EL PASO HEALTH & REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain medical records on each resident that were accurately documented for one (Resident #1) of 5 residents reviewed for accuracy of resident's medical records. <BR/>On three occasions Resident #1 was administered 300 MG of Gabapentin at bedtime but this was not documented in his medical record. <BR/>On two occasions Resident #1 received treatment for gangrene and pressure ulcer on his left foot but this was not documented on his medical record. <BR/>Resident #1 received treatments for a pressure ulcer on his right heel for which there were no orders or documentation. <BR/>This failure could put residents at risk of not receiving ordered medication or treatments, receiving undocumented medications or treatments, and/or receiving excessive doses of medications or unnecessary treatments. <BR/>Findings include:<BR/>Closed record review of Resident #1's face sheet, dated 03/11/2023, documented that he was a [AGE] year-old male admitted to the facility on [DATE]. <BR/>Record review of Resident #1's hospital discharge instructions dated 02/16/2023 documented in part that he was to receive 300 MG of gabapentin (a pain medication) at bedtime for Type 2 Diabetes with diabetic neuropathy. He had a diagnosis of Left Foot Status Post Hallux amputation with necrotic area tissue (surgery removing the big toe on the left foot but with death of some of the tissue). He also had a stage 2 pressure ulcer (bed sore that has broken though the top layer of skin and some of the layer below) on his right heel. <BR/>Record review of Resident #1's hospital record dated 02/24/2023 documented he was receiving treatments for the infected amputated toe wound, a deep tissue injury (pressure ulcer) to the left heel, and a right heel deep tissue injury. He was receiving 300 MG of Gabapentin daily at bedtime for Type 2 Diabetes with diabetic neuropathy. <BR/>Record review of Resident #1's History and Physical dated 03/02/2023 completed by the Facility Physician stated that he had an amputation of his left great toe, an unstageable wound to the left heel and a deep tissue injury to the right heel. The facility was to continue Gabapentin capsules 300 MG orally once a day. <BR/>Record review of Resident #1's physician's Order Recap Report for the months of February and March 2023 documented an order dated 03/02/2023 to be started 03/04/2023 to cleanse the left foot with normal saline (salt water), pat dry, put on xeroform (gauze dressing with petrolatum and an antimicrobial) and wrap the foot in an ace bandage every Tuesday, Thursday and Saturday. There were no orders for treatment of the right heel. An order was documented dated 03/01/2023 to administer 300 MG of Gabapentin at bedtime daily. <BR/>Record review of Resident #1's MAR and TAR for March of 2023 revealed that administration of Gabapentin 300 MG was not documented on 03/02/2023, 03/07/2023 or 03/08/2023. Treatment of the resident's left foot was not documented on 03/04/2023 or 03/09/2023. No treatments for the resident's right foot appeared pm the MAR/TAR. <BR/>In an interview on 03/15/2023 at 4:22 PM the DON said that she did not know why Resident #1's Gabapentin 300 MG was not documented as administered on 03/02/2023, 03/07/2023 or 03/08/2023 and did not know why wound treatments to Resident #1's left heel were not documented. She said that administration of medications and treatments should be documented on the MAR or TAR. She said that she (the DON) and the ADONs were responsible for monitoring that medications and treatments were provided as ordered and were documented in the resident's medical record. <BR/>In observation, interview and record review 03/16/23 at 4:03 the DON provided a packing slip the facility pharmaceutical provider that documented that thirty 300 MG Gabapentin capsules had been delivered to the facility for Resident #1 on 03/01/2023. She provided a blister pack for 300 MG Gabapentin capsules for Resident #1 dated 03/01/2023 from which nine capsules had been dispensed. She stated that the dispensing nurse must have neglected to document that the medication had been administered to the resident. The DON stated that there was no order for care for Resident #1's pressure ulcer to his right heel, but there were progress notes from the Wound Care Nurse that she was providing treatment to his right heel. She said that there should have been orders for wound care to the right heel if treatments were to be provided. <BR/>In an interview on 03/16/2023 at 4:20 PM the Wound Care Nurse stated she had been in communication with Resident #1's podiatrist on 03/01/2023 to review orders for treatment and had entered the physician's orders for treatment of both feet in the computer software at that point. She said she assessed and provided treatment to Resident #1's left and right feet on 03/01/2023 and documented this in the MAR/TAR. She stated that she provided treatment for Resident #1's left and right feet on 03/04/2023 and 03/09/2023 and entered documentation of treatments to the MAR/TAR. She did not know why documentation of treatments to the left foot on 03/01, 03/04 and 03/09/2023 were not appearing on the MAR/TAR, or why the order and documentation of treatments for the right heel were not appearing on the Order Recap or the MAR. The Wound Care Nurse said she would look for additional documentation of the orders or provision of care. No further documentation was provided prior to exit. <BR/>In an interview on 03/16/23 at 4:03 PM wound care reports for March for Resident #1 were requested from the DON, but these were not provided prior to exit. <BR/>Record review of the facility policy titled Following Physician Orders dated 09/28/2021 documented in part that the nurse would document orders by entering the order with the time, date and signature on the physician order sheet, and transcribe the order to the medication or treatment administration record. <BR/>Record review of the facility policy Medication - Treatment Administration and Documentation Guidelines dated 02/02/2014 documented in part that accuracy of physician orders would be verified on the MAR or TAR prior to administering medications or treatments. Provision of medications or treatments would be documented with initials and/or signature on the MAR or TAR immediately following administration. MAR or TAR would be reviewed after medication or treatment administration to validate documentation was completed and supported services provided according to physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain essential mechanical and electrical equipment in safe operating condition for 1 facility of 1 reviewed for essential equipment. <BR/>1. <BR/>The facility did not provide necessary repairs for 1 industrial washing machines, 2 industrial dryers, 1 washer soap dispenser, and 1 washer bleach dispenser. <BR/>2. <BR/>2 of 10 Resident beds in C Hallway had head and foot boards that were broken. <BR/>3. <BR/>Resident #36 was sitting in his wheelchair with a broken footrest that had parts to the chair with sharp edges. <BR/>This failure could place residents who had their clothes laundered by the facility at risk no having sufficient linen available to meet residents needs and place residents who use sleep on facility beds at risk for injury from lose head or foot boards that may fall on them or screws/bolts that my scratch or puncture them as they are lying or sitting down. <BR/>Findings included: <BR/>Interview with the Maintenance manager on 04/27/23 at 9:11 AM, he stated that he was not responsible for the soap dispensing mechanism on the washers and that would be the responsibility of the vendor and the housekeeping supervisor. He stated the responsibility of fixing the washers and dryers would fall in his job description. However, he can only try and if it becomes too complicated, he will just call a contract company to come and fix it. The maintenance manager stated, I personally have not worked on the washer and dryer, I have called a vendor. The maintenance manager stated he has been employed for the facility for 4 months, since he started working the 2 dryers and one washer have not been working about 2 months. He stated they had a vendor come and work on the washer on 4/25/23 but he was uncertain why the washer was still not working and was going to follow up. The maintenance manager stated the facility purchased a dryer and would be arriving on Monday 5/1/23. The maintenance manager denied having manuals for the washing machines or dryers and no quality assurance monitoring was being done on the machines to ensure they are working properly. The Maintenance manager stated if the issue continued and was not addressed it can lead to mold on clothing and pest which can be very harmful to residents. <BR/>Interview and record review on 04/26/2023 beginning at 4:18 PM DON stated the facility is transitioning to a Tele-system where staff can input work orders from anywhere in the facility on the kiosk system but that not everyone knows how to use it yet to include the Maintenance Director. DON stated the facility staff are still supposed to write repairs in the maintenance logbook. DON reviewed the maintenance log and stated she saw the work order for the broken headboard on room C-108 but not in room C-115. DON stated the risk to the residents for the boards not being fixed was the residents could get hurt when laying down with the boards falling on them or an injury with the bolts/screw. <BR/>Interview with DON on 04/27/23 at 10:15 AM revealed residents had communicated they had issues with delay in personal clothing and linen availability. The DON stated the issues were brought up and addressed as a team with the laundry/housekeeping department. <BR/>Observation on 04/27/2023 at 6:31 PM in the laundry room outside inside on the wall was two different dispenser each having 4 hooks ups and tubing that run down to containers on the floor of liquid laundry chlorine beach, laundry neutral detergent, and liquid laundry-built detergent. There were two washers and only one worked. The broken washer on the right needed to have the computer from inside replaced. The other washer had clothes inside as it was being washed. In the other room there were 3 dyers and only one worked (furthest to the wall). The middle dryer was being used for spare parts to fix the dryer to the right closet to the exit, but that dryer was not working as well. There were bags upon bags of clothes on lined up on the wall and in bins needing to be washed. <BR/>Head/Foot Boards<BR/>Observation on 04/24/2023 at 9:29 AM in room C-108 there was a broken headboard on a bed (Bed A) that was tilted sideways not bolted on correctly. Bed B had a broken headboard hanging on the metal bar of the bar exposing a long bolt/screw. Bed B had the footboard of the bed was hanging and tilted slightly exposing another bolt/screw about an inch long. <BR/>Observation on 04/24/2023 at 10:17 AM in room C-115 the headboard of bed A was hanging away (the board on one end was still screwed to the bar and the other was not) from the bed and screwed/bolted down. <BR/>Interview on 04/24/2023 at 9:11 AM Laundry Worker G said one of the washers and two of the dryers in the facility laundry had been broken for about three months. Laundry Worker stated that as a result large amounts of dirty laundry would accumulate in the laundry area. Laundry Worker G stated that also the laundry did not have enough soap or other laundry products (chemicals) and so was worried about whether the linens were sanitary or not. Laundry Worker G stated she thought her supervisor had spoken to the facility administration, but she did not know when. Laundry Worker G stated the conditions in the laundry had been going on for a while and the situation had not improved. <BR/>Interview on 04/24/2023 at 10:21 AM LVN A stated the beds head and footboards broken in room C-108 were reported to maintenance a long time ago but could not remember how long ago it was. LVN A stated it still had not been fixed. LVN A stated the headboards not being fixed was a risk for the residents for a potential physical injury. <BR/>Interview on 04/24/20223 at 10:24 AM Maintenance Director he received a report about the bed boards being broken in room C-108 but did not have the time to fix it. Maintenance Director stated he had not received report about the broken headboard in room C-115. Maintenance Director stated there was a risk to the residents and they could hurt themselves when lying down by hitting the bolts/screw or the boards falling on their heads or if they are on their standing up the boards falling on their feet. <BR/>Interview on 04/26/2023 at 4:18 PM DON stated the facility is transitioning to a Tele-system where staff can input work orders from anywhere in the facility on the kiosk system but that not everyone knows how to use it yet to include the Maintenance Director. DON stated the facility was still using the maintenance log for work orders. DON reviewed the maintenance log and stated she see saw the work order for the broken headboard on room C-108 but not in room C-115. DON stated the risk to the residents for the boards not being fixed was the residents could get hurt when laying down with the boards falling on them or an injury with the bolts/screw. DON stated that staff tell the Maintenance Director directly about what needs to be fixed but he forgets to fix it. DON stated staff need to be inputting repairs in the maintenance logbook. <BR/>Resident #36<BR/>Record review of Resident #36's Face Sheet revealed admission on [DATE] and readmission on [DATE] to the facility. <BR/>Record review of Resident #36's facility diagnosis report dated 04/27/2023 revealed a diagnosis of dementia, muscle weakness, difficult walking, and lack of coordination. <BR/>Record review of Resident #36's MDS quarterly dated 01/31/2023 revealed a brief interview mental status score of 7, ADLs indicate transfer/locomotion on unit of 1 (supervision) and 1 (one person assistance), not marked for wheelchair, is a 4 (supervision/touching assistance) on chair/bed to chair (Wheelchair) transfer, 4 (supervision/touching assistance) walk 10 feet and a 3 (partial/moderate assistance) walk 50 feet, marked a 1 for wheelchair manual. <BR/>Record review of Resident #36's care plan dated 08/02/2023 alteration in musculoskeletal status. Interventions are to monitor complications related to arthritis, joint pain, joint stiffness, swelling, contracture formation, pain after exercise or weight bearing. Activities are dependent on staff for cognitive stimulation, activity attendance, social interaction. Interventions are to converse with resident while providing care, provide the resident with assistance as needed during the activity. No mention of mobility with wheelchair or walking on care plan. <BR/>Observation and Interview on 04/24/2023 beginning at 10:05 AM with Resident #36. Resident #36 was in his wheelchair sitting down. It was noted the left footrest was broken leaving three black sharp long backets that hold the pedal. Resident #36's left leg was moved away from the black backets. Resident #36 stated he did not know how long the footrest was broken or if the staff knew it was broken. <BR/>Interview on 04/25/2023 at 1:57 PM LVN A stated he was not aware of the broken footrest and the CNAs if they had seen it broken should have reported it immediately to him. LVN A stated the footrest with the sharp edges could potentially cause an injury to Resident #36's leg/foot with a skin tear, scratch, or his foot could get caught with the broken pieces. <BR/>Interview on 04/26/2023 at 10:46 AM CNA L stated when they come into work they focus on the resident and pay attention to the resident's equipment to make sure it was working and in good condition. CNA L stated if CNAs see something broken or wrong with the equipment of wheelchairs, they immediately notify the nurse. CNA L stated she was unaware that Resident #36's footrest was broken. CNA L stated the risk to the resident could have been if he tried to step on the broken pieces, he could injury himself or fall. <BR/>Interview on 04/26/2023 at 2:20 PM LVN M stated broken medical equipment had to be report by the CNAs to him or therapy. LVN M stated medical equipment like wheelchair or walker if broken are reported to maintenance. LVN M stated there is a maintenance logbook in the main nurse's station where they can write the damages in. LVN M stated she was unaware that Resident #36 had a broken footrest. LVN M stated the risk could be injury to his skin or possible fall if his leg got caught on the broken footrest.<BR/>Interview on 04/27/2023 at 2:28 PM DON stated if the wheelchair or other medical equipment was broken the facility would see if it was basic or specialized medical equipment in which they would send the equipment out for repair. DON stated any broken wheelchairs, walker, or broken items are reported to the nurse. DON stated the risk for not reporting a wheelchair footrest Resident #36 could become a fall risk or have a skin tear on his leg with the sharp brackets from the broken footrest. <BR/>Interview on 04/27/2023 at 5:00 PM Administrator stated staff are repairs are written in the maintenance log located in the nurse's station. Administrator stated facility staff report damages to Maintenance Director directly but ends up forgetting about the repairs and damage item does not get fixed. Administrator stated they have in-serviced staff over and over to write repairs in the maintenance log, but facility staff don't do it. Administrator stated the Maintenance Director was only one person and it was a lot of work for him. Administrator stated the risk to the residents with the other repairs would depend on what those damages are. Administrator stated she approval from corporate to hire another maintenance man who was going to be tasked with certain areas to help expedite repairs and help elevate some of the workload from the Maintenance Director. Administrator stated the broke head and footboards should have been fixed by maintenance and the risk to the resident in room C-108 was that the resident could have hit herself on the exposed bed bars hurting herself. Administrator stated if the wheelchair had a broken footrest for Resident #36, then the staff were supposed to take the wheelchair out of serve and put a note on it stating it was broken so no one else would use it. Administrator stated staff are to report a broken wheelchair or walker immediately. Administrator stated there was a risk to the resident in which the resident could get a skin tear and possibly get punctured by the broken footrest. <BR/>Interview with on 04/25/2023 at 08:45 AM Administrator stated they did not have a facility policy regarding reporting of broken equipment. <BR/>Record review of facility policy Provision of Quality Life dated 01/10/2023 revealed the facility will create and sustain an environment that humanizes and promotes each resident's well-being and feeling of self-worth and self-esteem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming, personal and oral hygiene, for 1 Resident (#1) of 6 residents reviewed for activities of daily living. <BR/>The facility failed to provide fingernail care for Resident #1 by not maintaining trim and clean fingernails.<BR/>This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem.<BR/>The findings include: <BR/>Record review of Resident #1's face sheet, dated 3/27/25, indicated the resident was admitted on [DATE] with diagnoses: hemiplegia (paralysis of one side of the body, either right or left) and hemiparesis (weakness of one side of the body, either right or left) following cerebral infarction (stroke) affecting left non-dominant side, dysarthria (difficulty in speech because of weakness of the speech muscles), unspecified dementia, and Alzheimer's disease (a brain disorder that affects memory, thinking, and behavior).<BR/>Record review of Resident #1's admission MDS dated [DATE] indicated a BIMS score of 2, indicating severe cognitive impairment. Per the MDS, Resident #1 required moderate assistance with personal hygiene meaning the helper did more than half the effort. <BR/>Record review of Resident #1's Care Plan dated 03/15/25, revealed ADL Self-care performance deficit and interventions included nursing staff to Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care.<BR/>Observation on 3/26/25 at 11:24 AM of Resident #1 revealed she had nails approximately 1 inch off the nail bed for all fingers on both her hands. Her fingernails on both hand hands were observed with dirt under them and chipped nail polish. Resident #1 was not able to voice whether she liked her nails this length or not.<BR/>During an interview on 3/26/25 at 1:32 PM with CNA A, she said that residents are offered nail trimming services during the resident's scheduled shower. She stated if the resident is diabetic, nurses were to trim fingernails. CNA A stated that fingernails of residents should be maintained short and clean. She stated long fingernails can cause an infection control risk.<BR/>During an interview on 3/26/25 at 3:27 PM with LVN B, she said that nursing staff such as nursing assistants were to offer residents nail trimming during the resident's shower. She stated if the resident was diabetic only nurses were to file down fingernails. LVN B stated if a resident did not want nails groomed, the ADON, DON and family member were notified. She stated the risks for residents having long nails included residents could scratch themselves causing injury, or also an infection control issue as there are possible bacteria entrapped under the nail.<BR/>In an interview on 03/26/25 at 4:00 PM with the ADON, she said that residents received grooming services with their fingernails on Sundays. She stated that if resident's nails are observed long, the service could be offered at any time. She stated the nurses were responsible for monitoring (checking during daily rounds) residents through their rounding during their shift and could offer to trim or cut the resident's nails. She stated the risks for residents having long and dirty nails included infection risk, as the resident could touch their face or scratch their skin. <BR/>In an interview on 3/26/25 at 4:15 PM with the DON, she said that residents were offered nail grooming services from CNAs on the residents' scheduled shower days. She stated the nurses were to offer nail grooming service if the resident is diabetic. She stated the CNAs are responsible for monitoring, filing and cleaning the resident's nails, and the nurses could file and trim nails including diabetic residents. The DON stated If any resident declined care, they are to notify the charge nurse so that nurse could go in to assess and find the reason on why the resident does not want care at the time. She stated the resident had the right to have clean nails. The DON stated the risks of residents having ungroomed nails included an infection control concern to the resident. <BR/>Record review of facility's policy and procedures titled Activities of Daily Living, revised 2007, read in part: The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure a resident who needs respiratory care is provided such care consistent with professional standards of practice for 2 of 10 residents (Residents #2, #3) who were reviewed for respiratory care in that:<BR/>1. The facility failed to ensure Resident #2's oxygen concentrator filter was clean.<BR/>2. The facility failed to ensure Resident #3's oxygen concentrator filter was clean.<BR/>These deficiencies could affect the residents who received continuous oxygen and oxygen as needed and can result in a respiratory infection.<BR/>Findings include: <BR/>Resident #2<BR/>Record Review of Resident #2's face sheet dated 3/27/25 revealed a [AGE] year-old male that was admitted [DATE]. Resident #2 diagnoses included: Lymphedema (a condition of localized swelling caused by compromised lymphatic system), muscle weakness, obstructive sleep apnea, and peripheral vascular disease (a condition that narrows the vessels away from the heart and brain causing pain and discomfort in the limbs).<BR/>Record Review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. The MDS revealed the resident required extensive assistance in bed mobility from 2 persons to physically assist.<BR/>Record Review of Resident #2's Care Plan last revised 10/22/24 revealed that Resident #2 is at risk for ineffective gas exchange and used oxygen therapy routinely or as needed. The interventions included administering oxygen therapy per physician's orders.<BR/>Observation on 3/26/25 at 10:13 AM at revealed Resident #2 sitting in bed with oxygen on through a nasal cannula (a medical device used to deliver supplemental oxygen to individuals with respiratory issues; it consists of a thin, flexible tube that wraps around the head, with two prongs that fit into the nostrils to provide oxygen directly) and an oxygen concentrator with dust particles on the filter. <BR/>Resident #3<BR/>Record review of Resident #3's face sheet dated 3/29/25 revealed a [AGE] year-old male with an initial admission date of 10/25/18, and re-admission date of 2/28/25. The face sheet revealed Resident #3's diagnoses included: cerebral infarction due to embolism (stroke due to a blockage in the blood vessel), metabolic syndrome (a cluster of conditions that increased the risk of heart disease, stroke, and type 2 diabetes), dysthymic disorder (persistent depressive disorder), cognitive communication disorder, hypertension (high blood pressure), and muscle weakness.<BR/>Record review of Resident #3's MDS dated [DATE] revealed a BIMS score of 15 , indicating no cognitive impairment. The MDS revealed Resident #3 required a 2-person limited to extensive assistance with ADLs such as bed mobility.<BR/>Record review of Resident #3's head and physical physician note dated 02/26/25 revealed Resident #3 is diagnosed with Acute Hypoxic respiratory failure and required oxygen supplementation, 4 liters, to achieve oxygen level of 92% or more. <BR/>Observation on 3/26/25 at 10:20 AM revealed Resident #3 sitting at his bed with oxygen on through a nasal cannula and an oxygen concentrator with dust on the filter.<BR/>In an interview on 3/26/25 at 3:29 PM with LVN , she stated that the resident's oxygen filters are cleaned every Sunday night. She stated that nursing staff, nurses, were responsible for monitoring, and maintaining oxygen filters. LVN stated the ADON and DON are also responsible for monitoring the cleanliness of the oxygen concentrator filters when they round. She stated the risks for oxygen concentrator filters not being clean included infection control issues since bacteria and dust collect.<BR/>In an interview on 03/26/25 at 4:05 PM with the ADON, she said that oxygen concentrator filters were to be cleaned once a week. She stated that CNAs can clean them. She stated that if the filter was damaged or needed a replacement, Central Supply are to supply a new filter. The ADON stated the risks for oxygen air filters being dirty included infection risk and possible malfunction of the oxygen concentrator. <BR/>During an interview on 3/26/25 at 4:19 PM with the DON, revealed she said that it is everybody's responsibility to monitor and clean the oxygen concentrator air filters. She stated Central Supply can also change them. She stated if staff are not able to clean or replace the filter, they should notify the nurse so it can be completed. The DON stated if the oxygen concentrator air filters were not cleaned, it can introduce foreign objects or bacteria to the resident's body. <BR/>Record Review of the oxygen concentrator manufacturer manual , read in part: recommended cleaning interval for the air filter is every 7 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 6 resident rooms, observed for housekeeping and maintenance, in that: <BR/>The facility failed to ensure CNA E used the facility work order system to input the lights in the restroom and room of Resident #5 would not turn on while Resident #5 wanted to use the restroom but was dark and could not see. <BR/>These failures could lead to resident injury and a diminished quality of life.<BR/>Findings include: <BR/>Record review of Resident #5's face sheet dated 01/15/25, revealed, admission on [DATE], re-admission on [DATE], and re-admission again on 02/22/22 to the facility. <BR/>Record review of Resident #5's facility history and physical dated 07/28/24, revealed, a [AGE] year-old female diagnosed with Anxiety, Cholecystitis (inflammation of the gallbladder), reduced mobility, history of falls, and GI bleeding (bleeding from any part of the digestive tract, from the mouth to the anus). <BR/>Record review of Resident #5's annual MDS dated [DATE], revealed, little to no impairment of cognition BIMS score of 15 and to be able to recall or make daily decisions. ADLs revealed to be independent for toileting, shower/bath, dressing. Independent for walking 10 feet/50 feet. <BR/>Record review of Resident #5's Care Plan dated 04/27/22, revealed the resident was incontinent of bowel/bladder related to history of UTI, confusion, and incontinence. Maintain unobstructed path to the bathroom. Resident #5 had impaired visual function and was at risk for falls, injury, and a decline in functional ability. Anticipate needs and meet them as able. Keep call light in reach when in room or bathroom. Involve in activities which do not require vision to participate such as music, parties, and exercise. Monitor and report eye problems, change in ability to perform ADLs, decline in mobility, sudden visual loss, tunnel vision, blurred vison, hazy vision. Resident #5 was able to see large print in a well illuminated room. ADLs was supervision with set-up for toileting due to impairment with balance coordination. <BR/>Observation and interview on 01/15/25 at 8:44 AM, with Resident #5, she stated she was looking for staff due to her lights in her restroom and room not turning on. Resident #5 showed state agency her room and tried to turn on the light switch in the room. It was observed that the light in the room was not turning on. Resident #5 stated she had to go to the restroom, but could not cause the light in the restroom would not turn on and was afraid to go to the restroom without the lights turning on. State agency tried turning on the lights in the restroom and would not turn on. It was observed that the room was dark, and, in the restroom, it was dark and darker if the restroom door was closed. It was observed that nothing could be seen if the restroom door was closed. Resident #5 had stated she told a nursing staff about the issues a little over an hour ago and did not know what had happened. <BR/>In an interview on 01/15/25 at 8:48 AM, with CNA E, she stated Resident #5 had told her about the lights not turning on in her room and restroom. CNA E stated she was looking for the floor charge nurse of the hall at the nurse's station and could not find her. CNA E stated since she was not able to find her, she went back to assist another resident with feeding as she was busy. CNA E stated she did not use the facility work order system to input the work order. CNA E stated she had been trained to use the facility work order system when facility needed to report facility stuff that needed fixing and tell the nurse. CNA E stated the risk of the lights not working for Resident #5 could have been a fall. <BR/>Observation on 01/15/25 at 8:50 AM, revealed, visible facility work order system QR Scan postings in around the nurse's station of the facility. <BR/>In an interview on 01/15/25 at 9:19 AM, with the Maintenance Director, he stated facility staff have been trained to use the facility work order system and what to do if they see, hear, or get reported facility stuff that were broken. The Maintenance Director stated there were QR Scan codes posted everywhere in the facility in which facility staff could place the work orders through there phones. The Maintenance Director stated not using the facility work order system could have a negative outcome of broken item(s) not getting fixed affecting the resident negatively depending on the situation. The Maintenance Director stated he was told of Resident #5's lights not turning on around 10 minutes ago which he observed that the lights were not turning on. The Maintenance Director stated Resident #5 told him she wanted them to turn on. The Maintenance Director stated an issue like the lights not turning on for Resident #5 was considered to be a 911 call (defined as notify the Maintenance Director immediately with clogged toilet, lights out, Exit lights out, etc.) and should have inputted into the facility work order system and told immediately. <BR/>In an interview on 01/15/25 at 10:49 AM, with ADON C and ADON D, ADON C stated all facility staff were trained on how to place a work order. ADON D stated there were QR Scan code postings throughout the facility in which facility staff could use the facility work order system to place work orders which was sent to the maintenance department. ADON C stated if nursing staff were reporting a work order issue and cannot find the nurse, then they need to directly let the Maintenance Director know aside from using the facility work order system. ADON D stated the risk would depend on the situation. <BR/>In an interview on 01/15/25 at 11:13 AM, with the Administrator, she stated facility staff were trained on the facility work order system on how to place work orders in. The Administrator stated the maintenance department should be reviewing the work orders daily. The Administrator stated the risk of not using the facility work order system could result in the broken item not being forgotten and would not be fixed. The Administrator stated the risk to the resident would depend on the situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #3) of 3 residents reviewed for accidents and supervision. <BR/>The facility failed to ensure CNA A secured the brakes on a mechanical lift when lifting and lowering Resident #3 to bed. <BR/>This failure could place residents at risk for falls or injury. <BR/>The findings included:<BR/>1. Record review of Resident #3's face sheet dated 1/14/25 revealed a [AGE] year-old female was readmitted to the facility on [DATE]. <BR/>Record review of Resident #3's history and physical dated 11/27/24 revealed diagnoses of diabetes (blood sugar is too high), hypertension (high blood pressure), pulmonary embolism (blood clot that blocks and stops blood flow to an artery in the lung), and an unstageable pressure ulcer of the heel. <BR/>Record review of Resident #3's significant change in condition MDS assessment dated [DATE] revealed a BIMS score of 15, indicating her cognition was intact. The resident was dependent on staff for transfers. <BR/>Record review of Resident #3's care plan dated 10/16/24 revealed a focus area of ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner and interventions that included assist x 2 (two people) with transfers, use mechanical lift. <BR/>In an observation on 1/14/25 at 1:28 pm, CNA A and CNA B assisted with perineal care and performed a mechanical lift transfer for Resident #3. During the transfer, the brakes on the mechanical lift were not engaged, causing the lift to move slightly. The resident was moved over the bed, with CNA A maneuvering the mechanical lift and CNA B assisting. The brakes were also not secured when lowering the resident onto the bed. <BR/>In an interview on 1/14/25 at 2:01 pm, CNA B stated that she had received training on how to properly hook the sling and secure brakes on mechanical lift. CNA B stated she received training twice a year. CNA B stated she did not see if CNA A had secured the brakes during the transfer. CNA B stated the brakes were required to be engaged when lifting and lowering the bed. CNA B stated risks included the potential for the mechanical lift to move during transfers, which could result in injury to the resident or staff. <BR/>In an interview on 1/14/25 at 2:14 pm, CNA A stated she had received training on proper mechanical lift use, including how to hook the sling, ensure the sling is in good condition, and secure brakes during transfers. CNA A stated she forgot to secure the brakes during the lift and did not secure them when lowering the resident because the bed had been moved up. CNA A stated risks included potential injury to the resident or staff due to unsecured brakes. <BR/>In an interview on 1/15/25 at 10:43 AM, with ADON C and ADON D, ADON C stated all nursing staff were trained on mechanical transfers and other transfers. ADON D stated they receive this training from the therapy department. ADON C stated when lifting a resident up from the bed or wheelchair the hoyer lift brakes have to be placed to lock. ADON D stated this was to secure and anchor the hoyer lift. ADON C stated the risk would be that the hoyer lift could move if it was not secure. <BR/>Record review of the facility's Hydraulic Lift policy not dated read in part Goals: the resident will achieve safe transfer to bed or chair via mechanical lift device. The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift. Procedure: prepare the lift by setting the adjustable base to its position. Lock or unlock the base wheels according to the lift manufacture's recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans in that: <BR/>The facility failed to implement a comprehensive person-centered care plan for Resident #1 requiring wearing cushion boots (redistributing device for the prevention of heel pressure ulcers). <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include: <BR/>Record review of Resident #1's face sheet dated 04/11/24, revealed, admission on [DATE] to the facility. <BR/>Record review of Resident #1's significant change in status MDS assessment dated [DATE], revealed, he was cognitively intact to be able to make daily decisions and able to recall information with a BIMS (tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 14. Resident #1 was diagnosed with Diabetes Mellitus, Pressure Ulcer of Sacral Stage 4, Pressure Ulcer of Unspecified site stage 4. Muscle wasting and atrophy (a joint disease, of which arthritis is a type). At risk for pressure ulcers. Resident #1 was marked down for having one or more unhealed pressure ulcers. Marked for pressure ulcer care. Care Area Assessment revealed care area trigger and care planning. <BR/>Record review of Resident #1's care plan dated 04/10/24, revealed, has a pressure ulcer or potential for pressure ulcer development. Deep tissue injury to left and right heel. Administer medications as ordered. Administer treatment as ordered and monitor for effectiveness. Left heel: clean with normal saline, pat dry, apply collagen sheet and cover with bordered gauze dressing. Ensure heels are floated with the use of pillows. There was no mention of Resident #1 having to wear cushion boots. <BR/>Record review of Resident #1's order recap dated 04/10/24, revealed, there were no orders from physician indicating that Resident #1 had to use cushion boots. Order dated 03/18/24, revealed, deep tissue injury to left heel: clean with normal saline, pat dry, apply collagen sheet, cover with gauze dressing, as needed and every day shift every Mon, Wed, Fri for wound care. Order dated 03/14/24, revealed, deep tissue injury to right heel: clean with normal saline, pat dry, apply betadine, cover with bordered gauze dressing, as needed and every day shift for wound care. <BR/>Observation on 04/10/24 at 11:54 AM, with the Wound Care Nurse. The Wound Care Nurse was looking for the cushion boots and found them on the dresser. Resident #1 had pillows underneath his knees. The Wound Care Nurse told Resident #1 that he needed to have the cushion boots on as well to help heal his heels that had the pressure ulcers. Resident #1 stated he keeps telling the CNAs over and over and over again, but they do not put on the cushion boots. <BR/>During an interview on 04/10/24 at 12:18 PM, with the Wound Care Nurse, she stated Resident #1 needed to have his cushion boots on to help heal his heels from the pressure ulcers. The Wound Care Nurse stated when wound care started, Resident #1 did not have his cushion boots on. The Wound Care Nurse stated she had already educated the nursing staff and Resident #1 in regard to having the cushion boots on to promote healing. The Wound Care Nurse stated not having the cushion boots could slow down the healing process or the wound could get worse. The Wound Care Nurse stated the cushion boots should be in the care plan of Resident #1. The Wound Care Nurse stated care planning would have let the nurses know to have the cushion boots on and not care planning it could lead to the wound worsening. <BR/>During an interview on 04/11/24 at 8:59 AM, with CNA H, she stated when showering or moving residents that have pressure ulcers on their heels, the nursing staff if ordered has to put on the cushion boots once they are done moving or showering the resident. CNA H stated not putting on the cushion boots could result in the injury getting injured more. <BR/>During an interview on 04/11/24 at 1:17 PM, with CNA E, she stated if a resident was required to have cushion boots on then once the nursing staff has completed doing whatever they were doing with the resident, then they have to put back on the cushion boots. CNA E stated this was so no more pressure ulcers developed. <BR/>During an interview on 04/11/24 at 4:09 PM, with LVN D, she stated cushion boots should be care planned for a resident. LVN D stated a care plan was to provide the services a resident would need. LVN D stated not care planning the cushion boots for a resident with pressure ulcers could result in wounds getting worse. <BR/>During an interview on 04/16/24 at 1:52 PM, with the DON, she stated the cushion boots for Resident #1 should have been care planned and Resident #1 also wanted them on. The DON stated it was expected to be care planned for reimbursement and the risk of not care planning could be the wound not healing. <BR/>Record review of the facility Comprehensive Care Planning policy not dated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that identified in the comprehensive assessment. The comprehensive care plan will describe the following - <BR/>The services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure biologicals were stored in locked compartments and accessed by authorized personnel for 1 (Resident #21) of 8 residents reviewed for medication storage, in that: Resident # 21 had two clear measuring cups at bedside, one with crushed medications and the second with a clear liquid, exposed and within reach of other residents. This failure could place residents at risk of access to medications not approved for administration by their physician. Findings included: Record Review of Resident # 21s' admission record dated 8/06/2025 revealed an [AGE] year-old female admitted to the facility on [DATE]. Record Review of Resident # 21's' history and physical dated 06/10/2025 revealed diagnoses of high blood pressure, other recurrent depressive disorder, constipation and rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood). Record Review of Resident # 21s' Quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating intact cognitive function. Record Review of Resident # 21's care plan revealed nursing interventions to include giving medications as per doctor's orders and to monitor for side effects of medication. Record review of Resident # 21's medication administration record dated 08/06/2025 revealed Resident #21's morning medications as Bupropion HCL oral tablet 75mg, Jardiance oral tablet 10mg, Losartan Potassium oral tablet 25 mg, Miralax Oral 17gm/scoop, Carvediol oral tablet 12.5mg, Docusate Sodium oral tablet 100mg, Lactulose oral solution 10gm/15ml and Simethicone oral tablet 80 mg. In an observation and interview on 08/04/25 at 10:15 am in Residents #21 room revealed, the room door open, two clear plastic measuring cups, one with crushed medications mixed with pudding and another cup with an unknown clear liquid on Resident #21's bedside table. Resident #21 did not know what the medications were. She stated that the nurse had left them for her to take after breakfast as she had requested. Resident #21's roommate was present in room as well. In an interview on 08/07/25 at 1:40 PM with LVN A, she stated that nurses and medication aids were to dispose of medications when residents did not want to take them. She stated that they were to never leave medication unattended for residents to take by themselves. She stated that when administering medications, nurses or medication aides were to stay with residents until residents finished taking medications to ensure that medication was ingested. She stated that leaving medications unattended could pose a risk to residents because it could easily be gotten a hold of, and the wrong resident could ingest the medication. She stated that whoever was administering the medication was responsible for ensuring medications were not left unattended or properly disposed of. In an interview on 08/07/2025 at 3:30pm with DON, revealed that medications were not to be left at bedside unattended for any resident. She stated that leaving medication unattended could potentially expose the resident to misuse of the medication such as medication being taken by another resident. She stated that it was also an infection control issue because it was exposed to air. She stated that it was the responsibility of the nurses to ensure that medications were not left at the bedside. In an interview on 08/07/25 at 4:30 PM with the Administrator, she stated that medications were not supposed to be left unattended at bedside. She stated that if a resident did not want to take medication at the time of administration, they were to dispose medications. She stated that leaving the medications at bedside could potentially expose other residents to getting a hold of the medications and accidentally taking them. She stated that it was the responsibility of either the nurse or medication aide to ensure that medications were being taken as per doctor's orders. She stated that she could not recall the last training/In service that was given over leaving medications at bedside. Record Review of facility policies and procedures titled Medication Administration and General Guidelines, not dated, reads in part Medications are administered at the time they are prepared. Medications are not pre-poured. The procedure reads observe the resident take the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure resident#1 was free from any physical or chemical restraints imposed for purposes of discipline or convenience for one (Resident #2) of five residents reviewed for freedom from physical restraints.