**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents have the right to request, refuse, and or discontinue treatment and to formulate an advance directive for 1 (R#82) of 6 residents whose records were reviewed for OOH-DNR Order forms: The facility failed to have Resident #82's Out-of-Hospital Do Not Resuscitate (OOH DNR) on admission or in a timely manner. This failure could place residents at risk for not having their end of life wishes honored. The findings included: Record review of Resident #82's admission record dated 06/05/2025 revealed he was a [AGE] year-old male admitted on [DATE]. His relevant diagnoses included kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), chronic obstructive pulmonary (a group of lung diseases that block airflow and make it difficult to breathe), and lack of coordination( a neurological condition that causes difficulty controlling muscle movements and balance). Record review of Resident #82's admission/5-day MDS assessment was still in progress. Record review of Resident #82's care plan dated 05/19/25 reflected a focus of DNR code status, his interventions in part included to honor his advanced directives, care wishes, and code status would be respected and honored as indicted (date initiated 05/20/25). Record review of Resident #82's order summary dated 06/05/25 reflected an active DNR order effective 05/19/25. In an interview and observation on 06/04/25 at 10:15 a.m., the SW said it was his responsibility to ensure that a resident whose code status was DNR had a completed OOH-DNR form in their medical electronic record. The SW was observed as he reviewed Resident #82's medical electronic record and said the OOH-DNR form had not been uploaded. The SW said he had audited Resident #82's medical electronic record on 06/03/25 and had discovered he had failed to initiate the process of obtaining an OOH-DNR form. The SW said there were no negative outcome to Resident #82 because he had a DNR order, his profile and care plan indicated he was a DNR. He said if Resident #82 had coded, he would be considered a DNR. In an interview on 06/04/25 at 10:30 a.m., the DON said it was the responsibility of the facility's SW to ensure an OOH-DNR form was obtained and correctly completed for each DNR resident. She said as long as there was an active DNR order, the code status of DNR would be entered on the resident's medical electronic record (profile and care plan). She said if a resident coded, nursing staff would immediately check the resident's electronic medical record to check their code status under their profile and ensure there was an active DNR order. She said as long as their profile and order matched, the resident would be considered a DNR. The DON said she had instructed the nursing staff that if they had any doubt about a resident's code status to immediately call the resident's representative. The DON said, whatever is active as an order is what would be most current. The DON said the topic of advanced directives were part of the nurse's skill check offs which were done yearly or as needed. In an interview on 06/04/25 at 3:15 p.m., LVN C, said if a resident coded, he would immediately check their electronic medical record to check their code status under their profile and physician's order. He said if the resident had a code status of DNR, she would also check under the miscellaneous tab to ensure the OOH-DNR form had been uploaded and had all required signatures. He said if the OOH-DNR form had not been uploaded or completed correctly, he would immediately contact the resident's representative for clarification. He said he had never experienced a situation in which a resident coded and their OOH-DNR form had not been uploaded. In an interview on 06/04/25 at 4:30 p.m., LVN G, said if a resident coded, she would immediately check the resident's electronic medical record to check for their code status under their profile and would also ensure there was an active DNR physician order. She said she would also check under the miscellaneous tab to ensure the OOH-DNR form was completed correctly. She said if the OOH-DNR form had not been uploaded or was missing signatures, she would consider the resident a full code. She said she had never experienced a situation in which a resident coded and their OOH-DNR form had not been uploaded. In an interview on 06/04/25 at 4:54 p.m., LVN H, said if a resident coded, she would immediately check their electronic medical record to check their code status under their profile and physician's order. She said if the resident had a code status of DNR, she would also check under the miscellaneous tab to ensure the OOH-DNR form had been uploaded and had all required signatures. LVN H said ultimately, as long as the resident's profile had them coded as a DNR and there was an active DNR order, she would consider the resident a DNR. She said she had never experienced a situation in which a resident coded and their OOH-DNR form had not been uploaded. An interview on 06/04/25 at 5:04 p.m., LVN I said if a resident coded, he would immediately check their electronic medical record to check their code status under their profile and physician's order. He said if the resident had a code status of DNR, he would also check under the miscellaneous tab to ensure the OOH-DNR form had been uploaded and had all required signatures. LVN I said as long as the resident's profile had them coded as a DNR and there was an active DNR order, he would consider the resident a DNR. He said she had never experienced a situation in which a resident coded and their OOH-DNR form had not been uploaded. Record review of the facility's Advanced Directives policy dated February 2017 and revised in January 2023 reflected: Compliance Guidelines: Every resident has the right to formulate an advance directive and to refuse treatment. The community will determine the existence of an advance directive at the time of admission .A copy of the advance directive and subsequent revisions will be included in the resident's medical record. Advanced directive implementation: The IDT will notify the medical provider of the resident's/representative's care decisions made to include expressed advanced directive, such as DNR code status. The nurse should then obtain a physician's order for appropriate care decision in order to initiate and implement the preferred treatment wishes expressed. IDT should initiate the Out of Hospital-Do Not Resuscitate (OOH-DNR) form and should obtain the medical provider/physician's signature as per the OOH-DNR form instructions. The Medical record and resident plan of care should reflect the resident's wishes as well as the physician orders in order to meet the directives described.