BRENTWOOD PLACE THREE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for two of 11 residents (Residents #41 and #65) reviewed for assessments.<BR/>1. The facility failed to accurately document Resident #41 admitted from a psychiatric hospital in the A1800 section of the admission MDS Assessment, dated 04/12/22, and Quarterly MDS assessment dated , 07/28/22. <BR/>2. The facility failed to accurately document Resident #41 had a serious mental illness in the PASRR: A1500 and A1510 sections of the admission MDS Assessment, dated 04/12/22. <BR/>3. The facility failed to accurately document Resident #65 admitted from a psychiatric hospital in the A1800 section of the admission MDS Assessment, dated 04/18/22. <BR/>4. The facility failed to accurately document Resident #65 had a serious mental illness in the PASRR: A1500 and A1510 sections of the admission MDS Assessment, dated 04/18/22. <BR/>These failures could place residents at risk of inaccurate PASRR Evaluations (PE) and ineligibility of PASRR benefits they may qualify for, which could result in a decreased quality of life, physical function, and psycho-social well-being.<BR/>The findings include:<BR/>1. Record review of Resident #41's face sheet revealed, a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Paranoid Schizophrenia (delusions and hallucinations), Major Depressive Disorder, recurrent, severe with psychotic symptoms (depression with loss of reality), Anxiety Disorder (excessive stress interfering with daily living) and on 06/21/22 diagnosed with Generalized Anxiety Disorder (constant worrying, restlessness, not concentrating) and Major Depressive Disorder, Single episode, mild (abnormal behavior and mood disorder). <BR/>Record review of Resident #41's admission MDS, dated [DATE], revealed A1500 No for having a serious mental and/or intellectual disability or related condition and admitted from an acute hospital. The BIMS cognitive score was 12 (cognitively intact), Yes for mood interview- 6 severity score- feeling down depressed, hopeless nearly every day, supervision with one person assist for most ADL's, always continent with bladder and bowel, without a mobility device and diagnoses included: Anxiety (excessive stress interfering with daily living), Depression (mood disorder causing sadness and loss of interest), Schizophrenia (serious mental disorder affecting thoughts), Post Traumatic Stress Disorder (stressful thoughts from past trauma) and Dependence on supplemental oxygen (extra oxygen required for oxygen deficiency in blood) . And had no falls and took antipsychotic, antianxiety and antidepressant medications and provided oxygen therapy . <BR/>Record review of Resident #41's Quarterly MDS Assessment, dated 07/28/22, revealed the resident was admitted from an acute care hospital. The MDS BIMS cognitive score was 14 (cognitively intact), Yes for mood interview 0 severity score - no mood indicators, limited to extensive with one person assistance for most ADL's, balance not steady for transitions and walking and use of a wheelchair, occasionally incontinent for bladder and bowel, diagnoses: Anxiety, Depression, Schizophrenia, Post Traumatic Stress Disorder and Dependence on supplemental oxygen. And had no falls and took antipsychotic, antianxiety and antidepressant medications and oxygen therapy.<BR/>Record review of Resident #41's, undated, Care Plan revealed, the resident had impaired cognitive function/impaired though processes, Anti-anxiety, Communication problem, Emphysema/COPD, Oxygen therapy, falls, anti-depressant, ADL's. <BR/>Record review of Resident #41's Psychiatric Hospital records revealed she admitted to the Psychiatric hospital on [DATE] for Major Depressive Disorder, recurrent and diagnoses of Major Depressive disorder, severe, with psychotic features, generalized anxiety disorder .Plan: Other specified Depressive Episodes - monitor the symptoms closely. Management per psychiatric team .Anxiety Disorder Unspecified - Monitor symptoms closely .continue the current medications, management per psychiatric team supportive care <BR/>Record review of Resident #41's PASRR Level 1 Screen assessment, dated 04/25/22, the resident screened Yes for Mental illness .Comments: PL1 uploaded in the wrong facility's portal <BR/>Record review of Resident #41's PASRR Evaluation assessment, dated 05/04/22, revealed the resident screened No inpatient psychiatric treatment .Based on the QMHP assessment, does this individual meet PASRR definition of mental illness .No, diagnoses Major depressive disorder, psychotic disorder with hallucination due to known physiological condition, Generalized anxiety disorder <BR/>2. Record review of Resident #65's face sheet, dated 09/26/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder (abnormal thoughts and unstable mood), Insomnia due to other mental disorder (inability to sleep due to mental disorder), Schizoaffective Disorder, Bipolar type (delusional-chronic brain disorder with depressive mood changes , Other abnormal Gait and mobility (weakness disorder walking), Anemia (low iron disorder). <BR/>Record review of Resident #65's admission MDS Assessment, dated 04/18/22, revealed, No serious mental illness and no conditions checked, admitted from acute hospital. The BIMS Score was 15 (cognitively intact), supervision with one person assist for most ADL's, unable to walk and not steady with transfers and used a wheelchair, always incontinent to bowel and bladder, diagnosis Schizophrenia, no falls, took antipsychotic and antidepressant medications <BR/>Record review of Resident #65's Quarterly MDS Assessment, dated 08/27/22, revealed the resident was admitted from a psychiatric hospital. The BIMS Score was 15 (cognitively intact), verbal behavioral symptoms at others occurred 1 to 3 days, rejected care occurred 1 to 3 days, limited functioning with one person assist with most ADL's, not steady an balance and transitions, used a wheelchair, frequently incontinent of bladder, occasionally incontinent of bowel, diagnoses Schizophrenia and insomnia due to other mental disorder and took antipsychotic medication <BR/>Record review of Resident #65's, undated, Care Plan revealed, Antidepressant medication, psychotropic medications, verbally aggressive towards staff, non-compliant with medication administration, falls, bowel and bladder, communication, ADL self-care deficit <BR/>Record review of Resident #65's Psychiatric Hospital Note revealed she was admitted to the Psychiatric hospital on [DATE] for psychosis and aggressive behavior with diagnosis Schizoaffective Disorder, initial treatment plan: Dangerous to self and others psychotic symptomatology and alcohol/substance dependence <BR/>Record review of Resident #65's PASRR Level 1 Screen assessment completed by the psychiatric hospital, dated 04/11/22, revealed Yes for mental illness. <BR/>Record review of Resident #65's PASRR Level 1 Screen assessment, dated 05/24/22, revealed Yes from a psychiatric hospital .Yes for mental illness .comments: PL1 not accepted due to demographic issues. Form re-submitted with corrections <BR/>Record review of Resident #65's Progress Note, dated 08/05/22, by Psychiatric NP, revealed: July 2022- Psychiatric hospitalization . [Resident #65] was sent to Psychiatric hospital for evaluation from 7/5-7/28/22. Prior to transfer, the pt had refusal of medications which led to increasing worsening behaviors, aggression and restless. On the day of her transfer, the pt had thrown different objects in the dining room area where other residents were. She had also punch staff members that were trying to restrain and remove her from dining room. Documentation is unclear of course of hospitalization. She returned to this facility <BR/>Record review of Resident #65's, undated, TMHP LTC Medicaid Activity Form revealed, 08/22/22 Form submitted .Individual placed in NF - Expedited admission .PL 1 submitted by nursing facility .08/26/22 individual placed in NF. PE confirmed <BR/>Record review of Resident #65's PASRR Evaluation assessment, dated 08/24/22, revealed yes for mental illness, Schizoaffective disorder, sleep disturbance, and no inpatient psychiatric treatment, C0800 based on the QMHP assessment, do this individual meet the PASRR definition of mental illness, No .diagnoses Schizoaffective disorder, insomnia due to other mental disorder, Schizoaffective disorder, bipolar, Type 2 diabetes mellitus and muscle weakness (generalized). <BR/>Interview on 09/27/22 at 11:29 AM, MDS F stated she had just started working at the facility a week ago and was responsible for doing the MDS Assessments and was a part of the IDT meetings and was not aware of any issues with the MDS assessments being inaccurate. <BR/>Interview on 09/27/22 at 12:38 PM, the DON stated the MDS nurse was made aware of who were PASRR positive and also notified the PASRR nurse of any updates. <BR/>Interview 09/27/22 at 1:01 PM, the RRN stated Resident #41 admitted to the facility 04/06/22, she was at a psychiatric hospital then admitted to the facility and Resident #65 had the wrong SS# on her PL 1 form and it was not accepted into the portal. She stated she was not sure who put the wrong building # for Resident #41 and if it was the psychiatric hospital who did it but the facility staff should have caught that and not approved her admission until it was corrected. She stated during their level of care meetings they went over demographics to review social security #, date of birth , name spelling and tried to be super cautious with the resident's information. <BR/>Interview on 09/27/22 at 2:48 PM, the PASRR Nurse stated he was not aware Resident #65 and #41's PL 1's had delays and submission issues and there were no issues with MDS inaccuracies. <BR/>Interview on 09/27/22 at 2:56 PM, LA/QMHP stated with Resident #41 having major depression, Schizophrenia and Generalized Anxiety Disorder and admitted from a psychiatric hospital increased the chances of her possibly being PASRR positive and stated the facility should have checked the TMHP LTC portal much sooner for the error messages to change the building #. She stated for Resident #65 the facility should have checked the TMHP LTC portal more often for the alerts about the wrong social security #. She stated at this campus, each facility building had their own MDS Nurse who entered the PL 1 information that was routed to the PASRR Nurse H. She stated the PASRR Nurse was the one contact person the LA/QMHP arranged the IDT meetings and coordination of care. She stated the LA/QMHP filled out the PE's based on the resident's MDS Assessment, medications list and face sheet. She stated if the MDS Assessment showed the resident admitted from an acute care hospital, the PE would show the same. She stated if the MDS assessments were wrong it would cause the PE to be inaccurate as well.<BR/>Record review of the facility's PASRR policy, dated 06/2020, revealed .Policy: III. The facility also conducts level 1 screening for current residents who experience a significant change in their condition based on MDS 3.0 Guidelines .failure to pre-screen residents prior to admission to the facility may result in the failure to identify residents who have or may have MI, ID or a related condition <BR/>Record review of the facility's Quality Assessment & Assurance Program policy, dated 06/2020, revealed Purpose: To ensure all services provided by the facility to residents meet the level of quality as required

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain nutrition, grooming and personal and oral hygiene for one (Resident #1) of six residents reviewed for ADLs.<BR/>The facility failed to ensure Resident #1 was provided incontinent care in a timely manner, resulting in the resident smearing fecal matter on his mattress, bed linens, window ledge and throwing the fecal matter on the floor of his bedroom. <BR/>This failure could place residents at risk for discomfort, infection, and dignity issues.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet, printed on 03/12/24, reflected Resident #1 admitted to the facility on [DATE]. Resident #1 had diagnoses of dementia (the loss of cognitive functioning), lack of coordination, apraxia following cerebral infarction (cognitive disorder that can occur after stroke), lack of coordination, obesity, hyperlipidemia (in excess of lipids or fats in your blood), essential (primary) hypertension (high blood pressure), heart failure, aphasia following cerebral infarction (a disorder that affects how you communicate), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body), muscle weakness, dysphagia - oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat).<BR/>Record review of Resident #1's quarterly MDS assessment, dated 02/25/24, reflected Resident #1 was not recommended for the brief interview for mental status. Section C - Cognitive Patterns, revealed Resident #1 had short-term and long-term memory problems and had severely impaired cognitive skills for decision making. Section GG - Functional Abilities and Goals, Question GG0130. Self-Care indicated Resident #1 required substantial physical assistance in ADLs of oral hygiene, toileting, dressing and personal hygiene and was completely dependent on facility staff in ADLs of bathing. <BR/>Record review of Resident #1's care plan, last reviewed on 12/12/23, revealed the following:<BR/>[Resident #1] has bowel and bladder incontinence r/t Right sided paresis secondary to Multiple CVA . Interventions - INCONTINENT: Check [Resident #1] frequently and as required for incontinence.<BR/>Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes <BR/>[Resident #1 has an ADL Self Care Performance Deficit r/t Hemiplegia, Impaired balance . Interventions . Toilet use: self-performance Extensive assistance. Toilet use: support provided One-person physical assist. Personal hygiene: self-performance Extensive assistance. Personal hygiene: support provided One-person physical assist.<BR/>In an observation and interview on 03/12/24 at 2:32 p.m., Resident #1 was observed lying in his bed. Resident #1 stated he was well. Resident #1's room had a pungent smell of urine and stool. Fecal matter was observed on Resident #1's hands, on the floor, near the foot of his bed, on his bed linens and on the window seal near his bed. Resident #1 stated he did not know how long he had been left soiled. <BR/>On 03/12/24 at 2:36 p.m., the surveyor notified RN A, which was the nurse assigned to Resident #1, of Resident #1's condition. RN A accompanied the surveyor to Resident #1's room and stated, he was not like this. RN A stated she was not sure where Resident #1's aide was, but she would ensure the resident was cleaned. <BR/>On 03/12/24 at approximately 2:45 p.m., the ADMIN, DON, RD, and RN A, were observed to enter Resident #1's room. Shortly after their entrance, the ADMIN and RD exited, and Resident #1 could be heard yelling no. <BR/>On 03/12/24 at 3:08 p.m., the RD stated to the surveyor, Resident #1 began to display a behavior of throwing his fecal matter around his room and refused to be changed. The RD stated Resident #1 would be referred for psychiatric services for the newly onset behavior. <BR/>In an interview on 03/12/24 at 4:21 p.m., RN A stated it was the facility's expectation for residents to be dry at all times. RN A stated aides were to ensure residents were checked every 2 hours and incontinent care be provided, as needed. RN A stated she conducted rounds at roughly 2:15 p.m. and did not recall a stool smell in Resident #1's room. RN A stated residents would experience skin breakdown, if they were left soiled for too long. RN A stated she would conduct rounds on residents more often, to ensure incontinent care was provided at all times. <BR/>In an interview on 03/12/24 at 5:53 p.m., the DON stated it was the facility's expectation that facility aides and nurses checked on resident every 2 hours and provided incontinent care when needed. The DON stated failing to provide incontinent care promptly could increase residents' chances of skin breakdown. The DON stated Resident #1's recently increased his refusals of care and this incident was his first time throwing his fecal matter. The DON stated she would begin to Inservice nursing staff on incontinent care and refusals. <BR/>In an interview on 03/12/24 at 6:08 p.m., the ADMIN stated it was the facility's expectation for nursing staff to round every 2 hours, answer call lights as they are pressed and provide incontinent care when a resident was wet. The ADMIN stated not providing incontinent care when needed could cause a resident to have skin breakdown. The ADMIN stated if a resident was observed to be soiled, they were to be changed immediately. The ADMIN stated it was the responsibility of facility aides to provide incontinent care but, the nurse was also responsible for ensuring care was provided to residents as needed. The ADMIN stated the facility would begin to Inservice nursing staff on ADL care and incontinent care. <BR/>Record review of the facility's policy entitle Perineal Care, revised in June 2020, read in part:<BR/>Purpose: To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown.<BR/>Policy: Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to review and revise the person-centered comprehensive care plan to reflect the resident's current status, for 2 of 5 residents (Resident #55 and Resident #88) reviewed for care plans.<BR/>The facility did not update Resident #55's care plan to reflect specific instructions for hospitalization and antibiotics. <BR/>The facility did not update Resident #88's care plan to reflect specific instructions for smoking. <BR/>These failure could place residents at risk for not receiving appropriate care and interventions to meet their current needs.<BR/>The findings were: <BR/>1. Review of Resident #55's MDS quarterly assessment dated [DATE], reflected he was a [AGE] year-old male admitted on [DATE]. His diagnoses included Schizophrenia (mental illness), sepsis (infection), and depression. His BIMs score of 1 reflected his cognitive status was severely impaired and he required moderate to maximum assist of one staff member for activities of daily living. <BR/>Record review of physician's orders for Resident #55 dated 07/12/23 reflected an order for a transfer to the hospital for an evaluation.<BR/>Record of the nursing progress notes dated 07/29/13 revealed Resident #55 returned to the facility following hospitalization for sepsis and to continue to receive and completed IV antibiotics .