**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to immediately inform the resident, consult with the resident's physician, notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 4 resident (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's physician when an injury of unknown origin was discovered on 5/06/2025. This deficient practice could place residents at risk of not having their physician informed when there was a change in condition resulting in a delay in medical intervention and decline in health. Findings include: Record review of Resident #1's Face Sheet revealed that the resident was a [AGE] year-old female. She was admitted to the facility on [DATE] and discharged on 5/06/2025. She was a respite care (temporary care services) resident. Diagnoses of Alzheimer's disease (brain condition that progressively damages memory, thinking, and learning skills), Hyperlipidemia (High cholesterol), Dysphagia (Difficulty swallowing), Protein-calorie malnutrition, Anxiety disorder (Mental health conditions characterized by excessive fear, dread, or apprehension that arises without a clear or appropriate cause), History of falling, Dementia (Loss of cognitive function), Adult failure to thrive (Substantial decline in overall health and functional abilities), Parkinson's disease with dyskinesia (Dyskinesia is a term used to describe involuntary, uncontrollable movements), and Pain. Record review of Resident #1's Care Plan revealed that Resident #1 had a fall on 5/03/2025. Goals include that Resident #1 will be free from complications related to falling over the next 3 days and resident at risk for falls resident safety will be maintained over the next 90 days. Resident fall interventions include assess contributing factors related to fall history, assess for potential fall-related injury prevention, looking at circumstances, location, medication, new or worsening medical problems, etc., Keep call light and most frequently used personal items within reach, remind resident to call when needing assistance. Record review of Resident #1's electronic medical records reflected Resident #1 had a progress note on 5/03/2025 at 4:51 PM that was entered by LVN B. The progress note referenced the assessment for Resident #1 and stated that Resident #1 had fallen asleep in her chair slouched over. LVN B repositioned Resident #1 attempting to prevent a fall. Approximately 30 minutes later, CNA C alerted LVN B that Resident #1 had repositioned herself. Resident #1 had fallen back asleep and slouched over causing Resident #1 to fall out of her chair. Resident #1 was assessed with no noticeable injuries. Resident #1 denied pain. Record review of Resident #1's MDS Assessment, dated 5/05/2025, reflected Resident #1 had a BIMS (Brief Interview for Mental Status Test) score of 2 (Severe Cognitive Impairment). Resident #1 was assessed to require assistance with ADLs including the following: transfers, personal hygiene, showers, and dressing. Record review of the facilities Activities of Daily Living care log on 6/18/2025, dated 5/06/2025, reflected that CNA provided ADL care to Resident #1 at 7:51 PM. No injuries or change in condition were noticed at that time. Record review of Resident #1's electronic medical records reflected Resident #1 had a progress note on 5/06/2025 at 10:56 PM that was entered by LVN A. The progress note stated that there was a concern made by the family about the resident's care and the family requested to speak with the Director of Nursing. Record review of LVN A's employee statement, not dated, reflected that LVN A was working the night shift on 5/06/2025 when Resident #1 was discharged at 10:56 PM. The resident was discharged because it was the end of her Respite Care. He stated that the family member had concerns about Resident #1's care because there was some bruising that the family was not aware of. He stated that he saw the bruising on Resident #1's face but there was no open wound. He stated Resident #1 was in her wheelchair with her head facing down and not able to voice what happened. Record review of TULIP (Texas Unified Licensure Information Portal) on 6/18/2025 revealed that the facility did not report the injury of unknown origin for the wound that was discovered on 5/06/2025. The facility failed to follow the requirements by not reporting the incident within 24 hours of discovering the incident. Observation of video submitted by Family Member X dated 5/07/2025 at 1:10 pm in Resident #1's room at the nursing facility revealed an injury located on the right side of Resident #1's cheek. The injury appeared as a linear abrasion that was deeper than a scratch. The skin where the injury was located was bright red, clotted, and an irregular shape about 2.5 centimeters in diameter which Physician D claimed was caused by blunt force trauma. Timestamp date is inconsistent with the time of Resident #1's discharge time and date. Observation of photograph submitted by Family Member X dated 5/07/2025 at 1:10 pm in Resident #1's room at the nursing facility revealed Resident #1's injury to the right side of her cheek. The injury appeared as a linear abrasion that was deeper than a scratch. The skin where the injury was located was bright red, clotted, and an irregular shape about 2.5 centimeters in diameter which Physician D claimed was caused by blunt force trauma. Timestamp date is inconsistent with the time of Resident #1's discharge time and date. Interview with Physician D on 6/18/2025 at 9:00 AM confirmed that the wound appeared to be open and recent to the time of the photograph. Interview with Wound Care Nurse H on 6/17/2025 at 2:10 PM revealed that the wound appeared to be open and recent to the time of the photograph. Interview on 6/17/2025 at 9:40 AM with Director of Nursing F revealed that staff are trained to notify the administrator, director of nursing, physician, and responsible party if they find a wound or injury of unknown origin. She stated the reason this wound was not reported was because it was not something that they thought was a new injury because it was assumed to be related to the fall incident that occurred on 5/03/2025. Director of Nursing F stated that the physician and family members were notified of the fall that occurred on 5/03/2025. It was a witnessed fall. Director of Nursing F stated that she had seen Resident #1 on 5/06/2025 during the day shift and the wound was not there at that time. She stated that she did not know that when the family called to complain about Resident #1's injury that they were talking about that specific injury that she was not aware of. She stated that she assumed that Resident #1's family were calling to complain about a bruise on the right side of Resident #1's face that was related to the fall that occurred on 5/03/2025. Interview on 6/17/2025 at 11:00 AM with RN I, revealed that he saw Resident #1 on 5/06/2025. and saw that she had a bruise on the right side of her face above her eye. He stated it was a light purple bruise but there was no open skin. He stated the wound did not have any open areas and that it was right above her eye. Interview on 6/18/2025 at 9:00 AM with Physician D revealed the facility did not notify her of the wound in the video and photograph that was discovered on 5/06/2025 at 10:56 PM. She stated that she was at the facility on 5/06/2025 and observed Resident #1 around 9:00 AM. She stated Resident #1 did not have the injury that can be seen in the video and photographs when she observed her. She stated that the injury had to of happened after she left the facility that day. She stated that the wound appeared to be open and would have met the criteria for someone who should have been seen by the wound care nurse. She stated that had she seen that wound she would have provided wound care by applying ointment and bandaging the wound. She stated that the wound was not significant but that it should still have been treated. She stated that the wound looked like it was caused by blunt trauma possibly from her slouching over in her wheelchair and hitting the wheelchair armrest. She stated that the resident slouches over in her chair a lot and she could have hit her face on her armrest. She stated that she remembered being notified by LVN B of Resident #1 having the fall on 5/03/2025. She stated that she did not think that the fall and the injury to her cheek are related and that they had to of occurred at separate times. She stated that she should be contacted about any new injury of unknown origin, open wound, or injury. Interview on 6/18/2025 at 10:00 AM with Administrator J, revealed that he had spoken to RN I and learned that Resident #1 had light bruising on 6/05/2025. He stated that RN I knew about Resident #1's fall on 5/03/2025 and thought that the bruising was related to the fall. Administrator J stated that all the staff were inserviced on 6/17/2025 on documentation and notifications. Administrator J stated that he had talked to LVN A and learned that the injury was there at the time of discharge on [DATE] at 10:56 PM. He stated that LVN A had talked to the family, and they wanted to know what happened to Resident #1's face. Administrator J stated that everyone that was communicating with the family was communicating with them under the assumption that they were all talking about the injury that was related to the fall that occurred on 5/03/2025 and not about the injury of unknown origin that was discovered on 5/06/2025. He stated that they were communicating with inaccurate information that they didn't know was inaccurate because of the circumstances of the fall occurring a few days prior. Administrator J stated that the staff didn't notice that this was a new injury to Resident #1's face and assumed it was from the fall. He stated that it was unfortunate but that's just what happened. He stated the staff were inserviced to go back and check or compare notes to make sure that they are consistent with any injuries that are discovered. Interview on 6/18/2025 at 10:30 AM with RN I, revealed that the wound to Resident #1's cheek in the photograph and video were not there when he saw the resident during the day shift around 3:00 PM on 5/06/2025. He stated that if there had been an open wound then he would have provided wound care immediately and documented it. He stated if there had been a new wound then he would have notified the family and physician. LVN A was attempted to be interviewed on 6/18/2025 at 1:08 PM. Message was left requesting a call back. Record Review of the Facility Abuse & Neglect Policy dated June 23, 2017, reviewed February 12, 2020, states that The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property, and (ii) timely investigation of and reporting to state and local agencies all allegation of abuse, neglect, exploitation and misappropriation of resident property. All managed healthcare facilities and all management company staff members or third parties providing services to such facilities and/or their residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting. The facility failed to report an injury of unknown origin that was discovered on 5/06/2025, to HHSC. This failure could place residents at risk for not having incidents reported as required. Findings included: Record review of Resident #1's Face Sheet revealed that the resident was a [AGE] year-old female. She was admitted to the facility on [DATE] and discharged on 5/06/2025. She was a respite care (temporary care services) resident. Diagnoses of Alzheimer's disease (brain condition that progressively damages memory, thinking, and learning skills), Hyperlipidemia (High cholesterol), Dysphagia (Difficulty swallowing), Protein-calorie