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #45) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #45 was coded in the MDS for Dialysis. This failure could place residents at risk for receiving inadequate care and services based on an inaccurate assessment. The findings included: Record review of Resident #45's face sheet dated 06/05/2025 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with an initial admit date of 09/27/2024. Pertinent diagnoses included: End of Stage Renal Disease (final stage of kidney disease, where kidneys can no longer function on their own), Dependence on Renal Dialysis, Cerebrovascular Disease (conditions that affect blood flow to the brain), Unspecified Dementia, Type 2 Diabetes (high levels of sugar in blood), Hypertension (high blood pressure), Gastrostomy Status (opening in the stomach to insert a tube for nutritional support), Hemiplegia and Hemiparesis (paralysis and weakness that affects only one side of the body). Record review of Resident #45's Quarterly MDS assessment dated [DATE] revealed: BIMS score of 06 indicating Resident #45 was severe cognitively impaired. Section O0110 - Special treatments, procedures, and programs - section J1 Dialysis was not marked. Record review of Resident #45's comprehensive care plan initiated on 01/10/2025 revealed Resident #45 had End Stage Kidney Disease and require Dialysis treatment with interventions Dialysis treatment as recommended / ordered by physician and Dialysis treatments at Davita [NAME] Meadows as indicated. In an interview on 06/05/2025 at 1:18 p.m. with MDS Coordinator, she stated that she and MDS D are responsible for completing the MDS assessments. She stated that she was assigned the 100 and 200 halls. MDS D was assigned the 300 and 400 halls. She stated that she signs off on the MDS assessments that MDS D completes because MDS D was an LVN and the MDS assessments need to be signed off by an RN. She confirmed that MDS D completed the quarterly MDS assessment for Resident #45 dated 05/06/2025. P. The MDS Coordinator verified that Dialysis was not marked on Resident #45's MDS assessment. She stated that she checked Resident #45 MDS assessment and that she missed it too, it was an oversight. She stated the negative outcome was that it will not show that the care was provided even though Resident #45 goes to dialysis and reimbursement would be affected. In an interview on 06/05/25 at 1:25 p.m. with MDS D, she stated that she and the MDS Coordinator are responsible for completing the MDS assessments. They divide the workload. She stated that the MDS Coordinator verifies the information and then signs off on it. MDS D confirmed that she was the one that completed the MDS assessment for Resident #45 dated 05/06/2025. She verified that Dialysis was not marked on the MDS assessment. MDS D stated that it was an oversight. She stated the negative outcome was that it would affect the reimbursement and it will show that the resident did not receive dialysis. In an interview on 06/05/25 at 3:32 p.m. with the DON, she stated both the MDS Coordinator and MDS D are responsible for completing the MDS assessments. They divide the facility; they each take 2 halls. The DON stated the MDS Coordinator signs off on the MDS assessments for MDS D due to MDS D was an LVN and they needed to be signed by an RN. There was no system in place that oversees that they are accurately completed. She stated that she had seen that Dialysis was not marked on Resident #45 MDS assessment dated [DATE]. The DON stated that it was an oversight. She stated the negative outcome for not completing them accurately was none for patient, but it would affect the facility payment. Record review of the facility's Comprehensive Assessments Policy dated January 2024 revealed - Comprehensive resident assessment: The community uses the Resident Assessment Instrument (RAI) to develop the comprehensive resident assessment. It identifies the care, services, and treatments that each resident needs to attain or maintain his or her highest practicable mental and physical functional status. Accuracy of Assessment: Each resident receives an accurate team member assessment of relevant care areas that provide team members with knowledge of each residents status, needs, strength, and areas of decline. Record review of CMS's RAI version 1.19.1 dated October 2024 revealed section: O0110: Special Treatments, Procedures, and Programs a. On admission b. while a resident c. at discharge J1: Dialysis Code peritoneal or renal dialysis which occurs at the nursing home or at another facility, record treatments or hemofiltration, Slow Continuous Ultrafiltration, Continuous Arteriovenous Hemofiltration, and Continuous Ambulatory Peritoneal Dialysis in this item.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, for 1 resident (Resident #9) of 24 residents whose care plans were reviewed. 1) The facility failed to ensure Resident #9's comprehensive care plan was updated after the code status was changed from full code to DNR on 05/21/25. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and the implementation of personalized plan of care developed to address their specific needs. The findings include: Record review of Resident #9's face sheet dated 06/04/25 reflected an [AGE] year-old-female with an original admission date of 01/29/25. Diagnoses included Dementia (general decline in cognitive abilities that affects a person's ability to perform everyday tasks) and Hypertension (high blood pressure). Record review of Resident #9's care plan initiated on 02/02/25 reflected: Resident/Family/RP does not have advance directives and elects Full Code Record review of Resident #9's physician orders dated 05/21/25 reflected DNR status. In an interview on 06/04/25 at 09:16 AM, the DON stated Resident #9's care plan reflects full code and should reflect her current DNR status. The DON stated Resident #9 was a full code and was changed to a DNR on 5/21/25 and the full code status was discontinued. The DON stated the care plan should have been revised. The DON stated that the SW and the MDS Coordinators are the ones responsible for updating care plans. The DON stated care plans are reviewed when a resident has a change in condition or any significant changes. The DON stated she does not know why the care plan was not updated. The DON stated in case of an emergency, the nurses would go based off the physician's orders to honor the residents code status. In an interview on 06/04/25 at 09:34 AM, the SW stated he and the MDS Coordinators are responsible for care plan revisions. The SW stated he usually takes charge when there is a code status change, but there is no specific person in charge of making sure the code status is revised. The SW stated he does try to audit care plans every quarter along with quarterly care plan meetings but could not state why the care plan was not revised. The SW stated Resident #9's care plan should have been revised, but the nurses know to go by the physician's orders. In an interview on 06/04/25 at 09:58 AM, the MDS Coordinator stated it was a team effort, but MDS Coordinators, nursing, and the SW were responsible for making sure the care plans are updated. The MDS Coordinator stated she oversaw the 100 and 200 hall resident care plans. The MDS Coordinator stated she had no reason why Resident #9's care plan was not updated and as she usually checked the residents' care plans that are in her halls every morning. The MDS Coordinator stated she was surprised to find out Resident #9's care plan was not updated. The MDS stated she was responsible for making sure Resident #9 ' s care plan was accurate. The MDS Coordinator stated that resident care plans are reviewed every three months, and she was responsible for ensuring accuracy. The MDS Coordinator stated there was no negative impact to Resident #9 since the code status was correct in the orders. In an interview on 06/04/25 at 04:13 PM, LVN C stated the residents had a tab on their chart that states if they are a full code or DNR. LVN C stated if the care plan had a conflicting code status, he would follow what the physician orders state. LVN C stated there was also a list of DNR residents in a binder at the nurse's station but in an emergency, he would follow the physician's orders. Record review of the facility's Care Plans policy dated January 2023 reflected: Guidelines: Care Plans The care plan should be initiated upon admission, continued to be developed during the initial 48-72 hrs., throughout the completion of the admission comprehensive assessment. The care plan should be updated and reviewed at least quarterly thereafter, then annually and with significant changes in conditions as defined in the RAI (Resident Assessment Instrument) manual. Additional updates to the care plan may be done as indicated. The care plan should be considered a part of the medical record and should be utilized in conjunction with the complete medical record. The care plan should serve as a guide, which should direct care needs, care choices and care preferences. However, the care plan in not an all-inclusive reflection of prescribed or recommended care by the IDT.