<BR/>Record review of Resident #55's Care Plan updated on 09/03/23 reflected, there were not a care plan goals to reflect specific instructions for hospitalization and IV antibiotics. <BR/>2. Review of Resident #88's MDS annual assessment dated [DATE], reflected he was a [AGE] year-old male admitted on [DATE]. His diagnoses included: Hypertension (increased blood pressure), PTSD (mental health disease), and depression (mental health illness). His BIMs score of 9 reflected his cognitive status was moderately impaired. He required moderate assist of one staff member for activities of daily living. <BR/>Record review of clinical assessments for Resient #88 reflected dated 10/26/23 reflected a safe smoking assessment . Resident #88 smoked with the other residents, supervised by staff.<BR/>Record review of Resident #88's Care Plan initiated on 10/26/23 reflected, there was not a care plan goal to reflect specific instructions for smoking safety. <BR/>Interview on 11/14/23 at 1:06 p.m. with the Regional MDS Consultant revealed she, the other ADON, the DON and were responsible for updating resident care plans. She further stated, We do have a difficult time updating all the care plans. There are so many changes and now that you have brought to my attention, I will see that the care plans are updated for all the needs of each resident, including smoking, antibiotics, IV therapy & interventions.<BR/>Interview on 11/16/23 at 2:55 p.m. with the DON revealed the MDS Coordinator and ADONs were responsible for initiating and updating the care plan as needed. The DON stated it was a team effort to update and the care plans and should be updated when the changes occurred. The DON stated the follow-up on care plan updates should be completed by the nursing administrative team . The care plans should include all the needs of the residents, including IVs, smoking, and antibiotics.<BR/>Review of the facility's policy titled Care Plans, Comprehensive Person-Centered dated August 20, 2020, reflected the following:<BR/> .include measurable objective and timeframe; Describe the services that are to be finished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wee-being .include the resident's stated goals upon admission and desired outcome; changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the residents stay.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for four (Halls 200, 400, 500, 600, nurse's station, lobby, conference room and the main dining rooms), of six halls reviewed for pest control program. <BR/>The facility had live common house flies and gnats in areas of the facility including the lobby, nurses station, halls 200, 400, 500 and 600 , conference room and the dining room. <BR/>This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.<BR/>Findings Include:<BR/>Observation and interview 11/13/23 at 9:30 a.m., revealed 1-5 live house flies crawling on the bed covers of Resident #52 on Hall 200 There was a fly strip hanging on the resident's wall beside the window, with three dead flies and 15 dead gnats. Resident #52 stated that the fly strip was there because he was tired of the flies and the gnats flying around in his room, so he bought the fly strip. Resident #52 was asked if he had reported the flies and gnats to anyone, and he said he had told the CNA several times. <BR/>Observation on 11/13/23 at 9:45 a.m., revealed four gnats crawling on the table in the conference room.<BR/>Observation on 11/13/23 at 10:45 a.m. revealed a gnat crawling on the medication cart on Hall 200 . <BR/>Observation and interview on 11/13/23 at12:20 p.m., in the main dining room revealed a swarm of five gnats flying around the dining cart with drinks on it. An unknown resident was sitting at a table trying to eat his meal, while swatting at the gnats. The resident stated the gnats were bad and they were in the dining room all the time. He pointed toward the door to the smoking area, in the dining room and said the flies come from there . He said he did see the pest man at thei in the past two weeks but he did not know what he was treating. <BR/>Observation on 11/13/23 at 12:27 p.m., revealed Resident #53 on hall 600, a gnat was flying around his uncovered feet, when he was in bed. <BR/>Observation on 11/14/23 at 5:15 a.m., revealed a gnat was flying around at the nurse's station.<BR/>Observation and interview on 11/14/23 at 6:30 a.m. on hall 400 revealed a gnat flying around Resdient #62's heads MA E was giving the resident his medications. MA E was asked if he saw the gnats or flies in the facility and he stated occasionally. When he was asked what he did when he saw the pests he stated he would tell the maintenance man. <BR/>Observation and interview on 11/14/23 at 7:30 a.m., on Hall 400 revealed two gnats flying around Resident #66; there were two gnats flying around his head. LVN A was administering Resident # 66's G-tube (feeding tube) medications. Gnats were on the cuff of LVN A's 's glove and she continued to administer medications. LVN A saw the gnats and stated the gnats were bad she tried to tell the families not to bring food or fruit. The LVN cleansed her hands and changed her gloves. LVN A stated she would tell the maintenance man. <BR/>In an interview on 11/14/23 at 9:00 a.m., the Maintenance Director for the campus revealed he would check the pest control logs, located the nurse's station for any pest . The Maintenance Director stated he checked the log daily and he was not aware there was a gnat or fly problem in the facility. He said he would contact the pest control company to come today. <BR/>An interview with CNA D on 11/14/23 at 9:48 a.m., revealed common house flies and gnats had been in the facility for several weeks. She had not reported the flies and she did not know about a pest control log. CNA D stated she was not sure why she had not reported the flies. <BR/>Observation on 11/14/23 at 12:21 p.m., revealed 5-7 live common house flies around the food of two residents in the dining area that required assistance for eating. The flies landed on the food of the residents. Additional observations in the dining area revealed residents using their hands to wave away gnats from landing on their food. Further observation revealed a blue light trap for flies/gnats was unplugged, and there was a sign on the side that reflected to not unplug. <BR/>In a confidential group interview on 11/14/23 at 10:30 a.m., 8 residents revealed there was a fly/gnat problem. The residents stated the facility staff and Administrator had been told, but the flies/gnats continued to be a problem. The residents stated they had seen the pest control provider at the facility but whatever the pest control provider was using to treat the flies/gnats was not making a difference. The residents said that people were always going out the back door to the patio and that could be where they were coming in. <BR/>Observation and interview on 11/14/23 at 12:06 p.m. on Hall 500 revealed Resident #69 had two gnats around the resident's hands and next to her face. Resident #69 stated she saw little black flies all the time and lately they seemed to be more. She stated she did not like the little flies in her room and she thought made the place feel dirty. Resident #69 stated she had not told anyone. <BR/>Observation on 11/14/23 at 12:48 p.m., revealed three live gnats at the nurse's station. <BR/>An interview on 11/14/23 at 2:00 p.m. with the Administrator revealed the facility had routine pest control visits during each month, if there was problem with gnats and flies, he was not aware. He stated he would make sure the pest control company came today and treated. <BR/>Record review of the Facility's Pest Sighting Log revealed: dated 04/27/23 through the last entry 10/23/23 mentioned no flies or gnats.<BR/>Record review of the pest control provider service information dated 11/02/23 through 11/15/23 revealed the following regarding the technician comments, There were entries for all pests including gnat and flies. On 11/15/23 was the last visit from the pest control provider, after the surveyor's intervention, checked specifically for flies and gnats for fruit flies/gnats dusted drains and sprayed <BR/>Record review of the facility's policy dated 08/2020, and titled Pest control reflected to ensure the facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of the residents, facility staff, and visitors .the facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests .windows are screened at all times .garbage and trash is not permitted to accumulate in any part of the facility .the facility staff will report to the housekeeping supervisor any sign of rodents or insects .the housekeeping supervisor will take immediate action to remove any pests from the facility

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 the facility's only kitchen.<BR/>1.The facility failed to ensure food items in the refrigerators (3) and freezers (3) were labeled and stored in accordance with the professional standards for food service. <BR/>2. The facility failed to discard items stored in refrigerators not properly sealed/secure or past the best buy, consume by or expiration dates. <BR/>3. The facility failed to develop, implement and or provide a policy for Food Labeling and Procurement and or holding leftovers in the refrigerator. <BR/>4. The facility failed to have opened containers of potentially hazardous foods or leftovers dated or used within 7 days or according to facility policy. <BR/>These failures could place residents at risk for food-borne illness and cross contamination.<BR/>Findings included:<BR/>Observations of Refrigerator #1 on 09/25/22 at 11: 09 AM revealed the following: <BR/>-16-1 lb. of fresh Strawberries in original packaging, dated 9/21, had several berries that were molded, damaged or overripened (deeper red color and mushy exterior), in at least 8 of the containers. <BR/>-1 large zip top bag with medium amount of sliced Turkey deli meat, unsecured closed with no label of item description, no open date or consume by/discard date reflected. <BR/>- At the bottom of the refrigerator #1, 1-32 oz plastic container with lid, of Chopped Garlic in water dated 8/2 with manufacturer's expiration date 9/7/22. The lid was unsecured closed on one side.<BR/> -1 Large container Picante Sauce Medium, dated 9/12, had no open date or consume by date. <BR/>-1 Large zip top bag, dated 9/23, with salad mix in original packaging inside, both bags were open/unsecured. There was also no label of item description and no consume by date. <BR/> -1 large zip top bag, dated 9/2, with shredded cheddar cheese in original packaging inside. The cheese and the zip top bag were unsecured/open to air, there was no open date or consume by date. <BR/>-1 zip top bag of sliced yellow cheese block in original packaging, dated 9/21, both bags were unsecured closed/open to air. <BR/> -1 medium stainless-steel pan with applesauce, covered with plastic wrap, dated 9/22. The plastic wrap was not secured along the long side of the pan, leaving it partially open to air. <BR/>-1 large clear container with lid, with dark purple jelly, dated 9/15, no received by date, no consume by or discard date reflected. <BR/>Observations of the Kitchen on 09/25/22 at 10:51 AM revealed the following: <BR/>-4-24 muffin cup pan with uncooked rolls in each cavity, the pans were sitting on the steam table, uncovered. <BR/>-Under the preparation table was 1 tray with 15 clear 2 oz containers with lids containing a dark liquid. Only one of the containers had a piece of blue tape with the date 9/21 on it. Otherwise, no label of item description, no consume by date. <BR/>-Outside of Fridges #1, #2 and #3 were dirty, smudged and the bottom vent covers were dirty.<BR/>-There was a cell phone lying on the preparation table next to box of gloves. <BR/>-1 Large white bin with lid, had dry oatmeal inside, dated 9/14 but there was no consume by or discard date. <BR/>-1 Large white bin with lid, had flour in it, dated 8/24/22, there was no consume by or expiration date. <BR/>- Large white bins with lids, labeled flour and sugar were dirty around the outside of the bins.<BR/>Observations of Freezer #1 on 09/25/22 at 10:58 AM revealed the following: <BR/>-Double door freezer, the outside doors were smudged and dirty. The bottom vent cover is dirty. <BR/>-3 Bags of yellow liquid (frozen), out of original box, dated 9/14, there was no label of item description. <BR/>-1 Medium white opaque container with lid of BBQ Heat & Serve chopped Brisket, dated 9/21, the lid on the container is broken on side and cracked on the top. <BR/>Observations of Refrigerator #3 on 09/25/22 at 11:25 AM revealed the following: <BR/>-1 tray with 3 small white bowls. 1 bowl of applesauce and 2 bowls of fruit cocktail, no label of each individual item, no open date/pulled date or no consume by date. <BR/>-4 trays with approximately 30- 2 oz. clear containers with lids, per tray, with mayonnaise in them and 1 with mustard. There were no dates pulled, no label of description and no consume by or discard by date reflected. <BR/>Observations of the Dry Storage Room on 09/25/22 at 11:27 AM revealed the following: <BR/>-1 Fly noted flying in the dry storage room. <BR/>-On the shelf across from Freezer #2, 1 Large container of Silver Source Pancake Syrup, dated 9/7, previously opened. There was no open date or consume by date reflected. <BR/>-1 Large white bin with lid, had grits, dated 8/15/22 there was no received by date or consume by date. <BR/>-Sitting on top of the rice container,1 package of small Flour tortillas, with no manufacturer packaging date or expiration date. There was no received by date, no label of item description, no consume by date. <BR/>-1 container with lid of Rice, dated 8/3/22, no open date, no consume by date. <BR/>-1 container with lid of Fish Fry Mix, dated 8/3/22, had no open date and no consume by date. <BR/>Observations of Freezer #2 on 09/25/22 at 11:34 AM revealed the following: <BR/>-1 large bag of dinner rolls, dated 9/21, there was no label of item description, no consume by date. <BR/>-4 bags of Hush Puppies, dated 9/21, there was no label of item description, no consume by date. <BR/>Observations of the Kitchen on 09/27/22 at 09:10 AM revealed the following: <BR/>-Noted on the door of Freezer #1, there was a staff cleaning assignment sheet for week of September 25- October 2, 2022. There were assignments for cleaning the refrigerators and the freezers. Outside of Refrigerators #1, #2, and #3 remained dirty as was the vent covers at the bottom of them. <BR/>Observations of Freezer #3 on 09/27/22 at 12:44 PM revealed the following: <BR/>-1 Large zip top bag filled with green peas, dated 9/26/22, no open date or consume by or discard date reflected. <BR/>-1 large zip tip bag half filled with fried okra, dated 9/19. No open date or consume by date reflected.<BR/>In an interview on 09/25/22 at 11:36 AM with Dietary Aide D, he stated that they cleaned and sanitized inside and outside of the refrigerators and freezers. He also stated they wiped off the dining room tables. He said, I change my sanitizing solution twice during breakfast and twice during lunch and more if the solution gets too dirty. <BR/>In an interview on 09/25/22 at 12:22 PM with Dietary Manager, she stated that when the produce came in, we stored as soon as it came in. She said, we check it then store it and its everyone's job to label food when it comes in. She stated the facility got it's produce from PFG, as well as the rest of the facility's food. She stated they (dietary) did not have any issues with the vendor thus far. She stated when new residents admitted , herself and the dietician evaluated the resident to find out what foods they liked, disliked and food preferences as well as any food allergies. The new admitting resident's diet came from the Nursing Department. The Dietary Manager stated that she kept a binder of this information to have as a reference for her and the staff.<BR/>In an interview on 09/26/22 at 11:38 AM with Dietary Manager, she was shown the fresh strawberries in refrigerator #1. The Dietary Manger said, if they (food item) come in and some are molded we refuse the whole case. [NAME] C would have checked in the produce that day. He is in charge when I am not here. I was out of town for a company training on the day these (strawberries) came in. She said, that we (facility) get a food delivery every Wednesday and I am sending those back when they come and deliver this Wednesday (09/28/22). We would not have served the strawberries; we would have changed the dessert. The strawberries were supposed to be used in a dessert last week but when I came back Thursday (09/22/22) morning I saw those and said, that is the wrong order. No, we are not using those, and they are being sent back. We changed the dessert and had something else. Fresh fruit goes bad quickly. That is why I ordered frozen on certain things that will go bad quick or within a week's time. I had ordered frozen strawberries, they sent fresh.<BR/>In an interview on 9/26/22 at 11:41 AM with [NAME] C, He stated he did not check in the delivery on 09/21/22, when the strawberries were delivered with the ordered items. [NAME] C stated he did not know who checked them in.<BR/>In an interview on 09/27/22 at 09:10 AM with the Dietary Manager, she stated there was a binder for cleaning logs. The staff was responsible for cleaning the refrigerators and the other equipment. She stated for the food items in the large white bins with lids, they did not put the expiration or use by date from the packaging when placing the oatmeal, sugar, flour and grits. She said, we put the date that we refill the bin then we put the item in the bin, but the facility's policy does not require we put the expiration date of that item on the bin. She stated personal cell phones and personal items are not allowed in the kitchen. She said, there are lockers in the back bathroom. They did that because I was not here. You know when the boss is away, anything goes but no that is not allowed. She stated that leftover food items were only kept in the refrigerator for 3 days. The Dietary Manager said, We (dietary) uses First in, first out. Sometimes I have to remind them, hey no, use the one that is already opened first. She stated she even puts sticker on items to remind staff to use an item first before using an unopened or later dated item. <BR/>Review of the Facility's Nutrition Services Food Storage Policy, Policy No.-DS-52, Version 1.0, Date Revised 12/2020, reflected Policy: Food items will be stored, thawed, and prepared in accordance with good sanitary practice. Procedure: VI. Fresh Fruits Storage Guidelines A. Fresh fruit should be checked and sorted for ripeness. C. Unwashed produce should not be placed in the refrigerator with or near prepared foods. D. Fresh fruit should be ordered and delivered frequently to ensure freshness. E. Rotate fruit so that oldest produce is used first. VIII. Canned Fruit Storage Guidelines . E. Recommended use is within 12 months. X. Frozen Vegetable Storage Guidelines . C. Recommended use is within 6 months. XI. Canned Vegetable Storage Guidelines . E. Recommended use is within 12 months XIII. Dry Storage Guidelines. G. Any opened products should be placed in storage containers with tight fitting lids. H. Label and date storage products.