cm in width and no measurable depth<BR/>Review of Resident #1's Wound Management Detail Report dated 2/09/23 at 2:36 PM by LVN-AE revealed: Pressure Ulcer Sacrum not present on admission measured 1.5cm in length by 1cm in width and no measurable depth<BR/>Review of Resident #1's electronic orders revealed:<BR/>Ascorbic acid (vitamin c) tablet; 500mg 1 tab oral once a day (start date 10/08/22)<BR/>Wound Treatment Order: Location: Pressure Wound of the Left Ischium Partial Thickness. Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Once a day (start date 10/20/22)<BR/>Wound Treatment Order: Location: Unstageable of the Right Ischium Full Thickness. Clean with Normal Saline/Wound Cleanser. Apply collagen Calcium Alginate with silver. Cover with bordered foam dsg. Once a Day. (start date 10/20/22)<BR/>Wound Treatment Order: Location: Pressure Wound of the Left Ischium Partial Thickness. Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Twice a Day-PRN (start date 11/29/22)<BR/>Wound Treatment Order: Location: Unstageable of the Right Ischium Full Thickness. Clean with Normal Saline/Wound Cleanser. Apply collagen Calcium Alginate with silver. Cover with bordered foam dsg. Twice A Day - PRN (start date 11/29/22)<BR/>Cleanse sacrum with normal saline or wound cleanser apply thin layer of triad, yellow tube, to wound two times a day. Every Shift (start date 12/29/22)<BR/>Cleanse left heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg as needed. Every Shift (start date 2/10/23)<BR/>Cleanse left heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg daily. Once A Day. Morning 06:00 AM - 06:00 PM (start date 2/10/23)<BR/>Cleanse right heel with normal saline or wound cleanser apply calcium alginate to wound bed and secure with bordered dsg as needed. Every Shift - PRN (start date 2/10/23)<BR/>Cleanse right heel with normal saline or wound cleanser apply calcium alginate to wound bed and secure with bordered dsg daily. Once A Day. Morning 06:00 AM - 06:00 PM (start date 2/10/23)<BR/> Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: <BR/>Problem: Resident has a pressure ulcer to left buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change.; Problem: Resident has a pressure ulcer to left heel related to immobility. Goal: Resident's ulcer will not increase in size. Approach: Conduct a systematic skin inspection during daily treatment . Use heel protectors as tolerated or cushion under legs as tolerated to relieve pressure on the heels.; Problem: Resident has a pressure ulcer to right buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change.; Problem: pressure Ulcer Sacrum Stage III. Goal: Area will show improvement in the next 14 days. Approach: Turn every 2 hours and prn.<BR/>In an interview on 02/19/2023 at 2:38 PM, Corporate Clinical Company Leader RN-I stated the facility would accept responsibility for Resident #1's pressure ulcers and that they were facility acquired. She stated that she could not find any documentation that they were not acquired in the facility. Corporate Clinical Company Leader RN-I stated that the failure of the facility to prevent Resident #1 from developing new pressure ulcers could result in an infection and that the failure was due to ongoing staffing issues.<BR/>In an interview on 02/22/23 at 09:57 AM, LVN-AE the former wound care nurse for the facility, stated that on weekends RN-V would not do wound care for the residents on Station 1. LVN-AE stated that Resident #1's wound got worse because RN-V would have the wrong dressings on the resident. LVN-AE stated that Resident #1's sacrum was to be left open to air per physician orders, but she would come back on Monday and there would be a dressing (silicone border dressing) covering the wound and when she would remove the dressing, it would take the new healing skin off. She stated Resident #1 did not show pain, just that her wounds would be worse.<BR/>In an interview on 2/23/23 at 11:35 AM, the Wound Care Physician stated that his expectation was that his orders would be followed and the wound care for the residents would be done. He stated that all of Resident #1's wounds were facility acquired.<BR/>Review of Resident #1's electronic record from 05/20/2022 to 02/23/2023 revealed no evidence of physician's progress note demonstratiting the resident's pressure ulcers were clinically unavoidable.<BR/>Resident #79<BR/>Review of Resident #79's electronic Face Sheet revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis (an infection in the bone caused by bacteria), pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus (inflammatory disease caused when the immune system attacks its own tissues causing fatigue and pain), major depressive disorder, dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), dependence on supplemental oxygen, chronic atrial fibrillation (irregular heart beat), Methicillin resistant Staphylococcus aureus (certain type of bacteria resistant to treatment by many common antibiotics), and Type 2 diabetes mellitus.<BR/>Review of Resident #79's admission MDS dated [DATE] revealed:<BR/>Section C: Cognitive Patterns BIMS Score of 15 indicating no cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated one Stage III pressure ulcer present upon admission and one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar present upon admission.<BR/>Review of Resident #79's Quarterly MDS dated [DATE] revealed:<BR/>Section C: Cognitive Patterns BIMS Score of 11 indicating moderate cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated two Stage IV pressure ulcers present upon admission, and one Unstageable pressure ulcer that was not present upon admission.<BR/>Site 1: Sacrum<BR/>Review of Resident #79's Wound Management Wound History dated 11/15/2022 at 8:08 am revealed: Pressure Ulcer to Sacrum present on admission.<BR/>Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Stage 4 Pressure Wound Sacrum Full Thickness measured 1.7cm in length by 0.7cm in width with 1.2c in depth.<BR/>Review of Resident #79's Wound Care Physician Progress Note dated 01/12/2023 revealed: The histology report from the biopsy of the sacrum taken on 01/05/2023 indicates acute osteomyelitis.<BR/>Site 2: Right Heel<BR/>Review of Resident #79's Wound Management Detail Report dated 11/15/2022 at 8:11am by LVN-AE revealed: Stage III pressure ulcer to right heel measured 0.3cm in length by 0.3cm in width with 0.1cm in depth.<BR/>Review of Resident #79's Wound Management Wound History dated 11/25/2022 at 7:33am revealed: Pressure Ulcer to right heel present on admission and healed.<BR/>Review of Resident #79's Wound Management Wound History dated 12/29/2022 at 2:31am revealed: Pressure Ulcer to right heel present on admission.<BR/>Review of Resident #79's Wound Management Detail Report dated 02/23/2023 at 7:11pm by Corporate Clinical Company Leader RN-I revealed: Stage IV Pressure Ulcer to right heal measured 0.5cm in length by 0.6cm in width with unmeasurable depth. The wound had necrotic tissue type.<BR/>Review of Resident #79's skin assessment records revealed no evidence of systematic skin inspection during treatment between 11/25/2022 and 12/29/2022.<BR/>Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Unstageable due to necrosis (death of cells in body tissues) of the Right Heel Full Thickness measured 1cm in length by 1.1cm in width with no measurable depth. <BR/>Review of Resident #79's Wound Care Physician Progress Notes dated 12/29/2022 revealed deterioration to a Stage IV Pressure Wound of the Right Heel.<BR/>Review of Resident #79's electronic orders revealed:<BR/>Multivitamin plus Minerals 1 tablet by mouth daily (start date 11/15/22)<BR/>Left heel cleanse with ns or wound cleanser and apply sure-prep two times daily for preventative (start date 11/25/22)<BR/>Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved (start date 11/25/22)<BR/>Cleanse right heel with normal saline or wound cleanser, apply sure-prep to heel two times daily for preventative (start date 11/25/22)<BR/>Ascorbic acid (vitamin c) 500mg 1 tablet by mouth daily (start date 11/29/22)<BR/>Pro-Stat AWC (amino acids-protein hydrolys) 17-100 gram-kcal/30ml give 30ml by mouth twice a day (start date 11/29/22)<BR/>Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved (twice a day - PRN, morning, bedtime) (start date 11/29/22)<BR/>Cleanse right heel with normal saline or wound cleanser apply anasept to wound and secure with a bordered dressing daily (start date 12/29/22)<BR/>Use cushioned boots while in bed as tolerated (start date 1/3/23)<BR/>Ertapenem 1 gram IV daily for 42 days r/t osteomyelitis (start date 1/13/23 end date 2/24/23)<BR/>Review of Resident #79's Treatment Administration Records from November 2022 to February 2023 revealed no evidence of wound treatments completed on 12/02/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023.<BR/>Review of Resident #79's electronic record revealed no evidence of reposition every 2 hours and as needed and conduction of systematic skin inspection daily between 11/25/2022 and 12/29/2022.<BR/>Review of Resident #79's Care Plan last revised 1/30/23 revealed: <BR/>Problem: Pressure Sores/Skin Care. Goal: Prevent/Heal pressure sores and skin breakdown. Approach: follow facility skin care protocol; preventative measures use cushioned boots for heels while in bed as tolerated, off load heels while in bed; report to charge nurse any redness or skin breakdown immediately; treatment as ordered; turn and reposition every 2 hours and PRN; Problem: Resident has a pressure ulcer to right heel r/t immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection. Approach: . conduct a systematic skin inspection during treatment .; Problem: Resident has a pressure ulcer to sacrum r/t immobility. Goal: Resident's ulcer will heal without complications. Approach: use cushion provided by family for pressure reduction when resident is in chair; conduct a systematic skin inspection daily during treatment .<BR/>Observation on 2/18/23 at 3:30 PM Resident #79 was lying in bed, turned slightly onto his left side with heels floated on pillows and heel protectors to bilateral feet.<BR/>Observation on 2/19/23 at 10:30 AM Resident #79 was lying in bed flat on his back with heels floated on pillows, bilateral heel protectors were in place.<BR/>Observation on 2/20/23 at 9:40 AM Resident #79 was sitting in Geri-chair in dialysis suite with pillows elevating feet. Resident #79 had 2 blankets covering his legs because he stated that room was always cold, surveyor unable to verify if heel protectors were in place.<BR/>Observation on 02/20/23 3:25 PM: RN-V gathered supplies as ordered from treatment cart and placed in resealable plastic bag with resident #79's name written on it and carried bag to resident's room. MDS-RN and LVN-Q entered room and donned gloves. LVN-Q used hand sanitizer prior to entering resident room. MDS-RN was not observed to use hand sanitizer after entering Resident #79's room. RN-V used hand sanitizer, cleaned tray table with sanitizer wipes and placed wax paper on cleaned tabletop without donning gloves. RN-V removed 2 6inx6in foam border dressing from package and dropped on wax paper, removed 3 saline ampules, 1 can of wound spray, 1 tube of barrier cream, 4inx4in gauze, calcium alginate packing, and cotton tipped applicators from resealable plastic bag and placed on wax paper without donning gloves. RN-V saturated 4x4 gauze with saline without donning gloves. RN-V donned clean gloves. Resident #79 assisted onto his left side by MDS-RN. Dirty dressing and soiled packing removed by MDS-RN; soiled dressing was dated 2/18/23. Wound appeared beefy red inside, wound edges well-defined and healthy looking, area surrounding wound was bright red and irritated in appearance, area appeared larger than size of foam border dressing (6x6in) but no measurements were taken during this dressing change. Without changing soiled gloves, RN-V cleaned wound with saline soaked gauze, patted area dry with dry gauze, opened calcium alginate package and used cotton tipped applicator to pack calcium alginate packing into wound. Clean 6inx6in foam border dressing placed over wound. Resident rolled onto his back then LVN-Q stated, don't forget you have to date time and initial the dressing. RN-V assisted resident back onto his left side and RN-V dated and initialed the clean dressing. RN-V did not change gloves in between dirty and clean dressing. RN-V removed her gloves and donned a clean pair. LVN-Q held Resident #79's leg by the calf while RN-V removed Resident #79's right heel dressing, soiled dressing did not appear to have a date and initial on it. RN-V sprayed wound cleanser on right heel wound, applied wound cleanser to wound with cotton tipped applicator, and applied a clean 6inx6in foam bordered dressing. RN-V dated and initialed the clean dressing to Resident #79's right heel. RN-V removed her gloves. RN-V donned clean gloves and removed dressing to left heel, wound cleanser and gauze used to clean left heel. MDS-RN stated that there were no orders for the treatment or dressing to the left heel, but the staff do them as a preventative measure. RN-V removed her gloves, collected trash, and left the room. Surveyor attempted to find RN-V for an interview regarding the wound care, but she was unable to be located.<BR/>Interview on 2/24/23 at 4:48 PM, LVN-Q stated wound care with Resident #79 on 2/20/23 performed by RN-V went badly. She stated she did not see RN-V wash hands or use sanitizer at any time before or during the dressing changes, but she did see her change her gloves in between each wound. LVN-Q stated that was not the correct procedure for hand hygiene during wound care and could lead to recontamination of the wound. She stated that RN-V was feeling overwhelmed but that was not an excuse. She stated that it was just overall not good.<BR/>In an interview on 2/21/23 at 11:35 AM, Corporate Clinical Company Leader RN-H stated Resident #79 was admitted to facility on 11/15/22 with stage 3 to sacrum and stage 3 to right heel and that both wounds were documented on admission. Corporate Clinical Company Leader RN-H stated that in her investigation of the Resident #79's chart, it appeared that the wound care/treatment nurse at the time documented the right heel wound was healed on 11/25/22 even though the wound was never healed. She stated the right heel wound was re-identified as a stage 4 on 12/29/22. She stated that because the wound was documented as healed it went one month without treatment or observation leading to it progress to a stage 4. She stated that Resident #79's sacral wound was a stage 3 on admission but had worsened to a stage 4. She stated the documentation stating the wound was improving even with the presence of osteomyelitis was strictly referring to the wound bed appearance from her understanding. Corporate Clinical Company Leader RN-H stated the resident was diagnosed with osteomyelitis at the site of the sacral wound by the wound care physician. She stated the staff was supposed to do skin sweeps weekly to check wounds and get measurements and the wound care doctor saw residents weekly as well. The staff did their checks on the residents that the doctor did not see. The measurements were documented in the wound management section of the chart. Corporate Clinical Company Leader RN-H stated wound care was documented on the treatment administration record only unless something was wrong or there were changes. If there was something different with a wound, she stated a prudent nurse would document in a focused observation note or progress note what was observed, notify the doctor of the change in the resident's condition, then document that the doctor was notified. She stated the wound care physician's progress notes were uploaded into the resident's EMR electronically and that he was able to put his own orders in remotely. She stated if someone did transcribe orders for him it would be the nurse who did rounds with him while he was in the building seeing residents, normally the wound care/treatment nurse when the facility had one or the DON. If the resident was a new admission and the wound care physician was giving orders, the admitting nurse would be responsible for transcribing the orders and verifying everything was in the resident's chart correctly. Corporate Clinical Company Leader RN-H stated when an order was put into the facility's charting program it went directly onto the MAR. She stated during the morning meeting, the staff should have been going over all new orders received to make sure all orders had been signed and verified and that nothing had been missed during rounds. Corporate Clinical Company Leader RN-H stated all information regarding wounds had been provided or would be found in focused observation notes.<BR/>In an interview on 02/22/23 at 09:57 AM, LVN-AE the former wound care nurse for the facility, stated that on weekends RN-V would not do wound care for the residents on Station 1. When LVN-AE would ask RN-V why it was not being done, RN-V would say it was because she would be frustrated and that she was one person and could not get them (treatments) done. LVN-AE did not understand why because RN-V always had a med aide, so that would have left her free to do the treatments. LVN-AE stated that the wounds would have the same dressing on them on Monday that she put on the residents on Friday. LVN-AE stated she worked Monday through Friday as the treatment/wound care nurse. LVN-AE reported RN-V to the DON and the former Administrator, then later reported it to Regional Nurse Consultant and others who no longer work for the company. She was told by all of them that they would talk to RN-V. LVN-AE stated it never got corrected. LVN-AW felt the residents did not receive wound care as ordered by the physician when she was not in building. LVN-AE stated that every Thursday the wound care physician would see residents but by the time he came, she had a week to make them look better, so he did not make comments that the residents' wounds were worse. LVN-AE stated she got conflicting information from DON's regarding skin assessments. LVN-AE stated at first, she would do skin assessments on wound care residents, then was told the nurses were supposed to do skin assessments and she was only supposed to do the wound management (measurements, wound descriptions). LVN-AE said she left the facility because the facility was not willing to change and hold RN-V accountable for wound care, and she was afraid of losing her license due to the wounds in the facility.<BR/>In an interview on 2/22/23 at 10:25 AM, LVN-P stated since the wound care nurse quit whoever was working the floor was responsible for wound care for the residents. She stated typically, there was a charge nurse and a med nurse on the day shift, and they helped each other out with the residents. LVN-P stated Station 1 had 6 residents getting wound care at that time. When wound care was done, she stated she only signed off on the TAR and she never put a progress note in just to state the wound care had been done. She stated if there were changes to the wound it was documented in a progress note, the doctor was notified, she would notify the family and continue the treatment or write orders if any new orders were given. She stated a nurse always rounded with the wound care doctor when he saw the residents. She stated he was in the facility weekly, and she rounded with him last week because there was no one else to do it. LVN-P stated until the facility hired a new wound care nurse, she believed the DON was going to take over rounding with him.<BR/>In an interview on 2/22/23 at 10:49 AM, Corporate Clinical Company Leader RN-H stated that she was not aware skin assessments were not being done accurately and treatments were not being done until surveyors arrived at the facility. She stated the facility was currently in the process of revising their wound care program to address wound care management, assessments, treatments, and care planning issues the facility had been experiencing.<BR/>In an interview on 2/23/23 at 11:35 AM, the Wound Care Physician stated that his expectation was that his orders would be followed and the wound care for the residents would be done. Wound Care Physician stated that if a resident's wound care was not done as ordered over the weekend that when he came to the facility on Thursday, the wounds would have time for improvement by the time he saw them again if the treatments were started back up on Monday. He stated he did rounds with the floor nurses when he saw the residents.<BR/>Review of facility policy Prevention of Pressure Injuries revised May 2022 revealed:<BR/>Purpose: The purpose of this protocol is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors.<BR/>Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable.<BR/>Prevention:<BR/>Skin Care<BR/>1. <BR/>Keep the skin clean and hydrated.<BR/>2. <BR/>Clean promptly after episodes of incontinence.<BR/>3. <BR/>Avoid alkaline soaps and cleansers.<BR/>4. <BR/>Use a barrier product to protect skin from moisture.<BR/>5. <BR/>Use incontinence products with high absorbency.<BR/>6. <BR/>Do not rub or otherwise cause friction on skin that is at risk of pressure injuries.<BR/>7. <BR/>Use facility-approved protective dressings for at risk individuals.<BR/>Nutrition<BR/>1. <BR/>Conduct nutritional screenings for residents at risk.<BR/>2. <BR/>Conduct a comprehensive nutritional assessment for any res[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident's environment remained free of accident and hazards, and each resident's received adequate supervision to prevent accidents and altercations for 2 of 14 residents (Resident #36 and Resident #45) reviewed for accidents and supervision. <BR/>The facility failed to ensure there was adequate supervision on Station 2/Hall 2 (men secured locked unit) to prevent a resident-to-resident physical altercation between Resident #36 and Resident #45 on 02/19/23. <BR/>These failures placed residents at risk for injury and undue psychosocial distress due to lack of supervision provided by the facility. <BR/>Findings include:<BR/>Station 2 Hall 1 (Men's Secured Unit)<BR/>In an observation on 02/14/23 at 11:47 am, revealed Station 2 Hall 1 had 14 residents with known behaviors. 1 agency CNA, ADON, and LVN-PH were observed on the hall. <BR/>In an interview on 02/14/23 at 11:00 am, CNA-JF said she worked 6am to 6pm and worked 12 hours by herself on the women's secured unit, with 1 resident requiring 1:1 supervision. A staff member would come in every 2 hours to check on her. She said she did not feel safe working alone and was unable to prevent resident to resident altercations. CNA-JF stated she had received training in the past for Alzheimer's/dementia but not for residents with behaviors. <BR/>In an interview on 02/14/23 at 11:47 am, LVN-PH said the facility usually had 2 staff on the men's secured unit and 1 staff on the women's secured unit during the day shift. She floated between the 2 units but spent the majority of her time on the men's unit as that was where her desk as. She said 1 staff on the women's secured unit was not enough to protect the residents. She said staff was cut back from 2 staff to 1 staff on the women's unit about a month ago. <BR/>Resident #36<BR/>Record review of Resident #36's undated face sheet revealed he was a [AGE] year old male admitted on [DATE] with the following diagnoses: Moderate psychological disability, <BR/>unspecific dementia without behavioral disturbances, personality change due to unknown psychological condition, and intermittent explosive disorder (explosive eruptions that occur suddenly, with little or no warning). <BR/>Record review of Resident #36's Quarterly MDS assessment, dated 11/21/22, revealed a BIMS score of 00 which indicated severe cognitive impairment. Further review of MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. None of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavior symptoms directed towards others behavior did not occur, B. Verbal behaviors symptoms directed towards others behavior did not occur, C. Other behavioral symptoms not directed towards others behavior <BR/>did not occur. Section G: Functional Status. G0110. Activities of Daily Living Assistance: H. Eating: 1 (supervision oversight, encouragement or cueing). G0120 Bathing: Self Performance: 3 (Physical help in part of bathing activity). G0300: Balance during transitions and walking: A. Moving from seated to standing position 1 (not steady, but able to stabilize without human assistance. B. Walking (with assistive device if used) 1 (not steady, but able to stabilize without human <BR/>assistance).<BR/>Review of Resident #36 Care Plan dated 01/18/2023 (Last Care Conference) revealed the following: Problem I have behavioral symptoms at times tearing up/destroying the mini blinds in my room. I wander at times that is why I am on a secure unit. I am not usually aggressive. On 02/24/23 I Wandered in another resident's room space, and he hit me on the chest, I hit his arm as a reaction to being stuck. This is not my normal behavior, and I was remorseful that this happened. Goal: Privacy will be maintained via alternate means (drape and or privacy curtains) mini blinds will not be hung. On 02/14/23 I will not strike out at any other Resident in the next 90 <BR/>days. Approach: Always ask for help if resident becomes abusive/resistive. Ask assistance from staff If placed in an uncomfortable situation.<BR/>Resident #45<BR/>Record review of Resident #45's Annual MDS assessment, dated 11/21/22, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Diagnosis Diagnoses included dementia, Epilepsy (seizure disorder), and schizophrenia (a mental disorder in which people interpret reality abnormally). Resident #45 had a BIMS score of 00 which indicated severe cognitive impairment. Further review of MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. None of the above (psychosis). E0200. Behavioral Symptoms: A. Physical behavior symptoms directed towards others - behavior did not occur, B. Verbal behaviors symptoms directed towards others - behavior did not occur, C. Other behavioral symptoms not directed towards others - behavior did not occur. Section G: Functional Status. G0110. Activities of Daily Living Assistance: H. Eating: 1 (supervision-oversight, encouragement or cueing). G0120 Bathing: Self-Performance: 3 (Physical help in part of bathing activity). G0300: Balance during transitions and walking: A. Moving from seated to standing position - 1 (not steady, but able to stabilize without human assistance. B. Walking (with assistive device if used) - 1 (not steady, but able to stabilize without human assistance).<BR/>During an observation on 02/19/23 at 11:00 AM, Surveyor witnessed a physical altercation between Resident #36 and Resident #45 on the men's secured locked unit. Resident #36 was standing in the dayroom area approximately 10 feet away from the doorway and as Resident #45 entered through the doorway, Resident #36 went up to him and hit him in the chest with a closed fist. Resident #45 fell into a chair, and he immediately got up and continued on his way. <BR/>In an interview on 02/22/23 at 10:10 AM, the Interim Administrator said she had spoken to SW-EJJ about Resident #36's behavior. She said Resident #36 had an Intellectual Developmental Disability and did not qualify to be sent to a psychiatric hospital. She also said his Guardian refuses to allow him to be sent to one. She said Resident #36's Guardian was a social worker at the group home he was previously staying at and said Resident #36 would be inappropriate for that care option. The Interim Administrator said she was not aware of the altercation between Resident #36 and Resident #45 on 02/19/23. She said Resident #36 should be on one-on-one monitoring to protect the other residents. <BR/>In an interview on 02/23/23 at 11:17 AM, CNA-JG and TNA-AL said they were never informed Resident #36 needed one-on-one monitoring. When asked how the other residents react when there are altercations between residents, they said the other residents get upset.<BR/>In an interview on 02/23/23 at 10:30 AM, SW-EJJ was asked why two residents were sent to a psychiatric hospital when there were behaviors related to physical altercation and Resident #36 continues to remain in the men's locked unit. SW-EJJ said Resident 36 had been in a group home all his life and his behaviors were mostly yelling and acting out. Usually going outside and walking around helps his behaviors and smoking calms him down. When asked, how do staff monitor his behaviors, she said we just monitor him, he sits and eats with another resident who keeps him calm. When asked about his history of previous altercations and behaviors hitting residents and it upsetting other residents, per staff. She said she personally had not witnessed any behaviors with altercations. When brought to her attention the altercation recorded in progress notes she said, she had not personally seen Resident #36 hit anyone. When asked how the facility protects residents from being hit by Resident #36, she said we monitor him. She said he could be sitting across from someone and reach over and punch someone, how can you anticipate what is going to happen.<BR/>In an interview on 02/23/23 at 12:37 PM, NP-KR said Resident #36 was difficult because he does not speak and was not able to express himself. She said, Resident #36's primary doctor had discontinued his Seroquel and his behaviors increased and she put him back on the Seroquel which seems to have help calm him down. As far as protecting the other residents from his behaviors, that is up to the facility. She said she was not aware he hit another resident on 02/19/23.<BR/>Record review of Resident #36's progress notes from 12/02/23 until 02/19/23 revealed the following behaviors related to altercations:<BR/>A. 12/02/2022 at 2:56 PM, Resident #36 was showing aggressive behavior to staff taking off shirt and yelling at staff.<BR/>B. 12/03/2022 at 3:39 AM, .Resident yelling, hitting his head and hit the exit door with his fist then ate a cigarette. <BR/>C. 12/04/2022 at 11:55 AM, CNA (unidentified) reported Resident #36 was standing in the living area when another resident was ambulating by him (Resident #36). Resident #36 let (Resident #40 - female) walk by him then hit her with closed fist (no location of where she was hit was identified). Residents were separated and taken out to smoke. No redness to resident who was hit noted at this time. <BR/>D. 12/08/2022 at 3:37 AM, After returning from smoke break resident (Resident #36) ate a cigarette. Staff tried to get cigarette from resident, he (Resident #36) began swinging fist and yelling. Quickly calmed and walked to room. <BR/>E. 01/09/2023 at 11:32 AM Resident (Resident #36) went out to have a cigarette and when he came inside, he was standing by the door and another resident (unidentified) walking fast came by him and he hit her on the left shoulder with his left hand. <BR/>F. 01/10/2023 at 12:31 PM, CNA (unidentified) reports, her, and another CNA (unidentified) had resident (Resident #36) in bathroom attempting to change brief when he (Resident #36) became combative.<BR/>G. 01/13/2023 at 5:12 PM, Resident cries and occasionally threatens staff with fist.<BR/>H. 02/19/2023 at 12:46 PM: Resident (#36) was standing up by the outside door and hit a Resident (identified as Resident #45 by staff (HA-LB who witnessed the event) when he came into the Unit from outside. He (Resident #36) hit him (Resident #45) in the chest. Residents were separated. (Progress notes did not indicate who separated the residents).