**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 incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 1 resident (Resident#49) reviewed for indwelling catheters. The facility failed to prevent Resident#49's urinary catheter bag/tubing from touching the floor. This failure could place residents at risk of cross contamination and urinary tract infections. Findings included: Record review of Resident #49 ' s face sheet dated 06/03/25 revealed a [AGE] year-old male admitted on [DATE]. Resident #49 had primary diagnoses of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (cognitive disorders characterized by progressive decline in memory, thinking, reasoning, and other mental abilities that interfere with daily life and activities), and obstructive and reflex uropathy (two conditions affecting the urinary tract, obstructive uropathy is a blockage prevents urine from draining properly and reflux is where urine flows backward from the blader into the ureters and kidneys instead of draining properly). Record review of Resident #49 ' s Physician ' s Order Summary as of 06/03/25 revealed Foley Catheter 16 FR 30 cc, change monthly and PRN every night shift starting on the 15th and ending on the 15th every month related to Obstructive and Reflux Uropathy, unspecified. Record review of Resident #49 ' s Quarterly MDS dated [DATE] revealed he had clear speech, was able to understand others and was understood by others, had a BIMS of 06 which indicated he had severe cognitive impairment and had an indwelling catheter. Record review of Resident #49 ' s comprehensive care plan initiated on 11/22/24 and revised on 01/31/25 revealed he had an indwelling catheter relating to obstructive uropathy with interventions for catheter care every shift and as indicated, change catheter per physician ' s orders and check for tubing kinks each shift and during care encounters and monitor for s/sx of discomfort and abnormalities report those findings to MD as indicated. Observation on 06/03/25 at 9:56 a.m. revealed Resident #49 lying on a low bed, on his back, catheter bag hanging from the bottom rail of the bed and the catheter bag was resting on the floor. Interview on 06/03/25 at 9:57 a.m. revealed Resident #49 was unaware catheter bag was on the floor. Resident #49 was able to answer simple questions but could not provide information of how long the catheter bag was on the floor. Resident #49 said he did not have any concerns with the care provided. In an interview on 06/03/25 at 10:00 a.m., CNA E was informed and shown the catheter bag touching the floor. CNA E said the catheter bag should not touch the floor. CNA E said she did not know who hung the catheter bag on the bottom rail of the bed. CNA E said she had just started her round and had not gotten to Resident #49 ' s room yet. In a follow-up interview on 06/03/25 at 11:34 a.m. CNA E said she was supposed to hang the catheter bag low at the side of the bed but not too low it touches the floor. CNA E said when she lowers the bed, she must be sure the catheter bag was not touching the floor. CNA E said the catheter bag should not touch the floor because the floor was dirty, and it could get contaminated. If the catheter bag got contaminated, it could cause an infection. CNA E said she was trained in how to provide catheter care. In an interview on 06/04/25 at 3:42 p.m., CNA F said the CNAs were responsible to hang the catheter bags at the side of the bed. CNA F said when she lowers the bed, she must check that the bag was not touching the floor. CNA F said the nurses check to see if the resident has the leg band and the CNAs check to make sure the bag is not on the floor. CNA F said every time they did a round; they checked that the catheter bag was not on the floor. CNA F said the catheter bag should not touch the floor because it could lead to an infection. In an interview on 06/04/25 at 3:55 p.m., LVN C said the nurses were responsible to check the catheter bags were placed correctly. The LVN C said he checked on the catheter bags every shift. LVN C said the catheter bag should not touch the floor. LVN C said it should not touch the floor because the floor has bacteria and if the catheter bag touched the floor, it would travel up the bag and could lead to an infection. LVN said he is constantly monitoring the CNAs on the floor. In an interview on 06/05/25 at 10:53 a.m., the ADON said it was the nurse ' s responsibility to check the catheters were appropriately placed but all staff could check them and report if a catheter was not placed correctly. The staff should check on the catheters every shift, but they should check them frequently because some residents were very mobile, and the CNAs do incontinent care and drain the catheter bags. The ADON said the catheter should never be lifted above the bladder and should not touch the floor. The catheter should not be above the bladder because the urine could flow back into the bladder and residents would not be able to urinate. The catheter should not touch the floor due to infection. Bacteria could travel up the tubing and cause infection. ADON said the DON, ADON and nurses did spot checks on the CNAs to make sure they were doing their tasks and doing them correctly. In an interview on 06/05/25 at 3:16 p.m., the DON said direct staff were responsible for checking that the catheter placement was correct. The catheter bag should not be on the floor to reduce the chance of pathogens getting onto the catheter bag and tubing and reduce the chance of infection. The DON said she does rounds and would go into different halls to check on staff to make sure they are doing their tasks. The DON said they do annual performance reviews for CNAs. Record review of the facility ' s CNA/Caregiver Competency Checklist blank form under the section for Personal Care revealed Catheter tubing/Bag not touching floor/tubing not above bladder/privacy. Record review of the facility ' s policy on Incontinence and Catheterization Assessment and Evaluation revised in January 2024 did not address the proper placement of a catheter bag at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 6 (Resident #68, Resident #67) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #68's oxygen was administered at the correct setting of 2 liters per minute on 06/03/2025 as ordered by the physician. 2. The facility failed to ensure Resident #67's oxygen was administered at the correct setting of 2 liters per minute on 06/03/2025 as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: 1.Record review of Resident #68's admission record dated 06/03/2025 reflected a [AGE] year-old male with an admission date of 05/16/2025 and with an initial admit date of 09/30/2022. Pertinent diagnoses included Shortness of Breath, Paraplegia (paralysis that affects your legs, but not your arms), Heart Failure, Chronic Kidney Disease, Muscle Wasting and Atrophy (loss of muscle tissue), Type 2 Diabetes Mellitus, Dysphagia (difficulty swallowing), and Hypertension (high blood pressure). Record review of Resident #68's Quarterly MDS assessment, dated 05/21/2025 revealed oxygen therapy. Resident #68's BIMS score of 15, indicated he was cognitively intact. Record review of Resident #68's physician order dated 05/19/2025, revealed oxygen at 2 LPM via nasal cannula for SOB or saturation less than 92 as needed every shift. Record review of Resident #68's person-centered care plan, initiated date 10/21/2023 reflected Resident #68 used oxygen therapy related to shortness of breath. Intervention included Administer O2 as per MD orders. During an observation of Resident #68 on 06/03/2025 at 11:15 a.m. the oxygen level on the oxygen concentration machine was at 