malnutrition, Anxiety disorder (Mental health conditions characterized by excessive fear, dread, or apprehension that arises without a clear or appropriate cause), History of falling, Dementia (Loss of cognitive function), Adult failure to thrive (Substantial decline in overall health and functional abilities), Parkinson's disease with dyskinesia (Dyskinesia is a term used to describe involuntary, uncontrollable movements), and Pain. Record review of Resident #1's Care Plan revealed that Resident #1 had a fall on 5/03/2025. Goals include that Resident #1 will be free from complications related to falling over the next 3 days and resident at risk for falls resident safety will be maintained over the next 90 days. Resident fall interventions include assess contributing factors related to fall history, assess for potential fall-related injury prevention, looking at circumstances, location, medication, new or worsening medical problems, etc., Keep call light and most frequently used personal items within reach, remind resident to call when needing assistance. Record review of Resident #1's electronic medical records reflected Resident #1 had a progress note on 5/03/2025 at 4:51 PM that was entered by LVN B. The progress note referenced the assessment for Resident #1 and stated that Resident #1 had fallen asleep in her chair slouched over. LVN B repositioned Resident #1 attempting to prevent a fall. Approximately 30 minutes later, CNA C alerted LVN B that Resident #1 had repositioned herself. Resident #1 had fallen back asleep and slouched over causing Resident #1 to fall out of her chair. Resident #1 was assessed with no noticeable injuries. Resident #1 denied pain. Record review of Resident #1's MDS Assessment, dated 5/05/2025, reflected Resident #1 had a BIMS (Brief Interview for Mental Status Test) score of 2 (Severe Cognitive Impairment). Resident #1 was assessed to require assistance with ADLs including the following: transfers, personal hygiene, showers, and dressing. Record review of Resident #1's electronic medical records reflected Resident #1 had a progress note on 5/06/2025 at 10:56 PM that was entered by LVN A. The progress note stated that there was a concern made by the family about the resident's care and the family requested to speak with the Director of Nursing. Record review of LVN A's employee statement, not dated, reflected that LVN A was working the night shift on 5/06/2025 when Resident #1 was discharged at 10:56 PM. The resident was discharged because it was the end of her Respite Care. He stated that the family member had concerns about Resident #1's care because there was some bruising that the family was not aware of. He stated that he saw the bruising on Resident #1's face but there was no open wound. He stated Resident #1 was in her wheelchair with her head facing down and not able to voice what happened. Record review on 6/18/2025 of TULIP (Texas Unified Licensure Information Portal) revealed that the facility did not report the injury of unknown origin for the wound that was discovered on 5/06/2025. The facility failed to follow the requirements by not reporting the incident within 24 hours of discovering the incident. Observation of video submitted by Family Member X dated 5/07/2025 at 1:10 pm in Resident #1's room at the nursing facility revealed an injury located on the right side of Resident #1's cheek. The injury appeared as a linear abrasion that was deeper than a scratch. The skin where the injury was located was bright red, clotted, and an irregular shape about 2.5 centimeters in diameter which Physician D claimed was caused by blunt force trauma. Timestamp date is inconsistent with the time of Resident #1's discharge time and date. Observation of photograph submitted by Family Member X dated 5/07/2025 at 1:10 pm in Resident #1's room at the nursing facility revealed Resident #1's injury to the right side of her cheek. The injury appeared as a linear abrasion that was deeper than a scratch. The skin where the injury was located was bright red, clotted, and an irregular shape about 2.5 centimeters in diameter which Physician D claimed was caused by blunt force trauma. Timestamp date is inconsistent with the time of Resident #1's discharge time and date. Interview with Physician D on 6/18/2025 at 9:00 AM confirmed that the wound appeared to be open and recent to the time of the photograph. Interview with Wound Care Nurse H on 6/17/2025 at 2:10 PM revealed that the wound appeared to be open and recent to the time of the photograph. Interview on 6/17/2025 at 9:40 AM with Director of Nursing F revealed that staff are trained to notify the administrator, director of nursing, physician, and responsible party if they find a wound or injury of unknown origin. She stated the reason this wound was not reported was because it was not something that they thought was a new injury because it was assumed to be related to the fall incident that occurred on 5/03/2025. Director of Nursing F stated that the physician and family members were notified of the fall that occurred on 5/03/2025. It was a witnessed fall. Director of Nursing F stated that she had seen Resident #1 on 5/06/2025 during the day shift and the wound was not there at that time. She stated that she did not know that when the family called to complain about Resident #1's injury that they were talking about that specific injury that she was not aware of. She stated that she assumed that Resident #1's family were calling to complain about a bruise on the right side of Resident #1's face that was related to the fall that occurred on 5/03/2025. Interview on 6/17/2025 at 10:30 AM with CNA C revealed that Resident #1 was seen falling to the ground in the dining room on 5/03/2025. CNA C alerted LVN B of the fall and LVN B assessed Resident #1. CNA C stated that Resident #1 did not have any signs of injury. CNA C stated that he never saw a wound on Resident #1's face while she was at the facility. Interview on 6/17/2025 at 11:00 AM with RN I, revealed that he saw Resident #1 on 5/06/2025. and saw that she had a bruise on the right side of her face above her eye. He stated it was a light purple bruise but there was no open skin. He stated the wound did not have any open areas and that it was right above her eye. Interview on 6/17/2025 at 2:10 PM with Wound Care Nurse H revealed that she saw a bruise on the upper right side of Resident #1's face over the weekend of Saturday 5/03/2025 and Sunday 5/04/2025. She stated that it was a light bruise on the upper right side of her face. She stated that she was never informed of any open wounds or skin tears. She stated that the wound in the video and photograph appeared to be an open wound with bleeding. She stated that it had to have occurred after she saw the resident on the weekend because it was not there when she saw that resident sitting in her chair over the weekend. She stated that she also does not believe that the resident would have gone 24, 48, or even 72 hours with a with a wound that was visibly bleeding on her face without being notified about it. Interview on 6/17/2025 at 2:20 PM with Assistant Director of Nursing G, revealed that he did see the bruise that was on Resident #1's upper right-hand side of her face on 5/06/2025 that was a result of her fall on 5/03/2025. He stated that there was no cut or skin tear when he saw her, and that Resident #1 was not bleeding. He stated that he never saw the a wound on Resident #1's cheek. He stated that if he had seen a wound on Resident #1 he would have notified the director of nursing, doctor, and family. He would have addressed it with the wound care nurse too. Interview on 6/18/2025 at 9:00 AM with Physician D revealed the facility did not notify her of the wound in the video and photograph that was discovered on 5/06/2025 at 10:56 PM. She stated that she was at the facility on 5/06/2025 and observed Resident #1 around 9:00 AM. She stated Resident #1 did not have the injury that can be seen in the video and photographs when she observed her. She stated that the injury had to of happened after she left the facility that day. She stated that the wound appeared to be open and would have met the criteria for someone who should have been seen by the wound care nurse. She stated that had she seen that wound she would have provided wound care by applying ointment and bandaging the wound. She stated that the wound was not significant but that it should still have been treated. She stated that the wound looked like it was caused by blunt trauma possibly from her slouching over in her wheelchair and hitting the wheelchair armrest. She stated that the resident slouches over in her chair a lot and she could have hit her face on her armrest. She stated that she remembered being notified by LVN B of Resident #1 having the fall on 5/03/2025. She stated that she did not think that the fall and the injury to her cheek are related and that they had to of occurred at separate times. She stated that she should be contacted about any new injury of unknown origin, open wound, or injury. Interview on 6/18/2025 at 10:00 AM with Administrator J, revealed that he had spoken to RN I and learned that Resident #1 had light bruising on 6/05/2025. He stated that RN I knew about Resident #1's fall on 5/03/2025 and thought that the bruising was related to the fall. Administrator J stated that all the staff were inserviced on 6/17/2025 on documentation and notifications. Administrator J stated that he had talked to LVN A and learned that the injury was there at the time of discharge on [DATE] at 10:56 PM. He stated that LVN A had talked to the family, and they wanted to know what happened to Resident #1's face. Administrator J stated that everyone that was communicating with the family was communicating with them under the assumption that they were all talking about the injury that was related to the fall that occurred on 5/03/2025 and not about the injury of unknown origin that was discovered on 5/06/2025. He stated that they were communicating with inaccurate information that they didn't know was inaccurate because of the circumstances of the fall occurring a few days prior. Administrator J stated that the staff didn't notice that this was a new injury to Resident #1's face and assumed it was from the fall. He stated that it was unfortunate but that's just what happened. He stated the staff were inserviced to go back and check or compare notes to make sure that they are consistent with any injuries that are discovered. Interview on 6/18/2025 at 10:30 AM with RN I, revealed that the wound to Resident #1's cheek in the photograph and video were not there when he saw the resident during the day shift around 3:00 PM on 5/06/2025. He stated that if there had been an open wound then he would have provided wound care immediately and documented it. He stated if there had been a new wound then he would have notified the family and physician. LVN A was attempted to be interviewed on 6/18/2025 at 1:08 PM. Message was left requesting a call back. Record Review of the Facility Abuse & Neglect Reporting Policy dated June 23, 2017, reviewed February 12, 2020, states that: (ii) Timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation, and misappropriation of resident property. 3.2 All facility staff members have a duty to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the Administrator of the facility, who serves as the Abuse Coordinator. In the Administrator's absence, the Director of Nursing (DON) or another designee will be appointed to function as the interim Abuse Coordinator. 