<BR/>In an interview on 02/14/22 at 3:00 pm, the Corporate Regional Resource Nurse, said on January 10th, 2023, the facility moved 3 residents off the of Women's Secured Unit and moved 1 CNA to the general population which leaves only 1 staff on the unit (The census of the women's secured unit on 02/14/23, were a total of 6 residents with behavioral issues that required close supervision.) She stated I move staff to where they are needed, I'm not cutting staff no matter what they tell you. They might tell you they are short staffed, but they are not. She had an aide that goes to the unit whenever the CNA needs to give a resident a bath. When asked about how staff calls for help, she said they had walkie-talkies but they didn't work. Staff can use their personal cell phone to call for help. <BR/>In an interview on 02/15/23 at 9:15 am, CNA-JF stated there was not enough staff to provide adequate supervision for the residents on the female locked unit. She stated it was not safe with one person in the unit. She stated that the acuity was high due to behaviors, but Administration says that it was not. She stated that at times, they send staff who are not certified or aides such as the activity person to help. She said she usually worked by herself for the entire 12-hour shift. She said that if she needed help, she would have to go down the hallway, enter the keycode to unlock the door, open the door and call for help all while leaving the residents unsupervised as it is a long hallway. She said that she had permission to use her personal cell phone to call for help but no one will answer when she called. She said that Administration had told her that she sits the residents too close together, but she had nowhere for the residents to be as the unit was small. She said that during meals she was often by herself on the unit. She sat Resident #53 next to her because Resident #53 constantly required assistance and redirection. All the while she had to assist the other residents to eat and prevent another resident from constantly getting up and taking other residents drinks. She said it as a lot for one person to do. She also said she will only take a break or go to the bathroom when the LVN comes to administer medications or sometimes when the activity person comes into the unit. <BR/>In an interview on 02/15/23 at 11:00 am, with the Interim DON and Corporate Regional Resource Nurse, the Interim DON stated she talked to the Social Worker and Administrator that morning and told them they were not equipped to deal with Resident #53's behaviors. She stated, We are not a behavior unit, can we deal with these behaviors, yes, but it requires 1:1, 2:1, and sometimes even 3:1. When asked if she felt 1 staff on the Women's Secured Unit was sufficient, the Interim DON stated that 1 staff on the Women's Secured Unit was enough as the residents are a low acuity level and just custodial care. The Interim DON defined acuity level as medical needs only and stated she did not take into account behaviors when determining resident acuity. <BR/>In an observation on 02/15/23 at 3:50pm, Resident #53 was observed crawling on the floor with gait belt around her waist on the women's secured unit. The Interim DON was observed pulling on the gait belt to move the resident back.<BR/>In an interview on 02/16/23 at 11:40 am, CNA-JG stated: It's not safe for the other residents with only one CNA working on the women's locked unit alone and there's always only one CNA scheduled. There has been 2 CNAs for the last few days only because the state surveyors are in the building. CNA-JG said, we tell the DON all the time that we don't feel safe, and we need at least 2 CNAs back there, but they don't listen to us, and we're told to work it out. We have had some training, but no training ever received on how to provide care for residents who are aggressive or residents that have behavior problems.<BR/>In an observation and interview on 02/16/23 at 11:50 am, TNA-BM stated, I'm here on this unit today sitting 1:1 with Resident #53 because y'all (State Surveyors) are in the building, there's usually is only one CNA assigned. She stated it would be almost impossible for one person to care for the residents on the secure unit. We asked the DON and ADON all the time for more help, but we don't get any, and the residents suffer. TNA-BM stated, We have trainings, but I don't remember getting training on how to provide care for residents who are aggressive or residents that have behavior problems. TNA-BM was observed utilizing the gait belt around Resident #53's waist to restrict her movement and guide her away from other resident's multiple times.<BR/>In an interview on 02/16/23 at 3:00 pm, TNA-ML said she had been employed for 1 year at the facility and floated from unit to unit. She stated it is impossible to know the residents on different units if you don't get a report. She said, you just have to figure out the residents on all of the different units likes and dislikes as you go along. She stated there was supposed to be a Get to Know Me Book on each unit, but it usually was not in the place it is supposed to be, and if it was the staff are not given time to review it. The showers on the female locked unit are very difficult to complete if a resident was having behaviors when you arrive at work as there is only 1 CNA to deal with the situation. She also stated, I don't feel safe working alone on the female lock unit. Resident #53's mood and behaviors dictate the type of day every resident and staff on the unit are going to have. She stated she does not remember receiving training on how to provide care for residents who are aggressive and have behavior problems. She said concerning Resident #53, we were told to keep the other residents away from her utilizing the gait belt. <BR/>In an interview on 02/16/23 at 4:00 pm, CNA-DS stated there have been issues with Resident #53's behavior for a long time as she hit, scratched, bit, and kicked staff and residents. <BR/>In an interview with the Interim Administrator on 02/17/23 at 9:45 am, she stated she was aware there was a problem with staff scheduling and she had recently taken over the scheduling. She stated she scheduled the number of people to work. The charge nurses would assign the employees what hall they will be working on. She stated the facility did not write these assignments down and said she could not produce historic staffing sheets with assignments for each shift. She stated she could not tell where staff worked a week ago. <BR/>In an interview with the Interim Administrator 02/19/23 at 2:55 PM, she said the time clock does not always work properly. She said if the time clock does not work, the staff were expected to complete a paper time sheet and they were collected and put into the system within a day or two. She said the facility did not have records of staffing sheets with assigned halls for each shift worked. She denied any major incidents that had been attributed to staffing shortage, but stated it was possible that something could happen. <BR/>In an interview on 02/19/23 at 4:30 PM, the DON stated there was no way to tell which staff worked in which area of the facility on any given date. She stated the facility had recognized this being a concern and had put a new scheduling sheet in place that should make it easier to track this information. The DON stated if there was an allegation of abuse and neglect, there was no system in place to determine which staff was working in that area.<BR/>Record review of employee files revealed the facility was unable to produce evidence of training for staff on accidents, hazards, supervision, and performance evaluations to ensure the continuing competency of nurse's aides. <BR/>Record review of the facility policy Resident-to-Resident Altercations, dated as revised December 2016, revealed the following [in part]:<BR/>Policy Statement: All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator.<BR/>Policy Interpretation and Implementation: <BR/>1. Facility staff will monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator.<BR/>2. If two residents are involved in an altercation, staff will:<BR/>A. Separate the residents, and institute measures to calm the situation;<BR/>B. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation;<BR/>C. Notify each resident's representative and Attending Physician of the incident; <BR/>D. Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents; <BR/>F. Make any necessary changes in the care plan approaches to any or all of the involved individuals;<BR/>G. Document in the resident's clinical record all interventions and their effectiveness;<BR/>J. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident.<BR/>The facility failed to provide a policy relating to accidents/hazards/supervision by the time of exit on 02/24/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and complications associated with an indwelling catheter for number 1 of 2 (Resident #1) reviewed for catheters. <BR/>The facility failed to empty Resident #1's urinary catheter bag for two days, allowing the bag to fill overflowing up into the tubing that was inserted in the resident's bladder. The facility also failed to change the catheter when sediment was observed. Resident #1 was sent to a local hospital and diagnosed with sepsis (life threatening medical emergency related to the body's response to an infection) and a UTI.<BR/>An IJ was identified on 02/22/2023. The IJ template was provided to the facility on [DATE] at 4:55pm. While the IJ was removed on 02/24/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because the facilities need to complete in service training and evaluate their effectiveness of their plan of removal. <BR/>This failure placed residents at risk of not receiving care and services to prevent urinary tract infections or other issues related to bladder <BR/>Functioning.<BR/>Findings included:<BR/>Record review of Resident #1 face sheet dated 02/20/2023 revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 11/20/2022 with the following diagnoses: Unspecified fracture of left shaft/femur (bone in the thigh), Non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). <BR/>Record review of Resident #1 Discharge Minimum Data Set (MDS) Section C dated 09/19/2022 revealed in Section H (bladder and bowel) that she was frequently incontinent, 7 or more times episodes of incontinent, but 1 episode of continent). <BR/>Record review of Resident #1 Quarterly Minimum Data Set (MDS) Section C dated 11/15/2022 revealed in Section H (bladder and bowel) that resident had an indwelling catheter. <BR/>Observation and interview on 02/18/2023 at 10:15 AM, Resident #1's catheter bag was overflowing, urine in the tubing backing up. The catheter bag was leaking on the floor. Resident reported that it had not been drained in 2 days. The resident's urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. The DON was present with observation and visualized the catheter tubing and bag. When asked she said what she thought it was, she said that it appeared to be a puss like substance. She said that she was going to have it changed immediately. <BR/>Interview on 02/18/2023 at 1:20pm, the DON stated that indwelling catheter bags should always be covered. She also stated that catheter bags that are full of urine backflowing in the catheter tubing place the resident at risk for infections. She stated she did not know reason for overflow catheter bag with urine backflowing into the catheter . She said it was the nurses responsibility to change it. <BR/>Observation on 02/18/2023 at 3:58pm, revealed Resident #1 continued to have an indwelling catheter with an overfilled catheter bag with urine backflowing in the catheter tubing. The bag continued to be leaking urine onto the floor. The urine was cloudy, with sediment visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss. This observation was reported to the Corporate Regional Resource Nurse-J<BR/>Observation and interview on 02/19/2023 at 8:35 am, revealed Resident #1's catheter bag had been emptied; however, the catheter had not been changed and was observed to be crusted with sediment and puss like substance visible in the tubing. There was a trash bag on the floor under the uncovered catheter bag. Resident #1 stated that the trash bag was placed to catch the leaking urine from the catheter bag .<BR/>Interview on 02/19/2023 at 9:45 am, RN-V stated she had not gone to check Resident #1's catheter bag to check see if it had been drained or changed during previous day's shift. She reported it was delegated to her, but she was busy and had not had a chance to do it. <BR/>Interview on 02/19/2023 at 10:02 am, Corporate Regional Resource Nurse-J-J stated she had instructed RN-V to change Resident #1's catheter bag. She stated that RN-V reported that it had been changed. She collected a UA sample while changing it and would notify the physician . She stated that the catheter should have been changed due to the sediment. She said that she could see where there was an issue for concern. <BR/>Interview on 02/19/2023 at 11:04 am, the DON stated she asked LVN-O and RN-V to change Resident #1's catheter bag yesterday afternoon. She could not remember the exact time, but it was after lunch. She said she went back to Resident #1's rooms yesterday afternoon and it continued to not be completed. She then asked them again to complete the task. She stated this failure placed the residents at risk for an infection.<BR/>Interview on 02/19/2023 at 3:10pm, RN-V said she did not change Resident #1's catheter tubing but only changed the bag. She said she obtained a urine sample for an ordered UA from the catheter tubing that continued to have sediment and puss like substance but not from the bag. <BR/>Interview and observation on 02/19/23 03:15 PM, Corporate Regional Resource Nurse-J-J stated she instructed RN-V to change Resident #1's entire catheter on 02/18/2023.<BR/>Observation and interview on 02/19/2023 at 11:20 am, Resident #1 was speaking with surveyor without any distress. <BR/>Observation on 02/19/2023 at 2:57 pm, Resident #1 was observed unresponsiveness with emesis (vomiting) on chest by surveyors and Corporate Clinical Company Leader RN-I. Corporate Clinical Company Leader RN-I stated she had to check Resident #1's pulse because she wasn't sure if she was alive. <BR/>Interview on 02/19/2023 about 3:00pm, Resident #56 (Resident #1's roommate) said Resident #1 received her lunch tray about 12:00 pm and almost immediately started to throw up. Resident #56 then called for help, but no one came until about 2:00 pm. Resident #56 said that she told the staff that Resident #1 needed assistance, the staff was Assistant Administrator in Training who removed Resident #1's tray and stated, I can't help you and left the room. <BR/>Observation on 02/19/2023 at 3:25pm, Resident #1 was transferred to community hospital via EMS.<BR/>Interview on 02/19/2023 at 4:34pm, the DON said she looked at Resident #1's catheter yesterday (02/18/2023) and it appeared to have puss and sediment in the catheter tubing and catheter hub. She said it was her expectation that it was to be changed. She made an additional request for the catheter to be changed this morning by RN-V. The DON stated that she discovered that the Resident #1 left the facility (to the hospital) without a changed catheter tubing but only changed catheter bag. It was her expectation that it was changed yesterday. <BR/>Interview on 02/20/2023 at 3:57pm, CNA-Z stated Resident #1 had puss in her catheter tubing when she drained the catheter bag and performed incontinent care about 2 weeks ago. She stated she notified RN-V of the puss in resident's catheter tubing at that time. <BR/>Interview on 02/20/2023 at 04:04 PM, Resident #56 (Resident #1's roommate) said she presses the call light frequently and it takes a while to answer. She said that the lady that came to answer the call light after two hours of pressing it. She had long dark hair and was part of administration but did not work the floor. Resident #56 said that this staff went to the Resident #1 and said Oh, My God, when she saw the resident. Resident #56 said that the staff stated she couldn't help Resident #1 and left the room. Resident #56 said she thought the staff was coming back but never did. Resident #56 said that she could hear Resident #1 throwing up and gurgling. Resident #56 said no one changed their catheters. She said that yesterday (02/19/2023) the staff just changed the bag. Resident #56 said that the regional Hispanic nurse did in fact tell the nurse to just change the bag until she got caught up and that she could change it later. Resident #56 said it was the same nurse that told her in Spanish to butt out and put her hand to her mouth as in telling her to hush and she cut her eyes. <BR/>Interview on 02/20/23 04:34 PM, RN-V stated while in Resident's room that she was short of staff on 02/19/2023 and behind. She said that when the regional nurse came, she told her to change the catheter bag only. She said that she is often short staffed or without staff and can do what she can do. She said she is trying hard and stays for the residents. <BR/>Interview on 02/21/2023 at 4:46 PM, interview with Resident #1 family members A and B revealed that when they would come to see her, she would look malnourished , and her catheter bag was always full. <BR/>Review of Resident #1 physician orders dated 10/13/2022 revealed Foley Catheter: Size (10cc) FR (16) Diagnosis: Neurogenic bladder (lack bladder control due to brain, spine, or nerve problems)<BR/>Review of Resident #1's physician order dated 10/21/2022 revealed: Foley Catheter: May obtain urine sample via Foley Catheter Port as needed when a Urine Analysis is ordered. (If Foley Catheter has been in place greater than 14 days, change Foley Catheter before obtaining urine.) and Foley Catheter: Provide catheter care every shift. <BR/>Record review of Resident #1 electronic orders accessed on 02/20/2023 revealed there were orders to address her indwelling catheter. Resident #1 did have orders to change foley catheter and drainage bag as needed for indications of blockage, increased sediment, infection and displaced, as needed. <BR/>Record review of Resident #1 electronic care plan accessed on 02/20/2022 revealed the following: Problem - Resident #1 has Indwelling Foley Catheter: Goal - Resident will not show signs of urinary infection or urethral trauma. Interventions - Change catheter every per MD order, document urinary output; record the amount, type, color and odor, observe for leakage, keep catheter system a closed system as much as possible, position bag below level of bladder, provide catheter care as scheduled and PRN. Problem- Resident #1 has a urinary tract infection. Goal- resident will not exhibit signs of a urinary tract infection. Interventions- Administer Bactrim DS (antibiotic), encourage fluids, keep perineal area clean and dry and report signs or UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back pain/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine and blood in urine. Initiated date of 10/15/2022 and revised date of 01/31/2023.<BR/>Record review of Resident #1 most recent significant change Minimum Data Set (MDS) Section C dated 01/30/2023 revealed she had the ability to express ideas and wants and was able to understand others clearly. Resident #1 had a Brief Interview for Mental Status (BIMS) of 14 out of score of 15 which indicated an intact cognition. Resident #1 was extensive assistance for activities of daily living (ADL) except for eating where she required supervision.<BR/>Record review of Resident #1 significant change MDS on 01/30/2023 revealed Resident #1 had an indwelling catheter reported in section H: Bladder and Bowel. <BR/>Record review of Resident #1's vital reports, dated 02/21/2023, provided by Corporate Clinical Leader RN-H revealed the following documentation concerning Resident #1's catheter being drained, and the amount of urine noted, between 01/18/2023 until 02/19/2023, was not documented or done on- <BR/>o <BR/>01/20/2023 on day or night shift <BR/>o <BR/>01/21/2023 on day or night shift <BR/>o <BR/>01/22/2023 on day or night shift<BR/>o <BR/>01/23/2023 on day shift<BR/>o <BR/>01/24/2023 on day or night shift<BR/>o <BR/>01/25/2023 on day or night shift<BR/>o <BR/>01/26/2023 on day or night shift<BR/>o <BR/>01/27/2023 on day shift<BR/>o <BR/>01/28/2023 on day or night shift<BR/>o <BR/>01/29/2023 on day or night shift<BR/>o <BR/>01/30/2023 on day or night shift<BR/>o <BR/>01/31/2023 on day or night shift<BR/>o <BR/>02/01/2023 on day or night shift<BR/>o <BR/>02/02/2023 on day shift<BR/>o <BR/>02/03/2023 on day shift<BR/>o <BR/>02/04/2023 on day or night shift<BR/>o <BR/>02/05/2023 on day shift<BR/>o <BR/>02/06/2023 on day or night shift<BR/>o <BR/>02/07/2023 on day or night shift<BR/>o <BR/>02/08/2023 on day shift<BR/>o <BR/>02/09/2023 on day or night shift<BR/>o <BR/>02/10/2023 on day or night shift<BR/>o <BR/>02/11/2023 on day or night shift<BR/>o <BR/>02/12/2023 on day shift<BR/>o <BR/>02/13/2023 on day or night shift<BR/>o <BR/>02/14/2023 on day or night shift<BR/>o <BR/>02/15/2023 on day or night shift<BR/>o <BR/>02/16/2023 on day shift<BR/>Record review of hospital record dated 02/19/2023 at 8:48pm History and Physical, revealed the following physician's notes- We sent her to the ICU Again, clinically it just seems to be a very ill patient, who was sent from the nursing home for an honestly a bogus reason at this point. At any rate from what I can gather she had left sided weakness from a prior stroke, but today currently it seems like she is not moving the right side, so we will get MRI of the brain. She does have a UTI in her labs, which will be treated. <BR/>Record review of Resident #1's community hospital records revealed dated 02/19/2023, Resident #1 was admitted into community hospital ICU with diagnosis of UTI & rule out stroke.<BR/>Record reviewed on Resident #1's community hospital records labs, assessment and plan dated 02/19/2022 revealed, Resident #1 had a primary diagnosis of Urinary Tract Infection, with orders to check cultures, place her on ceftriaxone (antibiotic) <BR/>Record review of hospital records dated 02/21/2023 revealed that Resident #1 had a diagnosis of Sepsis (A life threatening complication or infection. Sepsis occurs when chemicals released in the bloodstream to fight an infection throughout the body. This can result in multi organ system failure and even death). <BR/>Records review of hospital records dated 02/21/2023 Resident #1's Assessment and Plan revealed:<BR/>1. <BR/>UTI in the setting on chronic indwelling foley catheter. Urine culture grew E coli. Blood cultures grew gram positive cocci. Start IV Vancomycin and Rocephin (antibiotics). <BR/>2. <BR/>Bacteremia: Blood culture grew gram positive cocci. Start IV Vancomycin (antibiotic) and Rocephin (antibiotic).<BR/>Record review of the facilitates policy titled Catheter Care, Urinary; dated September 2014 revealed:<BR/>Purpose: <BR/>The purpose of this procedure is to prevent catheter-associated urinary tract infections.<BR/>Preparations: <BR/>1. <BR/>Review the resident's care plan to assess for any special needs of the resident.<BR/>2. <BR/>Assemble the equipment and supplies as needed.<BR/>General Guidelines:<BR/>1. <BR/>Following aseptic insertion of the urinary catheter, maintain a closed drainage system.<BR/>2. <BR/>If it breaks in aseptic technique, disconnection or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered.<BR/>Input/Output: <BR/>1. <BR/>Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. <BR/>2. <BR/>Maintain an accurate record of the resident's daily output, per facility policy and procedure. <BR/>Maintaining Unobstructed Urine Flow:<BR/>1. <BR/>Check the resident frequently to be sure he/she is not lying on the catheter and to keep the catheter and tubing free of kinks.<BR/>2. <BR/>Unless specifically ordered, do not apply a clamp to the catheter.<BR/>3. <BR/>The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine tubing and drainage from flowing back into the urinary bladder.<BR/>Infection Control: <BR/>1. <BR/>Use standard precautions when handling manipulating the drainage system.<BR/>2. <BR/>Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag.<BR/>a. <BR/>Do not clean the periurethral area with antiseptics to prevent catheter associated UTI's while the catheter is in place. Routine hygiene.<BR/>b. <BR/>Be sure the catheter tubing and drainage are kept off the floor.<BR/>c. <BR/>Empty the drainage bag regularly using a separate, clean collection container for each resident. <BR/>d. <BR/>Empty the collection bag at least every 8 hours.<BR/>Changing Catheters:<BR/>1. <BR/>Changing indwelling catheters or drainage bags as routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstructions, or when the closed system is compromised.<BR/>Complication:<BR/>1. <BR/>Observe the resident for complications associated with urinary catheters.<BR/>a. <BR/>If the resident indicates that his/her bladder is full or that he/she needs to void, notify the physician.<BR/>b. <BR/>Check the urine for unusual appearance (color, blood).<BR/>c. <BR/>Notify the physician or supervisor in the event of bleeding, or if the catheter is accidently removed,<BR/>d. <BR/>Report any complications that the resident may have of burning, tenderness, or pain in the urinary area.<BR/>e. <BR/>Observe for signs or symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately. <BR/>Specimen Collection:<BR/>1. <BR/>If a small volume of urine is needed for a urinalysis or culture, cleanse the port with a disinfectant and aspirate from the needless port using a sterile syringe ir cannula adapter. <BR/>Documentation:<BR/>The following information should be recorded in the resident's medical record.<BR/>1. <BR/>The date and time the catheter care was given.<BR/>2. <BR/>The name and title of the individual giving the care<BR/>3. <BR/>All assessment data obtained when giving catheter care. <BR/>4. <BR/>Character of urine such as color (straw colored, dark, or red) clarity (cloudy, solid particles, or blood, and odor.<BR/>5. <BR/>Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain.<BR/>6. <BR/>Any problems or complaints made by the resident related to the procedure. <BR/>7. <BR/>How the resident tolerated the procedure.<BR/>8. <BR/>If the resident refused the procedure, the reasons why the interventions taken.<BR/>9. <BR/>The signature and title of the person recording the data.<BR/>Reporting:<BR/>1. <BR/>Notify the supervisor if the resident refuses the procedure.<BR/>2. <BR/>Report the information in accordance with the facility policy and professional standards of practice. <BR/>Record review of U.S. National Library of Medicine Medline Plus (https://medlineplus.gov/ency/article/003981.htm) electronically accessed on 03/01/2023 revealed the following: Indwelling catheter care. When to Call the Doctor. A urinary tract infection is the most common problem for people with an indwelling urinary catheter. Call your health care provider if you have signs of an infection, such as: Pain around your sides or lower back. Urine smells bad, or it is cloudy or a different color. Fever or chills. A burning sensation or pain in your bladder or pelvis. Discharge or drainage from around the catheter where it is inserted into your body. You do not feel like yourself. Feeling tired, achy, and have a hard time focusing. Also call your provider if: Your urine bag is filling up quickly, and you have an increase in urine. Urine is leaking around the catheter. You notice blood in your urine. Your catheter seems blocked and not draining. You notice grit or stones in your urine. You have pain near the catheter. You have any concerns about your catheter. Changing Your Catheter, you will need to change the catheter about every 4 to 6 weeks. Always wash your hands with soap and water before changing it. When to Call the Doctor. Your catheter seems blocked. You notice grit or stones in your urine. Your supplies do not seem to be working (balloon is not inflating or other problems). You notice a smell or change in color in your urine, or your urine is cloudy. You have signs of infection (a burning sensation when you urinate, fever, or chills).<BR/>This was determined to be an Immediate Jeopardy (IJ) on 02/22/2023 at 4:55 pm. The Interim Administrator, Corporate Survey Resource Personnel, Corporate Regional [NAME] President of Operations, and two (2) Corporate Clinical Company Leader RNs were notified. The Interim Administrator was provided with the IJ template on 02/22/2023 at 4:55 pm.<BR/>The following Plan of Removal was accepted on 02/23/2023 at 7:58pm and included:<BR/>Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 2/22/2023. <BR/>Action 1: <BR/>Resident #1 discharged to an acute care hospital for further evaluation on 2/19/2023. <BR/>Action 2: <BR/>The Director of Nursing and or/designee will in-service all nurses regarding resident assessment and charting/documentation. <BR/>The Director of Nursing and/or designee will in-service all nurses regarding foley catheter care. <BR/>The Director of Nursing and/or designee will in-service all CNAs, TNAs, Hospitality Aides regarding reporting foley catheters holding sediment/being foggy to the charge nurse and ensuring that they are emptying the bag as needed. <BR/>If the CNAs, TNAs, Hospitality Aides feel as if their concerns are not being followed through, they are to report immediately to the Director of Nursing this will be made evident through communication with the CNAs, TNAs, Hospitality Aides and their Director of Nursing. If the CNAs, TNAs, Hospitality Aides feel as if the charge nurse and nursing administration is not following up they should immediately report to their administrator. <BR/>How will the facility ensure that care needs are being communicated up the chain?<BR/>The facility will ensure care needs are communicated up the chain through open communication, rounding and speaking with staff/listening to their concerns, and facility's communication with their corporate support team. <BR/>How will missed treatments be communicated from shift to shift?<BR/>Nurses will be in-serviced to communicate, this communication can be verbal, 72-hour report/facility activity report (72-hour report/facility activity report contains new orders, progress notes written, discontinued orders, event reports, vitals outside of normal range, opened or created observations), and/or via telephone, to their nursing administration regarding missed treatments, as well as, communicating shift to shift on missed treatments. <BR/>Who will be monitoring that the nurses have an understanding of the importance to communicate identified issues with other shifts and administration?<BR/>The Director of Nursing, Administrative Nurses, and Administrator will monitor that the nurses have the understanding of the importance to communicate via writing on the 72-hour report/facility activity report, verbally, and/or via telephone identified issues with other shifts and administration by education, morning clinical meetings/review of the 72-hour report/activity report with nurses, nursing administration, and administration, and nursing-to-nurse report. <BR/>How will the facility ensure that Nurses and CNA's have a good understanding of individual resident care needs and who is monitoring their competency?