4LPM via nasal cannula. Observed Resident #68 in bed with head of the bed slightly elevated. No signs of respiratory distress noted. In an interview on 06/03/2025 at 11:18 a.m. with Resident #68, stated that the nurse checked his saturation this morning. He stated that he does not touch the oxygen machine. In an interview on 06/03/2025 at 11:25 a.m. LVN J, stated she was the nurse for Resident #68. LVN J agreed that the O2 setting was set at 4LPM. She stated the oxygen setting was supposed to be at 2 LPM per physician orders. She stated that she checked the setting yesterday when she replaced the water and tubing when Resident #68 returned from dialysis. She was not sure who might have moved it. LVN J stated that she checked Resident #68's oxygen tubing and saturation this morning. She stated that she usually checks the oxygen twice a day when she goes in to check his colostomy bag. LVN J stated that the negative outcome to keeping Resident# 68's oxygen setting at a of 4 LPM was that too much oxygen can hurt his lungs. In an interview on 06/03/25 at 4:39 p.m. with the ADON stated that the nurse was responsible for checking O2 setting. She stated the nurse was supposed to check it every shift, whenever the patient comes back from doctors' appointments, and as needed. The ADON stated the nurse was to follow the physician order for the oxygen setting. She stated the negative outcome of keeping it at a high setting would be that the patient would have expanded lungs and will get hyperoxia (high levels of oxygen). In an interview on 06/03/2025 at 4:46 p.m. with MDS D stated that she was responsible for supervising Resident #68's hall. She rounds once or twice a day. She checks that the O2 setting was at 2-4 liters depending on the physician order. That the resident was breathing ok and not in any distress. MDS D stated that she only checked Resident #68's tubing today and did not check the setting. She stated that the negative outcome would be that Resident #68 could hyperventilate if he continues that high rate. In an interview on 06/03/2025 at 4:56 p.m. with the DON, stated that the nurses assigned to that hall were responsible for checking the O2 setting. She stated that the nurses were to check the setting once per shift. The DON stated they were to follow oxygen settings on physician orders. The DON stated that they called the doctor and he said there was no negative outcome. She stated there were administrative nurses that oversee different wings. MDS D was the administrator responsible for overseeing Resident #68's hall. The DON stated that there was no negative outcome. 2. Record review of Resident #67's admission record dated 06/03/2025 revealed he was a [AGE] year-old female admitted on [DATE]. Her relevant diagnoses included kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (relying on a process to filter waste and excess fluid from the blood, as the kidneys were no longer functioning properly), and congestive heart failure ( a chronic condition in which the heart doesn't pump blood as well as it should). Record review of Resident #67's admission MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated her cognition was intact. Further review reflected; Resident #67 was on oxygen therapy on admission. Record review of Resident #67's care plan dated 04/09/25 reflected a focus of oxygen therapy related to CHF (date initiated: 04/10/25). Her interventions in part included administering O2 as per MD orders (date initiated: 04/10/25). Record review on 06/03/25 at 11:43 a.m., of Resident #67's order summary dated 06/03/25 reflected an active order of continuous oxygen, 2 liters per n/c every shift for SOB effective 04/10/25. During an observation on 06/03/25 11:35 a.m., Resident #67 was observed sitting in her wheelchair watching television in her room. She said she had been admitted to facility short-term to get physical therapy. She said she required continuous oxygen at 2 lpm. She said she had not experienced any shortness of breath or was under any respiratory distress. During an observation on 06/03/25 11:40 am, Resident #67's oxygen concentrator revealed it was set at 2.5 LPM. During an observation and interview on 06/03/25 at 11:45 a.m., LVN B was observed as he reviewed Resident #67's electronic medical record and said she had an active order of 2 lpm continuous oxygen. He then was observed as he checked Resident #67's oxygen concentrator and said her O2 was set at 2.5 lpm. He said there was no negative outcome to Resident #67 because she had not experienced any respiratory distress. He said the nursing staff were responsible to ensure a resident's oxygen setting was set as ordered during every shift. He said his shift started at 6 a.m. and had already checked on Resident #67 several times but had not checked her oxygen setting. LVN B said he had been in-serviced on oxygen administration regularly. In an interview on 06/03/25 at 11:53 a.m., the ADON, said Resident #67 had an active oxygen for at 2 lpm continuous via n/c. She said she had just gone into Resident #67's room and had changed her oxygen setting back to 2 lpm. She said, it was slightly above the ordered amount. The ADON said it was the nurse's responsibility to ensure a resident's oxygen concentrator was as ordered. She said the nursing staff were supposed to check the concentrators at least once every shift. The ADON said there were no negative outcome to Resident #67 not having her oxygen setting at 2 lpm because she had not experienced respiratory distress. In an interview on 06/04/25 at 9:12 AM, the DON said Resident #67 had an oxygen order of 2 lpm continuous via n/c. She said the nursing staff were responsible to ensure a resident's oxygen settings were set as ordered at least once every shift. She said the nursing staff completed skills competencies online as part of their in-service on oxygen administration. The DON said Resident #67 had no negative outcome due to not having her oxygen settings at 2 LPM as ordered. She said she had called her NP, and he too agreed that Resident #67 had not sustained any negative outcome and had not given any new orders. Record review of the facility's policy subject titled, Oxygen Administration, dated revised January 2023, revealed, Compliance Guidelines: A resident receives oxygen therapy when there is an order by a physician. Procedure: 3. Obtain physician orders for oxygen administration. Orders should include the following: c. flow rate of delivery

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: The facility failed to ensure that 1 of 2 juice nozzles was clean. This failure could place residents at risk of foodborne illnesses. The findings included: During the initial observation of the kitchen on 06/03/2025 at 10:30 a.m., revealed the juicer's nozzle dispenser had red and white slimy substance in the middle and a brown slimy substance on the outer part. In an interview on 06/03/25 at 10:35 a.m., the DM said his staff had a hard time removing the juicer nozzle but ensured it was cleaned daily. She said she did not know what the slimy substances were. She said she kept a weekly cleaning schedule which included the juice machine. The DM was not able to say what negative outcome to the residents was for having the juicer ' s nozzle with slimy substances. Record review of the kitchen' s weekly cleaning schedule from 06/01/25 to 06/04/25 reflected the juice machine/nozzles had been cleaned. Record review of the facility's General Kitchen Sanitation policy dated 01/2024 and revised 01/2025 reflected: Policy: The facility recognizes that foodborne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and foodborne illness. Procedure: 1. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware, and food contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #19, Resident #69) of 8 residents reviewed for infection control practices, in that: 1) The facility failed to ensure the WCN performed hand hygiene for at least 20 seconds prior to and after performing Resident #19's wound care. 2) The facility failed to ensure the CNA A performed hand hygiene for at least 20 seconds prior to and after assisting the WCN with Resident #19's wound care. 3) The facility failed to ensure LVN K followed enhanced barrier precautions while providing gastrostomy site care for Resident #69. These failures could place residents at risk for healthcare associated cross-contamination and infections. Findings include: 1) Record review of Resident #19's face sheet dated 06/04/25 reflected a [AGE] year-old-male with an initial admission date of 03/11/25. Diagnoses included acute kidney failure, stage 4 (deep wounds that may impact muscle, tendons, ligaments, and bone) pressure ulcer of the sacral region (bottom of the spine and lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone), above the knee right and left leg amputation, and type 2 diabetes (insufficient insulin production in the body). During an observation of wound care on 06/04/25 at 10:31 AM, the WCN performed hand hygiene prior to Resident #19's wound care for approximately 15 seconds. CNA A was observed performing hand hygiene for approximately 13 seconds prior to assisting the WCN with Resident #19's wound care. After wound care, the WCN removed her gloves and performed hand hygiene for approximately 5 seconds. CNA A also removed her gloves after assisting with Resident #19's wound care and performed hand hygiene for approximately 6 seconds. In an interview on 06/04/25 at 10:53 AM, the WCN stated handwashing should be 20 seconds or more. The WCN stated she was nervous, and she did count 20 seconds while washing her hands but guessed she was counting fast. The WCN stated it was important to wash hands properly to keep hands clean and to remove any bacteria. The WCN stated Resident #19 could get an infection, or the wound could become worse if the resident came in contact with any bacteria. The WCN stated she does not recall the last hands-on handwashing or infection control in-service, but stated staff did get in-serviced on infection control regularly. In an interview on 06/04/25 at 10:53 AM, CNA A stated hand washing should be at least 20 seconds or more. CNA A stated she was nervous, and it was important to wash hands properly to stop the spread of infection. CNA A stated she could not recall when the last handwashing in-service was but was maybe about a month ago. In an interview on 06/04/25 at 11:04 AM, the DON stated staff should wash their hands for more than 20 seconds because that was the recommended time to remove pathogens from the hands according to CDC. The DON stated if staff were not wearing gloves, they could carry pathogens on their hands and possibly expose pathogens to a resident. The DON stated depending on the patient, there could be bacterial growth and could affect the wound and could develop an infection. The DON stated staff do get hands on training for handwashing but was unsure when the last one was. In an interview on 06/04/25 at 11:10 AM, the ICP stated staff should lather their hands with soap and water for at least 20 seconds. The ICP stated it was important to get rid of bacteria on the hands and nails to prevent cross contamination and prevent infection or possible sepsis. The ICP stated the last in-service for hand washing was about a week ago with all staff and was done quarterly as well as computer-based training. 3) Record review of Resident #69's face sheet dated 06/04/2025 reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with an initial admit date of 11/06/2023. Pertinent diagnoses included: Gastrostomy Status (opening in the stomach to insert a tube for nutritional support), Dysphagia (difficulty swallowing), Unspecified Dementia, Type 2 Diabetes Mellitus (high levels of sugar in blood), Muscle Weakness, and Cerebrovascular Disease (conditions that affect blood flow to the brain). Record review of Resident #69's Quarterly MDS assessment, dated 04/20/2025 revealed her BIMS score of 0, indicated she had severe cognitive impairment. Further review revealed nutritional status were feeding tube (PEG). Record review of Resident #69's physician order dated 03/12/2025, revealed cleanse gastrostomy site with normal saline, pat dry with 4x4 gauze and leave open to air every shift and EBP (Enhanced Barrier Precautions): Practice EBP as indicated when in contact with Gastrostomy Tube every shift dated 03/25/2025. Record review of Resident #69's Comprehensive Care Plan, revision date 03/25/2025, revealed Resident #69 was at risk for infection or recurrent/chronic infection r/t compromised medical condition. Interventions: EBP (Enhanced Barrier Precautions) r/t: gastrostomy tube. During an observation on 06/04/2025 at 3:15 p.m. revealed LVN K applied gloves but did not wear a PPE gown when she provided gastrostomy site care on Resident #69. In an interview on 06/04/25 at 3:45p.m. with LVN K, she stated that EBP was indicated for residents who have gastrostomy tubes, foley catheters, wounds, or who have an infection. EBP requires the use of a gown and gloves during high contact patient care. LVN K stated that a PPE gown was supposed to be put on before going into the patient's room who were identified with EBP. She stated she did not put on the gown because she got nervous. LVN K stated that it was important to wear the required PPE when providing care to EBP patients to prevent the spread of germs and to protect themselves. In an interview on 06/04/2025 at 4:00 p.m. with the ICP, she stated EBP was to be used on high contact care for patients with Gtubes, PICC line, Foleys, and wounds. She stated that PPE includes gloves and a gown. The ICP stated that it was important to use proper PPE on EBP patients to not cross contaminate and to prevent the spread of infection. In an interview on 06/04/2025 at 4:14 p.m. the DON stated for EBP the staff needed to wear gowns, gloves and face shields if the patient has a trach or was coughing. She stated that EBP patients were identified as anyone who has gtube, indwelling catheters, wounds, and with certain MDROs. The DON stated that PPE for EBP patients was important because they were susceptible to receive bacteria. Record review of the facility's Infection Prevention and Control policy dated 3/13/19 reflected: Gloves and Handwashing Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. In addition to isolation practices, Enhanced Barrier Precautions (EBP) maybe implemented as an infection control intervention designed to reduce transmission of resistant organisms. The use of PPE, such as gown and gloves use during high contact resident care activities. EBP may be indicated as a recommendation by the CDC (when Contact Precautions do not otherwise apply) for residents with the following: -Wounds or indwelling medical devices, regardless of MDRO colonization status. EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Use of eye protection may be necessary when splash or spray may occur but was not necessary in other situations. Record review of the facility's Handwashing/Hand Hygiene policy dated January 2023 reflected: Guideline This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for situations such as this (including but not limited to): Between glove changes/After removing gloves; The following resource was found on the CDC website at https://www.cdc.gov/clean-hands/about/index.html reflected: The CDC handwashing guidelines recommend the following steps for effective handwashing: 1. Wet your hands with clean, running water (warm or cold), and turn off the tap. 2. Apply soap and lather your hands by rubbing them together, including the backs of your hands, between your fingers, and under your nails. 3. Scrub your hands for at least 20 seconds. 