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain nutrition, grooming and personal and oral hygiene for one (Resident #1) of six residents reviewed for ADLs.<BR/>The facility failed to ensure Resident #1 was provided incontinent care in a timely manner, resulting in the resident smearing fecal matter on his mattress, bed linens, window ledge and throwing the fecal matter on the floor of his bedroom. <BR/>This failure could place residents at risk for discomfort, infection, and dignity issues.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet, printed on 03/12/24, reflected Resident #1 admitted to the facility on [DATE]. Resident #1 had diagnoses of dementia (the loss of cognitive functioning), lack of coordination, apraxia following cerebral infarction (cognitive disorder that can occur after stroke), lack of coordination, obesity, hyperlipidemia (in excess of lipids or fats in your blood), essential (primary) hypertension (high blood pressure), heart failure, aphasia following cerebral infarction (a disorder that affects how you communicate), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body), muscle weakness, dysphagia - oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat).<BR/>Record review of Resident #1's quarterly MDS assessment, dated 02/25/24, reflected Resident #1 was not recommended for the brief interview for mental status. Section C - Cognitive Patterns, revealed Resident #1 had short-term and long-term memory problems and had severely impaired cognitive skills for decision making. Section GG - Functional Abilities and Goals, Question GG0130. Self-Care indicated Resident #1 required substantial physical assistance in ADLs of oral hygiene, toileting, dressing and personal hygiene and was completely dependent on facility staff in ADLs of bathing. <BR/>Record review of Resident #1's care plan, last reviewed on 12/12/23, revealed the following:<BR/>[Resident #1] has bowel and bladder incontinence r/t Right sided paresis secondary to Multiple CVA . Interventions - INCONTINENT: Check [Resident #1] frequently and as required for incontinence.<BR/>Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes <BR/>[Resident #1 has an ADL Self Care Performance Deficit r/t Hemiplegia, Impaired balance . Interventions . Toilet use: self-performance Extensive assistance. Toilet use: support provided One-person physical assist. Personal hygiene: self-performance Extensive assistance. Personal hygiene: support provided One-person physical assist.<BR/>In an observation and interview on 03/12/24 at 2:32 p.m., Resident #1 was observed lying in his bed. Resident #1 stated he was well. Resident #1's room had a pungent smell of urine and stool. Fecal matter was observed on Resident #1's hands, on the floor, near the foot of his bed, on his bed linens and on the window seal near his bed. Resident #1 stated he did not know how long he had been left soiled. <BR/>On 03/12/24 at 2:36 p.m., the surveyor notified RN A, which was the nurse assigned to Resident #1, of Resident #1's condition. RN A accompanied the surveyor to Resident #1's room and stated, he was not like this. RN A stated she was not sure where Resident #1's aide was, but she would ensure the resident was cleaned. <BR/>On 03/12/24 at approximately 2:45 p.m., the ADMIN, DON, RD, and RN A, were observed to enter Resident #1's room. Shortly after their entrance, the ADMIN and RD exited, and Resident #1 could be heard yelling no. <BR/>On 03/12/24 at 3:08 p.m., the RD stated to the surveyor, Resident #1 began to display a behavior of throwing his fecal matter around his room and refused to be changed. The RD stated Resident #1 would be referred for psychiatric services for the newly onset behavior. <BR/>In an interview on 03/12/24 at 4:21 p.m., RN A stated it was the facility's expectation for residents to be dry at all times. RN A stated aides were to ensure residents were checked every 2 hours and incontinent care be provided, as needed. RN A stated she conducted rounds at roughly 2:15 p.m. and did not recall a stool smell in Resident #1's room. RN A stated residents would experience skin breakdown, if they were left soiled for too long. RN A stated she would conduct rounds on residents more often, to ensure incontinent care was provided at all times. <BR/>In an interview on 03/12/24 at 5:53 p.m., the DON stated it was the facility's expectation that facility aides and nurses checked on resident every 2 hours and provided incontinent care when needed. The DON stated failing to provide incontinent care promptly could increase residents' chances of skin breakdown. The DON stated Resident #1's recently increased his refusals of care and this incident was his first time throwing his fecal matter. The DON stated she would begin to Inservice nursing staff on incontinent care and refusals. <BR/>In an interview on 03/12/24 at 6:08 p.m., the ADMIN stated it was the facility's expectation for nursing staff to round every 2 hours, answer call lights as they are pressed and provide incontinent care when a resident was wet. The ADMIN stated not providing incontinent care when needed could cause a resident to have skin breakdown. The ADMIN stated if a resident was observed to be soiled, they were to be changed immediately. The ADMIN stated it was the responsibility of facility aides to provide incontinent care but, the nurse was also responsible for ensuring care was provided to residents as needed. The ADMIN stated the facility would begin to Inservice nursing staff on ADL care and incontinent care. <BR/>Record review of the facility's policy entitle Perineal Care, revised in June 2020, read in part:<BR/>Purpose: To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown.<BR/>Policy: Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received food that accommodated their preferences for 2 residents (Resident #2, Resident #3) of 6 residents reviewed for dietary services.<BR/>The facility failed to honor Resident #2's and Resident#3's preferences which stated large portions. <BR/>This failure could place residents at risk of not having an opportunity to exercise choices for meals and created a potential for weight loss and a decline in their quality of life. <BR/>Findings included:<BR/>Review of Resident #2's Comprehensive MDS dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and elevated blood pressure. His cognitive patterns assessment reflected a BIMs of 10 meaning that Resident #2 was moderately impaired cognitively.<BR/>Review of Resident #2's Physician orders dated 04/26/23, revealed an order Regular diet regular texture, thin consistency, large portions.<BR/>Review of the lunch meal ticket for Resident#2, for 04/26/23 reflected, Notes: .Large portions <BR/>In an observation on 04/26/23 at 12:15 PM revealed one plate with 1 scoop of cheesy sausage with sauteed onions, 1 scoop of O'Brien potatoes and 1 scoop of turnip greens. The meal ticket reflected, Large Portions per request for Resident #2. <BR/>In an interview and observation on 04/26/23 at 1:15 PM Resident #2 was in his room. He stated the food was not enough. He pointed to his plate and stated it was not a large portion. He showed the surveyor the meal ticket which stated large for Resident #2.<BR/>Review of Resident #3's Comprehensive MDS dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, malignant neoplasm of the brain (cancer of the brain), and elevated blood pressure. His cognitive patterns assessment reflected a BIMs of 15 meaning that Resident #3 was cognitively intact.<BR/>Review of Resident #3's Physician orders dated 04/26/23, revealed an order Regular diet regular texture, thin consistency, large portions.<BR/>Review of the lunch meal ticket for Resident#3 for 04/26/23 reflected, Notes: .Large portions per request <BR/>In an observation on 04/26/23 at 12:15 PM revealed one plate with 1 scoop of cheesy sausage with sauteed onions, 1 scoop of O'Brien potatoes and 1 scoop of turnip greens. The meal ticket reflected, Large Portions per request for Resident #3. <BR/>Interview on 04/26/23 at 12:25 PM with [NAME] D revealed the Dietary Manager printed the meal cards. A dietary aide read the meal card to [NAME] D. [NAME] D stated the large portion was 1 full scoop and regular portion was more than half scoop.<BR/>Interview on 04/26/23 at 1:40 PM with the Dietary Manager revealed it was expected that her staff read the meal ticket. She stated if the meal ticket stated a large portion for a resident, then the cook supposed to put 1 scoop and half of the meat on the tray. She stated the expectation was that the large portion should be 1.5 spoon. She stated Resident#2 and Resident #3 were supposed to receive large portion as indicated on their lunch tickets. She stated the importance of following requests was that it was important to the resident, so they needed to make sure they followed the meal ticket. <BR/>Record review of the facility's policy, Dining Service Menu Guide revised 2020, reflected, . Small Portion/Large Portion . Large Portions Diet . Lunch and Supper: Serve 1.1/2 servings of the entr&eacute;e, starch, and vegetable. All other food potions served follow the Regular Diet portions and are not altered .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two of eight residents (Residents #29 and #10) reviewed for reasonable accommodations. <BR/>1. The facility failed to ensure Resident #29's call button was within reach while Resident #29 was in bed.<BR/>2. The facility failed to ensure Resident #10's call button was within reach of hand while Resident #10 was in wheelchair. <BR/>These failures could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity.<BR/>Findings include:<BR/>1. Record review of Resident #29's quarterly MDS assessment, dated 07/12/22 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included anemia (deficiency or red blood cells), hypertension (elevated blood pressure), dementia, muscle weakness and lack of coordination (uncoordinated movement). She required extensive assistance of two-person physical assistance with bed mobility, personal hygiene and toilet use.<BR/>Record review of Resident #29's Comprehensive Care Plan revised 07/26/22 reflected Resident #29 was at risk for falls related to : confusion, gait/balance problems, use of psychotropic medication, unaware of safety needs and Vertigo. Interventions included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation and Interview on 09/25/22 at 11:59 AM revealed, Resident #29 was lying in bed. Her call light was not within reach, it was on the floor under the bed. She stated she used her call light when she needed assistance, but it was not within reach of her for her to use it. <BR/>Interview and observation on 09/25/22 at 1:50 PM with CNA I revealed, resident # 29 moved in bed which caused the call light to fall on the floor. She stated it should have been within reach of Resident #29. CAN I stated she did routine rounds every 2 hours.<BR/>Interview on 09/26/22 at 11:35 AM with LVN K revealed, she was the charge nurse and Resident #29's call light should be within reach of resident while in bed. So, Resident #29 could use it when she needed assistance.<BR/>2. Record review of Resident #10's Quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (result of disrupted blood flow to the brain due to problems with blood vessels that supply it), paresis (muscle weakness caused by nerve damage) of the left side, hypertension (elevated blood pressure), dementia, seizure disorder (brain activity becomes abnormal) and cognitive communication deficit. She had a BIMS of 6, which indicated she was severely cognitively impaired. She required extensive assistance of two-person physical assistance with bed mobility, transfers and toilet use.<BR/>Record review of Resident #10's Comprehensive Care Plan last revised 07/14/22 reflected the following:<BR/>- Resident #10 was at risk for falling R/T [related] gait/balance problems, unaware of safety needs secondary to CVA (cerebral vascular accident) with left sided hemiplegia (paralysis), seizure disorder and Parkinson's. Interventions included Be sure (Resident #10's) call light is within reach and encourage the resident to use it for assistance as needed. <BR/>Observation on 09/26/22 at 12:47 PM revealed Resident #10 was sitting in her wheelchair in her room, on the left side of the bed. Her call light was wrapped around the right-side assist rail on her bed. Resident #10 was unable to answer questions. <BR/>Interview on 09/26/22 at 12:47 PM CNA J stated call lights were supposed to be within reach, she said that she would move the resident to the other side of the bed, and she said that she would make sure the call light was within reach. She said Resident #10 was able to use the call light using the right hand. Resident #2 used her left hand and arm not her right. <BR/>Interview on 09/26/22 at 12:55 PM with LVN K revealed, she was the charge nurse and Resident #10's call light should be within reach of resident while in wheelchair. So, Resident #10 could use it when she needed assistance.<BR/>Interview on 09/27/22 at 11:51 PM with the DON revealed, the call buttons should be within reach of residents so they could use it when they needed assistance and should be accessible to residents at all times. She stated they would initiate in-services to ensure staff were checking to ensure call buttons were within reach of residents before they leave the room. <BR/>Record review of the facility's policy Communication - Call System revised June 2020 reflected . II. Call cords will be placed within the resident's reach 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 assessments accurately reflected the resident's status for two of 11 residents (Residents #41 and #65) reviewed for assessments.<BR/>1. The facility failed to accurately document Resident #41 admitted from a psychiatric hospital in the A1800 section of the admission MDS Assessment, dated 04/12/22, and Quarterly MDS assessment dated , 07/28/22. <BR/>2. The facility failed to accurately document Resident #41 had a serious mental illness in the PASRR: A1500 and A1510 sections of the admission MDS Assessment, dated 04/12/22. <BR/>3. The facility failed to accurately document Resident #65 admitted from a psychiatric hospital in the A1800 section of the admission MDS Assessment, dated 04/18/22. <BR/>4. The facility failed to accurately document Resident #65 had a serious mental illness in the PASRR: A1500 and A1510 sections of the admission MDS Assessment, dated 04/18/22. <BR/>These failures could place residents at risk of inaccurate PASRR Evaluations (PE) and ineligibility of PASRR benefits they may qualify for, which could result in a decreased quality of life, physical function, and psycho-social well-being.<BR/>The findings include:<BR/>1. Record review of Resident #41's face sheet revealed, a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Paranoid Schizophrenia (delusions and hallucinations), Major Depressive Disorder, recurrent, severe with psychotic symptoms (depression with loss of reality), Anxiety Disorder (excessive stress interfering with daily living) and on 06/21/22 diagnosed with Generalized Anxiety Disorder (constant worrying, restlessness, not concentrating) and Major Depressive Disorder, Single episode, mild (abnormal behavior and mood disorder). <BR/>Record review of Resident #41's admission MDS, dated [DATE], revealed A1500 No for having a serious mental and/or intellectual disability or related condition and admitted from an acute hospital. The BIMS cognitive score was 12 (cognitively intact), Yes for mood interview- 6 severity score- feeling down depressed, hopeless nearly every day, supervision with one person assist for most ADL's, always continent with bladder and bowel, without a mobility device and diagnoses included: Anxiety (excessive stress interfering with daily living), Depression (mood disorder causing sadness and loss of interest), Schizophrenia (serious mental disorder affecting thoughts), Post Traumatic Stress Disorder (stressful thoughts from past trauma) and Dependence on supplemental oxygen (extra oxygen required for oxygen deficiency in blood) . And had no falls and took antipsychotic, antianxiety and antidepressant medications and provided oxygen therapy . <BR/>Record review of Resident #41's Quarterly MDS Assessment, dated 07/28/22, revealed the resident was admitted from an acute care hospital. The MDS BIMS cognitive score was 14 (cognitively intact), Yes for mood interview 0 severity score - no mood indicators, limited to extensive with one person assistance for most ADL's, balance not steady for transitions and walking and use of a wheelchair, occasionally incontinent for bladder and bowel, diagnoses: Anxiety, Depression, Schizophrenia, Post Traumatic Stress Disorder and Dependence on supplemental oxygen. And had no falls and took antipsychotic, antianxiety and antidepressant medications and oxygen therapy.