<BR/>Nurses and Nurse Aides will have a good understanding of individual care needs by understanding on how to pull the residents' care plans from the electronic medical record. This action will be in-serviced. <BR/>The Director of Nursing and/or designee will ensure competency through requesting staff to demonstrate understanding, at random, 3 times weekly, for 4 weeks. <BR/>All indicated staff will be in-service immediately prior to working their next shift. All new and temporary (internal/external agency) staff will be in-serviced over the above information, the administrator and/or <BR/>Director of Nursing will ensure this by checking the schedule and ensuring a designee will in-service the material for anyone on the schedule that has yet to be in-serviced. <BR/>Date: 2/23/2023<BR/>Person(s) Responsible: Administrator and Director of Nursing <BR/>Action 3: <BR/>On 2/20/2023 the Clinical Company Leaders, Regional Resource Nurse-J, and/or designee completed foley catheter rounds to ensure all foley catheters are in good condition and changed those that were needed. <BR/>All residents' orders with indwelling catheters were reviewed by Clinical Company Leaders, Regional Resource Nurse-J, and/or designee. Clinical Company Leaders, Regional Resource Nurse-J, and/or designee validated the foley/suprapubic catheter order set was entered in the resident's chart. No additional identified areas of concern on 2/20/2023. <BR/>Date: 2/22/2023<BR/>Person(s) Responsible: Clinical Company Leaders, Regional Resource Nurse-J, and/or designee<BR/>Action 4: <BR/>Three times a week Director of Nursing will complete random audits on foley catheters and foley catheter documentation for 4 weeks. Director of Nursing will share findings with administrator and educate staff/perform a skills check off as needed. <BR/>Date: 2/22/2023<BR/>Person(s) Responsible: Director of Nursing and Administrator<BR/>Action 5: <BR/>Ad Hoc QAPI meeting performed with administrator, DON, corporate team and Medical Director. <BR/>Date: 2/22/2023<BR/>Person(s) Responsible: Administrator<BR/>Monitoring of facilities Plan of Removal through observations, interviews, and record reviews from 02/23/2023 at 7:58pm to 02/24/2023 at 6:48pm revealed:<BR/>Resident #1 was transferred to local acute care hospital for further evaluation on 02/19/2023.<BR/>Facility provided documentation of completion of foley catheter rounds ; and Ad Hoc QAPI meeting performed. <BR/>Interviews on from 02/23/2023 at 7:58pm to 02/24/2023 at 6:48pm with 5 CNAs, 2 TNAs, and 1 Hospitality aide revealed they had been educated on foley catheters and communication. <BR/>Interviews on from 02/23/2023 at 7:58pm to 02/24/2023 at 6:48pm with 7 nurses revealed they had been educated foley catheter care and communication <BR/>The Interim Administrator, Corporate Survey Resource Personnel, Corporate Regional [NAME] President of Operations, and two (2) Corporate Clinical Company Leader RNs were informed the Immediate Jeopardy was removed on 02/24/2023 at 6:48pm. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an acceptable parameter of nutritional status was maintained for 1 of 4 residents (Resident #645) who were reviewed for nutritional status, in that:<BR/>1. Resident #645 had a significant weight loss of 14 pounds, a 9.52% loss, in a six (6) day period.<BR/>2. Resident #645's physician was not notified of the weight loss, and no nutritional interventions were implemented as a result.<BR/>This failure could place the resident at risk for compromised nutritional and health status and continued weight loss. <BR/>The findings included:<BR/>Review of Resident #645's Face Sheet, dated 2/23/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: systemic lupus erythematosus (autoimmune disease where the body attacks itself); gastro-esophageal reflux disease without esophagitis (heartburn that burns the throat); rheumatoid arthritis, unspecified (autoimmune arthritis that affects the joints); essential (primary) hypertension (high blood pressure); heart failure, unspecified (failure of the heart to function properly); venous insufficiency (poor circulation of extremities); pain, unspecified; and generalized anxiety disorder. <BR/>Review of Resident #645's weight history revealed a height of 64 inches and an initial recorded weight of 147.4 pounds on 2/06/23, 147 pounds on 2/09/23, and 133 pounds on 2/15/23. The resident had a weight loss of 9.77% in 9 days and a weight loss of 9.52% in 6 days.<BR/>Review of Resident #645's Nutrition Assessment, dated 2/10/23, revealed a documented height of 64 inches and a weight of 147 pounds. The Registered Dietician documented the Resident able to eat independently, consumed 76-100% of meals, and was likely meeting estimated needs at that time. The Registered Dietician noted future weight loss was likely related to receiving hospice services, the resident was at risk for dehydration related to receiving Lasix (diuretic medication), and there were no weight changes since admission. The recommendation was to continue weekly admit weights with a goal to maintain weight at a 1-2% gain or loss. There were no further documented nutrition assessments or notes in the resident's electronic health record.<BR/>Review of Resident #645's current physician orders, dated 2/22/23, revealed an order dated 2/04/23 for a regular diet with regular texture with thin consistency fluids. There were no documented orders for nutritional supplements. The orders included an order dated 2/04/23 for Weight on admission and then weekly on Monday for 3 Weeks.<BR/>Review of the progress notes for Resident #645 on 2/23/23 revealed there was no documented evidence the resident's physician, representative, or the dietician had been notified regarding the resident's significant weight change.<BR/>Review of Resident #645's Hospice medical record (paper chart) on 2/23/23 revealed there was no documented evidence the Hospice Physician or Hospice Nurse had addressed the resident's weight loss.<BR/>Review of Resident #645's admission MDS Assessment, dated 2/13/23, revealed a BIMS had not been completed. The resident was assessed as having short-term and long-term memory problems, moderately impaired decision-making skills, required supervision while eating, was 64 inches tall and weighed 147 pounds, and did not receive a therapeutic diet or mechanically altered diet.<BR/>Review of Resident #645's comprehensive care plan, dated 2/07/23, revealed it addressed ADLs with the resident performing the task of eating meals three times daily and a bedtime snack at her highest practicable level, and nutritional status with a goal to maintain stable weight and approaches to record meal percentages and weigh monthly.<BR/>Observation on 2/19/23 at 12:53 PM revealed Resident #645 was seated in the armchair in her room and was being fed the lunch meal by the Assistant Administrator. Resident #645 was served a regular diet consisting of chili, cornbread, Mexican style corn, and peach parfait for dessert. She was served 2 glasses with iced tea of thin consistency. Resident #645 drank 1 glass of iced tea and ate almost 100% of her meal with the staff member's assistance. <BR/>In an interview on 2/18/23 at 10:27 AM, the family members of Resident #645 stated the resident had end-stage lupus and was more confused now. The family members stated Resident #645 was in the hospital and came to the facility about two weeks ago and was receiving Hospice care services. The family members stated the facility seemed to be short staffed. They stated they had arrived one evening to visit about one week ago and there was food all over the floor in the resident's room. They stated the food was from the lunch meal. The family stated Resident #645 fed herself and her hand was not too steady. They stated she spilled food while trying to eat. <BR/>In a telephone interview on 2/20/23 at 11:56 AM, Resident #645's representative voiced concern that the resident no longer knew how to feed herself, needed assistance to eat and was not being fed by staff. She stated she thought the resident had lost weight.<BR/>In an observation and interview on 2/22/23 at 12:32 PM, charge nurse LVN-P was feeding Resident #645 the lunch meal in her room. The meal included roast beef with brown gray and sliced carrots. LVN-P stated the resident really did need assistance to eat and needed to be fed. Resident #645 picked up the remote control to the television and tried to put it in her mouth and LVN-P stopped her. The LVN stated Resident #645 was eating well today.<BR/>In an interview on 2/23/23 at 12:15 PM, the MDS-LVN stated she did not have a specific date as to when significant weight losses were identified. She stated the Corporate Regional Resource Nurse-J had notified all the residents' responsible parties and physicians regarding residents' significant weight loss and had documented a progress note in the residents' electronic health records. She stated there were 26 residents that would have significant change in condition MDS assessments completed due to weight loss, and Resident #645 was on the resident list for significant weight loss. She stated the resident's significant weight loss was identified on the day when the survey team brought resident weight losses to the facility's attention. MDS-LVN stated Resident #645's Significant Change MDS Assessment was dated 2/20/23 (Monday) and was still in the process of being completed. Advised MDS-LVN that review of Resident #645's electronic health record progress notes revealed no documentation the resident's responsible party or physician had been notified regarding the resident's weight loss. MDS-LVN stated the Corporate Regional Resource Nurse-J may have documented notification in the residents' progress notes prior to Resident #645 being identified as having had a weight loss.<BR/>In an interview on 2/23/23 at 2:22 PM, the Corporate Survey Resource Personnel-L stated she was not sure when residents' significant weight losses were identified. She stated the responsible party, physician, and dietician were supposed to be notified.<BR/>In an interview and record review on 2/23/23 at 1:30 PM, the Corporate Clinical Resource Nurse provided a copy of the facility's policy and procedure for weight loss. The policy was entitled Nutrition Interventions to Avoid Weight Loss and Dehydration During COVID-19. The Corporate Clinical Resource Nurse stated that was the only policy she could find for weight loss and nutrition.<BR/>In an interview and record review on 2/23/23 at 4:00 PM, the Corporate Clinical Resource Nurse provided a copy of Resident #645's meal intake report. The report was titled Vitals Report dated 9/23/2022 - 2/23/2023 and only listed the dates and the meals served - breakfast, lunch, dinner, and bedtime snack - and did not document the percentage of the meal intake. The Corporate Clinical Resource Nurse stated the report was all she was able to access, and it was all they had.<BR/>Review of Resident #645's Vitals Report for meals, dated 9/23/22 - 2/23/23, revealed the first meal recorded was the dinner meal and a bedtime snack on 2/07/23 and the most recent meal recorded was breakfast on 2/16/23. The meal intake percentages were not recorded. <BR/>There were no meals documented as follow:<BR/>- 2/04/23 through 2/06/23: no meals; <BR/>- 2/07/23: no breakfast or lunch;<BR/>- 2/08/23: no breakfast or lunch;<BR/>- 2/09/23: no meals;<BR/>- 2/10/23: no breakfast or lunch;<BR/>- 2/12/23: no dinner;<BR/>- 2/14/23: no meals;<BR/>- 2/15/23: no meals;<BR/>- 2/16/23: no lunch or dinner;<BR/>- 2/17/23 through 2/23/23: no meals.<BR/>Review of the facility's policy and procedure for Nutrition Interventions to Avoid Weight Loss and Dehydration During COVID-19, dated as revised 4/10/20, revealed the following [in part]:<BR/>Policy: <BR/>The facility is committed to assisting residents in maintaining and maximizing their nutritional status during the COVID-19 pandemic and non-communal dining restrictions. Residents eating in their rooms may have decreased intake due to lack of socialization and visits from family .<BR/>Procedures:<BR/>1. Nursing and hospitality staff members will accurately monitor resident oral intake at meals and document in the medical record. Residents noted to have intake 50% or less for 3 days will be flagged for staff review .<BR/>2. Food first will be used to meet the needs of residents with weight loss, poor intake or increased nutrient needs whenever possible. Staff should obtain new food preferences from the resident and alert the dietary manager of new requests to update the tray ticket. For residents with fair to good intake, staff is to provide additional calories using high-calorie, high-protein foods at meal times .<BR/>5. Use of fortified foods at each meal should be sued to provide additional calories and protein for residents unable to meet estimated calorie and/or protein needs with current intake. Increasing the number and types of fortified foods may result in greater acceptance of fortified foods .<BR/>6. Nursing and hospitality staff should ensure that all residents are receiving adequate fluid intake each day .<BR/>10. All nutritional supplements will be ordered by the physician and placed on the Medication Administration Record (MAR). The percent intake of supplements will be recorded on the MAR. Nursing will note any resident refusing supplements for three days and alert the facility RDN that an alternate plan of care needs to be created.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure that 3(Residents #2, #10, and #13) of 9 residents reviewed for respiratory care were provided care consistent with professional standards of practice in that:<BR/>Resident #2, #10, #13, and did not have their small volume nebulizer mask or mouthpiece bagged when not in use.<BR/>This deficient practice could place residents who received oxygen and treatments at risk of respiratory infection.<BR/>Findings include:<BR/>Resident #2<BR/>Review of Resident #2's admission Record, dated 02/23/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses Alzheimer's disease, muscle weakness, dysphasia (difficulty swallowing), and acute respiratory infection. <BR/>Review of Resident #2's quarterly MDS Assessment, dated 12/22/22 revealed she had ordered respiratory therapy treatments. <BR/>Review of Resident #2's Progressive Notes, 02/23/23, revealed resident is being monitored for active infection. Transmission precautions in place. <BR/>Review of Physician Orders dated 08/16/2022 revealed ipratroprium-bromide 0.5 mg (3ml) normal saline one ampule as needed.<BR/>During observation on 02/19/2023 at 7:20 AM (medication observation) RN-V was taking glucometer checks with resident who were diabetic (inability to produce sufficient insulin for blood sugars), Resident #2 was the roommate of the resident being checked for blood sugars. Resident #2 had a nebulizer set up which included nebulizer cup and mask uncovered laying on Resident #2's personal refrigerator. Small amount of medication remained in the bottom of the nebulizer cup. <BR/>Resident #10<BR/>Review of Resident #10's admission Record, dated 02/23/23, revealed he was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecific lower respiratory tract infection, hypokalemia (low potassium in blood) nausea vomiting diarrhea, muscle weakness and Parkinson's disease. <BR/>Review of Resident #10's quarterly MDS dated [DATE] revealed she had a BIMS of 15 indicating she was cognitively intact and able to make her needs known. <BR/>Review of Resident #10's care plan, updated 12/28/22, revealed: Focus: In effective breathing due to Parkinson's disease. Approach: Administer oxygen at 2 liters a minuet via nasal cannula. Interventions/Tasks: Bronchodilators via nebulizer as ordered by physician.<BR/>Review of Physician Orders dated 12/13/2022 revealed ipratroprium-bromide 0.5 mg (3ml) (bronchodilator-medication that opens the airways) normal saline every 4 hours as needed for shortness of breath. Continuous oxygen at 2 liters per nasal cannula. Oxygen tubing to be changed weekly on Sundays <BR/>During an observation on 02/23/2023 at 4:00 PM Resident #10's nebulizer and mask was laying on top of the compressor that drives the device to nebulize the medication to inhale; uncovered with small amounts of medication remaining in the bottom of the medication cup in the nebulizer device. <BR/>During an interview on 02/23/2023 at 4:05 PM Resident #10 said she often puts the nebulizer and mask on the bed beside her until the nurse or aide comes and put it up. When it was revealed, the nebulizer was not in the bag she said she thought it should be. Resident #10 said the nurse will put the nebulizer back in the bag when is thinks about it or when it is time for the next breathing treatment. <BR/>Resident #13<BR/>Review of Resident #13's admission Record, dated 02/23/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses Alzheimer's disease, muscle weakness, dysphasia, and seasonal allergies. <BR/>Review of Resident #13's quarterly MDS dated [DATE] revealed she required oxygen therapy - no days using nebulizer beathing therapy.<BR/>Review of Resident #13's Care Plan dated 05/04/2022 revealed the following: Problem: Resident required oxygen during sleep disorder. Goal: Resident will not exhibit signs of hypoxia (low oxygen in blood)<BR/>During observation on 02/19/2023 at 7:40 AM (medication observation) RN-V was taking glucometer checks with resident who were diabetic, and Resident #13 was the roommate of the resident being checked for blood sugars. Resident #13 had a nebulizer set up with mouthpiece uncovered with a bag missing, laying on top of Resident #13's walker. <BR/>During interview on 02/19/2023 at 7:50 AM RN-V said she only check blood sugars and gives insulin, the medication nurse was responsible for making sure the nebulizers are put up. She said she is the charge nurse on Station 1 but did not reveal her knowledge regarding how or when nebulizers should be stored. <BR/>Review of website https://www.orovillehospital.com/ dated 02/28/2023 revealed the defines the responsibility of the Charge Nurse: The Charge Nurse is responsible for the smooth and efficient patient flow within the clinic. Delegates assignments and provides supervision for the support staff in accordance with their level of training and the patient's acuity. Works, in cooperation with medical providers to ensure the quality of patient care<BR/>During an Interview on 02/23/2023 at 2:05 PM the Corporate Survey Resource Personnel-L stated her expectation were that nebulizers should be bagged when not in use. <BR/>Review of facility's policy titled; Oxygen Administration dated October 2006 revealed the following:<BR/>Documentation:<BR/>1. <BR/>Date and time procedure was performed.<BR/>Review website https://www.ncbi.nlm.nih.gov viewed on 02/28/2023 revealed the following regarding maintaining infection control related to small volume nebulizers.<BR/>o <BR/>Clean and disinfect the nebulizer accessories using liquid/hospital-grade disinfectants such as isopropanol (70%) or hydrogen peroxide (3%)[38]<BR/>o <BR/>Cleaning and disinfection of common areas and surfaces (doorknobs, bedrails, table-tops, light switches, and patient handsets) should also be taken care of[37,39]<BR/>o <BR/>Hospital-grade cleaning and disinfecting agents are recommended for all horizontal and frequently touched surfaces?

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents were seen by a physician at least every 60 days for 5 of 7 (Resident # 3, 11, 41, 49, 51) reviewed for physician visits.<BR/>The facility failed to have Resident #3 seen by a physician since 12/04/22.<BR/>The facility failed to have Resident #11 seen by a physician since 12/04/22.<BR/>The facility failed to have Resident #41 seen by a physician since 11/11/22.<BR/>The facility failed to have Resident #49 seen by a physician since 12/03/22.<BR/>The facility failed to have Resident #51 seen by a physician since 12/03/22.<BR/>These failures placed residents at risk of a decline in health status or untreated conditions.<BR/>Findings included:<BR/>Record Review of Resident #3 Quarterly MDS dated [DATE] revealed: A [AGE] year-old male with an admission date of 12/21/18. He had an active diagnosis list that included: Cerebral Infarction (Primary), CAD, CHF, HTN, PVD, Stroke, Hemiparesis.<BR/>Record Review of List of Resident Last Primary Physician Visit printed 02/23/23 revealed: Resident #3 was last seen by the Primary Physician on 12/04/22. <BR/>Record Review of Resident #11 Quarterly MDS dated [DATE] revealed: A [AGE] year-old male with an admission date of 04/03/22. He had an active diagnosis list that included: Schizoaffective disorder, Manic type (Primary), Anemia, Diabetes Melitus, Dementia, Malnutrition, COPD. <BR/>Record Review of List of Resident Last Primary Physician Visit printed 02/23/23 revealed: Resident #11 was last seen by the Primary Physician on 12/04/22. <BR/>Record Review of Resident #41 Annual MDS dated [DATE] revealed: A [AGE] year-old female with an admission date of 05/30/22. She had an active diagnosis list that included: Type II Diabetes Melitus (Primary), HTN, GERD, Neurogenic bladder, Hyperlipidemia, Thyroid disorder, Dementia, Anxiety disorder, Depression, Schizophrenia, PTSD, Colostomy status.<BR/>Record Review of List of Resident Last Primary Physician Visit printed 02/23/23 revealed: Resident #41 was last seen by the Primary Physician was 11/11/22.<BR/>Record Review of Resident #49 Quarterly MDS dated [DATE] revealed: A [AGE] year-old male with an admission date of 12/09/21. He had an active diagnosis list that included: Cancer (unspecified), CHF, HTN, Hyperlipidemia, Stroke, Dementia, COPD, Colostomy status. <BR/>Record Review of List of Resident Last Primary Physician Visit printed 02/23/23 revealed: Resident #49 was last seen by the Primary Physician on 12/03/22.<BR/>Record Review of Resident #51 Quarterly MDS dated [DATE] revealed: A [AGE] year-old female with an admission date of 07/27/22. She had an active diagnosis list that included: Chronic respiratory failure with hypoxia (Primary), HTN, Diabetes Melitus, Depression, Morbid obesity, Chronic atrial fibrillation. <BR/>Record Review of List of Resident Last Primary Physician Visit printed 02/23/23 revealed: Resident #51 was last seen by the Primary Physician on 12/03/22.<BR/>During an interview on 02/24/23 at 10:30AM, ADM said she could not find any other information to indicate that the residents had been seen by their primary physician any more recently than her list provided. She said she was aware that regulation stated that a resident needed to be seen by their primary physician at a minimum of every 60 days. ADM said that the scheduling and/or tracking of physician visits would be something that the DON would keep track of and felt that the failure in the physician visits was due to the recent changes of old and new DON's. The current DON had only been in the facility for approximately a week at that point. She said it could be a task to have for ADON's in the absence of a DON, however, they had recent changes with ADON staff as well. ADM said she did not understand why the physician had not seen the identified residents in so long, as he was usually in the facility every 2 weeks. <BR/>During an interview on 02/24/23 at 6:45PM, ADM said she had no additional evidence to provide. <BR/>Record Review of Facility Policy labeled Attending Physician Responsibilities last revised 10/21 revealed: the attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirement, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. The visit schedule will be at least every 30 days for the first 90 days after admission, and then at least every 60 days thereafter. The physician will maintain progress notes that cover pertinent aspects of a residence medical condition and his or her current status and goals. Periodically Cortana the physician's documentation should indicate review and acknowledgement of a resident's program of care. The review should be extensive enough to ensure that the current approach overall is consistent with the individual's medical conditions, goals, prognosis, and wishes. During visits, the attending physician will determine each resident's overall condition and the status of specific medical issues by seeing and evaluating the individual, speaking with staff (as needed) and (as indicated) with responsible parties/families, and reviewing relevant information. At the time of the visit, the physician will respond to questions and concerns such as the status of medical issues (including any acute episodes of illness since the last visit), diagnostic test results, impact of medical condition on the individuals functional, physical, or cognitive status, and continued relevance of current medications and treatment. At each visit, the attending physician will provide a progress note (written, typed, or electronic) in a timely manner for placement in the medical record. The note should either be written or entered at the time of the visit or, if dictated or otherwise prepared after the visit, should be returned to the Center for placement on the chart within a week. Overtime, these progress notes should address significant active problems and risk factors, reasons for changing or maintaining current treatments or medications, and an evaluation of how medical treatments related to the individual's overall function and quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing care to attain or maintain the highest practicable physical, mental, and psychosocial well-being for # of # Residents reviewed for sufficient staffing.<BR/>1. <BR/>The facility failed to ensure there was sufficient staffing for 02/17/2023 6:00pm-6:00am shift with a facility census of 91 residents where 4 residents were total dependent on transfers.<BR/>2. <BR/>The Assistant Administrator was assisting Resident #645 to eat lunch meal in her room. The Assistant Administrator had no training on assisting resident with eating.<BR/>These failures could place residents at risk of not receiving care and services to meet their needs<BR/>Findings include:<BR/>Review of facility times sheets for 02/17/2023 revealed only two staff (CNA-AG and LVN-AC) were the only staff working in the facility with census of 91 residents where 4 residents were total dependent on transfers from 6:00 PM until 6:00 AM.<BR/>Review of Resident #645's Face Sheet, dated 2/23/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: systemic lupus erythematosus (autoimmune disease where the body attacks itself); gastro-esophageal reflux disease without esophagitis (heartburn that burns the throat); rheumatoid arthritis, unspecified (autoimmune arthritis that affects the joints); essential (primary) hypertension (high blood pressure); heart failure, unspecified (failure of the heart to function properly); venous insufficiency (poor circulation of extremities); pain, unspecified; and generalized anxiety disorder. <BR/>Review of Resident #645's admission MDS Assessment, dated 2/13/23, revealed a BIMS had not been completed. The resident was assessed as having short-term and long-term memory problems, moderately impaired decision-making skills, required supervision while eating, was 64 inches tall and weighed 147 pounds, and did not receive a therapeutic diet or mechanically altered diet.<BR/>Review of Resident #645's current physician orders, dated 2/22/23, revealed an order dated 2/04/23 for a regular diet with regular texture with thin consistency fluids.<BR/>In an interview on 2/18/23 at 10:27 AM, the family members of Resident #645 stated the facility seemed to be short staffed. They stated they had arrived one evening to visit about one week ago and there was food all over the floor in the resident's room. They stated the food was from the lunch meal. The family stated Resident #645 fed herself and her hand was not too steady. They stated she spilled food while trying to eat.<BR/>Observation on 2/19/23 at 12:53 PM revealed Resident #645 was seated in the armchair in her room and was being fed the lunch meal by the Assistant Administrator. Resident #645 was served a regular diet consisting of chili, cornbread, Mexican style corn, and peach parfait for dessert. She was served 2 glasses with iced tea of thin consistency. Resident #645 drank 1 glass of iced tea and ate almost 100% of her meal with the Assistant Administrator's assistance. <BR/>In an interview on 2/22/23 at 9:45 AM, the Assistant Administrator stated she had not ever been a C.N.A. When asked if she had fed Resident #645 at times other than on Sunday 2/19/23 at lunch time, she stated no, she had not fed Resident #645 before that meal, but she had fed other residents. When asked about the other residents she had fed, the Assistant Administrator stated she had probably fed 5 other residents off and on over the course of the year she had worked in the facility. She stated she usually just helped pass meal trays. She stated she helped Resident #645 eat the lunch meal on 2/19/23 because they needed aides. When asked if she had ever been trained to feed residents and been evaluated with a skills test or if she had taken a paid feeding assistant course, she stated no, I have not. The Assistant Administrator inquired how she could be trained to assist residents with eating and asked if it could be done by computer-based training or by the DON. <BR/>In an interview on 2/23/23 at 9:22 AM, RN Corporate Clinical Company Leader-H stated the facility did not use paid feeding assistants. When asked how the facility trained staff to assist residents to eat or with feeding, she stated the CNAs were taught that during nurse aide training. When asked how non-nursing staff and office staff were trained for assisting residents with eating or feeding, RN Corporate Clinical Company Leader-H stated other staff should not be feeding residents. When asked if the facility had a policy and procedure for staff assistance with resident eating and feeding, she stated she would look for a policy and procedure.<BR/>In an interview on 02/23/23 at 10:00am, the DON stated that non-nursing staff should not assist residents with eating unless they have been trained.<BR/>During an interview at 02/18/2023 at 11:35am, Resident #90 stated that it takes forever for someone to respond to a call light. She stated the nursing staff never explain the delay in answering. <BR/>During observation and interview on 02/18/2023 at 12:14pm, Resident #13's call light was activated at 11:25am while surveyor was in the room interviewing her. Nursing staff did not answer the activated call light until 12:14pm, total of 49 minutes, while surveyor was still in the room. Resident #13 stated that staff do not care about the residents and the call lights. <BR/>Resident #79<BR/>Review of Resident #79's electronic Face Sheet dated revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis, pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus, major depressive disorder, dependence on renal dialysis, dependence on supplemental oxygen, chronic atrial fibrillation, Methicillin resistant Staphylococcus aureus, and Type 2 diabetes mellitus.<BR/>Review of Resident #79's admission Assessment MDS dated [DATE] revealed that he scored 15 on his mental status exam indicating that he was cognitively intact. He required extensive or total dependence on staff for all ADLs except for eating, for which he only required setup. He used a wheelchair for mobility. He was always incontinent of bowel and bladder. <BR/>During an interview on 02/18/2023 at 3:30pm, Resident #79 stated there was not enough manpower in the facility. He stated that during the night shift on 02/17/2023, the facility was only staffed with two people. He stated he turned on his call light at 6:30pm for assistance to change incontinent brief and it was 12:30 AM before the staff got around to it. He said the staff came in a couple of times to tell him that they were busy and had to wait for help and they would be back as soon as they could. He stated that was not the first time that had happened. He stated he hasn't found any staff that don't want to help him, they just can't because there aren't enough of them. He believes it is because of poor management. He stated that call lights never get answered quickly. He stated he has only had 2 showers since he has been here, everything else had been quick bed baths because the staff tell him they don't have enough people to do proper showers.