4. Rinse your hands well under clean, running water. 5. Dry your hands using a clean towel or air dry them. Use hand sanitizer when you can't use soap and water.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to be free of misappropriation of property and exploitation for 2 of 2 residents (Resident #1 and Resident #2) reviewed for misappropriation and exploitation, in that: 1. The facility failed to ensure the BOM asked Resident #1 and Resident #2 RP's for permission to use their spending account card. 2. The facility failed to ensure the BOM gave the AD permission to use Resident #1 and Resident #2's spending account card for other residents. 3. The facility failed to ensure the AD did not use Resident #1 and Resident #2's spending account card for unauthorized transactions on 4 occasions. As a result, Resident #1 lost $318.64, and Resident #2 lost $313.72 from their spending account card. These failures could affect residents and their responsible party by preventing them from having access to their funds. The findings included: 1.Record review of Resident #1's admission record, dated 04/30/25, reflected a [AGE] year-old female admitted on [DATE], an initial admit date of 08/13/23, and an original admit date of 12/30/22. Her relevant diagnoses included senile degeneration of the brain (encompasses a range of neurological disorders characterized by a progressive decline in cognitive function, impacting memory, reasoning, and the ability to perform everyday activities), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and dementia (a progressive decline in mental abilities, like memory, thinking, and reasoning, that significantly impacts a person's ability to perform daily activities). Further review reflected she had a Resident Representative. Record review of Resident #1's quarterly MDS assessment, dated 04/10/25 reflected a BIMS score of 00, which indicated her cognition was severely impaired. Record review of Resident #1's quarterly care plan, dated 02/17/25 reflected she had impaired thought process related to Alzheimer's disease. Her intervention in part included notify MD of any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding other, level of consciousness, mental. (date initiated 08/29/23). 2. Record review of Resident #2's admission record, dated 04/30/25, reflected an [AGE] year-old female admitted on [DATE] and an original admission date of 03/09/18. Her relevant diagnoses included Parkinson's disease ( a disorder of the central nervous system that affects movement, often including tremors), vascular dementia (brain damage caused by multiple strokes), and cognitive communication deficit (occurs when communication problems are caused by issues with cognitive processes like attention, memory, or executive function). Further review reflected she had a Resident Representative. Record review of Resident #2's quarterly MDS assessment dated [DATE], reflected her BIMS score was 99, which reflected her cognition was severely impaired. Record review of Resident #2's quarterly care plan dated 03/17/25, reflected she had impaired cognitive function and impaired processes related to vascular dementia. Her interventions, in part included to communicate with the resident/family/caregivers regarding residents capabilities and needed as needed. In an interview on 04/30/25 at 11:00 a.m., the BOM said both Resident #1 and Resident #2 had received a spending account card from their medical insurance provider that ran from 01-01-24 to 12-31-24. She said each month both residents received a deposit of $50.00 into their spending account card for them to use on over-the-counter medications and/or groceries. She said if the funds were not used, they rolled over onto the following month. The BOM said the spending account cards did not require a personal identification number when used. She said at one point (not sure when) she advised the AD that Resident #1 and Resident #2 had a spending account card that had not been used and had given her permission to use them to buy snacks for Resident #1, Resident #2, and other residents. She said both Resident #1 and Resident #2 had RPs, but she had failed to call them to get their permission to use their spending account cards. The BOM said the AD used Resident #1 and Resident #2's cards on several occasions. The BOM said at first she kept Resident #1 and Resident #2's spending account cards in a safe she kept in her office along with the receipts of what was purchased. She said at some point (not sure when) she said the AD had kept Resident #1's and Resident #2's spending cards in her office (did not remember the reason) and she had forgotten to get them back. The BOM said on 10/18/24, Resident #1's RP approached her and asked if the facility had received Resident #1's spending account card. She said that's what prompted the investigation into the use of Resident #1 and Resident #2's spending cards. The BOM said after their investigation, it was discovered the AD had used $318.64 from Resident #1's spending account card and $313.72 from Resident #2's spending account card. The BOM said prior to that incident, the facility did not have a protocol on how to manage a resident's spending account cards, and she did not know the cards could not be used for other residents or that they needed their RPs permission to use them. The BOM said Resident #1 and Resident #2 spending account cards had been mailed to the facility and were not given to their RP's. She said after the investigation, the Administrator had purchased 2 gift cards to reimburse Resident #1 and Resident #2 RP's but had not yet reimbursed them because he was waiting until after the state's investigation. Record review of Resident #1's receipts reflected: 1. On 05/22/24 at 12:36 p.m., a total of $82.39 was purchased with program card. 2. On 05/22/24 at 3:24 p.m., a total of $85.62 was purchased with program card. 3. On 08/16/24 at 2:14 p.m., a total of $150.63 was purchased with program card. Record review of Resident #2's receipts reflected: 1. On 05/22/24 at 3:18 p.m., a total of $120.09 was purchased with program card. 2. On 08/16/24 at 1:04 p.m., a total of $193.63 was purchased with program card. During an observation on 04/30/25 at 1:10 p.m., Resident #2 was observed in the dining room, she required feeding assistance, her plate consisted of a pureed diet. Resident #2 had her eyes closed and was not verbal. During an observation on 04/30/25 at 1:30 p.m., Resident #1 was observed lying sleep in her bed. In an interview on 04/30/25 at 2:44 p.m., Resident #1's RP said on 10/18/24, while she visited Resident #1 at the facility, she was approached by an insurance representative who tried to recruit Resident #1 and as an incentive, the representative told her Resident #1 would qualify for a spending account card. Resident #1's RP said that's when she remembered she had already applied for Resident #1 in January 2024 but never received the spending account card. She said she approached the BOM and asked her if Resident #1's spending account card had been mailed to the facility. Resident #1's RP said the BOM told her yes, but when the BOM opened the safe she had in her office, the card was not in there. the BOM told her she needed to ask the AD if she had Resident #1's spending account card and that she would get back with her. Resident #1's RP said she had told the BOM, Resident #1 should have a large amount in the card since it had not been used, that's when she was told by the BOM that Resident #1's card had already been used to purchase snacks for Resident #1 and other residents. Resident #1's RP said later that day while still at the facility, she had bumped into the AD and asked her why she had Resident #1's spending account card, not asking her for permission to use the card and why she had purchased snacks for other residents. Resident #1's RP said the AD told her she did have the Resident #1's spending account card but did not know she needed her permission to use it and that she was not supposed be used to purchase snacks for other residents. Resident #1's RP said she observed the AD going back to her office to get Resident #1's spending account card and then gave it to her. Resident #1's RP said she was upset because the facility never called to get her permission to use Resident #1's spending account card much less to buy snacks for other residents. She said her mother suffered from senile and was not able to give consent. She said the Administrator called her days later to let her know he had completed his investigation and that the AD had been terminated. Resident #1's RP was told if she wanted to contact the local law enforcement, she could. Resident #1's RP said the Administrator had also told her she would be reimbursed the full amount that was used from Resident #1's spending account card but up until 04/30/25, she had not been reimbursed. In an interview on 04/30/25 at 4:47 p.m., the Administrator said the BOM had been approached by Resident #1's RP regarding Resident #1's spending account card. He said the RP found out the AD had used Resident #1's spending account card to purchase snacks for her and other residents without her permission. The Administrator said he immediately started an investigation and self-reported to State. He said he had spoken with the AD, and she had confirmed that she used Resident #1's spending account card to buy snacks for Resident #1 and other residents and that she had not called her RP to get permission to use the spending account card. He said he explained to the AD that she should not have purchased snacks/groceries for other residents. He said in reviewing Resident #1's receipts, he noticed the AD had purchased a 12-pack energy drinks. He said he asked the AD about the purchase and the AD said the 12-pack energy drinks were for her personal use and had accidently included in the items purchased with Resident #1's card. The Administrator said he immediately suspended her pending the investigation. The Administrator said during the investigation he discovered the AD had also used Resident #2's spending account card to purchase snacks for Resident #2 and other residents. He said the AD had failed to call Resident #1 and Resident #2's RP to get permission to use their spending account card. He said he had purchased two gift cards for the amount the AD had spent on Resident #1 and Resident #2's spending card to reimburse their RP's. The Administrator said he still had the gift cards because he wanted to wait until after the intake had been investigated by state. He said at the time of the incident, the facility did not have a policy on how to manage a resident's spending account cards. He said he had included Resident #2 in his investigation but had not self-reported the incident to state nor had informed her RP. The Administrator said the BOM had been responsible for giving the AD permission to use Resident #1 and Resident #2's spending account cards and had failed to call their RP's. He said after his investigation, the AD had been terminated, the BOM had received a written write-up, the allegation of misappropriation had been confirmed and the facility had created a policy related to the resident's spending account cards effective 10/29/24 (he said which was good for the remained of 2024 only). The Administrator said he had not contacted the local law enforcement because the facility's policy did not indicate to do so but had advised Resident #1's RP she could call herself. The Administrator said all staff had been in-serviced on the topic of abuse, neglect, neglect and exploitation on 10/18/24. In a telephone interview on 05/01/25 at 3:49 p.m., Resident #2's RP said she had received a telephone call from the Administrator on 05/01/25 to let her know the former AD had used Resident #2's spending account card without her permission and had purchased snacks for Resident #2 and other residents. The RP said the administrator told her he had already investigated the incident, and the AD had been terminated but had forgotten to call her to let her know when he concluded the investigation. She said the Administrator told her he would be reimbursed the entire amount the AD used from Resident #2's spending account card. The RP said she had wished she had been notified before the purchases since Resident #2 was not verbal and would not be able to say what she wanted. The RP said the Administrator gave her the option to contact law enforcement if she wanted to pursue charges. The RP said she was not going to press charges. In an interview on 05/04/25 at 7:50 p.m., the AD (former) said the BOM had informed her that Resident #1 and Resident #2 had been allowed spending cards from their insurance. She said the BOM had given her permission to use Resident #1 and Resident #2's spending account cards to buy snacks for them and other residents. She said she was never told she needed to get Resident #1 and Resident #2 RP's permission before using their spending account cards. The AD said she used Resident #1 and Resident #2's spending account card on several occasions to buy snacks for them and other residents but did not remember the amount used. She said all the food items bought were for Resident #1, Resident #2, and other residents except for one time she accidently included a 12-pack energy drink when buying groceries for Resident #1. The AD said she had immediately told the BOM about it and told her she wanted to reimburse Resident #1's spending account card but that the BOM told her she did not know how to reimburse monies back into the spending account cards and that she would get back to her. She said at the beginning of the year, the BOM kept Resident #1 and Resident #2's spending account cards in a safe in her office but sometime before the BOM went on vacation (not sure of the date) she told her to keep the spending account cards in her office in case she needed them while she was out. The AD said on 10/18/24, the Administrator approached her and asked her if she had used Resident #1 and Resident #2's spending card for other residents, if she had purchased a 12-pack energy drink, and if she had asked their RP's for permission to use their card. The AD said she told the Administrator the BOM had given her permission to use Resident #1 and Resident #2's spending account cards to buy snacks/groceries for them and other residents. The AD said she also told the Administrator that she had purchased a 12-pack energy drink for her personal use with Resident #1's spending account card by accident. The AD said she told the Administrator she had immediately notified the BOM of the purchase and her intention to reimburse Resident #1's spending account card but that the BOM told her she did not know how to reimburse monies back into the spending account cards. The AD said she was terminated because she had not requested permission from Resident #1 and Resident #2 RP's, because she had used Resident #1 and Resident #2's spending account card for other residents and because she had purchased a 12-pack energy drink with Resident #1's spending account card. Record review of the facility's Statement of Resident Rights policy implemented on February 2017 and revised in January 2023 reflected: Compliance Guidelines: The community should educate, encourage, and honor the rights of those we serve. Further, the community should assist a resident/patient to fully exercise their rights as applicable. Residents/Patients do not give up their rights when entering a [NAME] Community. Resident/Patient Rights include: 3.The right to be free from abuse and exploitation. Record review of the facility's policy on Abuse Guidance: Preventing, Identifying and Reporting policy implemented on February 2017 