3.3 Upon receiving an allegation abuse, neglect, exploitation or misappropriation, the Abuse Coordinator will a) notify the Regional Director of Operations and Regional Nurse Consultant, b) initiate an investigation into the allegation, c) in conjunction with the Region Director of Operations and Regional Nurse Consultant determine whether the allegation is reportable under federal and state regulations, and d) if the allegation is reportable, report such allegation to the State Regulatory Agency, Adult Protective Services (where state law provides jurisdiction in skilled nursing or assisted living facilities), and in certain cases, local law enforcement, within the following timeframes: A. 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 B. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #205) reviewed for intravenous fluids. RN A failed to change Resident #205's Central Venous Catheter line dressing using sterile technique. This failure could affect residents by placing them at risk for infections and cross-contamination. Findings include: Record review of Resident #205's Minimum Data Set Assessment, dated 02/11/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE], his BIMS score was 15/15 indicating intact cognition. His diagnoses included blood stream infection due to central venous catheter, respiratory failure, pneumonia (an infection that inflames the air sacs in one or both lungs). Record review of Resident #205's Order Summary Report, dated January 2023, reflected: PICC LINE (CVC) DRESSING CHANGE every 7 days 1 time per day, Dx: Bloodstream infection due to central venous catheter, subsequent encounter. An observation on 02/19/25 at 2:24 PM with Resident #205 revealed he was awake and lying on the bed. He had a PICC (CVC) line in his right upper chest with a dressing that has a one-inch tear on it. The line entry site was not red or swollen. RN A entered the resident's room with donned gown, clean gloves. She wiped the bed side table, let it to dry, and put the dressing change kit on it. RN A changed gloves performed hands hygiene, opened the sterile kit, got the mask from the kit and put it on the resident; RN A was wearing a mask as well. RN A removed gloves, sanitized hands, donned sterile gloves, and separated the sterile supplies individually for clear view. RN A put a white drape from the sterile kit underneath the line lumens without touching them, then removed the old dressing. RN A, without changing gloves, cleaned the line exit site with chlorhexidine, applied the Bio Patch, and clean dressing without using the skin prep on the sterile kit. RN A removed the white drape and proceeded to dispose of the rest of the sterile kit on the trash. When RN A was asked about the extra sterile gloves in the kit, she replied for a helper in case she needed another person to help her with the dressing change. In an interview on 02/19/25 at 2:47 PM with RN A, she stated supposed to change gloves with hands hygiene going from dirty to clean during the dressing change. RN A stated she received sterile dressing change training as an RN student at school two years ago, in the facility on hire two years ago, and annually. RN A stated the risk, if proper sterile technique was not followed, could be the development of infection for the residents. In an interview on 02/19/25 at 3:12 PM with the DON, she stated her expectation for the staff doing central venous/PICC line dressing change was to follow the proper sterile techniques, and to change gloves with hands hygiene going from dirty to clean tasks. The DON stated the nurse RNs received training with check list on the central venous line care on hire, and annually. The DON stated the risk, if proper sterile technique was not followed, could be the development of infection for the residents. Record review of RN A's annual skill check revealed it was done on 09/20/24. Record review of the facility's policy Titled Infusion Therapy Policy and Procedure Manual-2011 reflected: Midline, PICC and Central catheter dressing changes are performed using strict sterile technique . Removes and disposes of old dressing . Removes gloves and washes hands Sets up the sterile dressing tray .

**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 1 of 3 Residents (Resident #64) reviewed for respiratory care. 1. The facility failed to obtain an order for Resident #64's use of supplemental O2 with stated liter amount to be delivered. 2. The facility failed to include rationale for the use of O2 for Resident #64 from 02/16/25 through 02/18/25. These failures could place residents who received oxygen therapy at risk of receiving an incorrect amount of oxygen and the risk of oxygen toxicity. Findings Included: Record review of Resident #64's significant change MDS assessment dated [DATE], reflected an [AGE] year-old female with a re-entry date of 12/06/24 to the facility. She had a BIMS score of 9 which indicated her cognition was moderately impaired. Diagnoses included dementia, fractured hip, and coronary artery disease (damage or disease of the hearts major blood vessels). The resident required substantial to maximum assistance with ADL's. Resident #64 had not experience shortness of breath in the previous 5 days and had not received Oxygen therapy while a resident. Record review of Resident #64's care plan with an onset date of 02/15/25 reflected, Breathing patterns onset 02/15/25. Evidenced by Ipratropium 0.5 mg-albuterol 3 mg (used to open airways) .1 solution for Nebulization (converts liquid medication into a fine mist to be inhaled directly into the lungs) .Goal-Resident will demonstrate effective respiratory rate, depth, and pattern over the next 90 days .Interventions .Administer medications, respiratory treatments, and oxygen as ordered . Record of Resident #64's Physician orders report dated 02/20/25, reflected, Ipratropium 0.5 mg-albuterol 3 mg/3 ml nebulization-1 solution for nebulization inhalation every 6 hours with a start date of 02/17/25. There were no orders for oxygen therapy. Record review of Resident #64's Medication administration record dated February 2025 reflected, . ipratropium 0.5 mg-albuterol 3 mg (2.5 mg base)/3 mL nebulization. (IPRATROPIUM BROMIDE/ALBUTEROL SULFATE) 1 Solution for Nebulization Inhalation every 6 hours NEBULIZATION Dx: Nasal congestion Start Date:02/17/2025. Medication had been administered every 6 hours as ordered. There was no administration recorded for Oxygen therapy from 02/01/25 through 02/18/25. Record review of Resident #64's nurses notes dated 02/16/25 reflected: 05:15 a.m. Resident in bed resting comfortably resp. even and unlabored, crackle lung sound noted on auscultation, breathing treatment administrated as ordered with an effective result. 02 sats 94-96% on 02 @ 2L via NC Signed by LVN G 11:11 a.m. Resident lethargic, alert oriented x 1, sleeping comfortably, no s/sx of respiratory distress or any other discomfort noted, sating at 95% on 2l of oxygen .[NP] On call notified. IV hydration completed. Received orders for midline (IV access) insertion x1, normal saline 0.9% IV X 2 liters, CEFTRIAXONE (antibiotic) 1 GRAM Q 24HRS X 3 DAYS, vital signs q 6 hours x 48 hours Family notified Singed by LVN F. In an observation on 02/18/25 at 10:05 a.m., Resident #64 was observed in bed with O2 via nasal cannula. The O2 concentrator was set to deliver 2 liters per minute. In an interview on 02/20/25 at 11:30 a.m. with LVN F, she stated Resident #64 was having difficulty breathing a few days ago and they had to place her on oxygen. She stated her breathing had improved, but she still had a bad cough and some crackles in her lungs. She stated they had a standing order from the physician that they could apply oxygen at 2 liters and titrate according to the resident's oxygen saturation level and resident's comfort. She stated the order should be in the physician orders. LVN F searched the physician orders and MAR, and stated there were no orders put in. She stated she would add the orders now. In an interview with the DON on 02/20/25 at 11:35 a.m., she stated even though they had a standing order list from the physician, the staff had to place those orders into the electronic physician orders which would then populate to the MAR/TAR. She stated the staff had to have an order for the amount of Oxygen to be administered, if it was continuous or as needed, when it was applied and the necessary assessment that needed to be performed for anyone receiving Oxygen therapy. She stated failing to have the order in place, placed a resident at risk lack of continuity of care and the specific amount of Oxygen to be administered. In an interview on 02/20/25 at 11:40 a.m. with LVN G, he stated he worked the night shift on 02/16/25 and stated Resident #64 was on O2 when he arrived. He stated he assessed her vitals and O2 sats and documented in the nurses' notes, but stated he did not check to see if there was an order for the Oxygen. He stated he assumed the order was in place. He stated they were required to have an order for any oxygen administration and the amount to be administered. Record review of the facility's policy titled, Oxygen Therapy, Concentrator-Initiation, dated January 2020, reflected, The licensed staff will provide the prescribed amount oxygen therapy to the residents as prescribed by physician and according to practice guidelines .Procedure: Review physician's orders .Turn liter flow to the prescribed amount .Document in the eMar/eTar ordered oxygen therapy administration .

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 10 residents (Resident #23, Resident #22, Resident #72, and Resident #64) observed for infection control. 1. The facility failed to ensure MA C administered Resident 23's medication without cross contaminating her medications on 02/18/25. 2. The facility failed to ensure MA B prepared Resident 72's medication without cross contaminating her medications on 02/18/25. 3. The facility failed to ensure MA B sanitized the blood pressure cuff between use on Resident #22 and Resident #72 on 02/18/25. 4. The facility failed to ensure that CNA D changed her gloves and performed hand hygiene while providing incontinence care to Resident #64 on 02/18/25. 4. The facility failed to ensure the Treatment Nurse used the required PPE for Resident #64, who was on enhanced barrier precautions due to her venous access device and wounds, while performing wound care on 02/19/25. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. During medication observation on 02/18/25 at 08:50 a.m., MA C was observed at the medication cart. MA C performed hand hygiene and prepared Resident #23's morning medications. MA C placed eight medications in one plastic medication cup and 1 medication (iron supplement) in a second medication cup, stating the resident usually refused her iron supplement. MA C entered the resident's room and asked the resident if she wanted her iron supplement. Resident #23 stated she would take her iron supplement. MA C poured the supplement into the cup containing the 8 other medications and handed the pill cup to the resident. Resident #23 poured the medication into her mouth, dropping one of the pills into the crook of her arm. MA C picked up the fallen pill with her bare hands, and placed it into the palm of her hand for Resident #23 to retrieve from her hand. Resident #23 retrieved the pill from MA C palm and took it with the remainder of her medications. In an interview on 02/20/25 at 09:10 a.m. with MA C she stated she realized she had cross contaminated the medication when she touched it with her hand. She stated she should have disposed of the medication and retrieved a new medication. She stated she had been taught they were not supposed to touch any of the medications with their hands due to the risk of cross contamination. 