<BR/>During an interview and observation on 02/19/2023 at 1:27pm, Resident #51 stated she activated her call light at 12:15pm because she spilled tea on her bed shortly after getting her lunch tray. She stated that several people had come in to ask what she needed and said they would go get help and never returned. Staff was observed answering the light at 12:57 PM, leaving the room then returning at 1:08 PM with 3 other staff members to assist in changing her linens and cleaning her up. She stated that her indwelling catheter tubing and bag were leaking on 02/16/2023. She stated she reported to the day shift nurse who just placed a towel under the leaking bag. She stated it was not changed until 02/18/2023. She stated that since she has been placed on Hospice, she felt as if the facility staff were somewhat letting my care slide. She stated if it wasn't for Hospice nursing staff, she would not be bathed. She stated she has to contact Hospice nursing staff for issues for constipation.<BR/>During an interview 02/19/2023 at 2:55pm, Interim Administrator stated she was aware of the facility concerns with providing staff for the facility. She stated the concern had been going from way back. She stated the facility had a big turnover in administration and she believed this contributed to the staffing concern. She stated she had a meeting every week with corporate to discuss the staffing concerns and several things have been put into place to attempt to correct the concern, including placing ads, offering sign on bonuses, etc. She stated that compensation was also a concern because the staff could make more money if worked at the hospital. She stated the facility was short staffed, especially on the weekends. She stated it was specifically every other weekend that they do not have staffing coverage. She stated they used agency staff, when they show up, or pull from facility administrative staff to provide coverage. She stated it was possible for major incidents to be attributed to the staffing shortage. <BR/>In an interview on 2/20/23 at 1:47 PM TNA-W stated the facility was always short staffed. TNA-W stated that Administration knows that we are short staffed and say they try to get us extra help, but we don't really know if they do or how they do it.<BR/>During an interview on 02/20/2023 at 4:34 pm, RN-V stated the facility was short staffed on 02/19/2023 and she was behind on her nursing tasks. She stated the facility is often short staffed or without staff.<BR/>During an interview on 02/22/2023 at 1:02pm, MDS-LVN stated she was the only nurse in the facility completing MDS Assessments. She stated that the workload was very heavy, and it was easy to miss things on the assessments. She stated that the other MDS-RN completes some care plans but has no MDS experience, so it falls on the MDS-LVN to complete.<BR/>During an interview on 02/22/2023 at 6:30 pm, TNA-W stated the facility is routinely short-staffed. She stated that she had expressed her concerns with administration including the Corporate Regional Resource Nurse-J. She stated that she is just told they are working on getting staff. <BR/>Record review of facility assessment dated [DATE] Part 3 titled Facility Resourced Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies revealed: <BR/>Station 1: Days (6:00am to 6:00pm)<BR/>LVN/RN Days = 1<BR/>Med Aide Day = 1<BR/>CNAs = 4<BR/>Station 2: Days (6:00am to 6:00pm)<BR/>LVN/RN Days = 2<BR/>CNAs = 6<BR/>Station 1: Nights (6:00pm to 6:00am)<BR/>LVN/RN Days = 1<BR/>Med Aide Day = 1<BR/>CNAs = 2<BR/>Station 2: Days (6:00am to 6:00pm)<BR/>LVN/RN Days = 2<BR/>CNAs = 4<BR/>We will review censes and add or cancel staff as census and needs increase.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week, for 10 of 12 months (January, March, April, May- August, October-December 2022) reviewed for RN coverage 60 days between 01/2022 to 12/2022. <BR/>The facility failed to ensure a RN coverage for 8 consecutive hours for 60 days between 01/2022 to 12/2022.<BR/>These failures could place all residents at risk of care and clinical needs not being met. <BR/>Findings include:<BR/>Record review of Facility's RN coverage reporting system (PBJ) reviewed between 01/01/2022 to 12/31/2023 revealed no evidence of RN coverage for 60 of 365 days:<BR/>1. <BR/>*1/1/2022 with no RN coverage<BR/>2. <BR/>*1/2/2022 with no RN coverage<BR/>3. <BR/>*1/8/2022 with no RN coverage<BR/>4. <BR/>*1/9/2022 with no RN coverage<BR/>5. <BR/>*3/27/2022 with no RN coverage<BR/>6. <BR/>*4/9/2022 with no RN coverage<BR/>7. <BR/>*4/10/2022 with no RN coverage<BR/>8. <BR/>*4/23/2022 with no RN coverage<BR/>9. <BR/>*4/24/2022 with no RN coverage<BR/>10. <BR/>*5/7/2022 with no RN coverage<BR/>11. <BR/>*5/8/2022 with no RN coverage<BR/>12. <BR/>*5/14/2022 with no RN coverage<BR/>13. <BR/>*5/15/2022 with no RN coverage<BR/>14. <BR/>*5/21/2022 with no RN coverage<BR/>15. <BR/>*5/22/2022 with no RN coverage<BR/>16. <BR/>*6/4/2022 with no RN coverage<BR/>17. <BR/>*6/5/2022 with no RN coverage<BR/>18. <BR/>*6/18/2022 with no RN coverage<BR/>19. <BR/>*6/19/2022 with no RN coverage<BR/>20. <BR/>*7/1/2022 with no RN coverage<BR/>21. <BR/>*7/2/2022 with no RN coverage<BR/>22. <BR/>*7/3/2022 with no RN coverage<BR/>23. <BR/>*7/16/2022 with no RN coverage<BR/>24. <BR/>*7/17/2022 with no RN coverage<BR/>25. <BR/>*7/22/2022 with no RN coverage<BR/>26. <BR/>*7/23/2022 with no RN coverage<BR/>27. <BR/>*7/24/2022 with no RN coverage<BR/>28. <BR/>*7/31/2022 with no RN coverage<BR/>29. <BR/>*7/30/2022 with no RN coverage<BR/>30. <BR/>*8/6/2022 with no RN coverage<BR/>31. <BR/>*8/7/2022 with no RN coverage<BR/>32. <BR/>*8/13/2022 with no RN coverage<BR/>33. <BR/>*8/14/2022 with no RN coverage<BR/>34. <BR/>*10/8/2022 with no RN coverage<BR/>35. <BR/>*10/09/2022 with no RN coverage<BR/>36. <BR/>*10/15/2022 with no RN coverage<BR/>37. <BR/>*10/16/2022 with no RN coverage<BR/>38. <BR/>*10/27/2022 with no RN coverage<BR/>39. <BR/>*10/28/2022 with no RN coverage<BR/>40. <BR/>*11/10/2022 with no RN coverage<BR/>41. <BR/>*11/11/2022 with no RN coverage<BR/>42. <BR/>*11/19/2022 with no RN coverage<BR/>43. <BR/>*11/20/2022 with no RN coverage<BR/>44. <BR/>*11/21/2022 with no RN coverage<BR/>45. <BR/>*11/24/2022 with no RN coverage<BR/>46. <BR/>*11/25/2022 with no RN coverage<BR/>47. <BR/>*11/29/2022 with no RN coverage<BR/>48. <BR/>*12/3/2022 with no RN coverage<BR/>49. <BR/>*12/4/2022 with no RN coverage<BR/>50. <BR/>*12/5/2022 with no RN coverage<BR/>51. <BR/>*12/8/2022 with no RN coverage<BR/>52. <BR/>*12/9/2022 with no RN coverage<BR/>53. <BR/>*12/13/2022 with no RN coverage<BR/>54. <BR/>*12/14/2022 with no RN coverage<BR/>55. <BR/>*12/17/2022 with no RN coverage<BR/>56. <BR/>*12/18/2022 with no RN coverage<BR/>57. <BR/>*12/19/2022 with no RN coverage<BR/>58. <BR/>*12/22/2022 with no RN coverage<BR/>59. <BR/>*12/27/2022 with no RN coverage, and<BR/>60. <BR/>*12/31/2022 with no RN coverage<BR/>During an interview on 02/24/23 at 01:46 PM, the Admin stated, the negative effects for no RN coverage were that the residents may not have gotten good care deserved and needed. She stated herself (Admin) and the DON should monitor the staff they need with coverage. The failures, she felt were due to the turnover of staff which were excessive. Her expectations for RN coverage were for the facility to have good care for the residents in all staffing and care areas . <BR/>During an interview on 02/24/23 at 02:00 PM, the DON stated the reasoning for having RN's were to have higher levels of skills and recourse for residents with the care needed. She added, she could not state why there was a failure being she was new to this position and facility, but guessed it was most likely due to staff overturn. The DON stated RN's were very important to have on staff for assessing resident's needs. The negative impact to residents, if a serious change of condition were not to be acted on immediately, it could have serious outcomes. She felt the failure were not having made working staff schedules, or on call staff available. Her expectations were for the DON and Admin to monitor RN coverage appropriately seeing fit where needed. <BR/>During exit conference on 02/24/2023 at 7:00pm, the facility administration could did not provide evidence of policies or procedures regarding utilization of RNs for 8 consecutive hours a day/7 days a week.

Based on observation, interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation in that:<BR/>The facility failed to dispose of and have procedures for handling drugs and biologicals according to federal, state, and local laws. <BR/>The facility failed to make sure that a resident's medications are returned to him/her to the new facility, or to the family, only if the attending physician approves it. <BR/>These failures could result in decreased medication effectiveness or increased risk of medication errors.<BR/>Finding include:<BR/>During observation on 02/18/2023 at 04:04 PM, LVN-R stated to the DON that there was a basket of keys in her office to the medication destruction box. The DON did not know where the drug destruction box was stating, at and stated, I literally do not know. <BR/>During an interview on 02/18/2023 at 04:30 PM, the DON stated she did not know where the drug destruction logbook would be and would be looking for it. She stated it should have been in her office previously along with the destroyed meds.<BR/>Record Review on 02/19/2022 of facility's medication disposition record revealed 3 months of documented logs (November, December, January). <BR/>During observation and interview on 02/23/2023 at 10:50, the RN-U of med with Med Cart #2 revealed:<BR/>2 bottles of nasal spray and 4 blister packs of hydrocodone 7.5-325, 234 tabs. This resident was transferred to another facility on 02/19/2023 . RN-U stated these meds had been discharged with no documentation in the narcotic book. <BR/>During an interview on 02/23/2023 at 11:50 AM, the Admin stated the facility had not previously had anyone to take the discharged medications from the carts. They are supposed to have turned them in to the DON but there had not been one. <BR/>During an interview on 02/23/2023 at11:52 AM, the DON stated, she is new to LTC and will only answer to what she thinks is right. She did not know how long the logs should be kept. If the Resident was transferred, all medications should had been sent with them. <BR/>During an interview on 02/23/2023 at 12:00 PM, Corporate Clinical Company Leader RN-H stated the current DON has had no orientation and the discharged meds should have gone with the resident when transferred. If the nurses did not send all medications with resident and had not discharged those medications with the proper paperwork, there could be a drug diversion. Corporate Clinical Company Leader RN-H stated the risk to residents was running out before the prescription is ready to be re-filled. Her expectations were for the residents to not go without their medication with the DON monitoring that. The staff failures were where the medications had not been monitored. <BR/>Record review of the facility policy Discarding and Destroying Medications revised 10/2014, revealed;<BR/>Policy Statement: Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances.<BR/>Policy Interpretation and Implementation <BR/> 3. Unless otherwise prohibited under applicable federal or state laws, individual resident medication supplied and sealed unopened containers may be returned to the issuing pharmacy for disposition provided that: <BR/>b. Oh such medications are identified as to what or control number; and<BR/>c. The receiving Pharmacist and the Registered Nurse employed by the facility sign a separate log that lists the residents name; the name, strength, prescription number (if applicable) and amount of the medication returned; and the date the medication was returned <BR/> 5. c. Disposal of controlled substances must take place immediately) no longer than three days) after discontinuation of youth by the resident <BR/> 10. The medication disposition record will contain the following information:<BR/>a. <BR/>The residents name; <BR/>b. <BR/>Date medication disposed;<BR/>c. <BR/> The name and strength of the medication; <BR/>d. <BR/>The name of the dispensing pharmacy;<BR/>e. <BR/>The quantity disposed;<BR/>f. <BR/>Method of disposition; <BR/>g. <BR/>Reason for disposition; and<BR/>h. <BR/>The signature of witnesses.<BR/>11. Completed medication disposition records shall be kept on file in the facility for at least two (2) years, or as mandated by state law governing the retention and storage of such records.

Based on observation, interview, and record review, the facility failed to provide foods at a safe and appetizing temperature for 1 of 1 meal reviewed for palatable temperatures.<BR/>Facility failed to serve food that retained safe palatable temperature for lunch service.<BR/>These failures placed 90 of 92 residents at risk for foodborne illnesses due to food temperatures.<BR/>Findings included:<BR/>During an interview on 02/18/23 at 10:58AM with Resident #85, she complained that the food was usually cold.<BR/>During an interview on 02/18/23 at 2:45PM with Resident # 5, he said the food was always cold. <BR/>During an interview on 02/18/23 at 2:55PM with Resident #59, he said the food was always cold. <BR/>During an observation and interview on 02/19/23 at 12:40PM with Resident #59, he was visibly upset and yelling and cursing, LVN CD was assisting resident with meal. Resident #59 loudly complained that his food was late and that it was cold. <BR/>During an interview on 02/19/23 at 01:07PM with LVN CD, she said Resident #59 always complained that his food was late and /or cold.<BR/>During an observation on 02/22/23 from 11:30AM to 12:30PM, <BR/>the service line meal item temperatures included:<BR/>Beef Roast 180 degrees F<BR/>Sliced Carrots 200 degrees F<BR/>Red Potatoes 180 degrees F.<BR/>11:40AM-Kitchen staff began preparing meal trays for residents.<BR/>11:44AM-First meal cart out to dining room on Unit 1. No staff in dining room, DM had to go tell nursing staff that meal trays were ready.<BR/>11:54AM-Nursing staff entered the dining room on Unit 1 and began to look at resident meal trays and compare them to the resident meal cards. 1 nursing staff asked the DM for a tea pitcher and began making drinks for the meal trays on the cart. DM said there was usually more staff in the dining room prior to meal trays coming out of kitchen. She said the kitchen staff responsibility was to make the meal trays and get them out of the kitchen for nursing to serve to the residents. She said it was the responsibility of the nursing staff to make the resident drinks. DM said after the meal trays left the kitchen it was no longer the responsibility of kitchen staff to serve the meals to the residents. <BR/>12:02PM-Nursing staff began serving residents in dining room for Unit 1 from the first meal cart.<BR/>12:04PM-First meal cart out to dining room on Unit 2. 1 staff in the dining room began making iced tea for the meals.<BR/>12:10PM-The drinks had been made and 2 staff members began serving residents in the dining room for Unit 2 their meals.<BR/>12:16PM-Final cart with surveyor sample tray out of the kitchen.<BR/>12:21PM-Nursing staff preparing resident drinks for meal trays on the final cart and began serving hall trays.<BR/>12:26PM-Sample tray provided after all residents served their meal. Food temperature of meal tray as followed:<BR/>Beef Roast-95 degrees F<BR/>Sliced Carrots- 120 degrees F<BR/>Red Potatoes-110 degrees F<BR/>Surveyor team sample of tray indicated the food temperature was cool. DM said that the temperatures had been a drop of almost 100 degrees for some food items and that waiting for nursing staff to pass out trays could be some of the reason for the food being cold. She said that a Resident Council meeting last year, (unable to remember which month), indicated that residents complained about their tea being warm and the ice melted. She said the facility decided that their solution would be to no longer have the kitchen be responsible for resident drinks on meal trays. DM said it would be the responsibility of nursing staff to make resident drinks for meal trays fresh, so that the ice would not be melted in the tea. RVPO sampled meal and said that the food was cold. <BR/>During an interview on 02/22/23 at 3:35PM with TNA GM, she said she had been working day shift since October of 2022 and meals had been served on a hall cart with no drinks from the kitchen since at least that time. She said it was the responsibility of the nursing staff to make resident drinks before serving the meals to the residents. TNA GM said she did not know the exact reason for that, but that it had something to do with previously the ice was melted in the tea and residents didn't like that, so the nurses and aides had to make the drinks with fresh ice and tea before they were placed on the meal trays after the kitchen made the trays and right before they were served to the residents. She said there would usually be a resident smoke break right before lunch time, so it would be difficult for the nursing staff to get back and start preparing the drinks prior to the kitchen getting the meal trays out for the nursing staff to pass out to the residents. <BR/>During an interview on 02/22/23 at 3:40PM with the Activity Director, she said that she remembered last year having a resident council meeting that the residents complained about their ice being melted in their tea and it being warm when they got their lunch and supper. She said she wrote a grievance from that council meeting, and it was discussed with administration. Activity Director said the solution that administration came up with was that the nursing department would be responsible for making the drinks fresh after the kitchen made meal trays, so that the tea would have fresh ice and it would not be melted. Activity Director provided the Resident Council meeting minutes and grievance form that she filled out that was for April of 2022.<BR/>During an interview on 02/23/23 at 3:20PM, ADM said that it was usually a responsibility of the kitchen staff to make the drinks for the residents. She said it did not make sense that the former administration would make a decision for nursing to make the drinks as a solution for ice being melted in tea.<BR/>During an interview on 02/24/23 at 6:45PM, ADM said she had no additional evidence to provide. <BR/>Record review of Facility Resident Council Meeting and Grievance form dated 04/29/2022 revealed: residents state that when they receive meals lunch and supper the ice is always melted, they would like to have ice in their drinks <BR/>Record review of Facility policy labeled Food and Nutrition Services revised 09/2021 revealed: . And nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.<BR/>Record review of CMS form 672 dated 02/19/23 revealed a census of 92 with 2 residents that received enteral nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitization.<BR/>1. <BR/>The facility failed to ensure ground meat was thawed properly.<BR/>2. <BR/>The facility failed to ensure the cook performed hand hygiene appropriately when preparing food.<BR/>3. <BR/>The facility failed to ensure foods were sealed and/or labeled properly.<BR/>4. <BR/>The facility failed to ensure the foods were not stored past expiration date.<BR/>Thess failures could place residents that eat out of the kitchen at risk for contamination and foodborne illnesses.<BR/>Findings included:<BR/>During an observation of the kitchen on 01/19/2025 between 2:15 p.m. - 2:50 p.m. revealed the following: <BR/>Sink:<BR/>1 plastic dish sitting in a sink with 4 tubes of ground meat sitting vertically in the dish that was filled with water and water running into the container. The ground meat was not submerged in the water with approximately 30% of ground meat outside of the water and water was running in the middle of the 4 tubes and not covering the meat.<BR/>Pantry:<BR/>*1 clear plastic bag not sealed and was open to air held an opened bag of potato chips dated 2-12-25 & 2-25-25.<BR/>*7 expired bottles of Lemon Juice from concentrate with written date of 10/02 on the outside of the bottles. Manufacture date on the bottle lids was 01/24/2025.<BR/>Refrigerator #1:<BR/>*1 clear plastic bag not sealed and was open to air held an opened bag of pink circular meat. There was no description on the bag.<BR/>*1 expired bottle of Lemon Juice from concentrate with written date of 10/02 on the outside of the bottle. Manufacture date on the bottle lid was 01/24/2025. <BR/>Refrigerator #2:<BR/>*1 sealed plastic container of grape jelly with no date on label.<BR/>Freezer # 1:<BR/>*1 box of 3 containers of whipped topping sitting on the floor on its side to the left of freezer door. <BR/>*1 bag of a circular breaded item with no description and no date. <BR/>*2 bags of what appeared to be frozen pancakes with no description and no date.<BR/>During an interview on 02/16/2025 at 2:53 p.m., the cook stated bags of food being stored should be sealed. He stated after opening food item it should be labeled with open date. He stated if foods were not stored in their original container, then they should have item description on them. He stated no food should be stored on the floor. The cook stated meat should be dethawed in the refrigerator, but meat would need to be placed in the refrigerator several days before needed to dethaw in the refrigerator. He stated he had been rotating the meat during the thawing process due to all the meat was not submerged in the water in dish in sink. He stated he had started defrosting the meat about an hour prior. He stated he was responsible for storing, labeling, and preparing foods.<BR/>During an observation on 02/16/2025 at 4:11 p.m., the cook started pureeing foods for diner service. He donned gloves without washing his hands and began pureeing meat entree. He added all ingredients into the blender until food item was appropriate consistency He then moved food into container and covered with foil prior to putting item into the freezer. He took blender to the dish room and removed his gloves. The cook rinsed out blender prior to running through the dish washer and he did not wash hands before touching sanitized blender. He then [NAME] blender back to puree station and put down on counter. He reached into a bucket of water solution and pulled out a rag then wiped down counter under blender and bottom of blender machine. He put blender back together then put gloves on his hands. He did not perform hand hygiene prior to putting on gloves. He then started on pureeing the rest of dinner items. <BR/>During an interview on 02/16/2025 at 6:45 p.m., the cook stated he should have washed his hands when changing out gloves during food preparation. He stated he had just forgotten to do so when being observed. He stated he was a train wreck and nervous. He stated not labeling food items with date and description could cause the wrong food item to be given to residents with allergies to that food item and could cause the residents to get sick. He stated not storing food items appropriately could cause residents to be sick.<BR/>During an interview on 02/17/2025 at 3:29 p.m., the DM stated food stored outside of the original container should be labeled with food description and date. She stated no food should be stored on the floor and should be stored at least 6 inches off of the floor. She stated foods should not be stored in the pantry or in the refrigerator past the manufacture's expiration date and the date the manufacturer had on container was the expiration date. The DM stated she expected for food items to be disposed of when item passed the expiration date. She stated anyone who puts up food items off the delivery truck and during food preparation were responsible for making sure items were stored correctly with appropriate label. She stated she does monitor that food was labeled, stored at least 6 inches off of the floor and not expired. She stated she last monitored the kitchen the week prior. The DM stated packages of food should be stored in sealed containers after opened. She stated ground meat should be thawed submerged under running water. She stated kitchen staff should wash hands with soap and water during glove changes. She stated she expected for HH to be done when moving from one task to another in the kitchen and not performing could lead to cross contamination and bacteria spread. She stated she had been working for the facility for approximately one week and will be monitoring the kitchen at least 2-3 times a week. She stated not labeling food appropriately with description of food item and dates could lead to allergic reaction. She stated she would have thrown food away without date on label because staff would not know when food should be disposed of. The DM stated not thawing out meat correctly could lead to some of the food being in the danger zone for longer than appropriate time and could cause bacteria to grow.<BR/>During a telephone interview on 02/17/2025 at 5:00 p.m., the dietician stated foods stored outside of their original container should be labeled with description and date. She stated foods should be stored 6 inches above the floor. She stated foods should be disposed of and not kept past the expiration date. She stated packages of food items should be sealed so not to expose food to the elements. She stated typically frozen meat was thawed during the cooking process, in the cooler or under cold running water. She stated not submerging frozen meat could more than likely cause it to thaw unevenly and cause foodborne illness. She stated every time gloves were changed during food preparation then HH should be performed in between glove changes. She stated the dietary manager monitors that kitchen staff store, prepare and prepare food appropriately. She stated she was available for training and does observe how staff store and prepare food. She stated the kitchen staff had been changing and there was a new DM which could have led to failures of HH, meat thawing, and food storage or staff may have forgotten their training. She stated she felt more education was needed. She stated that not storing food appropriately and not performing HH correctly could lead to illness from bacteria. <BR/>During an interview on 02/17/2025 at 9:39 a.m., the ADMN stated she expected for kitchen staff to follow policies on food storage, preparation, and hand hygiene. She stated the DM monitored that kitchen staff were following the facility's policy. She stated not storing and preparing food appropriately could cause residents to get sick. <BR/>Record Review of facility's policy titled Food Preparation and Handling dated 2018 revealed: <BR/>Procedure: <BR/>1. General Guidelines a. Use clean, sanitized surfaces, equipment and utensils. b. Wash hands properly before beginning food preparation .<BR/>2. Thawing Foods a. Thaw meat, poultry and fish in a refrigerator at 41&deg;F or less. b. Foods may also be thawed using the following procedures: i. Completely submerged under running water at a temperature of 70&deg;F or below with sufficient water velocity to agitate and float off loosened food particles into the overflow: 1. For a period of time that does not allow thawed portions of ready-to-eat food to rise above 41&deg;F; or 2. For a period of time that does not allow thawed portions of a raw animal food requiring cooking to be above 41&deg;F for more than four hours including the time the food is exposed to the running water and the time needed for preparation for cooking.<BR/>Record Review of facility's policy titled Handwashing/Hand Hygiene dated 01/20/2023 revealed: <BR/>Hand hygiene must be performed prior to donning and after doffing gloves.<BR/>Record Review of facility's policy titled Preventing Foodborne Illness - Food Handling dated April 2022 revealed:<BR/>All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .Potentially hazardous foods held in the danger zone (41&deg;F to 135&deg;F) for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) will be discarded.<BR/>Record Review of facility's policy titled Food Storage dated 2018 revealed:<BR/>1. Dry storage rooms .d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated .2. Refrigerators .d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage .e. Use all leftovers within 72 hours. Discard items that are over 72 hours old .3. Freezers .c. Store all foods on racks or shelves off the floor. <BR/>Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed on 02/19/2025 revealed: <BR/>3-602.11 Food Labels. <BR/>(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. <BR/>(B) Label information shall include: <BR/>(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; <BR/>(2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; <BR/>(3) An accurate declaration of the net quantity of contents; <BR/>(4) The name and place of business of the manufacturer, [NAME], or distributor; and <BR/>(5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf <BR/>(6) Except as exempted in the Federal Food, Drug, and Cosmetic Act &sect; 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. <BR/>Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.<BR/>3-501.13 Thawing.<BR/>Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed:<BR/>(A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) <BR/>or less Pf; or <BR/>(B) Completely submerged under running water: <BR/>(1) At a water temperature of 21oC (70oF) or below Pf,<BR/>(2) With sufficient water velocity to agitate and float off loose particles in an overflow Pf, and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 4 of 4 Residents (Resident #1, Resident #79, Resident #53, Resident #57) reviewed for administration quality of care, in that:<BR/>1. <BR/>Resident #1 had an indwelling urinary catheter that had not been drained for 2 days causing backflow of urine due to nursing staff not following physician's orders and the facility's lack fo administrative monitoring an ensuring resient care. The catheter tubing had sediment and puss like substance in tubing. Resident #1 became unresponsive, sent to hospital, initial diagnosis of UTI, and admitted to ICU due to nursing staff neglecting to follow physician's orders.<BR/>2. <BR/>Resident #1 had five facility acquired pressure ulcers that progressed to Stage III and Stage IV due to nursing staff neglecting to follow physician's orders. Facility administrative personnel did not monitor and ensure nursing staff followed physician orders and provided residents care to attain highest practicable well-being. <BR/>3. <BR/>Resident #79 had one Stage III pressure ulcer upon admit that worsened to have osteomyelitis due to nursing staff neglecting to follow physician's orders. The facility's administration did not ensure it's resident skin assessments and wound treatments were completed by nursing staff and monitored by administrative personnel for effectiveness and completeness <BR/>4. <BR/>The facility's administrative personnel did not ensure nursing staff were sufficiently staffed in the women's secured locked hall for resident safety. Station 2 Hall 6 was a women's secured locked hall with six (6) female residents with known behaviors with one (Resident #53) of the six (6) women required 1:1 level of supervision. The facility failed to staff the Hall with more than one trained staff consistently. The staff utilized a gait belt around Resident #53 to redirect, restraint her movement, and prevent altercations from other residents. <BR/>5. <BR/>The facility's administrative personnel did not ensure nursing staff were sufficiently staffed in the men's secured locked hall for resident safety. Station 2 Hall 2 was a men's secured locked hall with fourteen (14) male residents with known behaviors. On 01/06/2023, there was a resident/resident altercation and no staff were located on the hall. <BR/>An Immediate Jeopardy (IJ) was identified on 02/23/2023. The IJ template was provided to the facility on [DATE] at 10:28am. While the IJ was removed on 02/24/2023, the facility remained out of compliance at a scope of pattern and a severity of actual harm because the facility's need to evaluate the effectiveness of their corrective actions.<BR/>These failures placed residents at risk of physical and psychological harm due to lack of oversight by facility administration. <BR/>The findings included:<BR/>1. <BR/>Record review of Resident #1 face sheet revealed a [AGE] year-old female admitted on [DATE] with a most recent admission date of 11/20/2022 with the following diagnoses: Unspecified fracture of left shaft/femur, Non ST elevation myocardial infraction (heart attack due to inadequate blood to the heart), gram negative sepsis (bacteria in the blood), neurogenic bladder (deficiency in bladder control due to brain, spinal cord or nerve problem) and urinary tract infection, site not specified (infection in any part of the urinary system). <BR/>Review of Resident #1's Significant Change in Status MDS dated [DATE] revealed: Section C Cognitive Patterns BIMS Summary Score of 14 indicating no cognitive impairment; Section H Bladder and Bowel indicated indwelling catheter<BR/>Record review of Resident #1 electronic care plan accessed on 02/20/2022 revealed the following: Problem - Resident #1 has Indwelling Foley Catheter: Goal - Resident will not show signs of urinary infection or urethral trauma. Interventions - Change catheter every per MD order, document urinary output; record the amount, type, color and odor, observe for leakage, keep catheter system a closed system as much as possible, position bag below level of bladder, provide catheter care as scheduled and PRN. Problem- Resident #1 has a urinary tract infection. Goal- resident will not exhibit signs of a urinary tract infection. Interventions- Administer Bactrim DS (antibiotic), encourage fluids, keep perineal area clean and dry and report signs or UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back pain/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine and blood in urine. Initiated date of 10/15/2022 and revised date of 01/31/2023.<BR/>Review of Resident #1 physician orders dated 10/13/2022 to 10/21/2022 revealed <BR/>-Foley Catheter: Size (10cc) FR (16) Diagnosis: Neurogenic bladder (lack bladder control due to brain, spine, or nerve problems). <BR/>-May obtain urine sample via Foley Catheter Port as needed when a Urine Analysis is ordered. (If Foley Catheter has been in place greater than 14 days, change Foley Catheter before obtaining urine.) <BR/>-Provide catheter care every shift.<BR/>-Change catheter and drainage bag as needed for indications of blockage, increased sediment, infection, displacement as needed.<BR/>Record review of Resident #1's vital reports revealed no evidence of catheter care, drainage of catheter bag and amount of urine obtained during drainage on 48 occasions between 01/18/23 and 02/19/23.<BR/>During observations between 02/18/2023 at 10:15 am to 02/18/2023 at 3:58, Resident #1 was observed to have an indwelling catheter bag that was full and overflowing with urine that was backflowing in the catheter tubing as well as urine leaking onto the floor on three (3) occasions. The catheter bag was dated 01/12. The urine was cloudy, with sediment (matter that settles to the bottom of a liquid) visible in tubing and bag. There was a thick cloudy substance in the tubing that appeared to be puss.<BR/>Interview on 02/18/2023 at 10:16 AM, the DON stated Resident #1's catheter tubing and bag appeared to be a puss like substance and required to be changed immediately. The DON stated Resident #1's catheter bag should always been covered and that the bag being completely full to where it is overflowing places resident at risk for infection. She stated she did not know the rationale for the catheter bag to be overflowing with urine and backflowing in the catheter tubing.<BR/>During an observation 02/19/2023 at 8:35 am, Resident #1's catheter bag had been emptied; however, the foley catheter tubing had not been changed and was observed to be crusted with sediment and puss like substance visible in the tubing. <BR/>During an interview on 02/19/2023 at 8:40 am, the DON stated she delegated the task for changing Resident #1's catheter but did not know rationale for the task to not have been completed.<BR/>Interview on 02/19/2023 at 10:02 am, Corporate Regional Resource Nurse-J-J stated she had instructed RN-V to change Resident #1's catheter bag. She stated that RN-V reported that it had been changed. She collected a UA sample while changing it and would notify the physician. She stated that the catheter should have been changed due to the sediment. She said that she could see where there was an issue for concern. <BR/>During an interview on 02/19/2023 at 10:02 am, Corporate Clinical Company Leader RN-I stated Resident #1's catheter should have been changed due to the sediment alone. She said that she could see where there was an issue for concern. <BR/>Interview on 02/19/2023 at 11:04 am, the DON stated she went back to Resident #1's rooms on 02/18/2023 in the afternoon and the task to change the catheter continues to not be completed. She then asked nursing staff again to complete the task. She stated this failure placed the residents at risk for an infection.<BR/>Observation and interview on 02/19/2023 at 11:20 am, Resident #1 was speaking with surveyor without any distress. <BR/>Observation on 02/19/2023 at 2:57 pm, Resident #1 was observed unresponsiveness with emesis (the action or process of vomiting) on chest by surveyors and Corporate Clinical Company Leader RN-I. Corporate Clinical Company Leader RN-I stated she had to check Resident #1's pulse because she wasn't sure if she was alive. <BR/>Interview on 02/19/2023 about 3:00pm, Resident #56 (Resident #1's roommate) said Resident #1 received her lunch tray about 12:00 pm and almost immediately started to throw up. Resident #56 then called for help, but no one came until about 2:00 pm. Resident #56 said that she told the staff that Resident #1 needed assistance, the staff was Assistant Administrator in Training who removed Resident #1's tray and stated, I can't help you and left the room. <BR/>Review of Resident #56's quarterly MDS dated [DATE] revealed Section C Cognitive Patterns BIMS Score of 15 indicating no cognitive impairment.<BR/>During an interview on 02/19/2023 at 3:10pm, RN-V stated she did not change Resident #1's catheter tubing but just changed the bag. She stated she obtained a urine sample from the catheter tubing that was observed to be crusted with sediment and puss like substance visible in the tubing. <BR/>During an interview on 02/19/2023 at 3:15pm, Corporate Regional Resource Nurse-J-J stated that she instructed RN-V to change Resident #1's entire catheter and not just the bag. She stated she did not verify the task was completed.<BR/>Observation on 02/19/2023 at 3:25pm, Resident #1 was transferred to community hospital via EMS.<BR/>Interview on 02/19/2023 at 4:34pm, DON said she looked at Resident #1's catheter yesterday (02/18/2023) and it appeared to have puss and sediment in the catheter tubing and catheter bag entry hub. She said it was her expectation that it was to be changed. She made an additional request for the catheter to be changed this morning by RN-V. The DON stated that she discovered that the Resident #1 left the facility (to the hospital) without a changed catheter tubing but only changed catheter bag. It was her expectation that it was changed yesterday. <BR/>During an interview on 02/19/2023 at 4:34 pm, the DON stated that Resident #1's catheter appeared to have puss and sediment in the catheter tubing and catheter bag entry hub. She stated it was her expectation that catheter to be changed 02/18/2023. She stated Resident #1 left the facility to the community hospital without the catheter being changed.<BR/>Interview on 02/20/2023 at 3:57pm, CNA-Z stated Resident #1 had puss in her catheter tubing when she drained the catheter bag and performed incontinent care about 2 weeks ago. She stated she notified RN-V of the puss in resident's catheter tubing at that time. <BR/>Interview on 02/20/2023 at 04:04 PM, Resident #56 (Resident #1's roommate) said she pressed the call light frequently and it takes a while to answer. She said that the lady that came to answer the call light after two hours. She had long dark hair and was part of administration but did not work the floor. Resident #56 said that this staff went to the Resident #1 and said Oh, My God, when she saw the resident. Resident #56 said that the staff stated she couldn't help Resident #1 and left the room. Resident #56 said she thought the staff was coming back but never did. Resident #56 said that she could hear Resident #1 throwing up and gurgling. Resident #56 said no one changed their catheters. She said that yesterday (02/19/2023) the staff just changed the bag. Resident #56 said that the regional Hispanic nurse did in fact tell the nurse to just change the bag until she got caught up and that she could change it later. Resident #56 said it was the same nurse that told her in Spanish to butt out and put her hand to her mouth as in telling her to hush and she cut her eyes. <BR/>Interview on 02/20/23 04:34 PM, RN-V stated while in Resident's room that she was short of staff 02/19/2023 and behind. She said that when the regional nurse came, she told her to change the catheter bag only. She said that she is often short staffed or without staff and can do what she can do. She said she is trying hard and stays for the residents.<BR/>During an interview on 02/21/2023 at 1:24 pm, Corporate Clinical Leader RN-SB stated that not changing a catheter could place a resident at risk for an infection. She stated that Resident #1's entire catheter system should have been changed and not just the bag. She stated the failure was due to the RN not using appropriate nursing judgement. <BR/>During an interview on 02/21/2023 at 1:30 pm, Corporate Regional Resource Nurse-J stated she directed RN-V to change Resident #1's bag at the beginning of the shift and then later told RN-V to change the entire catheter. She stated that it appeared to be changed. She stated that the catheter should be changed any time there is puss or sediment in the tubing or bag. She stated that the catheter had not been changed prior to Resident #1 found unresponsiveness. She stated that the failure could result in infection, sepsis, and pain.<BR/>During an interview on 02/21/2023 at 2:50 pm, Corporate Clinical Leader RN-VR stated that Resident #1's record had inaccurate documentation due to days of no documentation of Resident #1's catheter care including urine output.<BR/>Record review of hospital record dated 02/19/2023 at 8:48pm History and Physical, revealed the following physician's notes- We sent her to the ICU Again, clinically it just seems to be a very ill patient, who was sent from the nursing home for an honestly a bogus reason at this point. At any rate from what I can gather she had left sided weakness from a prior stroke, but today currently it seems like she is not moving the right side, so we will get MRI of the brain. She does have a UTI in her labs, which will be treated. <BR/>Record review of Resident #1's community hospital records revealed dated 02/19/2023, Resident #1 was admitted into community hospital ICU with diagnosis of UTI & rule out stroke.<BR/>Record reviewed on Resident #1's community hospital records labs, assessment and plan dated 02/19/2022 revealed, Resident #1 had a primary diagnosis of Urinary Tract Infection, with orders to check cultures, place her on ceftriaxone (antibiotic) <BR/>Record review of hospital records dated 02/21/2023 revealed that Resident #1 had a diagnosis of Sepsis (A life threatening complication or infection. Sepsis occurs when chemicals released in the bloodstream to fight an infection throughout the body. This can result in multi organ system failure and even death). <BR/>Records review of hospital records dated 02/21/2023 Resident #1's Assessment and Plan revealed:<BR/>1.UTI in the setting on chronic indwelling foley catheter. Urine culture grew E coli. Blood cultures grew gram positive cocci. Start IV Vancomycin and Rocephin for empiric (preventative and protective) treatment. <BR/>2.Bacteremia: Blood culture grew gram positive cocci. Start IV Vancomycin (antibiotic) and Rocephin (antibiotic) for empiric treatment<BR/>2. <BR/>Review of Resident #1's admission MDS, dated [DATE], revealed Section C: Cognitive Patterns BIMS Score of 9 indicating moderate cognitive impairment; Section G: Functional Status limited/one-person assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions of no pressure ulcers. <BR/>Review of Resident #1's Significant Change MDS dated [DATE], revealed Section C: Cognitive Patterns BIMS Score of 14 indicating cognitively intact; Section G: Functional Status: extensive/two + persons assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated two Stage III pressure ulcers, one Stage IV pressure ulcer, and two Unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. <BR/>Site 1: Right buttock/ischium<BR/>Review of Resident #1's Wound Management Detail Report dated 07/28/2022 at 4:08pm by LVN-AD revealed: Pressure Ulcer to Right Buttock, not present on admission. Unstageable measured 2.8cm in length by 2.8cm in width with unmeasurable depth. <BR/>Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:44pm by LVN-Q revealed: Stage IV measured 4cm in length by 6cm in width with 2.5 measurable depth. <BR/>Review of Resident #1's physicians orders dated 10/20/2022 for pressure wound of right ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Once a day<BR/>Review of Resident #1's physicians orders dated 10/20/2022 for pressure wound of right ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply collagen Calcium Alginate with silver. Cover with bordered foam dsg. As needed twice a day<BR/>Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to right buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change.<BR/>Site 2: Left buttock/ischium<BR/>Review of Resident #1's Wound Management Detail Report dated 08/04/22 at 3:24pm by LVN-AD revealed: Pressure Ulcer to Left Buttock, not present on admission. Measured 4.5cm in length by 4cm in width with no measurable depth.<BR/>Review of Resident #1's Wound Management Detail Report dated 02/16/2023 at 5:50pm by LVN-Q revealed: Stage III measured 1.7cm in length by 4.2cm in width with 0.5cm measurable depth.<BR/>Review of Resident #1's physicians orders dated 10/20/2022 for pressure wound of left ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. Once a day<BR/>Review of Resident #1's physicians orders dated 11/29/2022 for pressure wound of left ischium (buttock) revealed: Clean with Normal Saline/Wound Cleanser. Apply: collagen then Calcium Alginate with silver. Cover with Primary Dressing: bordered foam dsg. As Needed twice a day.<BR/>Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to left buttock related to immobility and desensitized skin. Goal: Resident's ulcer will heal without complication. Approach: Conduct a systematic skin inspection daily by nurse with daily dsg change. <BR/>Site 3: Left heel<BR/>Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:17am by LVN-AE revealed: Unstageable - Deep Tissue Pressure Ulcer left heel not present on admission measured 5.5cm in length by 5cm in width with no measurable depth.<BR/>Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:54pm by LVN-Q revealed: Stage IV measured 3cm in length by 4cm in width with no measurable depth.<BR/>Review of Resident #1's physician orders dated 02/10/2023 revealed: Cleanse left heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg as needed. Once a day in the morning and as needed every shift<BR/>Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to left heel related to immobility. Goal: Resident's ulcer will not increase in size. Approach: Conduct a systematic skin inspection during daily treatment . Use heel protectors as tolerated or cushion under legs as tolerated to relieve pressure on the heels.<BR/>Site 4: Right heel<BR/>Review of Resident #1's Wound Management Detail Report dated 11/17/2022 at 9:15am by LVN-AE revealed: Pressure Ulcer Right Heel not present on admission measured 5cm in length by 7cm in width and no measurable depth.<BR/>Review of Resident #1's Wound Management Detail Report dated 02/16/23 at 5:52pm by LVN-Q revealed: Stage IV measured 2.7cm in length by 3.8cm in width and no measurable depth.<BR/>Review of Resident #1's physician orders dated 02/10/2023 revealed: Cleanse right heel with normal saline or wound cleanser apply calcium alginate to wound bed surrounding necrotic tissue and secure with bordered dsg as needed. Once a day in the morning and as needed every shift<BR/>Review of Resident #1's physician orders dated 10/08/22 revealed: Ascorbic acid (vitamin c) tablet; 500mg 1 tab oral once a day <BR/>Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: Resident has a pressure ulcer to right heel related to immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection Approach: .Conduct a systematic skin inspection during daily treatment Use heel protectors as tolerated or cushion under legs as tolerated to relieve pressure on the heels.<BR/>Site 5: Sacrum<BR/>12/29/22 Cleanse sacrum with normal saline or wound cleanser apply thin layer of triad, yellow tube, to wound two times a day. Every Shift <BR/>Review of Resident #1's Comprehensive Care Plan dated 01/31/2023 revealed: Problem: pressure Ulcer Sacrum Stage III. Goal: Area will show improvement in the next 14 days. Approach: Turn every 2 hours and prn.<BR/>3. <BR/>Review of Resident #79's electronic Face Sheet dated revealed he was a [AGE] year-old male admitted to the facility 11/15/22. He had diagnoses which included heart failure, end stage renal disease, current long-term use of antibiotics, acute osteomyelitis, pressure ulcer of right heel stage 4, chronic pain, pressure ulcer of sacral region, systemic lupus erythematosus, major depressive disorder, dependence on renal dialysis, dependence on supplemental oxygen, chronic atrial fibrillation, Methicillin resistant Staphylococcus aureus, and Type 2 diabetes mellitus.<BR/>Review of Resident #79's admission MDS dated [DATE] revealed Section C: Cognitive Patterns BIMS Score of 15 indicating no cognitive decline; Section G Functional Status indicated extensive/2+ person physical assistance with bed mobility, transfer, toilet use, and personal hygiene; Section M: Skin Conditions indicated one Stage III pressure ulcer present upon admission and one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar present upon admission.<BR/>Review of Resident #79's Quarterly MDS dated [DATE] revealed Section M: Skin Conditions indicated two Stage IV pressure ulcers present upon admission, and one Unstageable pressure ulcer that was not present upon admission.<BR/>Site 1: Sacrum<BR/>Review of Resident #79's Wound Management Wound History dated 11/15/2022 at 8:08 am revealed: Pressure Ulcer to Sacrum present on admission.<BR/>Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Stage 4 Pressure Wound Sacrum Full Thickness measured 1.7cm in length by 0.7cm in width with 1.2c in depth.<BR/>Review of Resident #79's Wound Care Physician Progress Note dated 01/12/2023 revealed: The histology report from the biopsy of the sacrum taken on 01/05/2023 indicates acute osteomyelitis.<BR/>Review of Resident #79's physicians orders dated 11/25/2022 revealed: Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing every day until resolved. Cleanse right heel with normal saline or wound cleanser, apply sure-prep to heel two times daily for preventative. Left heel cleanse with ns or wound cleanser and apply sure-prep two times daily for preventative<BR/>Review of Resident #79's physicians orders dated 11/29/2022 revealed: Area to sacrum cleanse with ns or wound cleanser pack with calcium alginate to wound bed secure with foam border dressing as needed until resolved.<BR/>Review of Resident #79's Treatment Administration Record from November 2022 to February 2023 revealed no evidence of treatments on 12/02/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023<BR/>Review of Resident #79's Care Plan last revised 1/30/23 revealed: <BR/>Problem: Resident has a pressure ulcer to sacrum r/t immobility. Goal: Resident's ulcer will heal without complications. Approach: use cushion provided by family for pressure reduction when resident is in chair; conduct a systematic skin inspection daily during treatment .<BR/>Review of Resident #79's electronic record revealed no evidence of reposition every 2 hours and as needed and conduction of systematic skin inspection daily between 11/25/2022 and 12/29/2022.<BR/>Site 2: Right Heel<BR/>Review of Resident #79's Wound Management Detail Report dated 11/15/2022 at 8:11am by LVN-AE revealed: Stage III pressure ulcer to right heel measured 0.3cm in length by 0.3cm in width with 0.1cm in depth.<BR/>Review of Resident #79's Wound Management Wound History dated 11/25/2022 at 7:33am revealed: Pressure Ulcer to right heel present on admission and healed.<BR/>Review of Resident #79's Wound Care Physician Progress Notes dated 12/01/2022 revealed: Unstageable due to necrosis (death of cells in body tissues) measured 1cm in length by 1.1cm in width with no measurable depth. <BR/>Review of Resident #79's Wound Care Physician Progress Notes dated 12/29/2022 revealed deterioration to a Stage IV Pressure Wound of the Right Heel.<BR/>Review of Resident #79's Wound Management Wound History dated 12/29/2022 at 2:31am revealed: Pressure Ulcer to right heel present on admission.<BR/>Review of Resident #79's Wound Management Detail Report dated 02/23/2023 at 7:11pm by Corporate Clinical Company Leader RN-I revealed: Stage IV Pressure Ulcer to right heal measured 0.5cm in length by 0.6cm in width with unmeasurable depth. The wound had necrotic tissue type.<BR/>Review of Resident #79's physician orders dated 12/29/2022 revealed: Cleanse right heel with normal saline or wound cleanser apply anasept (antibiotic) to wound and secure with a bordered dressing daily.<BR/>Review of Resident #79's physician orders dated 01/03/2023 revealed: Use cushioned boots while in bed as tolerated<BR/>Review of Resident #79's Treatment Administration Record from November 2022 to February 2023 revealed no evidence of treatments on 12/03/2022, 12/25/2022, 12/26/2022, 01/01/2023, 01/05/2023, 01/08/2023, 01/11/2023, 01/19/2023, 02/04/2023, 02/08/2023, 02/11/2023, 02/19/2023<BR/>Review of Resident #79's Care Plan last revised 1/30/23 revealed: <BR/>Problem: Pressure Sores/Skin Care. Goal: Prevent/Heal pressure sores and skin breakdown. Approach: follow facility skin care protocol; preventative measures use cushioned boots for heels while in bed as tolerated, off load heels while in bed; report to charge nurse any redness or skin breakdown immediately; treatment as ordered; turn and reposition every 2 hours and PRN<BR/>Problem: Resident has a pressure ulcer to right heel r/t immobility. Goal: Resident's ulcer will not increase in size. Ulcer will not exhibit signs of infection. Approach: . conduct a systematic skin inspection during treatment .<BR/>Review of Resident #79's skin assessment records revealed no evidence of systematic skin inspection during treatment between 11/25/2022 and 12/29/2022.<BR/>Review of Resident #79's physicians orders dated 11/29/2022 revealed: Ascorbic acid (vitamin c) 500mg 1 tablet by mouth daily. Pro-Stat AWC (high-calorie, complete protein liquid for Advance Wound Care) 17-100 gram-kcal/30ml give 30ml by mouth twice a day. <BR/>Review of Resident #79's physician orders dated from 01/13/2023 to 02/24/2023 revealed: Ertapenem (strong antibiotic to treat serious infections) 1 gram IV daily for 42 days related to osteomyelitis<BR/>In an interview on 02/19/2023 at 2:38 PM, Corporate Clinical Company Leader RN-I stated the facility owned Resident #1's pressure ulcers and that they were facility acquired. She stated that she could not find any documentation that they were not acquired in the facility. Corporate Clinical Company Leader RN-I stated that the failure of the facility to prevent Resident #1 from developing new pressure ulcers could result in an infection and that the failure was due to ongoing staffing issues.<BR/>During an interview on 02/20/2023 at 2:30pm, Corporate Clinical Company Leader RN-I stated her expectations were for skin assessments to be completed weekly and the nursing staff were not consistence with documenting the treatments with the interim and acting DON monitoring. She stated these failures were due to communications between staff members. She stated that the lack of communication negative impacts the continuity of care.<BR/>During an observation on 02/20/23 at 3:25 PM of Resident #79's wound care revealed RN-V completed wound care with the assistance of MDS-RN and LVN Q. RN-V failed to change gloves after removing sacrum dirty wound dressing and beginning to apply treatment and clean dressing to sacrum. RN-V had to be reminded by LVN-Q to date and initial new dressing to the sacrum. RN-V also failed to perform hand hygiene before applying new gloves to begin treatment to right heel. Following the treatment, RN-V was unable to be located for an interview.<BR/>In an interview on 2/21/23 at 11:35 AM, Corporate Clinical Company Leader RN-H stated in her investigation of the Resident #79's chart, it appeared that the wound care/treatment nurse at the time documented the right heel wound was healed on 11/25/22 even though the wound was never healed. She stated the right heel wound was re-identified as a stage 4 on 12/29/22. She stated that because the wound was documented as healed that it went one month without treatment or observation leading to it progress to a stage 4. She stated that Resident #79's sacral wound was a stage 3 on admission but had progressed to a stage 4. She stated If there was something different with a wound that a prudent nurse should have document in a focused observation note or progress note what was observed, notify the doctor of the change in the resident's condition, then document that the doctor was notified. She stated it was her expectation that if someone did transcribe orders for Wound Care Doctor that it would be the nurse who did rounds with him or if the resident was a new admission and the wound care physician was giving orders, the admitting nurse would be responsible for transcribing the orders and verifying everything was in the resident's chart correctly. She stated that during the morning meeting, it was her expectation that the staff should have been going over all new orders received to make sure all orders had been signed and verified and that nothing had been missed during rounds. <BR/>During an interview on 02/22/2023 at 9:57am, WC LVN-MB stated that she reported to Corporate Regional Resource Nurse-J, previous administrator, and previous DON the concerns of lack of wound care during the days WC LVN-MB was not scheduled. <BR/>In an interview on 2/22/23 at 10:49 AM, Corporate Clinical Company Leader RN-H stated that she was not aware that skin assessments were not being done accurately and treatments were not being done until surveyors arrived at the facility. <BR/>4. <BR/>Record review of Resident #53's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. She resided on Station 1 Hall 6 which was a Woman's secured unit (the average age of the women residents on Station 1 Hall 6 was 76 years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 diseases and infections for 1 of 3 residents (Resident #18) observed for infection control. <BR/>1. The facility failed to ensure CNA B used the required PPE for Resident #18, (gown) who was on enhanced barrier precautions due to her Foley Catheter while performing Foley Catheter Care on 02/19/25. <BR/>These failures could place the residents at risk of cross-contamination and development of infection.<BR/>Findings included: <BR/>Record review of Resident #18's face sheet, dated 2/18/25, reflected a [AGE] year-old female with an admission date of 2/15/19. Resident #1 had a diagnosis which included dementia, disorder of urinary system, and type 2 diabetes mellites. <BR/>Record review of Resident #18's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 8, indicating moderate cognitive impairment. <BR/>Record review of Resident #18's Care Plan dated 2/18/25 with ADL's indicated Resident #18 has problem with recurrent urinary tract infections. <BR/>During an observation on 2/18/25 at 9:18 AM, CNA B gathered supplies for Resident #18's catheter care and placed supplies in a plastic bag. CNA B entered room with plastic bag and did not don gown. She performed hand hygiene and put on gloves in the room prior to performing care to the resident. CNA B performed foley catheter care using clean wipe each x 4 and cleaned catheter from the resident's skin, away from the resident. CNA B disposed of each used wipe into disposal bag and performed hand hygiene after care completed and gloves removed. Resident #18's foley catheter bag was suspended to the left side of her bed and in a privacy bag. Resident #18 had sign on door notifying staff of EBP (enhanced barrier precautions). There was no PPE directly outside of room or handing on the door . <BR/>During an interview on 2/19/25 at 04:25 PM LVN A stated Resident #18 was on enhanced barrier precautions due to her having an indwelling foley catheter. she stated that means that any employee that goes into Resident #18's room and performs any kind of patient care associated to the foley, the employee should be wearing all the gear. she stated all the gear includes gown, gloves, and mask.<BR/>During an interview on 2/19/25 at 05:45 PM DON stated that she was the infection preventionist. She stated that enhanced barrier precautions are in place to protect the residents and employees while performing patient care from spreading any bacteria. She stated that an employee that performed foley catheter care should have been wearing the required ppe. She stated the required ppe was mask, gloves, and gown. She stated that CNA B should have been wearing a gown while she performed foley care. She stated that if the proper ppe was not worn, it could put Resident #18 at risk for an infection. <BR/>Attempted to contact CNA B on 2/19/24 at 5:50 pm by phone, no answer, left message. <BR/>Record review of facilities policy titled Enhanced Barrier Precautions dated 4/1/24 indicated: <BR/>Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. <BR/>9. Enhance barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate the assessment of Resident, (Resident #19 and Resident #65 ) with the pre-admission screening and resident review (PASRR) program, of resident assessments reviewed for PASRR evaluations.<BR/>The facility did not correctly complete a new PL1 form for Resident #19 and Resident #65 when the was a new mental health diagnosis added. <BR/>This failure could affect residents with psychiatric diagnoses who may not be evaluated and receive needed PASRR services.<BR/>The findings were:<BR/>Review of Resident# 19's Face Sheet, not dated, revealed she was admitted to the facility on [DATE]. Resident#19's diagnoses included: Major depressive disorder, recurrent severe without psychotic features (characterized by at least 2 weeks of pervasive low mood, low self-esteem and loss of interest or pleasure), Post traumatic stress disorder (condition that last months or years with triggers that can bring back memories of trauma). <BR/>Review of Resident#19's Physician Orders dated 05/10/2022 revealed order for divalproex; (500mg, amt: 1; oral, twice a day; shift 1 and shift 2) for Major Depressive Disorder. <BR/>Review of Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident#19 could understand others and was understood by others; had a no cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 15. <BR/>Review of Resident#19's Care Plan dated 05/24/2023 revealed the following areas:<BR/>Psychological wellbeing- exhibit attention seeking behavior, false statements, and exaggerations due to diagnosis of PTSD, major depression, and anxiety. I will have fewer episodes of attention seeking. <BR/>Medications- At risk for adverse complications associated with medications and to monitor for side effects, complications associated with antianxiety and antidepressant medications. <BR/>There was no mental health or PASRR areas care planned. <BR/>Behavioral symptoms- Resident makes false accusations towards staff when he is angry or upset. Resident is to have three accusations or less per month.<BR/>Review of Resident#19's PASRR Level One Screening Forms dated 11/04/2021 revealed Resident#19 was not positive for mental illness and was negative for intellectual disability or developmental disability. A 1012 form (which is a mental illness/dementia form) was not completed or submitted at this time. <BR/>Review of Resident#19's 1012 form (which is a mental illness/dementia form) dated 07/18/2023 showed it had been completed but not yet signed by the physician. <BR/>Review of Resident#65's Face Sheet, not dated, revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #65's diagnoses included: Psychotic disorder with delusions due to known physiological condition (A disorder that produces psychosis to where the person believes an organism is making plans to hurt or kill them), Major depressive disorder, single episode, severe without psychotic features (clinical depression that last more than 2 weeks). <BR/>Review of Resident#65's Physician Orders dated 05/10/2022 revealed order for Seroquel; (50mg, amt: 1; oral, twice a day; at morning time and bedtime for psychotic disorder with delusions. <BR/> Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident#65 could usually understand others and was usually understood by others; had cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 12 (cognitively intact). <BR/>Review of Resident#65's Care Plan dated 06/28/2023 revealed the following areas:<BR/>Antipsychotic medication- At risk for adverse complications associated with psychotropic medications and to monitor for side effects, complications associated with antipsychotics. There was no mental health or PASRR areas care planned. <BR/>Behavioral symptoms- Resident makes false accusations towards staff when he is angry or upset. Resident is to have three accusations or less per month.<BR/>Review of Resident#65's PASRR Level One Screening Form dated 12/20/2022 revealed Resident#65 was not positive for mental illness and was negative for intellectual disability or developmental disability. A 1012 form (which is a mental illness/dementia form) was not completed or submitted at this time. <BR/>Review of Resident#65's 1012 form (which is a mental illness/dementia form) dated 07/19/2023 showed it had been completed but not yet signed by the physician. <BR/>Interview with the DON on 07/19/2023 at 10:39 AM revealed that PASRR and 1012 forms (which is a mental illness/dementia form) were to be completed by the MDS Coordinator. <BR/>Interview with the MDS Coordinator on 07/19/2023 at 1:30 PM revealed that she should have completed a new PL1 for when a qualifying diagnosis was added for Resident #19 and Resident #65. She stated that this failure could place the residents at risk for not receiving the mental health care they are entitled to. She revealed she was new in this position, and she was just learning it all. <BR/>Record review of the facility's policy entitled, Pre-admission Screening and Resident Review (PASRR) revised on 05/21/2022 stated that <BR/>3. A resident with MI or ID/DD must have a resident review conducted when there is a significant change in the resident's condition. The nursing facility is required to notify the LIDS or the LMHA.<BR/>4. The facility must use the Mental illness/Dementia resident review form (Form 1012) for assistance in determining whether a resident needs further evaluation if a resident currently has a negative PL1 and is suspected to have a diagnosis with mental illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide each resident with an ongoing program of individual activities designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 2 of 2 residents (Resident #s 19 and 39) who were reviewed for individual in-room activity programs, in that:<BR/>1. Resident #19 was paralyzed and remained in bed. There was no documented evidence she had received one-to-one in-room visits and participated in individual activities at least one time weekly during May 2023 as documented as an activity goal in her comprehensive care plan dated 5/24/2023.<BR/>2. Resident #39 received hospice care services and always remained in bed. There was no documented evidence she had received one-to-one in-room visits and participated in individual activities at least one time weekly during May 2023 as documented as an activity goal in her comprehensive care plan dated 4/04/2023.<BR/>The facility's failure placed the residents at risk for social isolation, a decline in mental health status, and decreased feelings of well-being within their environment.<BR/>The findings included:<BR/>1. Resident #19<BR/>Review of Resident # 19's Resident Face Sheet, dated 07/19/2023, revealed she was a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses of Quadriplegia (paralysis of all 4 limbs). <BR/>Review of Resident #19's Care Plan, dated 05/24/2023, Category Activities, revealed she would participate in one on one in room activities, at least 3 times a week. Resident will participate in Bingo and special events.<BR/>Review of Resident #19's Electronic Medical Record revealed the following activity records:<BR/>April 2023<BR/>04/11/2023- one-on-one<BR/>04/18/2023- one-on-one<BR/>04/21/2023- one-on-one<BR/>May 2023<BR/>05/05/2023- one-on-one<BR/>05/15/2023- one-on- one<BR/>05/23/2023- one-on-one<BR/>June 2023<BR/>06/15/2023- one-on-one<BR/>06/26/2023- one-on-one<BR/>July 2023<BR/>No provided<BR/>Review of In Room Activities, revealed Resident #39 received the following in room activities:<BR/>April 2023<BR/>04/03/2023 10 minutes - calendar<BR/>04/17/2023 15 minutes - sensory<BR/>04/19/2023 10 minutes - social<BR/>No In Room Activities were documented for May 2023.<BR/>June 2023<BR/>06/02/2023 15 minutes - manicures<BR/>06/07/2023 15 minutes - social<BR/>06/08/2023 10 minutes - sensory<BR/>06/09/2023 5 minutes - snow cones<BR/>06/28/2023 5 minutes - order catfish corner<BR/>06/30/2023 15 minutes - manicure<BR/>No other activities were documented for the month of June.<BR/>July 2023<BR/>07/03/2023 10 minutes - social reading<BR/>07/05/2023 5 minutes - hydration<BR/>07/07/2023 10 minutes - taste of chocolate<BR/>07/10/2023 5 minutes - sensory<BR/>07/12/2023 60 minutes - bingo<BR/>07/15/2023 10 minutes - social<BR/>Observation and interview on 07/18/2023 at 11:20 AM revealed Resident #19 was lying in bed watching TV. She stated that she did not get out of bed at all and that no one had been to visit her in a couple of months. She revealed that she enjoyed going to activities but since she was immobile, she had not been going. She stated that she has asked for in room activities and that they are too busy to provide them on a routine schedule. <BR/>2. Resident #39<BR/>Review of Resident # 39's Resident Face Sheet, dated 07/19/2023, revealed she was a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses of obstructive and reflux uropathy; muscle wasting and atrophy; muscle weakness; lack of coordination; chronic atrial fibrillation; depression; respiratory failure; diabetes mellitus; and morbid obesity.<BR/>Review of Resident #39's Quarterly Activity Assessment, dated 05/05/2023, revealed Resident #39 was unable to participate in group activities, but was able to participate in independent activity choice, one to one activity, and one to one visits. This review revealed Resident #39 responsive to one-to-one activities. The category titled Focus of Programming, documented 1:1 activities and Independent Activities.<BR/>Review of Resident #39's Care Plan, dated 04/04/2023, Category Activities, revealed resident would participate in 1 activity per week.<BR/>Review of Resident #39's Electronic Medical Record revealed no activity notes were documented in any areas of the records.<BR/>Review of In Room Activities, revealed Resident #39 received the following in room activities:<BR/>April 2023<BR/>04/03/2023 10 minutes - calendar<BR/>04/11/2023 10 minutes - order in<BR/>04/17/2023 10 minutes - mail and ordering<BR/>04/19/2023 10 minutes - sensory<BR/>04/21/2023 15 minutes - phone tech help<BR/>No other activities were documented for the month of April.<BR/>No In Room Activities were documented for May 2023.<BR/>June 2023<BR/>06/02/2023 10 minutes - social / phone help<BR/>06/05/2023 15 minutes - phone help<BR/>06/09/2023 10 minutes - phone / social<BR/>06/25/2023 10 minutes - social<BR/>06/28/2023 5 minutes - social / room clean<BR/>06/30 2023 60 minutes - family / social / birthday<BR/>No other activities were documented for the month of June.<BR/>July 2023<BR/>07/03/2023 15 minutes - phone payment help<BR/>07/05/2023 5 minutes - hydration<BR/>07/07/2023 10 minutes - sensory<BR/>07/10/2023 10 minutes - current events<BR/>07/12/2023 10 minutes - room clean / phone help<BR/>07/15/2023 10 minutes - snack / hydration<BR/>07/17/2023 5 minutes - sensory / social<BR/>Observation and interview on 7/17/23 at 3:10 PM revealed Resident #39 was lying in bed with her lunch meal tray on the overbed table. Resident #39 stated she did not get out of bed. She stated she had a wheelchair and her brother had taken it home. <BR/>In an interview on 7/18/23 at 11:49 AM, Resident #39 stated she received hospice care services and remained in bed. She stated she watched the television in her room and sometimes talked with her brother on her cell phone. She stated the activity director helped her with paying her bills.<BR/>In an interview on 07/19/2023 at 12:30 PM, the Activity Director revealed that she had been shredding the activity sheets. She stated that she thought they were only supposed to retain the last 90 days for their records. She stated that activities were being recorded on in the electronical records. She revealed that this failure could place bed bound residents at risk of being isolated.<BR/>Review of the facility's policy and procedure for Individual Activities and Room Visits, dated August 2006, revealed the following [in part]:<BR/>3. It is recommended that residents on a full room visit program receive at a minimum, three room visits per week. Typically, then to 15 minutes in length.<BR/>5.Residents who choose not to attend group activities will maintain an independent program. It is the responsibility of the facility and the activity staff to make regular contact and offer supplies, as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitization.<BR/>1. <BR/>The facility failed to ensure ground meat was thawed properly.<BR/>2. <BR/>The facility failed to ensure the cook performed hand hygiene appropriately when preparing food.<BR/>3. <BR/>The facility failed to ensure foods were sealed and/or labeled properly.<BR/>4. <BR/>The facility failed to ensure the foods were not stored past expiration date.<BR/>Thess failures could place residents that eat out of the kitchen at risk for contamination and foodborne illnesses.<BR/>Findings included:<BR/>During an observation of the kitchen on 01/19/2025 between 2:15 p.m. - 2:50 p.m. revealed the following: <BR/>Sink:<BR/>1 plastic dish sitting in a sink with 4 tubes of ground meat sitting vertically in the dish that was filled with water and water running into the container. The ground meat was not submerged in the water with approximately 30% of ground meat outside of the water and water was running in the middle of the 4 tubes and not covering the meat.<BR/>Pantry:<BR/>*1 clear plastic bag not sealed and was open to air held an opened bag of potato chips dated 2-12-25 & 2-25-25.<BR/>*7 expired bottles of Lemon Juice from concentrate with written date of 10/02 on the outside of the bottles. Manufacture date on the bottle lids was 01/24/2025.<BR/>Refrigerator #1:<BR/>*1 clear plastic bag not sealed and was open to air held an opened bag of pink circular meat. There was no description on the bag.<BR/>*1 expired bottle of Lemon Juice from concentrate with written date of 10/02 on the outside of the bottle. Manufacture date on the bottle lid was 01/24/2025. <BR/>Refrigerator #2:<BR/>*1 sealed plastic container of grape jelly with no date on label.<BR/>Freezer # 1:<BR/>*1 box of 3 containers of whipped topping sitting on the floor on its side to the left of freezer door. <BR/>*1 bag of a circular breaded item with no description and no date. <BR/>*2 bags of what appeared to be frozen pancakes with no description and no date.<BR/>During an interview on 02/16/2025 at 2:53 p.m., the cook stated bags of food being stored should be sealed. He stated after opening food item it should be labeled with open date. He stated if foods were not stored in their original container, then they should have item description on them. He stated no food should be stored on the floor. The cook stated meat should be dethawed in the refrigerator, but meat would need to be placed in the refrigerator several days before needed to dethaw in the refrigerator. He stated he had been rotating the meat during the thawing process due to all the meat was not submerged in the water in dish in sink. He stated he had started defrosting the meat about an hour prior. He stated he was responsible for storing, labeling, and preparing foods.<BR/>During an observation on 02/16/2025 at 4:11 p.m., the cook started pureeing foods for diner service. He donned gloves without washing his hands and began pureeing meat entree. He added all ingredients into the blender until food item was appropriate consistency He then moved food into container and covered with foil prior to putting item into the freezer. He took blender to the dish room and removed his gloves. The cook rinsed out blender prior to running through the dish washer and he did not wash hands before touching sanitized blender. He then [NAME] blender back to puree station and put down on counter. He reached into a bucket of water solution and pulled out a rag then wiped down counter under blender and bottom of blender machine. He put blender back together then put gloves on his hands. He did not perform hand hygiene prior to putting on gloves. He then started on pureeing the rest of dinner items. <BR/>During an interview on 02/16/2025 at 6:45 p.m., the cook stated he should have washed his hands when changing out gloves during food preparation. He stated he had just forgotten to do so when being observed. He stated he was a train wreck and nervous. He stated not labeling food items with date and description could cause the wrong food item to be given to residents with allergies to that food item and could cause the residents to get sick. He stated not storing food items appropriately could cause residents to be sick.<BR/>During an interview on 02/17/2025 at 3:29 p.m., the DM stated food stored outside of the original container should be labeled with food description and date. She stated no food should be stored on the floor and should be stored at least 6 inches off of the floor. She stated foods should not be stored in the pantry or in the refrigerator past the manufacture's expiration date and the date the manufacturer had on container was the expiration date. The DM stated she expected for food items to be disposed of when item passed the expiration date. She stated anyone who puts up food items off the delivery truck and during food preparation were responsible for making sure items were stored correctly with appropriate label. She stated she does monitor that food was labeled, stored at least 6 inches off of the floor and not expired. She stated she last monitored the kitchen the week prior. The DM stated packages of food should be stored in sealed containers after opened. She stated ground meat should be thawed submerged under running water. She stated kitchen staff should wash hands with soap and water during glove changes. She stated she expected for HH to be done when moving from one task to another in the kitchen and not performing could lead to cross contamination and bacteria spread. She stated she had been working for the facility for approximately one week and will be monitoring the kitchen at least 2-3 times a week. She stated not labeling food appropriately with description of food item and dates could lead to allergic reaction. She stated she would have thrown food away without date on label because staff would not know when food should be disposed of. The DM stated not thawing out meat correctly could lead to some of the food being in the danger zone for longer than appropriate time and could cause bacteria to grow.<BR/>During a telephone interview on 02/17/2025 at 5:00 p.m., the dietician stated foods stored outside of their original container should be labeled with description and date. She stated foods should be stored 6 inches above the floor. She stated foods should be disposed of and not kept past the expiration date. She stated packages of food items should be sealed so not to expose food to the elements. She stated typically frozen meat was thawed during the cooking process, in the cooler or under cold running water. She stated not submerging frozen meat could more than likely cause it to thaw unevenly and cause foodborne illness. She stated every time gloves were changed during food preparation then HH should be performed in between glove changes. She stated the dietary manager monitors that kitchen staff store, prepare and prepare food appropriately. She stated she was available for training and does observe how staff store and prepare food. She stated the kitchen staff had been changing and there was a new DM which could have led to failures of HH, meat thawing, and food storage or staff may have forgotten their training. She stated she felt more education was needed. She stated that not storing food appropriately and not performing HH correctly could lead to illness from bacteria. <BR/>During an interview on 02/17/2025 at 9:39 a.m., the ADMN stated she expected for kitchen staff to follow policies on food storage, preparation, and hand hygiene. She stated the DM monitored that kitchen staff were following the facility's policy. She stated not storing and preparing food appropriately could cause residents to get sick. <BR/>Record Review of facility's policy titled Food Preparation and Handling dated 2018 revealed: <BR/>Procedure: <BR/>1. General Guidelines a. Use clean, sanitized surfaces, equipment and utensils. b. Wash hands properly before beginning food preparation .<BR/>2. Thawing Foods a. Thaw meat, poultry and fish in a refrigerator at 41&deg;F or less. b. Foods may also be thawed using the following procedures: i. Completely submerged under running water at a temperature of 70&deg;F or below with sufficient water velocity to agitate and float off loosened food particles into the overflow: 1. For a period of time that does not allow thawed portions of ready-to-eat food to rise above 41&deg;F; or 2. For a period of time that does not allow thawed portions of a raw animal food requiring cooking to be above 41&deg;F for more than four hours including the time the food is exposed to the running water and the time needed for preparation for cooking.<BR/>Record Review of facility's policy titled Handwashing/Hand Hygiene dated 01/20/2023 revealed: <BR/>Hand hygiene must be performed prior to donning and after doffing gloves.<BR/>Record Review of facility's policy titled Preventing Foodborne Illness - Food Handling dated April 2022 revealed:<BR/>All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .Potentially hazardous foods held in the danger zone (41&deg;F to 135&deg;F) for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) will be discarded.<BR/>Record Review of facility's policy titled Food Storage dated 2018 revealed:<BR/>1. Dry storage rooms .d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated .2. Refrigerators .d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage .e. Use all leftovers within 72 hours. Discard items that are over 72 hours old .3. Freezers .c. Store all foods on racks or shelves off the floor. <BR/>Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed on 02/19/2025 revealed: <BR/>3-602.11 Food Labels. <BR/>(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. <BR/>(B) Label information shall include: <BR/>(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; <BR/>(2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; <BR/>(3) An accurate declaration of the net quantity of contents; <BR/>(4) The name and place of business of the manufacturer, [NAME], or distributor; and <BR/>(5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf <BR/>(6) Except as exempted in the Federal Food, Drug, and Cosmetic Act &sect; 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. <BR/>Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.<BR/>3-501.13 Thawing.<BR/>Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed:<BR/>(A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) <BR/>or less Pf; or <BR/>(B) Completely submerged under running water: <BR/>(1) At a water temperature of 21oC (70oF) or below Pf,<BR/>(2) With sufficient water velocity to agitate and float off loose particles in an overflow Pf, and

Based on interview and record review the facility failed to implement their written policies and procedures to prohibit abuse, neglect, exploitation, and misappropriation of resident property for 6 of 6 employees (Laundry Staff F, Housekeeping Staff E, [NAME] B, CNA A, Dietary Aide C, and Maintenance Staff D) who were reviewed for the abuse protocol. <BR/>The facility did not complete reference checks for Laundry Staff F, Housekeeping Staff E, [NAME] B, CNA A, Dietary Aide C, and Maintenance Staff D prior to employment at the facility.<BR/>This failure could place residents at risk for abuse, neglect, and exploitation. <BR/>The findings include:<BR/>A Record Review of the employee files revealed they did not include reference checks for the following employees prior to employment:<BR/>Laundry Staff F date of hire 06/16/2023<BR/>Housekeeping Staff E - date of hire 06/06/2023<BR/>Cook B - date of hire 05/01/2023<BR/>CNA A - date of hire 05/01/2023<BR/>Dietary Aide C - date of hire 05/16/2023<BR/>Maintenance Staff D - date of hire 07/14/2023<BR/>In an interview on 07/17/2023 at 3:45 PM, the HR Coordinator revealed when hiring new employees, each department within the facility was responsible for their own reference checks. The HR Coordinator stated at least 2 references should be contacted prior to the new employee being hired. She stated she would give the application to the department supervisor, who would complete the reference checks and return the application to her, when complete. She stated the reference checks would be noted in the reference check area of the application. The HR Coordinator stated if the reference check area was incomplete, then the reference checks were not completed.<BR/>In an interview on 07/17/2023 at 4:00 PM, the Administrator revealed at least 2 references should be contacted prior to the new employee being hired. She stated the reference checks would be noted in the reference check area of the application. She stated if the reference check area was incomplete, then the reference checks were not completed. The Administrator stated it was HR Coordinator's responsibility to ensure the reference checks were completed.<BR/>Review of the facility's Abuse Prevention Program Policy, dated as revised 01/09/2023, revealed the following <BR/>[in part]:<BR/>Our Center conducts employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees. For purposes of this policy direct access employee means any individual who has access to a resident or patient of a Long TermLong-Term Care (LTC) Center or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact ,with a patient or resident of the Center or provider, as determined by the State.<BR/>The Personnel/Human Resources Director, or other designee, will conduct background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential employees and contract personnel who meet the criteria for direct access employee, as stated above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 (Resident #17) of 23 residents reviewed for medication storage.<BR/>The facility failed to ensure medications were not left in Resident #17 ' s personal refrigerator.<BR/>This failure could result in unauthorized persons having access to medication that was not intended for them or drug diversion.<BR/>Findings included:<BR/>During an observation and interview on 02/17/2025 at 11:42 a.m., Resident #17 ' s personal refrigerator had a bottle of prescription hydrocortisone (a steroid topical solution used for skin irritation) cream inside of the refrigerator with expiration date of 02/08/2025. Resident #17 stated just throw it away, I do not want anyone to get into trouble.<BR/>Record review of Resident #17 ' s quarterly MDS dated [DATE] Section M &ndash; Skin Conditions revealed Resident #17 had intact skin with no pressure ulcers or other problems.<BR/>Record review of Resident #17 ' s electronic physician orders revealed no order for hydrocortisone cream.<BR/>During an interview on 02/17/2025 at 11:57 a.m., LVN E stated prescription medication should not be left in resident rooms. She stated Resident #17 was not able to apply the cream to himself and hydrocortisone cream was probably left in room for staff convenience.<BR/>During an interview on 02/17/2025 at 12:24 p.m., LVN D stated Resident #17 should not have medications in his room.<BR/>During an interview on 02/17/2025 at 12:10 p.m., the DON stated she expected for prescription medication not to be stored in resident ' s room inside of their personal refrigerator. She stated angle rounds are responsible for monitoring resident ' s personal refrigerators and the ADMN received those rounds. The DON stated the affect on residents could be medication administration directions may not be followed from not knowing correct way to use medication. She stated staff not being thorough and doing a quick check could have led to the failure.<BR/>Record review of facility policy titled Storage of Medication dated November 2020 revealed Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for (Resident #169) 1 of 23 resident's rooms observed for environmental conditions.<BR/>The facility failed to ensure that Resident #169 ' s toilet was free from cracks at the base and was sturdily attached to the floor.<BR/>The facility's failure placed the residents at risk for diminished quality of life, discomfort, and safety.<BR/>The findings included:<BR/>Record review of Resident #169's electronic face sheet dated 02/19/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and most recently on 02/01/2025 with diagnoses to include: right foot drop (difficulty lifting the front part of the right foot and foot might drag on the floor when walking), muscle wasting and atrophy (breakdown of muscle fibers), muscle weakness, and unspecified abnormalities of gait and mobility.<BR/>Record review of Resident #169's admission MDS dated [DATE] revealed: BIMS score of 15 which indicated his cognition was intact. Further review of the MDS Section GG for functional limitation in range of motion revealed he used a wheelchair and was independent with toileting hygiene and transfer.<BR/>Record review of Resident #169's care plan dated 02/04/2025 revealed no evidence that Resident #169 needed assistance with toilet hygiene or transfer.<BR/>Record review of Resident #169's progress notes dated February 2025 revealed on 02/03/2025, 02/07/2025, 02/16/2025, and 02/18/2025 nurse documented Resident #169 needed supervision &ndash; oversight, encouragement or cueing for toilet use.<BR/>During an observation and interview on 02/17/2025 at 2:21 p.m., Resident #169 was sitting up in a wheelchair in his room. He stated he had made a complaint about his toilet being broken when the maintenance man had first started Resident #169 stated he was scared that he was going to fall off the toilet. Toiled observed in resident ' s restroom to have left side of toiled base busted. Toilet moved easily with hands approximately an inch to the left side when pressed down on.<BR/>During an interview on 02/19/2025 at 3:00 PM the MD stated he had been there two weeks. MD stated he remembers talking with Resident # 169 about the toilet but was not sure when. The MD stated after he had been there a week he had cut his finger and had to take a week off. The MD stated the expectation was for residents ' toilets be in working order.<BR/>During an interview and record review on 02/19/2025 at 4:41 PM LVN A stated she was made aware of the broken toilet by the pest control man. LVN A stated she had made a repair request on 2/10/2025 on their electronic system, which she displayed. LVN A stated the new MD did not show up on the electronic system so she had made request to the ADMN. LVN A stated a toilet that was broken at the base could cause Resident to fall if they did not feel secure when they sat on toilet.<BR/>During an interview on 02/19/2025 at 5:11 PM the ADMN stated her expectation was that Residents have a safe and clean environment to reside. The ADMN stated she was not aware of Resident #169 ' s toilet being broken. The ADMN stated she never checked the electronic system and did not know that staff could send them under her name. The ADMN stated affect on residents having broken equipment could cause injury to resident. The ADMN stated what led to failure was the new DM not being at facility because he had been on leave and staff not knowing the ADMN was not checking the electronic reporting system.<BR/>Record review of facility ' s admission agreement dated 02/22/2022 revealed: Resident ' s rights under Texas law .You have a right: .2) to safe, decent and clean conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 (Resident #17) of 23 residents reviewed for medication storage.<BR/>The facility failed to ensure medications were not left in Resident #17 ' s personal refrigerator.<BR/>This failure could result in unauthorized persons having access to medication that was not intended for them or drug diversion.<BR/>Findings included:<BR/>During an observation and interview on 02/17/2025 at 11:42 a.m., Resident #17 ' s personal refrigerator had a bottle of prescription hydrocortisone (a steroid topical solution used for skin irritation) cream inside of the refrigerator with expiration date of 02/08/2025. Resident #17 stated just throw it away, I do not want anyone to get into trouble.<BR/>Record review of Resident #17 ' s quarterly MDS dated [DATE] Section M &ndash; Skin Conditions revealed Resident #17 had intact skin with no pressure ulcers or other problems.<BR/>Record review of Resident #17 ' s electronic physician orders revealed no order for hydrocortisone cream.<BR/>During an interview on 02/17/2025 at 11:57 a.m., LVN E stated prescription medication should not be left in resident rooms. She stated Resident #17 was not able to apply the cream to himself and hydrocortisone cream was probably left in room for staff convenience.<BR/>During an interview on 02/17/2025 at 12:24 p.m., LVN D stated Resident #17 should not have medications in his room.<BR/>During an interview on 02/17/2025 at 12:10 p.m., the DON stated she expected for prescription medication not to be stored in resident ' s room inside of their personal refrigerator. She stated angle rounds are responsible for monitoring resident ' s personal refrigerators and the ADMN received those rounds. The DON stated the affect on residents could be medication administration directions may not be followed from not knowing correct way to use medication. She stated staff not being thorough and doing a quick check could have led to the failure.<BR/>Record review of facility policy titled Storage of Medication dated November 2020 revealed Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.

Based on observation, interview, and record review, the facility failed to ensure the results of the most recent survey of the facility conducted by the State surveyors and the facility's plan of correction and advocacy information were posted in a place readily accessible to residents, family members and legal representatives of residents, and the public in 1 of 2 facility stations (Station 1), in that:<BR/>1. The most recent State survey results with the facility's plan of correction were not readily accessible to residents who occupied rooms located on Station 1.<BR/>2. Resident advocacy information was not posted in a prominent location that was easily identified by residents and visitors on Station 1.<BR/>3. Residents on Station 1 did not have access to the code to unlock the door leading from the hallway to Station 2, which had the secured units, to review the survey results located by the Administrator's office.<BR/>The facility's failure placed residents and their family members and representatives at risk for violation of the right to contact advocacy agencies and review the findings from State surveys and investigations conducted in the facility without asking to review the reports.<BR/>The findings included: <BR/>During an observation and interview on 2/18/23 at 9:25 AM, the Administrator showed the way to Station 1 and opened a locked door with a code. She stated the building had numerous codes. The door opened to a hallway that led to the Station 1 dining room.<BR/>During the Resident Council Meeting, held on 2/20/23 at 1:08 PM in the Station1 dining room, the seven residents in attendance conveyed they did not know where resident advocacy information and the prior survey results were posted.<BR/>An observation and interview on 2/20/23 at 3:04 PM, accompanied by the Resident Council President and an unidentified staff member, revealed the Station 1 resident advocacy information was posted on a bulletin board on a wall located half way down the hallway named Buffalo Bluff. The Resident Rights and a sign, with notification the most recent survey binder was in a box by the administrator's office, were posted on the wall across the hallway next to the door to the dialysis treatment room. The survey results were not found in Station 1. The staff member stated the survey results were located by the Administrator's office in Station 2 and there was not a copy of the survey results in Station 1. It was observed that there were no room numbers by the doors and no residents occupied the rooms for that hall.<BR/>Observation on 2/22/23 at 9:36 AM revealed a Facility Survey Binder in a box located on the wall outside the door to Administrator's office in Station 2. The survey binder included the CMS 2567 for the survey dated 2/17/22 and for intake investigations conducted, with resulting citations, dated 9/26/22.<BR/>Review of the Resident Council Minutes form, dated 1/27/2023, revealed 12 residents had attended the meeting. <BR/>Review of the Resident Bed List Report, dated 2/18/2023, revealed the 12 residents who had attended the Resident Council Meeting on 1/27/2023 all occupied rooms located in Station 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control management system to ensure the facility was free of pests and rodents.<BR/>The facility failed to effectively remain free of cockroaches on locked unit, dining and common area, and rooms 202 through 211.<BR/>The facility failed to effectively remain free of ants, mice, and/or cockroaches per log. <BR/>These findings placed residents at risk of ill effects of pest infestation.<BR/>Findings included:<BR/>During an observation period of 02/18/23 through 02/24/23, it was noted that cockroaches were seen throughout many rooms and dining area/common area of locked unit rooms 202-211. Cockroaches were seen climbing on surveyor computer screens. They were seen scattering under cabinets, near refrigerator, sink in dining area, and were crawling along tables surveyors were utilizing. Cockroaches were seen throughout all rooms 202-211 on glue traps. <BR/>During an interview on 02/23/23 at 3:00PM with MM, he said the facility just recently changed pest control companies. He believed it had been a change effective 02/01/23. MM said the decision to change companies had been due to continued pest infestation in the facility. He said the new company had inspected the facility at the first of the month and had determined that the former pest control company had not been effective. He said the former company was not spraying for pests and was not baiting the traps to keep pests and rodents out of the facility. MM said they had glue traps throughout the building away from resident direct access to assist with eradicating the pests. He said he felt that the locked unit rooms 202 through 211 and their dining area and common area had a lot of cockroaches because they had moved the residents out of the unit and the cockroaches were out in search of food.<BR/>During an interview on 02/24/23 at 6:45PM, ADM said she had no additional evidence to provide. <BR/>Record Review of Pest Control Logs from 12/13/22 through 02/15/23 revealed: <BR/>Ants- <BR/>12/13/22-Hall 3 in RM [ROOM NUMBER]<BR/>12/30/22-Unit 2, 218 <BR/>01/03/23-Unit 2<BR/>01/11/23-Unit 2 RM [ROOM NUMBER]<BR/>01/18/23-Rm 218<BR/>01/24/23-Rm 235<BR/>01/27/23-Unit 2, bathroom tub<BR/>01/27/23-Unit 2, RM [ROOM NUMBER] and 214<BR/>02/04/23- RM [ROOM NUMBER] and 215<BR/>Cockroaches-<BR/>01/10/23-Hall 4 RM [ROOM NUMBER]<BR/>01/11/23-Unit 1 hallway<BR/>01/12/23-Rm 121 and 122<BR/>02/01/23-Unit 1<BR/>Mice and/or Mice droppings- <BR/>01/10/23-Rm 223<BR/>01/11/23-Unit 2 RM [ROOM NUMBER] and 219<BR/>01/15/23-Rm223<BR/>01/18/23- BOM, hall 4, station 2<BR/>01/27/23-Hallway Unit 2<BR/>01/27/23-Rm 227<BR/>02/02/23-Rm 227<BR/>02/04/23-Rm 227<BR/>Record Review of Facility Policy labeled Pest Control revised 05/2008 revealed: This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 (Resident #17) of 23 residents reviewed for medication storage.<BR/>The facility failed to ensure medications were not left in Resident #17 ' s personal refrigerator.<BR/>This failure could result in unauthorized persons having access to medication that was not intended for them or drug diversion.<BR/>Findings included:<BR/>During an observation and interview on 02/17/2025 at 11:42 a.m., Resident #17 ' s personal refrigerator had a bottle of prescription hydrocortisone (a steroid topical solution used for skin irritation) cream inside of the refrigerator with expiration date of 02/08/2025. Resident #17 stated just throw it away, I do not want anyone to get into trouble.<BR/>Record review of Resident #17 ' s quarterly MDS dated [DATE] Section M &ndash; Skin Conditions revealed Resident #17 had intact skin with no pressure ulcers or other problems.<BR/>Record review of Resident #17 ' s electronic physician orders revealed no order for hydrocortisone cream.<BR/>During an interview on 02/17/2025 at 11:57 a.m., LVN E stated prescription medication should not be left in resident rooms. She stated Resident #17 was not able to apply the cream to himself and hydrocortisone cream was probably left in room for staff convenience.<BR/>During an interview on 02/17/2025 at 12:24 p.m., LVN D stated Resident #17 should not have medications in his room.<BR/>During an interview on 02/17/2025 at 12:10 p.m., the DON stated she expected for prescription medication not to be stored in resident ' s room inside of their personal refrigerator. She stated angle rounds are responsible for monitoring resident ' s personal refrigerators and the ADMN received those rounds. The DON stated the affect on residents could be medication administration directions may not be followed from not knowing correct way to use medication. She stated staff not being thorough and doing a quick check could have led to the failure.<BR/>Record review of facility policy titled Storage of Medication dated November 2020 revealed Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary drugs for 1 of 7 residents (Resident #645) whose records were reviewed for psychotropic drugs, in that:<BR/>1. Resident #645 had an order for the antipsychotic medication Seroquel for a diagnosis of systemic lupus erythematosus, which was not an appropriate indication for use.<BR/>2. Resident #645 received an order for the antianxiety medication Xanax PRN (as needed) on 2/16/23 and the order did not include an end date after 14 days.<BR/>This failure placed residents at risk for being over medicated or experiencing undesirable side effects and could cause a physical or psychosocial decline in health status.<BR/>The findings included:<BR/>Review of Resident #645's Face Sheet, dated 2/23/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: <BR/>- systemic lupus erythematosus (autoimmune disease where the body attacks itself) <BR/>- gastro-esophageal reflux disease without esophagitis (heartburn that burns the throat) <BR/>- rheumatoid arthritis, unspecified (autoimmune arthritis that affects the joints)<BR/>- chronic post-rheumatic arthropathy [Jaccoud] (problems with the joints due to rheumatic fever when younger)<BR/>- chronic viral hepatitis B without delta-agent (viral disease of the liver)<BR/>- essential (primary) hypertension (high blood pressure) <BR/>- heart failure, unspecified (failure of the heart to function properly)<BR/>- venous insufficiency (poor circulation of extremities)<BR/>- nicotine dependence<BR/>- pain, unspecified <BR/>- generalized anxiety disorder. <BR/>Review of Resident #645's current physician orders, dated 2/22/23, revealed the following:<BR/>- Seroquel 100 mg by mouth 2 times daily for the diagnosis systemic lupus erythematosus, with an order start date of 2/04/23; the order was discontinued 2/16/23;<BR/>- Seroquel 100 mg give 1-1/2 tabs (=150 mg) by mouth 2 times daily for the diagnosis systemic lupus erythematosus, with an order start date on 2/16/23;<BR/>- Xanax 1 mg by mouth 4 times daily for the diagnosis generalized anxiety disorder, with an order start date on 2/04/23;<BR/>- Xanax 1 mg by mouth mid-day one time daily PRN (as needed) for the diagnosis of generalized anxiety disorder, with a start date on 2/16/23; there was not an end date.<BR/>The initial admission medication orders and diagnoses for indication for use, dated 2/04/23, were documented as entered by LVN-P.<BR/>Review of Resident #645's Medication Administration Records, dated February 2023, revealed Xanax 1 mg by mouth four times daily was administered as ordered; PRN Xanax had not been administered; Seroquel 100 mg two times daily, changed to Seroquel 150 mg two times daily on 2/16/23, was administered as ordered.<BR/>Review of Resident #645's PASRR Level 1 Screening, dated 2/03/23, revealed no evidence or indication of mental illness, intellectual disability, or developmental disability.<BR/>Review of Resident #645's admission MDS Assessment, dated 2/13/23, revealed there were no indications of MI, ID, or DD conditions; there were no Psychiatric/Mood Disorder diagnoses selected; and antipsychotic and antianxiety medications were given daily during the 7-day review period. <BR/>Review of Resident #645's comprehensive care plan, dated 2/07/23, revealed the administration of psychotropic medications had not been addressed.<BR/>In an interview on 2/22/23 at 12:32 PM, LVN-P charge nurse stated the nurse who received a faxed physician order or physician telephone order was responsible for entering the medication order into the resident's electronic health record. She stated the prescribing doctor also gave the diagnosis for the medication. LVN-P stated the order for Seroquel was an increase from 100 mg two times daily to 150 mg two times daily, due to Resident #645's behavior. She stated the Hospice Doctor gave the initial order for Seroquel and the order to increase the dosage of Seroquel. <BR/>Review of the facility's policy and procedure for Medication Monitoring and Medication Management, dated 2007, revealed the following [in part]:<BR/>Policy<BR/>Each resident's drug regimen is reviewed to ensure it is free from any unnecessary drugs. This includes any drug:<BR/>- in excessive dose (including duplicate drug therapy);<BR/>- without adequate monitoring;<BR/>- without adequate indication for its use;<BR/>- in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or<BR/>- any combination of these reasons . <BR/>Additional specific guidelines are applied to Psychotropic drugs which are defined as any drug that affects brain activities associated with mental processes and behavior. This includes, but are not limited to:<BR/>Antipsychotics; Antidepressants; Anti-anxiety; and Hypnotics.<BR/>Based on a comprehensive assessment of a resident, the facility must insure:<BR/>- Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record .<BR/>- PRN orders for psychotropic drugs are limited to 14 days. Exception: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order .<BR/>The intent of this requirement is that:<BR/>- each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being .<BR/>- PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.<BR/>Procedures<BR/>The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis and with consideration of resident preferences .<BR/>Antipsychotic Medications<BR/>Indication for use must be thoroughly documented in the medical record. While antipsychotic medication may be prescribed for expressions or indications of distress, the IDT must first identify and address any medical, physical, psychological causes, and/or social/environmental triggers. Any prescribed antipsychotic medication must be administered at the lowest possible dosage for the shortest period of time and is subject to the GDR requirements for psychotropic medications .

Based on observation, interview, and record review, the facility failed to implement its policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 5 (Resident #5, Resident #17, Resident #22, Resident #43, and Resident #49) of 23 residents reviewed for food and nutrition services.<BR/>The facility failed to ensure that Resident #17's personal refrigerator did not have expired goods stored and failed to log refrigerator's temperatures.<BR/>The facility failed to ensure that Resident #43's personal refrigerator had a thermometer inside to check temperature and failed to log refrigerator ' s temperatures.<BR/>The facility failed to ensure that Resident #22's personal refrigerator had temperature log during the month of February 2025 (last checked on 1/14/2025).<BR/>The facility failed to ensure that Resident #5 ' s personal refrigerator had temperature log during the month of February 2025 (last checked on 1/22/2025).<BR/>The facility failed to ensure that Resident #49 ' s personal refrigerator had temperature log during the month of February 2025 (last checked on 1/22/2025).<BR/>These failures could place residents at risk for foodborne illnesses.<BR/>The findings were: <BR/>During an observation on 2/17/2025 at 11:42 a.m., Resident #17 ' s personal refrigerator did not have temperature log and had a bottle of prescription hydrocortisone lotion inside of the refrigerator with expiration date of 02/08/2025.<BR/>During an observation on 02/17/2025 at 11:31 a.m., Resident #43 ' s personal refrigerator did not have thermometer inside and did not have temperature log.<BR/>During an observation on 02/17/2025 at 11:45 a.m., Resident #22 ' s personal refrigerator had temperature log dated January 2025 and last documented temperature obtained on 01/14/2025.<BR/>During an observation on 02/16/2025 at 5:33 p.m., Resident #5 ' s personal refrigerator had temperature log dated January 2025 and last documented temperature obtained on 01/22/2025.<BR/>During an observation on 02/16/2025 at 5:25 p.m., Resident #49 ' s personal refrigerator had temperature log dated January 2025 and last documented temperature obtained on 01/22/2025. The directions on temperature log had instructions to check temperature every 5 to 7 days per month.<BR/>During an interview on 02/17/2025 at 12:10 p.m., LVN D stated night shift staff were responsible for checking resident ' s personal refrigerators.<BR/>During an interview on 2/19/2025 at 5:11 p.m., the ADMN stated her expectation was that resident refrigerators temperatures should have been checked on a weekly basis and recorded on a form hanging on or near the fridge. The ADMN stated staff were assigned residents to check on weekly, called Angel Rounds, to ensure residents were receiving services they needed, rooms were being clean, check temperatures of refrigerators and clean refrigerators. The ADMN stated effect on resident ' s fridge temperatures being checked could be residents receive food that had been spoiled. The ADMN stated what led to failure was staff not doing a thorough check when doing their rounds.<BR/>Record Review of facility polity titled Personal Resident Refrigerators dated 09/11/2023 revealed 1. Dormitory-sized refrigerators are allowed in a resident ' s room under the following conditions: .b. The refrigerator maintains proper temperatures .2. Maintenance staff/or designee shall record refrigerator temperatures weekly on a temperature log attached to the refrigerator. a. A thermometer will be placed in and remain in the refrigerator. B. Temperatures will be at or below 41&deg;F, and freezers will be cold enough to keep foods frozen solid to the touch (or in accordance with state regulations) .3. Housekeeping and/or nursing staff as assigned shall clean the refrigerator weekly and discard any foods that are out of compliance .5. Accommodations shall be made for the resident to be present for temperature checks, observing food for sanitary storage, and cleaning of the refrigerator, if so desired by the resident. 6. The resident and/or family shall be educated on safe food storage and use of the refrigerator prior to its use, and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have enough qualified staff to provide adequate care for residents with mental and psychosocial disorders for 13 of 13 residents (Resident #6, Resident #9, Resident #15, Resident #36, Resident #38, Resident #40, Resident #43, Resident #53, Resident #57, Resident #74, Resident #83, Resident #88, and Resident #199) reviewed for staffing behavioral health needs. <BR/>1. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #43, Resident #53 and Resident #74 to prevent a resident-to-resident physical altercation that led to injuries that required treatment of Resident #43 and Resident #53 on 12/03/22. <BR/>2. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #40 and Resident #53 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #40 on 12/21/22. <BR/>3. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #9 and Resident #53 to prevent a resident-to-resident physical altercation that led that required treatment to an injury of Resident #9 on 12/21/22. <BR/>4. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #6 and Resident #40 to prevent a resident-to-resident physical altercation that led to an injury that required medical treatment of Resident #40 on 01/01/23. <BR/>5. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residentson Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #40, Resident #53 and Resident #74 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #53 on 01/26/23. <BR/>6. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 2 (men secured locked unit) to meet the needs of Resident #57 and Resident #83 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #57 on 01/06/23. <BR/>7. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 2 (men secured locked unit) to meet the needs of Resident #57 and Resident #88 to prevent a resident-to-resident physical altercation that led to an injury that required treatment of Resident #57 on 02/04/23. <BR/>8. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 2 (men secured locked unit) to meet the needs of Resident #38 and Resident #199 to prevent a resident-to-resident physical altercation that led that required treatment to an injury of Resident #38 on 01/22/23. <BR/>9. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #15 and Resident #53 to prevent a resident-to-resident physical altercation on 11/26/22. <BR/>10. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #36 and Resident #40 to prevent a resident-to-resident physical altercation on 12/04/22. <BR/>11. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station 2/Hall 6 (women secured locked unit) to meet the needs of Resident #40 and Resident #74 to prevent a resident-to-resident physical altercation on 12/06/22. <BR/>12. The facility failed to ensure there was sufficient staffing with necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on Station /Hall 6 (women secured locked unit) to meet the needs of Resident #6 and Resident #53 to prevent a resident-to-resident physical altercation on 12/20/22. <BR/>13. The facility failed to ensure there was sufficient staffingwith necessary competencies to maintain safety and highest practicable physical, mental and psychosocial well being for residents on . on Hall 200/Unit 2 (women secured locked unit) to meet the needs of Resident #6 to prevent her from eating Styrofoam during lunch on 02/18/23. Resident #6 had a history of ingesting inedible objects.<BR/>An IJ was identified on 02/22/2023. The IJ template was provided to the facility on [DATE] at 4:56pm While the IJ was removed on 02/24/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy because the facility needed to continue to evaluate the effectiveness of their corrective actions.<BR/>These failures could place residents at risk for being provided care by staff who are not trained to care for resident with identified behavioral issues.<BR/>Findings include:<BR/>Record review of Facility assessment dated [DATE], Part 3, titled Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies revealed: <BR/>Staff: Licensed nurses: Station 2 (Station 2 has 6 halls): LVN/RN Days: 2 and Nights: 2 (12hour shifts). Direct Care Staff/CNAs: Station 2: Days 6, Nights 4 (12-hour shifts).<BR/>Station 2 Hall 6 (Women's Secured Unit)<BR/>In an observation on 02/14/23 at 11:00 am, Station 2 Hall 6 had 6 residents with known behaviors including 1 resident who required 1:1 supervision. One CNA was observed on the hall. <BR/>Station 2 Hall 1 (Men's Secured Unit)<BR/>In an observation on 02/14/23 at 11:47 am, Station 2 Hall 1 had 14 residents with known behaviors. 1 agency CNA, ADON, and LVN-T were observed on the hall. <BR/>In an interview on 02/14/23 at 11:00 am, CNA-E said she worked 6am to 6pm and worked 12 hours by herself on the women's secured unit, with 1 resident requiring 1:1 supervision. A staff member would come in every 2 hours to check on her. She said she did not feel safe working alone and was unable to prevent resident to resident altercations. CNA-E stated she had received training in the past for Alzheimer's/dementia but not for residents with aggressive behaviors. <BR/>In an interview on 02/14/23 at 11:47 am, LVN-T said the facility usually had 2 staff on the men's secured unit and 1 staff on the women's secured unit during the day shift. She floated between the 2 units but spent the majority of her time on the men's unit as that was where her desk as. She said 1 staff on the women's secured unit as not enough to protect the residents. She said staff was cut back from 2 staff to 1 staff on the women's unit about a month ago. <BR/>Resident #53 <BR/>Record review of Resident #53's electronic face sheet, dated 02/23/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. She was being housed on the women's secured unit (the average age of the residents was 76 years). Diagnosis included: anoxic brain damage; diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness; epilepsy and epileptic syndromes with seizures of localized onset; restlessness and agitation; post-traumatic stress disorder; repeated falls; muscle weakness (generalized); insomnia due to other mental disorder; major depressive disorder; anxiety disorder; dysphagia (difficulty in swallowing), altered mental status; pain; adult sexual abuse. <BR/>Record review of Resident #53's Quarterly MDS, dated [DATE], revealed the BIMS score was blank. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. None of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavior symptoms directed towards others - behavior of this type occurred 1 to 3 days, B. Verbal behaviors symptoms directed towards others - behavior not exhibited, C. Other behavioral symptoms not directed towards others - behavior of this type occurred 1 to 3 days. E0900: Wandering - 1 (Behavior of this type occurred 1 to 3 days). Section G: Functional Status. G0110. Activities of Daily Living Assistance: H. Eating: 3 (extensive assistance). G0120 Bathing: Self-Performance: 4 (Total dependence) G0300: Balance during transitions and walking: A. Moving from seated to standing position - 1 (not steady, but able to stabilize without human assistance). B. Walking (with assistive device is used) - 1 (Not steady, but able to stabilize without human assistance). Section P0100: Physical Restraints: Not used. <BR/>Record review of Resident #53's Care Plan, last edited on 02/13/23 revealed: Problem: I have periods of time where I am in constant motion/movement. Problem: I get frustrated because of my physical condition and may reach out to grab or hit others. Goal. To not hit other residents. Approach. Patient placed on 1:1 observation for at least 72 hours to prevent injury to others, will keep her separated from arms reach from other residents, put gloves on resident to prevent any injury if she reaches out. Problem: I have anxiety related to anoxic brain injury as evidence by I fidget constantly, grab at others, lick my hands and rub it on things and people, sit to stand frequently, stand up rapidly and attempt to walk with no regards to surroundings. Problem: Behavioral Symptoms - licking her hands and trying to touch others, invading others space, grabbing at others, sitting and or lying-in other residents' beds when they are not in them. Goal. Resident will have less than 5 bad outcomes due to grabbing at people and toward staff or other residents over the next 90 days. Approach: 15-minute checks, I will have increased supervision due to my behavior or grabbing at things and swinging my arms, I rest better with a quiet calm environment at night, Problem: Falls. Approach. Ordered an oversize bean bag for positioning. <BR/>Record review of Resident #53's transfer documentation packet, faxed on 04/19/2023 from previous facility revealed: resident required a locked facility that has more supervision and brain training support. On 04/21/22, Resident #53 was transferred from a sister facility requiring 1:1 supervision due to being threat to herself and others.<BR/>Record review of Nurse Practitioner progress note, dated 06/10/22, revealed Resident #53 was transferred from other facility due to not being able to continually provide the 1:1 care and attention that she requires.<BR/>Record review of Social Worker progress note, dated 09/12/22 at 5:27 pm, revealed: SW expressed to Family Member J, facility is not able to meet resident needs and SW will need to talk with Family Member J regarding plans to transition resident to another facility. <BR/>Record review of Social Worker progress note, dated 10/01/22 at 10:33 am, revealed: SW expressed to Family Member J, facility is not able to meet resident needs.<BR/>1. Review of facility investigation on 12/03/22 at 3:53 pm, Resident #53 slapped the face of Resident #43, and Resident #74 retaliated. A record review of the Provider Investigation Report revealed Resident #43 was sitting in the recliner minding her own business and for no reason Resident #53 slapped Resident #43 in the face. This in turn upset Resident #74 who scratched Resident #53 on the arm. Resident #42 had slight redness noted to the left side of her face. Resident #53 had several scratch marks to her upper right arm. Resident #53 was placed on increased supervision with staff. <BR/>Record review of Resident #53's progress note dated 12/03/22 at 4:39 am, revealed Resident #53 had multiple behaviors throughout the evening and night. Grabbing at residents. Attempting to remove snacks from other residents. Walking on knees and crawling on the floor. Attempting to hit and kick staff during care. Removing clothes and brief and walking down hall. Walks to exit door of secured unit 1 and slaps and then tries to open locked door. No documentation resident was on 1:1 supervision.<BR/>Record review of Resident #53's progress note dated 12/03/22 at 3:53 pm, revealed Resident #53 hit another resident across the face. (Resident was not identified.)<BR/>Record review of Resident #53's progress note dated 12/03/22 at 5:46pm, revealed another resident was yelling get away, get away. Resident #53 hit another resident in the face and the other resident scratched at Resident #53's upper arm. Residents were separated. Resident #53 then went toward another resident and attempted to hit her, but the LVN intervened. (Other residents were not identified.) <BR/>Record review of Resident #53's progress note dated 12/03/22 at 6:05 pm, revealed Resident #53 was on 1:1 supervision. <BR/>Record review of Resident #53's progress note dated 12/03/22 at 6:43pm, LVN-T documented in Resident #53's progress notes per DON, resident to be 1:1. If no staff available to be 1:1 then resident can be on Q (every) 15-minute checks.<BR/>Record Review of Resident #53's progress note dated 12/03/22 at 10:15 pm, revealed Resident #53 was on 15-minute checks. <BR/>During an interview on 02/17/23 at 9:45 am, the Interim Administrator stated she could not provide documentation of who or how may staff were working on the women's secured unit at that time of the incident or documentation of 15-minute checks. <BR/>2. Review of facility investigation on 12/21/22 at 11:25 am, Resident #53 scratched Resident #9 on the forehead. A record review of the Provider Investigation Report revealed, Resident #9 was sitting in a chair when Resident #53 approached her and brushed Resident #9 on her forehead, causing a small 2cm X 1cm scratch. The facility stated Resident #53 did not intend to hurt Resident #9 as both residents were acting per their norm. <BR/>Record review of Resident #53's progress note, dated 12/21/22 at 5:35 am, revealed resident #53 had multiple behaviors throughout the shift, including crawling on the floor, pulling and trying to remove the keypad cover, attempting to open doors, removing pants and brief and walking naked in the hallway, pulling a sign off the door, grabbing at residents and attempting to take their snacks, refusing evening medications, and attempting to climb in bed with another resident. Resident received Diazepam 15mg and it was documented it was not effective. <BR/>Record review of Resident #53's progress notes, dated 12/21/22 at 12:09 pm, revealed Resident #53 scratched another resident in the face. Resident also attempted to grab and hit the nurse. <BR/>3. Review of facility investigation on 12/21/22 at 1:52 pm, Resident #53 reached out her arm causing a skin tear to Resident #9. A record review of the Provider Investigation Report revealed, Resident #53 was ambulating in the hallway and reached out grabbing Resident #9's arm causing a small 1cm X 2cm skin tear to her forearm. The facility stated it is normal for Resident #53 to reach out and grab objects and people within reach. <BR/>Record review of progress notes, dated 12/21/22 at 9:40 pm, revealed Resident #53 was non-stop agitated and should have been on 1:1 observation. Resident #53 scratched and pulled the hair of the LVN on duty. Upon discussion with the ADON, Resident #53 was to be monitored until further notice. Record review of progress notes revealed no documentation of resident being placed on 1:1 observation. <BR/>5. Review of facility investigation on 01/26/23 at 7:00 pm, Resident #53 made contact with Resident #40's face and Resident #74 retaliated. A record review of the Provider Investigation Report revealed, Resident #40 walked to close to Resident #53 who flailed her hands making contact with Resident #40's face. Resident #74 intervened and scratched Resident #53 on her elbow. The scratch was visible. Resident #53 was placed on 1:1 observation until she went to sleep. <BR/>Record review of Resident #53's progress note dated 01/26/23 at 7:00 pm revealed, an unknown resident was sitting in a chair watching TV when Resident #53 walked past the unknown resident and hit her on the jaw with a closed fist. <BR/>Record review of Resident #53's progress note dated 01/26/23 at 7:10 pm revealed, Resident #53 walked past resident #40 and attempted to slap her. Resident #74 grabbed Resident #53's right elbow causing a 1.5cm X 0.5cm superficial scratch. Resident #53 was already currently on 1:1 monitoring. <BR/>9. Review of facility investigation on 11/26/22 at 4:00 pm, Resident #53 pulled the hair of Resident #15 and Resident #74 retaliated. A record review of the Provider Investigation Report revealed, Resident #74 was in the hallway when Resident #53 attempted to hit her, Resident #74 hit Resident #53 on the arm. Resident #15 was sitting at the dining room table and Resident #53 came up and pulled Resident #15's hair. Resident #53 was placed on 15-minute checks. <BR/>Record review of Resident #53's progress note dated 11/26/22 at 3:50 pm, revealed Resident #53 was walking in the dining room and pulled Resident #15's hair. Resident #74 hit Resident #53 on the right arm after she pull Resident #15's hair. No documentation that Resident #53 was placed on 15-minute checks. <BR/>12. Review of facility investigation on 12/20/22 at 1:15 pm, Resident #53 reached out towards Resident #6 and Resident #6 reached out toward #53 swiping her in the face. A record review of the Provider Investigation Report revealed, Resident #53 unknowingly/unintentionally reached out (per her norm) toward Resident #6 brushing her face, in return Resident #6 swatted at Resident #53 in reaction and was instructed to not do that anymore. No injury noted. <BR/>Record review of Resident #53's progress note dated 12/20/22 at 3:07 pm, revealed Resident #53 was in the dining room reaching out towards Resident #6. Resident #6 slapped Resident #53 in the face on the right cheek. No injury. Residents were separated. <BR/>Resident #6 <BR/>Record review of Resident #6's electronic face sheet accessed on 02/14/22 revealed an [AGE] year-old female whose most recent admission date was 12/20/21 to the female secured locked unit with diagnosis to include: Alzheimer's Disease, macular degeneration (deterioration of the retina of the eye that causes vision loss), and hypertension (high blood pressure).<BR/>Record review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. Other behavioral symptoms not directed toward others - behavior not exhibited. E0800 Rejection of care - behavior did not occur, E0900 Wandering - behavior occurred 1-3 days. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance - Supervision. 2. Support: set up help only. <BR/>Record review of Resident's #6's Care Plan dated 11/02/22 revealed the following problems and approaches: At risk for elopement - (problem start date 01/12/23) Requires secure unit placement. Attempted to take out of the secure unit. She started to wander aimlessly throughout all halls and rooms placing her at risk for other residents becoming aggressive towards her. Goal: Resident will be safe throughout her surroundings for 90 days. Approaches: Secure unit placement evaluation quarterly and prn. Elopement assessment quarterly and prn, Problem: (start date 01/05/23) Resident has physically abusive behavioral symptoms. Resident was hit by another resident and in return hit the other resident several times in defense. Goal resident will not harm self or others secondary to physically abusive behavior. Approach: avoid over stimulation, noise, crowding, and other physically aggressive residents), Avoid power struggles with resident, divert resident's behavior by encouraging resident to move to another common area away from distraction and other potentially aggressive residents who might provoke an unwanted response from resident #6 such as aggression, maintain a calm environment and approach, Problem: (start date 12/16/2019) I have impaired vision related to macular degeneration. Goal: I will not have accidents as a result of eye disease. Approaches: Assist as needed with ADL's and toileting Problem: At risk for falls, Goal: I will be free of falls Approaches included: increase staff supervision with intensity based on resident needs. <BR/>13. In an observation and interview on 02/18/23 at 12:43 pm during lunch on the Women's Secured Unit, the Assistant Administrator in Training was assisting Resident #53, she was attempting to spoon feed her, while the resident was constantly standing up and down, attempting to leave the table, and grabbing at her and other residents. The Director of Rehab was watching the rest of the residents, attempting to assist Resident #6 who was eating Styrofoam. Resident #40 was attempting to eat a piece of uncut chicken fried steak with the plastic fork sticking through the middle of it. There was no nurse present in the dining room during this time. The Director of Rehab attempted to get the Styrofoam from Resident #6 but never succeeded. The Assistant Administrator in Training and DOR said Resident #40 was supposed to eat finger foods due to the resident not allowing them to assist her with eating. <BR/>A record review of Resident #6's Get to Know Me information, not dated, prepared by the Social Worker, revealed For all meals take everything off her tray; just leave the plate and just a spoon - if not, she will hoard everything in sight and chew on napkin and plastics. <BR/>Resident #40 <BR/>Record review of Resident #40's electronic face sheet accessed on 02/14/22 revealed a [AGE] year-old female whose most recent admission date was 01/06/23 to the female secured locked unit with diagnosis to include: fractured left hip, osteoporosis (disease of bone that makes them brittle), history of falling, Alzheimer's Disease, and major depressive disorder.<BR/>Record review of Resident #40's Annual MDS dated , dated 01/11/23, revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E 0800 Rejection of care: behavior did not occur. Section E 0900 Wandering - behavior did not occur. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance. 2. Self-performance - Set up help only. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: Z. none of the above. <BR/>Record review of resident #40's Care Plan revealed the following problems and approaches: Problem: Mood state - start date 01/06/23 resident exhibits socially inappropriately disruptive behavioral symptoms. Resident wanders about without direction and becomes physically aggressive (hitting, kicking etc.) when she gets near other residents or staff in her path as well as being hit by resident's she provokes with her unwanted behavior. Goal: Resident will not harm self or others secondary to socially inappropriate, disruptive behavior of opportunistically hitting or kicking residents who get in her pathway or reach while she wanders. Approach: Assess whether the behavior endangers the resident or others. Intervene, if necessary, by moving resident to a safe area, to wander, avoid over stimulation (noise, crowding and other physically aggressive residents, when resident begins to reach for, hit, kick, or grab others, provide for basic needs pain, hunger toileting, too hot/cold etc. Problem: behavioral symptoms: (start date 09/09/22) I pace up and down the halls frequently with no regards to others in my path. 08/01/22 I walked up behind another resident and got hit in the stomach. 08/17/22 I pushed another resident in the hallway while I was pacing up and down the hall. 08/26/22 I hit another resident in the face while walking in the hallway. 12/04/22 Hit by another resident. Goal: I will have less than 3 episodes of physical aggression with other people in my path over the next 90 days. Approaches: I will be redirected to least crowded areas when pacing. I will have increased monitoring and a referral to a behavioral center.<BR/>4. Review of facility investigation on 01/01/23 at 4:50 pm, Resident #40 hit Resident #6, and Resident #6 hit Resident #40 back. A record review of the Provider Investigation Report revealed, Resident #40 approached Resident #6's wheelchair and bumped the wheelchair with her foot making contact with the back of Resident #6's head. Resident #6 turned around in reaction and made contact with Resident #40's face. No injury noted per report. <BR/>Record review of Resident #40's progress notes, dated 01/01/23 at 6:32pm, revealed Resident #40 kicked another resident's wheelchair and tapped her lightly on the head. That resident turned around and hit Resident #40 on the left eye and on her back several times. Resident #40 had redness under her left eye and redness to her upper back. <BR/>11. Review of facility investigation on 12/06/22, Resident #40 kicked Resident #74 and Resident #74 retaliated hitting Resident #40's back. A record review of the Provider Investigation Report revealed, Resident #74 was unintentionally kicked in the leg by Resident #40. Resident #74 then hit Resident #40 in the right shoulder. No injury reported. <BR/>Record review of Resident #40's progress notes dated 12/06/22 at 5:40 pm, revealed Resident #40 kicked Resident #74 in the right leg. Resident #74 hit Resident #40 in the back. No injury reported. <BR/>Resident #43 <BR/>Record review of Resident #43's face sheet in the electronic medical record, accessed on 02/14/22 revealed a [AGE] year-old female whose most recent admission date was 10/14/22 to the female secured locked unit with diagnosis to include: Alzheimer's Disease, schizoaffective Disorder (a mental health condition), and hypertension (high blood pressure).<BR/>Record review of Resident #43's Significant Change in Status MDS dated [DATE], revealed her BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E0800 Rejection of care: behavior did not occur. Section E0900 Wandering - behavior did not occur. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance - set up help. 2. Support: 1-person physical assist. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: Z. none of the above. <BR/>Record review of Resident #43's Care Plan revealed the following problems and approaches: Problem: (start date 08/23/21) I have a history of aimless wandering increasing safety concerns. 12/03/22 Behavior from another resident. Goal: I will have less than 2 episodes of wandering into others space over the next 90 days. Approaches: I will be redirected if I walk up to someone and invade their personal space, I will be redirected as needed when wandering to prevent me from going into an unsafe area, I will reside in the secured unit. Problem Start Date: 08/10/2021 Category: Falls. I am at risk for falls related to unsteadiness. Approaches: I will be encouraged to wear footwear that fit properly and have non-skid soles. I will be redirected from areas I don't need to be in. Problem: for elopement- (start date 01/11/23). Goal - Resident will not wander out of designated secure area over the next 90 days. Approach: Secure Unit Placement. Secure unit evaluation quarterly and PRN, elopement assessment quarterly and PRN Risk related to Alzheimer's /dementia.<BR/>Resident #74 <BR/>Record review of Resident #74's Face Sheet document in the electronic medical record accessed on 02/14/22 revealed an [AGE] year-old female whose most recent admission date was 01/06/23 to the female secured locked unit with diagnosis to include: dementia with behavioral disturbance, major depressive disorder, and delusional disorder.<BR/>Record review of Resident #74's Annual MDS dated [DATE], revealed a BIMS score interview was 00 which indicated severe cognitive impairment. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. none of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavioral symptoms directed towards others - behavior not exhibited, B. Verbal behavioral symptoms directed towards others - behavior not exhibited. C. other behavioral symptoms not directed toward others - behavior not exhibited. Section E0800 Rejection of care: behavior did not occur. Section E0900 Wandering -behavior did not occur. Section G: Functional Status: G0110. Activities of Daily Living Assistance: H. Eating:1. Self-Performance - supervision. 2. Support: set up help only. Section K: Swallowing/Nutrition Status: K0100. Swallowing Disorder: Z. none of the above. <BR/>Record review of Resident #74's Care Plan revealed the following problems and approaches: Problem: At risk for elopement - (start date 01/11/23). Goal: Resident will be kept safe in surroundings. Approaches: continuous placement in secure unit, elopement assessment quarterly and nail care weekly. Problem: Behavioral symptoms - resident exhibits verbal and physical aggression when other residents invade her space and surroundings. Goal: Resident will not show behaviors of aggression. Approaches: Remove and provide a quiet place, staff will encourage rapport with other residents, staff will encourage redirection when resident exhibiting bouts of verbal/ physical aggression, I will have increased supervision until reviewed by psych services., I will be assisted to a quiet place when things become too loud for me, Keep environment calm and relaxed. <BR/>Resident #9 <BR/>Record review of Resident #9's Annual Assessment MDS, dated [DATE], revealed Resident #9 was admitted to the facility on [DATE]. Diagnosis include [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control management system to ensure the facility was free of pests and rodents.<BR/>The facility failed to effectively remain free of cockroaches on locked unit, dining and common area, and rooms 202 through 211.<BR/>The facility failed to effectively remain free of ants, mice, and/or cockroaches per log. <BR/>These findings placed residents at risk of ill effects of pest infestation.<BR/>Findings included:<BR/>During an observation period of 02/18/23 through 02/24/23, it was noted that cockroaches were seen throughout many rooms and dining area/common area of locked unit rooms 202-211. Cockroaches were seen climbing on surveyor computer screens. They were seen scattering under cabinets, near refrigerator, sink in dining area, and were crawling along tables surveyors were utilizing. Cockroaches were seen throughout all rooms 202-211 on glue traps. <BR/>During an interview on 02/23/23 at 3:00PM with MM, he said the facility just recently changed pest control companies. He believed it had been a change effective 02/01/23. MM said the decision to change companies had been due to continued pest infestation in the facility. He said the new company had inspected the facility at the first of the month and had determined that the former pest control company had not been effective. He said the former company was not spraying for pests and was not baiting the traps to keep pests and rodents out of the facility. MM said they had glue traps throughout the building away from resident direct access to assist with eradicating the pests. He said he felt that the locked unit rooms 202 through 211 and their dining area and common area had a lot of cockroaches because they had moved the residents out of the unit and the cockroaches were out in search of food.<BR/>During an interview on 02/24/23 at 6:45PM, ADM said she had no additional evidence to provide. <BR/>Record Review of Pest Control Logs from 12/13/22 through 02/15/23 revealed: <BR/>Ants- <BR/>12/13/22-Hall 3 in RM [ROOM NUMBER]<BR/>12/30/22-Unit 2, 218 <BR/>01/03/23-Unit 2<BR/>01/11/23-Unit 2 RM [ROOM NUMBER]<BR/>01/18/23-Rm 218<BR/>01/24/23-Rm 235<BR/>01/27/23-Unit 2, bathroom tub<BR/>01/27/23-Unit 2, RM [ROOM NUMBER] and 214<BR/>02/04/23- RM [ROOM NUMBER] and 215<BR/>Cockroaches-<BR/>01/10/23-Hall 4 RM [ROOM NUMBER]<BR/>01/11/23-Unit 1 hallway<BR/>01/12/23-Rm 121 and 122<BR/>02/01/23-Unit 1<BR/>Mice and/or Mice droppings- <BR/>01/10/23-Rm 223<BR/>01/11/23-Unit 2 RM [ROOM NUMBER] and 219<BR/>01/15/23-Rm223<BR/>01/18/23- BOM, hall 4, station 2<BR/>01/27/23-Hallway Unit 2<BR/>01/27/23-Rm 227<BR/>02/02/23-Rm 227<BR/>02/04/23-Rm 227<BR/>Record Review of Facility Policy labeled Pest Control revised 05/2008 revealed: This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents.

Based on interview and record review, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility for 1 of 1 surety bonds reviewed. <BR/>The facility failed to ensure that the facility's $60,000.00 surety bond was enough to cover the $71,340.82 total residents' trust fund account balance.<BR/>This deficient practice could affect all residents who deposited personal funds with the facility, and place residents at-risk of their personal funds not being assured.<BR/>The Findings included: <BR/>During an interview on 12/21/2023 at 11:24 AM the ADMN stated the average balance of the resident trust fund for the past 3 months was $71,340.82. The ADMN stated her expectation was the surety bond should have covered the funds in the trust fund. The ADMN stated corporate was responsible to manage the surety bond and trust funds. The ADMN stated the effect on residents could have been residents not able to get their money. The ADMN stated she was not sure what led to the failure.<BR/>Review of facility policy titled, Surety Bond dated March 2021, revealed: Our facility has a current surety bond to assure the security of all residents' personal funds deposited with the facility. 1. A surety bond is an agreement between the facility, the insurance company, and the resident or the State acting on behalf of the resident, wherein the facility and the insurance company agree to compensate the resident for any loss of residents' funds that the facility holds, accounts for, safeguards, and manages. 2. This facility holds a surety bond to guarantee the protection of residents' funds managed by the facility on behalf of its residents.<BR/>3. All funds (including refundable deposits) entrusted to the facility for a resident are covered by the surety bond. 4. The purpose of the surety bond is to guarantee that the facility will pay the resident for losses occurring from any failure by the facility to hold, account for, safeguard, and manage the residents' funds (i.e., losses occurring as a result of acts or errors of negligence, incompetence or dishonesty).

Based on observation, interview, and record review, the facility failed to post the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily.<BR/>The daily nursing staffing information was posted but did not include the total numbers of actual hours worked for RNs, LVNs, and CNAs.<BR/>The facility's failure could affect the residents and/or visitors to the facility who may desire to know how many nursing staff were present and on duty and the actual hours worked per each shift daily.<BR/>The findings included:<BR/>In observations on 07/17/2023 through 07/19/2023 of the facility's daily nursing posting, revealed it failed to display the required total number and actual hours worked. <BR/>In an interview on 07/19/2023, the DON said the daily nursing posting was not correct. The form should have been filled out completely as it did not have the total number and actual hours worked. He said he has been the DON for a week, and he would get it fixed. He said failure to post the actual hours worked had the potential to prevent residents and/or visitors to the facility who may desire to know how many nursing staff were present and on duty and the actual hours worked per each shift daily.<BR/>In an interview on 07/19/23 at 3:26 PM, the Administrator stated she would get it corrected and make sure it would be filled out correctly with all of the required information. <BR/>Record review of the facility's policy Staffing, dated as revised July 2021, revealed the following [in part]:<BR/>Policy Statement: Our center provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the center assessment.<BR/>Policy Interpretation and Implementation: <BR/>5. Staffing levels for direct care staffing is updated each shift and posted in a public area.

Based on interview and record review, the facility, with a capacity of more than 120 beds, failed to employ a qualified social worker on a full-time basis. <BR/>The facility failed to ensure facility had a full-time social worker. <BR/>This failure could affect all residents of the facility by placing them at increased risk of psychosocial decline and poor quality of life. <BR/>The findings included:<BR/>During an interview on 12/20/23 at 03:30 PM the SW stated she was a corporate social worker. The SW stated she worked part time at facility and was only there maybe 20 hours per week. The SW stated she was also responsible for several other facilities. <BR/>During an interview on 12/21/23 at 10:18 AM the ADMN stated her expectation was to have a full-time social worker but had not been able to hire a social worker. The ADMN stated the corporate SW was in the building weekly. The ADMN stated the facility had not had a full-time social worker since the end of August of 2023. The ADMN stated she did not think there was a negative effect on residents, she felt that the cooperate SW was covering and had filled in the gaps. The ADMN stated she was responsible to ensure the position was filled. The ADMN stated what led to failure was she was not able to find a person with the qualifications to hire.<BR/>Record review of the facility policy titled, Social Services dated October 2010, revealed no evidence the position was to be full-time. <BR/>Record review of Form 3740 titled Bed Classification dated 12/20/2023 revealed the facility had a licensed capacity of 188 resident beds.