and revised in January 2024 reflected: Compliance Guidelines: Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It is the responsibility of our team members, community consultants, attending physicians, family members, visitors, etcetera. To promptly report any incident, I was suspected neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to community management. Seven Elements of ANE .Prevention-The Administrator/Abuse Coordinator has the overall responsibility for the coordination and implementation of the ANE prevention and reporting program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency for 1 of 2 Residents (Resident #2) who were reviewed for misappropriation of property, in that: The facility failed to report when the AD used Resident #2's Spending Account Card without her permission to purchase food items for Resident #2 and other residents. This failure could place residents at increased risk for potential abuse to unreported allegations of misappropriation of property. The findings were: Record review of Resident #2's admission record, dated 04/30/25, reflected an [AGE] year-old female admitted on [DATE] and an original admission date of 03/09/18. Her relevant diagnoses included Parkinson's disease ( a disorder of the central nervous system that affects movement, often including tremors), vascular dementia (brain damage caused by multiple strokes), and cognitive communication deficit (occurs when communication problems are caused by issues with cognitive processes like attention, memory, or executive function). Record review of Resident #2's quarterly MDS assessment dated [DATE], reflected her BIMS score was 99, which reflected her cognition was severely impaired. Further review reflected Resident #2 had a legal guardian. Record review of Resident #2's quarterly care plan dated 03/17/25, reflected she had impaired cognitive function and impaired processes related to vascular dementia. Her interventions, in part included to communicate with the resident/family/caregivers regarding residents capabilities and needed as needed. In an interview on 04/30/25 at 11:00 a.m., the BOM said Resident #2's spending account card had also been used by the AD without getting permission from her RP and had been used to purchase food items for other residents. The BOM said Resident #2 had received a spending account card from her medical insurance provider that ran from 01/24 to 12/24. She said each month Resident #2 would get deposited $50.00 into her card for her to use on over-the-counter medications and/or groceries. She said if the funds were not used, they would roll over onto the following month. The BOM said at one point (not sure when) she advised the AD that Resident #2 had a spending account card that had not been used and she had given the AD permission to use them to buy snacks for Resident #2 and other residents. She said Resident #2 had an RP, but she had failed to call RP to get permission to use the spending account card. The BOM said the AD had used Resident #2's card on several occasions. The BOM said she kept Resident #2's spending account card in a safe she kept in her office along with the receipts of what was purchased but at one point she said the AD kept Resident #2's spending cards in her office (did not remember the reason) and she had forgotten to get it back. The BOM said on 10/18/24, the Administrator investigated an allegation of misappropriation of property for another resident and it was discovered AD had also used Resident #2's spending account card and had been included in his investigation. She said after their investigation, it was determined the amount the amount used on Resident #2's spending account card was $313.72. In an interview on 04/30/25 at 4:47 p.m., the Administrator said that on 10/18/24, he had investigated an allegation of misappropriation of property that included Resident #2. He said it was determined that the BOM had given the AD permission to use Resident #2's spending account card without her AR's permission and to use it to purchase food items for other residents also. He said the AD had been suspended on 10/18/24 and later terminated on 10/28/24. The Administrator said the BOM had received a disciplinary action on 10/28/24, all staff had been in-serviced on the topic of ANE on 10/18/24. The Administrator said he had confirmed the allegation of misappropriation of property on Resident #2 but had forgotten to report it to state and had not called her RP to let her know of the allegation and findings. In a telephone interview on 05/01/25 at 3:49 p.m., Resident #2's RP said she received a telephone call from the Administrator on 05/01/25 to let her know that on 10/28/24, the former AD had been terminated because she had used Resident #2's spending account card without her (RP's) permission and because the AD had used Resident #2's spending account card to purchase snacks/groceries for other residents. Resident #2's RP said the Administrator told her he had forgotten to call her when he first learned of the incident and when he had concluded his investigation. Resident #2's RP said the Administrator told her he had purchased a gift card with the amount the AD had used from Resident #2's spending account card and that it would be mailed to her since she lived out of state. Resident #2's RP said she had wished she had been notified before the purchases since Resident #2 was not verbal and would not be able to say what she wanted. In an interview on 05/04/25 at 7:50 p.m., the AD (former) said the BOM had informed her that Resident #2 had been allowed a spending card from her insurance and had given her permission to use her card to buy snacks for her and other residents. She said the BOM never told her she needed to get Resident #2's RP permission before using her spending account card. She said she used Resident #2's spending account card on several occasions to buy snacks for her and other residents but did not remember the amount used. She said at the beginning of the year, the BOM kept Resident #2's spending account cards in a safe in her office but sometime before the BOM went on vacation (sometime in the summer of 2024) she told her to keep the spending account cards in her office. The AD said on 10/18/24, the Administrator approached her and questioned about using Resident #2's spending card for her and other residents. She said she told the Administrator the BOM had given her permission to use the card for Resident #2 and other residents. She said the Administrator told her she was not supposed to have used Resident #2's card for other residents and suspended her pending the investigation. She said on 10/28/24, she had been terminated. Record review of the facility's policy on Abuse Guidance: Preventing, Identifying and Reporting policy implemented on February 2017 and revised in January 2024 reflected: Compliance Guidelines: Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It is the responsibility of our team members, community consultants, attending physicians, family members, visitors, etcetera. To promptly report any incident, I was suspected neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to community management. Seven Elements of ANE .Reporting/Response-All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities are individual as may be required by law and per the current state/federal reporting requirements. Reporting Allegations or Suspicions of Abuse: Allegations of, incidents of or suspicions of abuse or neglect are reportable to state authorities in accordance with HHSC's PL 19-17 .Report alleged or suspicions of abuse to HHSC by email reporting or via TULIP reporting withing the designated time frames in accordance with HHSC's PL- 1917, not later than 24 hours if the events that cause the allegation do not involve abuse and no not result in serious bodily injury.