<BR/>Record review of Resident #41's, undated, Care Plan revealed, the resident had impaired cognitive function/impaired though processes, Anti-anxiety, Communication problem, Emphysema/COPD, Oxygen therapy, falls, anti-depressant, ADL's. <BR/>Record review of Resident #41's Psychiatric Hospital records revealed she admitted to the Psychiatric hospital on [DATE] for Major Depressive Disorder, recurrent and diagnoses of Major Depressive disorder, severe, with psychotic features, generalized anxiety disorder .Plan: Other specified Depressive Episodes - monitor the symptoms closely. Management per psychiatric team .Anxiety Disorder Unspecified - Monitor symptoms closely .continue the current medications, management per psychiatric team supportive care <BR/>Record review of Resident #41's PASRR Level 1 Screen assessment, dated 04/25/22, the resident screened Yes for Mental illness .Comments: PL1 uploaded in the wrong facility's portal <BR/>Record review of Resident #41's PASRR Evaluation assessment, dated 05/04/22, revealed the resident screened No inpatient psychiatric treatment .Based on the QMHP assessment, does this individual meet PASRR definition of mental illness .No, diagnoses Major depressive disorder, psychotic disorder with hallucination due to known physiological condition, Generalized anxiety disorder <BR/>2. Record review of Resident #65's face sheet, dated 09/26/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder (abnormal thoughts and unstable mood), Insomnia due to other mental disorder (inability to sleep due to mental disorder), Schizoaffective Disorder, Bipolar type (delusional-chronic brain disorder with depressive mood changes , Other abnormal Gait and mobility (weakness disorder walking), Anemia (low iron disorder). <BR/>Record review of Resident #65's admission MDS Assessment, dated 04/18/22, revealed, No serious mental illness and no conditions checked, admitted from acute hospital. The BIMS Score was 15 (cognitively intact), supervision with one person assist for most ADL's, unable to walk and not steady with transfers and used a wheelchair, always incontinent to bowel and bladder, diagnosis Schizophrenia, no falls, took antipsychotic and antidepressant medications <BR/>Record review of Resident #65's Quarterly MDS Assessment, dated 08/27/22, revealed the resident was admitted from a psychiatric hospital. The BIMS Score was 15 (cognitively intact), verbal behavioral symptoms at others occurred 1 to 3 days, rejected care occurred 1 to 3 days, limited functioning with one person assist with most ADL's, not steady an balance and transitions, used a wheelchair, frequently incontinent of bladder, occasionally incontinent of bowel, diagnoses Schizophrenia and insomnia due to other mental disorder and took antipsychotic medication <BR/>Record review of Resident #65's, undated, Care Plan revealed, Antidepressant medication, psychotropic medications, verbally aggressive towards staff, non-compliant with medication administration, falls, bowel and bladder, communication, ADL self-care deficit <BR/>Record review of Resident #65's Psychiatric Hospital Note revealed she was admitted to the Psychiatric hospital on [DATE] for psychosis and aggressive behavior with diagnosis Schizoaffective Disorder, initial treatment plan: Dangerous to self and others psychotic symptomatology and alcohol/substance dependence <BR/>Record review of Resident #65's PASRR Level 1 Screen assessment completed by the psychiatric hospital, dated 04/11/22, revealed Yes for mental illness. <BR/>Record review of Resident #65's PASRR Level 1 Screen assessment, dated 05/24/22, revealed Yes from a psychiatric hospital .Yes for mental illness .comments: PL1 not accepted due to demographic issues. Form re-submitted with corrections <BR/>Record review of Resident #65's Progress Note, dated 08/05/22, by Psychiatric NP, revealed: July 2022- Psychiatric hospitalization . [Resident #65] was sent to Psychiatric hospital for evaluation from 7/5-7/28/22. Prior to transfer, the pt had refusal of medications which led to increasing worsening behaviors, aggression and restless. On the day of her transfer, the pt had thrown different objects in the dining room area where other residents were. She had also punch staff members that were trying to restrain and remove her from dining room. Documentation is unclear of course of hospitalization. She returned to this facility <BR/>Record review of Resident #65's, undated, TMHP LTC Medicaid Activity Form revealed, 08/22/22 Form submitted .Individual placed in NF - Expedited admission .PL 1 submitted by nursing facility .08/26/22 individual placed in NF. PE confirmed <BR/>Record review of Resident #65's PASRR Evaluation assessment, dated 08/24/22, revealed yes for mental illness, Schizoaffective disorder, sleep disturbance, and no inpatient psychiatric treatment, C0800 based on the QMHP assessment, do this individual meet the PASRR definition of mental illness, No .diagnoses Schizoaffective disorder, insomnia due to other mental disorder, Schizoaffective disorder, bipolar, Type 2 diabetes mellitus and muscle weakness (generalized). <BR/>Interview on 09/27/22 at 11:29 AM, MDS F stated she had just started working at the facility a week ago and was responsible for doing the MDS Assessments and was a part of the IDT meetings and was not aware of any issues with the MDS assessments being inaccurate. <BR/>Interview on 09/27/22 at 12:38 PM, the DON stated the MDS nurse was made aware of who were PASRR positive and also notified the PASRR nurse of any updates. <BR/>Interview 09/27/22 at 1:01 PM, the RRN stated Resident #41 admitted to the facility 04/06/22, she was at a psychiatric hospital then admitted to the facility and Resident #65 had the wrong SS# on her PL 1 form and it was not accepted into the portal. She stated she was not sure who put the wrong building # for Resident #41 and if it was the psychiatric hospital who did it but the facility staff should have caught that and not approved her admission until it was corrected. She stated during their level of care meetings they went over demographics to review social security #, date of birth , name spelling and tried to be super cautious with the resident's information. <BR/>Interview on 09/27/22 at 2:48 PM, the PASRR Nurse stated he was not aware Resident #65 and #41's PL 1's had delays and submission issues and there were no issues with MDS inaccuracies. <BR/>Interview on 09/27/22 at 2:56 PM, LA/QMHP stated with Resident #41 having major depression, Schizophrenia and Generalized Anxiety Disorder and admitted from a psychiatric hospital increased the chances of her possibly being PASRR positive and stated the facility should have checked the TMHP LTC portal much sooner for the error messages to change the building #. She stated for Resident #65 the facility should have checked the TMHP LTC portal more often for the alerts about the wrong social security #. She stated at this campus, each facility building had their own MDS Nurse who entered the PL 1 information that was routed to the PASRR Nurse H. She stated the PASRR Nurse was the one contact person the LA/QMHP arranged the IDT meetings and coordination of care. She stated the LA/QMHP filled out the PE's based on the resident's MDS Assessment, medications list and face sheet. She stated if the MDS Assessment showed the resident admitted from an acute care hospital, the PE would show the same. She stated if the MDS assessments were wrong it would cause the PE to be inaccurate as well.<BR/>Record review of the facility's PASRR policy, dated 06/2020, revealed .Policy: III. The facility also conducts level 1 screening for current residents who experience a significant change in their condition based on MDS 3.0 Guidelines .failure to pre-screen residents prior to admission to the facility may result in the failure to identify residents who have or may have MI, ID or a related condition <BR/>Record review of the facility's Quality Assessment & Assurance Program policy, dated 06/2020, revealed Purpose: To ensure all services provided by the facility to residents meet the level of quality as required

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed not to admit new residents with a MI unless the LA determined their PASRR status for two of 11 residents (Resident #65 and #41) reviewed for PASRR screenings. <BR/>1. The facility failed to refer Resident #41's PASRR level 1 screen to the TMHP LTC portal within 72 hours to the LA after she was positive for a MI on 04/06/22 and did not correct the PASRR submission error which resulted in her PE not being completed by the LA until 05/04/22. <BR/>2. The facility failed to refer Resident #65's PASRR level 1 screen to the TMHP LTC portal within 72 hours to the LA after she re-admitted from a psychiatric hospital to this facility on 08/03/22 and the PL 1 was not submitted until 08/22/22. <BR/>3. The facility failed to refer Resident #65's PASRR level 1 screen to the TMHP LTC Portal within 72 hours to the LA after she was positive for a MI on 04/12/22 and did not correct the PASRR submission error which resulted in her PE not being completed by the LA until 08/24/22. <BR/>These failures could place residents with a positive PASRR to be at risk of not getting individualized and specialized services they may be eligible for in a timely manner, which could result in a decreased quality of life, physical function, and psycho-social well-being.<BR/>Findings include:<BR/>1. Record review of Resident #41's face sheet revealed, a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Paranoid Schizophrenia (delusions and hallucinations), Major Depressive Disorder, recurrent, severe with psychotic symptoms (depression with loss of reality), Anxiety Disorder (excessive stress interfering with daily living) and on 06/21/22 diagnosed with Generalized Anxiety Disorder (constant worrying, restlessness, not concentrating) and Major Depressive Disorder, Single episode, mild (abnormal behavior and mood disorder). <BR/>Record review of Resident #41's Order Summary Report dated 09/26/22 revealed, she took:<BR/>Quetiapine Fumarate tablet 25 mg for Paranoid Schizophrenia 2 tablets 50 mg two times a day (ordered 04/27/22) .Quetiapine Fumarate tablet 100 mg at bedtime (ordered 04/18/22) . <BR/>Xanax tablet .25 mg three times a day for anxiety disorder (ordered 08/04/22). <BR/>Record review of Resident #41's admission MDS, dated [DATE], revealed A1500 No for having a serious mental and/or intellectual disability or related condition and admitted from an acute hospital. The BIMS cognitive score was 12 (cognitively intact), Yes for mood interview- 6 severity score- feeling down depressed, hopeless nearly every day, supervision with one person assist for most ADL's, always continent with bladder and bowel, without a mobility device and diagnoses included: Anxiety (excessive stress interfering with daily living), Depression (mood disorder causing sadness and loss of interest), Schizophrenia (serious mental disorder affecting thoughts), Post Traumatic Stress Disorder (stressful thoughts from past trauma) and Dependence on supplemental oxygen (extra oxygen required for oxygen deficiency in blood) . And had no falls and took antipsychotic, antianxiety and antidepressant medications and provided oxygen therapy . <BR/>Record review of Resident #41's Quarterly MDS assessment dated [DATE] revealed admitted from acute care hospital, MDS BIMS cognitive score was 14 (cognitively intact), Yes for mood interview 0 severity score - no mood indicators, limited to extensive with one person assistance for most ADL's, balance not steady for transitions and walking and use of a wheelchair, occasionally incontinent for bladder and bowel, diagnoses: Anxiety, Depression, Schizophrenia, Post Traumatic Stress Disorder and Dependence on supplemental oxygen. And had no falls and took antipsychotic, antianxiety and antidepressant medications and oxygen therapy.<BR/>Record review of Resident #41's Care Plan undated revealed, Impaired cognitive function/impaired though processes, Anti-anxiety, Communication problem, Emphysema/COPD, Oxygen therapy, falls, anti-depressant, ADL's.<BR/>Record review of Resident #41's PASRR Level 1 Screen assessment dated [DATE] screened, Yes for Mental illness .Comments: PL1 uploaded in the wrong facility's portal <BR/>Review of Resident #41's PASRR Evaluation assessment dated [DATE] revealed, screened No inpatient psychiatric treatment .Based on the QMHP assessment, does this individual meet PASRR definition of mental illness .No, diagnoses Major depressive disorder, psychotic disorder with hallucination due to known physiological condition, Generalized anxiety disorder <BR/>Record review of Resident #41's Psychiatric Hospital records revealed she admitted to the Psychiatric hospital on [DATE] for Major Depressive Disorder, recurrent and diagnoses of Major Depressive disorder, severe, with psychotic features, Generalized anxiety disorder .Plan: Other specified Depressive Episodes - monitor the symptoms closely. Management per psychiatric team .Anxiety Disorder Unspecified - Monitor symptoms closely .continue the current medications, management per psychiatric team supportive care <BR/>Record review of Resident #41's TMHP LTC Medicaid Activity Form, revealed on 04/05/22, a PL 1 form was submitted .04/13/22 an alert was created and submitted in the Nursing Facility to certify able to/unable to serve the individual .05/02/22 Form inactivated the P1 has been inactivated because a new form was submitted for the individual 05/02/22 .PE confirmed 05/06/22 <BR/>2. Record review of Resident #65's face sheet, dated 09/26/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder (abnormal thoughts and unstable mood), Insomnia due to other mental disorder (inability to sleep due to mental disorder), Schizoaffective Disorder, Bipolar type (delusional-chronic brain disorder with depressive mood changes , Other abnormal Gait and mobility (weakness disorder walking), Anemia (low iron disorder). <BR/>Record review of Resident #65's Order Summary Report dated 09/26/22 revealed, Benztropine Mesylate (Parkinson), Paliperidone Palmitate ER suspension syringe (Schizophrenia), Trazodone (Insomnia). <BR/>Record review of Resident #65's admission MDS assessment dated [DATE] revealed, No serious mental illness and no conditions checked, admitted from acute hospital, BIMS Score was 15 (cognitively intact), supervision with one person assist for most ADL's, unable to walk and not steady with transfers and used a wheelchair, always incontinent to bowel and bladder, diagnosis Schizophrenia (serious mental disorder affecting thoughts), no falls, took antipsychotic and antidepressant medications <BR/>Record review of Resident #65's Quarterly MDS assessment dated [DATE] revealed, admitted from a psychiatric hospital on [DATE], BIMS Score was 15 (cognitively intact), Verbal behavioral symptoms at others occurred 1 to 3 days, Rejected care occurred 1 to 3 days, limited functioning with one person assist with most ADL's, not steady an balance and transitions, used a wheelchair, frequently incontinent of bladder, occasionally incontinent of bowel, diagnoses Schizophrenia and insomnia due to other mental disorder and took antipsychotic medication <BR/>Record review of Resident #65's Care Plan undated revealed, Antidepressant medication, psychotropic medications, Verbally aggressive towards staff, Non-compliant with medication administration, falls, bowel and bladder, communication, ADL self-care deficit <BR/>Record review of Resident #65's Psychiatric Hospital Note revealed she was admitted to the Psychiatric hospital on [DATE] for psychosis and aggressive behavior with diagnosis Schizoaffective Disorder, initial treatment plan: Dangerous to self and others psychotic symptomatology and alcohol/substance dependence . <BR/>Record review of Resident #65's PASRR Level 1 Screen assessment completed by the psychiatric hospital dated 04/11/22 revealed Yes for mental illness. <BR/>Record review of Resident #65's PASRR Level 1 Screen assessment dated [DATE] revealed Yes admitted from a psychiatric hospital .Yes for mental illness .comments: PL1 not accepted due to demographic issues. Form re-submitted with corrections <BR/>Record review of Resident #65's Progress Note dated 08/05/22 by Psychiatric NP, revealed: July 2022- Psychiatric hospitalization . Resident #65 was sent to Psychiatric hospital for evaluation from 7/5-7/28/22. Prior to transfer, the pt had refusal of medications which led to increasing worsening behaviors, aggression and restless. On the day of her transfer, the pt had thrown different objects in the dining room area where other residents were. She had also punch staff members that were trying to restrain and remove her from dining room. Documentation is unclear of course of hospitalization. She returned to this facility <BR/>Record review of Resident #65's PASRR Evaluation assessment dated [DATE] revealed yes for mental illness, Schizoaffective disorder, sleep disturbance, and no inpatient psychiatric treatment, C0800 based on the QMHP assessment, do this individual meet the PASRR definition of mental illness, No .diagnoses Schizoaffective disorder, insomnia due to other mental disorder, Schizoaffective disorder, bipolar, Type 2 diabetes mellitus and muscle weakness (generalized). <BR/>Record review of Resident #65's TMHP LTC Medicaid Activity Form, revealed no PASRR submissions until 06/10/22 placed in nursing facility - expedited admission .PL1 submitted by Nursing facility .06/17/22 Individual placed in nursing home - PE confirmed .08/22/22 individual placed in NF - Expedited admission .PL 1 submitted by NF .08/26/22 Individual placed in a nursing facility - PE confirmed. <BR/>Interview on 09/26/22 at 4:14 pm, MDS F stated she just started working at this facility a week ago and was not too familiar with the residents and was not sure how long the previous MDS had been gone. She stated Residents #65 and #41 were PASRR level 1 positive, but their PE Assessments were negative. <BR/>Interview and observation on 09/27/22 at 9:20 am, Resident #41 stated she needed more therapy and felt short winded and weak when she went to the bathroom, dressed and anytime she was active and on her feet. She stated she required continuous oxygen therapy and needed of a wheelchair because she was borrowing her sister's wheelchair and promised her sister to return it back to her soon. She stated she would like to get a little purse size oxygen machine because she did not want to take the big old tank around. The wheelchair appeared to be too small and appeared to have rust on it and was dirty. She stated she weighed 168 pounds and took medications for hallucinations and involuntary movements because her hand shook. <BR/>Interview on 09/27/22 at 10:46 am, the Rehab Director stated Resident #41 could benefit from more PT for gait training and transfers, she was not aware her wheelchair was her sisters and stated Resident #41 ambulated in her room and staff assisted her to the therapy room in her wheelchair. She stated Resident #41 was getting OT for ADL's and self-care and Resident #65 was getting OT for self-care and ADL's and PT for transfers and had knee pain. She stated Resident #65 had no falls but last month she went to a psychiatric hospital. She stated she received skilled services for two weeks after returning from the hospital and was now getting Medicare Part B therapy. She stated Resident #65 used a wheelchair to get around but could benefit with getting more OT services. <BR/>Interview on 09/27/22 at 10:59 am, SW G stated Resident #41 received psychiatric and counseling services for Paranoid Schizophrenia, Generalized anxiety disorder and Major depressive disorder. She stated Resident #65 received psychiatric and counseling services for schizo-affective affect and Insomnia. <BR/>Interview on 09/27/22 at 11:09 am, RN B stated Resident #41 was getting psychiatric and counseling services for anxiety and was just a very anxious person. <BR/>Interview on 09/27/22 at 11:29 am, MDS F stated she was responsible for submitting the PASRR forms to the PASRR nurse and was not aware of any discrepancies with the PASRR forms being inaccurate or submitted late. She stated she did the MDS Assessments and was a part of the IDT meetings and was not aware of any issues with the MDS assessments being inaccurate. She stated the PASRR nurse kept up with the resident's PASRR's via access to the facility's MDS Assessments and admissions records and the PASRR nurse was a part of the admission's team. <BR/>Interview on 09/27/22 at 11:57 am, the RRN stated MDS F used to be the PASRR Nurse who was responsible for the PASRR