2. During medication observation on 02/18/25 at 09:15 a.m., MA B was observed at the medication cart in the dining room area on the memory care unit. MA B performed hand hygiene and obtained Resident 22's blood pressure. MA B returned to the medication cart and placed the blood pressure cuff on top of the cart. MA B sanitized her hands and pulled Resident #22's medication and administered his medications to him at the dining room table. MA B returned the medication cart, sanitized her hands and picked up the unsanitized blood pressure cuff and took Resident #72's blood pressure. MA B returned to the medication cart and placed the blood pressure cuff on top of the medication cart. MA B sanitized her hands and opened the medication cart to retrieve Resident #72's medication. MA B pulled keys from her pocket and unlocked the Locked section of the medication cart and retrieved a blister pack containing Resident #72's Xanax (anti-anxiety). MA B punched the blister pack over the plastic medication cup, but the pill remained stuck inside the blister pack. MA B took her finger and pulled the tablet out of the blister pack into the plastic cup. MA B then continued to pull 5 more medications. MA B crushed all the medication except the 1 tablet of potassium (mineral) and then mixed all the pills into yogurt and administered the medications to Resident #72. In an interview with MA B on 02/18/25 at 09:30 a.m., she stated she was supposed to sanitize the blood pressure cuff between resident-use and stated she had forgotten that step. She stated she had been taught they were not supposed to touch any of the medication with bare hands and stated she should have gotten a spoon to retrieve the stuck pill. She stated the reason for not touching the medication and sanitizing the blood pressure cuff was to prevent the spread of germs prevent the spread of infections. In an interview on 02/19/25 at 03:40 p.m. with the DON, she stated the staff were taught to punch the medication directly into the med cup without touching the medication to prevent cross contamination. She stated the staff could have used a spoon to retrieve the medication from the blister pack and should have disposed of the dropped medication and retrieved a new pill. She stated they had all been taught to clean equipment between resident use. She stated they went over and over infection control practice with the staff. 3. In an observation on 02/18/25 at 10:05 a.m., CNA D and CNA E entered Resident #64's room to provide incontinence care. Both staff donned a gown, performed hand hygiene, and put on gloves. CNA D opened the resident's brief and pushed it downward toward the resident's buttocks. CNA D provided peri care from front to back, wiping once and changing wipes with each stroke. Both staff rolled the resident onto her left side. CNA D wiped from front to back, removed her gloves, and performed hand hygiene. CNA D then removed the soiled brief and placed the clean brief under the resident without changing her gloves or performing hand hygiene. Both staff rolled the resident back onto her back and fastened the brief. Both staff removed their gown and gloves and performed hand hygiene. In an interview on 02/18/25 at 10:08 a.m., CNA D stated she should had removed the soiled brief, and then changed her gloves and perform hand hygiene. She stated the way she did it cross contaminated the clean brief and potentially the resident. She stated they had been taught to change their gloves and perform hand hygiene when finished with the dirty and before going to the clean. 4. In an observation on 02/19/25 at 10:05 a.m. revealed the Treatment Nurse at the treatment cart preparing wound care supplies for Resident #64's wound to her left heel. The Treatment Nurse placed her supplies on a piece of wax paper and entered Resident #64's room. The Treatment Nurse placed the supplies on the resident's bed, performed hand hygiene and put on gloves, but did not put on a gown. The Treatment Nurse removed the old dressing off her left heel revealing a moderate amount of blood-tinged drainage, removed her gloves and performed hand hygiene and put on clean gloves. The Treatment Nurse cleaned the wound with Normal Saline and applied hydrogel (gel that increases moisture level in the wound) and covered it with a dry dressing. The Treatment Nurse then removed her gloves and performed hand hygiene. In an interview on 02/20/25 at 10:15 a.m. with the Treatment Nurse, she stated she did not think Resident #64 was on Enhanced Barrier precautions because the wound did not have significant drainage and she thought the Resident had a peripheral line, not a PICC line. She stated she was taught that if the resident had a minor wound and a peripheral line, they did not have to use Enhanced Barrier precautions. She stated since the resident did have a PICC line, she should have worn a gown. She stated she was not sure if the wound alone would require a gown. In an interview on 12/05/24 at 11:10 a.m. with the DON, she stated staff were supposed to wash hands and change gloves before and after completion of cleaning a resident, and after completion of care. She stated they had worked so hard with the staff on skills and stated they were all aware of what they were supposed to be doing. She stated the risk of failing to perform hand hygiene was increased infections and cross contamination. She stated any resident with a central line or PICC line required the staff to wear a gown for high contact care. She stated simple skin tears did not require the use of gown but stated Resident #64's wound would not be described as a simple skin tear. She stated they had done training with all the staff on Enhanced Barrier precautions as well as infection control. She stated the reason the residents were placed in Enhanced Barrier precautions was because they were more susceptible to spread of infection and provided an extra level of protection. She stated they did skills checks and education upon hire and annually on infection control, hand hygiene, and Enhanced Barrier precautions, or as needed when training needs were identified. Record review of the facility's policy titled, Disinfecting and Sterilizing Resident Care Equipment, dated January 2022, reflected, Equipment will be maintained and kept sanitized or disinfected in accord with acceptable policies .Only EPA-approved cleaning products and germicides are utilized for the cleaning, disinfection and sterilization of resident equipment .Non-critical items are those that either do not touch the resident or touch only intact skin. Such items include .blood pressure cuffs .These items rarely transmit disease. However, it is imperative that these items are clean . Record review of the facility's policy titled, Medication Administration, dated January 2024, reflected, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so .hands are washed with soap and water and gloves applied prior to handling tablets . Record review of the facility's policy titled, Hand Hygiene for Staff and Residents, dated January 2022, reflected, .Hand Hygiene is the most important component for preventing the spread of infection .Hand hygiene is done before .resident contact .taking part in a medical or surgical procedure .After contact with soiled or contaminated articles, such as articles that are contaminated body fluids . Record review of the facility policy titled, Enhanced Barrier Precautions, dated April 2024, reflected, Many residents in nursing homes are at increased risk of becoming colonized and developing infections with multi-drug resident organisms .Indications .Wounds and/or indwelling medical devices even if the resident is not known to be infection or colonized with an MDRO .High Contact Resident care Activities .Wound care: any skin opening requiring a dressing .EBP are sued in conjunction with standard precautions and expand ethe use of PPE to donning of gown and gloves during high contact care activities that provide opportunities of r transfer of MDROs to staff hands and clothing .

**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 for one (Resident #2) of one resident reviewed for catheter care. The facility failed to ensure LVN B maintained Resident #2's indwelling urinary catheter drainage bag below the bladder level during wound care on 11/19/24. This failure placed residents at risk for not receiving care appropriate to address their incontinence and risk for infection. Findings included: A record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included multiple sclerosis (a disease resulting in nerve damage), stage 4 pressure ulcer, and neuromuscular dysfunction of bladder (the nerves and muscles of the bladder don't communicate properly with the brain, resulting in bladder control issues). Resident #2 had a BIMS of 12 which indicated Resident #2's cognition was moderately impaired. She required extensive assistance of two-person physical assistance with bed mobility. MDS assessment, section bowel and bladder reflected resident had an indwelling urinary catheter. Record review of Resident #2's care plan revised on 01/25/24 reflected, Urinary catheter . Resident will be free of complications of indwelling catheter . Goal: Resident will be free of complication of indwelling catheter . Interventions: Care/changing of urinary catheter as ordered . Review of Resident #2's Order Summary report dated November 2024, reflected, Foley Catheter ( indwelling urinary catheter) every shift to continuous gravity drainage and catheter care. with a start date of 06/19/24. Observation on 11/19/24 at 11:32 AM, revealed LVN B entered Resident #2's room to do wound treatment. CNA C entered Resident #2's room to assist LVN B. Both staff washed hands, donned gowns and gloves. LVN B unhooked the urinary catheter bag from the bed rail and put it flat on the foot of bed, above the resident's bladder. LVN B provided wound care to the sacrum wound. During the procedure urine was observed flowing back toward the resident's bladder. LVN B finished the treatment and then she hooked the urinary catheter bag onto the bed rail. Observation of the urinary catheter bag revealed approximately 300 milliliters of urine in the bag. In an interview with LVN B on 11/19/24 at 11:49 AM, she stated that the urinary catheter bag tubing was short and to prevent pulling on the catheter tubing she put the catheter bag on the bed. She stated the catheter bag and catheter tubing were supposed to be kept below the bladder. She stated failing to do this could cause the urine to back up and might cause an infection. She stated she supposed to empty the catheter bag before putting it on the bed. In an interview with the DON on 11/20/24 at 12:59 PM, she stated any resident with an indwelling urinary catheter should always have the catheter bag and catheter tubing below the bladder. She stated not keeping the urinary catheter bag below the resident's bladder, placed them at risk of urinary tract infection. She stated to ensure staff were knowledgeable in the care of indwelling catheter the facility does skills competency checks. She stated when staff needed to be re-trained, she provided the in-service training. Record review of LVN B's competency check off for catheter care revealed she was proficient in care as of 11/20/24. No other training was provided. Review of the facility's policy titled, Urinary Catheter Infection Prevention reviewed January 2022 reflected, . 8. Gravity drainage bags are positioned below the level of the patient's bladder .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident#1) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #1 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was an [AGE] year-old male with initial admission date to the facility on [DATE]. His diagnoses included fracture of part of neck of left femur (the bone of the thigh), Obstructive uropathy (urine cannot drain through the urinary tract), and Alzheimer's disease. Resident #1 had a BIMS of 99 which indicated Resident #1 was unable to complete brief interview for mental status. Resident #1 required moderate assistance with personal hygiene. Review of Resident #1's Comprehensive Care Plan, revised 07/04/24, reflected the following: Care area: Self-Care Deficit Goal: [Resident #1] Will maintain or improve self-care area of dressing, grooming hygiene and bathing Interventions: . Provide assistance with self-care as needed. An observation on 11/19/24 at 09:47 AM, revealed Resident #1 was laying in his bed. The nails on both hands were approximately 0.3 centimeters in length extending from the tip of his fingers and had black substance underneath the nails and around the nail beds. Resident #1 was unable to answer questions. In an interview on 01/19/24 at 11:00 AM, with CNA A revealed she was assigned to Resident #1. She stated that most ADL's such as hair trimming, nail clipping was completed during shower times. She revealed that since Resident #1 was not a Diabetic resident, CNAs were responsible for clipping and cleaning his nails. CNA A stated that fingernail clipping should be done weekly or as needed and the risk of not cleaning/ trimming fingernails could be increased risk of infection. CNA A stated she did not check Resident #1's nails this morning when she changed him. In an interview with the DON on 11/20/24 at 12:59 PM, revealed her expectation was that nail care should be provided as needed, especially during shower time. She stated that CNAs were responsible for doing nail care unless the resident had a diagnosis of diabetes. She also stated that as the DON, either herself or her designee were responsible to do routine rounds for monitoring. The DON stated that residents having long, and dirty fingernails could be an infection control issue and skin breakdown. Record review of the facility policy titled Bathing revised 02/12/20 reflected: . Perform hand hygiene and perform nail care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one (Resident #5) of eight residents reviewed for ADLs. The facility failed to ensure Resident #5 had her fingernails cleaned and trimmed. This failure could place residents at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings include: Record review of Resident #5's quarterly MDS assessment, dated 01/11/24, reflected a [AGE] year-old female with an admission date of 08/14/14. Resident # 5 was unable to participate in the brief interview for mental status and staff had assessed her to be severely cognitively impaired. Resident #5 was dependent for all ADLs and had no history of refusing care. Active diagnoses included cerebral vascular accident (stroke), hemiplegia (paralysis), heart failure and dementia. Record review of Resident #5's comprehensive care plan reviewed and continued 12/05/23, reflected, .[Resident #5] has a self-care deficit in all Activities of Daily living. Requires total staff performance of ADLS's due to .Contractures to bilateral hands, knees, and shoulders .Interventions .Total assist with dressing, grooming hygiene, and bathing . Record review if Resident #5's ADL Flow Sheet for 01/01/24 through 01/22/24 reflected resident had received a bath on the evening shift on Mondays, Wednesday, and Fridays. Observed Resident #5 on 01/23/24 at 10:00 a.m. lying in bed. Both hands were drawn up in a fist. Both hands noted with long thumb nails approximately ½ inch long. Resident appeared to understand questions but cannot vocalize response. Resident #5 was unable to open hands. In an interview with CNA I on 01/24/24 at 11:00 a.m. she stated they were responsible for trimming residents' nails on bath days. She stated Resident #5 was a 2p.m.-10 p.m. bath on Monday, Wednesday and Friday's. She stated she had not noticed Resident #5's nails. In an interview CNA K and CNA J on 01/24/24 at 2:45 p.m. both staff stated they were not providing nail care to Resident #5 because someone else was assigned to nail care. CNA J stated they did Resident #5's bed bath on Monday, Wednesday, and Friday, but not her nail care. CNA J did not know who was assigned to do the nail care. In an observation and interview with RN H on 01/24/24 at 2:50 p.m. at Resident #5's bedside, she stated Resident #5's nails needed to be trimmed. She stated the facility in the past had assigned one staff member to do nail care unless the resident was diabetic, but stated she was not sure who it was. RN J inspected Resident #5's hands revealing some nails on her left were shorter but were dirty with dark gray substance under them. Both thumb nails were over ½ inch in length. She stated with the resident's contractures her nails needed to be kept short and clean to prevent skin breakdown. In an interview with LVN G on 01/24/24 at 03:05 p.m. he stated the CNAs were responsible for trimming residents' nails, unless they were diabetic. He stated Resident #5 was not diabetic, but with her hand contractures it might be difficult for the CNAs to trim her nails. He stated the Medical Records clerk use to trim resident's nails but stated she had not done that since the first of January 2024. In an Interview with the Medical Records clerk on 01/24/24 at 03:10 p.m. she stated nail care was done on the resident's scheduled shower days. She stated she was a floor CNA and recently became the medical records clerk. She stated she used to trim the majority of the residents' nails. She stated she had not done that since the end of December 2023. She stated would highlight a resident list and give it to the nurse on any residents she had trimmed nails. She stated she could see where it got miscommunicated. She stated she had trimmed Resident #5's nails in the past but could not remember when she had trimmed them last. She stated Resident #5's hands were very contracted. Interview with the DON on 01/24/24 at 03:30 p.m. she stated it was the CNAs responsibility to make sure residents nails were trimmed and clean. She stated it was done on the resident's shower days. She stated she would make sure the staff were aware of their responsibility. She stated failing to keep resident's nails trimmed and clean could cause skin scratches, risk of infections, and someone with contractures could cause skin breakdown. Review of facility's policy Bathing, dated January 2023 reflected, Staff will provide bathing services for residents within standard practice guidelines .Perform hand hygiene and perform nail care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #5) of three residents reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #5's contracture to her right and left hands after discharge from occupational therapy on 11/13/23. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Record review of Resident #5's quarterly MDS assessment, dated 01/11/24, reflected a [AGE] year-old female with an admission date of 08/14/14. Resident # 5 was unable to participate in the brief interview for mental status and staff had assessed her to be severely cognitively impaired. The Resident had lower extremity impairment on both sides. Resident #5 was dependent for all ADLs and had no history of refusing care. Resident #5 had not received OT or PT services in the seven days look back period. Resident #5 had not received restorative care, splints, or braces. Active diagnoses included cerebral vascular accident (stroke), hemiplegia (paralysis), heart failure and dementia. Record review of Resident #5's comprehensive care plan reviewed and continued 12/05/23, reflected, .[Resident #5] has limited Range of Motion of all extremities .Interventions included .Assess contracted area/areas with decreased ROM for evidence of skin breakdown: report significant changes to MD .Use devises, appliances, splints, or positioning pillows as indicated. Hand rolls placed to bilateral hands . Record Review of Occupational Therapy Discharge summary dated [DATE] reflected, .Dates of Services: 10/16/23-11/13/23 .Short-Term Goals .Patient will safely wear a hand roll and-or a palmar guard on bilateral hands for up to 4 hours w/minimal signs and symptoms of redness, swelling, discomfort or pain .Previous tolerance 10/28/23 .3 hours Discharge .11/13/23 .5 hours Assessment and Summary of Skilled Services Prognosis to Maintain current level of function- Excellent with consistent staff support . Record review of Resident #5's Electronic Medical Record reflected a nursing restorative plan initiated on 11/16/22 for 6 weeks. No record found indicting restorative continued beyond the initial 6-week period. Record review of Resident #5's Consolidated Physician orders, dated 01/24/23 reflected, .Occupation Therapy services 3-5x/week for 1 week with emphasis on Upper extremity therapeutic exercise. Therapeutic activities, Modalities, and Patient/caregiver education . with a start date of 01/23/24. An observation of Resident #5 on 01/23/24 10:00 a.m. revealed both hands drawn into a fist. Resident #5 was unable to open hands or move fingers. Thumb nails on both hands were approximately 1/2 inches long. Unable to view other nails. No hand splints or hand rolls in place. In an interview with CNA J on 01/23/24 at 12:15 p.m. she stated Resident #5 used to have a ball like splint that therapy placed in her hands but stated she had not seen it for several months. She stated the residents' hands were awfully hard to open. In an interview with LVN G on 01/23/24 at 1:30 p.m. he stated therapy had been placing splints in Resident #5's hands. He stated he had never had an order for nursing to place splints in her hands. He stated they had placed washcloths in her hands in the past. He stated he thought she was under therapy services at this time. In an interview with the DOR on 01/23/24 at 02:10 p.m. she stated they had put Resident #5 on physical therapy for her legs and hips around the first of January. She stated the resident was on their contracture management list and they did quarterly screenings on her. She stated the previous date of service for Resident #5 was 10/16/23 through 11/13/23 with Occupational therapy and that was for the contractures to her hands. She stated she was not sure if the resident was put on restorative after she was discharged in November, she stated the OT would probably know. In an interview with OTR D on 01/23/24 at 02:20 p.m. he stated when he discharged Resident #5 from therapy in November 2023, he met with the MDS nurse, and the restoratives aide about the residents ongoing needs and he thought they were adding her to restorative. He stated he was splinting both hands and was doing stretching when he saw her in October and November last year. In an Interview with MDS F on 01/23/24 at 02:25 p.m. she stated she provided oversight for the restorative program. She stated Resident #5 had not been on restorative since 2022. She stated Resident #5 was currently on Physical therapy services. She stated she did not recall having a conversation with OTR D about placing the resident on restorative in November 2023. She stated they only had one Restorative aide and could only care 9-10 residents at a time. She stated they could assign application of splints and range of motion to the nursing staff. She stated therapy used to send written restorative plans when they were discharging residents and the resident needed restorative, but they had stopped doing that. She stated now they just discussed it during stand-up meetings. She stated failing to provide ongoing range of motion and splinting could cause a decline in the resident's range of motion and worsening of her contractures. In an Interview with PTA C 01/23/24 at 02:35 a.m. he stated he evaluated Resident #5 and picked her up on physical therapy services. He sated he seen her for decreased mobility to her lower extremities but stated due to the progression of her hand contractures her had started splinting her hands. He stated they had rapidly progressed from her previous round of therapy. He stated he had started her on stretches and splinting to get her back to her previous level. In an interview with the Restorative Aide on 01/23/24 at 2:40 p.m. she stated she had worked in the position of Restorative Aide for about 6 months. She stated Resident #5 had never been assigned to her for restorative services. She stated she recalled having a conversation with therapy and the MDS nurse about putting her on restorative but stated she had never been assigned to her. In a follow up interview with the DOR on 01/23/24 at 02:45 p.m., she stated she and the MDS nurse communicate daily and review upcoming quarterly screenings and residents who will be coming off therapy services. She stated they only had one Restorative aide that worked Monday through Friday. She stated if they had a resident who required ongoing splinting or range of motion, she would request nursing to write the order so it could be continued, and they could monitor the resident's skin. She stated she was not sure what happened with Resident #5, and stated they just dropped the ball. She stated by not having her splinting and stretching continued it could cause a decline and worsening of the residents' contractures. In a follow up interview with OTR D on 01/24/24 at 8:45 a.m. her stated he re-evaluated Resident #5 on 01/23/24 and had placed her on occupational therapy for her hand contractures. He stated he had placed hand rolls in both hands yesterday and she was able to tolerate them for 4 hours. He stated they would be educating the nursing staff on her ongoing needs when he discharged her from therapy. Record review of the Occupation Therapy Evaluation and Plan of treatment dated 01/23/24 reflected, .Clinical Impression: Patient was fitted with bilateral hand rolls and was able to tolerate donning orthosis for 4 hours without signs of redness and discomfort. Bilateral palm protector/palm guard will be ordered, and a restorative nursing program will be implemented with emphasis on proper orthotic fitting and schedule .Skilled OT services are warranted to design and implement Restorative Nursing Program . In an interview with the DON on 01/24/24 at 08:50 a.m. she stated Resident #5 should have been picked up by nursing services for range of motion and splinting when she was discontinued from therapy services in November 2023. She stated therapy just needed to let her know what the ongoing needs were going to be. She stated failing to have interventions in place for residents with limited range of motion could lead to worsening of a resident's contractures and decline in function. Review of the facility's policy titled, Screening, Rehabilitation, dated April 2012, reflected, .Any patient/resident identified by the interdisciplinary team, as requiring a rehabilitation scree will have the screening initiate by a Physical, Occupation Therapist or Assistant, or Speech Language Pathologist withing 48 hours of notification of the request and quarterly A patient /resident is referred for a rehabilitation screen in response to any of the following .Contracture risks or splinting needs .Decline in ROM .A rehab screen is a hands-off' process by which the therapist reviews the medical record, observes the patient/resident, and interviews the patient/resident, caregivers, interdisciplinary team, and/or family to identify the patient's /resident's prior level of function, expectations for return of function and discharge plan .The screening process requires no more than 10 to 15 minutes of the therapist time .The outcome of the screen may be to proceed with a request for a physician's order to evaluate . Review of the facility's policy titled, Quality of Life Rounds Procedures,' dated May 7, 2017, reflected, To identify all therapy/restorative appropriate changes in condition of residents and provide medically necessary services as indicate to ensure the highest practical level of care for each resident .The facility will first ensure that current systems are in place for addressing changes in condition .Any residents identified with decline in ADL . will be referred to Therapy for screening .A team including a MDS, Charge Nurse, CNA, Restorative Aide and Therapy Representative assigned to cover each hall of the nursing facility will be established .The teams will make rounds .complete the quarterly joint mobility screens ( Nursing) and screen resident (Therapy). Changes noted on the mobility screen, declines identified by staff, or triggers noted on Quality Measures will be documented (by charge nurse) and resident will be referred for a therapy eval .Residents identified in the morning meeting to have changes in condition . or other related conditions will be referred to therapy via the Nursing to Therapy communication form .It will be the responsibility of the Restorative Aide9s) to maintain restorative plans and CNASs may perform the maintenance programs The DON or MDS Nurse will be designated as a liaison to the restorative program to insure resident's plans are appropriate . Review of the facility's policy titled, Joint Mobility, Splints, and Range of Motion, dated February 2020, reflected, Standard of Practice: The nursing staff will assist the resident with activities of daily living regarding joint mobility, splinting and range of motion using restorative and rehabilitative care techniques .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for two (Resident #17, Resident #72) of eight Residents reviewed for accidents/hazards/supervision/ devices. The facility failed to properly maintain wheelchairs for Residents #17 and Resident# 72. This failures could affect the resident by placing the residents at risk for discomfort, pain, and injuries. Resident #17 Record review of Resident #17's quarterly MDS assessment dated [DATE] revealed resident was a [AGE] year-old female with an admission date of 03/10/2023. Resident #17 had a BIMS score of 9 indicating moderate cognitive impairment. Resident #17 required 2-person assistance with transfers, and she used a manual wheelchair for mobility. Resident #17 had an active diagnosis of Non-Traumatic Brain Dysfunction (injury to the brain), End-Stage Renal Disease (kidney failure), Muscle weakness, type 2 diabetes mellitus with diabetic nephropathy (Deterioration of kidney function due to high blood sugar). Record review of Resident #17's care plan dated 03/16/2023 revealed Resident #17 had muscular weakness, 03/19/2023 care plan revealed Resident #17 was a fall risk, 12/26/2023 care plan revealed Resident #17 was at risk for skin breakdown. An interview and observation with Resident #17 on 01/23/2024 at 09:56 AM revealed resident was sitting on her wheelchair in her room. Resident complained that the right wheel of her wheelchair was hard to move. Resident stated this was affecting her mobility since it was hard for her to wheel the wheelchair. Resident stated she had reported this issue to a staff member some time back and it was fixed. Resident stated she reported the current problem to a staff (she could not remember the name or title of that staff member) few days ago but nobody came to fix it. It was observed the right arm rest of the wheelchair was touching the right wheel while resident was seated in her wheelchair. Resident #72 Record Review of Resident #72' quarterly MDS assessment dated [DATE] revealed resident was a [AGE] year old male with an admission date of 02/21/2022. Resident #72 had a primary diagnosis of unspecified Dementia, Congestive Heart Failure, diabetes mellitus. Resident has a BIMS score of 9 indicating moderate cognitive impairment. Resident #72 was a one person assist with transfers and bed mobility. Record Review of Resident #72's care plan dated 12/23/23 revealed resident was wheelchair was wheelchair dependent for ambulation. Care Plan dated 12/26/23 revealed resident was a fall risk. An interview and observation of Resident #72 on 12/25/2024 at 02:40 PM revealed Resident #72 was sitting on his wheelchair in his room. Resident #72's stated both arm rests of the wheelchair were torn and exposed. Resident #72 stated the maintenance Director was aware of the issue and he was waiting on parts to arrive to replace the arm rests. Resident #17 stated the maintenance director noticed he issue few weeks ago. The interview with CNA L on 01/24/2024 at 11:27 AM, he stated he was not aware of Resident #17 and Resident #72's wheelchair related problems. CNA L stated every staff member of the facility was expected to report to the charge nurse and enter in the maintenance log located in the nurse's station, when they saw or heard about an issue related to resident's wheelchairs. CNA L stated if a wheelchair was not repaired in a timely manner, it may cause accidents, skin tear to the resident. The interview with CNA M on 01/24/2024 at 11:38 AM, she stated she was not aware of Resident #17 and Resident #72's wheelchair related problems. CNA M stated if she was aware of the problems related to the resident's wheelchair, she would report it to the charge nurse, report it to the maintenance director and in the maintenance log located in the nurses station. The maintenance director checks the maintenance log every day and address any concerns reported to him. CNA M stated a resident can get hurt if a wheelchair was not maintained properly. The interview with ADON E on 01/24/24 11:46, he stated he was not aware the wheelchair issues to Resident #17 and Resident #72. ADON E stated if he learned about a wheelchair issue, he would send a group text via group Me, which could be seen by the maintenance director, DON, Administrator. He would also report it in the maintenance log located in all the nurses' stations. ADON E stated if a wheelchair was not well maintained, it could cause fall risk, affects a resident's free movement and skin tear. The interview with LVN N on 01/24/24 12:21 PM, she stated she was not aware of Resident #17 and Resident #72's issues with their wheelchair. LVN N stated Resident #17 had an issue with her wheelchair around a month ago, her wheelchair arm rest was raised and the issue was resolved. LVN N stated the current wheelchair issues related to Resident #17 and Resident #72 were not reported in the maintenance log. LVN N stated if she knew about the wheelchair issue, she would have reported in the maintenance log, so that the maintenance director would see it when he checked the maintenance log daily. LVN N stated the issues related to resident's wheelchair could cause fall, skin tear, mobility impairment to the residents. The interview with maintenance director on 01/2/2024 at 12:28 PM revealed he was not aware of the current issues with the wheelchairs of Resident #17, he learned about Resident #72's wheelchair arm rest issue few weeks ago when he was doing a routine check and he ordered the parts for it but he could not fix the arm rest since he has not received the parts yet. He stated he had informed the resident the reason for the delay in getting the parts for replacement. Maintenance director stated he checked the maintenance log at the nurses station every day and he did not see any reports about Resident #17's wheelchair issue. He stated a wheelchair which was not maintained could cause fall risk, mobility impairment, skin tear to the resident. Interview with the DON on 01/24/24 at 02:21 PM revealed she was not aware of Resident #17 and Resident #72's wheelchair issues. The DON stated Therapy department and Maintenance department share the responsibility for wheelchairs. The DON stated Maintenance orders parts for the wheelchairs. Therapy department evaluate, repair and order new wheelchairs. The DON stated there was no specific system in place for reporting the issues with wheelchair to therapy. All staff can report to the charge nurse or to therapy if they see or hear a concern about the wheelchair via text message or verbally. The DON stated she was not aware of any maintenance log available at the nurse's station to log wheelchair related issues. The DON stated residents are at risk for fall, skin tear, mobility issues if a wheelchair was not repaired or maintained properly. The interview with the Administrator on 01/25/2024 at 10:55 AM revealed all the staff were responsible to immediately report an issue with a resident's wheelchair in the maintenance log located in the nurses' stations. She stated all the staff had access to the maintenance director's phone number and the staff are expected to report any serious concern regarding a resident's wheelchair to the maintenance director immediately. She stated there were extra wheelchairs available at the facility and if a damage was reported, the resident could get a replacement wheelchair. The Administrator stated the Maintenance director was responsible for repairing and maintaining the wheelchairs. She stated a wheelchair which was not maintained properly could cause fall risk, injury, mobility impairment, skin tear to a resident. Record review of the maintenance log located in nurses' station at the 300 hall and 400 hall revealed Resident #17 and Resident #72's wheelchair related issues were not reported. Record review of the facility's Resident General Equipment Cleaning policy with a review date of 02/20/2023 revealed Resident's general equipment will be cleaned on a routine basis in accordance with manufacturer's specifications and guidelines. Facility will check equipment weekly or as needed, General equipment may include wheelchairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one (Resident #7) of four residents reviewed for behavioral health services. The Social Worker failed to follow up to ensure Resident #7 received a psychiatric service after a referral was made on 11/02/23. This failure could place residents at risk for not receiving behavioral health services and a decline in Quality of life. Findings Included: Record review of Resident #7 quarterly MDS assessment dated [DATE] reflected an [AGE] year-old female with an admission date of 10/31/23. Resident #7 had a BIMS of 9 which indicated she was moderately cognitively impaired. There were no behaviors, signs of delusions or rejection of care noted on the assessment. Resident #7 had active diagnosis which included Alzheimer's, dementia with unspecified severe psychotic disturbance (suggestive of mental or emotion unsoundness or instability) and depression. Record review of Resident #7's care plan with an onset date of 11/27/23 reflected, .History of Dementia with behaviors .History of being hostile towards roommate at other Long term care facility prior to admitting to this facility .History of Alzheimer's with psychotic disturbance .Behavioral aggression, Anger, Verbally abusive, Socially inappropriate, frustration, poor judgement and history of yanking curtains, cursing at others prior to admitting to the facility .Interventions .Frequent visual checks .Maintain behavior log .Referral to psychiatry/psychology services .remove resident from immediate situation to assure safety . Record Review of Resident #7's Consolidated physician orders dated 01/24/24 reflected resident was taking 75 mg of Seroquel ( antipsychotic) 1 tablet twice a day and Amitriptyline (antidepressant) 50 mg 1 tablet at bedtime. Resident #7 was taking both medications upon admission on [DATE]. Record review of Resident #7's Behavior Monitoring log from 11/01/23 through 01/23/24 reflected the facility was monitoring for hallucinations. No hallucinations were reported on day of monitoring. Record review of the Social Workers progress noted dated 11/02/23 reflected, SW made a psych referral to [psychiatric services] due to diagnosis of Anxiety, Alzheimer's, Dementia with psychotic disturbance .delusions and being hostile toward her roommate at the previous facility she was at. SW received consent from residents [family member] to receive psych services SW will continue to follow up as needed . Record review of Resident #7's electronic medical record did not reflect a psychiatric assessment or progress notes. In an observation on 01/23/24 at 9:25 a.m. revealed Resident #7 in her room eating her breakfast. No complaints at that time. In an interview with the Social Worker on 01/24/24 at 1:05 p.m. she stated she had made a referral to the facility's psychiatric services. She stated she assumed Resident #7 was receiving psychiatric services. The social worker presented a fax cover sheet to the psychiatric services dated 11/02/23 and it was confirmed as sent. The Social Worker stated she had not followed up with the psychiatric provided and stated she had never followed up after making a referral. She stated she would reach out to them to see when they saw the resident. In an interview with the DON 01/24/24 at 01:23 p.m. she stated Resident #7 was admitted from another facility and was already on Seroquel. She stated the resident had also received services from psychiatric services at her pervious facility and the same psychiatric provider would also be following her here. She stated the Social Worker was responsible for making the referral when the resident admitted to the facility. In a follow up with the Social Worker on 01/24/24 at 01:40 p.m. she stated she contacted the psychiatric provider, and they stated they never received the referral. She stated she had never followed up after making a referral, she just sent them. She stated she was not sure who was responsible for following up when referrals were made. She stated she never spoke with the psychiatric provider and had no idea which resident's they were seeing when they came to the facility. In an interview with the Administrator 01/24/24 at 02:00 p.m. she revealed it was the Social Workers responsibility to follow up on any ancillary service referred. She stated they would put a system in place where referrals made were checked off when the ancillary service came and provided the services. She stated not following up could cause a delay in care and services to the residents. In an interview with the DON 01/24/24 at 02:05 p.m. she stated the Social Worker was responsible for making the referral to the psychiatric provider and following up to ensure the services had been provided. She stated failing to do this causes a delay in the resident receiving necessary services and a possible mental decline and helps determine if the resident is on the proper medications. In an interview with Resident #7's family member on 01/24/23 at 3:54 p.m. she stated the facility had requested her consent for psychiatric services with Resident #7 admitted to the facility. She stated she consented and stated the resident had been on those services at the previous facility. She stated the resident had been treated for depression for several years. She stated she wanted the Resident to have these services if would help with depression and dementia. Record review of the facility's policy titled, Behavior Management- Social Service Referral, dated February 2020, reflected, Standards of Practice: The staff will make social services referrals as deemed appropriate when the resident's behavioral incident and/or accident pattern increases .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a condition as diagnosed and documented in the clinical record, and the resident received behavioral interventions unless clinically contraindicated in an effort to discontinue these drugs for 1 (Resident #86) of 5 residents reviewed for unnecessary medications. The facility failed to attempt gradual dose reduction for Resident #86's Divalproex (antipsychotic) and Seroquel (antipsychotic) medications. The facility failed to have specific side effect monitoring for Resident #86s Divalproex and Seroquel medications. These failures could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings included: Review of Resident #86's face sheet dated 01/25/24 reflected Resident #86 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, Dysphagia, Cognitive Communication Deficit and Generalized Anxiety Disorder. Review of Resident #86s Significant Change MDS assessment dated [DATE] reflected Resident #86 was readmitted to the facility on [DATE] with diagnoses of Alzheimer's disease, malnutrition, anxiety disorder, depression, bipolar disorder and dementia. Resident #86 had a BIMS of 99 indicating she was severely cognitively impaired. Resident #86 had physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others. Resident #86 received antianxiety, antidepressant and antipsychotic medications. Resident #86 received antipsychotics on a routine basis only and no GDR had been attempted. It reflected GDR had not been documented by a physician as clinically contraindicated. Review of Resident #86's Comprehensive Care Plan last reviewed on 12/13/23 reflected the following: - Resident #86 was on Anticonvulsant related to: mood stabilizer and history of behaviors evidenced by Divalproex medication. Interventions included ask physician to review medication for possible dose reduction every three months and observe for possible side effects. - Resident #86 psychotropic drug use related to history of dementia with behaviors evidenced by Quetiapine medication and dementia with psychosis. Interventions included monitor behavior every shift and document, observe for possible side effects every shift: muscle rigidity, bladder retention, orthostatic hypotension, sedation, dry mouth, balance problem, unsteady gait, restlessness and physician to review medication for possible dose reduction. Review of Resident #86's January physician orders dated 01/25/24 reflected Resident #86 was on the following antipsychotic medications: - Dated 12/19/23 to 01/12/24 Divalproex (Depakote) 250 mg tablet, delayed release - 1 tablet by mouth daily for Bipolar disorder at 7:00 AM. - Dated 01/12/24 Divalproex 125 mg capsule, delayed release sprinkle 1 capsule by mouth every morning for Alzheimer's disease at 7:00 AM. - Dated 11/30/23 to 01/10/24 Divalproex 125 mg capsule, delayed release sprinkle 3 capsules by mouth for persistent mood [affective] disorder at 16:30 - Dated 01/20/24 Divalproex 250 mg capsule, delayed release sprinkle 3 capsules by mouth for persistent mood [affective] disorder at 16:30 - Dated 08/21/23 Quetiapine (Seroquel) 50 mg tablet - 1 tablet by mouth 3 times per day (7:00, 11:00 and 15:00) for Dementia with other behavioral disturbance Review of Resident #86's October 2023 to January 2024 MAR reflected the following: - Dated 08/03/23 to 10/30/23 Resident #86 received Divalproex 125 mg tablet at 7:00 AM - Dated 10/30/23 to 11/03/23 Resident #86 received Divalproex 125 mg capsule - 2 capsules at 7:00 AM - Dated 01/12/24 Resident #86 received Divalproex 125 mg tablet at 7:00 AM - Dated 08/08/23 to 11/03/23 Resident #86 received Divalproex 500 mg capsule - 1 capsule at 5:30 PM - Dated 11/30/23 to 01/10/24 Resident #86 received Divalproex 125 mg capsule - 3 capsules at 4:30 PM - Dated 01/10/24 Resident #86 received Divalproex 250 mg capsule - 3 capsules at 4:30 PM - Dated 10/30/23 to 11/30/23 Resident #86 received Divalproex 125 mg capsule - 4 capsules at 8:00 PM - Dated 08/21/23 Resident #86 received Quetiapine (Seroquel) 50 mg tablet - 1 tablet by mouth 3 times per day at 7:00, 11:00 and 15:00. There was no side effect monitoring for Divalproex and Quetiapine medications. Review of Resident #86's pharmacy recommendation dated 10/19/23 and signed 10/27/23 by physician reflected the combined use of two or more antipsychotic medications has not been demonstrated to be more effective than single agent and has the potential for increased side effects. Please review the duplicate antipsychotic therapy with Quetiapine, Risperidone and Divalproex .Checked All medications are to be continued as they improve the quality of this resident's life. The benefits outweigh the risks. Physician documented arrange with psych consult. Review of December 2023 to January 2024 behavioral monitoring reflected the following behaviors: - There were no behaviors of physical aggression and refusing care documented in December 2023. - Dates on 01/02/24, 01/14/24 an 01/21/24 revealed Resident #86 had physical aggression. - Dates on 12/30/23, 01/11/24, 01/14/24, 01/21/24 revealed Resident #86 had restlessness behaviors. - Dates on 12/01/23, 12/03/23 and 12/04/23, 01/14/24, 01/17/24 and 01/21/24 revealed Resident #86 had wandering behavior. Further review of the behavior monitoring revealed it did not specify specific side effects to the medications to monitor for Quetiapine and Divalproex medications. Review of Nurses notes from November 2023 to January 2024 reflected the following: -Dated 01/05/24 by RN H Resident #86 had a witnessed fall in tv room with no injuries and vital signs stable. -Dated 12/14/23 by LVN Q Resident #86 was seen by psychiatry with new order to increase am Depakote to 250 mg Q AM .[family member] in agreeance, mar reflects changes. -Dated 12/13/23 by LVN S Resident #86 had unwitnessed with head injury, laceration to right front part of scalp .on call notified, ordered for resident to be seen out for evaluation and stitches and UA with culture to be performed upon return .Resident RP notified, Resident sent via 911, stretcher with EMS. -Dated 12/07/23 by LVN T Resident #86 observed falling by one of the CNA's. Resident seen by this nurse onsite. Resident has mild swelling to right side of forehead with small laceration. Area cleaned and covered with bandage. Resident assisted to room d/t restlessness and multiple attempts to get up on her room .DON, NP and son notified of fall. Resident in no distress at this time. Will continue to monitor for any changes. -Dated 11/30/23 by LVN Q Resident #86 seen by NP with new order for Depakote 125 po in the morning and 375 mg at bedtime, Lorazepam 0.5 mg . -Dated 11/21/23 by LVN S Resident #86 fell in the hallway while walking unassisted. Fall was unwitnessed but CNAs responded fast in help resident up. Nurse performed full body assessment, skin intact .no bruising, abrasions or redness noted. When checking range of motion resident showed (signs) of pain when lifting her right shoulder. ADON notified, .on call notified, left a message for family. Order for stat shoulder x-ray or neuro checks in place. -Dated 11/14/23 by LVN S Resident #86 was walking in the hallway unassisted when she seemed to become weak and fell to ground, resident did hit her head. Witnessed by nurse at the nursing station. Resident normally ambulates with no assistance or devices. On call was notified, resident placed on neuro check. ROM checked. Skin intact, no injuries noted. Supervisor and family notified . Review of Resident #86's Psychiatric assessment dated [DATE] reflected Resident #86 had diagnoses of bipolar disorder, anxiety disorder and dementia. Resident #86 is unable to provide information due to cognitive impairment. Pt is poorly engaged in interview due to cognitive impairment and confusion. Pt has minimal interaction with provider. Patient doesn't appear to have depressive however anxiety noted with anxious mood .per staff: behaviors have improved slightly however pt continues to be restless. Observations on 01/23/24 at 9:43 AM, 9:52 AM and 1:12 PM Resident #86 sleeping in her bed. Observation on 01/24/24 at 8:12 AM revealed Resident #86 was sleeping in her room lying down. Observation on 01/24/24 at 9:12 AM revealed Resident #86 was sleeping in her room lying down. Observation and Interview on 01/24/24 at 9:16 AM revealed MA M was in Resident #86's room feeding Resident #86 with head of bed elevated but Resident #86 had to be prompted and woken up by MA M since Resident #86 was sleepy. MA A stated she had just started feeding Resident #86 since she was sleeping so she waited to assist Resident #86 after she was done in dining room with other residents. She stated Resident #86 would grab and eat other residents' food so she feed her in her room. MA M stated sometimes Resident #86 slept in especially if she had trouble sleeping the night before. Interview on 01/25/24 at 10:25 AM with the DON stated Resident #86 had no gradual dose reduction for her antipsychotic medications of Depakote and Seroquel. She stated the Consultant Psychiatrist was at the facility today who was currently seeing Resident #86 for psychiatric services. Interview on 01/25/24 at 11:10 AM with Consultant Psychiatrist revealed she first met with Resident #86 on 11/03/23 doing her initial psychiatric assessment. She stated Resident #86 was extremely agitated, kept saying repetitive responses like fine, fine, fine and blurting out. She stated Resident #86 showed no signs of psychosis or depression. She stated Resident #86 was on psychotropic medications for Bipolar mixed episodes. She stated she made no psychotropic medication changes at this time since it was first time meeting with Resident #86 and would look at gradual dose reduction of her psychotropic medications. She stated nursing staff told her the previous psychiatrist medicated Resident #86 due to behavioral issues of aggression and wandering. She stated on her next visit with Resident #86 on 11/13/23 the nursing staff mentioned to her about increased aggression, agitation and combative toward others so she made medication changes. She stated she changed Resident #86's am Depakote dose from 125 mg to 250 mg and kept the Depakote dosage at bedtime the same. She stated the facility did not communicate to her about pharmacy recommendations of gradual dose reduction. She stated she had not reviewed Resident #86's behavioral monitoring and based her decisions about psychotropic medications on staff interviews about Resident #86's behaviors. She stated her plan was to work on decreasing Depakote doses first and then address the Seroquel medication. She stated she was not sure when the last gradual dose reduction was for Seroquel and Depakote medications for Resident #86. She stated staff had not reported to her about Resident #86 becoming more sleepier in the morning. She stated the risk to residents with dementia being on antipsychotics could place residents at risk for falls. She stated both antipsychotics could make Resident #86 more tired and sleepier. She stated she would review and make changes to Resident #86's psychotropic medications today. Interview on 01/25/24 at 11:58 AM with the ADON revealed Resident #86 had been more sleepier the last 2 days and yesterday he noticed she was sleeping more at breakfast. He stated Resident #86 did get up for breakfast and would grab other resident's food on their plates. He stated he was not certain if there were specific side effects for Resident #86. He stated side effects for Seroquel and Depakote were increased drowsiness/sleeping, change in cognition from normal, change in appetite. He stated the nurses should be documenting behaviors for Resident #86 on the behavioral monitoring documentations and any side effects to medications on a nurse progress note. ADON was not aware of Depakote medication side effect could be increased agitation or aggressive behaviors. He stated he did not review the pharmacy recommendations but the DON reviewed them. Interview on 01/25/24 at 12:25 PM with LVN Q revealed he noticed yesterday Resident #86 had been sleeping more than usual. He stated Resident #86 was more active and increased behaviors usually in the evening and night. He stated he would be concerned for Seroquel side effects if resident had increased drowsiness/sleepiness, change in activity level from usual and decrease in appetite. He stated Resident #86 grabbed other residents' food when she was in dining room with other residents during meal time. LVN Q stated Depakote side effects could be increased drowsiness/sleepiness and increase in aggression/agitation behavior. He stated they monitored resident's behaviors on the behavioral monitoring each shift. Interview on 01/25/24 at 2:37 PM with LVN R revealed Resident #86 had increased behaviors of wandering, grabbing and eating other residents' food, screaming and aggressive towards staff. She stated sometimes redirection helped but other times it did not. She stated the side effects to Seroquel and Depakote were drowsiness, lethargic, eating less than usual. She stated she had not noticed any side effects for Resident #86. Interview on 01/25/24 at 2:32 PM with Pharmacy Consultant revealed he expected the facility to try gradual dose reduction for Seroquel and Depakote medications every 4 months when stable. He stated the risk for residents with dementia on would be falls. He stated the side effects of Seroquel and Depakote would be drowsiness and dizziness. Interview on 01/25/24 at 3:10 PM with DON revealed the charge nurses could review the consents for Seroquel and Depakote if they were not aware of the specific side effects. She stated the facility had not attempted a Seroquel gradual dose reduction for Resident #86 since admit and the note in physician's November note reflected about gradual dose reduction attempt for Depakote not being effective. She stated she referred to the policy on psychotropic drug use and gradual dose reduction. She stated residents with dementia diagnosis with psychotropic medication use placed the resident at risk for increased falls and dehydration. She stated moving forward she would communicate with psych services about gradual dose reduction and psychotropic drug use. She expected the nurse staff to document residents with behaviors on the behavioral monitoring tool. Review of facility's policy Psychotropic Drugs - Use revised 07/27/22 reflected the facility will use psychotropic drug therapy when appropriate to enhance the quality of life, while maximizing functional potential and well-being of the patient/resident. 2. Qualified staff will monitor the patient/resident for potential undesirable side effects that are associated with the use of the psychotropic drugs according to CMS, State specific rules and regulation and Practice Guidelines .For drug therapy: Within the first year in which a resident is admitted on a psychotropic medication or after the facility has initiated a psychotropic medication: GDR attempts in two separate quarters with at least one month between the attempts. The GDR must be attempted annually thereafter unless clinically contradicted. Non-pharmacological approaches must be attempted and documented instead of using psychotropic medications, along with use of psychotropic medications, and while GDR is attempted .Antipsychotic drugs are not used if one or more of the following is/are the ONLY indication: 1. Wandering 2. Poor self-care 3. Restlessness 4. Impaired memory 5. Anxiety 6. Depression 7. