Chisolm Trail Nursing and Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of three residents (Resident #1) reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 had a physician's order for suctioning, and order for monitoring for secretions, or an order for when to replace the suction machine's cannister and tubing. <BR/>This deficient practice could place residents at risk of aspiration, aspiration pneumonia, or hospitalization. <BR/>Findings Included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including aspiration (inhaling something into your airway) of fluid as the cause of abnormal reaction, cerebral infarction (stroke), anoxic (lack of oxygen) brain injury, dysphagia (difficulty in swallowing), and hypoxemia (abnormally low level of oxygen in the blood). <BR/>Review of Resident #1's annual MDS assessment, dated 02/20/25, reflected a BIMS score of 99, indicating he was unable to complete the interview. Section K (Swallowing/Nutritional Status) reflected he had a feeding tube. Section O (Special Treatments, Procedures, and Programs) reflected he did not require suctioning as a respiratory treatment. <BR/>Review of Resident #1's quarterly care plan, revised 01/28/25, reflected he was dependent on tube feeding/inadequate oral intake due to dysphagia and NPO with an intervention of providing oral care daily or PRN. <BR/>Review of Resident #1's physician orders in his EMR, on 03/04/25, reflected no orders for suctioning, monitoring for secretions, or when to replace the suction machine's cannister or tubing.<BR/>Review of Resident #1's physician order, dated 07/16/24, reflected provide oral care every shift.<BR/>Review of Resident #1's hospital records, dated 02/21/25 - 02/24/25, reflected the following:<BR/> . admitted with altered mental status and hypoxia. [Resident #1] has a history of recurrent aspiration pneumonia. [Resident #1] was admitted to the floor and started on IV antibiotics . <BR/> . I do suspect that he still having silent aspiration .<BR/>During an observation and interview on 03/04/25 at 9:28 AM revealed Resident #1 lying on his bed utilizing continuous oxygen. He was struggling to breathe, there were secretions in his mouth, and was pointing to his suctioning machine on his bedside table. This Surveyor went to the nurses' station and let RN A know Resident #1 was in distress. RN A stated, Oh I am sure he needs me to suction him and went to his room. <BR/>During an interview on 03/04/25 at 12:08 PM, RN A stated Resident #1 was having secretions because he had a peg tube. He stated he had started having secretions since he recently came back from the hospital with aspiration pneumonia (02/24/25). He stated the order to suction was in his TAR under oral care and he was to be suctioned he believed every shift.<BR/>During an interview on 03/04/25 at 12:29 PM, the MDSC stated oral care was considered cleaning the residents' mouth with utensils to clean out residue and clean their teeth. She stated it was important to keep their mouths clean and moist. She stated residents that are NPO should receive the same oral care, but the staff needed to ensure the head of their beds were elevated to reduce the risk of aspiration. She stated suctioning would only be considered part of oral care if they needed to suction something from their mouth they could not remove while providing oral hygiene care. She stated if a resident needed regular suctioning to remove secretions, she would expect to see an order for PRN suctioning. She stated it was important because an order was needed for anything that was done for a resident, especially someone who was NPO who may be not able to tell you they needed it. She stated it was the responsibility of the nurses to get physician orders. She stated residents that were NPO did not get fluids through their mouths which could increase excessive secretions which could cause aspiration or aspiration pneumonia. She stated Resident #1 did not have excessive secretions in the past but was not sure if that had changed since his recent hospital visit. She stated she believed he would be a high potential for needing PRN suctioning due to him being a high-risk of aspiration and his history of aspiration pneumonia. She stated there should be an order to assess regularly for secretions, PRN suctioning if the nursing staff were regularly utilizing the suctioning machine, and when to change out the cannister and tubing. <BR/>Review of the facility's undated Airway Management Policy reflected the following:<BR/> .<BR/>2. Review patient's electronic health record (EHR), including health care provider's order and nurses' notes for patient's normal pulse oximeter values, baseline and trends in respiratory rate and effort for breathing, frequency of suctioning, and response to suctioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents had the right to be free from physical abuse and neglect for two (Resident #1 and Resident #3) of five residents reviewed for abuse and neglect.<BR/>1. The facility failed to ensure Resident #1 was not physically abused by FM on 05/25/2025 when FM hit Resident #1 after Resident #1 became agitated and hit the FM. <BR/>2. The facility failed to protect Resident #3 from physical abuse by Resident #2. Resident #3 wandered into Resident #2's room and was hit by Resident #2 after Resident #2 stated I'm going to hit you.<BR/>These failures placed residents at risk of abuse, neglect, trauma, and psychosocial harm.<BR/>Findings include: <BR/>1. Review of Resident #1's face sheet dated 05/28/2025 reflected a [AGE] year-old man admitted on [DATE] with diagnoses of unspecified dementia (cognitive functioning severe enough to affect daily life where type cannot be determined), depression (mood disorder characterized by persistent sadness), other specified arthritis (multiple sites) (inflammation in multiple joints), primary generalized osteoarthritis (breakdown of cartilage in multiple joints), Spondylosis (ongoing wear and wear on spinal joints and disks), and essential hypertension (high blood pressure). <BR/>Review of Resident #1's admission MDS dated [DATE] reflected a BIMS score of 2 which indicated severe cognitive impairment. Further review reflected Resident #1 had inattention and had difficulty focusing and being easily distractible. <BR/>Review of Resident #1's care plan dated 05/22/2025 reflected Resident #1 had little, or awareness of safety or boundaries related to other's personal space and wandered within his living space interventions included invite Resident #1 to participate in activities. Further review revealed care plan dated 05/27/2025 reflected Resident #1 had behaviors that included physical aggression. <BR/>Review of incident report dated 05/25/2025 by LVN B reflected there was an altercation between Resident #1 and FM. When LVN B walked onto the memory care unit, Resident #1 was pacing and assessed for injury. LVN B spoke with FM and stated that Resident #1 was sitting in a chair beside Resident #5. FM told Resident #1 he had to leave and Resident #1 stood up and said Resident #5 was his (Resident #1's) wife. Resident #1 then punched FM twice in the face. FM punched Resident #1 in the cheek in self-defense. NP was notified, DON, ADM and Resident #1's RP. <BR/>Review of police report dated 05/25/2025 reflected incident was reported at 5:43 PM. Review reflected police spoke with FM and FM indicated that he went to visit Resident #5 and when FM entered Resident #5's room, Resident #1 was there. FM stated Resident #1 became confrontational and believed Resident #5 was his wife. FM claimed Resident #1 punched FM in the face twice and FM punched Resident #1 back and knocked him to the ground in self-defense. FM declined to press charges and a small mark was observed on FM right cheek. Further review reflected Resident #1 wandered the hallway and swelling was observed with band-aid over Resident #1's left cheek. Police officer attempted to speak with Resident #1 and appeared not fully aware or did not recall the incident. <BR/>Observation on 05/28/2025 at 10:46 AM, revealed Resident #1 was asleep in his room on his bed. Resident #1 was observed with bruising around his left eye that appeared dark purple. <BR/>Observation on 05/28/2025 at 11:46 AM, revealed Resident #5 no longer resided on the memory care unit and was non-verbal and non-ambulatory. <BR/>Observation and interview on 05/28/2025 at 4:41 PM, revealed Resident #1 sitting in his room with 1:1 supervision. Resident #1 stated his eye was fine and stated peanut butter stuff caused the bruise. <BR/>During an interview on 05/28/2025 at 11:39 PM, CNA E stated she was not at work when the incident with Resident #1 occurred. CNA E stated that Resident #1 appeared the same since he admitted to the facility and had not noticed any changes or pain. CNA E stated she never had concerns with FM's behavior during visits to the facility and he always appeared calm. <BR/>During an interview on 05/28/2025 at 11:42 AM, CNA F stated that she worked yesterday (05/27/2025) and both yesterday and today (05/28/2025) she was to remain 1:1 with Resident #1. CNA F stated that she was required to keep Resident #1 within eyesight at all times. CNA F stated there have been no issues with his behavior and that she redirected him if he went to another resident's room. CNA F stated that she had not noted any changes in Resident #1 and that his appetite has also remained the same. <BR/>During an interview on 05/28/2025 at 12:02 PM, CNA C stated that she worked on 05/25/2025. CNA C stated that she started to gather residents for dinner and she asked Resident #1 to make his way to the dining room, but he stayed on the hall. CNA C stated this was before 5:00 pm which was dinner time. CNA C stated that Resident #1 sat in a chair next to Resident #5's bed and rubbed her face and Resident #1 recognized Resident #5 as a relative. CNA C stated she asked Resident #1 to leave the room and he became agitated and she attempted to redirect him, but was not successful. CNA C stated that she left to get LVN B and as she went to do so FM arrived to visit Resident #5. CNA C stated that FM asked Resident #1 to leave the room and Resident #1 stated no this is my dad. CNA C stated when she returned Resident #1 was near a medication cart and had blood on his face and FM came from Resident #5's room. CNA C stated when Resident #1 first walked up he stated two guys beat me up and after ice was applied Resident #1 stated he fell off a train. CNA C stated that FM appeared calm and did not yell and did not sound aggressive and apologized when he spoke with LVN B. CNA C stated that Resident #1 did not recall the event after it occurred and ate 100% of his dinner that evening and had no additional incidents the remainder of her shift. CNA C stated Resident #1 remained on 1:1 the remainder of her shift. <BR/>During an interview on 05/28/2025 at 1:01 PM, the DON stated that he was made aware of the incident with Resident #1 and FM on Sunday (05/25/2025) when MCD called. The DON stated he instructed MCD to place Resident #1 on 1:1. The DON stated NP ordered a facial x-ray and results were pending. The DON stated the police were called and FM visited supervised and outside the memory care unit. The DON stated that no concerns with FM had been observed or concerns regarding his behavior and he was usually very quiet. The DON stated that there had been no behaviors reported by Resident #1 prior to the incident. The DON stated that Resident #1 wandered throughout the memory care unit and had not had any outburst previously. <BR/>During an interview on 05/28/2025 at 1:14 PM, the MCD stated that she was called by LVN B and informed that an altercation occurred between Resident #1 and FM on 05/25/2025. The MCD stated that she contacted the DON and ADM immediately after speaking with LVN B. The MCD stated she instructed CNA C and LVN B to remain with Resident #1. The MCD stated she interviewed FM and he stated that he found Resident #1 sitting in Resident #5's room. The MCD stated that FM reported that Resident #1 swung at FM so FM swung back at Resident #1 in reaction. The MCD called the police to make a report and stated the DON instructed MCD to ask FM to leave the facility. The MCD stated that prior to the incident FM would visit from out of state and would visit during meals to feed Resident #5. The MCD described FM's demeanor as calm, respectful and stated he often brought staff food. The MCD denied that FM was harsh or aggressive prior to the incident. The MCD stated that FM was instructed he could not enter the facility and visits had to occur with supervision. The MCD stated that Resident #1 was placed on 1:1 and a staff member was asked to stay on the shift later and remain on 1:1 with Resident #1. MCD stated that Resident #1 had not been physically aggressive or have outburst prior to the incident. MCD stated Resident #1 usually wandered. <BR/>During an interview on 05/28/2025 at 1:27 PM, the ADM stated he was made aware of the incident with Resident #1 on 05/25/2025 after 4:00 PM and before 5:00 PM. The ADM stated that LVN B contacted him and LCD reached out as well. The ADM stated that it was reported there was an altercation between FM and Resident #1. The ADM stated that Resident #1's RP was notified as well as the staff that was working to assess and separate FM and Resident #1. The ADM stated that all other residents in memory care was assessed, and a police report was made. The ADM stated that in order to protect other residents, Resident #1 was placed on 1:1 supervision and FM was asked to leave the building and instructed that he was not allowed inside the building. The ADM stated he had a discussion with FM via telephone on 05/27/2025 that visitation could be held outside and would be supervised. The ADM stated FM was informed he was not allowed back in the building at this time in order to protect all the residents. The ADM stated the FM was confused initially and FM believed his (FM) actions were justified. The ADM stated there was no concerns with FM's actions or behaviors until 05/25/2025. The ADM stated that prior to the incident Resident #1 had no behavioral concerns or physical aggression prior to the incident. The ADM stated Resident #1 would stay on 1:1 supervision for his safety and the safety of other residents. <BR/>During an interview on 05/28/2025 at 4:36 PM, CNA G stated she did not work during the incident with FM and Resident #1. CNA G stated that physical abuse included hitting, slapping or punching. CNA G stated that any suspicious or witnessed abuse would be reported to the abuse coordinator who was the ADM. CNA G stated that Resident #1 had to be redirected constantly and wandered into other residents' rooms. <BR/>During an interview on 05/28/2025 at 4:42 PM, CNA H stated she was on 1:1 with Resident #1 and he just woke up. CNA H stated any incidents that involved a family member to resident would be reported to the charge nurse and ADM. CNA H stated physical abuse was hitting someone or being aggressive. <BR/>During an interview on 058/28/2025 at 4:55 PM, LVN J stated that an example of physical abuse included hitting or scratching of any kind and would be reported immediately to the ADM and DON and potentially police after the resident was separated. <BR/>A telephone interview was attempted to LVN B on 05/28/2025 at 12:44 PM, and 06/05/2025 at 12:02 PM, there was no answer.<BR/>During an interview on 06/11/2025 at 10:01 AM, FM stated that he arrived at the facility on 05/25/2025 it was around 4:00 PM. FM stated that he went to visit Resident #5. FM stated CNA C was at the end of the hall near Resident #5's room and heard CNA C tell Resident #1 that is not your room, come on. FM stated that Resident #1 sat next to Resident #5's bed in a chair and Resident #1 patted Resident #5's head. FM stated that he told Resident #1 that was not his room and Resident #1 was going to have to leave. FM stated Resident #1 jumped up and said you stupid ass this is my wife. FM stated he turned to look for CNA C and Resident #1 hit FM and kicked him in the shin and knocked FM on the floor. FM stated that Resident #1 caused FM's glasses to bend. FM stated he subdued Resident #1 and stated he hit Resident #1. FM stated Resident #1 hit FM and did not back down so FM hit Resident #1. FM stated that Resident #1 then left the room. FM stated he was unsure if CNA C witnessed the incident but stated when he looked around he did not see anyone. FM stated he hit Resident #1 once and Resident #1 fell to the ground and he held Resident #1 because Resident #1 still tried to hit FM. FM stated when Resident #1 relaxed, FM let him up and stated he held him down for about 20-30 seconds. FM stated he reported that Resident #1 hit FM twice to staff and the police. FM stated that Resident #5 had been a resident at the facility since 2016 and he was informed he could only visit Resident #5 outside the facility. FM stated he received a statement from ADM about the visitation restrictions and it was to be ongoing with no end date. FM stated he was not allowed to enter the facility at all and that included the common area. FM stated that he did nothing wrong. FM stated that the day prior to the incident Resident #1 had entered Resident #5's room and touched Resident #5's roommate's feet and then left. <BR/>Review of in-service dated 05/08/2025 with topic of dealing with aggressive behaviors was completed with all staff and included tips for working with residents who had dementia/Alzheimer's. <BR/>Review of in-service dated 05/28/2025 completed with staff reflected training was reviewed with the topic of current restricted visitation and 1:1 care. FM was not allowed to visit Resident #5 without supervision and needed to visit outside away from other / minimal residents with nursing team to supervise. Resident #1 was currently on 1:1 supervision until IDT concluded it was safe to discontinue. <BR/>Review of safety surveys completed with 9 residents dated 05/28/2025 reflected there were no concerns noted from additional residents interviewed.<BR/>Review of total body skin and body assessment conducted with 11 residents in the memory care unit dated 05/27/2025 reflected there were no new wounds observed. <BR/>Review of 9 staff questionnaire dated 05/28/2025 reflected staff were aware of who to report abuse to, changes such as a bruise or cut on a resident and to report any incident. <BR/>Review of letter addressed to FM from ADM dated 05/28/2025 reflected that due to the incident on 05/25/2025, FM was not allowed to enter the facility and any visitation with Resident #5 required supervision outside of he facility. The letter reflected that the facility had a responsibility to assure the residents were safe and supervised visitation was to assure no other resident and the potential of any possible harm. <BR/>Review of in-service dated 05/26/2025 reflected training was reviewed with staff over abuse policy, report guidelines, resident rights. <BR/>During an interview on 06/05/2025 at 12:06 PM, the ADM stated that a written letter was going to be sent to FM, but the facility's legal team had not approved it yet. <BR/>Review of in-service dated 05/26/2025 reflected training was reviewed with staff over abuse policy, report guidelines, resident rights. <BR/>2. Review of Resident #2 face sheet dated 05/28/2025 reflected a [AGE] year-old man admitted on [DATE] and discharged on 04/13/2025 with diagnoses of idiopathic epilepsy and epileptic syndromes (group of syndromes characterized by seizures without identified brain abnormalities), chronic pain syndrome (pain lasting longer than three to six months), other specified disorders of the brain (wide range of brain conditions), and dysphagia (difficulty swallowing). <BR/>Review of Resident #2's discharge MDS dated [DATE] reflected no BIMS score was completed due to Resident #2 discharged from the facility. Further review reflected there was no physical symptoms directed towards others in the 7 days prior to the assessment. <BR/>Review of Resident #2's care plan dated 03/06/2025 reflected he had a physical functioning deficit with transfers and required assistance. Interventions reflected to use a Hoyer with transfers. There were no behaviors noted in Resident #2's care plan. <BR/>Review of skin assessment dated [DATE] for Resident #2 reflected no bruising or open areas noted, there were no reddened areas, open areas (cuts/tears) found. <BR/>Review of Resident #3 face sheet dated 05/28/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia (cognitive functioning severe enough to affect daily life where type cannot be determined), other abnormalities of gait and mobility (clumsy, unsteady movements), other lack of coordination (wide range of conditions where there is a disruption in the body's ability to coordinate movements), and unspecified glaucoma (condition of fluid buildup in the eye that can cause vision loss or blindness). <BR/>Review of Resident #3's quarterly MDS dated [DATE] reflected Resident #3 had a BIMS score of 7 which indicated severe cognitive impairment. Further review reflected Resident #3 had no physician behavioral symptoms directed toward others 7 days prior to the assessment. <BR/>Review of Resident #3's care plan dated 04/19/2025 reflected Resident #3 had little or no awareness of safety or no boundaries and went into other resident's rooms. Interventions reflected to re-direct Resident #3 to his room to rummage through items safely, invite him to participate in activities and offer opportunities for social interaction. <BR/>Review of Resident #3's care plan dated 06/05/2025 reflected he had behaviors which included being aggressive with others. Interventions included help residents avoid situations or people that are upsetting and attempt interventions before behaviors begin. <BR/>Review of skin assessment dated [DATE] for Resident #3 reflected no bruising or open areas noted, there were no reddened areas, open areas (cuts/tears) found. <BR/>During an interview on 05/28/2025 at 4:48 PM, Resident #3 stated he did not recall any incident with another resident. Resident #3 stated he felt safe at the facility. Resident was observed laying in bed in his room. <BR/>Review of surveys completed with 9 residents date 04/07/2025 reflected there were no concerns noted from any resident and they were aware of who the abuse prevention coordinator was. <BR/>Review of body audit's completed with 28 residents dated 04/08/2025 through 04/10/2025 reflected there were no suspicious alterations in skin found. <BR/>Review of incident report dated 04/06/2025 with a time of 10:00 AM reflected RN A was outside of Resident #3's room and he kicked open Resident #2's door and entered the doorway of Resident #2's room. Resident #2 asked Resident #3 to leave his room and Resident #2 stated before I kick your [Resident #3's] ass. Resident #3 responded do it and Resident #2 punched Resident #3 in the face. Further review reflected DON, family and NP were notified and RN A separated the residents. Incident report reflected no injuries were noted on either resident. Further review reflected Resident #3 was confused and wandered into other residents' rooms. <BR/>Review of investigation summary by ADM dated 04/07/2025 reflected nursing reported an incident that occurred on 04/06/2025 between Resident #2 and Resident #3. Further review reflected Resident #3 wandered into Resident #2's room and a dispute was heard by nursing and intervened and separated both residents. Resident #3 and Resident #2 lived on separate halls and were assessed with no signs of bruising or marks. ADM stated he spoke with Resident #2 and he stated there was an argument and Resident #3 did not recall. ADM stated there were no concerns or lasting effects. <BR/>Review of 10 staff questionnaires dated 04/07/2025 reflected staff were aware of who to report abuse to, changes such as a bruise or cut on a resident and to report any incident. <BR/>Review of statement dated 04/06/2025 by CNA K reflected she was writing to report an incident that occurred that involved Resident #2 and Resident #3. CNA K wrote that when she was in the hallway after lunch she observed Resident #3 roaming and entered the room of Resident #2. CNA K's statement reflected Resident #3 proceeded to kick the door and directed a verbal threat at Resident #2 that Resident #3 was going to hit Resident #2. CNA K stated she did not witness Resident #3 strike Resident #2 but she did hear Resident #2 said you hit me upon the nurses entry to the room. <BR/>During an interview on 05/28/2025 at 4:19 PM, RN A stated that Resident #3 tended to wander door to door and kicked the doors open with his foot to other resident rooms. RN A stated she was charting and Resident #3 kicked open Resident #2's door. RN A stated Resident #2 told Resident #3 to quit and get away from the door. RN A stated when she turned she saw Resident #2 was at the door and hit Resident #3. RN A stated that she reported it to the physician, family member and reported it to the DON. RN A stated that she assessed each resident and completed a head-to-toe assessment and there were no injuries. RN A stated that Resident #3 was the only resident who was hit. RN A stated the residents was separated and removed from the area. RN A stated that any resident-to-resident incidents should be reported to the DON and the ADM. RN A stated looking back she saw that resident-to-resident incident could have been abuse and neglect. RN A stated at the time she thought it was just an incident and only did an incident report. <BR/>During an interview on 05/28/2025 at 4:33 PM, the DON stated the incident occurred prior to his role as DON at the facility. The DON stated that all emergencies were reported to him and the ADM. <BR/>During an interview on 05/28/2025 at 4:36 PM, CNA G stated if she observed an incident between two residents, would let the nurse know what was going on. CNA G stated that physical abuse included hitting, slapping or punch . CNA G stated that any suspicious or witnessed abuse would be reported to the abuse coordinator who was the ADM.<BR/>During an interview on 05/28/2025 at 4:49 PM, LVN I stated that for incidents that involved residents she would separate the individuals and ask someone to assist . LVN I stated she would assess for any injuries and notify the ADM, MD, RP, and DON. LVN I stated that physical abuse was pulling, tugging, or being rough with a resident. LVN I stated any abuse or suspicion of abuse would be reported to the DON as soon as it occurred. <BR/>During an interview on 05/28/2025 at 5:07 PM, the ADM stated that he was made aware of the incident with Resident #3 and Resident #2. ADM stated that he spoke with nursing and it was stated Resident #3 was going down the hallway and Resident #2 stated for Resident #3 to get out of the room. The ADM stated nursing intervened and no injuries were found. The ADM stated he spoke with both residents the next day and they had no concerns. The ADM stated he was not able to confirm Resident #2 struck Resident #3. The ADM stated an investigation was conducted but he was unable to confirm that Resident #2 stuck Resident #3 and he understood from RN A that a commotion was overheard. The ADM stated staff are educated on abuse and neglect at least three or four times a year. <BR/>During an interview on 06/05/2025 at 11:25 AM, the SSD stated that she was familiar with Resident #3. The SSD stated that normally Resident #3 was calm, but lately he went into other resident's rooms and kicked the doors open. The SSD stated she knew he had an altercation with Resident #2 but was not sure what happened. The SSD stated that Resident #3 started to wonder recently (last few months). The SSD stated Resident #3 is redirected, taken outside on the patio as interventions. <BR/>During an interview on 06/05/2025 at 11:39 PM, the AD stated Resident #3 was a very sweet person and liked to listen to music, have snacks and play bingo. The AD stated that Resident #3 never exhibited behavior during activities and was easily directed to activities. The AD stated that she had observed Resident #3 on different halls than his own, but he did not go into other resident's room or kicked doors. The AD stated Resident #3 looked out the window. The AD stated she has not observed increased wandering. The AD stated Resident #2 had no aggressive behavior that was observed and stated he preferred to remain in his room most of the time and he was quiet. <BR/>During an interview on 06/05/2025 at 11:46 AM, the ADON stated that she started at the facility at the end of April 2025. The ADON stated she had observed Resident #3 as pleasant and had not observed him wandering or going into other resident's rooms and that he was just sitting in his wheelchair. The ADON stated that according to other people he can be aggressive, but was unable to recall anything specific. The ADON stated that interventions for Resident #3 included increased rounding, communication in shift report, discussion in morning meeting of any issues. <BR/>During an interview on 06/05/2025 at 12:06 PM, the ADM stated that prior to the incident on 04/06/2025, Resident #3 wandered. The ADM stated Resident #3 would be up and active in activities and during that time he would have an eye on him. The ADM stated that interventions included redirection, trying to keep his mind stimulated and offered activities. The ADM stated Resident #3 would also visit his ex-spouse who was also a resident at the facility and that he enjoyed eating meals with her. The ADM stated that prior to the incident there was nothing reported that Resident #3 had wandered into other residents' rooms just that he wandered in general. The ADM stated potential harm for increased wandering behaviors was that other residents could be startled. <BR/>During an interview on 06/05/2025 at 12:21 PM, the DON stated that Resident #3 was usually a calm guy and moved around the halls and looked for his ex-spouse. The DON stated that he knocked on doors until he found the ex-spouse. The DON stated that he did not consider this wandering because Resident #3 had a purpose and goal to find the ex-spouse. The DON stated that once Resident #3 found the ex-spouse he remained in her room. The DON stated that some resident yelled when Resident #3 opened the door. The DON stated that interventions for Resident #3 were to move him to the secured unit and bring him out to the ex-spouse to prevent him going up and down each hall. The DON stated he was also taken out to the back patio. <BR/>Review of in-service dated 04/06/2025 reflected abuse policy, reporting guidelines and resident rights was reviewed with all staff. <BR/>During an interview on 06/05/2025 at 12:06 PM, the ADM stated he prevented abuse and neglect in the facility through education of staff and checking in with residents and families. The ADM stated that the phone number for the abuse coordinator was posted in resident rooms. <BR/>During an interview on 06/05/2025 at 12:21 PM, the DON stated that abuse and neglect was prevented by rounding and residents, reeducating the team and what abuse and neglect was. The DON stated it was important to continue to educate staff on what they are supposed to do and how to conduct themselves. The DON listed example of abuse as hitting or punching. <BR/>Review of facility policy titled Abuse Policy dated 02/2017 reflected abuse is the willful (individual acted deliberately, not that they must have intent to injury or harm) infliction of injury that resulted in physical harm, pain or mental anguish. The facility shall take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident or other residents that may be affected. <BR/>Review of facility policy titled Resident's Rights and Quality of Life dated 05/01/2012 reflected a resident has the right to be free from verbal, sexual, physical and mental abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect resulted in bodily injury, to other officials (including the State Agency) for 4 of 6 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for abuse and neglect.<BR/>1. The facility failed to report to the State Agency an incident that involved Resident #1 on 05/25/2025 within the allotted timeframe. <BR/>2. The facility failed to report to the State Agency an incident that involved Resident #2 and Resident #3 on 04/06/2025.<BR/>3. The facility failed to report to the State Agency after x-ray results revealed Resident #4 sustained a fracture after a fall on 03/31/2025 within the allotted timeframe.<BR/>This failure could place residents at risk for harm to include physical abuse, a diminished quality of life, and psychosocial harm.<BR/>Findings include: <BR/>1. Review of Resident #1 face sheet dated 05/28/2025 reflected a [AGE] year-old man admitted on [DATE] with diagnoses of unspecified dementia (cognitive functioning severe enough to affect daily life where type cannot be determined), depression (mood disorder characterized by persistent sadness), other specified arthritis (multiple sites) (inflammation in multiple joints), primary generalized osteoarthritis (breakdown of cartilage in multiple joints), Spondylosis (ongoing wear and wear on spinal joints and disks), and essential hypertension (high blood pressure). <BR/>Review of Resident #1 admission MDS dated [DATE] reflected a BIMS score of 2 which indicated severe cognitive impairment. Further review reflected Resident #1 had inattention and had difficulty focusing and being easily distractible. <BR/>Review of Resident #1 care plan dated 05/22/2025 reflected Resident #1 had little, or awareness of safety or boundaries related to other's personal space and wandered within his living space. Further review revealed care plan dated 05/27/2025 reflected Resident #1 had behaviors that included physical aggression. <BR/>Review of incident report dated 05/25/2025 reflected an incident occurred between Resident #1 and a FM in which Resident #1 struck the FM and FM struck Resident #1 that resulted in bruising to Resident #1's face. Further review reflected the incident occurred on 05/25/2025. <BR/>Review of TULIP intake submission reflected the facility first learned of the incident on 05/25/2025 at 6:00 PM but the report was not submitted until 05/26/2025.<BR/>Review of intake email from the ADM reflected submission was sent into the state agency on 05/26/2025 at 3:58 PM, and not within two hours of incident despite Resident #1 suffering from facial bruising. <BR/>A telephone interview was attempted to LVN B on 05/28/2025 at 12:44 PM, but there was no answer.<BR/>During an interview on 05/28/2025 at 1:14 PM, the MCD stated that she was called by LVN B that an incident occurred and involved Resident #1. The MCD stated that she contacted the DON and ADM immediately after speaking with LVN B. <BR/>During an interview on 05/28/2025 at 1:27 PM, the ADM stated he was made aware of the incident with Resident #1 on 05/25/2025 after 4:00 PM and before 5:00 PM. The ADM stated that LVN B contacted him and LCD reached out as well. The ADM stated that it was reported there was an altercation between FM and Resident #1. The ADM stated that Resident #1's RP was notified as well as the staff that were working to assess and separate FM and Resident #1. The ADM stated that all other residents in memory care were assessed, and a police report was made. The ADM stated that in order to protect other residents, Resident #1 was placed on 1:1 supervision and FM was asked to leave the building and instructed that he was not allowed inside the building. The ADM stated he had a discussions with FM via telephone on 05/27/2025 that visitation could be held outside and would be supervised. The ADM stated FM was informed he was not allowed back in the building at this time in order to protect all the residents. The ADM stated FM was confused initially and FM believed his (FM) actions were justified. The ADM stated there were no concerns with FM's actions or behaviors until 05/25/2025. The ADM stated that prior to the incident Resident #1 had no behavioral concerns or physical aggression prior to the incident. The ADM stated Resident #1 would stay on 1:1 supervision for his safety and the safety of other residents. <BR/>2. Review of Resident #2's face sheet dated 05/28/2025 reflected a [AGE] year-old man admitted on [DATE] and discharged on 04/13/2025 with diagnoses of diagnoses of idiopathic epilepsy and epileptic syndromes (group of syndromes characterized by seizures without identified brain abnormalities), chronic pain syndrome (pain lasting longer than three to six months), other specified disorders of the brain (wide range of brain conditions), and dysphagia (difficulty swallowing). <BR/>Review of Resident #2's discharge MDS dated [DATE] reflected no BIMS score was not completed due to Resident #2 discharged from the facility. Further review reflected there was no physical symptoms directed towards others in the 7 days prior to the assessment. <BR/>Review of Resident #2's care plan dated 03/06/2025 reflected he had a physical functioning deficit with transfers and required assistance. Interventions reflected to use a Hoyer with transfers. There were no behaviors noted in Resident 2's care plan. <BR/>Review of skin assessment dated [DATE] for Resident #2 reflected no bruising or open areas noted, there were no reddened areas, open areas (cuts/tears) found. <BR/>Review of Resident #3 face sheet dated 05/28/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia (cognitive functioning severe enough to affect daily life where type cannot be determined), other abnormalities of gait and mobility (clumsy, unsteady movements), other lack of coordination (wide range of conditions where there is a disruption in the body's ability to coordinate movements), and unspecified glaucoma (condition of fluid buildup in the eye tat can cause vision loss or blindness). <BR/>Review of Resident #3 quarterly MDS dated [DATE] reflected Resident #3 had a BIMS score of 7 which indicated severe cognitive impairment. Further review reflected Resident #3 had no physician behavioral symptoms directed toward others 7 days prior to the assessment. <BR/>Review of Resident #3's care plan dated 04/19/2025 reflected Resident #3 had little or no awareness of safety or no boundaries and went into other resident's rooms. Interventions reflected to re-direct Resident #3 to his room to rummage through items safely, invite him to participate in activities and offer opportunities for social interaction. <BR/>Review of Resident #3's care plan dated 06/05/2025 reflected he had behaviors which included being aggressive with others. Interventions included help residents avoid situations or people that are upsetting and attempt interventions before behaviors begin. <BR/>Review of incident report dated 04/06/2025 reflected RN A was outside of Resident #3's room and he kicked open Resident #2's door and entered the doorway of Resident #2's room. Resident #2 asked Resident #3 to leave his room and Resident #2 stated before I kick your [Resident #3's] ass. Resident #3 responded do it and Resident #2 punched Resident #3 in the face. Further review reflected DON, family and NP were notified and RN A separated the residents. Incident report reflected no injuries were noted on either resident. Further review reflected Resident #3 was confused and wandered into other residents' rooms. <BR/>Review of investigation summary by the ADM dated 04/07/2025 reflected nursing reported an incident that occurred on 04/06/2025 between Resident #2 and Resident #3. Further review reflected Resident #3 wandered into Resident #2's room and a dispute was heard by nursing and intervened and separated both residents. Resident #3 and Resident #2 lived on separate halls and were assessed with no signs of bruising or marks. The ADM stated he spoke with Resident #2 and he stated there was an argument and Resident #3 did not recall. The ADM stated there were no concerns or lasting effects. <BR/>During an interview on 05/28/2025 at 4:19 PM, RN A stated that Resident #3 tended to wander door to door and kicked the doors open with his foot to other resident rooms. RN A stated she was charting and Resident #3 kicked open Resident #2's door. RN A stated Resident #2 told Resident #3 to quit and get away from the door. RN A stated when she turned she saw Resident #2 was at the door and hit Resident #3. RN A stated that she reported it to the physician, family member and reported it to the DON. RN A stated that she assessed each resident and completed a head-to-toe assessment and there were no injuries. RN A stated that Resident #3 was the only resident who was hit. RN A stated the residents were separated and removed from the area. RN A stated that any resident-to-resident incidents should be reported to the DON and the ADM. RN A stated looking back she saw that resident-to-resident incident could have been abuse and neglect. RN A stated at the time she thought it was just an incident and only did an incident report. <BR/>Review of TULIP on 05/28/2025 reflected no intakes were submitted by the facility related to incident between Resident #2 and Resident #3. <BR/>During an interview on 05/28/2025 at 4:33 PM, DON stated the incident occurred prior to his role as DON at the facility. DON stated that all emergencies were reported to him and the ADM. <BR/>During an interview on 05/28/2025 at 5:07 PM, the ADM stated that he was made aware of the incident with Resident #3 and Resident #2 but could not recall when exactly. The ADM stated that he spoke with nursing and it was stated Resident #3 was going down the hallway and Resident #2 stated Resident #3 to get out of the room. The ADM stated nursing intervened and no injuries were found. The ADM stated he spoke with both residents the next day and they had no concerns. The ADM stated he was not able to confirm Resident #2 struck Resident #3. The ADM stated an investigation was conducted but he was unable to confirm that Resident #2 stuck Resident #3 and he understood from RN A that a commotion was overheard. The ADM stated staff are educated on abuse and neglect at least three or four times a year. <BR/>During an interview on 06/05/2025 at 12:06 PM, the ADM stated that prior to the incident on 04/06/2025 Resident #3 wandered. The ADM stated Resident #3 would be up and active in activities and during that time he would have an eye on him. The ADM stated that interventions included redirection, trying to keep his mind stimulated and offered activities. The ADM stated Resident #3 would also visit his ex-spouse who was also a resident at the facility and that he enjoyed eating meals with her. The ADM stated that prior to the incident there was nothing reported that Resident #3 had wandered into other residents' rooms just that he wandered in general. The ADM stated potential harm for increased wandering behaviors was that other residents could be startled. <BR/>3. Review of Resident #4's face sheet dated 05/28/2025 reflected Resident #4 was admitted on [DATE] and discharged on 04/02/2025 as a hospice respite resident with diagnoses of senile degermation of brain (various neurological disorders that cause ongoing decline in cognitive functioning, memory and reason), essential hypertension (high blood pressure) and pain unspecified (discomfort that does not have a clear cause or a particular area of the body).<BR/>Review of Resident #4's discharge MDS dated [DATE] reflected Resident #4 was unable to complete the BIMS assessment. Further review reflected Resident #4 had a fall since admission and a major injury from 1 fall. <BR/>Review of Resident #4's progress note by RN A dated 03/30/2025 reflected Resident #4 was found on floor in his room and had complaints of pain to right hip and an order was received for an x-ray. <BR/>Review of incident report by RN A dated 03/30/2025 with a time of 7:30 PM reflected Resident #4 was found in his room on the floor. Resident #4 was confused and unable to express how he got onto the floor. Vitals were taken and on-call NP was notified. There were no injuries observed at the time of the incident. Resident #4 had complaints of right hip pain. Pre-disposing factors included non-compliance with care. <BR/>Review of provider investigation reported dated 04/07/2025 reflected incident was reported to HHSC on 04/02/2025 despite x-ray results being returned to the facility on [DATE]. Review of investigation summary reflected it was unable to determine how the fall occurred and hospice opted to treat in-house. <BR/>Review of Resident #4's orders reflected he had an order to monitor for pain every shift dated 03/31/2025. <BR/>Review of Resident #4's March and April 2025 MARS reflected there was no pain indicated during any shift between 03/31/2025 and 04/02/2025. <BR/>Review of Resident #4's physician orders dated 03/28/2025 reflected he had an order for morphine sulfate .25 ml to give every hour as needed for mild pain and 1 mg to give every hour as needed for severe pain. Resident #4 was administered .25 m1 of morphine one time on 03/30/2025.<BR/>Review of Resident #4's radiology results report reflected report date was 03/31/2025 at 1:06 AM, with examination date on 03/30/2025 at 10:33 PM. Findings reflected right sub capital impaction fracture with minimal callus and mild displacement. Findings reflected mild degenerative changes were seen. <BR/>During an interview on 05/28/2025 at 4:19 PM, RN A did not recall Resident #4 or his fall. RN A stated fall interventions included to have the bed in a low position. RN A stated if an x-ray returned with a fracture, family, physician and DON were made aware of any findings. <BR/>During an interview on 05/28/2025 at 4:36 PM, CNA G stated that if she found a resident had a fall she would let the nurse know and make sure the resident was safe. CNA G stated that residents were not to be moved after a fall until they were assessed. CNA G stated that she prevented falls with residents by clearing clutter, providing resident with a walker if needed and ensure they had proper footwear. <BR/>During an interview on 05/28/2025 at 4:42 PM, CNA H stated that fall prevention interventions included ensuring a resident had a low bed, a fall mat if the nurse let them know they needed one. <BR/>During an interview on 05/28/2025 at 4:49 PM, LVN I stated fall interventions included signs to call for help and educating a resident to use the call light for assistance. LVN I stated any x-ray that reveled a fracture would be reported to the doctor or on-call NP, ADM, DON and RP right away. <BR/>During an interview with 05/28/2025 at 4:55 PM, LVN J stated that after a fall a resident was assessed for injuries and then assisted to the bed or chair. LVN J stated that interventions for falls included keeps residents within eyesight, frequent rounding and to have bed in a low position. LVN J stated that an x-ray that revealed a fracture would be reported to the doctor and DON right away. <BR/>During an interview on 05/28/2025 at 5:07 PM, the ADM stated after he was made aware of an allegation of abuse or neglect he had 24 hours to report it to the state agency. The ADM stated he expected staff to report any resident-to-resident altercation. The ADM stated that he was made aware of the incident with Resident #2 and Resident #3 and that he spoke with RN A and that she reported Resident #2 stated for Resident #3 to get out of Resident #2's room but nursing intervened and confirmed there were no injuries. The ADM stated he spoke with both Resident #2 and Resident #3 the following day (04/07/2025) and he was unable to confirm that Resident #2 struck Resident #3 and neither resident was able to recall the incident. The ADM stated that the DON at the time did speak with RN B and that RN B stated she overheard the two residents but was out in the hallway. The ADM stated that he did review the incident report for Resident #2 and Resident #3, but ADM was unable to confirm the altercation had occurred and that it was just a commotion. The ADM stated that an investigation was initiated, and he spoke with both residents. The ADM stated only incidents that involved immediate danger were reported within a two hour time frame. The ADM stated he was made aware of the results of Resident #4's x-ray midmorning on 03/31/2025 and that the results were returned late 03/31/2025. The ADM stated that there was no specific facility policy on reporting and that information was included in the facility abuse policy. <BR/>Review of facility in-service dated 03/31/2025 reflected topic was reviewed over preventing falls with all staff. <BR/>Review of facility in-service dated 03/31/2025 reflected program content of Elder Justice Act/ Resident Rights/ Reporting guidelines was covered with all staff. In-service included facility policy titled Elder Justice Act Reporting dated 03/13/2020 which reflected employee reporting requirements included employes to report reasonable suspicion of a crime to the state agency within a designated time frame. Further review reflected if the reportable event results in serious bodily injury, the staff member shall report the suspicion immediately, but not later than two (2) hours after forming the suspicion. If t he reportable event does not result in serious bodily injury, the staff member shall report the suspicion not later than 24 hours after forming the suspicion. <BR/>Review of facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy dated 01/219 reflected the purpose of the policy was to prevent abuse, neglect and exploitation and to ensure reporting and investigation of alleged violations (which included injuries of unknown source) in accordance with state laws. The policy defined injury of unknown source as source of the injury was not observed or could not be explained by the resident and the injury was suspicious because of the extent of the injury. Reporting and response section of the policy reflected all violations will be reported to the administrator immediately and immediately report all alleged violations to the administrator, state agency and/or law enforcement within specified timeframes. Specified time frames as indicated in policy reflected allegations with serious bodily injury should be reported immediately but not later than 2 hours after forming the suspicion. Allegations with no serious bodily injury should be reported no later than 24 hours. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of three residents (Resident #1) reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 had a physician's order for suctioning, and order for monitoring for secretions, or an order for when to replace the suction machine's cannister and tubing. <BR/>This deficient practice could place residents at risk of aspiration, aspiration pneumonia, or hospitalization. <BR/>Findings Included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including aspiration (inhaling something into your airway) of fluid as the cause of abnormal reaction, cerebral infarction (stroke), anoxic (lack of oxygen) brain injury, dysphagia (difficulty in swallowing), and hypoxemia (abnormally low level of oxygen in the blood). <BR/>Review of Resident #1's annual MDS assessment, dated 02/20/25, reflected a BIMS score of 99, indicating he was unable to complete the interview. Section K (Swallowing/Nutritional Status) reflected he had a feeding tube. Section O (Special Treatments, Procedures, and Programs) reflected he did not require suctioning as a respiratory treatment. <BR/>Review of Resident #1's quarterly care plan, revised 01/28/25, reflected he was dependent on tube feeding/inadequate oral intake due to dysphagia and NPO with an intervention of providing oral care daily or PRN. <BR/>Review of Resident #1's physician orders in his EMR, on 03/04/25, reflected no orders for suctioning, monitoring for secretions, or when to replace the suction machine's cannister or tubing.<BR/>Review of Resident #1's physician order, dated 07/16/24, reflected provide oral care every shift.<BR/>Review of Resident #1's hospital records, dated 02/21/25 - 02/24/25, reflected the following:<BR/> . admitted with altered mental status and hypoxia. [Resident #1] has a history of recurrent aspiration pneumonia. [Resident #1] was admitted to the floor and started on IV antibiotics . <BR/> . I do suspect that he still having silent aspiration .<BR/>During an observation and interview on 03/04/25 at 9:28 AM revealed Resident #1 lying on his bed utilizing continuous oxygen. He was struggling to breathe, there were secretions in his mouth, and was pointing to his suctioning machine on his bedside table. This Surveyor went to the nurses' station and let RN A know Resident #1 was in distress. RN A stated, Oh I am sure he needs me to suction him and went to his room. <BR/>During an interview on 03/04/25 at 12:08 PM, RN A stated Resident #1 was having secretions because he had a peg tube. He stated he had started having secretions since he recently came back from the hospital with aspiration pneumonia (02/24/25). He stated the order to suction was in his TAR under oral care and he was to be suctioned he believed every shift.<BR/>During an interview on 03/04/25 at 12:29 PM, the MDSC stated oral care was considered cleaning the residents' mouth with utensils to clean out residue and clean their teeth. She stated it was important to keep their mouths clean and moist. She stated residents that are NPO should receive the same oral care, but the staff needed to ensure the head of their beds were elevated to reduce the risk of aspiration. She stated suctioning would only be considered part of oral care if they needed to suction something from their mouth they could not remove while providing oral hygiene care. She stated if a resident needed regular suctioning to remove secretions, she would expect to see an order for PRN suctioning. She stated it was important because an order was needed for anything that was done for a resident, especially someone who was NPO who may be not able to tell you they needed it. She stated it was the responsibility of the nurses to get physician orders. She stated residents that were NPO did not get fluids through their mouths which could increase excessive secretions which could cause aspiration or aspiration pneumonia. She stated Resident #1 did not have excessive secretions in the past but was not sure if that had changed since his recent hospital visit. She stated she believed he would be a high potential for needing PRN suctioning due to him being a high-risk of aspiration and his history of aspiration pneumonia. She stated there should be an order to assess regularly for secretions, PRN suctioning if the nursing staff were regularly utilizing the suctioning machine, and when to change out the cannister and tubing. <BR/>Review of the facility's undated Airway Management Policy reflected the following:<BR/> .<BR/>2. Review patient's electronic health record (EHR), including health care provider's order and nurses' notes for patient's normal pulse oximeter values, baseline and trends in respiratory rate and effort for breathing, frequency of suctioning, and response to suctioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in experimental research, and to formulate advance directives for 3 of 10 residents (Resident #1, #4 and #65) reviewed for advance directives. The facility failed to ensure that Resident #1's out of hospital DNR was uploaded to the electronic health record and the care plan was updated.The facility failed to ensure that Resident #4's out of hospital DNR was signed by the physician and uploaded to the electronic health record on [DATE].The facility failed to ensure that Resident #65's out of hospital DNR was signed by the physician and uploaded to the electronic health record on [DATE]. These failures could place residents at-risk of having their wishes dishonored, and of having CPR performed against their wishes. Findings included: Record review of Resident #1's Face sheet dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included pneumonia, dysphagia pharyngoesophageal phase (inability to empty from the throat to the esophagus), hypertension (high blood pressure), dementia (memory, thinking, difficulty), history of falling, pain in shoulder, asthma, dependency on wheelchair, chronic obstructive pulmonary disease (chronic progressive lung disease), anemia (not enough healthy red blood cells), hyperlipidemia (high cholesterol), respiratory failure, kidney failure, and urinary tract infection. Record review of Resident #1's admission MDS dated [DATE] reflected she had a BIMS Score of 07, indicating severe impairment (significate limitation of basic work activity).Record review of Resident #1's Care Plan dated [DATE] revealed Resident # 1's advance directive was a full code. Record review of Resident #1's electronic health record on [DATE] at 02:23 PM reflected no Out of Hospital DNR in the electronic health record. Record review of the Out of Hospital DNR revealed an Out of Hospital DNR was signed on [DATE] and uploaded to Resident #1's medical record on [DATE] at 3:45pm.Record review of Resident #1's Doctor's Orders revealed a doctor's order dated [DATE] was signed for a DNR directive. Record review of Resident #4's admission record, dated [DATE], revealed an [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), hyperlipidemia (abnormally high level of fats in the blood), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs).Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS of 01, which indicated severe cognitive impairment. Record review of Resident #4's order summary, dated [DATE], revealed Do Not Resuscitate with an order date [DATE]. Record review of Resident #4's electronic health record revealed an out of hospital DNR form dated [DATE]. Review of Resident #4's out of hospital DNR revealed under the section titled Physician's Statement no signature by the physician, no date, no printed name, and no license number. Further review revealed under All persons who have signed above must sign below, acknowledging that this document has been properly completed, no signature by the physician. Record review of Resident #4's care plan, dated [DATE] and last revised on [DATE], revealed Resident #4 had chosen to do not resuscitate with goal Patient's wishes will be honored.Review of Resident #65's face sheet dated [DATE] revealed Resident #65 was admitted on [DATE] and readmitted on [DATE] with a primary diagnosis of cerebral infarction (a stroke occurs when the blood vessels in the brain are blocked). The advance directive listed was DNR. The resident was in the secured unit. Review of Resident #65's care plan dated [DATE] revealed resident selected a DNR code status. Goal listed was patient's wishes will be honored. Review of Resident #65's quarterly MDS dated [DATE], revealed a BIMS score of 09, which indicated moderate cognitive impairment. Review of Resident #65's clinical record revealed an OOH-DNR form dated [DATE]. Further review revealed that under the section all persons who have signed above must sign below, acknowledging that this document has been properly completed there was no signature from the physician. During an interview on [DATE] 03:23 PM with the DON, he stated there was not a central location for DNR forms. He stated all residents' DNRs should be in their electronic health record. During an interview on [DATE] at 03:11 PM with the WC LVN, she stated a physician's signature was required on the out of hospital DNR for it to be valid. She stated medical records was responsible for uploading valid out of hospital DNRs to the electronic health record. The WC LVN stated if a valid out of hospital DNR was not in the electronic health record, then the resident may be given CPR even though their wishes were for do not resuscitate.During an interview on [DATE] at 04:10 PM with the MDS LVN, she stated all out of hospital DNR forms require the physician to sign in 2 separate areas on the form for it to be valid. She stated the SW was responsible for ensuring the DNR form was completed correctly and uploaded to the electronic clinical record. The MDS LVN stated if there was not a valid DNR in the electronic health record then the facility must act as if the resident is a full code, and they are required to start CPR. During an interview on [DATE] at 04:40 PM with the SW, she stated that a valid out of hospital DNR required 2 signatures from the physician for it to be valid. She stated she thought medical records, or the nursing department was responsible for ensuring out of hospital DNRs are completed correctly. The SW stated medical records were responsible for uploading the out of hospital DNRs to the residents' electronic health record. She stated if a valid DNR was not in the electronic health record then that could be a huge situation because [the facility staff] would not know [the resident's] preferences in an emergency.During an interview on [DATE] at 04:49 PM with the MR LVN, she stated the physician must sign an out of hospital form in 2 places for it to be valid. She stated she and the SW were responsible for ensuring out of hospital forms are completed correctly. She stated if there was an order for the resident to have DNR as their code status, then the resident's wish would be honored in the facility, but if the resident were sent out to the hospital, their wishes might not be honored in route to the hospital because of not having a valid DNR. During an interview on [DATE] at 5:06 PM with the DON, he stated a physician's signature is required on the out of hospital DNR form for it to be valid. He stated the SW, and nurses were responsible for ensuring the out of hospital DNRs were completed correctly and were valid. The out of hospital DNR was supposed to be uploaded immediately after obtaining all the necessary signatures. He stated if a valid DNR was not in the electronic health record, then families may get upset because a resident might be revived despite their/the family's wishes. During an interview on [DATE] at 05:35 PM with the ADM, he stated a physician's signature was required on the out of hospital DNR form to make it valid. He stated previously nursing leadership was responsible for ensuring the out of hospital DNR was completed correctly, but with the new company it is the SW's responsibility. He stated the SW was responsible for uploading valid DNR forms to the residents' electronic health record. The ADM stated, if a valid out of hospital DNR is not in the electronic health record, then the resident may get CPR against their wishes. Record review of, undated, facility policy titled, Self Determination End of Life Measures revealed .Competent adults may issue advance directives in accordance with applicable state laws.Upon admission, the facility will provide the individual with a copy of his/her rights under Texas law concerning the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.If the resident has already executed an advanced directive, the facility will obtain a copy and place it on the clinical record. The facility will respect the wishes of the resident as outlined in the advance directive. The primary nurse will note the resuscitation status of the resident on all applicable clinical records. Also, document whether the resident has executed the advance directive.The facility will ensure compliance with the requirements of Texas law concerning appropriate health care provisions when a resident has not provided written documentation for his/her advance directive, has not made a decision regarding his/her advance directive, or is incapacitated.Record review of health and safety code 166.083(b)(4)(6) dated [DATE] revealed an OOH-DNR order at minimum must contain statement that the physician signing the document is the attending physician of the person and that the physician is directing health care professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue certain life-sustaining treatment on behalf of the person and places for the printed names and signatures of the witnesses or the notary public's acknowledgment and for the printed name and signature of the attending physician of the person and the medical license number of the attending physicianFurther review of health and safety code 166.089(3) dated [DATE], revealed an OOH-DNR order form appears valid when it includes the signature or digital or electronic signature of the declarant or persons executing or issuing the order and the attending physician in the appropriate places designated on the form for indicating that the order form has been properly completed.

**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 that included measurable objectives and timeframes to meet the residents' medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment for 2 of 10 residents (Residents #1 and #7).1. The facility failed to ensure the care plan was updated when Resident #7's code status was changed from full code to DNR on [DATE].2. The facility failed to ensure the care plan was updated when Resident #1's code status was changed from full code to DNR on [DATE].This failure could place residents at-risk of having their wishes dishonored, and of having CPR performed against their wishes.Findings included:Record review of Resident #7's admission record, dated [DATE], reflected a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs), type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), and bipolar disorder (a mental illness that causes extreme mood swings). The advance directive listed was DNR. Record review of Resident #7's change of condition MDS, dated [DATE], reflected she had a BIMS of 11, indicating moderate cognitive impairment.Record review of Resident #7's care plan, dated [DATE], dated [DATE], reflected Resident #7 was a full code. Record review OOH revealed an Out of Hospital DNR was signed on [DATE]. Record review of Resident #7's Order Summary, dated [DATE], revealed an order Do Not Resuscitate with a start date [DATE]. Record review of Resident #1's Face sheet dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included pneumonia, dysphagia pharyngoesophageal phase (inability to empty from the throat to the esophagus), hypertension (high blood pressure), dementia (memory, thinking, difficulty), history of falling, pain in shoulder, asthma, dependency on wheelchair, chronic obstructive pulmonary disease (chronic progressive lung disease), anemia (not enough healthy red blood cells), hyperlipidemia (high cholesterol), respiratory failure, kidney failure, and urinary tract infection. Record review of Resident #1's Quarterly MDS dated [DATE] revealed she had a BIMS Score of 07, indicating severe impairment. Record review of Resident #1's Care Plan dated [DATE] revealed Resident #1 was a full code. Record review of the OOH revealed an Out of Hospital DNR was signed on [DATE] and uploaded to Resident #1's medical record on [DATE].Record review revealed a doctor's order dated [DATE] was signed for a DNR directive. During an interview on [DATE] at 04:10 PM with the MDS LVN, she stated the SW was responsible for updating care plans when the advance directives change. She stated if the care plan did not align with the resident's decision for advance directives, then the resident might get CPR even though they chose DNR. During an interview on [DATE] at 04:40 PM with the SW, she stated when a resident chose to change their advance directives to DNR, then the DNR is uploaded to the electronic health record, and the care plan should be changed. She stated she was unsure if she was supposed to update the care plan or if it was the MDS LVN that was responsible. She stated if the care plan did not reflect the resident chose to be DNR then in an emergency the staff would be unaware of how to proceed and may give the resident CPR against their wishes. During an interview on [DATE] at 04:49 PM with the MR LVN, she stated when a resident chose DNR as their advance directives, then their care plan needed to be updated. She stated the facility had transitioned to new owners and was unsure who was responsible for updating the care plans. The MR LVN stated if the care plans were not updated to reflect the resident's choice for DNR then it might cause confusion in the event of an emergency, and the resident could be given CPR. During an interview on [DATE] at 05:06 PM with the DON, he stated once a resident completes the paperwork to change their code status to DNR, then the paperwork is uploaded into the electronic health record, their title bar is changed and their care plan should be updated. He stated he believed it was the MDS LVN's responsibility to change the care plan, but it could be a shared responsibility. He stated this was checked during the resident's quarterly care plan meeting. He stated if the care plan did not reflect the resident chose DNR, then the resident may be revived with CPR, and it could affect their future quality of life.During an interview on [DATE] at 05:35 PM with the ADM, he stated that once a change in advance directives was received, then it was documented in the electronic health record, the DNR form was uploaded into the chart, and the care plan was updated to reflect the resident's wishes. He stated that all changes in advance directives was reviewed in the morning meetings by management. He stated if the care plan was not updated with the resident's wishes for DNR, then the facility may go against the resident's wishes and start CPR. Record review of undated facility policy titled, Comprehensive Care Planning reflected, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following: .the right to refuse treatment.Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices, and goals during their stay at the facility.Person-centered care means the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices.Residents' preferences and goal may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one of two residents (Resident #4) reviewed for pressure injuries. The facility failed to ensure wound care was performed as ordered by the wound care doctor for Resident #4. Resident #4 missed 6 wound care treatments in July 2025 and August 2025. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain.Findings included:Record review of Resident #4's admission record, dated 08/06/2025, revealed an [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), hyperlipidemia (abnormally high level of fats in the blood), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs).Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS of 01, which indicated severe cognitive impairment. Section M (Skin Conditions) revealed she had one or more pressure ulcers/injuries.Record review of Resident #4's care plan, dated 07/17/2025 and last revised on 07/29/2025, revealed Focus: The resident has a pressure ulcer or potential for pressure ulcer development with Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness.Record review of Resident #4's order summary, dated 08/06/2025, revealed Cleanse stage IV pressure wound to right heel wound with normal saline or wound cleanser, apply collagen and cover with calcium alginate and protective foam secured with kerlix and tape one time a day for right heel wound with an order date of 07/08/2025.Record review of Resident #4's treatment administration record for July 2025 and August 2025 revealed Resident #4 had no wound care treatment signed off on the following dates: 07/19/2025, 07/20/2025, 07/24/2025, 08/02/2025, 08/03/2025, and 08/04/2025. Record review of Resident #4's most recent wound care physician note, dated 07/29/2025, revealed Wound Progress: Improved evidenced by decreased necrotic [dead] tissue, decreased surface area.Attempted phone interview with wound care physician on 08/07/2025 at 02:23 PM, no answer, voicemail was left but no return call prior to exit.During an interview on 08/07/2025 at 03:11 PM with the WC LVN, she stated she was responsible for wound care treatments when she was scheduled to work. She stated when she is off work the charge nurses are responsible for providing wound care to the residents. The WC LVN stated wound care was signed off on the treatment administration record after completion of wound care. She stated Resident #4 had a stage IV (a pressure injury that is characterized by full-thickness tissue loss that exposes underlying muscle, tendon, or bone) pressure wound to the right heel. She stated the wound care for Resident #4 was to clean with saline/wound cleanser, the apply collagen powder, cover with calcium alginate, the secure with a foam dressing. The WC LVN stated wound care was ordered for Resident #4 to be performed daily. She stated Resident #4 had a wound care physician assess the wound on a weekly basis. She stated, after reviewing the treatment administration record, that it appeared no wound care treatments were performed on 07/19/2025, 07/20/2025, 07/24/2025, 08/02/2025, and 08/03/2025. The WC LVN stated she worked on 08/04/2025 and performed wound care but forgot to check it off on the treatment administration record. She stated she was upset after providing wound care on 08/04/2025 because she removed the same dressing that she applied on 08/01/2025. She stated the dressing she removed had her initials and the date of 08/01/2025 indicating that no wound care was provided the two days prior. The WC LVN stated she notified the DON but did not document it in the chart. She stated the wound did not show signs of deterioration from not receiving wound care over the previous two days. The WC LVN stated if wound care was not performed as ordered on a daily basis, then the wound could deteriorate or get worse. During an interview on 08/07/2025 at 04:10 PM with the MDS LVN, she stated the WC LVN was responsible for wound care during the week and the charge nurses were responsible for wound care on the weekends. She stated she thought the ADON did a weekly audit to ensure treatments and medications were administered as ordered. The MDS LVN stated it was policy to sign off on the treatment administration record once the treatment was performed. She stated if wound care was not being performed as ordered, then the wound could deteriorate even with one missed treatment. Attempted a phone interview on 08/07/2025 at 04:49 PM with the charge nurse responsible for wound care on 08/02/2025 and 08/03/2025, but no answer. A voicemail was left but a return call was not received prior to exit. During an interview on 08/07/2025 at 05:06 PM with the DON, he stated the WC LVN was responsible for wound care, but when she was not at work, then the charge nurse was responsible for providing the treatment. The DON stated he and the ADON were responsible for running an audit report to ensure treatments were being performed as ordered. He stated it is policy to sign off in the treatment administration record once the wound care had been performed. He stated the effectiveness of the wound care treatment was determined by the measurements and reports received from the wound care physician provided with their weekly visits. The DON stated the nurse that was responsible for wound care on 07/19/2025 and 07/20/2025 was no longer working at the facility. The DON stated if wound care was not done, the wound could get worse, the resident could get septic (a life-threatening medical emergency caused by the body's extreme response to an infection), or the resident could develop osteomyelitis (an infection in the bone). He stated, even a few days can make it go from good to horrible. During an interview on 08/07/2025 at 05:35 PM with the ADM, he stated the WC LVN or charge nurses were responsible for performing wound care treatments as ordered by the wound care physician. He stated he expected staff to sign off on the treatment administration record once the treatment has been performed. He stated he was unsure of the current wound care being provided to Resident #4. He stated if wound care was not performed daily as ordered then the progression of healing could be reversed, and the wound could get worse. Record review of facility policy titled Wound Treatment Management, dated 2021, revealed Policy:To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.-Policy Explanation and Compliance Guidelines:1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.7. Treatments will be documented on the Treatment Administration Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) (for Resident #8) to meet the needs of each resident for 1 of 1 medication storage room and 1 of 3 (hall 1 nurses' medication cart) medications cart reviewed for pharmacy services. The facility failed to ensure expired medications were removed from the medication storage room and the hall 1 nurses' medication cart on 08/07/2025. The facility failed to ensure that the narcotic count sheet accurately reflected the amount of Resident #8's phenobarbital (a controlled medication used in the treatment of seizures) stored in the hall 5 nurses' medication cart. This failure could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose, and/or adverse reactions from receiving medications past their expiration date. Findings included: 1. Record review of Resident #8's admission record, dated 08/07/2025, reflected a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including epilepsy (a long-term neurological disorder characterized by recurrent, unprovoked seizures), cognitive communication deficit (problem with communication caused by cognition rather than a language or speech deficit), and cerebral palsy (a neurological disorder that affects body movement and muscle coordination caused by abnormal brain development or damage to the brain during pregnancy, childbirth, or shortly after birth). Record review of Resident #8's quarterly MDS, dated [DATE], reflected a BIMS was not conducted due to him rarely/never being understood. Section C - Cognitive Patterned reflected Resident #8 had memory problem with short-term and long-term memory. Record review of Resident #8's order summary, dated 08/07/2025, reflected Phenobarbital Oral Elixir 20MG/5ML (Phenobarbital) Give 15 ml via PEG-tube [a tube surgically inserted directly to the stomach for nourishment and medication administration] two times a day for seizures. An observation on 08/07/2025 at 08:26 AM of hall 5 nurses' medication cart with the WC LVN revealed a bottle of phenobarbital that was full, manufacturer label stated 473ml, 2/2 was handwritten on the top of the bottle. The bottle of phenobarbital had a prescription label for Resident #8. The narcotic count sheet revealed under the amount remaining column 1397. Record review of Resident #8's phenobarbital narcotic count sheet reflected 2 bottles of phenobarbital was received from the pharmacy on 07/17/2025 in the amount of 946 ml, but the staff member that received the medication doubled that starting amount to 1892 ml. During an interview on 08/07/2025 at 08:28 AM with the WC LVN, she stated she had just received the keys and did not count with the previous person due to being nervous about medication administration observation. She stated it appeared the staff member who received the medication doubled the amount of medication received because there were two bottles, and everyone had just subtracted the amount taken instead of counting what was there. During an observation and interview on 08/07/2025 at 08:48 AM, the DON was notified of the miscalculation and medication reconciliation (corrected medication count) with 973 ml was completed by the DON and WC LVN together. The DON stated the medication form appeared to be miscalculated due to the first incorrect calculation. He stated it was his expectation that staff count the medication in front of them and not calculate the remaining amount based off previous totals. He stated he would start an in-service for staff related to correctly counting narcotics. An observation on 08/07/2025 at 11:22 AM of the medication storage room (facility had only one) with the ADON revealed three bottles of Oyster Shell Calcium with Vitamin D 500mg-5mcg with an expiration date of 06/2025. During an interview on 08/07/2025 at 11:28 AM with the ADON, she verified the three bottles of medication (Calcium with Vitamin D) were expired. She stated all nursing staff with access to the medication room were responsible for checking for expired medications. The ADON stated there was not a specific staff member or timeline assigned for checking the medication storage room for expired medications. She stated the DON periodically checked to ensure staff were checking the medication storage room for expired medications. The ADON stated medication may lose their effectiveness if given to a resident past the expiration date. An observation on 08/07/2025 at 12:42 PM of the hall 1 nurses' medication cart with LVN G revealed one bottle of Bismuth Subsalicylate 525mg/30ml with an expiration date of 08/2024. During an interview on 08/07/2025 at 12:53 PM with LVN G, she verified the bottle of medication (Bismuth Subsalicylate) was expired. LVN G stated she had worked at the facility for 2 weeks. She stated she was unsure who was responsible for checking for expired medications on the medication carts. She also was unsure of how often the carts were checked for expired medications. LVN G stated if an expired medication was administered to a resident, then the medication may not be as effective, or the resident could develop an illness including an upset stomach. During an interview on 08/07/2025 at 03:11 PM with the WC LVN, she stated all the nurses were responsible for checking the medication storage room for expired medications, and she stated she was unsure how often the medication storage room was being checked. The WC LVN stated she was unsure if anyone verified the medication storage room was being checked for expired medications. She stated the nurses and medication aides assigned to the medication cart were responsible for checking for expired medications daily. The WC LVN stated she was unsure if anyone verified the medication carts were checked for expired medications. The WC LVN stated if an expired medication was administered to a resident, the medication may not be as effective. She stated the off-going and on-coming nurse are responsible for counting the controlled medications anytime the keys to the medication cart changed hands. She stated the resident could negatively be impacted by not counting each time the keys changed hands, because the resident may run out of medication faster than reflected on the count sheet and miss a dose. During an interview on 08/07/2025 at 04:10 PM with the MDS LVN, she stated she was unsure who or how often the medication storage room was checked for expired medications. The MDS LVN stated the nurses were responsible for checking all medication carts for expired medications, but she stated she was unsure how often the medication carts were checked. The MDS LVN stated if an expired medication was administered to a resident, the medication may not have the intended effect. She stated the charge nurse was responsible for counting the controlled medications between each shift. She stated if the medications were not counted correctly, then the resident could run out of medication sooner than expected which could possibly lead to seizures. During an interview on 08/07/2025 at 04:49 PM with the MR LVN, she stated all nursing staff with access to the medication storage room were responsible for checking the medication storage room for expired medication at least one time a month. She stated the nurses and medication aides responsible for the medication carts were responsible for checking the medication carts for expired medications weekly. The MR LVN stated if an expired medication were administered to a resident, then the resident might have an adverse reaction like, diarrhea, stomach pain, or an intolerance to the medication. She stated the nurses were responsible for counting all controlled medications at shift change. She stated she did not think that by not counting the medication accurately, it could negatively affect a resident. During an interview on 08/07/2025 at 05:06 PM with the DON, he stated he expected the central supply person and charge nurses to check the medication storage room daily for expired medications. He stated there was not a process in place for ensuring the medication storage room was checked. The DON stated he expected the nurses and medication aides to check the medication carts every shift for expired medications. He stated there was not a process in place for ensuring the medication carts were checked for expired medications. The DON stated if a resident was given an expired medication, then the resident could have an adverse reaction like anaphylaxis (an allergy to something that can cause the throat to swell and close) and it would also me a medication error. The stated he expected the charge nurses and medications aides to count the controlled medications in the medication carts each shift. He stated he sign off sheets that indicated staff counted together every other day or so. He stated if the controlled medication count sheets were not accurate then the resident might be billed for more medication than is allowed or the resident could possibly miss a dose due to lack of medication. During an interview on 08/07/2025 at 05:35 PM with the ADM, he stated he expected the nursing team to check the medication room for expired medications at least monthly. He stated he expected the nurses to check the medication carts for expired medications daily. The ADM stated the nursing administration team was responsible for verifying expired medications were removed from the medication carts weekly. The ADM stated he was unsure how administering expired medication could negatively impact a resident. He stated the nurses were responsible for counting all controlled medications in their medication cart during shift change. He stated nursing management monitored for the nurses to count the controlled medications daily. The ADM stated if the controlled medications were not counted accurately, then a resident may miss a dose of medication. Record review of facility policy titled Medication Storage in the Facility, dated 2025, revealed: Policy.Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedure.13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exits[spelling?]. Record review of facility policy titled Storage of a Controlled Substance, dated 2003, and facility policy titled Medication Storage in the Facility, dated 2025, revealed no mention counting medication.Record review of facility in-service titled Narcotic Count, dated 08/07/2025, revealed .Accurate count when receiving medication and narcotic count each shift is crucial.1. When receiving any type of controlled substances whether it is from pharmacy or an admission, two signatures are required for verification.2. Narcotic count is required at shift change or when another staff member takes over the cart at any time.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 3 (hall 1 nurse's medication cart) Nurse's medication carts reviewed. 1. The facility failed to ensure the nurses' medication cart for hall 1 was secured by a lock when it was left unattended by LVN G on 08/07/2025.These failures could place residents at risk of illness or injury due to missing medication or if unattended medication were consumed. Findings included:An observation on 08/07/2025 at 10:23 AM on hall 1 revealed the nurses' medication cart for hall 1 was left unattended and unlocked.During an interview on 08/07/2025 at 10:25 AM with LVN G, she stated she was responsible for the hall 1 nurses' medication cart that was left unlocked. She stated she forgot to lock the medication cart when she walked down hall 1. She stated leaving the medication cart unlocked could negatively impact a resident because anyone could get into the medication cart and take something they are not supposed to. During an interview on 08/07/2025 at 03:11 PM with the WC LVN, The WC LVN stated the policy of the facility was to lock the medication cart to secure it any time staff walked away from it. She stated it was the responsibility of the staff member who had the keys to the cart to lock the cart. The WC LVN stated if a medication cart were left unlocked, then a resident could get into the medications, take a medication that was not meant for them, and have an adverse reaction, or a medication may go missing and the resident might miss a dose. During an interview on 08/07/2025 at 04:10 PM with the MDS LVN, The MDS LVN stated the policy for securing the medication carts was to take the keys and lock it anytime staff walk away from the medication cart. She stated the staff member with the keys to the medication cart was responsible for ensuring it was secured when they walk away from it. She stated securing the medication carts was monitored daily during walking rounds by management staff. The MDS LVN stated a resident could take a medication that was not meant for them, or a resident could access an ointment meant for the skin and eat it. During an interview on 08/07/2025 at 04:49 PM with the MR LVN, The MR LVN stated the facility's policy was too close and lock the medication cart anytime the staff member responsible for the cart walked away from it. She stated nursing management did walking rounds two times a day and ensuring the medication carts were closed and locked was included in the rounds. The MR LVN stated, if a medication cart was left unlocked, then a resident could take a medication not meant for them and it could cause adverse reactions like dizziness and falls. During an interview on 08/07/2025 at 05:06 PM with the DON, The DON stated the policy was to lock all medication carts when left unattended. He stated it was the responsibility of the staff member who was signed off responsibility of the cart at the beginning of their shift to keep the cart locked when left unattended. He stated all staff were responsible for monitoring if a cart was left unlocked. The DON stated if a medication cart were left unlocked, then residents could take something out of the medication cart or put something in the medication cart that did not belong there. He stated, it is a serious safety issue. During an interview on 08/07/2025 at 05:35 PM with the ADM, The ADM stated it was his expectation that staff lock the medication carts anytime they walk away from it. He stated all staff monitor for the medication carts to be locked during their rounds. The ADM stated, if a medication cart were left unlocked, then there is a possibility a resident could get into the medication cart and get something that is not theirs and take it, and that could lead to side effects. Record review of facility policy titled Medication Storage in the Facility, dated 2025, revealed Policy.Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedure.2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g., medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety for 3 of 5 residents (Residents #5, Resident #20, and Resident #78) reviewed for smoking. The facility failed to keep Residents #5, Resident #20, and Resident #78's cigarettes and lighters in a safe place per their policy. This failure placed all residents at risk for serious injury, harm, and/or death due to possible fire or smoking inside the building. Findings Included: Resident #5 Record review of Resident #5's Face sheet dated 08/06/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included end stage renal disease, unsteadiness on feet, limitation of activities due to disability, atrial fibrillation (abnormal heart rhythm), chronic obstructive pulmonary disease (chronic progressive lung disease), dementia (memory, thinking, difficulty), low back pain, hyperlipidemia (high cholesterol), legal blindness, hypertension (high blood pressure), insomnia (difficulty sleeping), and tobacco use. Record review of Resident #5's Annual MDS dated [DATE] reflected he had a BIMS Score of 12, indicating moderate impairment. The MDS revealed Resident #5 was a current tobacco user. Record review of Resident #5's Care Plan dated 06/22/2025 revealed Resident #5 was an everyday smoker. Interventions in place was Keep lighter at nurses' station along with cigarettes in smoking box, maintain appropriate level of supervision as determined by smoking assessment, Resident #5 will only smoke in designated smoking areas and smoking apron as indicated. Record review of Resident #5's Smoking assessment dated [DATE] revealed that resident is safe to smoke unsupervised at this time, and all smoking materials will be kept at the nurses station. Resident #20 Record review of Resident #20's Face sheet dated 08/06/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20 had diagnoses which included cerebral infraction (stroke), dementia (memory, thinking, difficulty), seasonal allergies, non-ST elevation myocardial infarction (a type of heart attack characterized by reduced blood flow to the heart, leading to heart muscle damage), type 2 diabetes mellitus with unspecified complications (high blood sugar), hyperlipidemia (high cholesterol), and cardiomyopathy (a disease of the heart muscle). Record review of Resident #20's Quarterly MDS dated [DATE] reflected he had a BIMS Score of 09, indicating moderate impairment. The MDS did not indicate Resident #20 was a current tobacco user. Record review of Resident #20's Care Plan dated 05/29/2025 revealed Resident# 20 was an everyday smoker. Interventions in place was Assist to and from designated smoking area, assure smoking material is extinguished prior to patient leaving smoking area, observe patient for unsafe smoking behaviors or attempts to obtain smoking materials from outside sources, patient not to have cigarettes or smoking material on person, provide smoking apron while smoking and place patient in position to assure visualization of ashtray. Record review of Resident #20's Smoking assessment dated [DATE] revealed that resident is safe to smoke unsupervised at this time, and all smoking materials will be kept at the nurses station. Resident # 78 Record review of Resident #78's Face sheet dated 08/06/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #78 had diagnoses which included multiple fractures of the pelvis, protein-calorie malnutrition (inadequate intake of both protein and calories), type 2 diabetes mellitus without complications (high blood sugar), and personal history of transient ischemic attack (a short period of symptoms like those of a stroke). Record review of Resident #78's admission MDS dated [DATE] reflected he had a BIMS Score of 09, indicating moderate impairment. The MDS did not indicate Resident #78 was a current tobacco user. Record review of Resident #78's Care Plan dated 07/31/2025 revealed Resident# 78 smoked. Interventions in place was Ensure smoking occurs in designated smoking areas, ensure that no oxygen is located in the smoking area while the resident is smoking, no smoking materials or igniter's will be stored in the resident rooms, safe smoking assessment every month, and this resident is safe to smoke unsupervised, at this time. Record review of Resident #78's Smoking assessment dated [DATE] revealed that resident is safe to smoke unsupervised at this time, and all smoking materials will be kept at the nurses station. Observation of smoking on 08/05/2025 at 4:08 p.m., revealed there were five residents outside for the smoke break. Resident #20 was observed with a pack of cigarettes in her bra, Resident #5 was observed pulling a pack of cigarettes and a lighter out of his pocket. Resident #78 was observed with a pack of cigarettes in her pocket. During an interview on 08/06/2025 12:00 PM with Resident #5 revealed that he had been given instructions on smoking. He said it covered where he goes to smoke and the times that he can smoke. He said the smoking area is outside of Hall 3. He said staff are available when they smoke. He said that the facility gave all the smoking residents a smoking apron. He said he was able to keep his cigarettes on him until recently. He said that the facility just took them from him yesterday because State was here. He said when he had his cigarettes he would keep them in a drawer in his room. During an interview on 08/06/2025 12:05 PM with Resident #20 revealed that she was given the smoking instructions. She said it covered that she could not smoke inside the facility. She said that she had to go outside to the smoking area to smoke. She said that the smoking area is at the end of Hall 3. She said she does not use an apron when she is in the smoking area. She said that she was able to keep her cigarettes and lighter. She said they took her cigarettes and lighter yesterday. She said that she would keep her cigarettes in her bra or in her drawer. She also said that she had people come in and take things from her room in the past. During an interview on 08/06/2025 2:25 PM with Resident #78 revealed that the facility let her keep her cigarettes until 08/05/2025. She said she wanted to know why the facility took her cigarettes from her. She said the facility let her keep them when she got to the facility. She said that the facility did go over the instructions on smoking today with her. She said the facility told her they would start keeping the cigarettes in a clear box. She said the facility instructed her that the staff would take the residents out to smoke during the designated smoking times. She said the smoking area was at the end of hall 3. She also said when she was able to keep her cigarettes she would put them in her top drawer. During an interview on 08/07/2025 11:50 AM with the AD revealed that she had been trained on the smoking policy. She said the training covered the residents must wear aprons, staff must be present while residents are smoking, and the residents are allowed only two cigarettes during the smoke break. She said that there was a list of staff that take the residents out to smoke. She was not sure how often the residents were assessed for safe smoking. She said that residents were not allowed to keep their cigarettes and lighters on them. She said they have never been able to keep them. She said the smoking material is kept in a box at the nurse's station. She said the residents could burn themselves or another resident could get ahold of the cigarettes if the resident kept them. She said that all staff were responsible for monitoring to ensure that the residents did not keep their cigarettes and lighters. She said the staff monitor it by taking the cigarettes after the smoke breaks. She said that Residents #5, Resident #20, and Resident #78 have not had any smoking accidents. She said she did not know why Residents #5, Resident #20 and Resident #78 had their cigarettes and lighters. During an interview on 08/07/2025 3:46 PM with MA E revealed that he had been trained on smoking policy. He said the policy for smoking was that the resident had to smoke outside in the designated area. He said that the residents had to put the smoking apron on before they smoked. He said that the residents were allowed to have two cigarettes and staff had to be present while the residents smoked. He said that different staff take the residents out at different times. He said the residents were educated daily on the smoking policy because they wanted to go outside to smoke all day long. He said the interventions were that the facility had specific times, aprons and staff were there when residents smoked for interventions. He said the residents are a part of the interventions planning and it is discussed when the facility does the residents care plan. He said that residents are not allowed to keep their smoking materials. He also said the residents have never been allowed to keep their smoking materials. He said if residents kept their smoking materials, they could hurt themselves or others. He said that everyone was responsible for monitoring to ensure residents do not have their smoking materials. He said that he did not know why Residents #5, Resident #20 and Resident #78 had their cigarettes and lighters on them. He said that Residents #5, Resident #20, and Resident #78 have not had any smoking related accidents. During an interview on 08/07/2025 5:05 PM with the DON revealed he had been trained on smoking policy. He said the smoking policy was that the facility did a smoking assessment to ensure they are safe to smoke. He said staff take the residents out to smoke and keep the residents in the line of sight. He said that when the residents are done smoking the staff were to collect all the cigarettes and lighters from the residents. He said that the safe smoking assessments were done quarterly. He said that the residents were educated daily on smoking rules because they want to go outside all day long. He said that the interventions in place were aprons, red cigarette cans, the safe smoking assessments and staff present when residents are smoking. He said that the activity director does include the resident in the decision of the interventions. He said the residents were not allowed to keep their smoking materials on them. He said if residents kept their cigarettes and lighters other residents could get ahold of them. He said that all staff were responsible for ensuring the residents do not have their smoking materials. He said staff monitored it by observations and when the smoking break is over. He said he did not know why Residents #5, Resident #20 and Resident #78 had their smoking materials. He also said that none of the residents have had any smoking accidents. During an interview with the ADM on 08/07/2025 at 5:35pm revealed that he had been trained on smoking policy. He said the policy for smoking was that the resident could smoke during the designated times with staff present. He said that staff were assigned to take the residents out to smoke during the smoking times. He said that residents were assessed for safe smoking monthly. He also said that the residents were educated on the smoking rules at least quarterly. He said that interventions in place were the assessments, the residents wearing the aprons, and staff monitoring the residents. He said residents are a part of the smoking intervention decisions. He said that residents were not allowed to keep their smoking materials on them. He said if residents kept their smoking material they might try to smoke in their room or give cigarettes to other residents. He said all staff were responsible for ensuring that residents did not have their smoking materials. He said that it was monitored through observation and the staff would confiscate it when they see a resident with smoking materials. He said he did not know why Residents #5, Resident #20 and Resident #78 had their smoking material on them. He said Residents #5, Resident #20 and Resident #78 have not had any smoking related accidents. Record review of the Smoking Policy dated 11/1/2017 revealed matches, lighters or other ignition sources for smoking are not permitted to be kept or stored in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one of two residents (Resident #4) reviewed for pressure injuries. The facility failed to ensure wound care was performed as ordered by the wound care doctor for Resident #4. Resident #4 missed 6 wound care treatments in July 2025 and August 2025. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain.Findings included:Record review of Resident #4's admission record, dated 08/06/2025, revealed an [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), hyperlipidemia (abnormally high level of fats in the blood), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs).Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS of 01, which indicated severe cognitive impairment. Section M (Skin Conditions) revealed she had one or more pressure ulcers/injuries.Record review of Resident #4's care plan, dated 07/17/2025 and last revised on 07/29/2025, revealed Focus: The resident has a pressure ulcer or potential for pressure ulcer development with Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness.Record review of Resident #4's order summary, dated 08/06/2025, revealed Cleanse stage IV pressure wound to right heel wound with normal saline or wound cleanser, apply collagen and cover with calcium alginate and protective foam secured with kerlix and tape one time a day for right heel wound with an order date of 07/08/2025.Record review of Resident #4's treatment administration record for July 2025 and August 2025 revealed Resident #4 had no wound care treatment signed off on the following dates: 07/19/2025, 07/20/2025, 07/24/2025, 08/02/2025, 08/03/2025, and 08/04/2025. Record review of Resident #4's most recent wound care physician note, dated 07/29/2025, revealed Wound Progress: Improved evidenced by decreased necrotic [dead] tissue, decreased surface area.Attempted phone interview with wound care physician on 08/07/2025 at 02:23 PM, no answer, voicemail was left but no return call prior to exit.During an interview on 08/07/2025 at 03:11 PM with the WC LVN, she stated she was responsible for wound care treatments when she was scheduled to work. She stated when she is off work the charge nurses are responsible for providing wound care to the residents. The WC LVN stated wound care was signed off on the treatment administration record after completion of wound care. She stated Resident #4 had a stage IV (a pressure injury that is characterized by full-thickness tissue loss that exposes underlying muscle, tendon, or bone) pressure wound to the right heel. She stated the wound care for Resident #4 was to clean with saline/wound cleanser, the apply collagen powder, cover with calcium alginate, the secure with a foam dressing. The WC LVN stated wound care was ordered for Resident #4 to be performed daily. She stated Resident #4 had a wound care physician assess the wound on a weekly basis. She stated, after reviewing the treatment administration record, that it appeared no wound care treatments were performed on 07/19/2025, 07/20/2025, 07/24/2025, 08/02/2025, and 08/03/2025. The WC LVN stated she worked on 08/04/2025 and performed wound care but forgot to check it off on the treatment administration record. She stated she was upset after providing wound care on 08/04/2025 because she removed the same dressing that she applied on 08/01/2025. She stated the dressing she removed had her initials and the date of 08/01/2025 indicating that no wound care was provided the two days prior. The WC LVN stated she notified the DON but did not document it in the chart. She stated the wound did not show signs of deterioration from not receiving wound care over the previous two days. The WC LVN stated if wound care was not performed as ordered on a daily basis, then the wound could deteriorate or get worse. During an interview on 08/07/2025 at 04:10 PM with the MDS LVN, she stated the WC LVN was responsible for wound care during the week and the charge nurses were responsible for wound care on the weekends. She stated she thought the ADON did a weekly audit to ensure treatments and medications were administered as ordered. The MDS LVN stated it was policy to sign off on the treatment administration record once the treatment was performed. She stated if wound care was not being performed as ordered, then the wound could deteriorate even with one missed treatment. Attempted a phone interview on 08/07/2025 at 04:49 PM with the charge nurse responsible for wound care on 08/02/2025 and 08/03/2025, but no answer. A voicemail was left but a return call was not received prior to exit. During an interview on 08/07/2025 at 05:06 PM with the DON, he stated the WC LVN was responsible for wound care, but when she was not at work, then the charge nurse was responsible for providing the treatment. The DON stated he and the ADON were responsible for running an audit report to ensure treatments were being performed as ordered. He stated it is policy to sign off in the treatment administration record once the wound care had been performed. He stated the effectiveness of the wound care treatment was determined by the measurements and reports received from the wound care physician provided with their weekly visits. The DON stated the nurse that was responsible for wound care on 07/19/2025 and 07/20/2025 was no longer working at the facility. The DON stated if wound care was not done, the wound could get worse, the resident could get septic (a life-threatening medical emergency caused by the body's extreme response to an infection), or the resident could develop osteomyelitis (an infection in the bone). He stated, even a few days can make it go from good to horrible. During an interview on 08/07/2025 at 05:35 PM with the ADM, he stated the WC LVN or charge nurses were responsible for performing wound care treatments as ordered by the wound care physician. He stated he expected staff to sign off on the treatment administration record once the treatment has been performed. He stated he was unsure of the current wound care being provided to Resident #4. He stated if wound care was not performed daily as ordered then the progression of healing could be reversed, and the wound could get worse. Record review of facility policy titled Wound Treatment Management, dated 2021, revealed Policy:To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.-Policy Explanation and Compliance Guidelines:1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.7. Treatments will be documented on the Treatment Administration Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability of services of a lesser intensity, for two of four residents (Resident #1 and Resident #2) reviewed for specialized rehabilitative services, in that:<BR/>The facility failed to:<BR/>- Ensure Resident #1 received PT and OT as ordered.<BR/>- Ensure Resident #2 was evaluated for PT, OT, or ST upon admission as ordered in her admission clinical records.<BR/>This failure could place residents at risk of decline or decrease in their physical capabilities. <BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility for aftercare following joint replacement surgery. Her diagnoses included unsteadiness on feet, age-related physical debility, and other reduced mobility. <BR/>Review of Resident #1's admission MDS assessment, dated 04/04/24, reflected a BIMS of 15, indicating she had no cognitive impairment. Section J (Health Conditions) reflected she had a major surgical procedure (hip replacement) requiring active care during the SNF stay. Section O (Special Treatments, Procedures, and Programs) reflected she had one day of OT four days of PT in the past seven days.<BR/>Review of Resident #1's baseline care plan, dated 03/29/24, reflected no focuses related to therapy or post-operation care.<BR/>Review of Resident #1's physician orders, dated 03/29/24, reflected the following:<BR/>PT Clarification: PT services 5x/week for 5 weeks<BR/>OT Clarification: [Resident #1] to be seen QDx5x8wks<BR/>Review of Resident #1's PT documentation, on 04/12/24, reflected she received PT services on 03/30/24, 04/03/24, and 04/05/24. <BR/>On 04/08/24 it was documented that a therapist was unavailable and on 04/11/24 it reflected [Resident #1] declines participation with PT on this date reporting increased knee pain, stomach cramps, and legs hurting despite pain medication.<BR/>Review of Resident #1's OT documentation, on 04/12/24, reflected she received OT services on 04/07/24 and 04/11/24.<BR/>Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), muscle wasting and atrophy (wasting away), major depressive disorder, and other lack of coordination. <BR/>Review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS of 6, indicating a severe cognitive impairment. Section O (Special Treatments, Procedures, and Programs) reflected she was not receiving any PT or OT.<BR/>Review of Resident #2's quarterly care plan, revised 02/09/24, reflected she had impaired neurological status related to cardiovascular accident (stroke) and hemiplegia/hemiparesis (paralysis) on the right side with an intervention of observing her for changes in condition.<BR/>Review of Resident #2's MD assessment/admission clinical records, dated 10/11/23, reflected the following:<BR/>HPI: [Resident #2] is here to initiate nursing home admittance to (facility).<BR/>Orders: PT and OT for ROM and balance<BR/>Orders: ST for cognitive therapy<BR/>Review of Resident #2's NP progress note, dated 11/07/23, reflected the following:<BR/> . Recommend following up with therapy PT/OT eval .<BR/>Review of Resident #2's OT documentation, dated 02/21/24, reflected she was evaluated for OT services with a goal of being able to pull her pants up.<BR/>Review of Resident #2's PT documentation, dated 03/06/24, reflected she was evaluated for PT services with a goal of getting her right leg strong.<BR/>During an observation and interview on 04/12/24 at 9:48 AM revealed Resident #1 and #2 sitting outside. Resident #1 stated she had received therapy maybe three times since she was admitted . She stated she had her hip replaced and it was important to her that she get strong enough to go back to living independently at her home. She stated the therapy she was receiving was inadequate and she was discharging from the facility the following Wednesday, 04/17/24, with home health services. She stated she had used the home health agency in the past and believed they provided more effective therapy than she was receiving at the facility. Resident #2 then stated when it came to therapy, she had not received shit since she was admitted . She was irritated and stated she could not understand why. She stated they (staff) had told her she was on some kind of damn list.<BR/>During an interview on 04/12/24 at 10:04 AM, the ADON stating there had been issues with the therapy department. She stated they utilized a contract agency for therapy services and the DOR had been struggling to get staffing. She stated there were therapists at the facility five days a week but they were never the same days. She stated her expectations were that Resident #1 was getting therapy five times a week. She stated she was not sure if that had been happening. She stated Resident #2 recently got evaluated for PT and OT and they were waiting on her insurance to approve the services.<BR/>During an interview on 04/12/24 at 11:42 AM, the DOR stated she was notified in morning meetings when residents needed therapy evaluations. She stated she was never notified about Resident #2 needing therapy until she verbally requested it. She stated they were still waiting on her insurance for approval. She acknowledged Resident #1 had only received PT three times and OT twice since her admission. She was unable to give any explanation as to why that happened except, she stated she had been out sick earlier in the week (04/08/24 - 04/10/24) and since she was the main PTA, PT was not provided those days. She stated they have a COTA who provides OT Thursdays - Sundays, except they did not come the previous Thursday - Sunday (03/28/24 - 03/31/24) and was looking into why they did not come. She then stated the COTA was PRN and did not have a set schedule. She stated a negative outcome of residents not receiving therapy as ordered could be a decline in physical ability and they would not meet their goals.<BR/>During an interview on 04/12/24 at 12:37 PM, the ADM stated her expectations were that therapy was provided as ordered. She stated she did not have a DON so it was the responsibility of the ADON and the MRD to review clinicals upon a resident's admission. She stated neither her current ADON or MRD were working at the facility when Resident #2 was admitted and she had not known she should have been receiving therapy. She stated her current DOR had already put in her two weeks and she (the DOR) had been irresponsible with her leadership. She stated the DOR had not been utilizing the tools she had. She stated she was out earlier in the week (DOR) and did not even notify her leadership to ensure another PT was sent to the facility. She stated they had already ensured therapists would be at the facility today and carrying on through next week. She stated if residents did not receive therapy per their orders, a negative outcome could be they may not meet their goals.<BR/>Review of the facility's Frequency/Duration/Intensity of Therapy Services, dated 2024, reflected the following:<BR/>It is the policy that therapists both employees and contractors determine frequency, duration, and intensity of therapy services to provide to each patient for optimal functional outcomes and expectation of improvement of quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 20 (Resident #15) residents reviewed for dining services in 1 of 1 dining room.<BR/>The facility failed to promote Resident #15's dignity while dining when staff did not serve the resident their lunch tray at the same time as other residents at the same table for lunch on 07/09/2024. <BR/>This failure could affect all residents who were eat in the dining room, by contributing to poor self-esteem, and unmet needs.<BR/>Findings included:<BR/>Review of Resident #15's Face Sheet dated 07/09/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included dementia (memory, thinking difficulty), abnormality of albumin (problems with liver and kidney function), epiphora due to insufficient drainage (excessive watering of the eye), stenosis of right lacrimal punctum (narrowing of the external opening of the eye), stenosis of left lacrimal punctum (narrowing of the external opening of the eye), age related nuclear cataract (hardening of the center part of the eye), hypertensive retinopathy (damage to blood vessels in the eye due to high blood pressure), vitamin D deficiency, muscle wasting, lack of coordination, cerebral infraction (long term effects of a stroke), hypokalemia (low potassium levels), abdominal pain, repeated falls, need for assistance with personal care, unsteadiness on feet, iron deficiency, hyperlipidemia (high cholesterol), Alzheimer's disease (brain disorder that gets worse over time), mood disorder, nutritional anemia (not enough healthy red blood cells), type 2 diabetes mellitus with unspecified complications (high blood sugar), hypo-osmolality and hyponatremia (low plasma sodium), depression, hypertension (high blood pressure), muscle weakness, age related osteoporosis (skeletal disorder), dysphagia (difficulty swallowing), difficulty walking, cognitive communication deficit (problems with communication), and symbolic dysfunctions (development disorder of speech and language). <BR/>Record review of Resident #15's Quarterly MDS dated [DATE] revealed that Resident #15's BIMs score was 8 which meant the resident was moderately impaired . <BR/>Resident #15's comprehensive care plan dated 11/04/2023 revealed resident had impaired communication due to impaired cognition and hearing difficulty.<BR/>Review of Resident #35's Face Sheet dated 07/09/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included anxiety, anterior subcapsular polar (cloudiness in the eye), nuclear cataract (hardening of the center part of the eye), long term use of anticoagulants (blood clot medication), osteoarthritis (joint disease), post COVID, history of falling, difficulty walking, lack of coordination, weakness, pain in the spine, abnormal posture, need for assistance with personal care, unsteadiness on feet, abnormalities of gait and mobility, atrial fibrillation (abnormal heart rhythm), muscle wasting, hypo-osmolality and hyponatremia (low plasma sodium), basal cell carcinoma of skin (skin cancer), cognitive communication deficit (problems with communication), muscle weakness, and chronic embolism and thrombosis of unspecified vein (blood clots in blood vessels).<BR/>Record review of Resident #35's Quarterly MDS stated 02/08/2024 revealed she had a BIMs score of 99, which meant Resident #35 was unable to complete the assessment for mental status. <BR/>Observation of dining services on 07/09/2024 at 12:00pm revealed that resident #35 received her meal tray at 12:08pm while her table mate Resident #15 did not get her tray until 12:23pm. Observation further revealed that after Resident #35 got her meal tray staff passed trays to the all the other residents in the dining room before realizing Resident #15 did not have her meal tray. <BR/>An interview with Resident #15 on 07/09/2024 at 12:31pm revealed the resident did not want to talk to the state surveyor. <BR/>An interview with CNA C on 07/11/2024 at 8:23am revealed the policy for dining tray pass was that all residents at the same table were to receive their meal trays before staff move on to the next table. CNA C stated that the nurses were responsible for ensuring all residents at the same table have their trays before passing trays to another table. She stated the negative outcome of a resident not getting his or her tray at the same time could result in the resident could become upset about not getting his or her food. She stated she did not know why Resident #15 did not get her tray before staff moved onto the next table. <BR/>An interview with CNA B on 07/11/2024 at 8:30am revealed the policy for dining tray pass was that all residents get their trays before moving on to the next table. CNA B stated that the nurses and aids were responsible for ensuring all residents at the same table had their trays before passing trays to another table. She stated that sometimes the kitchen gets busy, and the kitchen does not have their food as reason they may have to wait for their food. She stated the outcome of a resident not getting their food at the same time could be that the resident felt left out. <BR/>An interview with the DON on 07/11/2024 at 8:40am revealed the policy for dining tray pass was that all the trays for a table should come out together. She stated the nurse and everyone in the dining room was responsible for ensuring all residents at a table had their meal tray before moving to the next table. She stated by a resident not getting his or her meal tray at the same time as their table mate could result in emotional issues or the resident feeling left out. She stated she does not know why Resident #15 did not get her meal tray at the same time as her table mate. She stated staff must pay better attention.<BR/>An interview with the ADM on 07/11/2024 at 8:48pm revealed to the policy for .dining tray pass was to make sure everyone gets fed at the same time before moving on. She stated that all staff were responsible for ensuring all residents had their meal tray at the table before moving on. She stated by not giving residents their meal trays at the same time the resident may feel forgotten. She stated she did not know why Resident #15 was not given her meal tray at the same time as her table mate. She stated the resident should have gotten her meal tray. <BR/>Record Review of Dining and Meal Service Policy dated 08/01/2012 revealed individuals at the same table will be served and assisted at the same time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 5 residents (Resident #47) reviewed for resident rights.<BR/>The facility failed to ensure Resident #47's call light was within reach on 07/11/24. <BR/>This failure could place residents at risk of needs not being met. <BR/>Findings included: <BR/>Record review of Resident #47's admission Record dated 07/11/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities), dysphagia (difficulty swallowing, cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of the bones wear down).<BR/>Record review of Resident #47's Quarterly MDS dated [DATE] revealed a BIMS of 99 indicating Resident #47 could not complete the assessment. Section GG-Functional Abilities and Goals revealed Resident #47 was dependent with bathing, toileting hygiene, and personal hygiene . <BR/>Record review of Resident #47's progress notes dated 05/13/24 revealed Hoyer for transfers, call light within reach.<BR/>In an observation on 07/11/24 at 9:51 AM Resident #47's call light was on the floor and out of residents reach. Resident #47 was in bed resting quietly with eyes closed and blankets pulled up to chest area. Resident #47 opened his eyes when the state surveyor called his name but was non-verbal. Resident #47 appeared clean, groomed, and no foul odors or areas of concern were noted. Resident #47 was not in any sign of pain or distress. <BR/>In an interview on 07/11/24 at 09:59 AM with MA, she stated she had been trained on call light placement. She stated she had always made sure the residents call lights were in their reach and that the residents had whatever they needed prior to leaving the residents rooms. She stated if a resident did not have their call light in reach, it could have caused an accident to happen, or the resident would not have been able to call for help. She stated the resident call lights should be in reach at all times. <BR/>In an observation on 07/11/24 at 10:09 AM, Resident #47's call light remained on the floor and out of residents reach. <BR/>In an interview on 07/11/24 at 10:11 AM, LVN A stated Resident #47's call light should not be on the floor. She stated call lights should always be in the residents reach and she had been trained on call light placement. She stated if a call light were not in reach that could potentially cause a resident to not be able to call for help, the resident could be in pain or distress, and could have needed help. She stated she had been trained on call light placement.<BR/>In an interview on 07/11/24 at 10:25 AM, CNA A stated she had been trained on call light placement. She stated the call lights should always be within reach. She stated if a call light were not in residents reach, a resident could have choked or could not call for help. <BR/>In an interview on 07/11/24 at 10:34 AM the ADM stated staff were trained on call light placement. She stated call lights should be in place and within residents reach. She stated all staff were responsible for ensuring residents call lights were in place and within reach of residents. She stated if a call light were out of a residents reach, it could cause an incident or accident to occur. <BR/>In an interview on 07/11/24 at 10:45 AM, the DON stated the nurses and CNAs were responsible for the residents call light placement. She stated staff were trained on call light placement. She stated residents call lights should always been within reach. She stated if a residents call light was not in reach, incidents could possibly happen, and the resident may not be able to call for help.<BR/>07/11/24 at 10:49 AM Requested policies for call light placement from the DON. <BR/>07/11/24 at 11:24 AM Requested policies for call light placement from the Administrator.<BR/>Record review of documents given from the ADM from a book titled Clinical Nursing Skill & Techniques 10th Edition Volume 1 written by authors Perry-[NAME]-[NAME]-LaPlante revealed in chapter 14 on page 382 that residents safety begins with patient's immediate environment and call button should be in reach and call system should be easily accessible. Chapter 14 on page 383 revealed Maintain call light within reach. Chapter 18 on page 545 revealed 16. Be sure nurse call system is in an accessible location within patient's reach. Feet and nails often require special care to prevent infection, odors, pain, and injury to soft tissues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure resident rights for personal privacy for 4 of 6 residents (Resident # 6, Resident # 14, Resident #20, and Resident # 43) residents reviewed for personal privacy.<BR/>The facility failed to knock on Resident #6, #14, #20, and #43's room when going into the residents' rooms. <BR/>The deficient practice could affect all residents right to privacy in the facility and cause the resident to feel like their privacy was being invaded or the facility was not their home. <BR/>Findings included:<BR/>Review of Resident #6's Face Sheet dated 07/10/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6's diagnoses included senile degeneration of brain, protein deficiency, COVID, schizophrenia (mental disorder), major depressive disorder, nuclear cataract (hardening of the center part of the eye), mood disorder, abnormalities of gait and mobility, muscle wasting, expressive language disorder, muscle weakness, hypertension (high blood pressure), dysphagia (difficulty swallowing), lack of coordination, vitamin D deficiency, cognitive communication deficit (problems with communication), Asthma (breathing difficulty), type 2 diabetes mellitus with diabetic neuropathy (nerve damage due to diabetes), malaise (feeling of general discomfort), heart disease, bronchitis (inflammation in the lungs causing couch), muscle wasting, psychotic disorder with delusions, neuralgia and neuritis (severe pain due to damaged nerves), dementia (memory, thinking difficulty), type 2 diabetes mellitus with hyperglycemia (high blood sugar), solitary pulmonary nodule (small mass in the lung), anemia (not enough healthy red blood cells), hypothyroidism (too much iodine causing the thyroid to produce too much thyroid hormone), anxiety, insomnia (difficulty sleeping), chronic pain, chronic obstructive pulmonary disease (chronic progressive lung disease), duodenal ulcer (a break in the inner lining of the stomach), gastroparesis (delayed emptying of the stomach), scoliosis (irregular curve of the spine), muscle wasting, kidney disease, difficulty walking, abnormalities of gait and mobility, lack of coordination, and long term drug therapy.<BR/>Record review of Resident #6's Quarterly MDS revealed Resident #6 has a BIMs score of 9, indicating the resident did not understand or make self-understood most of the time. <BR/>Review of Resident #14's Face Sheet dated 07/10/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #14's diagnoses included intermediate dry stage (vision loss), open angle with borderline findings low risk (one or more eyes at risk of glaucoma), presence of intraocular lens (clear artificial lens), abnormality of albumin (problems with liver and kidney function), lack of coordination, dementia (memory, thinking difficulty), COVID, depression, dysphagia (difficulty swallowing), need for assistance with personal care, unsteadiness on feet, abnormalities of gait and mobility, hypothyroidism (too much iodine causing the thyroid to produce too much thyroid hormone), muscle weakness, lack of coordination, pain in left knee, type 2 diabetes mellitus without complications (high blood sugar), type 2 diabetes mellitus with chronic kidney disease (kidney disease due to diabetes), cerebral infraction (long term effects of a stroke), hypertension (high blood pressure), osteoarthritis of the knee (joint disease), and spinal stenosis (spaces inside the bones of the spine get too small). <BR/>Record review of Resident #14's Quarterly MDS revealed Resident #6 has a BIMs score of 2, indicating the resident did not understand or make self-understood. <BR/>Review of Resident #20's Face Sheet dated 07/10/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20's diagnoses included acute posthemorrhagic anemia (loss of large amount of blood quickly), hematemesis (vomiting of blood), open angle glaucoma, presence of intraocular lens (clear artificial lens), polyneuropathy (damage affecting the nerves roughly the same area on both sides of the body), COVID, reduced mobility, seizures, physical debility, hyperlipidemia (high cholesterol), lack of coordination, dysarthria and anarthria (severe speech sound disorder), need for assistance with personal care, dysphagia (difficulty swallowing), symbolic dysfunctions (development disorder of speech and language), abnormalities of gait and mobility, neuromuscular dysfunction of bladder (lack of bladder control), altered mental state, unsteadiness on feet, presence of neurostimulator (implanted device to shock the nerves), osteoporosis (skeletal disorder), pain in right shoulder, vitamin B12 deficiency, weakness, expressive language disorder, repeated falls, cognitive communication deficit (problems with communication), type 2 diabetes mellitus without complications (high blood sugar), bipolar disorder (extreme mood swings), major depressive disorder, glaucoma (eye disease), hypertension (high blood pressure), dysarthria following cerebral infraction (speech sound disorder after a stroke), rheumatoid arthritis (long term autoimmune disorder that primary affects joints), muscle wasting, and tremor (involuntary movement).<BR/>Record review of Resident #20's Quarterly MDS revealed Resident #6 has a BIMs score of 10, indicating the resident could understand or make self-understood. <BR/>Review of Resident #43's Face Sheet dated 07/10/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #43's diagnoses included disorder of bone density, overactive bladder, lack of coordination, abnormal posture, vitamin D deficiency, age related nuclear cataract (hardening of the center part of the eye), vitamin B12 deficiency, hypothyroidism (too much iodine causing the thyroid to produce too much thyroid hormone), hypertension (high blood pressure), embolism and thrombosis of unspecified vein (blood clots in blood vessels), constipation, pressure ulcer (bed sore), pain in joint, hematopoietic stem cell transplantation (cells that can develop into all types of blood cells ), muscle weakness, heartburn, adverse effect of antifungal antibiotics (antibiotics that don't work), feed for assistance with personal care, connective tissue and disc stenosis (spinal disease), neuromuscular dysfunction of bladder (lack of bladder control), calculus of kidneys (kidney stones), and depressive disorder . <BR/>Record review of Resident #43's Quarterly MDS revealed Resident #6 has a BIMs score of 15, indicating the resident could understand or make self-understood. <BR/>Observation of hall trays being passed on 07/09/2024 at 12:00pm revealed CNA C not knocking on Resident #20 or Resident #14's doors before entering the room. <BR/>Observation of hall trays being passed on 07/10/2024 at 12:09pm revealed CNA C not knocking on Resident #6, Resident #14, Resident #20, and Resident # 43's doors before entering the room. <BR/>An interview with CNA C on 07/11/2024 at 8:20am revealed that staff were supposed to always knock on a resident's door before entering. She stated that it was important to knock before entering because the resident could be doing something or be by the door. She stated if you do not knock, and the resident was by the door they could get hurt when you open the door. She stated that if staff did not knock on the door before entering it could cause the resident to feel like his or her privacy was being invaded. She stated she was used to saying knock, knock instead of knocking. She stated it was hard to carry a meal tray with one hand and knock on the resident's door. <BR/>An interview with the AM on 07/11/2024 at 8:35am revealed that she had been trained on resident rights and knocking on a resident's door before entering. She stated the policy was staff were to knock and announce themselves and wait for the resident to tell them to come in. She stated it was important to knock before entering to ensure the resident's right to privacy. She stated that if staff do not knock on the door the resident could get upset or irritated and feel as if staff were invading their privacy. The AM stated that she was not aware that she did not knock on the resident's door before entering. <BR/>An interview with the DON on 07/11/2024 at 8:43am revealed she had been trained on resident rights and knocking on the resident's door before entering. She stated all staff were required to knock on the resident's door before entering their room. She stated it was important to knock for the resident's rights and privacy. She stated that if staff did not knock on a resident's door the resident could feel like they were not being respected or their privacy was being invaded. She stated that one staff did not knock on the resident's door because she was worried about dumping the tray. She stated the staff still should have knocked on the door. <BR/>An interview with the ADM on 07/11/2024 at 8:54pm revealed staff were supposed to knock before entering a resident's room. She stated all staff and visitors were supposed to knock before entering a resident's room. She stated that it was important to knock before entering to ensure the resident's right for privacy was not being violated. She stated that if staff did not knock on the door before entering the resident might have felt like staff were not respecting their rights. She stated that some staff would say knock, knock but staff should be knocking. <BR/>An interview with Resident #43 on 07/11/2024 at 8:58am revealed that most of the time staff knock on the resident's door. She stated it does not bother her. Resident #43 also stated that there are times staff do not know and most the time she does not even notice staff did not knock. <BR/>An interview with Resident #14 on 07/11/2024 at 9:01am revealed that sometimes staff knock. She stated she would like for staff to knock every time. She stated she did not know how she felt about staff not knocking. <BR/>Record review of DMS Policy & Procedure Review of Residents' Rights dated 05/01/2012 revealed:<BR/>When must you knock and ask permission to enter a resident's room? Always to protect their right to privacy. A possible exception may be when the resident is in a life-threatening situation and/or unable to respond. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1of 5 residents (Resident #45) reviewed for ADLs.<BR/>The facility failed to ensure Resident #45 was provided personal grooming (shower and shaving) by facility staff. <BR/>This failure could place residents at risk for discomfort, and dignity issues.<BR/>Findings include:<BR/>Resident #45<BR/>Record review of Resident #45's face sheet, dated 05/25/2023, revealed a-[AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included end stage renal diseases (kidney failure) heart failure, lack of coordination (inability to walk), Dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), cerebral infarction, (a brain lesion in which a cluster of brain cells die limiting blood supply to the brain) and respiratory failure.<BR/>Record review of Resident #45's Annual MDS assessment, dated 04/21/2023, revealed a BIMS score of 8 out of 15, reflected moderately impaired cognition. Section on Hospice was left blank reflecting he was not on hospice during the assessment period.<BR/>Section D on mood was coded 0 indicating no mood. <BR/>Section E behavior was coded 0 indicating no behavior issue.<BR/>Section G Functional status: reflected the following coding-<BR/>Transfer was coded 4 total dependance full staff performance every time. <BR/>Dressing was coded 3 staff assistance. Personal hygiene was coded was coded 3 staff assistance. <BR/>Section G bathing was coded 3 physical help in part of bathing activity <BR/>Record review of Resident #45's care plan dated 09/14/2020 with a revision date of 04/25/2023 read in part-Impaired neurological status related to cerebral vascular accident (stroke).<BR/>Goal Resident #45 will be free of skin breakdown. <BR/>Intervention: assist in ADL and mobility as needed<BR/>Record review of Resident #45's Care plan dated 05/07/2023 read in part, I required assistance to complete my ADLs and use a wheelchair for locomotion.<BR/>Goal: Resident #45 will maintain a sense of dignity by being clean, dry, and free of odor and be well groomed. Date initiated 05/07/2023 Revision date 07/24/2023.<BR/>Intervention: provide shower, shave and oral care, hair and nail per schedule and when needed.<BR/>Observation and interview on 05/23/2023 at 10:00 AM revealed Resident # 45 was in bed alert and oriented. Observation revealed he had facial hair around his face, and he had a hospital gown on with food stained from breakfast. His fingernails were about half an inch long with dark looking particles in between his fingernails. He said he would like to be cleaned and shaved.<BR/>During an interview with CNA' M on 05/23/2023 at 10:15AM, she looked at Resident #45 and said Resident #45 was on hospice and hospice usually bathed and cleaned him on his shower days which she said was Monday, Wednesday, and Friday. CNA M said if they don't show up, she would clean him because he needed to be clean. She told Resident #45 that she would clean him up.<BR/>Observation on 05/24/2023 at 1:20PM, revealed Resident #45's nails were dirty, he still had his hospital gown on, and he was unshaved. <BR/>During an interview with RN C on 05/24/2023 at 1:00PM, RN C said Resident #45 refused ADL care according to CNA' M. CNA' M was off duty. RN C said she did not document it. RN C asked Resident #45 if he would like to be shaved and clean up Resident #45 said yes. RN C said she would clean and shave Resident #45.<BR/>During an interview with the MDS coordinator on 05/24/2023 at 11:45AM, she said Resident # 45 was not on hospice. She said Resident # 45 was discharged from hospice in January of 2023.<BR/>Record review of the Facility's policy un-numbered and undated title ADL'S read in part, Ensure ADL's are provided in accordance with acceptable standard of practice, the care plan and reasonable accommodation of resident's choice .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 of 6 residents (Residents #10, Resident #60, Resident#131, and Resident #39) reviewed for the usage of wrist blood pressure monitor.<BR/>LVN C and LVN D did not clean and disinfect the wrist blood pressure monitor while using it on Resident #10, Resident # 39, Resident #60, and Resident #131.<BR/>This failure could place the residents at the facility at risk of transmission of disease and infection.<BR/>Findings included:<BR/>Review of Resident #10's face sheet dated 07/10/24 reflected, Resident #10 admitted to the facility on [DATE]. She was an [AGE] year-old female diagnosed with hypertension, atherosclerotic heart disease (plaque buildup in the artery walls), anemia, coronary artery disease (insufficient supply of blood to heart), peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms), chronic obstructive pulmonary disease (breathing difficulty), dysphagia (difficult to swallow), urinary tract infection, and arthritis (swelling and tenderness of one or more joints).<BR/>Record Review of Resident #10's MDS dated [DATE], reflected she was admitted on [DATE] and the MDS was still in progress.<BR/>Record Review of Resident #10's care plan dated 07/10/24 revealed she had impaired cardiovascular status related to coronary artery disease, hypertension, and peripheral vascular disease and the relevant intervention was observing for abnormal vital signs and report. <BR/>Review of Resident # 10's MAR for July 2024, reflected:<BR/>Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate): Give 0.5 tablet by mouth two times a day for blood pressure. Hold medication for BP below 110/55 or pulse below 55.<BR/>Review of Resident #39's face sheet, dated 07/10/24, reflected Resident #39 initially admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male diagnosed with hypertensive heart disease, cerebral palsy (conditions that affects posture and movements), dysphagia (difficult to swallow), speech disturbances, cognitive communication deficit, muscle wasting, slurred speech, abnormalities of gait and mobility, lack of coordination, hyperlipidemia (high fat level), unsteadiness on feet, and hypothyroidism (low thyroid hormones).<BR/>Record Review of Resident #39's annual MDS assessment dated [DATE], reflected he had a BIMS score of 13, indicating his cognition was intact. <BR/>Record Review of Resident #39's care plan dated 07/10/24 revealed, impaired cardiovascular status related to hypertension, hypothyroidism, and hyperlipidemia and relevant intervention was observing for abnormal vital signs and report. <BR/>Review of Resident # 39's MAR for July 2024 reflected: <BR/>Propranolol HCl Tablet 40 MG: Give 1 tablet by mouth two times a day for BP.<BR/>An observation of taking blood pressure using a wrist blood pressure monitor on 07/10/24 at 9:20 am revealed LVN C failed to sanitize the wrist blood pressure monitor after using it on Resident #10 and before using it on Resident #39. LVN C took the blood pressure of Resident #10 with the wrist blood pressure monitor and without sanitizing the monitor she kept it on the top of the medication cart. After administering the medications to Resident #10, she moved on to Resident #39 and used the same blood pressure monitor on him without sanitizing it. <BR/>During an interview on 07/10/24 at 10:05 am LVN C stated she was aware of the necessity of sanitizing the blood pressure wrist monitor after every use on the residents. LVN C said she practiced this her whole career as a nurse however forgot to do it on that day. She stated there was a danger of transmitting diseases from one resident to another if the equipment was not sanitized properly. LVN C stated she received trainings on infection control quite often however could not remember if there was any in-services specifically related to sanitation of medical equipment. <BR/>Review of Resident #60's face sheet, dated 07/10/24, reflected Resident #60 initially admitted to the facility on [DATE] and readmitted on [DATE]. She was an [AGE] year-old female diagnosed with dementia, chronic obstructive pulmonary disease (difficulty to breath), hypertension, peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms), cardiac murmur, cognitive communication deficit. and hyperlipidemia,<BR/>Record Review of Resident #60's Quarterly MDS assessment dated [DATE], reflected he had a BIMS score of 06, indicating severe cognitive impairment. <BR/>Record Review of Resident #60's care plan dated 07/10/24 revealed she had impaired coronary artery disease, hypertension, and peripheral vascular disease and the relevant intervention was observing for abnormal vital signs and report. <BR/>Review of Resident # 60's MAR for July 2024 reflected: <BR/>1.Carvedilol Oral Tablet 25 MG (Carvedilol) Give 1 tablet by mouth two times a day related to Essential (primary) Hypertension hold SBP &lt; 110 DBP &lt;60 HR &lt;60. <BR/>2. Amlodipine Besylate Oral Tablet 10 MG (Amlodipine Besylate): Give 1 tablet by mouth one time a day related to Essential.<BR/>(primary) Hypertension, Hold SBP &lt; 110 DBP &lt;60 HR &lt;60.<BR/>Review of Resident #131's face sheet, dated 07/10/24, reflected Resident #131 admitted to the facility on [DATE]. She was an [AGE] year-old female diagnosed with dementia, type 2 diabetes, chronic obstructive pulmonary disease (disease causes labored breathing) , hypertension, congestive heart failure ( Heart fails to function properly) , rheumatoid arthritis (autoimmune disease that affects mostly the joints) , and major depressive disorder.<BR/>Record Review of Resident #131's Initial MDS assessment dated [DATE], reflected he had a BIMS score of 03, indicating severe cognitive impairment. <BR/>Record Review of Resident #131's care plan dated 07/10/24 revealed she had impaired congestive heart failure, coronary artery disease, and hypertension and the relevant intervention was observing for abnormal vital signs and report. <BR/>Review of Resident # 131's MAR for July 2024, reflected: <BR/>Amlodipine Besylate Oral Tablet 10 MG (Amlodipine Besylate): Give 1 tablet by mouth one time a day for HTN hold for SBP less than 110 or DBP less than 55. HR less than 55. <BR/>An observation on 07/10/24 at 10:40 AM revealed, while taking blood pressure using a wrist blood pressure monitor LVN D failed to sanitize the wrist blood pressure monitor before and after using it on Resident #60 and Resident #131. LVN D took the blood pressure of Resident #60 with the wrist blood pressure monitor. She did not sanitize the monitor prior to using it on Resident #60. After the completion of taking blood pressure and medication administration to Resident #60, she moved on to Resident #131 and took blood pressure with the unsanitized blood pressure cuff. <BR/>During an interview on 07/10/24 at 1:15PM, LVN D stated sanitizing blood pressure cuffs in between the residents was important. She continued, mistakes could happen with anyone and the best way to resolve it was learning from their mistakes. LVN D stated following infection control protocol was important to minimize spreading diseases from one resident to another. LVN D stated she received trainings on infection control two weeks ago and there were no in-services on sanitizing medical equipment. <BR/>During an interview on 07/11/24 at 11:00AM the DON stated she started working as the DON at the facility on 07/09/24. She stated her expectation was the nursing staff following facility policy/procedure for handwashing and sanitization of medical equipment that included sanitizing the blood pressure monitor every time after the use on residents. She added, this was essential to stop spreading transmittable diseases. <BR/>During an interview on 07/11/24 at 11:00AM the IP stated she did audit rounds quarterly covering all the activities at the facility and based on the observed deficiency the training programs developed. She stated sanitizing medical equipment in between residents was mandatory since a compromise in this would spread diseases. She stated she conducted most of the in-services and did not remember if any inservice specific to sanitizing medical equipment was conducted. <BR/>Review of facility's policy titled Equipment and department cleaning/Maintenance Policy dated April,2020 reflected:<BR/> Each piece of equipment used for patient/resident care is to be cleaned with a center approved surface disinfectant before and after each patient use. This includes, but not limited to wheelchairs, blood pressure cuffs, glucometers, temperature probes, lifts, all therapy equipment, shower chairs, bedside tables, and scales Equipment should not be used between patients without being appropriately disinfected .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1of 5 residents (Resident #45) reviewed for ADLs.<BR/>The facility failed to ensure Resident #45 was provided personal grooming (shower and shaving) by facility staff. <BR/>This failure could place residents at risk for discomfort, and dignity issues.<BR/>Findings include:<BR/>Resident #45<BR/>Record review of Resident #45's face sheet, dated 05/25/2023, revealed a-[AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included end stage renal diseases (kidney failure) heart failure, lack of coordination (inability to walk), Dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), cerebral infarction, (a brain lesion in which a cluster of brain cells die limiting blood supply to the brain) and respiratory failure.<BR/>Record review of Resident #45's Annual MDS assessment, dated 04/21/2023, revealed a BIMS score of 8 out of 15, reflected moderately impaired cognition. Section on Hospice was left blank reflecting he was not on hospice during the assessment period.<BR/>Section D on mood was coded 0 indicating no mood. <BR/>Section E behavior was coded 0 indicating no behavior issue.<BR/>Section G Functional status: reflected the following coding-<BR/>Transfer was coded 4 total dependance full staff performance every time. <BR/>Dressing was coded 3 staff assistance. Personal hygiene was coded was coded 3 staff assistance. <BR/>Section G bathing was coded 3 physical help in part of bathing activity <BR/>Record review of Resident #45's care plan dated 09/14/2020 with a revision date of 04/25/2023 read in part-Impaired neurological status related to cerebral vascular accident (stroke).<BR/>Goal Resident #45 will be free of skin breakdown. <BR/>Intervention: assist in ADL and mobility as needed<BR/>Record review of Resident #45's Care plan dated 05/07/2023 read in part, I required assistance to complete my ADLs and use a wheelchair for locomotion.<BR/>Goal: Resident #45 will maintain a sense of dignity by being clean, dry, and free of odor and be well groomed. Date initiated 05/07/2023 Revision date 07/24/2023.<BR/>Intervention: provide shower, shave and oral care, hair and nail per schedule and when needed.<BR/>Observation and interview on 05/23/2023 at 10:00 AM revealed Resident # 45 was in bed alert and oriented. Observation revealed he had facial hair around his face, and he had a hospital gown on with food stained from breakfast. His fingernails were about half an inch long with dark looking particles in between his fingernails. He said he would like to be cleaned and shaved.<BR/>During an interview with CNA' M on 05/23/2023 at 10:15AM, she looked at Resident #45 and said Resident #45 was on hospice and hospice usually bathed and cleaned him on his shower days which she said was Monday, Wednesday, and Friday. CNA M said if they don't show up, she would clean him because he needed to be clean. She told Resident #45 that she would clean him up.<BR/>Observation on 05/24/2023 at 1:20PM, revealed Resident #45's nails were dirty, he still had his hospital gown on, and he was unshaved. <BR/>During an interview with RN C on 05/24/2023 at 1:00PM, RN C said Resident #45 refused ADL care according to CNA' M. CNA' M was off duty. RN C said she did not document it. RN C asked Resident #45 if he would like to be shaved and clean up Resident #45 said yes. RN C said she would clean and shave Resident #45.<BR/>During an interview with the MDS coordinator on 05/24/2023 at 11:45AM, she said Resident # 45 was not on hospice. She said Resident # 45 was discharged from hospice in January of 2023.<BR/>Record review of the Facility's policy un-numbered and undated title ADL'S read in part, Ensure ADL's are provided in accordance with acceptable standard of practice, the care plan and reasonable accommodation of resident's choice .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food preparation and storage in that:<BR/>-One of one commercial can opener was not kept clean and in a sanitary condition.<BR/>-The facility failed to ensure expired food items were removed from the walk-in cooler.<BR/>-All food items in walk in cooler were properly sealed, labeled and dated with expiration date.<BR/>These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease.<BR/>Findings include:<BR/>Kitchen observation and interview on 05/23/23 between 8:30AM and 8:40AM with the Dietary Manager, revealed the following-<BR/>- The commercial can opener had a greasy dark substance around the cutting blade and the blade holder. The Dietary Manager said it need to be cleaned. <BR/>- The walk-in cooler had two large bags of shredded cabbage with liquid substance at the bottom of the bag. The bags were dated 04/28/23. Interview with the dietary Manager at this time, she said that was the date the bags were received. Further observation revealed a large bowl of salad (identified by the Dietary Manager as left-over salad from previous day 05/22/23) was unlabeled and undated. <BR/>-Two large bags of parmesan cheese out of original containers dated 04/28/23 were properly sealed and dated with used by dates<BR/>-Left over spaghetti and meat loaf dated 05/20/23 were properly labeled and dated with expiration\used by dates. All unlabeled food items were identified by the Dietary Manager.<BR/>Observation and interview on 05/24/23 at 12:30 PM, revealed a 32 oz half used bottle of lemon Juice dated used by 05/16/23. The Dietary Manager took the bottle of half used lemon out and said she was not aware that the lemon juice had expired.<BR/>During an interview on 05/24/23 at 1:30PM, the Dietary Manager said serving Residents with expired food may lead to food borne illness. She said she was responsible for ensuring that all expired food items and food products were removed from the kitchen. She said she was new to the facility and in the process of cleaning out what was not needed.<BR/>Record review of facility's policy undated, titled Food storage: Cold read in part-<BR/>Policy statement: it is the center policy to insure all time\temperature Control for safety, frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the USDA food code.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment for 4 of 18 (resident # 8, # 24, # 45, and #55,) residents reviewed for accuracy of assessment. <BR/>-The facility failed to ensure that for Residents # 8, # 24, # 45, and #55, the MDS assessment correctly noted the resident's lack of natural teeth, tooth fragments, and/or dentures.<BR/>-The facility failed to accurately assess Resident #24 for his mental illness (qualifying diagnoses) on his annual MDS assessment.<BR/>These failures could place residents at risk for not receiving care and services to meet their needs.<BR/>Findings included:<BR/>Resident # 8<BR/>Record review of Resident #8's face sheet, dated 05/25/2023, reflected a-[AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included, end stage renal diseases (kidney failure) heart failure, lack of coordination (inability to walk), Dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life) major depressive disorder and type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel).<BR/>Record review of Resident #8's Annual MDS assessment, dated 07/29/2022, revealed a BIMS score of 11 out of 15 reflected moderately impaired cognition. Further review of section L oral\ dental status -A -G was left blank. Letter Z none of the above were present was checked indicating that Resident # 8 had no dental concerns. <BR/>Record review of Resident #8's care plan dated 05/16/2019 with a revision date of 04/06/23 read in part Resident #8 dentition (pertains to the development of teeth and their arrangement in the mouth) is very poor.<BR/>Intervention: Encourage resident to do good oral care date initiated 05/16/19, provide diet as ordered.<BR/>Observation and interview on 05/23/23 at 10:00am revealed Resident #8 was in his room. Observation revealed he had few teeth in his mouth. He said he had dentures but does not use them because they are painful and sometimes hurts. He pointed to his dentures on his bed side table.<BR/>Resident # 24<BR/>Record review of Resident #24's face sheet, dated 05/25/2023, revealed a-[AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included seizures, bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs), Dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) anxiety, abnormal gait, and lack of coordination (inability to walk). <BR/>Record review of Resident #24's Annual MDS assessment, dated 03/12/2023 revealed a BIMS score of 9 out of 15 reflected moderately impaired cognition. Further review of section A 1510 PASRR condition complete if A0310 =1, 3,4, or 5; was left blank.<BR/>Review of section on oral\ dental status -A -G was left blank. Z none of the above were present was checked indicating that <BR/>Resident #24 had no dental concerns. <BR/>Record review of Resident #24's care plan dated 03/03/2021 with a revision date of 06/24/2023 read in part Resident #24 had an order for regular texture diet. Intervention: Resident #24 to tolerate diet texture and fluid intake. <BR/>Resident # 24 is ordered Trileptal for Bipolar disorder initiated 05/03/2022 revision on 03/15/23 intervention administer medication as ordered and monitor for effectiveness.<BR/>Observation and interview on 05/23/23 at 9:20AM, revealed Resident #24 was in his room. Observation revealed he had few teeth in his mouth. During an interview with Resident #24, he confirmed he had few natural teeth falling off and no dentures. He said he could not eat hard food due to an inability to chew. He said he eats what he can. <BR/>Resident # 45<BR/>Record review of Resident #45's face sheet, dated 05/25/2023, revealed a-[AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included end stage renal diseases (kidney failure) heart failure, lack of coordination (inability to walk), Dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), cerebral infarction, (a brain lesion in which a cluster of brain cells die limiting blood supply to the brain) and respiratory failure. <BR/>Record review of Resident #45's Annual MDS assessment, dated 04/21/2023, revealed a BIMS score of 8 out of 15, reflected moderately impaired cognition. Further review of section L oral\ dental status -A -G was left blank . Z - none of the above were present was checked indicating that Resident # 45 had no dental concerns. <BR/>Record review of Resident #45's care plan dated 09/14/2020 with a revision date of 04/25/23 indicated that the care plan did not address his oral cavity.<BR/>Observation and interview on 05/24/23 at 9:15AM, revealed Resident #45 was in his room. Observation revealed he had few teeth in his mouth During an interview with Resident #45 he confirmed he had few natural teeth and no dentures. He said he eats soft food, and at times could not eat the food due to an inability to chew. He said he does not have any dentures and turned his face.<BR/>Resident #55<BR/>Record review of Resident #55's face sheet, dated 05/25/2023, revealed a-[AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertensive heart disease with heart failure, Dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), and major depressive disorder.<BR/>Record review of Resident #55's admission MDS assessment, dated 08/08/2022 revealed a BIMS score of 3 out of 15 reflected severely impaired cognition. Further review of section L oral\ dental status -A -G was left blank . Z ( none of the above were present was checked indicating that Resident # 45 had no dental concerns. <BR/>Record review of Resident #55's care plan dated 08/08/22 with a revision date of 05/05/2023 indicated that Resident # 55 was on regular texture diet and the care plan did not address his oral cavity.<BR/>Observation and interview on 05/24/2023 at 9:15AM, revealed Resident #55 was in his room. Observation revealed he had no teeth in his mouth. During interview at this time, he pointed to his dentures on his nightstand. He did not answer further question. <BR/>During an interview with the MDS coordinator on 05/25/2023 at 3:00PM, she said she was responsible for completing and ensuring that MDS reflect Resident's condition. She said an inaccurate assessment would prevent residents from getting the necessary care needed to improve their health. She said she did observe residents prior to completing the MDS assessment but did not pay attention to their oral cavity. She said she overlooked Resident #24's medical diagnoses of bipolar disorder but would reach out to the local authority for his PASRR evaluation.<BR/>Facility's policy on MDS assessment accuracy was requested from the DON on 05/25/2023 but was not provided prior to exit on 05/25/2023.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food preparation and storage in that:<BR/>-One of one commercial can opener was not kept clean and in a sanitary condition.<BR/>-The facility failed to ensure expired food items were removed from the walk-in cooler.<BR/>-All food items in walk in cooler were properly sealed, labeled and dated with expiration date.<BR/>These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease.<BR/>Findings include:<BR/>Kitchen observation and interview on 05/23/23 between 8:30AM and 8:40AM with the Dietary Manager, revealed the following-<BR/>- The commercial can opener had a greasy dark substance around the cutting blade and the blade holder. The Dietary Manager said it need to be cleaned. <BR/>- The walk-in cooler had two large bags of shredded cabbage with liquid substance at the bottom of the bag. The bags were dated 04/28/23. Interview with the dietary Manager at this time, she said that was the date the bags were received. Further observation revealed a large bowl of salad (identified by the Dietary Manager as left-over salad from previous day 05/22/23) was unlabeled and undated. <BR/>-Two large bags of parmesan cheese out of original containers dated 04/28/23 were properly sealed and dated with used by dates<BR/>-Left over spaghetti and meat loaf dated 05/20/23 were properly labeled and dated with expiration\used by dates. All unlabeled food items were identified by the Dietary Manager.<BR/>Observation and interview on 05/24/23 at 12:30 PM, revealed a 32 oz half used bottle of lemon Juice dated used by 05/16/23. The Dietary Manager took the bottle of half used lemon out and said she was not aware that the lemon juice had expired.<BR/>During an interview on 05/24/23 at 1:30PM, the Dietary Manager said serving Residents with expired food may lead to food borne illness. She said she was responsible for ensuring that all expired food items and food products were removed from the kitchen. She said she was new to the facility and in the process of cleaning out what was not needed.<BR/>Record review of facility's policy undated, titled Food storage: Cold read in part-<BR/>Policy statement: it is the center policy to insure all time\temperature Control for safety, frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the USDA food code.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to coordinate assessments with the (PASARR) program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort. in that <BR/>-The facility failed to update the PASRR Level 1 forms for Resident #24 after a diagnoses of mental illness<BR/>This failure could place residents requiring PASRR services at risk of not having their special needs assessed and met by the facility. <BR/>Findings include:<BR/>Resident #24<BR/>Record review of Resident #24's face sheet, dated 05/25/2023, revealed a-[AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included seizures, bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs), Dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) anxiety, abnormal gait, and lack of coordination (inability to walk). <BR/>Record review of Resident #24's Annual MDS assessment, dated 03/12/2023 revealed a BIMS score of 9 out of 15 reflected moderately impaired cognition. Further review of section A 1510 PASRR condition complete if A0310 =1, 3,4, or 5; was left blank.<BR/>Record review of Resident #24's care plan dated 03/03/2021 with a revision date of 03/15/23 read in part I have a lot of hobbies or interest. I like to socialize during smoking breaks.<BR/>Goal-I will socialize when in group . Resident will enjoy activities three times a week initiated 03/21/23 revision date 06/12/23.<BR/>Intervention: activity calendar posted in room; Activity director to monitor \ discuss preference, invite me to sit in during activities letting me leave Encourage me to try new things.<BR/>Resident #24 had an order for Trileptal for Bipolar disorder. Date initiated 05/03/22 Revision on 03/15/23. <BR/>Goal: I will remain free from drug related complication: intervention Administered medication as ordered and for side effects.<BR/>Observation and interview on 05/23/23 at 9:20AM, revealed Resident #24 was in his room. In an interview, he said he wanted to sleep.<BR/>Observation and interview on 05/23/23 at 2:45PM, revealed Resident #24 was in his room lying down. He said he wanted to go home. He said he only goes out to smoke and come back to his room. He said he only socialized with others during smoking and there is nothing more to do. He said he would like to do other things and that is why he wanted to go home.<BR/>During an interview with MDS Coordinator on 05/24/23 at 3:00pm, she said Resident #24's PASRR on admission was negative and he was recently diagnosed with bipolar disorder last year. She looked at the Annual MDS assessment dated [DATE] and said she overlooked the section on his mental diagnoses and did not refer Resident #24 for PASRR level II evaluation. She said all residents with negative level 1 PASRR were supposed to be reassessed after a diagnosis of mental illness. She said she would reach out to the local authority to re-evaluate Resident #24. <BR/>Facility's policy on PASRR evaluation was requested , she said the facility followed the state recommended PASRR evaluation process.<BR/>Record review of the facility's PL1/PASARR/NFSS/1012/PCSP policy dated 1/16/2019 revealed The facility will ensure compliance with all Phase I and II guidelines of the PASARR Process for Long Term Care. The policy identified the MDS coordinators, marketing/admissions team members/social worker, administrator, DON, and IDT members as the parties responsible for compliance. The policy documented procedures including submission of a PL1 for all entering the facility. The policy further revealed If at any time a resident has a significant change, ., or you receive information that might indicate the resident may have a MI/ID/DD diagnosis or condition not contained in the medical record, please submit a PL1 form for the resident to be evaluated by the Local Authority.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 18 residents reviewed for unnecessary medications. (Resident #55)<BR/>The facility failed to have an appropriate diagnosis or adequate indication for the use of Resident #55's Seroquel (antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder).<BR/>This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.<BR/>Findings include:<BR/>Record review of Resident #55's face sheet dated 05/25/2023 indicated he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnosis included Hypertensive heart disease with heart failure, unspecified dementia, unspecified severity, with other behavior disturbance, and major depressive disorder.<BR/>Record review of Resident #55's consolidated medication orders indicated Resident #55 was on hospice with the following medication- <BR/>Morphine sulfate 10mg as needed every hour. <BR/>Potassium chloride ER tablet 20 MEQ by mouth<BR/>Quetiapine Fumarate tablet 50 mg give one tablet at bedtime related to unspecific dementia<BR/>Zofran tablet 4 MG as needed for nausea\vomiting. <BR/>Record review of pharmacy review dated 08/02/22 revealed a note from the consultant as followed Resident #55 was admitted with an order for an antipsychotic medication, Quetiapine 50 mg by mouth every night. Please provide diagnoses. <BR/>Recommendation: please consider gradual dose reduction attempt at this time.<BR/>Physician response: I decline the recommendation(s) above and do not which to implement any changes due to the reason documented below. Please provide CMS required patient specific rational why GRD attempt is likely to impaired function or increase behavior in this individual.<BR/>Record review of Resident #55's care plan dated 08/08/22, indicated a BIMs score of 99 reflected not interviewable (severely impaired on cognition). <BR/>Record review of Resident #55's care plan dated 08/01/22 with a revision date of 04/16/23 read in part-potential for drug related complication related to the use of psychotropic medication. <BR/>Goal will be free of psychotropic drug related complication<BR/>Intervention: observe for side effect and report to physician <BR/>Record review of Resident #55's treatment sheet dated 05/01/2023 revealed no change in behavior. From 05/01/23 through 05/24/23 indicated no behavior. <BR/>Observation on 05/23/23 at 10:30 am revealed Resident #55 was sitting on his wheelchair in the secured unit. Attempt was made to have an interview but could not hold a meaningful conversation. He was alert. He pointed to his dentures on his nightstand beside his bed. He nodded his head during interview but did not speak much. He could only answer yes or no questions.<BR/>During an interview on 05/25/22 at 11:00AM, the DON said Resident #55 was admitted from the hospital with the Quetiapine (Seroquel) 50 mg by mouth every night and had been on it since then. She said she was aware that Resident # 55 does not have the right diagnoses for the use Quetiapine 50 mg. <BR/>The DON said she had talked to Resident #55's Physician about the use of Seroquel without diagnoses and the Resident's physician refused to change\reduce the medication. Resident #55's Physician said Resident # 55 was doing well and stable. <BR/>The DON said the pharmacy consultant had also reviewed the medications and no changes were suggested. The DON said the failure of prescribing Seroquel without having an acceptable diagnosis could have caused adverse drug consequences such as health decline as well as increased confusion.<BR/>The DON said there was a pharmacy recommendation, but his physician declined the recommendation. She said Resident #55 was also on hospice. The Physician's phone number and facility's policy was requested on 05/25/23 at 11:15 AM from the DON. <BR/>Physician's phone number and facility's policy on the use of psychotropic drugs was not provided prior to exit on 05/25/23.