<BR/>The facility failed to ensure Residents #2 did not have pillows under his mattress which restricted his movement from getting off the bed and were not required to treat his medical symptoms. <BR/>This failure could put residents at risk of unnecessary restriction of their movements. <BR/>Findings included: <BR/>Resident #2 <BR/>Record review of Resident #2's admission Record revealed he was a [AGE] year-old male who was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation (irregular heartbeat), atherosclerosis (with rest pain bilateral legs, type 2 diabetes, hyperlipidemia (high cholesterol), unspecified dementia without behavioral disturbance, hypertension, vascular disease, and shortness of breath. <BR/>Record review of Resident #2's History and Physical dated 09/14/2024 did not have any documentation as the resident was just admitted into the facility on [DATE]. <BR/>Record review of Resident #2's MDS dated [DATE] did not have anything documented as it was still pending completion due to him being a new admit. <BR/>Record review of Resident #2's care plan, dated 09/14/2024, had no documentation regarding if the resident had any behavioral issues trying to get out of bed. The only focus that was set for the resident was the use of anxiety medication, with a goal that Resident #2 will be free from discomfort or adverse reactions related to anxiety therapy, with interventions of an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, fall, broken hips and legs, and monitor for safety. <BR/>Record review of Resident #2's order recap report dated 09/14/2024 revealed a floor mat or other fall prevention device was ordered. <BR/>In an observation on 09/20/2024 at 09:55 AM Resident #2 was lying in bed with about three pillows underneath his mattress. The pillows were placed on the left side under the resident's mattress causing the mattress to lean more towards the right side. Resident #2 could not verbalize complete sentences and mumbles words.<BR/> In an interview on 09/21/2024 at 10:00 AM CNA A, stated the pillows were put that way so he did not roll off the bed. He was always falling and if the pillows were placed under the mattress, then the resident was unable to roll to the floor. She stated that was how they've done it for a while, and no one has told her differently.<BR/>In an interview on 09/20/2024 at 11:13 AM RN A said that she just started here about 3 weeks ago and it was brought up to her attention by CNA A. RN A advised CNA A that it was not right and had her remove the pillows immediately. RN A educated CNA A and advised CNA A that there needed to be an order in place and there was not, so she needed to remove them, that it was a restraint. Resident #2 now does not have pillows under the mattress. RN A stated she always removed them if she sees that but believed CNA A has been doing it for a long time prior to her starting here.<BR/> In an interview on 09/20/2024 at 11:23 am, the DON was shown the picture of Resident #2 and how the pillows where under his mattress. The DON has been employed with facility since July 15, 2024. Stated the pillows underneath the mattress was not considered appropriate and did not know that staff were doing that. She stated if she knew that, she would have had them immediately take it off and in-service the staff. It was usually the same aid during the day all week-long until nighttime the facility would have a different one. She stated everyone has been in-serviced and the weekend staff will be as well. <BR/>On 09/21/2024 at 11:48 am an interview was conducted with ADON A and ADON B. ADON B has been employed with facility for 7 years and ADON B has been employed for 17 years with the facility. The same picture of Resident #2's pillows under the mattress were shown to both the ADON's. They both stated it was considered a restraint. They stated Resident #2 just arrived 2 weeks ago (more or less) and they stated they do educate their CNA's on ANE, Falls, and restraints. The last in-service was this past week, and they also have it on digital training system every year. ADON A can't recall if CNA A signed the in-service but did do the digital training system. She stated the resident had a consent form filed out by hospice and signed by family for bed rails, but they were taken off because he was not using them for repositioning. Staff knew it was a restraint free facility, and bed rails were only used for bed mobility. The resident wasn't using them, he was not able to move himself much, and the resident was not able to verbally communicate. The bed rails were removed last week, nursing staff removed them, called hospice, informed the family, did the assessment, and completed a consent while they were there. ADON B was not aware CNA A was placing the pillows like that. The CNAs usually work on their own, but the team nurses rotate so there was no same nurse on the same hallway all the time. There were 4 nurses on the floor right now, they should do rounds every 2 hours, at the beginning of the shift and on the off going shifts. ADON B couldn't say if they did it today since it was not seen. CNA A has been here about 3 years, they all know they were not supposed to do that.<BR/>In an interview on 09/21/2024 at 12:05pm, CNA A, stated she's had multiple in-services on restraints and knows what a restraint was. She stated this was the first time that she has done this because she knew better. She stated that RN A was the one that told her this morning to do that. She knew that it was wrong but because her nurse told her to, she listened. She knew that she was to put the bed at a low position and have the floor mat on the floor only if they were a fall-risk or depending on the orders.<BR/>Review of the facility policy Restraint revised February 1, 2007, states it is the policy of this facility to maintain an environment that prohibits the use of restraints for discipline of convenience. The facility is committed to nurturing the autonomy and independence of our residents by attempting to provide a restraint-free environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 2 (Resident #7 and Resident #8) of 6 residents reviewed for call light:<BR/>-Residents #7 and #8's call systems were not adequate to meet the needs of residents as both residents required padded call light buttons and both had push button call lights.<BR/>-Resident #7's and #8's call system were not placed within reach of the residents. <BR/>This failure could place residents who used call lights for assistance at risk in maintaining and/or achieving independent functioning, dignity, and well-being. <BR/>Findings included:<BR/>Record review of Resident #7's face sheet dated 06/09/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Resident #7's diagnoses included post traumatic seizures (seizures that occur at least 1 week after traumatic brain injury), Schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of thinking and social symptoms that interferes with daily functioning), hypertension (high blood pressure), hemiplegia, and hemiparesis following cerebral infarction (paralysis of partial or total body function on one side of the body), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (mood disorder that interferes with daily life), cirrhosis of liver (chronic liver damage from a variety of causes leading to scarring and liver failure), traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head).<BR/>Record review of Resident #7's Quarterly MDS dated [DATE], revealed a BIMS score of 07, which indicated severe cognitive impairment. Section G. revealed that Resident #7 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. Resident #7 was total dependence with toilet use and bathing. <BR/>Record review of Resident #7's care plan dated 06/09/2023, revealed Resident #7 had focus area that included ADLs: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Part of the interventions included: Resident to have padded call light. <BR/>Observation and interview on 6/9/2023 at 9:30 a.m., in Resident #7's room revealed the call light button was not visible. Further observation revealed Resident #7's unpadded call light button was on the floor under the resident's bed. Resident #7 did not respond to questions about his call button and whether he was able to reach the button. <BR/>During an interview on 6/9/2023 at 9:40 a.m., LVN E said that Resident #7's call button was out of his reach being under the bed. LVN E said that Resident #7 could not use a push button call button and should have had a padded call button. LVN E said she did not know why Resident #7 had a push button call light and would have it changed out immediately. LVN E said the risk to Resident #7 of not having his call button in reach and the proper type of call button was that his needs may not be met.<BR/>Record review of Resident #8's face sheet dated 06/09/2023, revealed an [AGE] year-old male, admitted to the facility on [DATE]. Resident #8's diagnoses included hemiplegia and hemiparesis following cerebral infarction (paralysis of partial or total body function on one side of the body), type 2 diabetes (body does not use insulin properly), acute respiratory failure (often caused by a disease or injury that affects your breathing, such as pneumonia, opioid overdose, stroke, or a lung or spinal cord injury), dementia (a group of thinking and social symptoms that interferes with daily functioning), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), and history of falling. <BR/>Record review of Resident #8's Quarterly MDS dated [DATE], revealed a BIMS score of 03, which indicated severe cognitive impairment. Section G. revealed Resident #8 was total dependence for bed mobility, transfer, locomotion, dressing, eating, toilet use, and personal hygiene.<BR/>Record review of Resident #8's care plan dated 06/09/2023, revealed Resident #8 had focus area that reflected resident has impaired visual function related to aging process and is at risk for falls, injury, and a decline in functional ability. Part of the interventions included: Keep call light in reach when in room or bathroom. Another focus area reads resident has communication problem related to dementia. Part of the interventions included: Ensure/provide a safe environment: call light in reach. Another focus area reads resident has an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner. Part of the interventions included: resident uses padded call light; and encourage resident to use call light to call for assistance before attempting any activities of daily living (ADLs) that resident cannot do independently. Another focus area reads 'resident has the potential for falls related to poor safety awareness. Part of the interventions included: Place the resident's call light within reach and encourage the resident to use it for assistance as needed. <BR/>Observation and interview on 6/9/2023 at 9:35 a.m., in Resident #8's room revealed the unpadded call light button was on the floor. Resident #8 did not respond to questions about his call button and whether he was able to reach the button. <BR/>During an interview on 6/9/2023 at 9:45 a.m., LVN E said that Resident #8's call button was out of his reach being on the floor. LVN E said that Resident #8 could not use a push call button and should have had a padded call button. LVN E said she did not know why Resident #8 had a push button call light and will have it changed out immediately. LVN E said the risk to Resident #8 of not having his call button in reach and the proper call button was that his needs may not be met.<BR/>During an interview on 6/9/2023 at 1:30 p.m., the DON said LVN E made her aware that the wrong call buttons were not on for the residents and call buttons were out of reach. The DON said Residents #7 and #8 are unable to push the call light button and should have had a padded call light button. The DON said she does not know why this was overlooked. The DON said the risk was not being able to meet the residents' needs.<BR/>Record of facility Call Light Response policy, dated 02/10/2021, reflected the purpose of the policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Process included the following: Special accommodations will be identified on the resident's person-centered plan of care, and provided accordingly (examples include touch pads, larger buttons, bright colors, etc.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans in that: <BR/>The facility failed to implement a comprehensive person-centered care plan for Resident #1 requiring wearing cushion boots (redistributing device for the prevention of heel pressure ulcers). <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include: <BR/>Record review of Resident #1's face sheet dated 04/11/24, revealed, admission on [DATE] to the facility. <BR/>Record review of Resident #1's significant change in status MDS assessment dated [DATE], revealed, he was cognitively intact to be able to make daily decisions and able to recall information with a BIMS (tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 14. Resident #1 was diagnosed with Diabetes Mellitus, Pressure Ulcer of Sacral Stage 4, Pressure Ulcer of Unspecified site stage 4. Muscle wasting and atrophy (a joint disease, of which arthritis is a type). At risk for pressure ulcers. Resident #1 was marked down for having one or more unhealed pressure ulcers. Marked for pressure ulcer care. Care Area Assessment revealed care area trigger and care planning. <BR/>Record review of Resident #1's care plan dated 04/10/24, revealed, has a pressure ulcer or potential for pressure ulcer development. Deep tissue injury to left and right heel. Administer medications as ordered. Administer treatment as ordered and monitor for effectiveness. Left heel: clean with normal saline, pat dry, apply collagen sheet and cover with bordered gauze dressing. Ensure heels are floated with the use of pillows. There was no mention of Resident #1 having to wear cushion boots. <BR/>Record review of Resident #1's order recap dated 04/10/24, revealed, there were no orders from physician indicating that Resident #1 had to use cushion boots. Order dated 03/18/24, revealed, deep tissue injury to left heel: clean with normal saline, pat dry, apply collagen sheet, cover with gauze dressing, as needed and every day shift every Mon, Wed, Fri for wound care. Order dated 03/14/24, revealed, deep tissue injury to right heel: clean with normal saline, pat dry, apply betadine, cover with bordered gauze dressing, as needed and every day shift for wound care. <BR/>Observation on 04/10/24 at 11:54 AM, with the Wound Care Nurse. The Wound Care Nurse was looking for the cushion boots and found them on the dresser. Resident #1 had pillows underneath his knees. The Wound Care Nurse told Resident #1 that he needed to have the cushion boots on as well to help heal his heels that had the pressure ulcers. Resident #1 stated he keeps telling the CNAs over and over and over again, but they do not put on the cushion boots. <BR/>During an interview on 04/10/24 at 12:18 PM, with the Wound Care Nurse, she stated Resident #1 needed to have his cushion boots on to help heal his heels from the pressure ulcers. The Wound Care Nurse stated when wound care started, Resident #1 did not have his cushion boots on. The Wound Care Nurse stated she had already educated the nursing staff and Resident #1 in regard to having the cushion boots on to promote healing. The Wound Care Nurse stated not having the cushion boots could slow down the healing process or the wound could get worse. The Wound Care Nurse stated the cushion boots should be in the care plan of Resident #1. The Wound Care Nurse stated care planning would have let the nurses know to have the cushion boots on and not care planning it could lead to the wound worsening. <BR/>During an interview on 04/11/24 at 8:59 AM, with CNA H, she stated when showering or moving residents that have pressure ulcers on their heels, the nursing staff if ordered has to put on the cushion boots once they are done moving or showering the resident. CNA H stated not putting on the cushion boots could result in the injury getting injured more. <BR/>During an interview on 04/11/24 at 1:17 PM, with CNA E, she stated if a resident was required to have cushion boots on then once the nursing staff has completed doing whatever they were doing with the resident, then they have to put back on the cushion boots. CNA E stated this was so no more pressure ulcers developed. <BR/>During an interview on 04/11/24 at 4:09 PM, with LVN D, she stated cushion boots should be care planned for a resident. LVN D stated a care plan was to provide the services a resident would need. LVN D stated not care planning the cushion boots for a resident with pressure ulcers could result in wounds getting worse. <BR/>During an interview on 04/16/24 at 1:52 PM, with the DON, she stated the cushion boots for Resident #1 should have been care planned and Resident #1 also wanted them on. The DON stated it was expected to be care planned for reimbursement and the risk of not care planning could be the wound not healing. <BR/>Record review of the facility Comprehensive Care Planning policy not dated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that identified in the comprehensive assessment. The comprehensive care plan will describe the following - <BR/>The services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to review and revise Resident Care Plans after each assessment for 1 (Resident #1) of 8 residents whose records were reviewed.<BR/>-Resident #1's Care Plan was not updated to reflect discontinuation of padding the wall. <BR/>These deficient practices could lead to errors in treatment and services provided based on incorrect information.<BR/>Findings included:<BR/>Resident #1:<BR/>Review of Resident #1's admission Record dated 09/13/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture), depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), muscle weakness, lack of coordination, intellectual disability (deficits in theoretical thinking/learning), seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain), and paraplegia (paralysis that affects your legs, but not your arms).<BR/>Review of Resident #1's quarterly MDS assessment dated [DATE], revealed a BIMS score of 12 indicating moderate cognitive impairment. Section E - Behavior revealed Resident #1 had not exhibited any physical, verbal or other behavioral symptoms. <BR/>Review of Resident #1's care plan dated 09/13/2024, reads in part Resident #1 had history of behavior problem as evidenced by resident will hit the wall with his hand. Part of the interventions included Place padding on wall to cushion the resident's hand in case the behavior continues. <BR/>During observation and interview on 09/16/2024 at 10:47 a.m., Resident #1 was observed lying in bed. One side of his bed was against the wall. The wall was noted without any padding. Resident #1 said he had moved to the room from another room last week but could not remember the date. Resident #1 said he did not need any padding for the wall as he did not hit the wall. Resident #1 said he did not know what instructions were written on his care plan regarding padding on the wall. <BR/>During an interview on 09/17/2024 at 10:05 a.m., ADON C said Resident #1's care plan still shows that wall should be padded. ADON C said the intervention step was in place in 2021 as Resident #1 had exhibited behaviors and hit the wall. ADON C said the care plan intervention step was no longer applicable as Resident #1 had not exhibited the behavior anymore since 2021, and the intervention should have come off his care plan. ADON C said Resident #1's care plan should have been updated and she did not know why the intervention was not taken off the care plan. ADON C reviewed Resident #1's injury history and noted there had been no injuries resulting from Resident #1 hitting the wall from 01/01/2023 to 09/17/2024. ADON C said the care plan should have been updated by nursing or the MDS department. <BR/>During an interview on 09/17/2024 at 1:03 p.m., the MDS Coordinator said the purpose of the care plan was to address what the resident needs. The MDS Coordinator said the care plan not being accurate or up to date could result in confusion. The MDS Coordinator said social services, nursing and MDS department were able to update the care plans. The MDS Coordinator said the care plan should be reviewed quarterly and whenever there was a change of condition to make sure information was accurate. The MDS Coordinator said Resident #1 did not have an order for a padded wall and that it was a precautionary part of the care plan. The MDS Coordinator said when it was determined that Resident #1 did not require the padding on the wall, it should have been removed from the care plan. The MDS Coordinator said nursing or social services could have removed the intervention step. The MDS Coordinator said it appeared that the intervention step carried over from 2021 and was overlooked for revision. <BR/>During an interview on 09/17/2024 at 1:20 p.m., the DON said the purpose of a care plan was to individualize a plan of care to address resident needs, behaviors, psychosocial needs, and other things like falls and other risks. The DON said the risk of care plans not being revised timely was confusion or providing the wrong type of services. The DON said care plans should be revised immediately or at least the following day when a change in the plan was identified. The DON said nursing services and MDS should revise the care plan as needed. The DON said there was no oversight on revisions and would begin an audit immediately.<BR/>During an interview on 09/17/2024 at 2:20 p.m., the Administrator said the purpose of a care plan was to let staff know how to take care of a resident. The Administrator said not revising a care plan timely could result in confusion in care of resident regarding if an intervention was still needed. The Administrator said nursing, MDS, and social services are responsible for updating and ensuring the care plan is accurate. <BR/>Review of facility-provided Comprehensive Care Planning policy undated, reads in part Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming, personal and oral hygiene, for 1 Resident (#1) of 6 residents reviewed for activities of daily living. <BR/>The facility failed to provide fingernail care for Resident #1 by not maintaining trim and clean fingernails.<BR/>This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem.<BR/>The findings include: <BR/>Record review of Resident #1's face sheet, dated 3/27/25, indicated the resident was admitted on [DATE] with diagnoses: hemiplegia (paralysis of one side of the body, either right or left) and hemiparesis (weakness of one side of the body, either right or left) following cerebral infarction (stroke) affecting left non-dominant side, dysarthria (difficulty in speech because of weakness of the speech muscles), unspecified dementia, and Alzheimer's disease (a brain disorder that affects memory, thinking, and behavior).<BR/>Record review of Resident #1's admission MDS dated [DATE] indicated a BIMS score of 2, indicating severe cognitive impairment. Per the MDS, Resident #1 required moderate assistance with personal hygiene meaning the helper did more than half the effort. <BR/>Record review of Resident #1's Care Plan dated 03/15/25, revealed ADL Self-care performance deficit and interventions included nursing staff to Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care.<BR/>Observation on 3/26/25 at 11:24 AM of Resident #1 revealed she had nails approximately 1 inch off the nail bed for all fingers on both her hands. Her fingernails on both hand hands were observed with dirt under them and chipped nail polish. Resident #1 was not able to voice whether she liked her nails this length or not.<BR/>During an interview on 3/26/25 at 1:32 PM with CNA A, she said that residents are offered nail trimming services during the resident's scheduled shower. She stated if the resident is diabetic, nurses were to trim fingernails. CNA A stated that fingernails of residents should be maintained short and clean. She stated long fingernails can cause an infection control risk.<BR/>During an interview on 3/26/25 at 3:27 PM with LVN B, she said that nursing staff such as nursing assistants were to offer residents nail trimming during the resident's shower. She stated if the resident was diabetic only nurses were to file down fingernails. LVN B stated if a resident did not want nails groomed, the ADON, DON and family member were notified. She stated the risks for residents having long nails included residents could scratch themselves causing injury, or also an infection control issue as there are possible bacteria entrapped under the nail.<BR/>In an interview on 03/26/25 at 4:00 PM with the ADON, she said that residents received grooming services with their fingernails on Sundays. She stated that if resident's nails are observed long, the service could be offered at any time. She stated the nurses were responsible for monitoring (checking during daily rounds) residents through their rounding during their shift and could offer to trim or cut the resident's nails. She stated the risks for residents having long and dirty nails included infection risk, as the resident could touch their face or scratch their skin. <BR/>In an interview on 3/26/25 at 4:15 PM with the DON, she said that residents were offered nail grooming services from CNAs on the residents' scheduled shower days. She stated the nurses were to offer nail grooming service if the resident is diabetic. She stated the CNAs are responsible for monitoring, filing and cleaning the resident's nails, and the nurses could file and trim nails including diabetic residents. The DON stated If any resident declined care, they are to notify the charge nurse so that nurse could go in to assess and find the reason on why the resident does not want care at the time. She stated the resident had the right to have clean nails. The DON stated the risks of residents having ungroomed nails included an infection control concern to the resident. <BR/>Record review of facility's policy and procedures titled Activities of Daily Living, revised 2007, read in part: The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #3) of 4 residents reviewed for gastrostomy tube management quality of care.<BR/>-The facility failed to ensure Residents #3 was provided with the correct feeding through gastrostomy tube (g-tube, feeding tube) as ordered per physician.<BR/>This failure could place residents who received feedings by gastrostomy tube at risk for decline in health and weight loss.<BR/>Findings included:<BR/>Review of Resident #3's admission Record dated 09/13/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included cerebral infarction (lack of oxygen to the brain causing damage to brain tissue), unspecified protein-calorie malnutrition, dysphagia (swallowing difficulties), and gastrostomy status (a feeding tube that delivers nutrition to your stomach). <BR/>Review of Resident #3's quarterly MDS assessment dated [DATE], revealed a BIMS score of 00 indicating severe cognitive impairment. Section GG - Functional Abilities and Goals revealed Resident #3 is dependent on staff for toileting, showering, dressing, and personal hygiene. Section K - Swallowing/Nutritional Status revealed Resident #3's nutritional approach was feeding tube. <BR/>Review of Resident #3's Order Summary dated 09/17/2024, revealed enteral feed order in the morning start continuous enteral feeding. Start at 0600 and run until midnight. Hold feeding from 0000 (12:00 a.m.) to 0600 (6:00 a.m.). <BR/>Review of Resident #3's care plan dated 09/17/2024, revealed Resident #3 required tube feeding related to dysphagia. Part of the interventions included resident was dependent with tube feeding and water flushes; see MD orders for current feeding orders. <BR/>Observation on 09/16/2024 at 1:45p.m., revealed Resident #3 was lying in bed asleep with head of bed elevated. There was tubing with Jevity 1.2 (liquid nutritional supplement that can be used for tube feeding or oral consumption) connected to a feeding pump on a pole next to Resident #3's bed. Continuous feed pump was turned off. <BR/>Observation and interview on 09/16/2024 at 2:46 p.m., revealed Resident #3 was lying in bed asleep with head of bed elevated. There was tubing with Jevity 1.2 connected to a feeding pump on a pole next to Resident #3's bed. Continuous feed pump was turned off. LVN I entered the room and noted the feed machine was off. LVN I said Resident #3 was on continuous enteral feeding during the day and did not know why the machine was turned off. LVN I said the CNAs had provided patient care to Resident #3 over an hour ago and may have turned off the machine. LVN I said no one told her the machine was turned off. LVN I began to assess the resident. LVN I said Resident #3 was not in any distress. LVN I said Resident #3 had not had any significant weight loss. LVN I said Resident #3's vitals were at baseline for the resident.<BR/>Review of Resident #3's weight records revealed initial weight taken on 06/21/2024 was 130.0 lbs. The latest weight taken on 09/10/2024 was 129.6. <BR/>During an interview on 09/17/2024 at 1:20 p.m., the DON said the purpose of enteral feeding was to give someone nutrients and calories that are required as they can no longer eat for themselves. The DON said the risk of failing to follow the orders and the feeding machine being turned off, if it were a recurring thing, would be a loss of weight, and malnutrition. The DON said an isolated incident would not necessarily have the same risk but needs to be addressed with staff to ensure it does not become a recurring issue. The DON said nursing staff are responsible to ensure that orders are being followed for residents. <BR/>During an interview on 09/17/2024 at 2:20 p.m., the Administrator said the purpose of enteral feeding was to provide nutrition to the resident. The Administrator said failure to follow orders for continuous feeding could result in the resident not receiving the required nutrition and caloric intake. The Administrator said nursing staff are responsible for following orders and resident care plan. <BR/>Record review of facility policy titled Enteral Nutrition dated 02/13/2007, reflected in part the facility will provide nutritionally complete enteral or parenteral feedings as ordered by the physician for the nourishment of residents who are unable to eat by mouth. The Nursing Services Department is responsible for all feeding equipment and the administration of tube feedings. Problems with the administration of the tube feeding are monitored and corrected by nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 (Resident #7) of 5 resident reviewed for accuracy of MDS assessment, in that: <BR/>The facility failed to ensure Resident #7's quarterly MDS accurately reflected the residents' history of falls. <BR/>This deficient practice could affect residents at the facility who had been assessed for risk of falls and could contribute to inadequate care. <BR/>Findings included: <BR/>Record review of Resident #7's face sheet dated 08/01/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #7's facility history and physical dated 05/29/24, revealed, an [AGE] year-old male diagnosed with Alzheimer's Disease, difficulty in walking, muscle wasting, muscle weakness, Dementia, lack of coordination, unspecified fall. <BR/>Record review of Resident #7's quarterly MDS dated [DATE], revealed severely impaired cognition to be able to recall or make daily decision with a BIMS score of 6. Resident #7's ADLs were independence with sit to stand, transfers, and walking. Resident #7 was not marked for any mobility devices. Resident #7 was diagnosed with unspecified fall, difficult in walking, muscle wasting, muscle weakness (no muscle strength), lack of coordination, and Alzheimer's Dementia. Resident #7 was marked for fall history as having no falls since admission or re-entry to the facility. <BR/>Record review of Resident #7's Care Plan dated 02/28/24, revealed he had the potential for falls related to impaired mobility and history of falls. Interventions: Fall Risk Screening upon admission and quarterly to identify risk factors. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. <BR/>Record review of Resident #7's Event Notes dated 06/23/24 and 06/25/24, revealed Resident #7 had a fall. On 06/23/24, Resident #7 fell on his rear and back hit the wall while trying to sit on a black round stool in the dining area. On 06/25/24, Resident #7 had an unwitnessed fall in his room and was found with his back against the closet door. <BR/>During an interview on 08/01/24 at 11:17 AM, Family Member D stated Resident #7 had a history of falls. <BR/>During an interview on 08/01/24 at 11:53 AM, Family Member E stated Resident #7 was having falls every week at the facility. <BR/>During an interview on 08/05/24 at 10:37 AM, the Physician stated Resident #7 had a history of falls. The Physician stated Resident #7 had no safety awareness. The Physician stated Resident #7's fall history should put in the MDS to alert nursing staff that Resident #7 was a fall risk. The Physician stated the risk of not putting in the MDS would be not alerting nursing staff regarding resident's special care needs. <BR/>During an interview on 08/05/24 at 11:35 AM, the MDS Coordinator stated the MDS department created the MDSs and were responsible for the MDSs. The MDS Coordinator stated Resident #7 had a history of falls. The MDS Coordinator stated the quarterly MDS dated [DATE], should have been marked indicating Resident #7 had a history of falls after admission or recently. The MDS Coordinator stated it would be important to have the MDS accurately marked because the information from the MDS was taken and put into the care plan and for interventions. The MDS Coordinator stated not marking the MDS accurately would have a negative outcome on the resident. <BR/>During an interview on 08/05/24 at 3:29 PM, the DON stated Resident #7 had a history of falls. The DON stated the DON would oversee MDS. The DON stated she did not know the process of an MDS. <BR/>Record review of the facility Resident Assessment Manual dated 2003, revealed, The facility will examine each resident and review the minimum date set expanded core elements specified in the RAI no less than once every three months and as appropriate. Results must be recorded to assure continued accuracy of the assessment.<BR/> The results of the assessment are used to develop, review, and revise the resident's comprehensive care plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans in that: <BR/>The facility failed to implement a comprehensive person-centered care plan for Resident #1 requiring wearing cushion boots (redistributing device for the prevention of heel pressure ulcers). <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include: <BR/>Record review of Resident #1's face sheet dated 04/11/24, revealed, admission on [DATE] to the facility. <BR/>Record review of Resident #1's significant change in status MDS assessment dated [DATE], revealed, he was cognitively intact to be able to make daily decisions and able to recall information with a BIMS (tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 14. Resident #1 was diagnosed with Diabetes Mellitus, Pressure Ulcer of Sacral Stage 4, Pressure Ulcer of Unspecified site stage 4. Muscle wasting and atrophy (a joint disease, of which arthritis is a type). At risk for pressure ulcers. Resident #1 was marked down for having one or more unhealed pressure ulcers. Marked for pressure ulcer care. Care Area Assessment revealed care area trigger and care planning. <BR/>Record review of Resident #1's care plan dated 04/10/24, revealed, has a pressure ulcer or potential for pressure ulcer development. Deep tissue injury to left and right heel. Administer medications as ordered. Administer treatment as ordered and monitor for effectiveness. Left heel: clean with normal saline, pat dry, apply collagen sheet and cover with bordered gauze dressing. Ensure heels are floated with the use of pillows. There was no mention of Resident #1 having to wear cushion boots. <BR/>Record review of Resident #1's order recap dated 04/10/24, revealed, there were no orders from physician indicating that Resident #1 had to use cushion boots. Order dated 03/18/24, revealed, deep tissue injury to left heel: clean with normal saline, pat dry, apply collagen sheet, cover with gauze dressing, as needed and every day shift every Mon, Wed, Fri for wound care. Order dated 03/14/24, revealed, deep tissue injury to right heel: clean with normal saline, pat dry, apply betadine, cover with bordered gauze dressing, as needed and every day shift for wound care. <BR/>Observation on 04/10/24 at 11:54 AM, with the Wound Care Nurse. The Wound Care Nurse was looking for the cushion boots and found them on the dresser. Resident #1 had pillows underneath his knees. The Wound Care Nurse told Resident #1 that he needed to have the cushion boots on as well to help heal his heels that had the pressure ulcers. Resident #1 stated he keeps telling the CNAs over and over and over again, but they do not put on the cushion boots. <BR/>During an interview on 04/10/24 at 12:18 PM, with the Wound Care Nurse, she stated Resident #1 needed to have his cushion boots on to help heal his heels from the pressure ulcers. The Wound Care Nurse stated when wound care started, Resident #1 did not have his cushion boots on. The Wound Care Nurse stated she had already educated the nursing staff and Resident #1 in regard to having the cushion boots on to promote healing. The Wound Care Nurse stated not having the cushion boots could slow down the healing process or the wound could get worse. The Wound Care Nurse stated the cushion boots should be in the care plan of Resident #1. The Wound Care Nurse stated care planning would have let the nurses know to have the cushion boots on and not care planning it could lead to the wound worsening. <BR/>During an interview on 04/11/24 at 8:59 AM, with CNA H, she stated when showering or moving residents that have pressure ulcers on their heels, the nursing staff if ordered has to put on the cushion boots once they are done moving or showering the resident. CNA H stated not putting on the cushion boots could result in the injury getting injured more. <BR/>During an interview on 04/11/24 at 1:17 PM, with CNA E, she stated if a resident was required to have cushion boots on then once the nursing staff has completed doing whatever they were doing with the resident, then they have to put back on the cushion boots. CNA E stated this was so no more pressure ulcers developed. <BR/>During an interview on 04/11/24 at 4:09 PM, with LVN D, she stated cushion boots should be care planned for a resident. LVN D stated a care plan was to provide the services a resident would need. LVN D stated not care planning the cushion boots for a resident with pressure ulcers could result in wounds getting worse. <BR/>During an interview on 04/16/24 at 1:52 PM, with the DON, she stated the cushion boots for Resident #1 should have been care planned and Resident #1 also wanted them on. The DON stated it was expected to be care planned for reimbursement and the risk of not care planning could be the wound not healing. <BR/>Record review of the facility Comprehensive Care Planning policy not dated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that identified in the comprehensive assessment. The comprehensive care plan will describe the following - <BR/>The services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming, personal and oral hygiene, for 1 Resident (#1) of 6 residents reviewed for activities of daily living. <BR/>The facility failed to provide fingernail care for Resident #1 by not maintaining trim and clean fingernails.<BR/>This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem.<BR/>The findings include: <BR/>Record review of Resident #1's face sheet, dated 3/27/25, indicated the resident was admitted on [DATE] with diagnoses: hemiplegia (paralysis of one side of the body, either right or left) and hemiparesis (weakness of one side of the body, either right or left) following cerebral infarction (stroke) affecting left non-dominant side, dysarthria (difficulty in speech because of weakness of the speech muscles), unspecified dementia, and Alzheimer's disease (a brain disorder that affects memory, thinking, and behavior).<BR/>Record review of Resident #1's admission MDS dated [DATE] indicated a BIMS score of 2, indicating severe cognitive impairment. Per the MDS, Resident #1 required moderate assistance with personal hygiene meaning the helper did more than half the effort. <BR/>Record review of Resident #1's Care Plan dated 03/15/25, revealed ADL Self-care performance deficit and interventions included nursing staff to Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care.<BR/>Observation on 3/26/25 at 11:24 AM of Resident #1 revealed she had nails approximately 1 inch off the nail bed for all fingers on both her hands. Her fingernails on both hand hands were observed with dirt under them and chipped nail polish. Resident #1 was not able to voice whether she liked her nails this length or not.<BR/>During an interview on 3/26/25 at 1:32 PM with CNA A, she said that residents are offered nail trimming services during the resident's scheduled shower. She stated if the resident is diabetic, nurses were to trim fingernails. CNA A stated that fingernails of residents should be maintained short and clean. She stated long fingernails can cause an infection control risk.<BR/>During an interview on 3/26/25 at 3:27 PM with LVN B, she said that nursing staff such as nursing assistants were to offer residents nail trimming during the resident's shower. She stated if the resident was diabetic only nurses were to file down fingernails. LVN B stated if a resident did not want nails groomed, the ADON, DON and family member were notified. She stated the risks for residents having long nails included residents could scratch themselves causing injury, or also an infection control issue as there are possible bacteria entrapped under the nail.<BR/>In an interview on 03/26/25 at 4:00 PM with the ADON, she said that residents received grooming services with their fingernails on Sundays. She stated that if resident's nails are observed long, the service could be offered at any time. She stated the nurses were responsible for monitoring (checking during daily rounds) residents through their rounding during their shift and could offer to trim or cut the resident's nails. She stated the risks for residents having long and dirty nails included infection risk, as the resident could touch their face or scratch their skin. <BR/>In an interview on 3/26/25 at 4:15 PM with the DON, she said that residents were offered nail grooming services from CNAs on the residents' scheduled shower days. She stated the nurses were to offer nail grooming service if the resident is diabetic. She stated the CNAs are responsible for monitoring, filing and cleaning the resident's nails, and the nurses could file and trim nails including diabetic residents. The DON stated If any resident declined care, they are to notify the charge nurse so that nurse could go in to assess and find the reason on why the resident does not want care at the time. She stated the resident had the right to have clean nails. The DON stated the risks of residents having ungroomed nails included an infection control concern to the resident. <BR/>Record review of facility's policy and procedures titled Activities of Daily Living, revised 2007, read in part: The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide foot care and treatment, or assist the resident in making appointments with a qualified person for 2 (Resident #3 and Resident #6) of 5 residents reviewed for quality of life. <BR/>The facility failed to ensure Resident #3 and Resident #6's toenails were trimmed and cleaned, or podiatry appointments scheduled. <BR/>This failure could place residents at risk of infection or mobility issues.<BR/>Findings include:<BR/>Resident #3<BR/>Record review of Resident #3's face sheet dated 08/05/24, revealed, admission on [DATE] to the facility. <BR/>Record review of Resident #3's outside facility history and physical dated 05/31/24, revealed, an [AGE] year-old male diagnosed with muscle wasting, lack of coordination, Type 2 Diabetes Mellitus, and anxiety. <BR/>Record review of Resident #3's quarterly MDS assessment dated [DATE], revealed severely impaired cognition to be able to recall and make daily decisions as evidence by a BIMS score of 4. ADLs for personal hygiene were substantial/maximal assistance (nursing staff do more than 50% of the help). Resident #3 was diagnosed with Diabetes Mellitus, Non-Alzheimer's Dementia, muscle weakness, muscle wasting, lack of coordination. <BR/>Record review of Resident #3's care plan dated 08/18/22, revealed, he had impaired cognition and was at risk of further decline. Resident needs supervision/assistance with all decision making. Diabetes care plan dated 12/29/22, revealed, inspect feet during bathing and as needed for open areas, sores, pressure areas, blisters, edema, or redness and report it to the nurse. ADLs care planned dated 04/15/24, revealed, personal hygiene care: the resident requires extensive assistance by one staff assistance. <BR/>Record review of Resident #3's order recap dated 11/07/23, revealed, Podiatrist consult. <BR/>Resident #6<BR/>Record review of Resident #6's face sheet dated 08/05/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #6's facility history and physical dated 05/29/24, revealed, an [AGE] year-old female diagnosed with muscle wasting, muscle weakness, lack of coordination, pain in the joints, and Type 2 Diabetes Mellitus.<BR/>Record review of Resident #6's annual MDS dated [DATE], revealed moderately impaired cognition to be able recall or make daily decisions as evidenced by a BIMS score of 9. ADLs for personal hygiene were supervision or touching assistance from staff. Resident #6 was diagnosed with Diabetes Mellitus, muscle weakness, muscle wasting, and lack of coordination. <BR/>Record review of Resident #6's care plan dated 01/24/22, revealed she required x1 staff for personal hygiene. Diabetes care plan dated 01/24/22, revealed, weekly skin checks to monitor skin for redness, circulatory problems, infection, and breakdown. Notify physician of any new skin conditions. <BR/>Record review of Resident #6's order recap dated 11/07/23 and end date of order 02/27/24 revealed she may have podiatry care for thick toenails PRN. There were no new orders present. <BR/>During an interview on 08/05/24 at 11:00 AM with the Resident Council group meeting members revealed they were not receiving nail care. The Resident Council group meeting members stated they had not seen the podiatrist since the facility had changed ownership back in 02/23/24. The Resident Council group meeting members stated they thought they were supposed to see the podiatry every 30 days. The Resident Council group meeting members stated before the ownership change, they were given a consent form to fill out and then taken by the previous Transporter to the podiatrist. <BR/>During an interview on 08/05/24 at 1:07 PM, Resident #1 stated he had his fingernails cut but not his toenails. Resident #1 stated it had been a long time since he had his toenails cut. <BR/>During an observation and interview on 08/05/24 at 1:20 PM, Resident #6 stated it had been a long time since her nails have been cut. Resident #6 stated it had been more than 4 months since they were cut. Resident #6 stated the podiatrist would cut her toenails. <BR/>During an interview on 08/05/24 at 1:25 PM, CNA I stated that nail care was done by the CNAs and only the fingernails. CNA I stated toenails were cut by the doctor. CNA I stated it had been more then 2-3 months since the doctor has come to cut resident toenails. CNA I stated that residents had complained to her that their feet hurt because they had not had their toenails cut. CNA I stated the resident was no longer at the facility. CNA I stated she told the nurse and was told that they were going to make an appointment to the doctor. CNA I stated that days later, the resident still complained about it. <BR/>During an interview on 08/05/24 at 1:36 PM, CNA I stated toenails are done by a doctor who went to the facility. CNA I stated it had been a long time since the doctor had went to the facility. <BR/>During an observation and interview on 08/05/24 at 1:38 PM, Resident #3 stated he could not remember the last time his toenails were cut. Resident #3 stated he did want his nails cut and had not refused to have them cut. <BR/>During an interview 08/05/24 at 1:42 PM, LVN G stated residents' toenails were done by the podiatrist. <BR/>During an observation and interview on 08/05/24 at 2:13 PM, with Resident #3 and LVN G. Resident #3 was in his room and LVN G took off Resident #3's right sock. Resident #3's toenails were yellow, jagged, thick, and broken. LVN G had asked Resident #3 if his toes hurt and Resident #3 shook his head up and down and stated, Si duele (English translation - Yes, it hurts). LVN G was touching Resident #3 toe and toenails and asking him where it hurt. Resident #3 did not answer. LVN G stated he could not recall the last time podiatry had gone to the facility. LVN G stated residents nor his staff had told him that residents were complaining because they want their nails cut. <BR/>During an interview on 08/05/24 at 2:00 PM, with ADON A and ADON B. ADON A stated CNAs do not provide toenail care for diabetics. ADON A stated the nursing staff set up the residents' appointments to see the podiatrist. ADON A stated the last time podiatry had gone to the facility was back in February 2024. ADON B stated it was very rare that they would get referrals for residents to see podiatry. ADON B stated the CNAs and nurses need to be checking the residents' toenails to see that they don't have ingrown toenails or anything wrong. ADON B stated, before, the Transporter would schedule the appointments and take the residents to see the podiatrist. ADON B stated the risk of not providing nail care could be infection or ingrown. <BR/>During an interview on 08/05/24 at 3:29 PM, the DON stated diabetic residents are to be seen by the Podiatrist. The DON stated Podiatry had come to the facility as she saw it on a group text from the facility. The DON stated after searching for the text message that she was wrong that Podiatry had not come to the facility. The DON stated an unknown resident (Could not remember the residents name) had asked her if she could cut her nails. The DON stated the ADONs (ADON A & ADON B) and herself had put out an in-service regarding fingernail and toenail care to the nursing staff about nail care for the residents. The DON stated she started working at the facility on 07/15/24 and did not know who was responsible for podiatry and residents seeing podiatry. The DON stated the negative outcome of not doing nail care for the residents could result in infection, and the resident(s) could scratch themselves or someone else. <BR/>During an interview on 08/05/24 at 4:09 PM, LVN C stated the Podiatrist was going to start going to the facility to cut the residents toenails. LVN C stated there had been residents that complained about toenail care and the facility nurses had tried to set up appointments to go see the podiatrist. LVN C stated the previous Transporter was being given the referrals from the nurses and then she would make the appointment for the residents to go see podiatry but the transporter no longer works at the facility since last week (08/02/24). LVN C stated she made all the appointments for residents herself. LVN C stated she had not made any podiatry appointments lately. LVN C stated she had not checked the residents' toenails lately. LVN C stated the risk would be ingrown toenails and infection. <BR/>Record review of the facility Nail Care manual dated 2003, revealed, Nail management was the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails .It includes cleansing, trimming, smoothing .Nail care especially trimming was performed by podiatrist in those with diabetes and peripheral vascular disease.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #3) of 3 residents reviewed for accidents and supervision. <BR/>The facility failed to ensure CNA A secured the brakes on a mechanical lift when lifting and lowering Resident #3 to bed. <BR/>This failure could place residents at risk for falls or injury. <BR/>The findings included:<BR/>1. Record review of Resident #3's face sheet dated 1/14/25 revealed a [AGE] year-old female was readmitted to the facility on [DATE]. <BR/>Record review of Resident #3's history and physical dated 11/27/24 revealed diagnoses of diabetes (blood sugar is too high), hypertension (high blood pressure), pulmonary embolism (blood clot that blocks and stops blood flow to an artery in the lung), and an unstageable pressure ulcer of the heel. <BR/>Record review of Resident #3's significant change in condition MDS assessment dated [DATE] revealed a BIMS score of 15, indicating her cognition was intact. The resident was dependent on staff for transfers. <BR/>Record review of Resident #3's care plan dated 10/16/24 revealed a focus area of ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner and interventions that included assist x 2 (two people) with transfers, use mechanical lift. <BR/>In an observation on 1/14/25 at 1:28 pm, CNA A and CNA B assisted with perineal care and performed a mechanical lift transfer for Resident #3. During the transfer, the brakes on the mechanical lift were not engaged, causing the lift to move slightly. The resident was moved over the bed, with CNA A maneuvering the mechanical lift and CNA B assisting. The brakes were also not secured when lowering the resident onto the bed. <BR/>In an interview on 1/14/25 at 2:01 pm, CNA B stated that she had received training on how to properly hook the sling and secure brakes on mechanical lift. CNA B stated she received training twice a year. CNA B stated she did not see if CNA A had secured the brakes during the transfer. CNA B stated the brakes were required to be engaged when lifting and lowering the bed. CNA B stated risks included the potential for the mechanical lift to move during transfers, which could result in injury to the resident or staff. <BR/>In an interview on 1/14/25 at 2:14 pm, CNA A stated she had received training on proper mechanical lift use, including how to hook the sling, ensure the sling is in good condition, and secure brakes during transfers. CNA A stated she forgot to secure the brakes during the lift and did not secure them when lowering the resident because the bed had been moved up. CNA A stated risks included potential injury to the resident or staff due to unsecured brakes. <BR/>In an interview on 1/15/25 at 10:43 AM, with ADON C and ADON D, ADON C stated all nursing staff were trained on mechanical transfers and other transfers. ADON D stated they receive this training from the therapy department. ADON C stated when lifting a resident up from the bed or wheelchair the hoyer lift brakes have to be placed to lock. ADON D stated this was to secure and anchor the hoyer lift. ADON C stated the risk would be that the hoyer lift could move if it was not secure. <BR/>Record review of the facility's Hydraulic Lift policy not dated read in part Goals: the resident will achieve safe transfer to bed or chair via mechanical lift device. The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift. Procedure: prepare the lift by setting the adjustable base to its position. Lock or unlock the base wheels according to the lift manufacture's recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans in that: <BR/>The facility failed to implement a comprehensive person-centered care plan for Resident #1 requiring wearing cushion boots (redistributing device for the prevention of heel pressure ulcers). <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include: <BR/>Record review of Resident #1's face sheet dated 04/11/24, revealed, admission on [DATE] to the facility. <BR/>Record review of Resident #1's significant change in status MDS assessment dated [DATE], revealed, he was cognitively intact to be able to make daily decisions and able to recall information with a BIMS (tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 14. Resident #1 was diagnosed with Diabetes Mellitus, Pressure Ulcer of Sacral Stage 4, Pressure Ulcer of Unspecified site stage 4. Muscle wasting and atrophy (a joint disease, of which arthritis is a type). At risk for pressure ulcers. Resident #1 was marked down for having one or more unhealed pressure ulcers. Marked for pressure ulcer care. Care Area Assessment revealed care area trigger and care planning. <BR/>Record review of Resident #1's care plan dated 04/10/24, revealed, has a pressure ulcer or potential for pressure ulcer development. Deep tissue injury to left and right heel. Administer medications as ordered. Administer treatment as ordered and monitor for effectiveness. Left heel: clean with normal saline, pat dry, apply collagen sheet and cover with bordered gauze dressing. Ensure heels are floated with the use of pillows. There was no mention of Resident #1 having to wear cushion boots. <BR/>Record review of Resident #1's order recap dated 04/10/24, revealed, there were no orders from physician indicating that Resident #1 had to use cushion boots. Order dated 03/18/24, revealed, deep tissue injury to left heel: clean with normal saline, pat dry, apply collagen sheet, cover with gauze dressing, as needed and every day shift every Mon, Wed, Fri for wound care. Order dated 03/14/24, revealed, deep tissue injury to right heel: clean with normal saline, pat dry, apply betadine, cover with bordered gauze dressing, as needed and every day shift for wound care. <BR/>Observation on 04/10/24 at 11:54 AM, with the Wound Care Nurse. The Wound Care Nurse was looking for the cushion boots and found them on the dresser. Resident #1 had pillows underneath his knees. The Wound Care Nurse told Resident #1 that he needed to have the cushion boots on as well to help heal his heels that had the pressure ulcers. Resident #1 stated he keeps telling the CNAs over and over and over again, but they do not put on the cushion boots. <BR/>During an interview on 04/10/24 at 12:18 PM, with the Wound Care Nurse, she stated Resident #1 needed to have his cushion boots on to help heal his heels from the pressure ulcers. The Wound Care Nurse stated when wound care started, Resident #1 did not have his cushion boots on. The Wound Care Nurse stated she had already educated the nursing staff and Resident #1 in regard to having the cushion boots on to promote healing. The Wound Care Nurse stated not having the cushion boots could slow down the healing process or the wound could get worse. The Wound Care Nurse stated the cushion boots should be in the care plan of Resident #1. The Wound Care Nurse stated care planning would have let the nurses know to have the cushion boots on and not care planning it could lead to the wound worsening. <BR/>During an interview on 04/11/24 at 8:59 AM, with CNA H, she stated when showering or moving residents that have pressure ulcers on their heels, the nursing staff if ordered has to put on the cushion boots once they are done moving or showering the resident. CNA H stated not putting on the cushion boots could result in the injury getting injured more. <BR/>During an interview on 04/11/24 at 1:17 PM, with CNA E, she stated if a resident was required to have cushion boots on then once the nursing staff has completed doing whatever they were doing with the resident, then they have to put back on the cushion boots. CNA E stated this was so no more pressure ulcers developed. <BR/>During an interview on 04/11/24 at 4:09 PM, with LVN D, she stated cushion boots should be care planned for a resident. LVN D stated a care plan was to provide the services a resident would need. LVN D stated not care planning the cushion boots for a resident with pressure ulcers could result in wounds getting worse. <BR/>During an interview on 04/16/24 at 1:52 PM, with the DON, she stated the cushion boots for Resident #1 should have been care planned and Resident #1 also wanted them on. The DON stated it was expected to be care planned for reimbursement and the risk of not care planning could be the wound not healing. <BR/>Record review of the facility Comprehensive Care Planning policy not dated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that identified in the comprehensive assessment. The comprehensive care plan will describe the following - <BR/>The services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary treatment and services based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries for 1 (Resident #3) of 3 residents reviewed for pressure ulcers. <BR/>The facility failed to provide proper wound care for Resident #1's facility acquired pressure ulcers to the right outer heel. <BR/>This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health. <BR/>Findings include: <BR/>Record review of Resident #1's face sheet dated 04/11/24, revealed, admission on [DATE] to the facility. <BR/>Record review of Resident #1's significant change in status MDS assessment dated [DATE], revealed, he was cognitively intact to be able to make daily decisions and able to recall information with a BIMS (tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 14. Resident #1 was diagnosed with Diabetes Mellitus, Pressure Ulcer of Sacral Stage 4, Pressure Ulcer of Unspecified site stage 4. Muscle wasting and atrophy (a joint disease, of which arthritis is a type). At risk for pressure ulcers. Resident #1 was marked down for having one or more unhealed pressure ulcers. Marked for pressure ulcer care. Care Area Assessment revealed care area trigger and care planning. <BR/>Record review of Resident #1's care plan dated 04/10/24, revealed, has a pressure ulcer or potential for pressure ulcer development. Deep tissue injury to left and right heel. Administer medications as ordered. Administer treatment as ordered and monitor for effectiveness. Left heel: clean with normal saline, pat dry, apply collagen sheet and cover with bordered gauze dressing. Ensure heels are floated with the use of pillows. <BR/>Record review of Resident #1's order recap dated 04/10/24, revealed, tissue injury to left heel: clean with normal saline, pat dry, apply collagen sheet, cover with gauze dressing, as needed and every day shift every Mon, Wed, Fri for wound care. Order dated 03/14/24, revealed, deep tissue injury to right heel: clean with normal saline, pat dry, apply betadine, cover with bordered gauze dressing, as needed and every day shift for wound care. <BR/>Observation on 04/10/24 at 11:54 AM, with the Wound Care Nurse. Resident #1's right heel as it was being lifted did not have a dressing on it. The wound was exposed to the elements. The Wound Care Nurse with gloves grabbed a clean gauze and wiped right heel. The Wound Care Nurse then grabbed a 4 by 4 dressing and placed it on Resident #1's right heel. The dressing was sealed on Resident #1's skin. Cushion boots were put on and Resident #1 was covered with a blanket. The Wound Care Nurse did not date or initial both the dressing(s). The Wound Care Nurse was looking for the cushion boots and found them on the dresser. Resident #1 had pillows underneath his knees. The Wound Care Nurse told Resident #1 that he needed to have the cushion boots on as well to help heal his heels that had the pressure ulcers. Resident #1 stated he keeps telling the CNAs over and over and over again, but they do not put on the cushion boots<BR/>During an interview on 04/10/24 at 12:18 PM, with the Wound Care Nurse, she stated Resident #1 did not have his wound dressing on his right heel and needed to have it on. The Wound Care Nurse stated she tells the nursing staff that if the wound dressing comes off to let her know to replace it with another dressing. The Wound Care Nurse stated the purpose of the dressing was to keep the Medi-honey or collagen on to heal the wound. The Wound Care Nurse stated not having the dressing on could worsen the wound by not letting it get better. The Wound Care Nurse stated she usually updates the dressing by labeling it with the date but did not have her marker to do it. The Wound Care Nurse stated the purpose of dating or labeling the dressing was so that the nursing staff knew when the dressings were changed. The Wound Care Nurse stated there was a risk of nursing staff not knowing the wound care was getting done if the dressing was not labeled and dated. The Wound Care Nurse, she stated the physician had given the order and it was a preventative measure. The Wound Care Nurse stated that physician orders needed to be placed for the cushion boots. The Wound Care Nurse did not answer if there would be a risk due to the Resident #1 already using them.<BR/>During an interview on 04/11/24 at 8:59 AM, with CNA H, she stated when showering or moving residents that have pressure ulcers on their heels, the nursing staff if ordered has to put on the cushion boots once they are done moving or showering the resident. CNA H stated not putting on the cushion boots could result in the injury getting injured more. <BR/>During an interview on 04/11/24 at 1:17 PM, with CNA E, she stated she would let the Wound Care Nurse know if the resident was missing a dressing so that they could replace it. CNA E stated having the dressing on would prevent infection. CNA E, she stated if a resident was required to have cushion boots on them then once the nursing staff has completed doing whatever they were doing with the resident, then they have to put back on the cushion boots. CNA E stated this was so no more pressure ulcers developed. <BR/>During an interview on 04/16/24 at 1:52 PM, with the DON, she stated anytime wound care was conducted and dressings placed had to be labeled with dates and initials. The DON stated labeling the dressing would let the nursing staff know when the dressing(s) was changed. The DON stated the risk of not labeling and dating the dressings was the wound getting worse or infected. The DON stated the nursing staff are to be reapplying the wound dressings if they are off and missing. The DON stated again the risk would be infection if the dressing was not replaced. <BR/>During an interview on 04/11/24 at 3:19 PM, with LVN G, she stated that cushion boots do not require a physician order as they are preventative measures. LVN G stated the purpose of physician orders was to indicate the treatment towards the resident. LVN G stated she would consider anything needing a physician order to be - medications, oxygen, transferring residents out of the hospital, wounds, and therapy. LVN G stated it would depend on the risk if not putting in the physician order. LVN G stated that assisted devices did need a physician's order. <BR/>During an interview on 04/11/24 at 4:09 PM, with LVN D, she stated the nursing staff and the resident(s) with wound care should be telling the nurses if they are missing wound dressings so that they may be replaced. LVN D stated the purpose of the dressing was to make a barrier and not allow any new bacteria from getting in. LVN D stated that once the dressing was applied it needed to be dated and initialed. LVN D stated not labeling the dressing could have a negative impact on the wound's treatment. LVN D, she stated that there was no need to have physician orders for the cushion boots, as they could be considered a nursing intervention. LVN D stated she would consider the cushion boots to be an assistive device. LVN D stated from nursing school she was taught that cushion boots were used as a preventative which did not require a physician order. <BR/>During an interview on 04/16/24 at 1:52 PM, with the DON, she stated anything that was a preventative measure that did not go inside the body does not require an order. The DON stated it was the facility's/company's policy to have physician orders for everything to be on the safe side. The DON stated the physician commented that a physician order was not warranted unless it was policy from the facility/company. The DON stated it was facility/company policy and the physician stated okay. <BR/>Record review of the facility Dressing Changes policy dated 2003, revealed, Dressing changes will be completed to maintain sterility. <BR/>Label the dressing with date, time, and initial. <BR/>Record review of the facility Physician's Orders policy dated 2015, revealed, Purpose: to monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and Activities of Daily Living order for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 2 (Resident #7 and Resident #8) of 6 residents reviewed for call light:<BR/>-Residents #7 and #8's call systems were not adequate to meet the needs of residents as both residents required padded call light buttons and both had push button call lights.<BR/>-Resident #7's and #8's call system were not placed within reach of the residents. <BR/>This failure could place residents who used call lights for assistance at risk in maintaining and/or achieving independent functioning, dignity, and well-being. <BR/>Findings included:<BR/>Record review of Resident #7's face sheet dated 06/09/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Resident #7's diagnoses included post traumatic seizures (seizures that occur at least 1 week after traumatic brain injury), Schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of thinking and social symptoms that interferes with daily functioning), hypertension (high blood pressure), hemiplegia, and hemiparesis following cerebral infarction (paralysis of partial or total body function on one side of the body), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (mood disorder that interferes with daily life), cirrhosis of liver (chronic liver damage from a variety of causes leading to scarring and liver failure), traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head).<BR/>Record review of Resident #7's Quarterly MDS dated [DATE], revealed a BIMS score of 07, which indicated severe cognitive impairment. Section G. revealed that Resident #7 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. Resident #7 was total dependence with toilet use and bathing. <BR/>Record review of Resident #7's care plan dated 06/09/2023, revealed Resident #7 had focus area that included ADLs: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Part of the interventions included: Resident to have padded call light. <BR/>Observation and interview on 6/9/2023 at 9:30 a.m., in Resident #7's room revealed the call light button was not visible. Further observation revealed Resident #7's unpadded call light button was on the floor under the resident's bed. Resident #7 did not respond to questions about his call button and whether he was able to reach the button. <BR/>During an interview on 6/9/2023 at 9:40 a.m., LVN E said that Resident #7's call button was out of his reach being under the bed. LVN E said that Resident #7 could not use a push button call button and should have had a padded call button. LVN E said she did not know why Resident #7 had a push button call light and would have it changed out immediately. LVN E said the risk to Resident #7 of not having his call button in reach and the proper type of call button was that his needs may not be met.<BR/>Record review of Resident #8's face sheet dated 06/09/2023, revealed an [AGE] year-old male, admitted to the facility on [DATE]. Resident #8's diagnoses included hemiplegia and hemiparesis following cerebral infarction (paralysis of partial or total body function on one side of the body), type 2 diabetes (body does not use insulin properly), acute respiratory failure (often caused by a disease or injury that affects your breathing, such as pneumonia, opioid overdose, stroke, or a lung or spinal cord injury), dementia (a group of thinking and social symptoms that interferes with daily functioning), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), and history of falling. <BR/>Record review of Resident #8's Quarterly MDS dated [DATE], revealed a BIMS score of 03, which indicated severe cognitive impairment. Section G. revealed Resident #8 was total dependence for bed mobility, transfer, locomotion, dressing, eating, toilet use, and personal hygiene.<BR/>Record review of Resident #8's care plan dated 06/09/2023, revealed Resident #8 had focus area that reflected resident has impaired visual function related to aging process and is at risk for falls, injury, and a decline in functional ability. Part of the interventions included: Keep call light in reach when in room or bathroom. Another focus area reads resident has communication problem related to dementia. Part of the interventions included: Ensure/provide a safe environment: call light in reach. Another focus area reads resident has an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner. Part of the interventions included: resident uses padded call light; and encourage resident to use call light to call for assistance before attempting any activities of daily living (ADLs) that resident cannot do independently. Another focus area reads 'resident has the potential for falls related to poor safety awareness. Part of the interventions included: Place the resident's call light within reach and encourage the resident to use it for assistance as needed. <BR/>Observation and interview on 6/9/2023 at 9:35 a.m., in Resident #8's room revealed the unpadded call light button was on the floor. Resident #8 did not respond to questions about his call button and whether he was able to reach the button. <BR/>During an interview on 6/9/2023 at 9:45 a.m., LVN E said that Resident #8's call button was out of his reach being on the floor. LVN E said that Resident #8 could not use a push call button and should have had a padded call button. LVN E said she did not know why Resident #8 had a push button call light and will have it changed out immediately. LVN E said the risk to Resident #8 of not having his call button in reach and the proper call button was that his needs may not be met.<BR/>During an interview on 6/9/2023 at 1:30 p.m., the DON said LVN E made her aware that the wrong call buttons were not on for the residents and call buttons were out of reach. The DON said Residents #7 and #8 are unable to push the call light button and should have had a padded call light button. The DON said she does not know why this was overlooked. The DON said the risk was not being able to meet the residents' needs.<BR/>Record of facility Call Light Response policy, dated 02/10/2021, reflected the purpose of the policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Process included the following: Special accommodations will be identified on the resident's person-centered plan of care, and provided accordingly (examples include touch pads, larger buttons, bright colors, etc.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans in that: <BR/>The facility failed to implement a comprehensive person-centered care plan for Resident #1 requiring wearing cushion boots (redistributing device for the prevention of heel pressure ulcers). <BR/>This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include: <BR/>Record review of Resident #1's face sheet dated 04/11/24, revealed, admission on [DATE] to the facility. <BR/>Record review of Resident #1's significant change in status MDS assessment dated [DATE], revealed, he was cognitively intact to be able to make daily decisions and able to recall information with a BIMS (tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 14. Resident #1 was diagnosed with Diabetes Mellitus, Pressure Ulcer of Sacral Stage 4, Pressure Ulcer of Unspecified site stage 4. Muscle wasting and atrophy (a joint disease, of which arthritis is a type). At risk for pressure ulcers. Resident #1 was marked down for having one or more unhealed pressure ulcers. Marked for pressure ulcer care. Care Area Assessment revealed care area trigger and care planning. <BR/>Record review of Resident #1's care plan dated 04/10/24, revealed, has a pressure ulcer or potential for pressure ulcer development. Deep tissue injury to left and right heel. Administer medications as ordered. Administer treatment as ordered and monitor for effectiveness. Left heel: clean with normal saline, pat dry, apply collagen sheet and cover with bordered gauze dressing. Ensure heels are floated with the use of pillows. There was no mention of Resident #1 having to wear cushion boots. <BR/>Record review of Resident #1's order recap dated 04/10/24, revealed, there were no orders from physician indicating that Resident #1 had to use cushion boots. Order dated 03/18/24, revealed, deep tissue injury to left heel: clean with normal saline, pat dry, apply collagen sheet, cover with gauze dressing, as needed and every day shift every Mon, Wed, Fri for wound care. Order dated 03/14/24, revealed, deep tissue injury to right heel: clean with normal saline, pat dry, apply betadine, cover with bordered gauze dressing, as needed and every day shift for wound care. <BR/>Observation on 04/10/24 at 11:54 AM, with the Wound Care Nurse. The Wound Care Nurse was looking for the cushion boots and found them on the dresser. Resident #1 had pillows underneath his knees. The Wound Care Nurse told Resident #1 that he needed to have the cushion boots on as well to help heal his heels that had the pressure ulcers. Resident #1 stated he keeps telling the CNAs over and over and over again, but they do not put on the cushion boots. <BR/>During an interview on 04/10/24 at 12:18 PM, with the Wound Care Nurse, she stated Resident #1 needed to have his cushion boots on to help heal his heels from the pressure ulcers. The Wound Care Nurse stated when wound care started, Resident #1 did not have his cushion boots on. The Wound Care Nurse stated she had already educated the nursing staff and Resident #1 in regard to having the cushion boots on to promote healing. The Wound Care Nurse stated not having the cushion boots could slow down the healing process or the wound could get worse. The Wound Care Nurse stated the cushion boots should be in the care plan of Resident #1. The Wound Care Nurse stated care planning would have let the nurses know to have the cushion boots on and not care planning it could lead to the wound worsening. <BR/>During an interview on 04/11/24 at 8:59 AM, with CNA H, she stated when showering or moving residents that have pressure ulcers on their heels, the nursing staff if ordered has to put on the cushion boots once they are done moving or showering the resident. CNA H stated not putting on the cushion boots could result in the injury getting injured more. <BR/>During an interview on 04/11/24 at 1:17 PM, with CNA E, she stated if a resident was required to have cushion boots on then once the nursing staff has completed doing whatever they were doing with the resident, then they have to put back on the cushion boots. CNA E stated this was so no more pressure ulcers developed. <BR/>During an interview on 04/11/24 at 4:09 PM, with LVN D, she stated cushion boots should be care planned for a resident. LVN D stated a care plan was to provide the services a resident would need. LVN D stated not care planning the cushion boots for a resident with pressure ulcers could result in wounds getting worse. <BR/>During an interview on 04/16/24 at 1:52 PM, with the DON, she stated the cushion boots for Resident #1 should have been care planned and Resident #1 also wanted them on. The DON stated it was expected to be care planned for reimbursement and the risk of not care planning could be the wound not healing. <BR/>Record review of the facility Comprehensive Care Planning policy not dated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that identified in the comprehensive assessment. The comprehensive care plan will describe the following - <BR/>The services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents are given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs) for 1 of 7 residents (Resident #26) reviewed for meal assistance. <BR/>The facility failed to encourage Resident #26 often during her meal per her care plan. <BR/>This failure could place residents that needed encouragement to eat to maintain ADL independence at risk of possible weight loss and avoid ADL decline. <BR/>Findings included: <BR/>Record review of Resident #26 ' s face sheet dated 06/19/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. <BR/>Record review of Resident #26 ' s history and physical dated 05/20/24 revealed a diagnosis of Alzheimer's disease, anorexia, cognitive communication deficit, and unspecified dementia. <BR/>Record review of Resident #26 ' s annual MDS assessment dated [DATE] revealed a BIMS score of 04, her cognitive was severely impaired and required supervision or touching assistance with eating. <BR/>Record review of Resident #26 ' s care plan dated 04/22/24 revealed focus area for ADL self-care performance deficit Alzheimer ' s dementia, muscle weakness, lack of coordination secondary to Alzheimer ' s disease with interventions/tasks of eating: supervision set up; requires encouragement often. <BR/>During an observation on 06/18/24 at 06/18/24 at 12:12 pm, CNA G assisted Resident #26 to the dining room and guided her to her seat. CNA G placed utensils within reach of Resident #26. <BR/>During an observation on 06/18/24 at 06/18/24 at 12:22 pm, Resident #26 was moving her food around the plate, was pushing the food to one side of the plate and was drinking her fluids. <BR/>During an observation on 06/18/24 at 12:26 pm, LVN H approached Resident #26 and asked her if she was done eating. Resident #6 had placed a napkin over her food. <BR/>During an observation on 06/18/24 at 12:34 pm, CNA I picked up Resident #26 ' s plate. CNA I stated Resident #26 had refused to eat and removed her plate from her. No second choice was offered, and no encouragement was provided during the 24 minutes Resident #26 had her lunch plate. CNA I stated she was familiar with Resident #26 ' s care needed and stated she did not offer a second choice because she knew Resident #26 would refuse. CNA I stated she did not encouraged Resident #26 to eat but respected her right to refuse her food. LVN H stated he had approached Resident #26, and she did not want to eat. LVN H stated he respected her right to refuse her food. LVN H stated he was not sure how many times they were expected to approach and offer help to residents. LVN H stated a second choice should have been offered to Resident #26 and asked CNA I to offer her a second choice. CNA I approached Resident #26 and asked her if she wanted a sandwich, and she nodded no. CNA I and LVN H stated the risk of not providing encouragement and/or offering a second choice was a possible weight loss. <BR/>During an interview on 06/19/24 at 11:19 am, Resident #26 ' s RP denied any concerns with care provided to resident, stating the facility appeared to be taking very good care of Resident #26. <BR/>During an interview on 06/19/24 at 2:37 pm, Interim DON stated it was expected for CNAs to approach and offer assistance and/or cue residents to eat during their meal. Interim DON stated if a resident does not eat, staff should have different staff approach residents to see if they were more receptive with different staff offering/cueing. Interim DON stated it was expected for staff to offer a second choice or supplement shake if they saw a resident refuse a meal. Interim DON stated CNAs were provided with meal assistance training upon hire, annually and as needed. Interim DON stated the risk for not offering second choice and/or providing encouragement to eat was possible weight loss. <BR/>During an interview on 06/20/24 at 1:32 pm, the Administrator stated it was expected for staff to encourage residents to eat at least 2-3 times during the meal. The Administrator stated CNAs were responsible for providing assistance and encouragement to eat. The Administrator stated the charge nurse was responsible for ensuring the CNAs were providing adequate meal assistance. The Administrator stated CNAs were trained for meal assistance upon hire, annually and as needed. The Administrator stated risks included weight loss and decline in ADL. <BR/>Record review of Nursing Responsibilities at Meal Service policy dated 2012 read in part Nursing services will cooperate with Dietary Department to ensure that each resident is served according to regulations. The use of properly trained and supervised volunteers, family members, and other individuals can enhance the quality of life and quality of care for residents. Procedure: Nursing Service associates should follow these guidelines regarding meal service: 5- Adapt space and equipment to assist residents in maintaining independent functioning, dignity, well-being, and self-determination. 9- Offer substitute food of equal nutritive value to a resident if the resident refuses a menu item or eats less than 50% of the meal. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming, personal and oral hygiene, for 1 Resident (#1) of 6 residents reviewed for activities of daily living. <BR/>The facility failed to provide fingernail care for Resident #1 by not maintaining trim and clean fingernails.<BR/>This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem.<BR/>The findings include: <BR/>Record review of Resident #1's face sheet, dated 3/27/25, indicated the resident was admitted on [DATE] with diagnoses: hemiplegia (paralysis of one side of the body, either right or left) and hemiparesis (weakness of one side of the body, either right or left) following cerebral infarction (stroke) affecting left non-dominant side, dysarthria (difficulty in speech because of weakness of the speech muscles), unspecified dementia, and Alzheimer's disease (a brain disorder that affects memory, thinking, and behavior).<BR/>Record review of Resident #1's admission MDS dated [DATE] indicated a BIMS score of 2, indicating severe cognitive impairment. Per the MDS, Resident #1 required moderate assistance with personal hygiene meaning the helper did more than half the effort. <BR/>Record review of Resident #1's Care Plan dated 03/15/25, revealed ADL Self-care performance deficit and interventions included nursing staff to Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care.<BR/>Observation on 3/26/25 at 11:24 AM of Resident #1 revealed she had nails approximately 1 inch off the nail bed for all fingers on both her hands. Her fingernails on both hand hands were observed with dirt under them and chipped nail polish. Resident #1 was not able to voice whether she liked her nails this length or not.<BR/>During an interview on 3/26/25 at 1:32 PM with CNA A, she said that residents are offered nail trimming services during the resident's scheduled shower. She stated if the resident is diabetic, nurses were to trim fingernails. CNA A stated that fingernails of residents should be maintained short and clean. She stated long fingernails can cause an infection control risk.<BR/>During an interview on 3/26/25 at 3:27 PM with LVN B, she said that nursing staff such as nursing assistants were to offer residents nail trimming during the resident's shower. She stated if the resident was diabetic only nurses were to file down fingernails. LVN B stated if a resident did not want nails groomed, the ADON, DON and family member were notified. She stated the risks for residents having long nails included residents could scratch themselves causing injury, or also an infection control issue as there are possible bacteria entrapped under the nail.