submissions and the new PASRR Nurse was PASRR Nurse H. She stated the facility had no delay in submitting the resident's PASRRS's and the timeframe the PL 1's was to be submitted into the TMHP LTC portal was as soon as possible. <BR/>Interview on 09/27/22 at 12:38 pm, the DON stated the PASRR nurse H was responsible for ensuring the PASRR's were submitted timely and accurately. She stated the PASRR Nurse was a part of the admission's process and there had been no complaints or issues about the PASRR forms not being submitted timely or accurately. She stated the MDS nurse was made aware who were PASRR positive and also notified the PASRR nurse of any updates. <BR/>Interview 09/27/22 at 1:01 pm, the RRN stated Resident #41 admitted to this facility 04/06/22, she was at a psychiatric hospital prior to admitting to this facility and a PL 1 and PE was entered on 03/01/22 for the wrong facility building, because they have three other buildings with the same name but different #'s. She stated they corrected Resident #41's PL 1 in the TMHP LTC portal on 05/02/22 because the TMHP portal showed the facility just had the wrong name on the building # and the PL 1 was inactivated at that facility and the PL 1 was transferred to this facility. She stated Resident #65 had the wrong SS# on her PL 1 form and it was not accepted into the portal and had to do a little research and identified why the PL 1 was getting rejected then they submitted another PL 1 with the correct social security # and then Resident #65's PE was completed 08/24/22, but it was negative for meeting the definition of PASRR. She stated before admitting a resident, they needed to really look at the building # on the PL1's to make sure the PASRR was at the right building and stated she was not sure who put the wrong building # for Resident #41 and if it was the psychiatric hospital the facility staff should have caught that and not approved her admission until it was corrected. She stated during their level of care meetings they went over demographics to review social security #, date of birth , name spelling and tried to be super cautious with the Resident's information. She stated they reviewed the TMHP simple LTC portal weekly and PASRR Nurse was designated to look in the TMHP LTC portal daily and was on call 24/7, including the weekends. <BR/>Interview on 09/27/22 at 2:48 pm, the PASRR Nurse H stated he was responsible for reviewing the TMHP portal and PASRR submissions and when a resident first admitted , the PL 1 was submitted within 72 hours and if the PL 1 was positive the LA had 7 days to get back to them to do the PE, then the facility had 14 days to set up IDT meeting. He stated not being aware of any PASRR delays with the resident's PL 1's and was implementing a new PASRR process with the LA/QMHP was also their trainer, to make it really easy for people reviewing the documents to easily read them. He stated he was not aware Resident #65 and #41's PL 1's had delays and submission issues.<BR/>Interview on 09/27/22 at 2:56 pm, LA/QMHP stated with Resident #41 having major depression, Schizophrenia and Generalized Anxiety Disorder and admitted from a psychiatric hospital increased the chances of her possibly being PASRR positive and stated the facility should have checked the TMHP LTC portal much sooner for the error messages to change the building #. She stated for Resident #65 the facility should have checked the TMHP LTC portal more often for the alerts about the wrong social security #. She stated each facility building had their own MDS Nurse who entered the PL 1 information that was routed to the PASRR Nurse H. She stated the PASRR Nurse was the one contact person the LA/QMHP arranged the IDT meetings and coordination of care.<BR/>Interview on 09/27/22 at 3:46 pm, the Admin stated he was not aware until today from RRN about an issue with the timing of the PASRR submissions and going forward the PASRR Nurse would check the portal for any errors on a daily basis. He stated for Resident #65 he was aware of the wrong social security issue delayed her PE and was not aware of any PASRR issues with Resident #41 but would talk to the PASRR Nurse to address the issue. He stated his expectation for PASRR assessments was making sure the PASRR process was excellent with responding to PASRR notifications and submitting information about the residents accurately. He stated PASRR Nurse H was responsible for ensuring the forms were submitted timely and if a resident did not get PASRR services the resident could get worse. <BR/>Record review of the facility's PASRR policy dated 06/2020 revealed, .Policy: III. The facility also conducts level 1 screening for current residents who experience a significant change in their condition based on MDS 3.0 Guidelines .failure to pre-screen residents prior to admission to the facility may result in the failure to identify residents who have or may have MI, ID or a related condition .Procedure: PASRR level 1 screening is to be completed before the individual is admitted to the facility <BR/>Record review of the facility's Quality Assessment & Assurance Program policy dated 06/2020 revealed, Purpose: To ensure all services provided by the facility to residents meet the level of quality as required

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain nutrition, grooming and personal and oral hygiene for one (Resident #1) of six residents reviewed for ADLs.<BR/>The facility failed to ensure Resident #1 was provided incontinent care in a timely manner, resulting in the resident smearing fecal matter on his mattress, bed linens, window ledge and throwing the fecal matter on the floor of his bedroom. <BR/>This failure could place residents at risk for discomfort, infection, and dignity issues.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet, printed on 03/12/24, reflected Resident #1 admitted to the facility on [DATE]. Resident #1 had diagnoses of dementia (the loss of cognitive functioning), lack of coordination, apraxia following cerebral infarction (cognitive disorder that can occur after stroke), lack of coordination, obesity, hyperlipidemia (in excess of lipids or fats in your blood), essential (primary) hypertension (high blood pressure), heart failure, aphasia following cerebral infarction (a disorder that affects how you communicate), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body), muscle weakness, dysphagia - oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat).<BR/>Record review of Resident #1's quarterly MDS assessment, dated 02/25/24, reflected Resident #1 was not recommended for the brief interview for mental status. Section C - Cognitive Patterns, revealed Resident #1 had short-term and long-term memory problems and had severely impaired cognitive skills for decision making. Section GG - Functional Abilities and Goals, Question GG0130. Self-Care indicated Resident #1 required substantial physical assistance in ADLs of oral hygiene, toileting, dressing and personal hygiene and was completely dependent on facility staff in ADLs of bathing. <BR/>Record review of Resident #1's care plan, last reviewed on 12/12/23, revealed the following:<BR/>[Resident #1] has bowel and bladder incontinence r/t Right sided paresis secondary to Multiple CVA . Interventions - INCONTINENT: Check [Resident #1] frequently and as required for incontinence.<BR/>Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes <BR/>[Resident #1 has an ADL Self Care Performance Deficit r/t Hemiplegia, Impaired balance . Interventions . Toilet use: self-performance Extensive assistance. Toilet use: support provided One-person physical assist. Personal hygiene: self-performance Extensive assistance. Personal hygiene: support provided One-person physical assist.<BR/>In an observation and interview on 03/12/24 at 2:32 p.m., Resident #1 was observed lying in his bed. Resident #1 stated he was well. Resident #1's room had a pungent smell of urine and stool. Fecal matter was observed on Resident #1's hands, on the floor, near the foot of his bed, on his bed linens and on the window seal near his bed. Resident #1 stated he did not know how long he had been left soiled. <BR/>On 03/12/24 at 2:36 p.m., the surveyor notified RN A, which was the nurse assigned to Resident #1, of Resident #1's condition. RN A accompanied the surveyor to Resident #1's room and stated, he was not like this. RN A stated she was not sure where Resident #1's aide was, but she would ensure the resident was cleaned. <BR/>On 03/12/24 at approximately 2:45 p.m., the ADMIN, DON, RD, and RN A, were observed to enter Resident #1's room. Shortly after their entrance, the ADMIN and RD exited, and Resident #1 could be heard yelling no. <BR/>On 03/12/24 at 3:08 p.m., the RD stated to the surveyor, Resident #1 began to display a behavior of throwing his fecal matter around his room and refused to be changed. The RD stated Resident #1 would be referred for psychiatric services for the newly onset behavior. <BR/>In an interview on 03/12/24 at 4:21 p.m., RN A stated it was the facility's expectation for residents to be dry at all times. RN A stated aides were to ensure residents were checked every 2 hours and incontinent care be provided, as needed. RN A stated she conducted rounds at roughly 2:15 p.m. and did not recall a stool smell in Resident #1's room. RN A stated residents would experience skin breakdown, if they were left soiled for too long. RN A stated she would conduct rounds on residents more often, to ensure incontinent care was provided at all times. <BR/>In an interview on 03/12/24 at 5:53 p.m., the DON stated it was the facility's expectation that facility aides and nurses checked on resident every 2 hours and provided incontinent care when needed. The DON stated failing to provide incontinent care promptly could increase residents' chances of skin breakdown. The DON stated Resident #1's recently increased his refusals of care and this incident was his first time throwing his fecal matter. The DON stated she would begin to Inservice nursing staff on incontinent care and refusals. <BR/>In an interview on 03/12/24 at 6:08 p.m., the ADMIN stated it was the facility's expectation for nursing staff to round every 2 hours, answer call lights as they are pressed and provide incontinent care when a resident was wet. The ADMIN stated not providing incontinent care when needed could cause a resident to have skin breakdown. The ADMIN stated if a resident was observed to be soiled, they were to be changed immediately. The ADMIN stated it was the responsibility of facility aides to provide incontinent care but, the nurse was also responsible for ensuring care was provided to residents as needed. The ADMIN stated the facility would begin to Inservice nursing staff on ADL care and incontinent care. <BR/>Record review of the facility's policy entitle Perineal Care, revised in June 2020, read in part:<BR/>Purpose: To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown.<BR/>Policy: Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed administered consistent with professional standards of practice for 1 (Residents #103) of 3 residents reviewed for infection control.<BR/>RN B failed to follow the facility's Intravenous Venous (IV) process placing the resident at increased risk for infection.<BR/>RN B did not utilize proper IV techniques and supplies with protecting an IV hub in an Intravenous Venous line in Resident #103's right arm. <BR/>These failures could place residents at risk for infection.<BR/>The findings were: <BR/>In a record review of Resident #103's Minimum Data Set (MDS) Assessment, dated 09/07/22, revealed a [AGE] year-old male, admitted [DATE], with a diagnoses which included Osteomyelitis of Vertebra and Lumbar Region (infection within the spinal column) and Intraspinal abscess (an infection that froms in the space between the skull bones and [NAME] lining). Section O - O0100 H. - reflected the resident received IV Medication. He was admitted for IV antibiotics related to his infection.<BR/>In a record review of Resident #103's Care Plan, dated 09/18/22, revealed a focus was his infection to his spinal abscess and osteomyelitis of the spine. The goal included he would be free from complications related to infections. The interventions included to administer IV antibiotics per physician orders; follow facility policy and procedures for IV procedures; and to maintain universal precautions when providing resident care.<BR/>In a record review of Resident #103's physician orders, dated 09/27/22, revealed to flush the IV line with 5 mL of normal saline before and after medication administration; change PICC/Midline dressing every Sunday morning; Vancomycin Hydrochloride solution with 2 grams intravenously daily every 24 hours for spinal abscess until 10/22/22; and Ceftriaxone Sodium 2 grams intravenously one time a day for spinal abscess and osteomyelitis until 10/20/22.<BR/>In an observation of Resident #103's IV line on 09/26/22 at 10:45 AM with RN B, the resident's IV Vancomycin HCL was observed being discontinued. RN B was observed washing her hands, applied gloves and cleaned the over bed table to arrange the supplies needed. RN B then washed her hands again and applied gloves. She removed the IV tubing from the resident IV hub. RN B flushed the line with 5 mL of normal saline then cleaned the hub with an alcohol pad. The uncapped IV hub was observed lying on Resident #103's arm. RN B placed the resident's bed sheet over his arm removed her gloves and washed her hands returned to the medication cart. <BR/>In an interview on 09/26/22 at 11:00 AM with RN B, she stated she did not have a cap to place on the IV hub. She stated she called them the green cap due to the color of the cap. She stated she would place a green cap on the hub, but at times the facility did not have them currently. RN B stated the resident received the IV antibiotics for a spinal infection and stated this practice could increase infection risk and by not placing a green cap on the hub, when not in use, could help prevent infections.<BR/>In an interview with the DON on 09/26/22 01:10 PM, she stated the facility had the green caps for the PICC/IV line hubs when not in use. The DON stated staff knew to come to her or go to medical supplies to get them. She also stated it was not part of the facility's policy to provide the caps to the PICC/IV line hubs but they typically did as part of their practice. She stated the caps were to help prevent infections. <BR/>In a observation and interview with the DON on 09/27/22 at 3:15 PM, she stated all the nurse's medication carts had a supply of the green IV hub caps and the supply of the green IV hub caps were observed at this time.<BR/>In a record review of the facility's Central Venous Catheter policy, dated 2/2009, revealed section II.Valve Change - 6. Disconnect the valve from the catheter, being careful not to touch the hub of the catheter. Hold the catheter in your hand so that the exposed hub does not come into contact with the skin of the chest or any other surface. 7. Pick up new catheter valve. Remove protective covering over male end, being sure not to touch the exposed tip.<BR/>In a record review of the National Library of Medicine - National Center of Biotechnology Information, Published online 2015 May 14, Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review revealed the following: Clinical Implications. It is critical for healthcare facilities and clinicians to take responsibility for compliance with basic principles of asepsis compliance, to involve frontline staff in strategies, to facilitate education that promotes understanding of the consequences of failure, and to comply with the standard of care for hub disinfection .2.2. Search Methodology - The purpose of this systematic review was to evaluate the supporting evidence for disinfection practices of NC, catheter hub, stopcock, and side ports that reduce the transfer of microorganisms through intravascular device access .XI. Catheter cap, access port, disinfecting cap, antimicrobial cap, hub protection cap, and port protector; XII. Infection prevention guidelines and recommendations.<BR/>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4446481/

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 the facility's only kitchen.<BR/>1.The facility failed to ensure food items in the refrigerators (3) and freezers (3) were labeled and stored in accordance with the professional standards for food service. <BR/>2. The facility failed to discard items stored in refrigerators not properly sealed/secure or past the best buy, consume by or expiration dates. <BR/>3. The facility failed to develop, implement and or provide a policy for Food Labeling and Procurement and or holding leftovers in the refrigerator. <BR/>4. The facility failed to have opened containers of potentially hazardous foods or leftovers dated or used within 7 days or according to facility policy. <BR/>These failures could place residents at risk for food-borne illness and cross contamination.<BR/>Findings included:<BR/>Observations of Refrigerator #1 on 09/25/22 at 11: 09 AM revealed the following: <BR/>-16-1 lb. of fresh Strawberries in original packaging, dated 9/21, had several berries that were molded, damaged or overripened (deeper red color and mushy exterior), in at least 8 of the containers. <BR/>-1 large zip top bag with medium amount of sliced Turkey deli meat, unsecured closed with no label of item description, no open date or consume by/discard date reflected. <BR/>- At the bottom of the refrigerator #1, 1-32 oz plastic container with lid, of Chopped Garlic in water dated 8/2 with manufacturer's expiration date 9/7/22. The lid was unsecured closed on one side.<BR/> -1 Large container Picante Sauce Medium, dated 9/12, had no open date or consume by date. <BR/>-1 Large zip top bag, dated 9/23, with salad mix in original packaging inside, both bags were open/unsecured. There was also no label of item description and no consume by date. <BR/> -1 large zip top bag, dated 9/2, with shredded cheddar cheese in original packaging inside. The cheese and the zip top bag were unsecured/open to air, there was no open date or consume by date. <BR/>-1 zip top bag of sliced yellow cheese block in original packaging, dated 9/21, both bags were unsecured closed/open to air. <BR/> -1 medium stainless-steel pan with applesauce, covered with plastic wrap, dated 9/22. The plastic wrap was not secured along the long side of the pan, leaving it partially open to air. <BR/>-1 large clear container with lid, with dark purple jelly, dated 9/15, no received by date, no consume by or discard date reflected. <BR/>Observations of the Kitchen on 09/25/22 at 10:51 AM revealed the following: <BR/>-4-24 muffin cup pan with uncooked rolls in each cavity, the pans were sitting on the steam table, uncovered. <BR/>-Under the preparation table was 1 tray with 15 clear 2 oz containers with lids containing a dark liquid. Only one of the containers had a piece of blue tape with the date 9/21 on it. Otherwise, no label of item description, no consume by date. <BR/>-Outside of Fridges #1, #2 and #3 were dirty, smudged and the bottom vent covers were dirty.<BR/>-There was a cell phone lying on the preparation table next to box of gloves. <BR/>-1 Large white bin with lid, had dry oatmeal inside, dated 9/14 but there was no consume by or discard date. <BR/>-1 Large white bin with lid, had flour in it, dated 8/24/22, there was no consume by or expiration date. <BR/>- Large white bins with lids, labeled flour and sugar were dirty around the outside of the bins.<BR/>Observations of Freezer #1 on 09/25/22 at 10:58 AM revealed the following: <BR/>-Double door freezer, the outside doors were smudged and dirty. The bottom vent cover is dirty. <BR/>-3 Bags of yellow liquid (frozen), out of original box, dated 9/14, there was no label of item description. <BR/>-1 Medium white opaque container with lid of BBQ Heat & Serve chopped Brisket, dated 9/21, the lid on the container is broken on side and cracked on the top. <BR/>Observations of Refrigerator #3 on 09/25/22 at 11:25 AM revealed the following: <BR/>-1 tray with 3 small white bowls. 1 bowl of applesauce and 2 bowls of fruit cocktail, no label of each individual item, no open date/pulled date or no consume by date. <BR/>-4 trays with approximately 30- 2 oz. clear containers with lids, per tray, with mayonnaise in them and 1 with mustard. There were no dates pulled, no label of description and no consume by or discard by date reflected. <BR/>Observations of the Dry Storage Room on 09/25/22 at 11:27 AM revealed the following: <BR/>-1 Fly noted flying in the dry storage room. <BR/>-On the shelf across from Freezer #2, 1 Large container of Silver Source Pancake Syrup, dated 9/7, previously opened. There was no open date or consume by date reflected. <BR/>-1 Large white bin with lid, had grits, dated 8/15/22 there was no received by date or consume by date. <BR/>-Sitting on top of the rice container,1 package of small Flour tortillas, with no manufacturer packaging date or expiration date. There was no received by date, no label of item description, no consume by date. <BR/>-1 container with lid of Rice, dated 8/3/22, no open date, no consume by date. <BR/>-1 container with lid of Fish Fry Mix, dated 8/3/22, had no open date and no consume by date. <BR/>Observations of Freezer #2 on 09/25/22 at 11:34 AM revealed the following: <BR/>-1 large bag of dinner rolls, dated 9/21, there was no label of item description, no consume by date. <BR/>-4 bags of Hush Puppies, dated 9/21, there was no label of item description, no consume by date. <BR/>Observations of the Kitchen on 09/27/22 at 09:10 AM revealed the following: <BR/>-Noted on the door of Freezer #1, there was a staff cleaning assignment sheet for week of September 25- October 2, 2022. There were assignments for cleaning the refrigerators and the freezers. Outside of Refrigerators #1, #2, and #3 remained dirty as was the vent covers at the bottom of them. <BR/>Observations of Freezer #3 on 09/27/22 at 12:44 PM revealed the following: <BR/>-1 Large zip top bag filled with green peas, dated 9/26/22, no open date or consume by or discard date reflected. <BR/>-1 large zip tip bag half filled with fried okra, dated 9/19. No open date or consume by date reflected.<BR/>In an interview on 09/25/22 at 11:36 AM with Dietary Aide D, he stated that they cleaned and sanitized inside and outside of the refrigerators and freezers. He also stated they wiped off the dining room tables. He said, I change my sanitizing solution twice during breakfast and twice during lunch and more if the solution gets too dirty. <BR/>In an interview on 09/25/22 at 12:22 PM with Dietary Manager, she stated that when the produce came in, we stored as soon as it came in. She said, we check it then store it and its everyone's job to label food when it comes in. She stated the facility got it's produce from PFG, as well as the rest of the facility's food. She stated they (dietary) did not have any issues with the vendor thus far. She stated when new residents admitted , herself and the dietician evaluated the resident to find out what foods they liked, disliked and food preferences as well as any food allergies. The new admitting resident's diet came from the Nursing Department. The Dietary Manager stated that she kept a binder of this information to have as a reference for her and the staff.<BR/>In an interview on 09/26/22 at 11:38 AM with Dietary Manager, she was shown the fresh strawberries in refrigerator #1. The Dietary Manger said, if they (food item) come in and some are molded we refuse the whole case. [NAME] C would have checked in the produce that day. He is in charge when I am not here. I was out of town for a company training on the day these (strawberries) came in. She said, that we (facility) get a food delivery every Wednesday and I am sending those back when they come and deliver this Wednesday (09/28/22). We would not have served the strawberries; we would have changed the dessert. The strawberries were supposed to be used in a dessert last week but when I came back Thursday (09/22/22) morning I saw those and said, that is the wrong order. No, we are not using those, and they are being sent back. We changed the dessert and had something else. Fresh fruit goes bad quickly. That is why I ordered frozen on certain things that will go bad quick or within a week's time. I had ordered frozen strawberries, they sent fresh.<BR/>In an interview on 9/26/22 at 11:41 AM with [NAME] C, He stated he did not check in the delivery on 09/21/22, when the strawberries were delivered with the ordered items. [NAME] C stated he did not know who checked them in.<BR/>In an interview on 09/27/22 at 09:10 AM with the Dietary Manager, she stated there was a binder for cleaning logs. The staff was responsible for cleaning the refrigerators and the other equipment. She stated for the food items in the large white bins with lids, they did not put the expiration or use by date from the packaging when placing the oatmeal, sugar, flour and grits. She said, we put the date that we refill the bin then we put the item in the bin, but the facility's policy does not require we put the expiration date of that item on the bin. She stated personal cell phones and personal items are not allowed in the kitchen. She said, there are lockers in the back bathroom. They did that because I was not here. You know when the boss is away, anything goes but no that is not allowed. She stated that leftover food items were only kept in the refrigerator for 3 days. The Dietary Manager said, We (dietary) uses First in, first out. Sometimes I have to remind them, hey no, use the one that is already opened first. She stated she even puts sticker on items to remind staff to use an item first before using an unopened or later dated item. <BR/>Review of the Facility's Nutrition Services Food Storage Policy, Policy No.-DS-52, Version 1.0, Date Revised 12/2020, reflected Policy: Food items will be stored, thawed, and prepared in accordance with good sanitary practice. Procedure: VI. Fresh Fruits Storage Guidelines A. Fresh fruit should be checked and sorted for ripeness. C. Unwashed produce should not be placed in the refrigerator with or near prepared foods. D. Fresh fruit should be ordered and delivered frequently to ensure freshness. E. Rotate fruit so that oldest produce is used first. VIII. Canned Fruit Storage Guidelines . E. Recommended use is within 12 months. X. Frozen Vegetable Storage Guidelines . C. Recommended use is within 6 months. XI. Canned Vegetable Storage Guidelines . E. Recommended use is within 12 months XIII. Dry Storage Guidelines. G. Any opened products should be placed in storage containers with tight fitting lids. H. Label and date storage products.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three (CNA A) staff members and eight of eight residents (Resident #81, #30, #10, #50, #62, #52, #91 and #73) reviewed for infection control procedures. <BR/>CNA A failed to perform hand hygiene after direct contact with residents #81, #30, #10, #50, #62, #52, #91, and #73 while serving meals on Hall 600. <BR/>This failure could place residents at risk for healthcare associated cross contamination and infections.<BR/>Findings included:<BR/>Record review of Resident #81's 5-day [other payment] MDS assessment, dated 10/03/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #81 had diagnoses which included: schizoaffective disorder (mental illness), and depressive disorder (mental illness). Resident #81 was alert and oriented and able to make decisions and required assistance of one staff for activities of daily living. <BR/>Record review of Resident #30's quarterly MDS Assessment, dated 11/22/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #30 had diagnoses which included: hypertension (high blood pressure) and Cerebral infarction (stroke). Resident #30 was alert and oriented, able to make decisions and required one staff for assistance with activities of daily living. <BR/>Record review of Resident #10's quarterly MDS Assessment, dated 12/07/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included: Hypertension (high blood pressure), Parkinson's disease (disease of muscle and nerves), and cerebral vascular disease (stroke). Resident #10 was alert and oriented and able to make decisions and required one staff for assistance with activities of daily living. <BR/>Record review of Resident #50's quarterly MDS Assessment, dated 12/13/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #50 had diagnoses which included: Hypertension (increased blood pressure), depressive disorder (mental illness), and muscle wasting (weakness). Resident #50 was moderately cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. <BR/>Record review of Resident #62's quarterly MDS Assessment, dated 12/11/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #62 had diagnoses which included: Hypertension (increased blood pressure), depressive disorder (mental illness), and muscle wasting (weakness). Resident #62 was moderately cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. <BR/>Record review of Resident #52's quarterly MDS Assessment, dated 12/05/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #52 had diagnoses which included: Hypertension (increased blood pressure), cerebral vascular disease (stroke), and muscle wasting (weakness). Resident #52 was severely cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. <BR/>Record review of Resident #91's quarterly MDS Assessment, dated 12/06/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #91 had diagnoses which included: Diabetes (increased blood sugar), seizures (brain disorder), and psychotic disorder (mental illness). Resident #91 was severely cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. <BR/>Record review of Resident #73's quarterly MDS Assessment, dated 12/16/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #73 had diagnoses which included: Hypertension (increased blood pressure), peripheral vascular disease (poor circulation), and osteomyelitis (infection of the bone). Resident #73 was alert and oriented and able to make decisions and required assistance of one staff for activities of daily living. <BR/>Observation on 01/07/2025 beginning at 8:00 a.m., revealed CNA A had walked down the hallway, did not use hand sanitizer, and served a breakfast tray to Resident #81, touched, and moved the overbed table in the resident's room, touched the hand and shoulder of Resident #81 assisting him to sit up and prepared the meal tray for the resident to eat his breakfast. CNA A did not have on gloves. CNA A was observed to not wash her hands or use hand sanitizer, available in the hallway and in her pocket, that had been provided to her by another staff member.<BR/>Observation on 01/07/2025 beginning at 8:05 a.m., CNA A was observed to enter Resident #30's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. CNA A did not have on gloves. She did not complete hand hygiene before going to the next resident.<BR/>Observation on 01/07/2025 beginning at 8:07 a.m., CNA A was observed to enter Resident #10's room touching the resident on the shoulder and hand, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. CNA A did not have on gloves. She did not complete hand hygiene before going to the next resident.<BR/>Observation on 01/07/2025 beginning at 8:08 a.m., CNA A was observed to enter Resident #50's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident.<BR/>Observation on 01/07/2025 beginning at 8:10 a.m., CNA A was observed to enter Resident #62's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident.<BR/>Observation on 01/07/2025 beginning at 8:11 a.m., CNA A was observed to enter Resident #52's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident.<BR/>Observation on 01/07/2025 beginning at 8:12 a.m., CNA A was observed to enter Resident #91's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident.<BR/>Observation on 01/07/2025 beginning at 8:15 a.m., CNA A was observed to enter Resident #73's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident.<BR/>An interview on 01/07/2025 at 8:25 a.m., CNA A stated she did not complete hand hygiene after having direct contact with residents. CNA A stated she was supposed to use the hand sanitizer in between serving each tray or wash her hands and she had some hand sanitizer in her pocket that had been provided by another staff member earlier. CNA A said she had been educated on completing hand hygiene. CNA A stated she did not sanitize her hands, after the first meal tray that was served because she had been called in to work and she was trying to get the breakfast trays served and she did not want the food to get cold. CNA A stated she knew she could spread germs if she did not clean her hands. <BR/>An interview with the DON on 01/08/2025 at 11:00 a.m., revealed that all staff must complete hand hygiene after having contact with residents. She stated CNAs were trained to wash their hands with soap and water prior to tray service, then use hand sanitizer between each tray service. The DON stated if the CNAs do not use appropriate hygiene, they can spread germs to the residents and themselves. The DON was the infection control preventionist and she stated they had completed hand washing and hand sanitizing in recent in-services and provided the CNAs with pocket size hand sanitizer. <BR/>An interview with the Administrator on 01/08/2025 at 11:15 a.m. revealed he could not believe that staff member had not followed their education concerning meal service and hand sanitizer. The Administrator stated he and the DON had both in-serviced and provided personal pocket hand sanitizer to the staff and educating them on the spread of germs, which could happen if they did not practice appropriate hand sanitizing. <BR/>Record review of an in-service dated November 2024 revealed CNA A received handwashing and hand sanitizing training, to prevent the spread of infection. Further review of in-service logs revealed an in-service conducted in November 2024 reflected: when passing trays in the hallways, sanitize after going in every room. Remember to wash your hands before starting meal service and use hand sanitizer between each tray served. <BR/>Record Review of an in-service dated December 2024 revealed CNA A received hand washing and hand sanitizing in-service explaining when to wash hands and when to use hand sanitizing and why to wash your hands and use the hand sanitizer. Further review reflected the use of alcohol gel or washing hands between each meal service tray. <BR/>Record review of the Facility's Policy titled Hand Hygiene revised June 2020 reflected: To ensure that all individuals use appropriate hand hygiene while at the facility . The facility considers hand hygiene the primary means to prevent the spread of infections . I. Facility staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections III. Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors . IV. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hands rub, etc.) are readily accessible and convenient for the staff use to encourage compliance with hand hygiene policy. V. Facility Staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited to . A. Wash hands with soap and water: . vi. Before and after food prep . 8. Alcohol-based hand hygiene products can and should be used to decontaminate hands: i. immediately upon entering a resident occupied area (single or multiple bed room, procedures or treatment room) regardless of glove use; .ii. Immediately upon exiting a resident occupied area 9 e.g., before exiting into a common area such as a corridor) regardless of glove use; . iii. Before moving from one resident to another in a multiple-bed room or procedure area regardless of gloves use

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #2) of three residents reviewed for care plans.<BR/>The facility failed to develop and implement a comprehensive person-centered care plan for Resident #2 to address large portion diet.<BR/>This failure could place residents at risk of requests and needs not being met.<BR/>The findings were:<BR/>Review of Resident #2's Comprehensive MDS dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and elevated blood pressure. His cognitive patterns assessment reflected a BIMs of 10 meaning that Resident #2 was moderately impaired cognitively.<BR/>Review of Resident #2's Physician orders dated 04/26/23, revealed an order Regular diet regular texture, thin consistency, large portions.<BR/>Review of the lunch meal ticket for Resident#2, for 04/26/23 reflected, Notes: .Large portions <BR/>Record review of Resident #2's Care Plan, dated 04/17/2023, revealed no mention of dietary plan for large portions.<BR/>In an interview on 04/26/23 at 01:35 PM, the DON stated the Dietary Manager was responsible for the dietary care plans.<BR/>The DON stated care plans were addressed at their daily clinical meetings with Interdisciplinary Team which included DON, dietary manager, MDS nurse and therapy director. The DON stated a care plan should have been done to address the large portion diet. The DON stated the individualized care plan was person centered and the facility used it to know the resident's needs or how to care for them. <BR/>Interview on 04/26/23 at 1:40 PM with the Dietary Manager revealed she was not supposed to do a care plan for the large portions diet. She stated since it was reflected on the meal ticket, there was no need to care plan. <BR/>Record review of the facility's policy Care Planning revised 06/2020 quoted in part, a comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs.

Based on observation, interviews, and record reviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (300 and 600 hall shower rooms) of three shower rooms reviewed for environmental conditions. <BR/>The facility failed to ensure the shower rooms on the 300 hall and 600 hall were free of a black substance in between the tiles. <BR/>This failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.<BR/>The findings included:<BR/>Observations on 03/12/24 from 3:10 p.m. to 3:20 p.m., of the shower rooms on the 300 and 600 halls revealed the following:<BR/>- <BR/>The 300-hall shower room had a black substance, about 6 inches in length, on the left wall of the shower in between the grout where the wall tile and floor tile met. <BR/>- <BR/>The 300-hall shower room had a black substance, about 15 inches in length, on the back wall of the shower in between the grout of the tiles. <BR/>- <BR/>The shower room on the 600-hall had a black substance, about 4 inches in length, on the back wall of the shower in between the grout where the wall tile and floor tile met. <BR/>In an interview on 03/12/24 at 3:53 p.m., the HSKS stated the RD showed her the areas of black substance in the 300 and 600 hall shower rooms. The HSKS stated housekeeping staff cleaned the showers with bleach and no-rinse sanitation solution. The HSKS stated staff would clean the shower rooms twice daily and after each use. The HSKS stated she believed the black substance was a buildup of soap scum. The HSKS stated she and her staff had tried to clean the showers grout by scrubbing them, but they were unable to scrub the substance off, so the showers would be regrouted. The HSKS stated residents were not affected by the black substances in the showers because the showers were sanitized after every use with a sanitizers that killed all organisms. The HSKS stated she would in-service her staff on cleaning and when to report conditions to herself and the maintenance director. <BR/>In an interview on 03/12/24 at 6:08 p.m., the ADMIN stated it was the expectation for the facility be clean and sanitary at all times, which was a responsibility of all facility staff. The ADMIN stated if facility staff noticed a needed repair, it was expected of them to report the issue, so it could be repaired. The ADMIN stated the residents were not affected by the black substances in the shower because the showers were cleaned daily and after each use with a sanitizer solution. The ADMIN stated the facility in-service facility staff on facility cleanliness, and maintenance request submission. The ADMIN stated he would monitor the condition of the shower rooms in the future to ensure the shower rooms were clean and in sanitary condition. <BR/>Record review of the facility's policy entitled Resident Room and Environment, revised in August of 2020, read in part:<BR/>Purpose: To provide resident with a safe, clean, comfortable and homelike environment. Policy: The facility provides residents with a safe, clean, comfortable and homelike environment . Procedure: I. Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order; .

Based on observation, interview, and record review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 1 (medication aide cart) of 1 medication cart reviewed for medication storage. <BR/>The facility failed to ensure:<BR/>The medication supplies were secured or attended by authorized staff when the medication aide's cart in hall 600 was left unlocked and unattended in the hallway 600.<BR/>This failure could place residents at risk to access and ingest of medications leading to a risk for harm and could lead to missing medication.<BR/>The findings include:<BR/>During an observation on 04/26/2023 at 8:36 AM, MA A stepped away from the medication aide cart, he entered Resident #2's room to administer medication. MA A left the medication cart in hallway 600, by room unlocked. The lock was in the out position and the drawers were able to be opened, leaving the medications accessible. The following medications were in the cart: Gabapentin 300 mg, omeprazole 20 mg, xarelto 20 mg, allopurinol 100 mg, furosemide 20 mg, tamsulosin 0.4 mg, metoprolol tartrate 25 mg, amlodipine 5 mg, and other medication. A resident in a wheelchair was in the hallway close by the medication cart during the observation. <BR/>Interview on 04/26/23 at 8:42 AM, MA A stated he did not normally leave the cart unlocked. MA A stated he was taught medication carts should be locked when not in use or out of sight because a resident could take the medications. MA A stated he forgot to lock the medication cart.<BR/>Interview on 04/26/23 at 1:35 PM, the DON stated it was her expectation that medication carts were locked when not in use. The DON stated if they were not locked, residents and staff could get into the cart and there would be opportunities for harm and medication to go missing. The DON stated she was responsible to do routine rounds for monitoring. <BR/>Record review of the facility's policy titled Storage of Medications dated September 2018, reflected the following: . 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts and medication supplies are locked when they are not attended by persons with authorized access

Based on observation, interview, and record review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 1 (medication aide cart) of 1 medication cart reviewed for medication storage. <BR/>The facility failed to ensure:<BR/>The medication supplies were secured or attended by authorized staff when the medication aide's cart in hall 600 was left unlocked and unattended in the hallway 600.<BR/>This failure could place residents at risk to access and ingest of medications leading to a risk for harm and could lead to missing medication.<BR/>The findings include:<BR/>During an observation on 04/26/2023 at 8:36 AM, MA A stepped away from the medication aide cart, he entered Resident #2's room to administer medication. MA A left the medication cart in hallway 600, by room unlocked. The lock was in the out position and the drawers were able to be opened, leaving the medications accessible. The following medications were in the cart: Gabapentin 300 mg, omeprazole 20 mg, xarelto 20 mg, allopurinol 100 mg, furosemide 20 mg, tamsulosin 0.4 mg, metoprolol tartrate 25 mg, amlodipine 5 mg, and other medication. A resident in a wheelchair was in the hallway close by the medication cart during the observation. <BR/>Interview on 04/26/23 at 8:42 AM, MA A stated he did not normally leave the cart unlocked. MA A stated he was taught medication carts should be locked when not in use or out of sight because a resident could take the medications. MA A stated he forgot to lock the medication cart.<BR/>Interview on 04/26/23 at 1:35 PM, the DON stated it was her expectation that medication carts were locked when not in use. The DON stated if they were not locked, residents and staff could get into the cart and there would be opportunities for harm and medication to go missing. The DON stated she was responsible to do routine rounds for monitoring. <BR/>Record review of the facility's policy titled Storage of Medications dated September 2018, reflected the following: . 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts and medication supplies are locked when they are not attended by persons with authorized access

Based on observation, interview, and record review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 1 (medication aide cart) of 1 medication cart reviewed for medication storage. <BR/>The facility failed to ensure:<BR/>The medication supplies were secured or attended by authorized staff when the medication aide's cart in hall 600 was left unlocked and unattended in the hallway 600.<BR/>This failure could place residents at risk to access and ingest of medications leading to a risk for harm and could lead to missing medication.<BR/>The findings include:<BR/>During an observation on 04/26/2023 at 8:36 AM, MA A stepped away from the medication aide cart, he entered Resident #2's room to administer medication. MA A left the medication cart in hallway 600, by room unlocked. The lock was in the out position and the drawers were able to be opened, leaving the medications accessible. The following medications were in the cart: Gabapentin 300 mg, omeprazole 20 mg, xarelto 20 mg, allopurinol 100 mg, furosemide 20 mg, tamsulosin 0.4 mg, metoprolol tartrate 25 mg, amlodipine 5 mg, and other medication. A resident in a wheelchair was in the hallway close by the medication cart during the observation. <BR/>Interview on 04/26/23 at 8:42 AM, MA A stated he did not normally leave the cart unlocked. MA A stated he was taught medication carts should be locked when not in use or out of sight because a resident could take the medications. MA A stated he forgot to lock the medication cart.<BR/>Interview on 04/26/23 at 1:35 PM, the DON stated it was her expectation that medication carts were locked when not in use. The DON stated if they were not locked, residents and staff could get into the cart and there would be opportunities for harm and medication to go missing. The DON stated she was responsible to do routine rounds for monitoring. <BR/>Record review of the facility's policy titled Storage of Medications dated September 2018, reflected the following: . 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts and medication supplies are locked when they are not attended by persons with authorized access

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three (CNA A) staff members and eight of eight residents (Resident #81, #30, #10, #50, #62, #52, #91 and #73) reviewed for infection control procedures. <BR/>CNA A failed to perform hand hygiene after direct contact with residents #81, #30, #10, #50, #62, #52, #91, and #73 while serving meals on Hall 600. <BR/>This failure could place residents at risk for healthcare associated cross contamination and infections.<BR/>Findings included:<BR/>Record review of Resident #81's 5-day [other payment] MDS assessment, dated 10/03/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #81 had diagnoses which included: schizoaffective disorder (mental illness), and depressive disorder (mental illness). Resident #81 was alert and oriented and able to make decisions and required assistance of one staff for activities of daily living. <BR/>Record review of Resident #30's quarterly MDS Assessment, dated 11/22/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #30 had diagnoses which included: hypertension (high blood pressure) and Cerebral infarction (stroke). Resident #30 was alert and oriented, able to make decisions and required one staff for assistance with activities of daily living. <BR/>Record review of Resident #10's quarterly MDS Assessment, dated 12/07/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included: Hypertension (high blood pressure), Parkinson's disease (disease of muscle and nerves), and cerebral vascular disease (stroke). Resident #10 was alert and oriented and able to make decisions and required one staff for assistance with activities of daily living. <BR/>Record review of Resident #50's quarterly MDS Assessment, dated 12/13/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #50 had diagnoses which included: Hypertension (increased blood pressure), depressive disorder (mental illness), and muscle wasting (weakness). Resident #50 was moderately cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. <BR/>Record review of Resident #62's quarterly MDS Assessment, dated 12/11/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #62 had diagnoses which included: Hypertension (increased blood pressure), depressive disorder (mental illness), and muscle wasting (weakness). Resident #62 was moderately cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. <BR/>Record review of Resident #52's quarterly MDS Assessment, dated 12/05/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #52 had diagnoses which included: Hypertension (increased blood pressure), cerebral vascular disease (stroke), and muscle wasting (weakness). Resident #52 was severely cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. <BR/>Record review of Resident #91's quarterly MDS Assessment, dated 12/06/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #91 had diagnoses which included: Diabetes (increased blood sugar), seizures (brain disorder), and psychotic disorder (mental illness). Resident #91 was severely cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. <BR/>Record review of Resident #73's quarterly MDS Assessment, dated 12/16/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #73 had diagnoses which included: Hypertension (increased blood pressure), peripheral vascular disease (poor circulation), and osteomyelitis (infection of the bone). Resident #73 was alert and oriented and able to make decisions and required assistance of one staff for activities of daily living. <BR/>Observation on 01/07/2025 beginning at 8:00 a.m., revealed CNA A had walked down the hallway, did not use hand sanitizer, and served a breakfast tray to Resident #81, touched, and moved the overbed table in the resident's room, touched the hand and shoulder of Resident #81 assisting him to sit up and prepared the meal tray for the resident to eat his breakfast. CNA A did not have on gloves. CNA A was observed to not wash her hands or use hand sanitizer, available in the hallway and in her pocket, that had been provided to her by another staff member.<BR/>Observation on 01/07/2025 beginning at 8:05 a.m., CNA A was observed to enter Resident #30's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. CNA A did not have on gloves. She did not complete hand hygiene before going to the next resident.<BR/>Observation on 01/07/2025 beginning at 8:07 a.m., CNA A was observed to enter Resident #10's room touching the resident on the shoulder and hand, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. CNA A did not have on gloves. She did not complete hand hygiene before going to the next resident.<BR/>Observation on 01/07/2025 beginning at 8:08 a.m., CNA A was observed to enter Resident #50's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident.<BR/>Observation on 01/07/2025 beginning at 8:10 a.m., CNA A was observed to enter Resident #62's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident.<BR/>Observation on 01/07/2025 beginning at 8:11 a.m., CNA A was observed to enter Resident #52's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident.<BR/>Observation on 01/07/2025 beginning at 8:12 a.m., CNA A was observed to enter Resident #91's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident.<BR/>Observation on 01/07/2025 beginning at 8:15 a.m., CNA A was observed to enter Resident #73's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident.<BR/>An interview on 01/07/2025 at 8:25 a.m., CNA A stated she did not complete hand hygiene after having direct contact with residents. CNA A stated she was supposed to use the hand sanitizer in between serving each tray or wash her hands and she had some hand sanitizer in her pocket that had been provided by another staff member earlier. CNA A said she had been educated on completing hand hygiene. CNA A stated she did not sanitize her hands, after the first meal tray that was served because she had been called in to work and she was trying to get the breakfast trays served and she did not want the food to get cold. CNA A stated she knew she could spread germs if she did not clean her hands. <BR/>An interview with the DON on 01/08/2025 at 11:00 a.m., revealed that all staff must complete hand hygiene after having contact with residents. She stated CNAs were trained to wash their hands with soap and water prior to tray service, then use hand sanitizer between each tray service. The DON stated if the CNAs do not use appropriate hygiene, they can spread germs to the residents and themselves. The DON was the infection control preventionist and she stated they had completed hand washing and hand sanitizing in recent in-services and provided the CNAs with pocket size hand sanitizer. <BR/>An interview with the Administrator on 01/08/2025 at 11:15 a.m. revealed he could not believe that staff member had not followed their education concerning meal service and hand sanitizer. The Administrator stated he and the DON had both in-serviced and provided personal pocket hand sanitizer to the staff and educating them on the spread of germs, which could happen if they did not practice appropriate hand sanitizing. <BR/>Record review of an in-service dated November 2024 revealed CNA A received handwashing and hand sanitizing training, to prevent the spread of infection. Further review of in-service logs revealed an in-service conducted in November 2024 reflected: when passing trays in the hallways, sanitize after going in every room. Remember to wash your hands before starting meal service and use hand sanitizer between each tray served. <BR/>Record Review of an in-service dated December 2024 revealed CNA A received hand washing and hand sanitizing in-service explaining when to wash hands and when to use hand sanitizing and why to wash your hands and use the hand sanitizer. Further review reflected the use of alcohol gel or washing hands between each meal service tray. <BR/>Record review of the Facility's Policy titled Hand Hygiene revised June 2020 reflected: To ensure that all individuals use appropriate hand hygiene while at the facility . The facility considers hand hygiene the primary means to prevent the spread of infections . I. Facility staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections III. Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors . IV. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hands rub, etc.) are readily accessible and convenient for the staff use to encourage compliance with hand hygiene policy. V. Facility Staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited to . A. Wash hands with soap and water: . vi. Before and after food prep . 8. Alcohol-based hand hygiene products can and should be used to decontaminate hands: i. immediately upon entering a resident occupied area (single or multiple bed room, procedures or treatment room) regardless of glove use; .ii. Immediately upon exiting a resident occupied area 9 e.g., before exiting into a common area such as a corridor) regardless of glove use; . iii. Before moving from one resident to another in a multiple-bed room or procedure area regardless of gloves use

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the right to be free from abuse for one (Resident #36) of seven residents reviewed for abuse.<BR/>The facility failed to ensure Resident #36 was free from abuse. On 3/07/2024 Hospitality Aide B called Resident #36 trash and used profanity when speaking to Resident #36.<BR/>The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 3/07/2024 and ended on 3/12/2024. The facility had corrected the noncompliance before the investigation began.<BR/>This failure could place residents at risk for abuse and psychological harm.<BR/>Findings included:<BR/>Record review of Resident #36's Quarterly MDS dated [DATE] revealed Resident #36 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of anxiety, depression, and schizophrenia (a mental disorder). The MDS also revealed a BIMS score of 15 (suggested no cognitive impairment) and Section E of the MDS revealed no behavioral symptoms were present.<BR/>Record review of Resident #36's undated care plan revealed Resident #36 was at risk for altered moods and depression.<BR/>Record review of the PIR dated 3/07/2024 revealed on 3/07/2024 that Resident #36 reported Hospitality Aide B called him trash and used profanity.<BR/>In an interview on 1/07/2025 at 8:32 a.m., Resident #36 reported a hospitality aide called him trash three times and used profanity. Resident #36 stated that the staff member was terminated and no one else had ever spoken to him like that again. Resident #36 stated the incident did not hurt him but made him mad. Resident #36 stated it was just words, and once she was gone that it was over with. <BR/>In an interview on 1/07/2025 at 10:04 a.m., Hospitality Aide B stated Resident #36 came out of nowhere telling her that she was always talking about other people. Hospitality Aide B stated Resident #36 cursed at her and called her names. Hospitality Aide B stated she then asked Resident #36 if she was all of the things he called her, then did that mean that he was white trash. Hospitality Aide B stated she was fed up with Resident #36 and started calling him names like trash. Hospitality Aide B reported she then left the area and reported Resident #36 to the nurse. Hospitality Aide B stated her actions may be abuse, but Resident #36 was abusing her. <BR/>Record review of witness statements dated 3/7/2024 revealed two residents witnessed the incident and confirmed the Hospitality Aide called Resident #36 trash. <BR/>In an interview on 1/07/2025 at 10:40 a.m., the ADM reported the two residents that witnessed the incident were not available for interview because one had passed away and the other transferred to another facility. <BR/>In an interview on 1/07/2025 at 9:46 a.m., the DON reported Hospitality Aide B was immediately suspended when Resident #36 reported the incident. The DON reported Hospitality Aide B acted like the incident was not a big deal because Resident #36 had a BIMS of 15. The DON reported Hospitality Aide B was terminated, safe surveys were completed to ensure no one else was affected by the incident, a trauma assessment was completed on Resident #36 that revealed no harm, and all staff were in-serviced regarding verbal abuse and customer service. The DON stated the risk to the residents depended on their life experiences but could have placed them at risk for trauma. The DON stated prior to this incident that all employees received training over abuse and neglect during orientation and in-services as needed afterwards. The DON stated all staff were responsible for monitoring everyone and reporting any signs or incidents of abuse or neglect to the administrator.<BR/>In an interview on 1/07/2025 at 10:40 a.m., the ADM reported Hospitality Aide B was immediately suspended after the incident was reported. The ADM reported when he spoke with Hospitality Aide B that she admitted to calling the resident trash. The ADM stated Resident #36 told him he was fine and there was no harm to him. The ADM stated cursing at a resident or calling them names was bad customer service. The ADM stated customer service training included resident rights and abuse and neglect.<BR/>Record review of facility policy titled Abuse Prevention and Prohibition Program, with a revision date of 10/24/2022, revealed Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse.<BR/>The facility took the following actions to correct the noncompliance prior to the investigation:<BR/>In an interview on 1/07/2025 at 9:46 a.m., the DON reported Hospitality Aide B was terminated, safe surveys were completed to ensure no one else was affected by the incident, and all staff were in-serviced regarding verbal abuse and customer service. <BR/>Record review of Hospitality Aide B's employee file revealed Hospitality Aide B was placed on suspension 3/07/2024 and employment was terminated on 3/12/2024 for violation of policy and procedure.<BR/>Record review of safe surveys dated 3/12/2024 revealed all residents responded they were not abused, were treated with respect, and felt comfortable telling the staff about their concerns.<BR/>Record review of in-service titled Abuse and Neglect, with a date of 3/7/2024, revealed 44 staff signatures and the summary listed on the in-service stated, We are not to engage in any type of verbal altercation with any residents, it is a form of verbal abuse. The residents have the right to say what they like. We are to remain professional and walk away, report behaviors to their charge nurse.<BR/>In an interview on 1/08/2025 at 4:34 p.m., the DON reported they included training specifically for verbal abuse and started checking the staff's knowledge during their in-services by asking the staff questions about abuse and customer service. The DON stated she and the administrator completed daily knowledge checks and education with every shift for 30 days. The DON reported after 30 days they did weekly checks and education for four weeks. The DON stated after that they started doing monthly in-services that included knowledge checks and education that would continue every month from now on. The DON stated she was responsible for ensuring all staff were educated. The DON stated she or the ADM would initial when the checks were completed on a form.<BR/>In an interview on 1/08/2025 at 4:40 p.m., the ADM confirmed that after this incident knowledge checks and education were performed on every shift for 30 days. The ADM stated they did weekly education and knowledge checks after that, and then monthly education and knowledge checks were completed. The ADM stated he reviewed the education and knowledge check sheets with the DON every month to ensure they were completed.<BR/>Record review of March calendar with title Resident's Rights, Abuse and Neglect, Customer Service revealed initials daily by the DON and ADM from March 8, 2024, until March 31, 2024.<BR/>Record review of April calendar with title Resident's Rights, Abuse and Neglect, Customer Service revealed initials daily by the ADM from April 1, 2024, until April 7, 2024. Initials by the DON or ADM were present weekly or more often from April 8, 2024, until April 30, 2024.<BR/>Record review of May calendar with title Resident's Rights, Abuse and Neglect, Customer Service revealed initials on dates May 3, 15, and 26th by the DON or ADM.<BR/>Record review of in-service binder revealed in-services titled Abuse and Neglect, were completed monthly from June 2024 until December 2024.<BR/>In an interview on 1/07/2025 at 7:53 a.m., Housekeeper C reported cursing at a resident would be verbal abuse. Housekeeper C stated he receives training for abuse and neglect about twice a month and was trained before he started working. Housekeeper C stated the DON provides the trainings and asks the staff questions about abuse to make sure they understand.<BR/>In an interview on 1/07/2025 at 7:55 a.m., Housekeeper D stated she receives training on abuse and neglect at least monthly, and it includes verbal abuse. Housekeeper D described verbal abuse as yelling or cursing at residents.<BR/>In an interview on 1/07/2025 at 10:24 a.m., Activities Coordinator E stated cursing at a resident would be verbal abuse. Activities Coordinator E stated that getting loud with a resident could be verbal abuse, and if staff was not able to handle a situation, then they should go get someone else. Activities Coordinator E reported she receives training on customer service and abuse monthly. Activities Coordinator E reported customer service training teaches staff how to treat residents with respect.<BR/>In an interview on 1/07/2025 at 12:44 p.m., RN F stated they do abuse and neglect training monthly that includes verbal abuse. RN F also stated that there is training on customer service. RN F reported customer service is speaking to the resident in a calm tone and not using bad language.<BR/>In an interview on 1/07/2025 at 1:14 p.m., RN G reported she receives monthly training for abuse and neglect that also included customer service. RN G stated cursing is verbal abuse and that she would immediately intervene if she witnessed any abuse. <BR/>In an interview on 1/08/2025 at 9:15 a.m., LVN H reported she had monthly training on abuse and neglect. LVN H stated training included customer service and verbal abuse. LVN H described verbal abuse as calling the residents names or speaking to the resident in an offensive way.<BR/>In an interview on 1/08/2025 at 10:32 a.m., RN I stated she received abuse and neglect training when she first started. RN I reported that abuse and neglect trainings were done monthly and included verbal abuse. RN I stated verbal abuse means you could not talk to residents any way you want to. RN I stated you have to be respectful to the residents.<BR/>In an interview on 1/08/2025 at 10:37 a.m., MA J reported he had abuse and neglect training monthly that included verbal abuse. MA J stated verbal abuse was spoken words that were inappropriate and offensive to the person that was spoken to.<BR/>In an interview on 1/08/2025 at 10:40 a.m., CNA K stated she received training for abuse and neglect monthly and it included verbal abuse. CNA K described verbal abuse as someone cursing at a resident or yelling at a resident. <BR/>In an interview on 1/08/2025 at 10:51 a.m., CNA L reported abuse and neglect training was done monthly with the DON and ADM. CNA L described verbal abuse as swearing at residents or belittling the residents or anything said in a negative form.<BR/>In an interview on 1/08/2025 at 10:56 a.m., Hospitality Aide M stated she received abuse and neglect training prior to working the floor and received it monthly now. Hospitality Aide M reported verbal abuse was included and that verbal abuse was when you talked to the resident in a mean way that you were not supposed to be doing. <BR/>In an interview on 1/08/2025 at 11:00 a.m., Hospitality Aide N stated she started working two days ago and received training on abuse and neglect before she worked the floor. Hospitality Aide N stated the training included verbal abuse and stated verbal abuse could be mistreating the resident with your tone or using curse words.

Based on observation, interviews, and record reviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (300 and 600 hall shower rooms) of three shower rooms reviewed for environmental conditions. <BR/>The facility failed to ensure the shower rooms on the 300 hall and 600 hall were free of a black substance in between the tiles. <BR/>This failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.<BR/>The findings included:<BR/>Observations on 03/12/24 from 3:10 p.m. to 3:20 p.m., of the shower rooms on the 300 and 600 halls revealed the following:<BR/>- <BR/>The 300-hall shower room had a black substance, about 6 inches in length, on the left wall of the shower in between the grout where the wall tile and floor tile met. <BR/>- <BR/>The 300-hall shower room had a black substance, about 15 inches in length, on the back wall of the shower in between the grout of the tiles. <BR/>- <BR/>The shower room on the 600-hall had a black substance, about 4 inches in length, on the back wall of the shower in between the grout where the wall tile and floor tile met. <BR/>In an interview on 03/12/24 at 3:53 p.m., the HSKS stated the RD showed her the areas of black substance in the 300 and 600 hall shower rooms. The HSKS stated housekeeping staff cleaned the showers with bleach and no-rinse sanitation solution. The HSKS stated staff would clean the shower rooms twice daily and after each use. The HSKS stated she believed the black substance was a buildup of soap scum. The HSKS stated she and her staff had tried to clean the showers grout by scrubbing them, but they were unable to scrub the substance off, so the showers would be regrouted. The HSKS stated residents were not affected by the black substances in the showers because the showers were sanitized after every use with a sanitizers that killed all organisms. The HSKS stated she would in-service her staff on cleaning and when to report conditions to herself and the maintenance director. <BR/>In an interview on 03/12/24 at 6:08 p.m., the ADMIN stated it was the expectation for the facility be clean and sanitary at all times, which was a responsibility of all facility staff. The ADMIN stated if facility staff noticed a needed repair, it was expected of them to report the issue, so it could be repaired. The ADMIN stated the residents were not affected by the black substances in the shower because the showers were cleaned daily and after each use with a sanitizer solution. The ADMIN stated the facility in-service facility staff on facility cleanliness, and maintenance request submission. The ADMIN stated he would monitor the condition of the shower rooms in the future to ensure the shower rooms were clean and in sanitary condition. <BR/>Record review of the facility's policy entitled Resident Room and Environment, revised in August of 2020, read in part:<BR/>Purpose: To provide resident with a safe, clean, comfortable and homelike environment. Policy: The facility provides residents with a safe, clean, comfortable and homelike environment . Procedure: I. Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain nutrition, grooming and personal and oral hygiene for one (Resident #1) of six residents reviewed for ADLs.<BR/>The facility failed to ensure Resident #1 was provided incontinent care in a timely manner, resulting in the resident smearing fecal matter on his mattress, bed linens, window ledge and throwing the fecal matter on the floor of his bedroom. <BR/>This failure could place residents at risk for discomfort, infection, and dignity issues.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet, printed on 03/12/24, reflected Resident #1 admitted to the facility on [DATE]. Resident #1 had diagnoses of dementia (the loss of cognitive functioning), lack of coordination, apraxia following cerebral infarction (cognitive disorder that can occur after stroke), lack of coordination, obesity, hyperlipidemia (in excess of lipids or fats in your blood), essential (primary) hypertension (high blood pressure), heart failure, aphasia following cerebral infarction (a disorder that affects how you communicate), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body), muscle weakness, dysphagia - oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat).<BR/>Record review of Resident #1's quarterly MDS assessment, dated 02/25/24, reflected Resident #1 was not recommended for the brief interview for mental status. Section C - Cognitive Patterns, revealed Resident #1 had short-term and long-term memory problems and had severely impaired cognitive skills for decision making. Section GG - Functional Abilities and Goals, Question GG0130. Self-Care indicated Resident #1 required substantial physical assistance in ADLs of oral hygiene, toileting, dressing and personal hygiene and was completely dependent on facility staff in ADLs of bathing. <BR/>Record review of Resident #1's care plan, last reviewed on 12/12/23, revealed the following:<BR/>[Resident #1] has bowel and bladder incontinence r/t Right sided paresis secondary to Multiple CVA . Interventions - INCONTINENT: Check [Resident #1] frequently and as required for incontinence.<BR/>Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes <BR/>[Resident #1 has an ADL Self Care Performance Deficit r/t Hemiplegia, Impaired balance . Interventions . Toilet use: self-performance Extensive assistance. Toilet use: support provided One-person physical assist. Personal hygiene: self-performance Extensive assistance. Personal hygiene: support provided One-person physical assist.<BR/>In an observation and interview on 03/12/24 at 2:32 p.m., Resident #1 was observed lying in his bed. Resident #1 stated he was well. Resident #1's room had a pungent smell of urine and stool. Fecal matter was observed on Resident #1's hands, on the floor, near the foot of his bed, on his bed linens and on the window seal near his bed. Resident #1 stated he did not know how long he had been left soiled. <BR/>On 03/12/24 at 2:36 p.m., the surveyor notified RN A, which was the nurse assigned to Resident #1, of Resident #1's condition. RN A accompanied the surveyor to Resident #1's room and stated, he was not like this. RN A stated she was not sure where Resident #1's aide was, but she would ensure the resident was cleaned. <BR/>On 03/12/24 at approximately 2:45 p.m., the ADMIN, DON, RD, and RN A, were observed to enter Resident #1's room. Shortly after their entrance, the ADMIN and RD exited, and Resident #1 could be heard yelling no. <BR/>On 03/12/24 at 3:08 p.m., the RD stated to the surveyor, Resident #1 began to display a behavior of throwing his fecal matter around his room and refused to be changed. The RD stated Resident #1 would be referred for psychiatric services for the newly onset behavior. <BR/>In an interview on 03/12/24 at 4:21 p.m., RN A stated it was the facility's expectation for residents to be dry at all times. RN A stated aides were to ensure residents were checked every 2 hours and incontinent care be provided, as needed. RN A stated she conducted rounds at roughly 2:15 p.m. and did not recall a stool smell in Resident #1's room. RN A stated residents would experience skin breakdown, if they were left soiled for too long. RN A stated she would conduct rounds on residents more often, to ensure incontinent care was provided at all times. <BR/>In an interview on 03/12/24 at 5:53 p.m., the DON stated it was the facility's expectation that facility aides and nurses checked on resident every 2 hours and provided incontinent care when needed. The DON stated failing to provide incontinent care promptly could increase residents' chances of skin breakdown. The DON stated Resident #1's recently increased his refusals of care and this incident was his first time throwing his fecal matter. The DON stated she would begin to Inservice nursing staff on incontinent care and refusals. <BR/>In an interview on 03/12/24 at 6:08 p.m., the ADMIN stated it was the facility's expectation for nursing staff to round every 2 hours, answer call lights as they are pressed and provide incontinent care when a resident was wet. The ADMIN stated not providing incontinent care when needed could cause a resident to have skin breakdown. The ADMIN stated if a resident was observed to be soiled, they were to be changed immediately. The ADMIN stated it was the responsibility of facility aides to provide incontinent care but, the nurse was also responsible for ensuring care was provided to residents as needed. The ADMIN stated the facility would begin to Inservice nursing staff on ADL care and incontinent care. <BR/>Record review of the facility's policy entitle Perineal Care, revised in June 2020, read in part:<BR/>Purpose: To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown.<BR/>Policy: Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need.

Based on observation, interviews, and record reviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (300 and 600 hall shower rooms) of three shower rooms reviewed for environmental conditions. <BR/>The facility failed to ensure the shower rooms on the 300 hall and 600 hall were free of a black substance in between the tiles. <BR/>This failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.<BR/>The findings included:<BR/>Observations on 03/12/24 from 3:10 p.m. to 3:20 p.m., of the shower rooms on the 300 and 600 halls revealed the following:<BR/>- <BR/>The 300-hall shower room had a black substance, about 6 inches in length, on the left wall of the shower in between the grout where the wall tile and floor tile met. <BR/>- <BR/>The 300-hall shower room had a black substance, about 15 inches in length, on the back wall of the shower in between the grout of the tiles. <BR/>- <BR/>The shower room on the 600-hall had a black substance, about 4 inches in length, on the back wall of the shower in between the grout where the wall tile and floor tile met. <BR/>In an interview on 03/12/24 at 3:53 p.m., the HSKS stated the RD showed her the areas of black substance in the 300 and 600 hall shower rooms. The HSKS stated housekeeping staff cleaned the showers with bleach and no-rinse sanitation solution. The HSKS stated staff would clean the shower rooms twice daily and after each use. The HSKS stated she believed the black substance was a buildup of soap scum. The HSKS stated she and her staff had tried to clean the showers grout by scrubbing them, but they were unable to scrub the substance off, so the showers would be regrouted. The HSKS stated residents were not affected by the black substances in the showers because the showers were sanitized after every use with a sanitizers that killed all organisms. The HSKS stated she would in-service her staff on cleaning and when to report conditions to herself and the maintenance director. <BR/>In an interview on 03/12/24 at 6:08 p.m., the ADMIN stated it was the expectation for the facility be clean and sanitary at all times, which was a responsibility of all facility staff. The ADMIN stated if facility staff noticed a needed repair, it was expected of them to report the issue, so it could be repaired. The ADMIN stated the residents were not affected by the black substances in the shower because the showers were cleaned daily and after each use with a sanitizer solution. The ADMIN stated the facility in-service facility staff on facility cleanliness, and maintenance request submission. The ADMIN stated he would monitor the condition of the shower rooms in the future to ensure the shower rooms were clean and in sanitary condition. <BR/>Record review of the facility's policy entitled Resident Room and Environment, revised in August of 2020, read in part:<BR/>Purpose: To provide resident with a safe, clean, comfortable and homelike environment. Policy: The facility provides residents with a safe, clean, comfortable and homelike environment . Procedure: I. Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order; .