<BR/>In an interview on 03/26/25 at 4:00 PM with the ADON, she said that residents received grooming services with their fingernails on Sundays. She stated that if resident's nails are observed long, the service could be offered at any time. She stated the nurses were responsible for monitoring (checking during daily rounds) residents through their rounding during their shift and could offer to trim or cut the resident's nails. She stated the risks for residents having long and dirty nails included infection risk, as the resident could touch their face or scratch their skin. <BR/>In an interview on 3/26/25 at 4:15 PM with the DON, she said that residents were offered nail grooming services from CNAs on the residents' scheduled shower days. She stated the nurses were to offer nail grooming service if the resident is diabetic. She stated the CNAs are responsible for monitoring, filing and cleaning the resident's nails, and the nurses could file and trim nails including diabetic residents. The DON stated If any resident declined care, they are to notify the charge nurse so that nurse could go in to assess and find the reason on why the resident does not want care at the time. She stated the resident had the right to have clean nails. The DON stated the risks of residents having ungroomed nails included an infection control concern to the resident. <BR/>Record review of facility's policy and procedures titled Activities of Daily Living, revised 2007, read in part: The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all residents were provided, based on the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored activities and individual activities, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 2 of 9 (Resident #65 and Resident #51) residents reviewed for activities. <BR/>The facility failed to provide regular, individualized activities to Resident #65 and Resident #51. <BR/>This failure placed residents at risk of decreased physical, mental, and psychosocial well-being. <BR/>Findings included: <BR/>Resident #51 <BR/>Record review of Resident #51 ' s face sheet dated 06/18/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE]. <BR/>Record review of Resident #51 ' s history and physical dated 07/11/23 revealed a diagnoseis of weakness, pain, history of falls, cerebral edema, and concussion with loss of consciousness of 30 minutes or less. <BR/>Record review of Resident #51 ' s annual MDS assessment dated [DATE] revealed a BIMS score of 12, his cognitive was intact. <BR/>Record review of Resident #51 ' s care plan dated 04/09/24 revealed a focus area for activities with interventions of provide the resident with materials for individual activities as desired. <BR/>During an interview on 06/18/24 at 9:04 am, Resident #51 was in his room. Resident #51 stated he did not attend group activities due to his legs hurting and needed to take it easy. Resident #51 stated he preferred to stay in his room and the facility did not provide materials for activities to do in his room. <BR/>Resident #65 <BR/>Record review of Resident #65 ' s face sheet dated 06/19/24 revealed a [AGE] year-old female was admitted to facility on 02/01/24. <BR/>Record review of Resident #65 ' s history and physical dated 02/01/24 revealed diagnoses of Alzheimer ' s dementia, anxiety, and depression. <BR/>Record review of Resident #65 ' s quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, her cognitive was intact. <BR/>Record review of Resident #65 ' s care plan dated 02/16/24 revealed focus area for activities with interventions/tasks of preferred activities: conversing with others, coloring, tell family stories. <BR/>During observation and interview on 06/18/24 at 8:49 am, Resident #65 was in her room and was alert and oriented to person, place and event. Resident #65 stated she would be included in the group activities but did not have anything to do afterwards. Resident #65 stated when group activities were over, she did not have anything to do in her room. Resident #65 stated the TV in her room was on her roommate's side and she did not have one for herself. Resident #65 stated she had also been asked what she enjoyed doing and had mentioned she liked to color and had not been provided with materials to color. Resident #65 stated she would become very bored and would pace up and down the hallway to keep busy. <BR/>During an interview on 06/19/24 at 1:31 pm, CNA G stated activities department were responsible for providing materials to residents for individualized leisure activities. CNA G stated activities staff would provide music and games daily and would visit for about 30 minutes. CNA G stated she had not seen Resident #65 with any materials to do activities in her room. <BR/>During an interview on 06/19/24 at 1:54 pm, LVN H stated he had not seen materials provided to Resident #54 for room activities. LVN H stated activities were responsible for providing materials to do activities in the room. LVN H stated he had noticed Resident #65 pace up and down the hallway but she and never mentioned she didn't have anything to do and/or that she was bored. <BR/>During an interview on 06/19/24 at 2:30 pm, Activities Assistant and Activities Director stated CNAs were responsible for providing materials for activities to do in room for the residents. Activities Assistant and Activities Director stated the CNAs could ask and had access to materials to provide to residents. Activities Assistant and Activities Director stated they had not received complaints regarding no materials being provided for in-room activities. Activities Assistant and Activities Director stated if residents did not receive materials that they enjoyed doing on their own, residents could become bored. <BR/>During an interview on 06/19/24 at 2:37 pm, Interim DON stated activities department were responsible for providing materials to residents for leisure activities. Interim DON stated she had not received complaints regarding individualized in room activities. Interim DON stated the risk of not providing materials for leisure activities was being bored. <BR/>During an interview on 06/20/24 at 1:32 pm, the Administrator stated the activities department were the ones responsible for providing materials for individualized leisure activities. The Administrator stated she had not received any complaints regarding in room activities. The Administrator stated the risk of not providing materials for in room activities included residents being isolated, lack of stimuli and possible depression. <BR/>Record review of Individualized Activity Programs dated 2011 read in part The Activity Director and staff will provide individual programming to meet individual needs and interests. Section #2 revealed Individual programs are developed and implemented on a regular basis consistent with individualized leisure interests and based on assessment. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents did not receive psychotropic drugs on a PRN basis for more than 14 days for one (Resident #61) of three residents reviewed for PRN psychotropic medication orders exceeding 14 days. <BR/>The facility failed to ensure that Resident #61 did not have a PRN order for Lorazepam (antianxiety medication) for more than 14 days.<BR/>This failure could place residents at risk of side effects from receiving unnecessary psychotropic medications. <BR/>Findings included:<BR/>Record review of Resident #61's face sheet dated 06/19/2024 revealed he was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #61's Progress Note dated 02/07/2024 revealed he had a diagnosis of anxiety disorder. <BR/>Record review of Resident #61's History and Physical dated 03/22/2024 revealed no diagnosis of anxiety disorder. <BR/>Record review of Resident #61's quarterly MDS assessment dated [DATE] revealed he was receiving antianxiety medication. A diagnosis of anxiety disorder was not indicated. <BR/>Record review of Resident #61's care plan initiated 05/20/2024 revealed he used an anti-anxiety medication for anxiety disorder and would be free from discomfort or adverse reactions related to anti-anxiety therapy. Interventions included educating the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-anxiety medication, and monitoring and documenting side effects of the medication including drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory<BR/>loss, forgetfulness, nausea, stomach upset, blurred or double vision, mania, hostility and rage, aggressive or impulsive<BR/>behavior, or hallucinations.<BR/>Record review of Resident #61's physician's order dated 03/23/2024 revealed he was to receive 2 MG of Lorazepam every 8 hours as needed for anxiety. The order was discontinued on 05/20/2024.<BR/>Record review of Resident #61's active physician's order dated 06/12/2024 indicated he was to receive Lorazepam (an anti-anxiety medication) every 8 hours as needed for anxiety. The order did not include a 14-day limit. The order indicated the medication was to treat the resident biting his lip. <BR/>Record review of Resident #61's MAR for April 2024 revealed he received 2 MG of Lorazepam on 04/06/2024, 04/12/2024, and 04/21/2024.<BR/>Record review of Resident #61's MAR for May 2024 revealed he received 2 MG of Lorazepam on 05/11/2024 and 05/14/2024.<BR/>Record review of Resident #61's MAR for June 2024 (accessed on 06/19/2024) revealed he received 2 MG of Lorazepam on 06/12/2024 and 06/18/2024. <BR/>In an interview on 06/20/24 at 02:47 PM, the interim DON revealed Resident #61 was getting Lorazepam as needed for biting his lip. She stated that the standard for PRN orders for psychotropic medications was that orders needed to specify a 14-day stop date. After 14 days the physician could reorder the medication. She said the stop date was the standard because if the medication was not needed it would be discontinued. She stated that if an order came in with a 14-day limit like Resident #61's order for Lorazepam, the nurse should ask the physician if he wanted to put a stop date. She said the 14-day stop date was necessary to prevent residents from receiving unnecessary medications which might have unwanted side effects. <BR/>Record review of the facility policy Psychotropic Drugs revised 10/25/2017 revealed PRN orders for psychotropic drugs are limited to 14 days. If there is a reason the physician wants to extend an order beyond 14 days the reason for this should be documented in the medical record and indicate the duration of the PRN order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain medical records on each resident that were accurately documented for one (Resident #1) of 5 residents reviewed for accuracy of resident's medical records. <BR/>On three occasions Resident #1 was administered 300 MG of Gabapentin at bedtime but this was not documented in his medical record. <BR/>On two occasions Resident #1 received treatment for gangrene and pressure ulcer on his left foot but this was not documented on his medical record. <BR/>Resident #1 received treatments for a pressure ulcer on his right heel for which there were no orders or documentation. <BR/>This failure could put residents at risk of not receiving ordered medication or treatments, receiving undocumented medications or treatments, and/or receiving excessive doses of medications or unnecessary treatments. <BR/>Findings include:<BR/>Closed record review of Resident #1's face sheet, dated 03/11/2023, documented that he was a [AGE] year-old male admitted to the facility on [DATE]. <BR/>Record review of Resident #1's hospital discharge instructions dated 02/16/2023 documented in part that he was to receive 300 MG of gabapentin (a pain medication) at bedtime for Type 2 Diabetes with diabetic neuropathy. He had a diagnosis of Left Foot Status Post Hallux amputation with necrotic area tissue (surgery removing the big toe on the left foot but with death of some of the tissue). He also had a stage 2 pressure ulcer (bed sore that has broken though the top layer of skin and some of the layer below) on his right heel. <BR/>Record review of Resident #1's hospital record dated 02/24/2023 documented he was receiving treatments for the infected amputated toe wound, a deep tissue injury (pressure ulcer) to the left heel, and a right heel deep tissue injury. He was receiving 300 MG of Gabapentin daily at bedtime for Type 2 Diabetes with diabetic neuropathy. <BR/>Record review of Resident #1's History and Physical dated 03/02/2023 completed by the Facility Physician stated that he had an amputation of his left great toe, an unstageable wound to the left heel and a deep tissue injury to the right heel. The facility was to continue Gabapentin capsules 300 MG orally once a day. <BR/>Record review of Resident #1's physician's Order Recap Report for the months of February and March 2023 documented an order dated 03/02/2023 to be started 03/04/2023 to cleanse the left foot with normal saline (salt water), pat dry, put on xeroform (gauze dressing with petrolatum and an antimicrobial) and wrap the foot in an ace bandage every Tuesday, Thursday and Saturday. There were no orders for treatment of the right heel. An order was documented dated 03/01/2023 to administer 300 MG of Gabapentin at bedtime daily. <BR/>Record review of Resident #1's MAR and TAR for March of 2023 revealed that administration of Gabapentin 300 MG was not documented on 03/02/2023, 03/07/2023 or 03/08/2023. Treatment of the resident's left foot was not documented on 03/04/2023 or 03/09/2023. No treatments for the resident's right foot appeared pm the MAR/TAR. <BR/>In an interview on 03/15/2023 at 4:22 PM the DON said that she did not know why Resident #1's Gabapentin 300 MG was not documented as administered on 03/02/2023, 03/07/2023 or 03/08/2023 and did not know why wound treatments to Resident #1's left heel were not documented. She said that administration of medications and treatments should be documented on the MAR or TAR. She said that she (the DON) and the ADONs were responsible for monitoring that medications and treatments were provided as ordered and were documented in the resident's medical record. <BR/>In observation, interview and record review 03/16/23 at 4:03 the DON provided a packing slip the facility pharmaceutical provider that documented that thirty 300 MG Gabapentin capsules had been delivered to the facility for Resident #1 on 03/01/2023. She provided a blister pack for 300 MG Gabapentin capsules for Resident #1 dated 03/01/2023 from which nine capsules had been dispensed. She stated that the dispensing nurse must have neglected to document that the medication had been administered to the resident. The DON stated that there was no order for care for Resident #1's pressure ulcer to his right heel, but there were progress notes from the Wound Care Nurse that she was providing treatment to his right heel. She said that there should have been orders for wound care to the right heel if treatments were to be provided. <BR/>In an interview on 03/16/2023 at 4:20 PM the Wound Care Nurse stated she had been in communication with Resident #1's podiatrist on 03/01/2023 to review orders for treatment and had entered the physician's orders for treatment of both feet in the computer software at that point. She said she assessed and provided treatment to Resident #1's left and right feet on 03/01/2023 and documented this in the MAR/TAR. She stated that she provided treatment for Resident #1's left and right feet on 03/04/2023 and 03/09/2023 and entered documentation of treatments to the MAR/TAR. She did not know why documentation of treatments to the left foot on 03/01, 03/04 and 03/09/2023 were not appearing on the MAR/TAR, or why the order and documentation of treatments for the right heel were not appearing on the Order Recap or the MAR. The Wound Care Nurse said she would look for additional documentation of the orders or provision of care. No further documentation was provided prior to exit. <BR/>In an interview on 03/16/23 at 4:03 PM wound care reports for March for Resident #1 were requested from the DON, but these were not provided prior to exit. <BR/>Record review of the facility policy titled Following Physician Orders dated 09/28/2021 documented in part that the nurse would document orders by entering the order with the time, date and signature on the physician order sheet, and transcribe the order to the medication or treatment administration record. <BR/>Record review of the facility policy Medication - Treatment Administration and Documentation Guidelines dated 02/02/2014 documented in part that accuracy of physician orders would be verified on the MAR or TAR prior to administering medications or treatments. Provision of medications or treatments would be documented with initials and/or signature on the MAR or TAR immediately following administration. MAR or TAR would be reviewed after medication or treatment administration to validate documentation was completed and supported services provided according to physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain essential mechanical and electrical equipment in safe operating condition for 1 facility of 1 reviewed for essential equipment. <BR/>1. <BR/>The facility did not provide necessary repairs for 1 industrial washing machines, 2 industrial dryers, 1 washer soap dispenser, and 1 washer bleach dispenser. <BR/>2. <BR/>2 of 10 Resident beds in C Hallway had head and foot boards that were broken. <BR/>3. <BR/>Resident #36 was sitting in his wheelchair with a broken footrest that had parts to the chair with sharp edges. <BR/>This failure could place residents who had their clothes laundered by the facility at risk no having sufficient linen available to meet residents needs and place residents who use sleep on facility beds at risk for injury from lose head or foot boards that may fall on them or screws/bolts that my scratch or puncture them as they are lying or sitting down. <BR/>Findings included: <BR/>Interview with the Maintenance manager on 04/27/23 at 9:11 AM, he stated that he was not responsible for the soap dispensing mechanism on the washers and that would be the responsibility of the vendor and the housekeeping supervisor. He stated the responsibility of fixing the washers and dryers would fall in his job description. However, he can only try and if it becomes too complicated, he will just call a contract company to come and fix it. The maintenance manager stated, I personally have not worked on the washer and dryer, I have called a vendor. The maintenance manager stated he has been employed for the facility for 4 months, since he started working the 2 dryers and one washer have not been working about 2 months. He stated they had a vendor come and work on the washer on 4/25/23 but he was uncertain why the washer was still not working and was going to follow up. The maintenance manager stated the facility purchased a dryer and would be arriving on Monday 5/1/23. The maintenance manager denied having manuals for the washing machines or dryers and no quality assurance monitoring was being done on the machines to ensure they are working properly. The Maintenance manager stated if the issue continued and was not addressed it can lead to mold on clothing and pest which can be very harmful to residents. <BR/>Interview and record review on 04/26/2023 beginning at 4:18 PM DON stated the facility is transitioning to a Tele-system where staff can input work orders from anywhere in the facility on the kiosk system but that not everyone knows how to use it yet to include the Maintenance Director. DON stated the facility staff are still supposed to write repairs in the maintenance logbook. DON reviewed the maintenance log and stated she saw the work order for the broken headboard on room C-108 but not in room C-115. DON stated the risk to the residents for the boards not being fixed was the residents could get hurt when laying down with the boards falling on them or an injury with the bolts/screw. <BR/>Interview with DON on 04/27/23 at 10:15 AM revealed residents had communicated they had issues with delay in personal clothing and linen availability. The DON stated the issues were brought up and addressed as a team with the laundry/housekeeping department. <BR/>Observation on 04/27/2023 at 6:31 PM in the laundry room outside inside on the wall was two different dispenser each having 4 hooks ups and tubing that run down to containers on the floor of liquid laundry chlorine beach, laundry neutral detergent, and liquid laundry-built detergent. There were two washers and only one worked. The broken washer on the right needed to have the computer from inside replaced. The other washer had clothes inside as it was being washed. In the other room there were 3 dyers and only one worked (furthest to the wall). The middle dryer was being used for spare parts to fix the dryer to the right closet to the exit, but that dryer was not working as well. There were bags upon bags of clothes on lined up on the wall and in bins needing to be washed. <BR/>Head/Foot Boards<BR/>Observation on 04/24/2023 at 9:29 AM in room C-108 there was a broken headboard on a bed (Bed A) that was tilted sideways not bolted on correctly. Bed B had a broken headboard hanging on the metal bar of the bar exposing a long bolt/screw. Bed B had the footboard of the bed was hanging and tilted slightly exposing another bolt/screw about an inch long. <BR/>Observation on 04/24/2023 at 10:17 AM in room C-115 the headboard of bed A was hanging away (the board on one end was still screwed to the bar and the other was not) from the bed and screwed/bolted down. <BR/>Interview on 04/24/2023 at 9:11 AM Laundry Worker G said one of the washers and two of the dryers in the facility laundry had been broken for about three months. Laundry Worker stated that as a result large amounts of dirty laundry would accumulate in the laundry area. Laundry Worker G stated that also the laundry did not have enough soap or other laundry products (chemicals) and so was worried about whether the linens were sanitary or not. Laundry Worker G stated she thought her supervisor had spoken to the facility administration, but she did not know when. Laundry Worker G stated the conditions in the laundry had been going on for a while and the situation had not improved. <BR/>Interview on 04/24/2023 at 10:21 AM LVN A stated the beds head and footboards broken in room C-108 were reported to maintenance a long time ago but could not remember how long ago it was. LVN A stated it still had not been fixed. LVN A stated the headboards not being fixed was a risk for the residents for a potential physical injury. <BR/>Interview on 04/24/20223 at 10:24 AM Maintenance Director he received a report about the bed boards being broken in room C-108 but did not have the time to fix it. Maintenance Director stated he had not received report about the broken headboard in room C-115. Maintenance Director stated there was a risk to the residents and they could hurt themselves when lying down by hitting the bolts/screw or the boards falling on their heads or if they are on their standing up the boards falling on their feet. <BR/>Interview on 04/26/2023 at 4:18 PM DON stated the facility is transitioning to a Tele-system where staff can input work orders from anywhere in the facility on the kiosk system but that not everyone knows how to use it yet to include the Maintenance Director. DON stated the facility was still using the maintenance log for work orders. DON reviewed the maintenance log and stated she see saw the work order for the broken headboard on room C-108 but not in room C-115. DON stated the risk to the residents for the boards not being fixed was the residents could get hurt when laying down with the boards falling on them or an injury with the bolts/screw. DON stated that staff tell the Maintenance Director directly about what needs to be fixed but he forgets to fix it. DON stated staff need to be inputting repairs in the maintenance logbook. <BR/>Resident #36<BR/>Record review of Resident #36's Face Sheet revealed admission on [DATE] and readmission on [DATE] to the facility. <BR/>Record review of Resident #36's facility diagnosis report dated 04/27/2023 revealed a diagnosis of dementia, muscle weakness, difficult walking, and lack of coordination. <BR/>Record review of Resident #36's MDS quarterly dated 01/31/2023 revealed a brief interview mental status score of 7, ADLs indicate transfer/locomotion on unit of 1 (supervision) and 1 (one person assistance), not marked for wheelchair, is a 4 (supervision/touching assistance) on chair/bed to chair (Wheelchair) transfer, 4 (supervision/touching assistance) walk 10 feet and a 3 (partial/moderate assistance) walk 50 feet, marked a 1 for wheelchair manual. <BR/>Record review of Resident #36's care plan dated 08/02/2023 alteration in musculoskeletal status. Interventions are to monitor complications related to arthritis, joint pain, joint stiffness, swelling, contracture formation, pain after exercise or weight bearing. Activities are dependent on staff for cognitive stimulation, activity attendance, social interaction. Interventions are to converse with resident while providing care, provide the resident with assistance as needed during the activity. No mention of mobility with wheelchair or walking on care plan. <BR/>Observation and Interview on 04/24/2023 beginning at 10:05 AM with Resident #36. Resident #36 was in his wheelchair sitting down. It was noted the left footrest was broken leaving three black sharp long backets that hold the pedal. Resident #36's left leg was moved away from the black backets. Resident #36 stated he did not know how long the footrest was broken or if the staff knew it was broken. <BR/>Interview on 04/25/2023 at 1:57 PM LVN A stated he was not aware of the broken footrest and the CNAs if they had seen it broken should have reported it immediately to him. LVN A stated the footrest with the sharp edges could potentially cause an injury to Resident #36's leg/foot with a skin tear, scratch, or his foot could get caught with the broken pieces. <BR/>Interview on 04/26/2023 at 10:46 AM CNA L stated when they come into work they focus on the resident and pay attention to the resident's equipment to make sure it was working and in good condition. CNA L stated if CNAs see something broken or wrong with the equipment of wheelchairs, they immediately notify the nurse. CNA L stated she was unaware that Resident #36's footrest was broken. CNA L stated the risk to the resident could have been if he tried to step on the broken pieces, he could injury himself or fall. <BR/>Interview on 04/26/2023 at 2:20 PM LVN M stated broken medical equipment had to be report by the CNAs to him or therapy. LVN M stated medical equipment like wheelchair or walker if broken are reported to maintenance. LVN M stated there is a maintenance logbook in the main nurse's station where they can write the damages in. LVN M stated she was unaware that Resident #36 had a broken footrest. LVN M stated the risk could be injury to his skin or possible fall if his leg got caught on the broken footrest.<BR/>Interview on 04/27/2023 at 2:28 PM DON stated if the wheelchair or other medical equipment was broken the facility would see if it was basic or specialized medical equipment in which they would send the equipment out for repair. DON stated any broken wheelchairs, walker, or broken items are reported to the nurse. DON stated the risk for not reporting a wheelchair footrest Resident #36 could become a fall risk or have a skin tear on his leg with the sharp brackets from the broken footrest. <BR/>Interview on 04/27/2023 at 5:00 PM Administrator stated staff are repairs are written in the maintenance log located in the nurse's station. Administrator stated facility staff report damages to Maintenance Director directly but ends up forgetting about the repairs and damage item does not get fixed. Administrator stated they have in-serviced staff over and over to write repairs in the maintenance log, but facility staff don't do it. Administrator stated the Maintenance Director was only one person and it was a lot of work for him. Administrator stated the risk to the residents with the other repairs would depend on what those damages are. Administrator stated she approval from corporate to hire another maintenance man who was going to be tasked with certain areas to help expedite repairs and help elevate some of the workload from the Maintenance Director. Administrator stated the broke head and footboards should have been fixed by maintenance and the risk to the resident in room C-108 was that the resident could have hit herself on the exposed bed bars hurting herself. Administrator stated if the wheelchair had a broken footrest for Resident #36, then the staff were supposed to take the wheelchair out of serve and put a note on it stating it was broken so no one else would use it. Administrator stated staff are to report a broken wheelchair or walker immediately. Administrator stated there was a risk to the resident in which the resident could get a skin tear and possibly get punctured by the broken footrest. <BR/>Interview with on 04/25/2023 at 08:45 AM Administrator stated they did not have a facility policy regarding reporting of broken equipment. <BR/>Record review of facility policy Provision of Quality Life dated 01/10/2023 revealed the facility will create and sustain an environment that humanizes and promotes each resident's well-being and feeling of self-worth and self-esteem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement written policies that prohibit and prevent abuse for 1 of 7 Resident #8) residents reviewed for abuse. <BR/>The facility failed to implement their abuse policy when they failed to immediately suspend the Driver after Resident #8 ' s allegation of mistreatment was reported. <BR/>This failure could place residents at risk of potential continued mistreatment and abuse. <BR/>Findings included: <BR/>Record review of Resident #8 ' s face sheet dated 06/19/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] and she was her own responsible party. <BR/>Record review of Resident #8 ' s history and physical dated 11/07/23 revealed diagnoses of diabetes mellitus type 2, kidney stones, chronic pain, restless leg syndrome, physical debility, and depression. <BR/>Record review of Resident #8 ' s quarterly MDS assessment dated [DATE] revealed a BIMS score of 10, indicating her cognitive was intact. <BR/>Record review of Resident #8 ' s nursing progress note dated 06/18/24 written by LVN K revealed [Resident #8] left facility with activity department. <BR/>Record review of Resident #8 ' s event note dated 06/19/24 revealed location of event was transportation van, cognition was oriented/ no problem and no pain. Description of event was [Resident #8] went out with activities on 06/18/24 to the park. Today [Resident #8] voicing that driver was too rough with her when transferring into van. Head to toe assessment performed. No bruising, discoloration or any injuries noted. No complaints of pain. The vital signs were: blood pressure was 142/82, temperature was 97.8 degrees, pulse was 90, respirations were 17 and blood glucose was 84. The Resident statement was [Resident #8] voiced driver was too rough with her while transferring to van. The NP and Resident #8 ' s family member was notified on 06/19/24. Other information not described above was [Resident #8] is own responsible party. She is alert and oriented x3, however confused at times. Family member called out of courtesy and informed of the situation. Family member voiced no concerns and stated she would talk with [Resident #8]. <BR/>Record review of Resident #8 ' s other event nurses note dated 06/20/24 written by LVN L revealed follow up note no new bruising, no new discoloration or any injuries noted. [Resident #8] has no complains of pain. No changes that required physician notification. <BR/>Record review of Resident #8 ' s other event nurses note dated 06/20/24 written by LVN M revealed follow up note no complaints of pain or discomfort. Head to toe assessment shows no injury or discoloration to the body. {Resident #8} has made no further comments about her trip to the park. No changes made that required physician notification. <BR/>Record review of the Driver ' s timecard dated 06/19/24 revealed she clocked in for her shift at 3:58 am and clocked out at 1:15 pm. <BR/>During an interview on 06/19/24 at 11:01 am, Resident #8 stated the Driver had been rough with her yesterday (06/18/24) when she had assisted her to the van. Resident #8 stated she had been rough while she was in the wheelchair and had caused her pain to her leg. Resident #8 stated she had not mentioned anything to any of the staff because she was waiting to talk to State Office Surveyors. Resident #8 stated she did not have any pain. Resident #8 was alert and oriented to person and event. Resident #8 did not appear in any distress while she recalled the alleged incident. <BR/>During an interview on 06/20/24 at 8:22 am, a call was placed to Resident #8 ' s family member, a voicemail was left to return the call. No call was returned by date and time of exit. <BR/>During an interview on 06/20/24 at 8:31 am, Resident #8 was in her bed resting. Resident #8 stated the people from administration, whose name she did not recall, had spoken to her yesterday regarding the incident. Resident #8 stated the nurse had assessed her shortly after but could not recall the time. Resident #8 stated she did not have any pain and she felt safe. <BR/>During an interview on 06/20/24 at 8:34 am, the Receptionist stated the Driver would pick up and drop off residents in the front entrance. The Receptionist stated she was able to see the Driver pick up and drop off residents in the front door and had not seen the Driver be rough with any residents. The Receptionist stated she had not received complaints from any residents and/or family members regarding the care provided by the Driver. <BR/>During an interview on 06/20/24 at 8:55 am, Activities Assistant the facility had scheduled an outing to the park on 06/18/24. The Activities assistant stated she had taken Resident #8 from her room to the lobby where the Driver then assisted her to the van. Activities Assistant she did not see anything unusual during their interaction. Activities Director stated Resident #8 had not mentioned the alleged incident to her and had not appeared any different during the outing. <BR/>During an interview on 09/20/24 at 9:01 am, Resident #58 who was alert and oriented to person, place, time, and event, stated he had gone to the outing on 06/18/24 to the park. Resident #58 stated he did not see anything out of the ordinary. Resident #58 stated Resident #8 was assisted by the Driver to be sat on the third row and was to his right side. Resident #58 stated after the Driver had assisted everyone to their seats, she had gone to each resident checking their seatbelts to ensure they were properly secured, and Resident #8 had not voiced any concerns. Resident #58 stated Resident #8 appeared ok during the outing. Resident #58 stated he had not seen the Driver been rough with anyone in any of the outings that he had been a part of. <BR/>During an interview on 06/20/24 at 1:53 pm, the Interim DON stated she had been notified by the Administrator of the allegation on 06/18/24 at around 11:30 am and had assisted her with following up with Resident #8. The Interim DON stated Resident #8 had mentioned the Driver had pushed her with her wheelchair in the front of the van. The Interim DON stated she did not voice any pain and no injuries were noted. <BR/>During an interview on 06/20/24 at 2:11 pm, ADON J stated she had been notified by the Administrator of Resident #8 ' s voiced allegation regarding Driver being rough with her. ADON J stated she had called the Driver on 06/18/24 at 11:53 am to inquire about her whereabouts and asked her to go to DON ' s office as soon as she arrived. ADON J stated she did not give specific of details due to the Driver being on the road. ADON J stated the Driver had arrived between 5-10 minutes after the call was made. ADON J stated the Driver had denied the alleged incident and stated that Resident #8 had not voiced any pain during and post outing to her. ADON J stated she had asked the Driver to write a statement and gave her the form for her to fill out. AODN J stated she assumed the Driver had gone to a private area to fill out the statement form. ADON J stated a couple of minutes had passed and she went to follow up on the Driver statement and could not find her. ADON J stated she placed a call to the Driver at 12:43 pm and asked where she was with the statement. ADON J stated the Driver told her she had taken Resident #19 to his dialysis appointment and was already back in the premises. ADON J stated she had explained to the Driver she was not supposed to take anyone anywhere due to the allegation made. ADON J stated the Driver had misunderstood the instructions given and was worried about Resident #19 missing his appointment. ADON J stated the Driver completed her statement and then clocked out for the day. <BR/>During an interview on 06/20/24 at 3:10 pm, Resident #19 was in his room and was alert and oriented to person, place, time, and event. Resident #19 stated the Driver had taken him to his dialysis appointment yesterday 06/19/24 and not been rough with him. Resident #19 stated the Driver had always been very kind and denied any concerns. Resident #19 stated he felt safe in the facility. <BR/>During an interview on 06/20/24 at 3:15 pm, the Administrator stated she had been notified of Resident #8 ' s allegation regarding the Driver being rough with her, on 06/10/24 at around 11:15am -11:30 am. The Administrator stated she and the Interim DON had gone to follow up with Resident #8 where she was assessed, and no injuries were noted, and no pain was voiced. The Administrator stated she had delegated to ADON J to call the Driver to inquire about her whereabouts and ask her to come in to DON office. The Administrator expected ADON J to have ensured the Driver wrote her statement and had exited the facility. The Administrator stated the Driver was suspended pending investigation. The Administrator stated the Driver had misunderstood what was asked from her and was concerned about getting Resident #19 to his dialysis appointment. The Administrator stated the driver had placed Resident #19 at risk for possible continued mistreatment. The Administrator stated the facility followed up with Resident #19 and he had denied any concerns with interactions with the Driver. The Administrator stated since she had been working in the facility, she had not received complaints regarding the Drivers care provided during transportation. <BR/>During an interview on 06/20/24 at 4:32 pm, the Driver stated she had taken a group of residents to a local park on 06/18/24 that included Resident #8. The driver denied the allegation and stated Resident #8 had been her normal self during transportation and post transportation. The Driver stated Resident #8 had not voiced any concerns and/or to her and did not act any differently with her. The driver stated she had been called by the ADON J to go to the office and was questioned about the alleged incident regarding being rough with Resident #8 and was asked to write a statement. The Driver stated the ADON J and Interim DON had asked her what transportation was pending for the rest of the day and she understood that they would find arrangements to pick Resident #19 up after dialysis. The Driver stated she was concerned about Resident #19 missing his dialysis appointment and opted to take him and write her statement after she got back. The Driver stated she got called again by ADON J when she was turning into the facility asking her about the written statement in which she was not supposed to take anyone anywhere after they had asked her to write the statement. <BR/>Record review of Abuse/Neglect policy dated 03/29/18 read in part The resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident ' s medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Section F subpart #4 read in part With an allegation of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, the employee(s) will immediately be suspended pending an investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 6 resident rooms, observed for housekeeping and maintenance, in that: <BR/>The facility failed to ensure CNA E used the facility work order system to input the lights in the restroom and room of Resident #5 would not turn on while Resident #5 wanted to use the restroom but was dark and could not see. <BR/>These failures could lead to resident injury and a diminished quality of life.<BR/>Findings include: <BR/>Record review of Resident #5's face sheet dated 01/15/25, revealed, admission on [DATE], re-admission on [DATE], and re-admission again on 02/22/22 to the facility. <BR/>Record review of Resident #5's facility history and physical dated 07/28/24, revealed, a [AGE] year-old female diagnosed with Anxiety, Cholecystitis (inflammation of the gallbladder), reduced mobility, history of falls, and GI bleeding (bleeding from any part of the digestive tract, from the mouth to the anus). <BR/>Record review of Resident #5's annual MDS dated [DATE], revealed, little to no impairment of cognition BIMS score of 15 and to be able to recall or make daily decisions. ADLs revealed to be independent for toileting, shower/bath, dressing. Independent for walking 10 feet/50 feet. <BR/>Record review of Resident #5's Care Plan dated 04/27/22, revealed the resident was incontinent of bowel/bladder related to history of UTI, confusion, and incontinence. Maintain unobstructed path to the bathroom. Resident #5 had impaired visual function and was at risk for falls, injury, and a decline in functional ability. Anticipate needs and meet them as able. Keep call light in reach when in room or bathroom. Involve in activities which do not require vision to participate such as music, parties, and exercise. Monitor and report eye problems, change in ability to perform ADLs, decline in mobility, sudden visual loss, tunnel vision, blurred vison, hazy vision. Resident #5 was able to see large print in a well illuminated room. ADLs was supervision with set-up for toileting due to impairment with balance coordination. <BR/>Observation and interview on 01/15/25 at 8:44 AM, with Resident #5, she stated she was looking for staff due to her lights in her restroom and room not turning on. Resident #5 showed state agency her room and tried to turn on the light switch in the room. It was observed that the light in the room was not turning on. Resident #5 stated she had to go to the restroom, but could not cause the light in the restroom would not turn on and was afraid to go to the restroom without the lights turning on. State agency tried turning on the lights in the restroom and would not turn on. It was observed that the room was dark, and, in the restroom, it was dark and darker if the restroom door was closed. It was observed that nothing could be seen if the restroom door was closed. Resident #5 had stated she told a nursing staff about the issues a little over an hour ago and did not know what had happened. <BR/>In an interview on 01/15/25 at 8:48 AM, with CNA E, she stated Resident #5 had told her about the lights not turning on in her room and restroom. CNA E stated she was looking for the floor charge nurse of the hall at the nurse's station and could not find her. CNA E stated since she was not able to find her, she went back to assist another resident with feeding as she was busy. CNA E stated she did not use the facility work order system to input the work order. CNA E stated she had been trained to use the facility work order system when facility needed to report facility stuff that needed fixing and tell the nurse. CNA E stated the risk of the lights not working for Resident #5 could have been a fall. <BR/>Observation on 01/15/25 at 8:50 AM, revealed, visible facility work order system QR Scan postings in around the nurse's station of the facility. <BR/>In an interview on 01/15/25 at 9:19 AM, with the Maintenance Director, he stated facility staff have been trained to use the facility work order system and what to do if they see, hear, or get reported facility stuff that were broken. The Maintenance Director stated there were QR Scan codes posted everywhere in the facility in which facility staff could place the work orders through there phones. The Maintenance Director stated not using the facility work order system could have a negative outcome of broken item(s) not getting fixed affecting the resident negatively depending on the situation. The Maintenance Director stated he was told of Resident #5's lights not turning on around 10 minutes ago which he observed that the lights were not turning on. The Maintenance Director stated Resident #5 told him she wanted them to turn on. The Maintenance Director stated an issue like the lights not turning on for Resident #5 was considered to be a 911 call (defined as notify the Maintenance Director immediately with clogged toilet, lights out, Exit lights out, etc.) and should have inputted into the facility work order system and told immediately. <BR/>In an interview on 01/15/25 at 10:49 AM, with ADON C and ADON D, ADON C stated all facility staff were trained on how to place a work order. ADON D stated there were QR Scan code postings throughout the facility in which facility staff could use the facility work order system to place work orders which was sent to the maintenance department. ADON C stated if nursing staff were reporting a work order issue and cannot find the nurse, then they need to directly let the Maintenance Director know aside from using the facility work order system. ADON D stated the risk would depend on the situation. <BR/>In an interview on 01/15/25 at 11:13 AM, with the Administrator, she stated facility staff were trained on the facility work order system on how to place work orders in. The Administrator stated the maintenance department should be reviewing the work orders daily. The Administrator stated the risk of not using the facility work order system could result in the broken item not being forgotten and would not be fixed. The Administrator stated the risk to the resident would depend on the situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the residents received education on the influenza immunizations for 1 of 6 (Resident #2) residents reviewed for immunizations. <BR/>1. The facility failed to document that Resident #2 or was provided education regarding the benefits and potential side effects of the influenza immunization and if the resident either receive the influenza immunization<BR/>This failure could place residents at risk for contracting a viral disease and cause respiratory complications, and potential adverse health outcomes. <BR/>Findings include: <BR/>Record review of Resident #2's face sheet dated 10/10/23 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of anxiety, hypertension (condition in which the force of the blood against the artery walls is too high), and atrial fibrillation (an irregular and often very rapid heart rhythm). <BR/>Record review of Resident #2's admission MDS assessment dated [DATE] revealed a BIMS score of 13, indicating his cognition was intact. The influenza and pneumococcal vaccination section had not been completed. The assessment was coded red with an alert of 20 days overdue. <BR/>Record review of Resident #2's electronic record revealed it did not have any documentation on influenza and pneumococcal vaccination status. <BR/>During interview on 10/10/23 at 9:48 am, Resident #2 was in his room and was alert and oriented to person, place, time, and event. Resident #2 stated upon admission he was not offered and/or educated on the flu vaccine and was wanting to get it now that the season was started. Resident #2 stated he was not asked about his immunization status when he arrived. <BR/>During interview on 10/10/23 at 2:28 pm, MDS Nurse E stated he was responsible for Resident #2 MDS admission assessment. MDS Nurse E stated admission MDS assessment was required to be completed at least within 5 days of admission. MDS Nurse E stated he was aware he was behind on some of the September assessments and had not asked for help to complete. MDS Nurse E stated he did not think there were any risks for incomplete MDS assessment other than payer source coding. <BR/>During interview on 10/10/23 at 2:45 pm, the DON stated history of immunization record and/or consent of refusal were required to be obtained by the admitting nurse. DON stated the admitting nurse should have at least offered and/or educated on the flu and pneumococcal vaccine upon admission or at least within 48 hours.DON stated risks included spread and/or inquired respiratory infection. <BR/>During interview on 10/10/23 at 3:00 pm, Medical Records stated she did not find a flu or pneumococcal consent or immunization record on hard copies for Resident #2 <BR/>During interview on 10/10/23 at 3:05 pm, NP stated if no immunization record was found, it was expected for staff to offer and educate on the flu and pneumococcal vaccine. NP stated risk included the spread and/or inquiring a respiratory infection. <BR/>Record review of Influenza Vaccination policy dated 08/01/22 revealed in part It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to immediately consult with resident physician and notify the resident representative when there was a significant change in the resident's physical or mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 (Resident #1) reviewed for notification of changes of condition.<BR/>The facility failed to notify the physician and establish vital signs when [AGE] year-old female Resident #1, with a history of dementia, had multiple episodes of emesis.<BR/>The facility failed to report to the NP or MD 08/10/23 when Resident #1 had a total of six episodes of emesis, beginning at approximately 10 a.m. The day shift CNA stated she informed the day RN after the second episode. The CNAs notified the facility nurses again at the change of shift, 2:20 pm, after 4 episodes. <BR/>The facility failed to notify the NP or MD until 5:00 pm-5:30 pm after the fifth episode and was not informed of Resident #1 being described as pale and shaking. NP stated if the nurses would have taken vitals for Resident #1 it would have established the baseline for her.<BR/>The facility failed to assess or document vital signs until 6:40 p.m., when the Resident #1's vitals were BP 90/50, pulse 101, respiration 24 when the resident was looking pale, and cool to touch, and had purplish lips. The NP or MD was not notified of additional episodes of emesis after the medication had been ordered and administered.<BR/>The facility failed to contact the NP or MD and instead contacted family for the decision to transport Resident #1 to the hospital. Resident #1 expired at the hospital.<BR/>This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/31/23. While the IJ was removed on 09/01/23, the facility remained out of compliance at a scope of actual harm and a severity level of isolated because the facility failed to have a system in place to ensure residents are monitored and assessed for changes in condition and are immediately reported to the attending physician.<BR/>This failure could affect residents by placing them at risk of delay medical treatment, hospitalization, decline in condition, and death. <BR/>Findings included: <BR/>Closed record Review revealed Resident #1's face sheet dated 08/12/23 listed initial admission on [DATE] and readmission on [DATE]. <BR/>Record Review Resident #1's history and physical dated 01/04/22 revealed a [AGE] year-old female. Past medical history multiple sclerosis, neurogenic bladder with chronic urinary tract infections due to intermittent catheterization.<BR/>Record Review Resident #1's quarterly MDS dated [DATE] revealed resident rarely made self-understood and rarely understands others; short-term, long term memory problems; Active Diagnoses-Renal Insufficiency, Renal Failure, or End-Stage Renal Disease, Neurogenic Bladder, Non-Alzheimer's Dementia, Multiple Sclerosis.<BR/>Record Review Resident #1's Care Plan revised 04/22/2023 revealed resident had neurogenic bladder and at times required catheterization. Monitor and report to Medical Doctor signs & symptoms of UTI. <BR/>Record review of the Emergency Medical Services report dated 08/10/23 documented unit was dispatched at 6:36 PM and arrived at 6:47 PM. At resident 6:48 PM. Call Type: Sick Person. Urgency: Immediate. Patient Condition: Hypotension (low blood pressure). Primary Symptom-Hypovolemic (a condition that occurs you're your body loses fluid). Patient Care Narrative: Assessment Exam: Skin: Cyanotic (bluish color due to inadequately oxygenated blood), Mental Status: Unresponsive. Eyes: Non-reactive (A pupil which remains excessively dilated in the presence of light). Patient Care Narrative: According to staff patient was last seen 5 minutes prior to EMS arrival. Upon arrival patient agonal (related to or associated with the act of dying, gasping for air) with cyanotic (bluish or purplish discoloration) presumed patient had aspirated on vomit. EMS assisted ventilations and transferred patient to stretcher where manual Cardiopulmonary Resuscitation was initiated. EMS wheeled patient to rescue. Once in rescue auto pulse pads were placed and patient was showing Asystole (when your heart's electrical system fails, causing your heart to stop pumping). On the monitor, had copious amount of fluid coming from mouth. Patient was being suctioned and given CPR and ventilations throughout transport. <BR/>Review of hospital emergency room record dated 08/10/23 6:59 PM, revealed [AGE] year-old female brought to emergency department in cardiac arrest. Reportedly was at the nursing facility having aspiration. When EMS arrived around 6:49 PM, she was found to be with agonal respiration (when someone who is not getting enough oxygen is gasping for air) and vomiting. No pulse was noted, and CPR started at this time. Patient was intubated by EMS in field, difficulty with bagging, copious vomitus, abdominal distention. ETT (Endotracheal Tube - tube used to provide oxygen and inhaled gases to the lungs) was suspected to be in the stomach and was replaced in the emergency department. Patient continued to receive CPR in the emergency room. Ultrasound was used to identify cardiac activity, but there were no signs of life until Resident #1 was then pronounced dead at 7:10 PM. <BR/>Record review of the office of medical examiner investigation dated 08/10/23 at 7:27 PM revealed the decedent was a [AGE] year-old white female who was viewed with episodes of emesis and hypotensive by staff while at the facility on 08/10/23. 911 was phoned and Emergency Medical Services responded and transported the decent to the local hospital with cardiopulmonary resuscitation in progress. The decedent arrived to the Emergency Department on 08/10/23 at approximately 6:59 PM. CPR was continued; however, the decedent was viewed asystolic and was pronounced on 08/10/23 at 7:10 PM by physician. The following information was provided on 08/10/23 approximately 6:30 PM facility staff phoned Representative Party and advised Representative Party, that the decedent had emesis episodes x 6 and had sugar of 340. The facility advised decedent's physician who ordered an abdominal x-ray; however, they wanted to know if Representative Party wanted the decedent to be transported to the hospital. Representative Party advised the facility she did want the decedent to be transported to the hospital.<BR/>Telephone interview on 08/12/23 at 11:00 AM with Resident #1's family member stated (RN I) called her on 08/10/23 at 6:30 PM to report Resident #1 had been vomiting all day and doctor had ordered an x-ray of the stomach and medication for nausea/vomiting. The family member stated, I told RN I to send Resident #1 to the hospital. When I called the nurse back, RN I reported that EMS had started CPR, when they got to the facility. The family member reported she had not been notified when Resident #1 started to vomit in the morning. The family member stated, If nurses had called to report to me when Resident #1 had the first emesis, I would have gone to check her and asked them to send her to the hospital. <BR/>Interview on 08/12/23 at 1:04 PM with RN I revealed she worked 08/10/23 and was getting report from RN J at the change of shift at approximately 2:00 PM, when CNA K came to the nurse's station to report Resident #1 had vomited. RN I stated they continued with report and then proceeded to count narcotics. RN I stated she assessed Resident #1 at approximately 3:00 PM-3:30 PM on that day, Resident #1 was sitting in a wheelchair in the dining room, looked pale and complained of nausea. RN I stated that at approximately 5:00 PM MA L reported to her Resident #1 had vomited. RN I stated she checked the resident's physician's orders and there was not a standing order for to treat nausea/vomiting so she called the NP to report resident had vomited x 2 on her shift and was nauseated. NP gave orders for a KUB (KUB is an x-ray performed to assess the abdominal area for causes of abdominal pain, or to assess the organs and structures of the urinary and/or gastrointestinal system) and Promethazine IM (intramuscular) TID (three times a day) as needed for nausea/vomiting. RN I reported she administered Promethazine IM as ordered to Resident #1 at approximately 5:35 PM. RN I stated CNA K reported to her at approximately 6:40 PM, that Resident #1 had vomited after Promethazine was administered and did not look well. RN I stated she immediately went to the room to assess Resident #1. Resident #1 was lying in bed, blood pressure was low, she looked pale, was sweating and was having difficulty breathing. RN I stated at around 6:40PM-6:45PM she notified Resident #1's family member at which time family member requested resident be sent to ER. RN I stated she had not notified the NP, Resident #1 continued to vomit after the Promethazine was administered, because they had standing order to treat nausea/vomiting. RN I stated she had not notified the NP that Resident #1 was going to be sent out to the hospital emergency room for evaluation per family member's request. RN I stated, they had been trained to immediately notify attending physician and resident's responsible party of changes in condition, notify physician if resident's condition does not improve after PRN (as needed) medications has been administered and get a Physician's Order to send the resident to the hospital for evaluation per family's request. <BR/>Telephone Interview on 08/12/23 at 2:42 PM RN J stated she worked on 08/10/23 and was assigned to Resident #1 during the morning shift, and resident did not have a change in condition during her shift. RN J denied CNA K had reported to her Resident #1 had vomited x 2 in the morning after breakfast. RN J stated, I was giving report to RN I at the change of shift at 2:00 PM, when CNA K came to the nurse's station to report Resident #1 had vomited. RN J stated she did not assess Resident #1 because her shift was over and continued to give report to RN I who was the on-coming nurse on the evening nurse and assigned to Resident #1. RN J stated that after report they proceeded to counted narcotics. RN J stated nurses have been trained to immediately assess and notify physician and/or nurse practitioner, responsible party when resident has a change in condition. <BR/>Telephone interview on 08/13/23 at 1:47 PM with RN I stated she did not notify the physician of the 1st emesis Resident #1 had at 2:00 PM. RN I stated that at approximately 3:00 PM-3:30 PM MA L reported to her that Resident #1 had vomited in the dining room, and she went to assess resident and noted had vomited undigested food and did not notify the physician. RN I stated CNA K had reported to her, Resident #1 had another episode of vomiting in the dining room and she did not go assess the resident and did not notify physician. RN I stated nurses had been trained to immediately assess the resident and notify the attending physician and responsible party of the change in condition. RN, I stated Resident #1 vomited for the 4th time in her room and asked resident if she wanted to go to the hospital but resident stated No. RN I stated she had administered Promethazine for nausea and vomiting at approximately 5:35 PM and resident continued to vomit. RN I stated she had not notified the attending physician or NP that resident continued to vomit after the Promethazine was administered because they had a standing order for Promethazine to administered as needed for nausea/vomiting. <BR/>Interview on 08/14/23 at 3:14 PM with CNA K reveled she had worked a double shift on 08/10/23 in the morning and evening shift and was assigned to Resident #1. CNA K stated, Resident #1 was not her usual self on that day and appeared to be having problems with eating. CNA K stated she went to resident's room after breakfast and noted Resident #1 vomited a large amount of undigested food that appeared to be egg/sausage. Resident #1 had vomitus on her left shoulder down to the leg. CNA K stated she left the room to go to answer the call light for another and forgot to report to RN J that Resident #1 had vomited. CNA K stated that approximately10 minutes later, she was walking by the Resident #1's room and noticed vomitus on the floor next by the side of the bed. CNA K stated she cleaned the emesis and saw RN J passing medications in the hallway and went to report to her that resident had vomited twice that morning. CNAK stated, RN J only looked at me and did not say anything. CNA K stated did not know if RN J had assessed the resident. CNA K reported that at approximately 1:45 PM Resident #1 yelling, so she went to the room to check the resident and noted that she had vomited for the 3rd. CNA K stated she did not immediately report to RN J that Resident #1 had vomited for the 3rd time during the morning shift because she was finishing her rounds. CNA K stated Resident #1 vomited for the 4th time while sitting in her wheelchair in the dining room at dinner time and had notified RN I. CNA K stated she did not know if RN I had assessed Resident #1. CNA K stated she was informed by resident's roommate family member at approximately 5:00 PM-5:30 PM that Resident #1 looked anxious and was shaking. CNA K stated she immediately reported this to RN I and did know if RN I went to go assess resident. CNA K stated MA L had reported to her that resident had vomited 2 times while in the dining and was being taken back to her room. CNA K stated she went to resident's room and Resident #1 did not look good, her breathing was different, fingertips were cold to touch, and lips looked slightly purplish. CNA K stated she informed RN I at around 5:30 PM. CNA K stated her and RN I went back to check on Resident #1 and tried taking Blood Pressure on right arm twice but could not get the reading and changed it to the left arm which was 76/50 and Pulse was 101. CNA K stated RN I gave Resident #1 a medication. CNA K stated at 6:30 PM Resident #1 was transferred to bed and was pale, with dark circles under her eyes. <BR/>Interview on 08/15/23 at 3:36 PM with MA L revealed she noted Resident #1 had vomited in the dining room at around 5:00 PM and had not immediately reported this to the nurses because she went to get a cup of coffee for Resident #1. MA L stated 1 to 2 minutes later Resident #1 vomited again so she went to report this to the RN I. MA L stated at 6:30 PM she noticed Resident #1's call light room was ringing, went to the resident's room and noted RN I and LVN N were in the room and asked her to assist with changing the resident. MA L stated they had been trained to immediately report to the nurses when a resident had a change in condition.<BR/>Interview on 08/15/23 at 4:19 PM with LVN N revealed she saw Resident #1 vomiting in the dining room during dinner time at approximately 5:00 PM, RN I was in the dining room and asked the CNAs to take Resident #1 to her room. LVN N stated at 6:00 PM-6:30 PM RN I had asked her to go with her to Resident #1's room to assist with changing the resident. LVN N stated RN I had checked resident's blood pressure and was 95/50, was pale, resident was trying to vomit but could not and was having trouble breathing. LVN N stated the CNAs needed to immediately report changes of condition and nurses immediately assess and notify the physicians of any changes of condition. LVN N stated if the doctor was not notified of a change of condition with a resident that would be a risk of not getting the necessary medical care.<BR/>Telephone interview on 08/15/23 at 9:04 AM with the NP revealed nurses should immediately report a change in condition to physician and/or NP. NP confirmed RN I, had reported to her in the afternoon that Resident #1 had vomited multiple times and gave orders for a KUB and Promethazine as needed for nausea/vomiting. NP stated Nurses need to assess the resident after each emesis to determine if the resident is constipated, amount and color of emesis and they are expected to immediately notify the physician and/or NP each time that the resident had an emesis. NP stated, If the medication ordered for nausea/vomiting, has been administered and the resident continues to have emesis the nurses are expected to immediately notify the physician/NP. <BR/>Interview on 08/15/23 at 4:43 PM with Roommate revealed that on 08/10/23 in the evening time she heard Resident #1 vomiting in the room but could not remember if it was before or after dinner time. <BR/>Second interview on 08/16/23 at 9:29 AM with RN J revealed Resident #1 was had an emesis at the change of shift at 2:00 PM, and she had not assessed the resident. RN J stated they had been trained to assess the residents when they had a change in condition, even if it was the change of shift. RN J stated they were trained to check the resident, check the vital signs, and immediately notify the doctor. RN J stated CNAs had been trained to immediately report to the nurses when a resident had a change in condition. RN J stated CNA K came to the nurses' station to report Resident #1 had vomited at the change of shift, when she was giving report to RN I. <BR/>Interview on 08/16/23 at 9:48 AM with Resident #1's roommates' family member revealed he arrived at the facility 08/10/23 at 5:30 PM and noticed Resident #1 was not in the cafeteria like she always was. Family Member #2 stated that upon return to the room at approximately 6:00 PM, Resident #1was not her usual self and appeared to be anxious and went to report this to CNA K. Family member #2 stated he told can K that Resident #1 was feeling sick and looked bad. Family member#2 stated Resident #1 was pale, eyes looked desperate, and upper body and hands were shaking. Family member #2 stated CNA K walked out of the room, and Family Member #2 followed CNA K and told CNA K Resident #1 needed help. Family member #2 stated he saw CNA K passed by the nurse's station and did not stop to talk to the nurses. <BR/>Interview on 08/16/23 at 11:34 AM with the DON revealed CNAs had been trained to immediately report to the nurses when residents had a change in condition and the nurses had been trained to immediately report changes in condition to the physician/nurse practitioner and responsible party. The DON stated it was very important for the nurses to report to physician and/or NP when a resident vomited to ensure resident did not have any adverse effects like dehydration or other complications. The DON stated if Resident #1 was administered the prescribed medication for nausea and vomiting and continued to vomit, the nurse should have immediately notified the physician and/or NP to see if the physician and/or NP to see if they wanted to make a change to the treatment plan and/or give orders to send the resident to the hospital for evaluation of change in condition. <BR/>Interview on 08/16/23 at 1:51 PM with the Administrator revealed CNAs had been trained and were expected to immediately report to the nurses when a resident has a change in condition. The Administrator stated the purpose of immediately reporting changes in condition to the nurses was for them to immediately assess the resident and call the physician and/or NP to ensure that the resident promptly received the needed medical care. The Administrator stated if the prescribed medication was not effective for a resident that had emesis, it was expected for the nurse to immediately notify NP or physician to see if they would make changes to the treatment plan. <BR/>Second interview on 08/29/23 at 9:56 AM with the DON revealed they had conducted in-service training after the incident with Resident #1 on 08/10/23 for all nurses and CNAs on immediately reporting changes in condition to the nurses; nurses were trained to immediately assessing residents when they had a change in condition, check vital signs, document assessment findings in the resident's electronic clinical record and immediately notifying physician and/or NP of change in condition. <BR/>Telephone call placed to attending Physician no answer, left a voice message to call surveyor back. <BR/>Second telephone interview on 08/29/23 at 11:13 AM NP stated the evening nurse had called her on 08/10/23 to report Resident #1 had vomited and had not provide any other information to her on that day regarding the status of the resident. NP stated nurses were expected to assess Resident #1 after each vomiting episode, check vital signs as part of the assessment and immediately report to physician and/or NP. NP stated, If the nurses do not check vital signs when a resident has a change in condition, we do not have a baseline to determine if the residents' condition is getting worse and a need to change the treatment plan and/or send the resident to the hospital for evaluation. NP stated she was not notified that Resident #1 had 6 emesis throughout the day on 08/10/23.<BR/>Interview on 08/29/23 at 2:01 PM LVN V stated nurses were in-serviced on 08/29/23 on assessing residents when they had a change in condition, checking vital signs, documentation of assessment in residents' electronic clinical record, and immediate notification to physician and/or NP of changes in condition.<BR/>Interview on 08/29/23 at 3:47 PM RN U stated since working for the facility she had not been in-serviced on anything as far as she recalls. <BR/>Interview on 08/29/23 at 4:18 PM with LVN S stated she had not been in-serviced on anything since she started working at the facility on the 14th of August 2023. LVN S stated she had not received any in-service training on what to do when a resident had a change in condition. <BR/>Review of 24-Hour Report Worksheet dated 08/10/23 on the 6-2 shift documented Resident #1 Emesis x1; laying down, now. There was not time indicated on the 24-hour report of when the vomiting occurred. <BR/>Review of 24-Hour Report Worksheet dated 08/10/23 on the 2-10 shift documented Resident #1 Emesis x4; NP notified. N.O. for KUB and Promethazine 12.5 mg TID PRN. Emesis x2 after New Orders, sent via Emergency Medical Services to hospital per family member's request. Coded on transfer to stretcher. <BR/>Review of Weights & Vital Signs Summary report for Resident #1 revealed, pulse was last checked on 03/01/23, 81 beats per minute-Regular; Temperature was last checked on 02/18/23 and was 97.2 Fahrenheit; Blood Pressure was last checked on 03/01/23 and was 117/73. <BR/>Record review RN I had not completed an SBAR assessment for Resident #1 on 08/10/23 when she notified NP on 08/10/23 of Resident #1 having vomited x 3 on the 2-10 shift. <BR/>Review of Order Recap Report dated 01/01/2023 - 08/31/2023 for Resident #1 documented in part:<BR/>-Order Date: 08/10/23 for portable KUB due to resident being confined to nursing home. Diagnosis: Pain. <BR/>-Order Date: 08/10/23 Promethazine HCL (Hydrochloride) inject 12.5 mg intramuscular every 8 hours as needed for nausea/vomiting. The Recap Order Report dated 01/01/2023 - 08/31/2023 for Resident #1 did not document an order to send the resident to the emergency room for evaluation of change in condition. <BR/>Review of Medication Administration Record (MAR) date 08/01/23 - 08/3123, printed on 08/12/23 for Resident #1 revealed an order for Promethazine HCL injection Solution inject 12.5 mg Intramuscular every 8 hours as needed for nausea/vomiting. Start Date: 08/10/23. MAR did not document Promethazine was administered as ordered on 08/10/23 by RN I. <BR/>Record review of facility's policy and procedure on Notification of Changes Reviewed/Revised 02/10/21 revealed: Policy: To provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. <BR/>The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: <BR/>-An emergency response situation that requires EMS involvement-A significant change in the physical, mental, or psychosocial status of the resident. <BR/>-A decision to transfer or discharge the resident to another facility.<BR/>Policy Explanation and Compliance Guidelines: -In the case of a resident who is incapable of making decision, the resident should still be notified. Notify the resident's physician. Decisions would be made by the legal representative or appropriate family members. <BR/>-The facility documents resident assessment(s), interventions, precision and family notifications on SBAR, nurses progress notes or telephone order forms (physician/family notice) as appropriate<BR/>The administrator, DON, and ADONs were informed on 08/31/23 at 10:44 AM that Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. <BR/>On 09/01/23 at 9:20 AM Administrator was notified 3rd Plan of removal was accepted. <BR/>The Plan of Removal revealed the facility took following actions:<BR/>1. <BR/>The DON in the morning meeting reviews the 24- hour report to identify any resident with a change in condition. DON/Designee will review documentation/assess if indicated, to verify that any identified change had a physician notification and documentation.<BR/>2. <BR/>The DON/Designee will review the Stop and Watch notebook daily to verify that any communication from nurse assistance to license nurse has been reviewed and with timely interventions as indicated.<BR/>3. <BR/>The DON/Designee will complete:<BR/>o <BR/>A license nurse QAPI tool daily x 30 days verifying license nurses training and knowledge in regard to the education they received (Vital Signs Guidelines, Clinical Practice Guidelines Alert Charting, Notification of Change of Condition, and The Stop and Watch program (A program in which CNAs see a resident having a change of condition and fill out a yellow form submitting it and reporting the change of condition to the nurses))<BR/>o <BR/>A Nurse Assistant QAPI tool daily x 30 days verifying nurse assistant training and knowledge in regard to the education they received (Notification of Change of Condition, and the Stop and Watch program)<BR/>On 8/31/2023 (unknown time) the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to notification of change in condition, and Quality of care and reviewed plan to sustain compliance.<BR/>Interviews and record review to confirm implementation of the Plan of Removal were conducted as follows:<BR/>Record review of facility Stop and Watch Early Warning Tool in-service dated 08/31/23-09/01/23 at 4:53 PM was signed and acknowledged competency by the CNAs. <BR/>Record review of facility changes in condition in-service dated 08/31/23 at 4:53 PM was signed and acknowledged competency by the CNAs. <BR/>Record review of facility notification changes in-service dated 08/31/23 at 1:00 PM was signed and acknowledged competency by the nurses.<BR/>Record review of the facility alert charting dated 08/31/23 at 1:00 PM was signed and acknowledged competency by the nurses. <BR/>Record review of the facility vital signs dated 08/31/23 at 1:00 PM was signed and acknowledged competency by the nurses. <BR/>Record review of facility SBAR Communication UDS for changes of conditions in-service dated 09/01/23 at 9:00 AM was signed and acknowledged competency by the nurses. <BR/>Record review of facility's stop and watch binder dated 09/01/23 at 10:03 AM revealed Stop and Watch Early Warning Tool. If you have identified a change while caring for or observing a resident, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can. <BR/>Record review of facility e-mail dated 09/01/23 at 3:23 PM indicating the licensed nurses on all other shifts cannot work until they have had this education (SBAR) and signed the in-service sheet. Make sure nurse manager at the beginning of each shift and throughout the weekend to provide this training before they work. <BR/>Interview on 08/29/23 at 2:01 PM with LVN V stated they were in-serviced on alert charting, vitals, and notification of changes. LVN V stated on alert charting which was charting everything that was reported by the CNAs regarding residents' changes of condition. LVN V stated vitals are to be taken when residents have changes of conditions. LVN V stated vitals establish a baseline for the resident. LVN V stated if a resident had a change of condition, they need to notify the physician or NP immediately regarding the change in the resident. LVN V stated anytime the CNAs see a change of condition they need to fill out a stop and watch yellow sheet and turn it in to the nurses so they can check on the resident. <BR/>Interview on 08/29/23 at 4:13 PM with LVN R stated, recently this month (August 2023) she had received in-services on changes of condition and assessing the residents. LVN R stated when preforming a head-to-toe assessment on a resident and something was found to let the physician know. LVN R stated she received an in-service on taking vitals and to communicate anything that was abnormal. LVN R stated it was important to take vitals when a resident had an incident because it could be a change of condition with the resident. LVN R stated she would then document it on the SBAR. <BR/>Interview on 08/30/23 at 8:53 AM CNA K stated yesterday 08/29/23 was the first time she had got an in-service on stop and watch and changes of condition. CNA K stated if a resident had a change of condition, then they are to report it and write it down on a paper that was at the nurse's station and submit it to the nurses. CNA K stated any changes of condition that are not normal are considered changes to a resident and need to be reported immediately.<BR/>Interview on 08/30/23 at 9:40 AM CNA W stated she received an in-service on changes of condition and vitals. CNA W stated she would report any changes a resident had that were not normal to the nurses. CNA W stated vitals are taken when a resident has a change in their condition that was different from what they normal act. <BR/>Interview on 08/30/23 at 9:53 AM CNA X stated she had been in-serviced on changes of condition with a resident, reporting, and stop and watch. CNA X stated if the resident was having a change of condition that was not their normal self, then the CNAs were expected to go to the nurse's station where the Stop and Watch yellow sheet was at and fill one out. CNA X stated once filled it would be turned into the nurses reporting the change in the resident. <BR/>Interview on 08/30/23 at 10:01 AM CNA Y stated she had received the in-services on changes of condition, reporting, and stop and watch. CNA Y stated anytime a resident shows a change in their condition the CNAs need to report it. CNA Y stated you go to the nurse's station and in the book called Stop and Watch fill out a yellow form. CNA Y stated once filled it was turned into the nurses so they may go assess the resident. <BR/>Interview on 08/30/23 at 10:10 AM CNA D stated that the Stop and Watch binder was at the nurse's station. CNA D stated it was for when a resident had a change in condition. CNA D stated if they saw a resident different from their norm then they were to report by going to the stop and watch binder and pulling out a yellow sheet and filling it out. CNA D stated it would be turned into the nurses for follow up. <BR/>Interview on 09/01/23 at 2:20 PM LVN AA stated she was in-serviced on alert charting, changes of condition, SBAR, and calling the physician. LVN AA stated anytime a resident has a change in condition it needed to be reported to the physician or if the CNAs see the change with a resident, they need to notify nursing. LVN AA stated the SBAR was where nurses document vitals, times, and anything vital with changes of condition with a resident. LVN AA stated it was a summary of what was going on with the resident. LVN AA stated everything needed to be charted regarding the residents change of condition and assess[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 5 (Resident #1) reviewed for quality of care.<BR/>The facility failed to notify the physician and establish vital signs when [AGE] year-old female Resident #1, with a history of dementia, had multiple episodes of emesis.<BR/>The facility failed to report to the NP or MD 08/10/23 when Resident #1 had a total of six episodes of emesis, beginning at approximately 10 a.m. The day shift CNA stated she informed the day RN after the second episode. The CNAs notified the facility nurses again at the change of shift, 2:20 pm, after 4 episodes. <BR/>The facility failed to notify the NP until 5:00 pm-5:30 pm after the fifth episode and was not informed of Resident #1 being described as pale and shaking. NP stated if the nurses would have taken vitals for Resident #1 it would have established the baseline for her.<BR/>The facility failed to assess or document vital signs until 6:40 p.m., when the Resident #1's vitals were BP 90/50, pulse 101, respiration 24 when the resident was looking pale, and cool to touch, and had purplish lips. The NP was not notified of additional episodes of emesis after the medication had been ordered and administered.<BR/>The facility failed to contact the NP and instead contacted family for the decision to transport Resident #1 to the hospital. Resident #1 expired at the hospital.<BR/>This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/31/23. While the IJ was removed on 09/01/23, the facility remained out of compliance at a scope of actual harm and a severity level of isolated because the facility failed to have a system in place to ensure residents are monitored and assessed for changes in condition and are immediately reported to the attending physician.<BR/>This failure could affect residents by placing them at risk of delay medical treatment, hospitalization, decline in condition, and death. <BR/>Findings included: <BR/>Closed record Review revealed Resident #1's face sheet dated 08/12/23 listed initial admission on [DATE] and readmission on [DATE]. <BR/>Record Review Resident #1's history and physical dated 01/04/22 revealed a [AGE] year-old female. Past medical history multiple sclerosis, neurogenic bladder with chronic urinary tract infections due to intermittent catheterization.<BR/>Record Review Resident #1's quarterly MDS dated [DATE] revealed resident rarely made self-understood and rarely understands others; short-term, long term memory problems; Active Diagnoses-Renal Insufficiency, Renal Failure, or End-Stage Renal Disease, Neurogenic Bladder, Non-Alzheimer's Dementia, Multiple Sclerosis.<BR/>Record Review Resident #1's Care Plan revised 04/22/2023 revealed resident had neurogenic bladder and at times required catheterization. Monitor and report to Medical Doctor signs & symptoms of UTI. <BR/>Record review of the Emergency Medical Services report dated 08/10/23 documented unit was dispatched at 6:36 PM and arrived at 6:47 PM. At resident 6:48 PM. Call Type: Sick Person. Urgency: Immediate. Patient Condition: Hypotension (low blood pressure). Primary Symptom-Hypovolemic (a condition that occurs you're your body loses fluid). Patient Care Narrative: Assessment Exam: Skin: Cyanotic (bluish color due to inadequately oxygenated blood), Mental Status: Unresponsive. Eyes: Non-reactive (A pupil which remains excessively dilated in the presence of light). Patient Care Narrative: According to staff patient was last seen 5 minutes prior to EMS arrival. Upon arrival patient agonal (related to or associated with the act of dying, gasping for air) with cyanotic (bluish or purplish discoloration) presumed patient had aspirated on vomit. EMS assisted ventilations and transferred patient to stretcher where manual Cardiopulmonary Resuscitation was initiated. EMS wheeled patient to rescue. Once in rescue auto pulse pads were placed and patient was showing Asystole (when your heart's electrical system fails, causing your heart to stop pumping). On the monitor, had copious amount of fluid coming from mouth. Patient was being suctioned and given CPR and ventilations throughout transport. <BR/>Review of hospital emergency room record dated 08/10/23 6:59 PM, revealed [AGE] year-old female brought to emergency department in cardiac arrest. Reportedly was at the nursing facility having aspiration. When EMS arrived around 6:49 PM, she was found to be with agonal respiration (when someone who is not getting enough oxygen is gasping for air) and vomiting. No pulse was noted, and CPR started at this time. Patient was intubated by EMS in field, difficulty with bagging, copious vomitus, abdominal distention. ETT (Endotracheal Tube - tube used to provide oxygen and inhaled gases to the lungs) was suspected to be in the stomach and was replaced in the emergency department. Patient continued to receive CPR in the emergency room. Ultrasound was used to identify cardiac activity, but there were no signs of life until Resident #1 was then pronounced dead at 7:10 PM. <BR/>Record review of the office of medical examiner investigation dated 08/10/23 at 7:27 PM revealed the decedent was a [AGE] year-old white female who was viewed with episodes of emesis and hypotensive by staff while at the facility on 08/10/23. 911 was phoned and Emergency Medical Services responded and transported the decent to the local hospital with cardiopulmonary resuscitation in progress. The decedent arrived to the Emergency Department on 08/10/23 at approximately 6:59 PM. CPR was continued; however, the decedent was viewed asystolic and was pronounced on 08/10/23 at 7:10 PM by physician. The following information was provided on 08/10/23 approximately 6:30 PM facility staff phoned Representative Party and advised Representative Party, that the decedent had emesis episodes x 6 and had sugar of 340. The facility advised decedent's physician who ordered an abdominal x-ray; however, they wanted to know if Representative Party wanted the decedent to be transported to the hospital. Representative Party advised the facility she did want the decedent to be transported to the hospital.<BR/>Telephone interview on 08/12/23 at 11:00 AM with Resident #1's family member stated (RN I) called her on 08/10/23 at 6:30 PM to report Resident #1 had been vomiting all day and doctor had ordered an x-ray of the stomach and medication for nausea/vomiting. The family member stated, I told RN I to send Resident #1 to the hospital. When I called the nurse back, RN I reported that EMS had started CPR, when they got to the facility. The family member reported she had not been notified when Resident #1 started to vomit in the morning. The family member stated, If nurses had called to report to me when Resident #1 had the first emesis, I would have gone to check her and asked them to send her to the hospital. <BR/>Interview on 08/12/23 at 1:04 PM with RN I revealed she worked 08/10/23 and was getting report from RN J at the change of shift at approximately 2:00 PM, when CNA K came to the nurse's station to report Resident #1 had vomited. RN I stated they continued with report and then proceeded to count narcotics. RN I stated she assessed Resident #1 at approximately 3:00 PM-3:30 PM on that day, Resident #1 was sitting in a wheelchair in the dining room, looked pale and complained of nausea. RN I stated that at approximately 5:00 PM MA L reported to her Resident #1 had vomited. RN I stated she checked the resident's physician's orders and there was not a standing order for to treat nausea/vomiting so she called the NP to report resident had vomited x 2 on her shift and was nauseated. NP gave orders for a KUB (KUB is an x-ray performed to assess the abdominal area for causes of abdominal pain, or to assess the organs and structures of the urinary and/or gastrointestinal system) and Promethazine IM (intramuscular) TID (three times a day) as needed for nausea/vomiting. RN I reported she administered Promethazine IM as ordered to Resident #1 at approximately 5:35 PM. RN I stated CNA K reported to her at approximately 6:40 PM, that Resident #1 had vomited after Promethazine was administered and did not look well. RN I stated she immediately went to the room to assess Resident #1. Resident #1 was lying in bed, blood pressure was low, she looked pale, was sweating and was having difficulty breathing. RN I stated at around 6:40PM-6:45PM she notified Resident #1's family member at which time family member requested resident be sent to ER. RN I stated she had not notified the NP, Resident #1 continued to vomit after the Promethazine was administered, because they had standing order to treat nausea/vomiting. RN I stated she had not notified the NP that Resident #1 was going to be sent out to the hospital emergency room for evaluation per family member's request. RN I stated, they had been trained to immediately notify attending physician and resident's responsible party of changes in condition, notify physician if resident's condition does not improve after PRN (as needed) medications has been administered and get a Physician's Order to send the resident to the hospital for evaluation per family's request. <BR/>Telephone Interview on 08/12/23 at 2:42 PM RN J stated she worked on 08/10/23 and was assigned to Resident #1 during the morning shift, and resident did not have a change in condition during her shift. RN J denied CNA K had reported to her Resident #1 had vomited x 2 in the morning after breakfast. RN J stated, I was giving report to RN I at the change of shift at 2:00 PM, when CNA K came to the nurse's station to report Resident #1 had vomited. RN J stated she did not assess Resident #1 because her shift was over and continued to give report to RN I who was the on-coming nurse on the evening nurse and assigned to Resident #1. RN J stated that after report they proceeded to counted narcotics. RN J stated nurses have been trained to immediately assess and notify physician and/or nurse practitioner, responsible party when resident has a change in condition. <BR/>Telephone interview on 08/13/23 at 1:47 PM with RN I stated she did not notify the physician of the 1st emesis Resident #1 had at 2:00 PM. RN I stated that at approximately 3:00 PM-3:30 PM MA L reported to her that Resident #1 had vomited in the dining room, and she went to assess resident and noted had vomited undigested food and did not notify the physician. RN I stated CNA K had reported to her, Resident #1 had another episode of vomiting in the dining room and she did not go assess the resident and did not notify physician. RN I stated nurses had been trained to immediately assess the resident and notify the attending physician and responsible party of the change in condition. RN, I stated Resident #1 vomited for the 4th time in her room and asked resident if she wanted to go to the hospital but resident stated No. RN I stated she had administered Promethazine for nausea and vomiting at approximately 5:35 PM and resident continued to vomit. RN I stated she had not notified the attending physician or NP that resident continued to vomit after the Promethazine was administered because they had a standing order for Promethazine to administered as needed for nausea/vomiting. <BR/>Interview on 08/14/23 at 3:14 PM with CNA K reveled she had worked a double shift on 08/10/23 in the morning and evening shift and was assigned to Resident #1. CNA K stated, Resident #1 was not her usual self on that day and appeared to be having problems with eating. CNA K stated she went to resident's room after breakfast and noted Resident #1 vomited a large amount of undigested food that appeared to be egg/sausage. Resident #1 had vomitus on her left shoulder down to the leg. CNA K stated she left the room to go to answer the call light for another and forgot to report to RN J that Resident #1 had vomited. CNA K stated that approximately10 minutes later, she was walking by the Resident #1's room and noticed vomitus on the floor next by the side of the bed. CNA K stated she cleaned the emesis and saw RN J passing medications in the hallway and went to report to her that resident had vomited twice that morning. CNAK stated, RN J only looked at me and did not say anything. CNA K stated did not know if RN J had assessed the resident. CNA K reported that at approximately 1:45 PM Resident #1 yelling, so she went to the room to check the resident and noted that she had vomited for the 3rd. CNA K stated she did not immediately report to RN J that Resident #1 had vomited for the 3rd time during the morning shift because she was finishing her rounds. CNA K stated Resident #1 vomited for the 4th time while sitting in her wheelchair in the dining room at dinner time and had notified RN I. CNA K stated she did not know if RN I had assessed Resident #1. CNA K stated she was informed by resident's roommate family member at approximately 5:00 PM-5:30 PM that Resident #1 looked anxious and was shaking. CNA K stated she immediately reported this to RN I and did know if RN I went to go assess resident. CNA K stated MA L had reported to her that resident had vomited 2 times while in the dining and was being taken back to her room. CNA K stated she went to resident's room and Resident #1 did not look good, her breathing was different, fingertips were cold to touch, and lips looked slightly purplish. CNA K stated she informed RN I at around 5:30 PM. CNA K stated her and RN I went back to check on Resident #1 and tried taking Blood Pressure on right arm twice but could not get the reading and changed it to the left arm which was 76/50 and Pulse was 101. CNA K stated RN I gave Resident #1 a medication. CNA K stated at 6:30 PM Resident #1 was transferred to bed and was pale, with dark circles under her eyes. <BR/>Interview on 08/15/23 at 3:36 PM with MA L revealed she noted Resident #1 had vomited in the dining room at around 5:00 PM and had not immediately reported this to the nurses because she went to get a cup of coffee for Resident #1. MA L stated 1 to 2 minutes later Resident #1 vomited again so she went to report this to the RN I. MA L stated at 6:30 PM she noticed Resident #1's call light room was ringing, went to the resident's room and noted RN I and LVN N were in the room and asked her to assist with changing the resident. MA L stated they had been trained to immediately report to the nurses when a resident had a change in condition.<BR/>Interview on 08/15/23 at 4:19 PM with LVN N revealed she saw Resident #1 vomiting in the dining room during dinner time at approximately 5:00 PM, RN I was in the dining room and asked the CNAs to take Resident #1 to her room. LVN N stated at 6:00 PM-6:30 PM RN I had asked her to go with her to Resident #1's room to assist with changing the resident. LVN N stated RN I had checked resident's blood pressure and was 95/50, was pale, resident was trying to vomit but could not and was having trouble breathing. LVN N stated the CNAs needed to immediately report changes of condition and nurses immediately assess and notify the physicians of any changes of condition. LVN N stated if the doctor was not notified of a change of condition with a resident that would be a risk of not getting the necessary medical care.<BR/>Telephone interview on 08/15/23 at 9:04 AM with the NP revealed nurses should immediately report a change in condition to physician and/or NP. NP confirmed RN I, had reported to her in the afternoon that Resident #1 had vomited multiple times and gave orders for a KUB and Promethazine as needed for nausea/vomiting. NP stated Nurses need to assess the resident after each emesis to determine if the resident is constipated, amount and color of emesis and they are expected to immediately notify the physician and/or NP each time that the resident had an emesis. NP stated, If the medication ordered for nausea/vomiting, has been administered and the resident continues to have emesis the nurses are expected to immediately notify the physician/NP. <BR/>Interview on 08/15/23 at 4:43 PM with Roommate revealed that on 08/10/23 in the evening time she heard Resident #1 vomiting in the room but could not remember if it was before or after dinner time. <BR/>Second interview on 08/16/23 at 9:29 AM with RN J revealed Resident #1 was had an emesis at the change of shift at 2:00 PM, and she had not assessed the resident. RN J stated they had been trained to assess the residents when they had a change in condition, even if it was the change of shift. RN J stated they were trained to check the resident, check the vital signs, and immediately notify the doctor. RN J stated CNAs had been trained to immediately report to the nurses when a resident had a change in condition. RN J stated CNA K came to the nurses' station to report Resident #1 had vomited at the change of shift, when she was giving report to RN I. <BR/>Interview on 08/16/23 at 9:48 AM with Resident #1's roommates' family member revealed he arrived at the facility 08/10/23 at 5:30 PM and noticed Resident #1 was not in the cafeteria like she always was. Family Member #2 stated that upon return to the room at approximately 6:00 PM, Resident #1was not her usual self and appeared to be anxious and went to report this to CNA K. Family member #2 stated he told can K that Resident #1 was feeling sick and looked bad. Family member#2 stated Resident #1 was pale, eyes looked desperate, and upper body and hands were shaking. Family member #2 stated CNA K walked out of the room, and Family Member #2 followed CNA K and told CNA K Resident #1 needed help. Family member #2 stated he saw CNA K passed by the nurse's station and did not stop to talk to the nurses. <BR/>Interview on 08/16/23 at 11:34 AM with the DON revealed CNAs had been trained to immediately report to the nurses when residents had a change in condition and the nurses had been trained to immediately report changes in condition to the physician/nurse practitioner and responsible party. The DON stated it was very important for the nurses to report to physician and/or NP when a resident vomited to ensure resident did not have any adverse effects like dehydration or other complications. The DON stated if Resident #1 was administered the prescribed medication for nausea and vomiting and continued to vomit, the nurse should have immediately notified the physician and/or NP to see if the physician and/or NP to see if they wanted to make a change to the treatment plan and/or give orders to send the resident to the hospital for evaluation of change in condition. <BR/>Interview on 08/16/23 at 1:51 PM with the Administrator revealed CNAs had been trained and were expected to immediately report to the nurses when a resident has a change in condition. The Administrator stated the purpose of immediately reporting changes in condition to the nurses was for them to immediately assess the resident and call the physician and/or NP to ensure that the resident promptly received the needed medical care. The Administrator stated if the prescribed medication was not effective for a resident that had emesis, it was expected for the nurse to immediately notify NP or physician to see if they would make changes to the treatment plan. <BR/>Second interview on 08/29/23 at 9:56 AM with the DON revealed they had conducted in-service training after the incident with Resident #1 on 08/10/23 for all nurses and CNAs on immediately reporting changes in condition to the nurses; nurses were trained to immediately assessing residents when they had a change in condition, check vital signs, document assessment findings in the resident's electronic clinical record and immediately notifying physician and/or NP of change in condition. <BR/>Telephone call placed to attending Physician no answer, left a voice message to call surveyor back. <BR/>Second telephone interview on 08/29/23 at 11:13 AM NP stated the evening nurse had called her on 08/10/23 to report Resident #1 had vomited and had not provide any other information to her on that day regarding the status of the resident. NP stated nurses were expected to assess Resident #1 after each vomiting episode, check vital signs as part of the assessment and immediately report to physician and/or NP. NP stated, If the nurses do not check vital signs when a resident has a change in condition, we do not have a baseline to determine if the residents' condition is getting worse and a need to change the treatment plan and/or send the resident to the hospital for evaluation. NP stated she was not notified that Resident #1 had 6 emesis throughout the day on 08/10/23.<BR/>Interview on 08/29/23 at 2:01 PM LVN V stated nurses were in-serviced on 08/29/23 on assessing residents when they had a change in condition, checking vital signs, documentation of assessment in residents' electronic clinical record, and immediate notification to physician and/or NP of changes in condition.<BR/>Interview on 08/29/23 at 3:47 PM RN U stated since working for the facility she had not been in-serviced on anything as far as she recalls. <BR/>Interview on 08/29/23 at 4:18 PM with LVN S stated she had not been in-serviced on anything since she started working at the facility on the 14th of August 2023. LVN S stated she had not received any in-service training on what to do when a resident had a change in condition. <BR/>Review of 24-Hour Report Worksheet dated 08/10/23 on the 6-2 shift documented Resident #1 Emesis x1; laying down, now. There was not time indicated on the 24-hour report of when the vomiting occurred. <BR/>Review of 24-Hour Report Worksheet dated 08/10/23 on the 2-10 shift documented Resident #1 Emesis x4; NP notified. N.O. for KUB and Promethazine 12.5 mg TID PRN. Emesis x2 after New Orders, sent via Emergency Medical Services to hospital per family member's request. Coded on transfer to stretcher. <BR/>Review of Weights & Vital Signs Summary report for Resident #1 revealed, pulse was last checked on 03/01/23, 81 beats per minute-Regular; Temperature was last checked on 02/18/23 and was 97.2 Fahrenheit; Blood Pressure was last checked on 03/01/23 and was 117/73. <BR/>Record review RN I had not completed an SBAR assessment for Resident #1 on 08/10/23 when she notified NP on 08/10/23 of Resident #1 having vomited x 3 on the 2-10 shift. <BR/>Review of Order Recap Report dated 01/01/2023 - 08/31/2023 for Resident #1 documented in part:<BR/>-Order Date: 08/10/23 for portable KUB due to resident being confined to nursing home. Diagnosis: Pain. <BR/>-Order Date: 08/10/23 Promethazine HCL (Hydrochloride) inject 12.5 mg intramuscular every 8 hours as needed for nausea/vomiting. The Recap Order Report dated 01/01/2023 - 08/31/2023 for Resident #1 did not document an order to send the resident to the emergency room for evaluation of change in condition. <BR/>Review of Medication Administration Record (MAR) date 08/01/23 - 08/3123, printed on 08/12/23 for Resident #1 revealed an order for Promethazine HCL injection Solution inject 12.5 mg Intramuscular every 8 hours as needed for nausea/vomiting. Start Date: 08/10/23. MAR did not document Promethazine was administered as ordered on 08/10/23 by RN I. <BR/>Record review of facility's policy and procedure on Notification of Changes Reviewed/Revised 02/10/21 revealed: Policy: To provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. <BR/>The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: <BR/>-An emergency response situation that requires EMS involvement-A significant change in the physical, mental, or psychosocial status of the resident. <BR/>-A decision to transfer or discharge the resident to another facility.<BR/>Policy Explanation and Compliance Guidelines: -In the case of a resident who is incapable of making decision, the resident should still be notified. Notify the resident's physician. Decisions would be made by the legal representative or appropriate family members. <BR/>-The facility documents resident assessment(s), interventions, precision and family notifications on SBAR, nurses progress notes or telephone order forms (physician/family notice) as appropriate<BR/>The administrator, DON, and ADONs were informed on 08/31/23 at 10:44 AM that Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. <BR/>On 09/01/23 at 9:20 AM Administrator was notified 3rd Plan of removal was accepted. <BR/>The Plan of Removal revealed the facility took following actions:<BR/>1. <BR/>The DON in the morning meeting reviews the 24- hour report to identify any resident with a change in condition. DON/Designee will review documentation/assess if indicated, to verify that any identified change had a physician notification and documentation.<BR/>2. <BR/>The DON/Designee will review the Stop and Watch notebook daily to verify that any communication from nurse assistance to license nurse has been reviewed and with timely interventions as indicated.<BR/>3. <BR/>The DON/Designee will complete:<BR/>o <BR/>A license nurse QAPI tool daily x 30 days verifying license nurses training and knowledge in regard to the education they received (Vital Signs Guidelines, Clinical Practice Guidelines Alert Charting, Notification of Change of Condition, and The Stop and Watch program (A program in which CNAs see a resident having a change of condition and fill out a yellow form submitting it and reporting the change of condition to the nurses))<BR/>o <BR/>A Nurse Assistant QAPI tool daily x 30 days verifying nurse assistant training and knowledge in regard to the education they received (Notification of Change of Condition, and the Stop and Watch program)<BR/>On 8/31/2023 (unknown time) the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to notification of change in condition, and Quality of care and reviewed plan to sustain compliance.<BR/>Interviews and record review to confirm implementation of the Plan of Removal were conducted as follows:<BR/>Record review of facility Stop and Watch Early Warning Tool in-service dated 08/31/23-09/01/23 at 4:53 PM was signed and acknowledged competency by the CNAs. <BR/>Record review of facility changes in condition in-service dated 08/31/23 at 4:53 PM was signed and acknowledged competency by the CNAs. <BR/>Record review of facility notification changes in-service dated 08/31/23 at 1:00 PM was signed and acknowledged competency by the nurses.<BR/>Record review of the facility alert charting dated 08/31/23 at 1:00 PM was signed and acknowledged competency by the nurses. <BR/>Record review of the facility vital signs dated 08/31/23 at 1:00 PM was signed and acknowledged competency by the nurses. <BR/>Record review of facility SBAR Communication UDS for changes of conditions in-service dated 09/01/23 at 9:00 AM was signed and acknowledged competency by the nurses. <BR/>Record review of facility's stop and watch binder dated 09/01/23 at 10:03 AM revealed Stop and Watch Early Warning Tool. If you have identified a change while caring for or observing a resident, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can. <BR/>Record review of facility e-mail dated 09/01/23 at 3:23 PM indicating the licensed nurses on all other shifts cannot work until they have had this education (SBAR) and signed the in-service sheet. Make sure nurse manager at the beginning of each shift and throughout the weekend to provide this training before they work. <BR/>Interview on 08/29/23 at 2:01 PM with LVN V stated they were in-serviced on alert charting, vitals, and notification of changes. LVN V stated on alert charting which was charting everything that was reported by the CNAs regarding residents' changes of condition. LVN V stated vitals are to be taken when residents have changes of conditions. LVN V stated vitals establish a baseline for the resident. LVN V stated if a resident had a change of condition, they need to notify the physician or NP immediately regarding the change in the resident. LVN V stated anytime the CNAs see a change of condition they need to fill out a stop and watch yellow sheet and turn it in to the nurses so they can check on the resident. <BR/>Interview on 08/29/23 at 4:13 PM with LVN R stated, recently this month (August 2023) she had received in-services on changes of condition and assessing the residents. LVN R stated when preforming a head-to-toe assessment on a resident and something was found to let the physician know. LVN R stated she received an in-service on taking vitals and to communicate anything that was abnormal. LVN R stated it was important to take vitals when a resident had an incident because it could be a change of condition with the resident. LVN R stated she would then document it on the SBAR. <BR/>Interview on 08/30/23 at 8:53 AM CNA K stated yesterday 08/29/23 was the first time she had got an in-service on stop and watch and changes of condition. CNA K stated if a resident had a change of condition, then they are to report it and write it down on a paper that was at the nurse's station and submit it to the nurses. CNA K stated any changes of condition that are not normal are considered changes to a resident and need to be reported immediately. <BR/>Interview on 08/30/23 at 9:40 AM CNA W stated she received an in-service on changes of condition and vitals. CNA W stated she would report any changes a resident had that were not normal to the nurses. CNA W stated vitals are taken when a resident has a change in their condition that was different from what they normal act. <BR/>Interview on 08/30/23 at 9:53 AM CNA X stated she had been in-serviced on changes of condition with a resident, reporting, and stop and watch. CNA X stated if the resident was having a change of condition that was not their normal self, then the CNAs were expected to go to the nurse's station where the Stop and Watch yellow sheet was at and fill one out. CNA X stated once filled it would be turned into the nurses reporting the change in the resident. <BR/>Interview on 08/30/23 at 10:01 AM CNA Y stated she had received the in-services on changes of condition, reporting, and stop and watch. CNA Y stated anytime a resident shows a change in their condition the CNAs need to report it. CNA Y stated you go to the nurse's station and in the book called Stop and Watch fill out a yellow form. CNA Y stated once filled it was turned into the nurses so they may go assess the resident. <BR/>Interview on 08/30/23 at 10:10 AM CNA D stated that the Stop and Watch binder was at the nurse's station. CNA D stated it was for when a resident had a change in condition. CNA D stated if they saw a resident different from their norm then they were to report by going to the stop and watch binder and pulling out a yellow sheet and filling it out. CNA D stated it would be turned into the nurses for follow up. <BR/>Interview on 09/01/23 at 2:20 PM LVN AA stated she was in-serviced on alert charting, changes of condition, SBAR, and calling the physician. LVN AA stated anytime a resident has a change in condition it needed to be reported to the physician or if the CNAs see the change with a resident, they need to notify nursing. LVN AA stated the SBAR was where nurses document vitals, times, and anything vital with changes of condition with a resident. LVN AA stated it was a summary of what was going on with the resident. LVN AA stated everything needed to be charted regarding the residents change of condition and assessments. <BR/>Second interview on 09/01/23 at 3:40 PM with LVN S stated she was in-serviced on 08/31/23 and on 09/01/23 with changes of condition, SBAR, and vital[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain medical records on each resident that were accurately documented for one (Resident #1) of 5 residents reviewed for accuracy of resident's medical records. <BR/>On three occasions Resident #1 was administered 300 MG of Gabapentin at bedtime but this was not documented in his medical record. <BR/>On two occasions Resident #1 received treatment for gangrene and pressure ulcer on his left foot but this was not documented on his medical record. <BR/>Resident #1 received treatments for a pressure ulcer on his right heel for which there were no orders or documentation. <BR/>This failure could put residents at risk of not receiving ordered medication or treatments, receiving undocumented medications or treatments, and/or receiving excessive doses of medications or unnecessary treatments. <BR/>Findings include:<BR/>Closed record review of Resident #1's face sheet, dated 03/11/2023, documented that he was a [AGE] year-old male admitted to the facility on [DATE]. <BR/>Record review of Resident #1's hospital discharge instructions dated 02/16/2023 documented in part that he was to receive 300 MG of gabapentin (a pain medication) at bedtime for Type 2 Diabetes with diabetic neuropathy. He had a diagnosis of Left Foot Status Post Hallux amputation with necrotic area tissue (surgery removing the big toe on the left foot but with death of some of the tissue). He also had a stage 2 pressure ulcer (bed sore that has broken though the top layer of skin and some of the layer below) on his right heel. <BR/>Record review of Resident #1's hospital record dated 02/24/2023 documented he was receiving treatments for the infected amputated toe wound, a deep tissue injury (pressure ulcer) to the left heel, and a right heel deep tissue injury. He was receiving 300 MG of Gabapentin daily at bedtime for Type 2 Diabetes with diabetic neuropathy. <BR/>Record review of Resident #1's History and Physical dated 03/02/2023 completed by the Facility Physician stated that he had an amputation of his left great toe, an unstageable wound to the left heel and a deep tissue injury to the right heel. The facility was to continue Gabapentin capsules 300 MG orally once a day. <BR/>Record review of Resident #1's physician's Order Recap Report for the months of February and March 2023 documented an order dated 03/02/2023 to be started 03/04/2023 to cleanse the left foot with normal saline (salt water), pat dry, put on xeroform (gauze dressing with petrolatum and an antimicrobial) and wrap the foot in an ace bandage every Tuesday, Thursday and Saturday. There were no orders for treatment of the right heel. An order was documented dated 03/01/2023 to administer 300 MG of Gabapentin at bedtime daily. <BR/>Record review of Resident #1's MAR and TAR for March of 2023 revealed that administration of Gabapentin 300 MG was not documented on 03/02/2023, 03/07/2023 or 03/08/2023. Treatment of the resident's left foot was not documented on 03/04/2023 or 03/09/2023. No treatments for the resident's right foot appeared pm the MAR/TAR. <BR/>In an interview on 03/15/2023 at 4:22 PM the DON said that she did not know why Resident #1's Gabapentin 300 MG was not documented as administered on 03/02/2023, 03/07/2023 or 03/08/2023 and did not know why wound treatments to Resident #1's left heel were not documented. She said that administration of medications and treatments should be documented on the MAR or TAR. She said that she (the DON) and the ADONs were responsible for monitoring that medications and treatments were provided as ordered and were documented in the resident's medical record. <BR/>In observation, interview and record review 03/16/23 at 4:03 the DON provided a packing slip the facility pharmaceutical provider that documented that thirty 300 MG Gabapentin capsules had been delivered to the facility for Resident #1 on 03/01/2023. She provided a blister pack for 300 MG Gabapentin capsules for Resident #1 dated 03/01/2023 from which nine capsules had been dispensed. She stated that the dispensing nurse must have neglected to document that the medication had been administered to the resident. The DON stated that there was no order for care for Resident #1's pressure ulcer to his right heel, but there were progress notes from the Wound Care Nurse that she was providing treatment to his right heel. She said that there should have been orders for wound care to the right heel if treatments were to be provided. <BR/>In an interview on 03/16/2023 at 4:20 PM the Wound Care Nurse stated she had been in communication with Resident #1's podiatrist on 03/01/2023 to review orders for treatment and had entered the physician's orders for treatment of both feet in the computer software at that point. She said she assessed and provided treatment to Resident #1's left and right feet on 03/01/2023 and documented this in the MAR/TAR. She stated that she provided treatment for Resident #1's left and right feet on 03/04/2023 and 03/09/2023 and entered documentation of treatments to the MAR/TAR. She did not know why documentation of treatments to the left foot on 03/01, 03/04 and 03/09/2023 were not appearing on the MAR/TAR, or why the order and documentation of treatments for the right heel were not appearing on the Order Recap or the MAR. The Wound Care Nurse said she would look for additional documentation of the orders or provision of care. No further documentation was provided prior to exit. <BR/>In an interview on 03/16/23 at 4:03 PM wound care reports for March for Resident #1 were requested from the DON, but these were not provided prior to exit. <BR/>Record review of the facility policy titled Following Physician Orders dated 09/28/2021 documented in part that the nurse would document orders by entering the order with the time, date and signature on the physician order sheet, and transcribe the order to the medication or treatment administration record. <BR/>Record review of the facility policy Medication - Treatment Administration and Documentation Guidelines dated 02/02/2014 documented in part that accuracy of physician orders would be verified on the MAR or TAR prior to administering medications or treatments. Provision of medications or treatments would be documented with initials and/or signature on the MAR or TAR immediately following administration. MAR or TAR would be reviewed after medication or treatment administration to validate documentation was completed and supported services provided according to physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 2 (Resident #7 and Resident #8) of 6 residents reviewed for call light:<BR/>-Residents #7 and #8's call systems were not adequate to meet the needs of residents as both residents required padded call light buttons and both had push button call lights.<BR/>-Resident #7's and #8's call system were not placed within reach of the residents. <BR/>This failure could place residents who used call lights for assistance at risk in maintaining and/or achieving independent functioning, dignity, and well-being. <BR/>Findings included:<BR/>Record review of Resident #7's face sheet dated 06/09/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Resident #7's diagnoses included post traumatic seizures (seizures that occur at least 1 week after traumatic brain injury), Schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of thinking and social symptoms that interferes with daily functioning), hypertension (high blood pressure), hemiplegia, and hemiparesis following cerebral infarction (paralysis of partial or total body function on one side of the body), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (mood disorder that interferes with daily life), cirrhosis of liver (chronic liver damage from a variety of causes leading to scarring and liver failure), traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head).<BR/>Record review of Resident #7's Quarterly MDS dated [DATE], revealed a BIMS score of 07, which indicated severe cognitive impairment. Section G. revealed that Resident #7 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. Resident #7 was total dependence with toilet use and bathing. <BR/>Record review of Resident #7's care plan dated 06/09/2023, revealed Resident #7 had focus area that included ADLs: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Part of the interventions included: Resident to have padded call light. <BR/>Observation and interview on 6/9/2023 at 9:30 a.m., in Resident #7's room revealed the call light button was not visible. Further observation revealed Resident #7's unpadded call light button was on the floor under the resident's bed. Resident #7 did not respond to questions about his call button and whether he was able to reach the button. <BR/>During an interview on 6/9/2023 at 9:40 a.m., LVN E said that Resident #7's call button was out of his reach being under the bed. LVN E said that Resident #7 could not use a push button call button and should have had a padded call button. LVN E said she did not know why Resident #7 had a push button call light and would have it changed out immediately. LVN E said the risk to Resident #7 of not having his call button in reach and the proper type of call button was that his needs may not be met.<BR/>Record review of Resident #8's face sheet dated 06/09/2023, revealed an [AGE] year-old male, admitted to the facility on [DATE]. Resident #8's diagnoses included hemiplegia and hemiparesis following cerebral infarction (paralysis of partial or total body function on one side of the body), type 2 diabetes (body does not use insulin properly), acute respiratory failure (often caused by a disease or injury that affects your breathing, such as pneumonia, opioid overdose, stroke, or a lung or spinal cord injury), dementia (a group of thinking and social symptoms that interferes with daily functioning), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), and history of falling. <BR/>Record review of Resident #8's Quarterly MDS dated [DATE], revealed a BIMS score of 03, which indicated severe cognitive impairment. Section G. revealed Resident #8 was total dependence for bed mobility, transfer, locomotion, dressing, eating, toilet use, and personal hygiene.<BR/>Record review of Resident #8's care plan dated 06/09/2023, revealed Resident #8 had focus area that reflected resident has impaired visual function related to aging process and is at risk for falls, injury, and a decline in functional ability. Part of the interventions included: Keep call light in reach when in room or bathroom. Another focus area reads resident has communication problem related to dementia. Part of the interventions included: Ensure/provide a safe environment: call light in reach. Another focus area reads resident has an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner. Part of the interventions included: resident uses padded call light; and encourage resident to use call light to call for assistance before attempting any activities of daily living (ADLs) that resident cannot do independently. Another focus area reads 'resident has the potential for falls related to poor safety awareness. Part of the interventions included: Place the resident's call light within reach and encourage the resident to use it for assistance as needed. <BR/>Observation and interview on 6/9/2023 at 9:35 a.m., in Resident #8's room revealed the unpadded call light button was on the floor. Resident #8 did not respond to questions about his call button and whether he was able to reach the button. <BR/>During an interview on 6/9/2023 at 9:45 a.m., LVN E said that Resident #8's call button was out of his reach being on the floor. LVN E said that Resident #8 could not use a push call button and should have had a padded call button. LVN E said she did not know why Resident #8 had a push button call light and will have it changed out immediately. LVN E said the risk to Resident #8 of not having his call button in reach and the proper call button was that his needs may not be met.<BR/>During an interview on 6/9/2023 at 1:30 p.m., the DON said LVN E made her aware that the wrong call buttons were not on for the residents and call buttons were out of reach. The DON said Residents #7 and #8 are unable to push the call light button and should have had a padded call light button. The DON said she does not know why this was overlooked. The DON said the risk was not being able to meet the residents' needs.<BR/>Record of facility Call Light Response policy, dated 02/10/2021, reflected the purpose of the policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Process included the following: Special accommodations will be identified on the resident's person-centered plan of care, and provided accordingly (examples include touch pads, larger buttons, bright colors, etc.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure a resident who needs respiratory care is provided such care consistent with professional standards of practice for 2 of 10 residents (Residents #2, #3) who were reviewed for respiratory care in that:<BR/>1. The facility failed to ensure Resident #2's oxygen concentrator filter was clean.<BR/>2. The facility failed to ensure Resident #3's oxygen concentrator filter was clean.<BR/>These deficiencies could affect the residents who received continuous oxygen and oxygen as needed and can result in a respiratory infection.<BR/>Findings include: <BR/>Resident #2<BR/>Record Review of Resident #2's face sheet dated 3/27/25 revealed a [AGE] year-old male that was admitted [DATE]. Resident #2 diagnoses included: Lymphedema (a condition of localized swelling caused by compromised lymphatic system), muscle weakness, obstructive sleep apnea, and peripheral vascular disease (a condition that narrows the vessels away from the heart and brain causing pain and discomfort in the limbs).<BR/>Record Review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. The MDS revealed the resident required extensive assistance in bed mobility from 2 persons to physically assist.<BR/>Record Review of Resident #2's Care Plan last revised 10/22/24 revealed that Resident #2 is at risk for ineffective gas exchange and used oxygen therapy routinely or as needed. The interventions included administering oxygen therapy per physician's orders.<BR/>Observation on 3/26/25 at 10:13 AM at revealed Resident #2 sitting in bed with oxygen on through a nasal cannula (a medical device used to deliver supplemental oxygen to individuals with respiratory issues; it consists of a thin, flexible tube that wraps around the head, with two prongs that fit into the nostrils to provide oxygen directly) and an oxygen concentrator with dust particles on the filter. <BR/>Resident #3<BR/>Record review of Resident #3's face sheet dated 3/29/25 revealed a [AGE] year-old male with an initial admission date of 10/25/18, and re-admission date of 2/28/25. The face sheet revealed Resident #3's diagnoses included: cerebral infarction due to embolism (stroke due to a blockage in the blood vessel), metabolic syndrome (a cluster of conditions that increased the risk of heart disease, stroke, and type 2 diabetes), dysthymic disorder (persistent depressive disorder), cognitive communication disorder, hypertension (high blood pressure), and muscle weakness.<BR/>Record review of Resident #3's MDS dated [DATE] revealed a BIMS score of 15 , indicating no cognitive impairment. The MDS revealed Resident #3 required a 2-person limited to extensive assistance with ADLs such as bed mobility.<BR/>Record review of Resident #3's head and physical physician note dated 02/26/25 revealed Resident #3 is diagnosed with Acute Hypoxic respiratory failure and required oxygen supplementation, 4 liters, to achieve oxygen level of 92% or more. <BR/>Observation on 3/26/25 at 10:20 AM revealed Resident #3 sitting at his bed with oxygen on through a nasal cannula and an oxygen concentrator with dust on the filter.<BR/>In an interview on 3/26/25 at 3:29 PM with LVN , she stated that the resident's oxygen filters are cleaned every Sunday night. She stated that nursing staff, nurses, were responsible for monitoring, and maintaining oxygen filters. LVN stated the ADON and DON are also responsible for monitoring the cleanliness of the oxygen concentrator filters when they round. She stated the risks for oxygen concentrator filters not being clean included infection control issues since bacteria and dust collect.<BR/>In an interview on 03/26/25 at 4:05 PM with the ADON, she said that oxygen concentrator filters were to be cleaned once a week. She stated that CNAs can clean them. She stated that if the filter was damaged or needed a replacement, Central Supply are to supply a new filter. The ADON stated the risks for oxygen air filters being dirty included infection risk and possible malfunction of the oxygen concentrator. <BR/>During an interview on 3/26/25 at 4:19 PM with the DON, revealed she said that it is everybody's responsibility to monitor and clean the oxygen concentrator air filters. She stated Central Supply can also change them. She stated if staff are not able to clean or replace the filter, they should notify the nurse so it can be completed. The DON stated if the oxygen concentrator air filters were not cleaned, it can introduce foreign objects or bacteria to the resident's body. <BR/>Record Review of the oxygen concentrator manufacturer manual , read in part: recommended cleaning interval for the air filter is every 7 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the minimum healthcare information necessary to properly care for a resident for 1 (Residents #1) of 4 residents reviewed for baseline care plans.<BR/>The facility's failed to ensure that Resident #1's baseline care plan included plans to treat his diagnosis of diabetes or to treat an infection and pressure ulcer on his left foot or a pressure ulcer on his right heel. <BR/>This deficient practice could place residents at risk of not receiving care essential to prevent decline in their condition. <BR/>The findings were:<BR/>Closed record review of Resident #1's face sheet, dated 03/11/2023, documented that he was a [AGE] year-old male admitted to the facility on [DATE]. <BR/>Record review of Resident #1's facility admission History and Physical dated 03/02/2023 documented in part that Resident #1 had a history of diagnoses including Type 2 Diabetes with diabetic neuropathy; Upon examination by the doctor, he was found to have a new left great toe amputation with dressing; an unstageable wound to his left heel, and a deep-tissue injury (pressure sore) to his right heel. <BR/>Record review of Resident #1's Hospitalist Discharge summary dated [DATE] documented in part that he had left foot osteomyelitis and necrosis after amputation of the left hallux of his foot (Infection where they had removed his left toe) and it was recommended that he continue with antibiotics (Daptomycin 600 MG every 48 hours via IV) and wound care for the foot. He had a diagnosis of insulin-dependent diabetes 2. He had a stage 2 ulcer on his right foot. <BR/>Record review Resident #1's baseline care plan dated 03/02/2023 documented no baseline care plan for diabetes, a diabetic diet or wound care. Under the heading Medication resident is taking neither antibiotics were checked. Under the heading Medical Condition, Is resident diabetic was checked No. Under the heading Skin, Skin Issues was marked No. The Baseline Care plan indicated that he did not have any skin issues. <BR/>In interview and record review on 03/13/2023 at 3:54 PM LVN A said that she was the admitting nurse for Resident #1. She remembered working on the assessments associated with his admission paperwork. She said that Resident #1 had come in very near the end of her shift, so she was not able to complete all the assessments, and passed the completion of the assessments, which would have included completion of the baseline care plan, on to LVN B, the nurse from the on-coming shift. <BR/>In an interview on 03/15/2023 at 8:33 AM LVN B said that she did not remember being told about the need to complete Resident #1's admission paperwork. <BR/>In an interview on 03/15/2023 at 4:22 PM the DON said that Resident #1's Baseline Care plan should have included his diagnosis of diabetes and need for wound care. She said that she (the DON) and ADONs were responsible for confirming that admission paperwork was completed. <BR/>Record review of the facility policy titled Baseline Care Plan dated 09/20/2020 documented in part that the baseline care plan would include information necessary to properly care for a resident including initial goals based on admission orders, physician orders, and dietary orders. The admitting nurse or supervising nurse would gather information from sources such as the admission physical assessment, and hospital transfer information to identify initial goals and interventions to address the resident's current needs. This would include interventions including any special needs such as for dialysis or wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain medical records on each resident that were accurately documented for one (Resident #1) of 5 residents reviewed for accuracy of resident's medical records. <BR/>On three occasions Resident #1 was administered 300 MG of Gabapentin at bedtime but this was not documented in his medical record. <BR/>On two occasions Resident #1 received treatment for gangrene and pressure ulcer on his left foot but this was not documented on his medical record. <BR/>Resident #1 received treatments for a pressure ulcer on his right heel for which there were no orders or documentation. <BR/>This failure could put residents at risk of not receiving ordered medication or treatments, receiving undocumented medications or treatments, and/or receiving excessive doses of medications or unnecessary treatments. <BR/>Findings include:<BR/>Closed record review of Resident #1's face sheet, dated 03/11/2023, documented that he was a [AGE] year-old male admitted to the facility on [DATE]. <BR/>Record review of Resident #1's hospital discharge instructions dated 02/16/2023 documented in part that he was to receive 300 MG of gabapentin (a pain medication) at bedtime for Type 2 Diabetes with diabetic neuropathy. He had a diagnosis of Left Foot Status Post Hallux amputation with necrotic area tissue (surgery removing the big toe on the left foot but with death of some of the tissue). He also had a stage 2 pressure ulcer (bed sore that has broken though the top layer of skin and some of the layer below) on his right heel. <BR/>Record review of Resident #1's hospital record dated 02/24/2023 documented he was receiving treatments for the infected amputated toe wound, a deep tissue injury (pressure ulcer) to the left heel, and a right heel deep tissue injury. He was receiving 300 MG of Gabapentin daily at bedtime for Type 2 Diabetes with diabetic neuropathy. <BR/>Record review of Resident #1's History and Physical dated 03/02/2023 completed by the Facility Physician stated that he had an amputation of his left great toe, an unstageable wound to the left heel and a deep tissue injury to the right heel. The facility was to continue Gabapentin capsules 300 MG orally once a day. <BR/>Record review of Resident #1's physician's Order Recap Report for the months of February and March 2023 documented an order dated 03/02/2023 to be started 03/04/2023 to cleanse the left foot with normal saline (salt water), pat dry, put on xeroform (gauze dressing with petrolatum and an antimicrobial) and wrap the foot in an ace bandage every Tuesday, Thursday and Saturday. There were no orders for treatment of the right heel. An order was documented dated 03/01/2023 to administer 300 MG of Gabapentin at bedtime daily. <BR/>Record review of Resident #1's MAR and TAR for March of 2023 revealed that administration of Gabapentin 300 MG was not documented on 03/02/2023, 03/07/2023 or 03/08/2023. Treatment of the resident's left foot was not documented on 03/04/2023 or 03/09/2023. No treatments for the resident's right foot appeared pm the MAR/TAR. <BR/>In an interview on 03/15/2023 at 4:22 PM the DON said that she did not know why Resident #1's Gabapentin 300 MG was not documented as administered on 03/02/2023, 03/07/2023 or 03/08/2023 and did not know why wound treatments to Resident #1's left heel were not documented. She said that administration of medications and treatments should be documented on the MAR or TAR. She said that she (the DON) and the ADONs were responsible for monitoring that medications and treatments were provided as ordered and were documented in the resident's medical record. <BR/>In observation, interview and record review 03/16/23 at 4:03 the DON provided a packing slip the facility pharmaceutical provider that documented that thirty 300 MG Gabapentin capsules had been delivered to the facility for Resident #1 on 03/01/2023. She provided a blister pack for 300 MG Gabapentin capsules for Resident #1 dated 03/01/2023 from which nine capsules had been dispensed. She stated that the dispensing nurse must have neglected to document that the medication had been administered to the resident. The DON stated that there was no order for care for Resident #1's pressure ulcer to his right heel, but there were progress notes from the Wound Care Nurse that she was providing treatment to his right heel. She said that there should have been orders for wound care to the right heel if treatments were to be provided. <BR/>In an interview on 03/16/2023 at 4:20 PM the Wound Care Nurse stated she had been in communication with Resident #1's podiatrist on 03/01/2023 to review orders for treatment and had entered the physician's orders for treatment of both feet in the computer software at that point. She said she assessed and provided treatment to Resident #1's left and right feet on 03/01/2023 and documented this in the MAR/TAR. She stated that she provided treatment for Resident #1's left and right feet on 03/04/2023 and 03/09/2023 and entered documentation of treatments to the MAR/TAR. She did not know why documentation of treatments to the left foot on 03/01, 03/04 and 03/09/2023 were not appearing on the MAR/TAR, or why the order and documentation of treatments for the right heel were not appearing on the Order Recap or the MAR. The Wound Care Nurse said she would look for additional documentation of the orders or provision of care. No further documentation was provided prior to exit. <BR/>In an interview on 03/16/23 at 4:03 PM wound care reports for March for Resident #1 were requested from the DON, but these were not provided prior to exit. <BR/>Record review of the facility policy titled Following Physician Orders dated 09/28/2021 documented in part that the nurse would document orders by entering the order with the time, date and signature on the physician order sheet, and transcribe the order to the medication or treatment administration record. <BR/>Record review of the facility policy Medication - Treatment Administration and Documentation Guidelines dated 02/02/2014 documented in part that accuracy of physician orders would be verified on the MAR or TAR prior to administering medications or treatments. Provision of medications or treatments would be documented with initials and/or signature on the MAR or TAR immediately following administration. MAR or TAR would be reviewed after medication or treatment administration to validate documentation was completed and supported services provided according to physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident and the resident's representative was notified of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for one of two residents (Resident #1) reviewed for transfer and discharge.<BR/>The facility failed to ensure a transfer or discharge notice was sent in writing to the resident, resident's representative and the facility's Ombudsman as soon as practicable.<BR/>This failure could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 01/30/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, kidney disease, Cirrhosis of the liver, anxiety disorder, major depressive disorder, impulse disorder and high blood pressure. <BR/>Record review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], revealed a BIMS score of 12, which indicated moderate cognitive impairment.<BR/>Record review of Resident 1's Physician Discharge summary, dated [DATE], reads in part. Resident sent out to ER for GBU evaluation. <BR/>In a telephone interview on 01/31/2023 at 8:55 a.m., FM stated he was the resident representative for Resident #1 and did not receive any written information on Resident #1 being discharged from the facility. The FM said he was called by a facility staff member who said Resident #1 was being transferred to the GBU for evaluation and the resident would be discharged from the facility due to aggression towards another resident. The FM said he contacted the Ombudsman about the discharge but did not have any other written information related to available advocacy services, discharge/transfer options, or any appeal processes.<BR/>In an interview on 01/31/2023 at 9:02 a.m., the Ombudsman stated her office had not received any information on transfer or discharge of Resident #1 from the facility. She stated she had no documentation or records of Resident #1 being discharged from the facility . The Ombudsman said she knew the resident was discharged as Resident #1's family contacted her.<BR/>In an interview on 1/31/2023 at 2:05 p.m., the Administrator said a written notice was not sent to Resident 1's representative regarding the discharge from the facility. The Administrator said the facility nursing staff did notify the resident representative verbally by phone. The Administrator said she did not know if the Ombudsman was notified or provided a written notice. The Administrator said Resident #1 was discharged due to endangering the health and safety of other residents. The Administrator said written notifications were handled by the facility Social Worker (SW). The Administrator said the facility currently did not have a SW for about a month now. The Administrator said she had enacted a contingency plan to cover the social services duties due to the vacant SW position. The Administrator said she did not know the facility had to send any written notice to the resident, resident's representative, and the Ombudsman for the immediate facility-initiated discharge. The Administrator said the risk of not notifying the resident, resident's representative, and Ombudsman in writing was they could say they were never notified of the discharge, which could interfere with discharge information being communicated which included the right to appeal . <BR/>Record review of the facility policy titled Transfer and Discharge, dated 02/20/2020, reads in part Emergency Transfers/Discharges: Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman; Provide transfer notice as soon as practicable to resident and representative, and Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced dignity and respect for 1 (Resident #43) of 6 residents reviewed for care that maintained or enhanced their dignity. <BR/>The facility failed to maintain Resident #43 sense of dignity by not proving the resident with a bath according to his bath schedule and changing his clothing to promote proper hygiene.<BR/>This failure could place residents who require assistance with bathing and changing their clothing at risk of decreased self-esteem affecting their dignity. <BR/>Findings included: <BR/>Record Review of Resident #43 face sheet dated 04/25/23 is a [AGE] year-old male admitted on [DATE]. <BR/>Record Review of Resident #43 care plan dated 10/29/2019 revealed Resident #43 has an ADL self-care deficit related to a history of stroke, expressive aphasia, hemiplegia, and Parkinson's and required limited assistance x1 for bathing and changing. <BR/>Record Review of Resident #43 MDS dated [DATE] revealed Resident #43 had a BIMS of 08 meaning he was moderately cognitively impaired. Section G's functional Status revealed one person's assistance for personal hygiene and is totally dependent for bathing; requires a wheelchair; limited range of motion to both lower extremities, and limited range of motion to the right upper arm. <BR/>Record Review of Resident #43 History and Physical revealed a diagnosis of Aphasia (a condition that affects the ability to communicate), right-side hemiplegia (loss of strength to the right arm), and hemiparesis (loss of strength to both legs). <BR/>Record Review of Resident #43 electronic record bathing task point of care response history for 30 days dated 04/25/23 revealed Resident #43 only had 6 baths from 3/29/23 to 4/25/23 with 2 documented refusals. <BR/>Observation on 04/25/23 at 11:47 AM Resident #43 was sitting in his wheelchair in the room noted resident's hair was uncombed and greasy. Resident #43 was wearing a white shirt where the collar of the shirt was noted to be yellow, and stiff with sweat. <BR/>Interview and observation with LVN H in the resident's room on 04/25/23 beginning at 11:54 AM regarding Resident #43 confirmed he had uncombed greasy hair, and the collar of his shirt was stiff and had a yellow stain all around the collar. Noted the resident's bed had stains on the sheets and pillowcase. LVN H stated the resident was scheduled to receive baths 3 times a week in the evenings on Tuesdays, Thursdays, and Saturdays. LVN H was unaware when Resident #43 last received a bath. <BR/>Interview and record review with DON on 04/27/23 beginning at 09:55 AM revealed, Resident #43 point of care response history and confirmed there were only 6 documented baths and 2 refusals for a 30-day period from 3/29/23 to 4/25/23. CNAs are trained upon hire on documentation to reflect the care provided. DON stated if the baths are not given then this can be a dignity issue for residents.<BR/>Record review of facility policy Activities of Daily Living Care Guidelines dated 01/23/2016 revealed residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene.<BR/>Record review of facility policy Provision of Quality Life dated 01/10/2023 revealed the facility will create and sustain an environment that humanizes and promotes each resident's well-being and feeling of self-worth and self-esteem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming, personal and oral hygiene, for 1 Resident (#1) of 6 residents reviewed for activities of daily living. <BR/>The facility failed to provide fingernail care for Resident #1 by not maintaining trim and clean fingernails.<BR/>This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem.<BR/>The findings include: <BR/>Record review of Resident #1's face sheet, dated 3/27/25, indicated the resident was admitted on [DATE] with diagnoses: hemiplegia (paralysis of one side of the body, either right or left) and hemiparesis (weakness of one side of the body, either right or left) following cerebral infarction (stroke) affecting left non-dominant side, dysarthria (difficulty in speech because of weakness of the speech muscles), unspecified dementia, and Alzheimer's disease (a brain disorder that affects memory, thinking, and behavior).<BR/>Record review of Resident #1's admission MDS dated [DATE] indicated a BIMS score of 2, indicating severe cognitive impairment. Per the MDS, Resident #1 required moderate assistance with personal hygiene meaning the helper did more than half the effort. <BR/>Record review of Resident #1's Care Plan dated 03/15/25, revealed ADL Self-care performance deficit and interventions included nursing staff to Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care.<BR/>Observation on 3/26/25 at 11:24 AM of Resident #1 revealed she had nails approximately 1 inch off the nail bed for all fingers on both her hands. Her fingernails on both hand hands were observed with dirt under them and chipped nail polish. Resident #1 was not able to voice whether she liked her nails this length or not.<BR/>During an interview on 3/26/25 at 1:32 PM with CNA A, she said that residents are offered nail trimming services during the resident's scheduled shower. She stated if the resident is diabetic, nurses were to trim fingernails. CNA A stated that fingernails of residents should be maintained short and clean. She stated long fingernails can cause an infection control risk.<BR/>During an interview on 3/26/25 at 3:27 PM with LVN B, she said that nursing staff such as nursing assistants were to offer residents nail trimming during the resident's shower. She stated if the resident was diabetic only nurses were to file down fingernails. LVN B stated if a resident did not want nails groomed, the ADON, DON and family member were notified. She stated the risks for residents having long nails included residents could scratch themselves causing injury, or also an infection control issue as there are possible bacteria entrapped under the nail.<BR/>In an interview on 03/26/25 at 4:00 PM with the ADON, she said that residents received grooming services with their fingernails on Sundays. She stated that if resident's nails are observed long, the service could be offered at any time. She stated the nurses were responsible for monitoring (checking during daily rounds) residents through their rounding during their shift and could offer to trim or cut the resident's nails. She stated the risks for residents having long and dirty nails included infection risk, as the resident could touch their face or scratch their skin. <BR/>In an interview on 3/26/25 at 4:15 PM with the DON, she said that residents were offered nail grooming services from CNAs on the residents' scheduled shower days. She stated the nurses were to offer nail grooming service if the resident is diabetic. She stated the CNAs are responsible for monitoring, filing and cleaning the resident's nails, and the nurses could file and trim nails including diabetic residents. The DON stated If any resident declined care, they are to notify the charge nurse so that nurse could go in to assess and find the reason on why the resident does not want care at the time. She stated the resident had the right to have clean nails. The DON stated the risks of residents having ungroomed nails included an infection control concern to the resident. <BR/>Record review of facility's policy and procedures titled Activities of Daily Living, revised 2007, read in part: The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure residents received parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #67) of 2 residents reviewed for Midline/PICC (Peripherally Inserted Central Catheter) care.<BR/>The facility failed to ensure Resident # 67's midline (intravenous catheter) tubing was changed every 72 hours or sooner if contamination was suspected or integrity of system was compromised from 04/19/2023 to 04/27/2023. Resident 67's midline site was not changed as ordered by the physician, and care to the site was not completed every 24 hours. <BR/>This failure placed residents at risk of developing an infection.<BR/>Findings included:<BR/>Record review of Resident #67's Face Sheet revealed admission [DATE] and readmission on [DATE] to the facility.<BR/>Record review of Resident #67's MDS quarterly dated 04/06/2023 revealed a brief interview mental status score of 15, diagnosis of urinary tract infection, discitis (an infection of the intervertebral disc space), and candida cystitis and urethritis (fungus balls in the renal, pelvis, ureter, bladder, and urethritis), marked for intravenous medications.<BR/>Record review of Resident #67's Care Plan dated 01/18/2023 revealed required intravenous therapy and was at risk for site infiltration, infection, pain, and other potential complications, change intravenous site dressing, tubing, extension sets, filters, stopcocks, and needleless devices according to facility policy, monitor site for swelling, redness, pain, streaking and drainage, dislodgement.<BR/>Record review of Resident #67's history and physical dated 04/06/2023 revealed a [AGE] year-old female with a diagnosis of candida cystitis and diskitis (discitis) (an inflammation of the vertebral disk space often related to infection).<BR/>Record review of Resident #67's order summary dated 04/08/2023 revealed PICC (Peripherally Inserted Central Catheter) line dressing to be changed every 7 days on Sunday and as needed every night shift.<BR/>Observation and Interview on 04/24/2023 beginning at 3:47 PM Resident #67 had a PICC line with dressing on her left inner arm dated 04/19/2023. The bottom right corner of the dressing was covered with a brown substance extending left wards on the dressing attachment. There was an outline of redness on the skin near the bottom right-hand side of the dressing. The gauze covering and holding in place the intravenous line was soaked a yellow substance and to the left of end of the gauze was a darker shade of red on the skin. Resident #67 stated that the dressing was causing itching, but she did not have pain. When resident would lift- up her arm, the line would dangle downwards as the adhesive from the dressing was not sticking to the skin. Resident #67 stated the nurses did not check on the dressing and only administered her medication through the line and leave.<BR/>Observation and Interview on 04/27/2023 at 10:22 AM revealed Resident #67's dressing still had not been changed. <BR/>Observation and Interview on 04/27/2023 beginning at 10:25 AM with LVN K stated the PICC line was supposed to be inspected daily on every shift for redness, swelling, blood, tape not sticking, itchiness. LVN K stated Resident #67 was not receiving medication via the PICC. LVN K stated licensed vocational nurse could change out the dressings to the PICC line as needed. LVN K stated the PICC dressing for resident #67 was to be changed out weekly on Sundays according to physician orders. LVN K stated the dressing on the PICC line for resident #67 was passed the 7 days and needed to be changed. LVN K stated the dressing was not sealing as the adhesive was no longer sticking to the skin and there was a brow or yellow unknow substance on the dressing.? LVN K stated the intravenous site care meant she would check for redness, inflammation, swelling, integrity of the dressing, and how the dressing looks. LVN K stated the PICC line dressing on Resident #67 needed to be changed by the way it looked as she was trained to do so. LVN K stated she would notify the doctor if the resident had informed her that she was itchy or had pain. LVN K stated the risk to the Resident #67 was an infection control issue if the site got infected and the infection traveled to her heart.<BR/>Interview on 04/27/2023 at 2:28 PM DON stated PICC Line dressing should be changed out once a week. DON stated the nurses flush the line every shift and make sure the dressing is intact and if the dressing needs to be changed as needed. DON stated the dressing should have a nice seal around the tape, the nurse looks for redness, warm to touch, and or bleeding at the site. DON stated licensed vocational nurses are trained to recognized if a dressing needs to be changed. DON stated licensed vocational nurses can change the dressing. DON stated that Resident #67's did not have an appropriate dressing on as it had a yellow substance which she did not know what it was, there was redness, and blood. DON stated that the dressing needed to be changed because the risk to the resident could be sepsis.<BR/>Record review of the facility policy Intravenous Therapy dated 08/10/2022 revealed IV tubing is changed every 72 hours or sooner if contamination is suspected or integrity of system is compromised. IV sites are changed as ordered by the physician, or if the site becomes infiltrated, or if the resident exhibits signs and symptoms of phlebitis (inflammation of a vein near the surface of the skin). IV placed longer than 72 hours will have IV site care done every 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure a resident who needs respiratory care is provided such care consistent with professional standards of practice for 2 of 10 residents (Residents #2, #3) who were reviewed for respiratory care in that:<BR/>1. The facility failed to ensure Resident #2's oxygen concentrator filter was clean.<BR/>2. The facility failed to ensure Resident #3's oxygen concentrator filter was clean.<BR/>These deficiencies could affect the residents who received continuous oxygen and oxygen as needed and can result in a respiratory infection.<BR/>Findings include: <BR/>Resident #2<BR/>Record Review of Resident #2's face sheet dated 3/27/25 revealed a [AGE] year-old male that was admitted [DATE]. Resident #2 diagnoses included: Lymphedema (a condition of localized swelling caused by compromised lymphatic system), muscle weakness, obstructive sleep apnea, and peripheral vascular disease (a condition that narrows the vessels away from the heart and brain causing pain and discomfort in the limbs).<BR/>Record Review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. The MDS revealed the resident required extensive assistance in bed mobility from 2 persons to physically assist.<BR/>Record Review of Resident #2's Care Plan last revised 10/22/24 revealed that Resident #2 is at risk for ineffective gas exchange and used oxygen therapy routinely or as needed. The interventions included administering oxygen therapy per physician's orders.<BR/>Observation on 3/26/25 at 10:13 AM at revealed Resident #2 sitting in bed with oxygen on through a nasal cannula (a medical device used to deliver supplemental oxygen to individuals with respiratory issues; it consists of a thin, flexible tube that wraps around the head, with two prongs that fit into the nostrils to provide oxygen directly) and an oxygen concentrator with dust particles on the filter. <BR/>Resident #3<BR/>Record review of Resident #3's face sheet dated 3/29/25 revealed a [AGE] year-old male with an initial admission date of 10/25/18, and re-admission date of 2/28/25. The face sheet revealed Resident #3's diagnoses included: cerebral infarction due to embolism (stroke due to a blockage in the blood vessel), metabolic syndrome (a cluster of conditions that increased the risk of heart disease, stroke, and type 2 diabetes), dysthymic disorder (persistent depressive disorder), cognitive communication disorder, hypertension (high blood pressure), and muscle weakness.<BR/>Record review of Resident #3's MDS dated [DATE] revealed a BIMS score of 15 , indicating no cognitive impairment. The MDS revealed Resident #3 required a 2-person limited to extensive assistance with ADLs such as bed mobility.<BR/>Record review of Resident #3's head and physical physician note dated 02/26/25 revealed Resident #3 is diagnosed with Acute Hypoxic respiratory failure and required oxygen supplementation, 4 liters, to achieve oxygen level of 92% or more. <BR/>Observation on 3/26/25 at 10:20 AM revealed Resident #3 sitting at his bed with oxygen on through a nasal cannula and an oxygen concentrator with dust on the filter.<BR/>In an interview on 3/26/25 at 3:29 PM with LVN , she stated that the resident's oxygen filters are cleaned every Sunday night. She stated that nursing staff, nurses, were responsible for monitoring, and maintaining oxygen filters. LVN stated the ADON and DON are also responsible for monitoring the cleanliness of the oxygen concentrator filters when they round. She stated the risks for oxygen concentrator filters not being clean included infection control issues since bacteria and dust collect.<BR/>In an interview on 03/26/25 at 4:05 PM with the ADON, she said that oxygen concentrator filters were to be cleaned once a week. She stated that CNAs can clean them. She stated that if the filter was damaged or needed a replacement, Central Supply are to supply a new filter. The ADON stated the risks for oxygen air filters being dirty included infection risk and possible malfunction of the oxygen concentrator. <BR/>During an interview on 3/26/25 at 4:19 PM with the DON, revealed she said that it is everybody's responsibility to monitor and clean the oxygen concentrator air filters. She stated Central Supply can also change them. She stated if staff are not able to clean or replace the filter, they should notify the nurse so it can be completed. The DON stated if the oxygen concentrator air filters were not cleaned, it can introduce foreign objects or bacteria to the resident's body. <BR/>Record Review of the oxygen concentrator manufacturer manual , read in part: recommended cleaning interval for the air filter is every 7 days.

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 4 of 8 rooms (A-7, A-11, A-13, and B-19) reviewed for environment. <BR/>The facility failed to ensure housekeeping and maintenance services were provided. <BR/>This failure could place residents at risk of decreased feelings of self-worth due to poor conditions of the facility interior. <BR/>Findings include: <BR/>Observation on 01/30/2023 at 11:00 a.m., in room A-11 revealed a light fixture positioned over an empty bed that appeared to be falling from one side. The was an approximate 2-inch broken floor tile noted by the empty bed. The restroom sink faucet was loose. A medium sized live roach was seen under the sink . <BR/>Observation on 01/30/2023 at 11:10 a.m., in room A-13 revealed a 4-inch by 4-inch cracked hole to a lower unpainted plastered part of a wall. There was a 2-inch broken floor tile noted on the open floor. There was an approximate 6-inch x 5-inch yellowish dry stain on the floor .<BR/>Observation on 01/30/2023 at 1:45 p.m., in room A-7, revealed a cracked windowsill. In the restroom, there was no lightbulb cover for the light above the restroom sink . <BR/>Observation on 01/30/2023 at 2:05 p.m., in room B-19, revealed a cracked windowsill. In the restroom, there was a plaster cover that was falling behind the commode which revealed a hole .<BR/>In an interview on 01/30/2023 at 3:00 p.m., the Maintenance Director said he had been working at the facility for about a month. He said the building was old and there were many maintenance issues when he took over with priorities being plumbing issues that required immediate attention. He said he was the only maintenance staff at the facility. He said he knew there were issues with holes in walls since he started working at the facility and was working to repair the holes. He said there were patches on the walls that had not been painted. He said he received information about needed repairs through work orders submitted by staff that were kept in a maintenance book at the nursing station. He said he did not know if there was a policy regarding work orders . <BR/>In an interview on 01/31/2023 at 2:05 p.m., the Administrator said the facility did not have a policy regarding maintenance or regarding assuring a safe clean and homelike environment. The Administrator said the expectation was that work orders were submitted, and the Maintenance Director would address the work orders based on priorities. The Administrator said there was only one maintenance staff member who was handling all work issues. The Administrator said the risk of being behind on repairs and housekeeping services was resident dissatisfaction and perception that the facility was dirty. <BR/>Record review of the Facility Maintenance Log, dated 01/01/2023 to 01/30/2023, documented no entries concerning the identified conditions . <BR/>Record review of the facility policy on Resident Rights, dated 02/20/2021, read in part, the resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 6 resident rooms, observed for housekeeping and maintenance, in that: <BR/>The facility failed to ensure CNA E used the facility work order system to input the lights in the restroom and room of Resident #5 would not turn on while Resident #5 wanted to use the restroom but was dark and could not see. <BR/>These failures could lead to resident injury and a diminished quality of life.<BR/>Findings include: <BR/>Record review of Resident #5's face sheet dated 01/15/25, revealed, admission on [DATE], re-admission on [DATE], and re-admission again on 02/22/22 to the facility. <BR/>Record review of Resident #5's facility history and physical dated 07/28/24, revealed, a [AGE] year-old female diagnosed with Anxiety, Cholecystitis (inflammation of the gallbladder), reduced mobility, history of falls, and GI bleeding (bleeding from any part of the digestive tract, from the mouth to the anus). <BR/>Record review of Resident #5's annual MDS dated [DATE], revealed, little to no impairment of cognition BIMS score of 15 and to be able to recall or make daily decisions. ADLs revealed to be independent for toileting, shower/bath, dressing. Independent for walking 10 feet/50 feet. <BR/>Record review of Resident #5's Care Plan dated 04/27/22, revealed the resident was incontinent of bowel/bladder related to history of UTI, confusion, and incontinence. Maintain unobstructed path to the bathroom. Resident #5 had impaired visual function and was at risk for falls, injury, and a decline in functional ability. Anticipate needs and meet them as able. Keep call light in reach when in room or bathroom. Involve in activities which do not require vision to participate such as music, parties, and exercise. Monitor and report eye problems, change in ability to perform ADLs, decline in mobility, sudden visual loss, tunnel vision, blurred vison, hazy vision. Resident #5 was able to see large print in a well illuminated room. ADLs was supervision with set-up for toileting due to impairment with balance coordination. <BR/>Observation and interview on 01/15/25 at 8:44 AM, with Resident #5, she stated she was looking for staff due to her lights in her restroom and room not turning on. Resident #5 showed state agency her room and tried to turn on the light switch in the room. It was observed that the light in the room was not turning on. Resident #5 stated she had to go to the restroom, but could not cause the light in the restroom would not turn on and was afraid to go to the restroom without the lights turning on. State agency tried turning on the lights in the restroom and would not turn on. It was observed that the room was dark, and, in the restroom, it was dark and darker if the restroom door was closed. It was observed that nothing could be seen if the restroom door was closed. Resident #5 had stated she told a nursing staff about the issues a little over an hour ago and did not know what had happened. <BR/>In an interview on 01/15/25 at 8:48 AM, with CNA E, she stated Resident #5 had told her about the lights not turning on in her room and restroom. CNA E stated she was looking for the floor charge nurse of the hall at the nurse's station and could not find her. CNA E stated since she was not able to find her, she went back to assist another resident with feeding as she was busy. CNA E stated she did not use the facility work order system to input the work order. CNA E stated she had been trained to use the facility work order system when facility needed to report facility stuff that needed fixing and tell the nurse. CNA E stated the risk of the lights not working for Resident #5 could have been a fall. <BR/>Observation on 01/15/25 at 8:50 AM, revealed, visible facility work order system QR Scan postings in around the nurse's station of the facility. <BR/>In an interview on 01/15/25 at 9:19 AM, with the Maintenance Director, he stated facility staff have been trained to use the facility work order system and what to do if they see, hear, or get reported facility stuff that were broken. The Maintenance Director stated there were QR Scan codes posted everywhere in the facility in which facility staff could place the work orders through there phones. The Maintenance Director stated not using the facility work order system could have a negative outcome of broken item(s) not getting fixed affecting the resident negatively depending on the situation. The Maintenance Director stated he was told of Resident #5's lights not turning on around 10 minutes ago which he observed that the lights were not turning on. The Maintenance Director stated Resident #5 told him she wanted them to turn on. The Maintenance Director stated an issue like the lights not turning on for Resident #5 was considered to be a 911 call (defined as notify the Maintenance Director immediately with clogged toilet, lights out, Exit lights out, etc.) and should have inputted into the facility work order system and told immediately. <BR/>In an interview on 01/15/25 at 10:49 AM, with ADON C and ADON D, ADON C stated all facility staff were trained on how to place a work order. ADON D stated there were QR Scan code postings throughout the facility in which facility staff could use the facility work order system to place work orders which was sent to the maintenance department. ADON C stated if nursing staff were reporting a work order issue and cannot find the nurse, then they need to directly let the Maintenance Director know aside from using the facility work order system. ADON D stated the risk would depend on the situation. <BR/>In an interview on 01/15/25 at 11:13 AM, with the Administrator, she stated facility staff were trained on the facility work order system on how to place work orders in. The Administrator stated the maintenance department should be reviewing the work orders daily. The Administrator stated the risk of not using the facility work order system could result in the broken item not being forgotten and would not be fixed. The Administrator stated the risk to the resident would depend on the situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 6 resident rooms, observed for housekeeping and maintenance, in that: <BR/>The facility failed to ensure CNA E used the facility work order system to input the lights in the restroom and room of Resident #5 would not turn on while Resident #5 wanted to use the restroom but was dark and could not see. <BR/>These failures could lead to resident injury and a diminished quality of life.<BR/>Findings include: <BR/>Record review of Resident #5's face sheet dated 01/15/25, revealed, admission on [DATE], re-admission on [DATE], and re-admission again on 02/22/22 to the facility. <BR/>Record review of Resident #5's facility history and physical dated 07/28/24, revealed, a [AGE] year-old female diagnosed with Anxiety, Cholecystitis (inflammation of the gallbladder), reduced mobility, history of falls, and GI bleeding (bleeding from any part of the digestive tract, from the mouth to the anus). <BR/>Record review of Resident #5's annual MDS dated [DATE], revealed, little to no impairment of cognition BIMS score of 15 and to be able to recall or make daily decisions. ADLs revealed to be independent for toileting, shower/bath, dressing. Independent for walking 10 feet/50 feet. <BR/>Record review of Resident #5's Care Plan dated 04/27/22, revealed the resident was incontinent of bowel/bladder related to history of UTI, confusion, and incontinence. Maintain unobstructed path to the bathroom. Resident #5 had impaired visual function and was at risk for falls, injury, and a decline in functional ability. Anticipate needs and meet them as able. Keep call light in reach when in room or bathroom. Involve in activities which do not require vision to participate such as music, parties, and exercise. Monitor and report eye problems, change in ability to perform ADLs, decline in mobility, sudden visual loss, tunnel vision, blurred vison, hazy vision. Resident #5 was able to see large print in a well illuminated room. ADLs was supervision with set-up for toileting due to impairment with balance coordination. <BR/>Observation and interview on 01/15/25 at 8:44 AM, with Resident #5, she stated she was looking for staff due to her lights in her restroom and room not turning on. Resident #5 showed state agency her room and tried to turn on the light switch in the room. It was observed that the light in the room was not turning on. Resident #5 stated she had to go to the restroom, but could not cause the light in the restroom would not turn on and was afraid to go to the restroom without the lights turning on. State agency tried turning on the lights in the restroom and would not turn on. It was observed that the room was dark, and, in the restroom, it was dark and darker if the restroom door was closed. It was observed that nothing could be seen if the restroom door was closed. Resident #5 had stated she told a nursing staff about the issues a little over an hour ago and did not know what had happened. <BR/>In an interview on 01/15/25 at 8:48 AM, with CNA E, she stated Resident #5 had told her about the lights not turning on in her room and restroom. CNA E stated she was looking for the floor charge nurse of the hall at the nurse's station and could not find her. CNA E stated since she was not able to find her, she went back to assist another resident with feeding as she was busy. CNA E stated she did not use the facility work order system to input the work order. CNA E stated she had been trained to use the facility work order system when facility needed to report facility stuff that needed fixing and tell the nurse. CNA E stated the risk of the lights not working for Resident #5 could have been a fall. <BR/>Observation on 01/15/25 at 8:50 AM, revealed, visible facility work order system QR Scan postings in around the nurse's station of the facility. <BR/>In an interview on 01/15/25 at 9:19 AM, with the Maintenance Director, he stated facility staff have been trained to use the facility work order system and what to do if they see, hear, or get reported facility stuff that were broken. The Maintenance Director stated there were QR Scan codes posted everywhere in the facility in which facility staff could place the work orders through there phones. The Maintenance Director stated not using the facility work order system could have a negative outcome of broken item(s) not getting fixed affecting the resident negatively depending on the situation. The Maintenance Director stated he was told of Resident #5's lights not turning on around 10 minutes ago which he observed that the lights were not turning on. The Maintenance Director stated Resident #5 told him she wanted them to turn on. The Maintenance Director stated an issue like the lights not turning on for Resident #5 was considered to be a 911 call (defined as notify the Maintenance Director immediately with clogged toilet, lights out, Exit lights out, etc.) and should have inputted into the facility work order system and told immediately. <BR/>In an interview on 01/15/25 at 10:49 AM, with ADON C and ADON D, ADON C stated all facility staff were trained on how to place a work order. ADON D stated there were QR Scan code postings throughout the facility in which facility staff could use the facility work order system to place work orders which was sent to the maintenance department. ADON C stated if nursing staff were reporting a work order issue and cannot find the nurse, then they need to directly let the Maintenance Director know aside from using the facility work order system. ADON D stated the risk would depend on the situation. <BR/>In an interview on 01/15/25 at 11:13 AM, with the Administrator, she stated facility staff were trained on the facility work order system on how to place work orders in. The Administrator stated the maintenance department should be reviewing the work orders daily. The Administrator stated the risk of not using the facility work order system could result in the broken item not being forgotten and would not be fixed. The Administrator stated the risk to the resident would depend on the situation.

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 4 of 8 rooms (A-7, A-11, A-13, and B-19) reviewed for environment. <BR/>The facility failed to ensure housekeeping and maintenance services were provided. <BR/>This failure could place residents at risk of decreased feelings of self-worth due to poor conditions of the facility interior. <BR/>Findings include: <BR/>Observation on 01/30/2023 at 11:00 a.m., in room A-11 revealed a light fixture positioned over an empty bed that appeared to be falling from one side. The was an approximate 2-inch broken floor tile noted by the empty bed. The restroom sink faucet was loose. A medium sized live roach was seen under the sink . <BR/>Observation on 01/30/2023 at 11:10 a.m., in room A-13 revealed a 4-inch by 4-inch cracked hole to a lower unpainted plastered part of a wall. There was a 2-inch broken floor tile noted on the open floor. There was an approximate 6-inch x 5-inch yellowish dry stain on the floor .<BR/>Observation on 01/30/2023 at 1:45 p.m., in room A-7, revealed a cracked windowsill. In the restroom, there was no lightbulb cover for the light above the restroom sink . <BR/>Observation on 01/30/2023 at 2:05 p.m., in room B-19, revealed a cracked windowsill. In the restroom, there was a plaster cover that was falling behind the commode which revealed a hole .<BR/>In an interview on 01/30/2023 at 3:00 p.m., the Maintenance Director said he had been working at the facility for about a month. He said the building was old and there were many maintenance issues when he took over with priorities being plumbing issues that required immediate attention. He said he was the only maintenance staff at the facility. He said he knew there were issues with holes in walls since he started working at the facility and was working to repair the holes. He said there were patches on the walls that had not been painted. He said he received information about needed repairs through work orders submitted by staff that were kept in a maintenance book at the nursing station. He said he did not know if there was a policy regarding work orders . <BR/>In an interview on 01/31/2023 at 2:05 p.m., the Administrator said the facility did not have a policy regarding maintenance or regarding assuring a safe clean and homelike environment. The Administrator said the expectation was that work orders were submitted, and the Maintenance Director would address the work orders based on priorities. The Administrator said there was only one maintenance staff member who was handling all work issues. The Administrator said the risk of being behind on repairs and housekeeping services was resident dissatisfaction and perception that the facility was dirty. <BR/>Record review of the Facility Maintenance Log, dated 01/01/2023 to 01/30/2023, documented no entries concerning the identified conditions . <BR/>Record review of the facility policy on Resident Rights, dated 02/20/2021, read in part, the resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on interview and record review the facility failed to ensure they employed a qualified social worker on a full-time basis for eight of eight weeks reviewed. <BR/>The facility, licensed for 150 beds, failed to have a full time Social Worker for seven weeks, from 12/05/2022 to 01/31/2023.<BR/>This failure could place residents at risk of unmet psychosocial needs and poor quality of life.<BR/>Findings include: <BR/>Record review of the Facility Summary Report revealed the facility was licensed for 150 bed capacity.<BR/>In an interview on 01/31/2023 at 9:13 a.m., the Human Resource Director (HRD) said the facility had not had a Social Worker since 12/05/2022. The HRD said the previous SW left a resignation letter without prior notice. The HRD said the position was posted on a job search website. <BR/>In an interview on 01/31/2023, the Administrator said the facility did not currently have a social worker for nearly two months. The Administrator said she started a contingency plan for the lack of a social worker to cover the SW duties. She said they took a team approach with the DON, ADONs, MDS Coordinators, and Activities Director covering duties. The Administrator said the Activity Director handled the grievances while they as a team approach for handling discharges. The Administrator said the SW position was posted since the previous SW left without notice. The Administrator said the risk of not having a social worker was resident psychosocial needs not being met.<BR/>Record review of the facility policy titled Social Services Personnel, dated 12/1997, read in part, Resident and their families have mental and psycho-social needs. Social services staff must be able to identify these needs and implement effective interventions. If the social worker is on leave or the position is vacant, the Administrator will develop a plan to cover the departmental duties.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 6 resident rooms, observed for housekeeping and maintenance, in that: <BR/>The facility failed to ensure CNA E used the facility work order system to input the lights in the restroom and room of Resident #5 would not turn on while Resident #5 wanted to use the restroom but was dark and could not see. <BR/>These failures could lead to resident injury and a diminished quality of life.<BR/>Findings include: <BR/>Record review of Resident #5's face sheet dated 01/15/25, revealed, admission on [DATE], re-admission on [DATE], and re-admission again on 02/22/22 to the facility. <BR/>Record review of Resident #5's facility history and physical dated 07/28/24, revealed, a [AGE] year-old female diagnosed with Anxiety, Cholecystitis (inflammation of the gallbladder), reduced mobility, history of falls, and GI bleeding (bleeding from any part of the digestive tract, from the mouth to the anus). <BR/>Record review of Resident #5's annual MDS dated [DATE], revealed, little to no impairment of cognition BIMS score of 15 and to be able to recall or make daily decisions. ADLs revealed to be independent for toileting, shower/bath, dressing. Independent for walking 10 feet/50 feet. <BR/>Record review of Resident #5's Care Plan dated 04/27/22, revealed the resident was incontinent of bowel/bladder related to history of UTI, confusion, and incontinence. Maintain unobstructed path to the bathroom. Resident #5 had impaired visual function and was at risk for falls, injury, and a decline in functional ability. Anticipate needs and meet them as able. Keep call light in reach when in room or bathroom. Involve in activities which do not require vision to participate such as music, parties, and exercise. Monitor and report eye problems, change in ability to perform ADLs, decline in mobility, sudden visual loss, tunnel vision, blurred vison, hazy vision. Resident #5 was able to see large print in a well illuminated room. ADLs was supervision with set-up for toileting due to impairment with balance coordination. <BR/>Observation and interview on 01/15/25 at 8:44 AM, with Resident #5, she stated she was looking for staff due to her lights in her restroom and room not turning on. Resident #5 showed state agency her room and tried to turn on the light switch in the room. It was observed that the light in the room was not turning on. Resident #5 stated she had to go to the restroom, but could not cause the light in the restroom would not turn on and was afraid to go to the restroom without the lights turning on. State agency tried turning on the lights in the restroom and would not turn on. It was observed that the room was dark, and, in the restroom, it was dark and darker if the restroom door was closed. It was observed that nothing could be seen if the restroom door was closed. Resident #5 had stated she told a nursing staff about the issues a little over an hour ago and did not know what had happened. <BR/>In an interview on 01/15/25 at 8:48 AM, with CNA E, she stated Resident #5 had told her about the lights not turning on in her room and restroom. CNA E stated she was looking for the floor charge nurse of the hall at the nurse's station and could not find her. CNA E stated since she was not able to find her, she went back to assist another resident with feeding as she was busy. CNA E stated she did not use the facility work order system to input the work order. CNA E stated she had been trained to use the facility work order system when facility needed to report facility stuff that needed fixing and tell the nurse. CNA E stated the risk of the lights not working for Resident #5 could have been a fall. <BR/>Observation on 01/15/25 at 8:50 AM, revealed, visible facility work order system QR Scan postings in around the nurse's station of the facility. <BR/>In an interview on 01/15/25 at 9:19 AM, with the Maintenance Director, he stated facility staff have been trained to use the facility work order system and what to do if they see, hear, or get reported facility stuff that were broken. The Maintenance Director stated there were QR Scan codes posted everywhere in the facility in which facility staff could place the work orders through there phones. The Maintenance Director stated not using the facility work order system could have a negative outcome of broken item(s) not getting fixed affecting the resident negatively depending on the situation. The Maintenance Director stated he was told of Resident #5's lights not turning on around 10 minutes ago which he observed that the lights were not turning on. The Maintenance Director stated Resident #5 told him she wanted them to turn on. The Maintenance Director stated an issue like the lights not turning on for Resident #5 was considered to be a 911 call (defined as notify the Maintenance Director immediately with clogged toilet, lights out, Exit lights out, etc.) and should have inputted into the facility work order system and told immediately. <BR/>In an interview on 01/15/25 at 10:49 AM, with ADON C and ADON D, ADON C stated all facility staff were trained on how to place a work order. ADON D stated there were QR Scan code postings throughout the facility in which facility staff could use the facility work order system to place work orders which was sent to the maintenance department. ADON C stated if nursing staff were reporting a work order issue and cannot find the nurse, then they need to directly let the Maintenance Director know aside from using the facility work order system. ADON D stated the risk would depend on the situation. <BR/>In an interview on 01/15/25 at 11:13 AM, with the Administrator, she stated facility staff were trained on the facility work order system on how to place work orders in. The Administrator stated the maintenance department should be reviewing the work orders daily. The Administrator stated the risk of not using the facility work order system could result in the broken item not being forgotten and would not be fixed. The Administrator stated the risk to the resident would depend on the situation.

**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 disease and infection for 1 (Resident #11) of 6 residents reviewed for infection control.<BR/>Resident #11's nasal cannula that was on the floor was placed back on Resident #11's nares (nostrils) without being replaced. <BR/>This deficient practice could place residents at risk for infection due to improper care practices. <BR/>Findings included: <BR/>Record review of Resident #11's face sheet dated 04/11/2024, revealed a [AGE] year-old female who was originally admitted on [DATE] and readmitted on [DATE].<BR/>Record review of Resident #11's H&P dated 10/06/2023, revealed Resident #11's assessment included: Monitor O2 maintain adequate O2 saturation keep Sat&gt;90%.<BR/>Record review of Resident #11's MDS quarterly assessment dated [DATE], revealed a BIMS score of 00 indicating severe cognitive impairment. Section Special Treatments, Procedures, and Programs revealed resident on oxygen therapy.<BR/>Record review of Resident #11's Order Summary Report dated 04/11/2024, revealed an order may use oxygen at 2 liter per minute via nasal cannula every shift, with order start date of 03/28/2024. <BR/>Observation and interview on 04/11/2024 at 8:38 a.m., Resident #11 was observed lying in bed without her nasal cannula on. LVN D entered the room and noted that the nasal cannula was on the floor. LVN D picked up the nasal cannula off the floor and put it back on Resident #11's face. LVN D was asked about the cannula being on the floor and LVN D said she should have grabbed another canula for infection control reasons. LVN D said it was her mistake and she does not have an excuse for making the mistake. <BR/>During an interview on 04/11/2024 at 1:17 p.m., CNA E said if a nasal canula was found on the floor, the CNA staff report it to the nurse so that the nurse can change the cannula because it was contaminated. CNA E said it would not be right if a staff or nurse put on the same contaminated cannula placing resident at risk of infection.<BR/>During an interview on 04/11/2024 at 2:07 p.m., CNA F said if the cannula is on the floor it needs to be changed because it is dirty and needs to be thrown away and a new one needs to be put on. CNA F said she would let the nurse know if the cannula was on the floor.<BR/>During an interview on 04/11/2024 at 3:19 p.m., LVN G said if a nasal cannula is found on the floor, it should be discarded and a new one put in place because the floor is dirty. LVN G said the risk was infection control. <BR/>During an interview on 04/11/2024 at 4:09 p.m., LVN D said if a cannula is found on the floor it was the responsibility of facility nurse is to replace it. LVN D said the risk of using the cannula that was on the floor was inviting bacteria into the body and infection control.<BR/>Record review of facility provided Oxygen Administration policy dated 03/21/2023, reads in part, change the tubing that is in use on one patient when it malfunctions or becomes visibly contaminated.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents in 2 (Resident #2 and Resident #6) of 8 rooms reviewed for the presence of pests in that:<BR/>The facility failed to ensure an effective pest control program was in place to keep cockroaches out of resident rooms and hallways. <BR/>This failure could place residents at risk of potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. <BR/>Findings include: <BR/>Observation on 01/30/2023 at 10:33 a.m. revealed a medium size live cockroach in room A-11's restroom running behind the commode. <BR/>Observation on 01/30/2023 at 2:05 p.m., a medium size dead roach was seen under the bed of Resident #6 .<BR/>Observation on 01/31/2023 at 11:05 a.m. revealed a medium size live roach (moving its legs in the air) was seen lying on its back in A-hallway. <BR/>In an interview on 01/30/2023 at 10:51 a.m., the Maintenance Director said pest control was at the facility about two weeks ago. He said if there were pests seen in the facility, the facility needed to call pest control, contracted by the facility. He said he had not received any reports of any pests seen. The Maintenance Director looked inside room A-11's restroom and saw the live roach and proceeded to step on the roach . <BR/>Interview on 01/30/2023 at 2:10 p.m., Resident #6 said he saw roaches on the floor at times but not very often . Resident #6 said he did not tell anyone about seeing the roaches.<BR/>In an interview on 01/31/2023 at 10:27 a.m., LVN A said the facility had a pest problem of roaches. She said she has seen an exterminator come spray at the facility about a few weeks ago, but they continued to have roaches .<BR/>In an interview on 01/31/2023 at 10:38 a.m., CNA C said she has seen roaches in the restrooms, coming into the facility. She said an outside exterminator fumigated regularly and had been there about a month ago .<BR/>In an interview on 01/30/2023 at 1:32 p.m., Resident #3 said she saw roaches in the hallways. She said she had not seen any roaches in her room because she kept her room clean . <BR/>In an interview on 01/30/2023 at 1:45 p.m., Resident #4 said she saw roaches during hotter seasons at the facility. Resident #4 said that the facility has a pest problem of roaches.<BR/>In an interview on 01/31/2023 at 2:05 p.m., the Administrator said the facility building was old and in need of repair. The Administrator said the facility had a pest control program where an outside extermination agency came to fumigate. The Administrator said the most recent visits by the extermination agency was on 11/11/2022, 12/05/2022, and 12/20/2022. The Administrator said she had not received any complaints of any pests. The Administrator said the risk of having pests in the facility was dissatisfaction from residents and the assumption the facility was not clean .<BR/>Record review of the facility policy titled Pest Control Program, dated 01/10/2020, read in part, It is the policy of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.

Based on observations and interviews the facility failed to dispose of garbage and refuse properly for 2 (Dumpsters #1 and #2) of 2 dumpsters located outside of the facility. <BR/>-Two dumpsters located outside the facility were open with their sliding doors open when not in use and trash was on the ground. <BR/>These failures could place residents at risk of decreased quality of life due to an exterior environment which could attract pests, rodents, and other animals. <BR/>Findings included: <BR/>Observation on 04/11/2024 at 11:15 a.m., two dumpsters were observed outside the facility on the back of the property. Dumpster #1 was observed with the sliding door open. There were several pieces of trash on the ground outside of the dumpster. Dumpster #2 was observed with the sliding door open with trash reaching the height of the side door. <BR/>Observation on 04/11/2024 at 12:59 p.m., two dumpsters were observed outside the facility on the back of the property. Dumpsters #1 and #2 were both observed with sliding doors opened. There were several pieces of trash on the ground outside of Dumpster #1. <BR/>During an interview on 04/11/2024 at 1:17 p.m., CNA E said CNAs and Housekeepers throw away the trash from the resident rooms. CNA E said there were trash barrels in the hallways and if they were not available, they throw the trash in the dumpsters outside. CNA E said staff open the dumpster door to throw out the trash and then close it afterwards. CNA E said if the dumpster doors are not closed there is a risk of contamination, infection control, and attracting pests. <BR/>During an interview on 04/11/2024 at 2:07 p.m., CNA F said briefs and gowns are bagged and thrown out in dumpsters behind the facility. CNA F said staff open the side door of the dumpster, throw the trash in, and then close the door. CNA F said the risk of failing to close the dumpster door was contamination and smells. CNA F said all staff who use the dumpster are responsible for ensuring the doors are closed and trash is picked up around the dumpsters. <BR/>During an interview on 04/11/24 at 2:50 p.m., the DM said Maintenance is responsible for the dumpster. The DM said Maintenance was also responsible for picking up the trash around the dumpster area. The DM said the dumpster doors are to be kept closed when not in use. The DM said the risk of not having the dumpsters closed and the area cleaned thoroughly was rodents and attracting flies. <BR/>During an interview on 04/16/24 at 8:45 AM, with the Maintenance Director, he stated that he was responsible for the trash on the ground near the dumpster but has been really busy with other work. The Maintenance Director stated the dumpster doors needed to be closed after throwing the trash away because it could invite pests. The Maintenance Director stated the trash on the floor ground could cause pests and roaches. The Maintenance Director stated it was everyone's responsibility to ensure the dumpster doors were closed. <BR/>During an interview on 04/16/24 at 1:52 PM, with the DON, she stated it was everyone's responsibility to pick up the trash off the ground near the dumpster. The DON stated the dumpster doors needed to be closed after every use. The DON stated not closing the dumpster doors or picking up the trash off the ground near the dumpster could attract roaches, bugs, and stray cats. The DON stated the risk would be infection.

**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 disease and infection for 1 (Resident #11) of 6 residents reviewed for infection control.<BR/>Resident #11's nasal cannula that was on the floor was placed back on Resident #11's nares (nostrils) without being replaced. <BR/>This deficient practice could place residents at risk for infection due to improper care practices. <BR/>Findings included: <BR/>Record review of Resident #11's face sheet dated 04/11/2024, revealed a [AGE] year-old female who was originally admitted on [DATE] and readmitted on [DATE].<BR/>Record review of Resident #11's H&P dated 10/06/2023, revealed Resident #11's assessment included: Monitor O2 maintain adequate O2 saturation keep Sat&gt;90%.<BR/>Record review of Resident #11's MDS quarterly assessment dated [DATE], revealed a BIMS score of 00 indicating severe cognitive impairment. Section Special Treatments, Procedures, and Programs revealed resident on oxygen therapy.<BR/>Record review of Resident #11's Order Summary Report dated 04/11/2024, revealed an order may use oxygen at 2 liter per minute via nasal cannula every shift, with order start date of 03/28/2024. <BR/>Observation and interview on 04/11/2024 at 8:38 a.m., Resident #11 was observed lying in bed without her nasal cannula on. LVN D entered the room and noted that the nasal cannula was on the floor. LVN D picked up the nasal cannula off the floor and put it back on Resident #11's face. LVN D was asked about the cannula being on the floor and LVN D said she should have grabbed another canula for infection control reasons. LVN D said it was her mistake and she does not have an excuse for making the mistake. <BR/>During an interview on 04/11/2024 at 1:17 p.m., CNA E said if a nasal canula was found on the floor, the CNA staff report it to the nurse so that the nurse can change the cannula because it was contaminated. CNA E said it would not be right if a staff or nurse put on the same contaminated cannula placing resident at risk of infection.<BR/>During an interview on 04/11/2024 at 2:07 p.m., CNA F said if the cannula is on the floor it needs to be changed because it is dirty and needs to be thrown away and a new one needs to be put on. CNA F said she would let the nurse know if the cannula was on the floor.<BR/>During an interview on 04/11/2024 at 3:19 p.m., LVN G said if a nasal cannula is found on the floor, it should be discarded and a new one put in place because the floor is dirty. LVN G said the risk was infection control. <BR/>During an interview on 04/11/2024 at 4:09 p.m., LVN D said if a cannula is found on the floor it was the responsibility of facility nurse is to replace it. LVN D said the risk of using the cannula that was on the floor was inviting bacteria into the body and infection control.<BR/>Record review of facility provided Oxygen Administration policy dated 03/21/2023, reads in part, change the tubing that is in use on one patient when it malfunctions or becomes visibly contaminated.

Based on observation, interview, and record review the facility failed to ensure that resident had the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility for all facility residents (81) and their families. <BR/>The facility failed to make the results of the most recent survey of the facility available to residents, and family members and legal representatives of residents.<BR/>This failure placed residents and family members and legal representatives of residents at risk of not being able to fully exercise their rights to be informed of the facility's survey citation history.<BR/>Findings included:<BR/>In a group interview on 04/25/2023 at 2:00 PM three of ten anonymous residents interviewed did not know they could review past survey reports or where these survey reports could be found.<BR/>Observation on 04/27/2023 at 5:20 PM in the facility reception area revealed a sign stating Survey Results with a document holder containing a folder and a binder. Record review of all the contents of the folder and binder revealed that it contained no survey results from any time or in any form. <BR/>In observation and interview on 04/27/2023 at 5:25 PM the Receptionist said he did not know where the survey results might be. He was observed looking through the storage areas at the receptionist desk, and then went into the offices behind the reception desk. He then returned and said that he could not find the survey results.<BR/>In an interview on 04/27/2023 at 5: 38 PM the Administrator said the state survey book was in the reception area. When told survey results were not found in the document holder under the Survey Results sign, she went to the reception area and looked at the documents under the Survey Results sign. The Administrator said that the survey results should be in that area and were there the last time she looked for them, a couple of months ago. She said it was her and the DON's responsibility to make sure the survey results were available in the reception area. She said that the risk to residents and families of not having the survey results available was that they would not be informed of issues in the building that they should know about.

**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 disease and infection for 1 (Resident #11) of 6 residents reviewed for infection control.<BR/>Resident #11's nasal cannula that was on the floor was placed back on Resident #11's nares (nostrils) without being replaced. <BR/>This deficient practice could place residents at risk for infection due to improper care practices. <BR/>Findings included: <BR/>Record review of Resident #11's face sheet dated 04/11/2024, revealed a [AGE] year-old female who was originally admitted on [DATE] and readmitted on [DATE].<BR/>Record review of Resident #11's H&P dated 10/06/2023, revealed Resident #11's assessment included: Monitor O2 maintain adequate O2 saturation keep Sat&gt;90%.<BR/>Record review of Resident #11's MDS quarterly assessment dated [DATE], revealed a BIMS score of 00 indicating severe cognitive impairment. Section Special Treatments, Procedures, and Programs revealed resident on oxygen therapy.<BR/>Record review of Resident #11's Order Summary Report dated 04/11/2024, revealed an order may use oxygen at 2 liter per minute via nasal cannula every shift, with order start date of 03/28/2024. <BR/>Observation and interview on 04/11/2024 at 8:38 a.m., Resident #11 was observed lying in bed without her nasal cannula on. LVN D entered the room and noted that the nasal cannula was on the floor. LVN D picked up the nasal cannula off the floor and put it back on Resident #11's face. LVN D was asked about the cannula being on the floor and LVN D said she should have grabbed another canula for infection control reasons. LVN D said it was her mistake and she does not have an excuse for making the mistake. <BR/>During an interview on 04/11/2024 at 1:17 p.m., CNA E said if a nasal canula was found on the floor, the CNA staff report it to the nurse so that the nurse can change the cannula because it was contaminated. CNA E said it would not be right if a staff or nurse put on the same contaminated cannula placing resident at risk of infection.<BR/>During an interview on 04/11/2024 at 2:07 p.m., CNA F said if the cannula is on the floor it needs to be changed because it is dirty and needs to be thrown away and a new one needs to be put on. CNA F said she would let the nurse know if the cannula was on the floor.<BR/>During an interview on 04/11/2024 at 3:19 p.m., LVN G said if a nasal cannula is found on the floor, it should be discarded and a new one put in place because the floor is dirty. LVN G said the risk was infection control. <BR/>During an interview on 04/11/2024 at 4:09 p.m., LVN D said if a cannula is found on the floor it was the responsibility of facility nurse is to replace it. LVN D said the risk of using the cannula that was on the floor was inviting bacteria into the body and infection control.<BR/>Record review of facility provided Oxygen Administration policy dated 03/21/2023, reads in part, change the tubing that is in use on one patient when it malfunctions or becomes visibly contaminated.

**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 disease and infection for 1 (Resident #11) of 6 residents reviewed for infection control.<BR/>Resident #11's nasal cannula that was on the floor was placed back on Resident #11's nares (nostrils) without being replaced. <BR/>This deficient practice could place residents at risk for infection due to improper care practices. <BR/>Findings included: <BR/>Record review of Resident #11's face sheet dated 04/11/2024, revealed a [AGE] year-old female who was originally admitted on [DATE] and readmitted on [DATE].<BR/>Record review of Resident #11's H&P dated 10/06/2023, revealed Resident #11's assessment included: Monitor O2 maintain adequate O2 saturation keep Sat&gt;90%.<BR/>Record review of Resident #11's MDS quarterly assessment dated [DATE], revealed a BIMS score of 00 indicating severe cognitive impairment. Section Special Treatments, Procedures, and Programs revealed resident on oxygen therapy.<BR/>Record review of Resident #11's Order Summary Report dated 04/11/2024, revealed an order may use oxygen at 2 liter per minute via nasal cannula every shift, with order start date of 03/28/2024. <BR/>Observation and interview on 04/11/2024 at 8:38 a.m., Resident #11 was observed lying in bed without her nasal cannula on. LVN D entered the room and noted that the nasal cannula was on the floor. LVN D picked up the nasal cannula off the floor and put it back on Resident #11's face. LVN D was asked about the cannula being on the floor and LVN D said she should have grabbed another canula for infection control reasons. LVN D said it was her mistake and she does not have an excuse for making the mistake. <BR/>During an interview on 04/11/2024 at 1:17 p.m., CNA E said if a nasal canula was found on the floor, the CNA staff report it to the nurse so that the nurse can change the cannula because it was contaminated. CNA E said it would not be right if a staff or nurse put on the same contaminated cannula placing resident at risk of infection.<BR/>During an interview on 04/11/2024 at 2:07 p.m., CNA F said if the cannula is on the floor it needs to be changed because it is dirty and needs to be thrown away and a new one needs to be put on. CNA F said she would let the nurse know if the cannula was on the floor.<BR/>During an interview on 04/11/2024 at 3:19 p.m., LVN G said if a nasal cannula is found on the floor, it should be discarded and a new one put in place because the floor is dirty. LVN G said the risk was infection control. <BR/>During an interview on 04/11/2024 at 4:09 p.m., LVN D said if a cannula is found on the floor it was the responsibility of facility nurse is to replace it. LVN D said the risk of using the cannula that was on the floor was inviting bacteria into the body and infection control.<BR/>Record review of facility provided Oxygen Administration policy dated 03/21/2023, reads in part, change the tubing that is in use on one patient when it malfunctions or becomes visibly contaminated.

Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 (kitchen) of 1 reviewed for residents.<BR/>1. <BR/>Food products in dry storage, freezer, and in refrigerator were not correctly labeled, wrapped, or were expired. <BR/>This failure could affect residents by placing them at risk of food borne illness.<BR/>Findings included: <BR/>Observation and Interview on 04/24/2023 beginning at 8:15 AM Assistant Dietary Manager in dry storage revealed a 7 pound can of pudding that did not have a date, breadcrumbs in a sealed zip lock bag did not an expiration date, a tied bag of pasta that was opened did was not labeled with the date and name, a sealed bag of enriched quick creamy wheat did not have an expiration date, and thick n easy ensures that were not labeled and dated. Assistant Dietary Manager stated the Dietary Manager and himself oversee food items are being labeled and dated. Assistant Dietary Manager stated the risk of not labeling or dating or correctly labeling food items could get residents sick if those foods items are served to them.<BR/>Observation and Interview on 04/24/2023 beginning at 8:25 AM Dietary Manager revealed the refrigerator had a container of cheese that was outdated and 25 cups that contained (juice, water, milk) were not dated. Dietary Manager stated the cups needed to be dated. Dietary Manager stated the labeling should have had an expiration date. Dietary Manager stated the importance of having food items labeled and correctly labeled was to ensure the dietary staff knew if the food was still fresh or if it was spoiled. Dietary Manager stated the risk to the resident if served would be stomach problem and getting sick.<BR/>Interview on 04/26/2023 9:27 AM [NAME] B stated foods coming in from the delivery truck or if they are opened the dietary staff need to label them with the date, name, and expiration dates. [NAME] B stated labeling food items ensures the life of the food to prevent any sickness. [NAME] B stated foods label incorrectly or not at all is a risk to the residents if served which could get them sick if the food was spoiled. <BR/>Interview on 04/26/23 at 9:44 AM Dietary Aid C stated food items need to be labeled because it lets people know food item, the date, and if it needs to be tossed out because it is expired. Dietary Aid C stated non labeled or incorrectly labeled food items could get the residents sick if the food item is served to them. Dietary Aid C stated the dietary staff ensure that food items are labeled correctly but was the overall it was the duty of the Dietary Manager to ensure.<BR/>Interview on 04/27/23 at 5:00 PM Administrator stated the importance of labeling foods was so the dietary staff would know what was in a container/bag, when it was prepared, and when it should be throw away. Administrator stated there is a risk to the residents if they are served foods that are not labeled or labeled incorrectly which would be food poisoning. <BR/>Record review of facility food safety and sanitation plan revealed ready to eat, date marking - will be clearly labeled using calendar date to indicate the date the product was prepared and the date the product must be used or discarded. Commercially prepared food products are clearly labeled using calendar date to indicate the date the product was opened and the date by which product must be used or discarded.

Based on observation, interview, and record review, the facility failed to ensure they had a full time DON for 1 of 1 facility reviewed for DON coverage. <BR/>The facility failed to have a full-time DON since 12/05/24 . <BR/>This failure could place residents at risk of a lack of nursing oversight and a higher level of care. <BR/>Findings included: <BR/>Record review of staff hours from 12/01/24 through 01/15/25 indicated there was no DON in the facility from 12/06/24 through 01/15/25. <BR/>In an interview on 01/14/25 at 8:40 AM, with the Administrator, ADON C, and ADON D, the Administrator stated the facility currently did not have a DON. ADON C stated the facility did not have an acting or interim DON. ADON D stated the facility was looking for a DON. <BR/>In an interview on 01/15/25 at 10:53 AM, with ADON C and ADON D, ADON C stated they did not have a full time DON but were actively seeking to hire a DON. ADON D stated the facility was about to hire a DON but the applicant at the last minute turned down the offer. ADON C stated the facility was using social media and other websites to actively try to recruit a DON. ADON C stated the risk of not having a DON would be that there might be some tasks that would be out of the scope of what some nurse can and cannot which why the facility needed a DON. ADON D stated the facility needed to have that oversight of a manager a DON to be looking at everything. <BR/>In an interview on 01/15/25 at 11:13 AM, with the Administrator, she stated the purpose of having a DON was so the DON could provide guidance to the nursing department. The Administrator stated the facility did have a corporate nurse and a weekend supervisor who was an RN that could provide that guidance. The Administrator stated the facility was using social media, websites, and by word of mouth to try to hire a DON. <BR/>In an interview on 01/15/25 at 12:22 PM, with HR, he stated the facility did not have a full time DON nor an interim DON. HR stated they had an applicant that they were going to hire for DON but in the minute the applicant turned down the offer . HR stated the facility was using social media and websites to try to hire a full DON. HR stated the purpose of a DON was to manage all the nursing department, regulate all the services for the residents, and making sure the residents had all the services they needed. HR stated the risk was that services being provided to residents might not have oversight to ensure they were being provided. HR stated the last DON's last day in the facility was on 12/02/24 and official last day was on 12/05/24, since then, the facility has not had a full DON. <BR/>In an interview on 01/15/25 at 12:32 PM, with the Administrator, she stated the facility did not have a DON policy and followed state guidelines.

Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 (kitchen) of 1 reviewed for residents.<BR/>1. <BR/>Food products in dry storage, freezer, and in refrigerator were not correctly labeled, wrapped, or were expired. <BR/>This failure could affect residents by placing them at risk of food borne illness.<BR/>Findings included: <BR/>Observation and Interview on 04/24/2023 beginning at 8:15 AM Assistant Dietary Manager in dry storage revealed a 7 pound can of pudding that did not have a date, breadcrumbs in a sealed zip lock bag did not an expiration date, a tied bag of pasta that was opened did was not labeled with the date and name, a sealed bag of enriched quick creamy wheat did not have an expiration date, and thick n easy ensures that were not labeled and dated. Assistant Dietary Manager stated the Dietary Manager and himself oversee food items are being labeled and dated. Assistant Dietary Manager stated the risk of not labeling or dating or correctly labeling food items could get residents sick if those foods items are served to them.<BR/>Observation and Interview on 04/24/2023 beginning at 8:25 AM Dietary Manager revealed the refrigerator had a container of cheese that was outdated and 25 cups that contained (juice, water, milk) were not dated. Dietary Manager stated the cups needed to be dated. Dietary Manager stated the labeling should have had an expiration date. Dietary Manager stated the importance of having food items labeled and correctly labeled was to ensure the dietary staff knew if the food was still fresh or if it was spoiled. Dietary Manager stated the risk to the resident if served would be stomach problem and getting sick.<BR/>Interview on 04/26/2023 9:27 AM [NAME] B stated foods coming in from the delivery truck or if they are opened the dietary staff need to label them with the date, name, and expiration dates. [NAME] B stated labeling food items ensures the life of the food to prevent any sickness. [NAME] B stated foods label incorrectly or not at all is a risk to the residents if served which could get them sick if the food was spoiled. <BR/>Interview on 04/26/23 at 9:44 AM Dietary Aid C stated food items need to be labeled because it lets people know food item, the date, and if it needs to be tossed out because it is expired. Dietary Aid C stated non labeled or incorrectly labeled food items could get the residents sick if the food item is served to them. Dietary Aid C stated the dietary staff ensure that food items are labeled correctly but was the overall it was the duty of the Dietary Manager to ensure.<BR/>Interview on 04/27/23 at 5:00 PM Administrator stated the importance of labeling foods was so the dietary staff would know what was in a container/bag, when it was prepared, and when it should be throw away. Administrator stated there is a risk to the residents if they are served foods that are not labeled or labeled incorrectly which would be food poisoning. <BR/>Record review of facility food safety and sanitation plan revealed ready to eat, date marking - will be clearly labeled using calendar date to indicate the date the product was prepared and the date the product must be used or discarded. Commercially prepared food products are clearly labeled using calendar date to indicate the date the product was opened and the date by which product must be used or discarded.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents in 2 (Resident #2 and Resident #6) of 8 rooms reviewed for the presence of pests in that:<BR/>The facility failed to ensure an effective pest control program was in place to keep cockroaches out of resident rooms and hallways. <BR/>This failure could place residents at risk of potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. <BR/>Findings include: <BR/>Observation on 01/30/2023 at 10:33 a.m. revealed a medium size live cockroach in room A-11's restroom running behind the commode. <BR/>Observation on 01/30/2023 at 2:05 p.m., a medium size dead roach was seen under the bed of Resident #6 .<BR/>Observation on 01/31/2023 at 11:05 a.m. revealed a medium size live roach (moving its legs in the air) was seen lying on its back in A-hallway. <BR/>In an interview on 01/30/2023 at 10:51 a.m., the Maintenance Director said pest control was at the facility about two weeks ago. He said if there were pests seen in the facility, the facility needed to call pest control, contracted by the facility. He said he had not received any reports of any pests seen. The Maintenance Director looked inside room A-11's restroom and saw the live roach and proceeded to step on the roach . <BR/>Interview on 01/30/2023 at 2:10 p.m., Resident #6 said he saw roaches on the floor at times but not very often . Resident #6 said he did not tell anyone about seeing the roaches.<BR/>In an interview on 01/31/2023 at 10:27 a.m., LVN A said the facility had a pest problem of roaches. She said she has seen an exterminator come spray at the facility about a few weeks ago, but they continued to have roaches .<BR/>In an interview on 01/31/2023 at 10:38 a.m., CNA C said she has seen roaches in the restrooms, coming into the facility. She said an outside exterminator fumigated regularly and had been there about a month ago .<BR/>In an interview on 01/30/2023 at 1:32 p.m., Resident #3 said she saw roaches in the hallways. She said she had not seen any roaches in her room because she kept her room clean . <BR/>In an interview on 01/30/2023 at 1:45 p.m., Resident #4 said she saw roaches during hotter seasons at the facility. Resident #4 said that the facility has a pest problem of roaches.<BR/>In an interview on 01/31/2023 at 2:05 p.m., the Administrator said the facility building was old and in need of repair. The Administrator said the facility had a pest control program where an outside extermination agency came to fumigate. The Administrator said the most recent visits by the extermination agency was on 11/11/2022, 12/05/2022, and 12/20/2022. The Administrator said she had not received any complaints of any pests. The Administrator said the risk of having pests in the facility was dissatisfaction from residents and the assumption the facility was not clean .<BR/>Record review of the facility policy titled Pest Control Program, dated 01/10/2020, read in part, It is the policy of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.

Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 (kitchen) of 1 reviewed for residents.<BR/>1. <BR/>Food products in dry storage, freezer, and in refrigerator were not correctly labeled, wrapped, or were expired. <BR/>This failure could affect residents by placing them at risk of food borne illness.<BR/>Findings included: <BR/>Observation and Interview on 04/24/2023 beginning at 8:15 AM Assistant Dietary Manager in dry storage revealed a 7 pound can of pudding that did not have a date, breadcrumbs in a sealed zip lock bag did not an expiration date, a tied bag of pasta that was opened did was not labeled with the date and name, a sealed bag of enriched quick creamy wheat did not have an expiration date, and thick n easy ensures that were not labeled and dated. Assistant Dietary Manager stated the Dietary Manager and himself oversee food items are being labeled and dated. Assistant Dietary Manager stated the risk of not labeling or dating or correctly labeling food items could get residents sick if those foods items are served to them.<BR/>Observation and Interview on 04/24/2023 beginning at 8:25 AM Dietary Manager revealed the refrigerator had a container of cheese that was outdated and 25 cups that contained (juice, water, milk) were not dated. Dietary Manager stated the cups needed to be dated. Dietary Manager stated the labeling should have had an expiration date. Dietary Manager stated the importance of having food items labeled and correctly labeled was to ensure the dietary staff knew if the food was still fresh or if it was spoiled. Dietary Manager stated the risk to the resident if served would be stomach problem and getting sick.<BR/>Interview on 04/26/2023 9:27 AM [NAME] B stated foods coming in from the delivery truck or if they are opened the dietary staff need to label them with the date, name, and expiration dates. [NAME] B stated labeling food items ensures the life of the food to prevent any sickness. [NAME] B stated foods label incorrectly or not at all is a risk to the residents if served which could get them sick if the food was spoiled. <BR/>Interview on 04/26/23 at 9:44 AM Dietary Aid C stated food items need to be labeled because it lets people know food item, the date, and if it needs to be tossed out because it is expired. Dietary Aid C stated non labeled or incorrectly labeled food items could get the residents sick if the food item is served to them. Dietary Aid C stated the dietary staff ensure that food items are labeled correctly but was the overall it was the duty of the Dietary Manager to ensure.<BR/>Interview on 04/27/23 at 5:00 PM Administrator stated the importance of labeling foods was so the dietary staff would know what was in a container/bag, when it was prepared, and when it should be throw away. Administrator stated there is a risk to the residents if they are served foods that are not labeled or labeled incorrectly which would be food poisoning. <BR/>Record review of facility food safety and sanitation plan revealed ready to eat, date marking - will be clearly labeled using calendar date to indicate the date the product was prepared and the date the product must be used or discarded. Commercially prepared food products are clearly labeled using calendar date to indicate the date the product was opened and the date by which product must be used or discarded.

Based on observations and interviews the facility failed to dispose of garbage and refuse properly for 2 (Dumpsters #1 and #2) of 2 dumpsters located outside of the facility. <BR/>-Two dumpsters located outside the facility were open with their sliding doors open when not in use and trash was on the ground. <BR/>These failures could place residents at risk of decreased quality of life due to an exterior environment which could attract pests, rodents, and other animals. <BR/>Findings included: <BR/>Observation on 04/11/2024 at 11:15 a.m., two dumpsters were observed outside the facility on the back of the property. Dumpster #1 was observed with the sliding door open. There were several pieces of trash on the ground outside of the dumpster. Dumpster #2 was observed with the sliding door open with trash reaching the height of the side door. <BR/>Observation on 04/11/2024 at 12:59 p.m., two dumpsters were observed outside the facility on the back of the property. Dumpsters #1 and #2 were both observed with sliding doors opened. There were several pieces of trash on the ground outside of Dumpster #1. <BR/>During an interview on 04/11/2024 at 1:17 p.m., CNA E said CNAs and Housekeepers throw away the trash from the resident rooms. CNA E said there were trash barrels in the hallways and if they were not available, they throw the trash in the dumpsters outside. CNA E said staff open the dumpster door to throw out the trash and then close it afterwards. CNA E said if the dumpster doors are not closed there is a risk of contamination, infection control, and attracting pests. <BR/>During an interview on 04/11/2024 at 2:07 p.m., CNA F said briefs and gowns are bagged and thrown out in dumpsters behind the facility. CNA F said staff open the side door of the dumpster, throw the trash in, and then close the door. CNA F said the risk of failing to close the dumpster door was contamination and smells. CNA F said all staff who use the dumpster are responsible for ensuring the doors are closed and trash is picked up around the dumpsters. <BR/>During an interview on 04/11/24 at 2:50 p.m., the DM said Maintenance is responsible for the dumpster. The DM said Maintenance was also responsible for picking up the trash around the dumpster area. The DM said the dumpster doors are to be kept closed when not in use. The DM said the risk of not having the dumpsters closed and the area cleaned thoroughly was rodents and attracting flies. <BR/>During an interview on 04/16/24 at 8:45 AM, with the Maintenance Director, he stated that he was responsible for the trash on the ground near the dumpster but has been really busy with other work. The Maintenance Director stated the dumpster doors needed to be closed after throwing the trash away because it could invite pests. The Maintenance Director stated the trash on the floor ground could cause pests and roaches. The Maintenance Director stated it was everyone's responsibility to ensure the dumpster doors were closed. <BR/>During an interview on 04/16/24 at 1:52 PM, with the DON, she stated it was everyone's responsibility to pick up the trash off the ground near the dumpster. The DON stated the dumpster doors needed to be closed after every use. The DON stated not closing the dumpster doors or picking up the trash off the ground near the dumpster could attract roaches, bugs, and stray cats. The DON stated the risk would be infection.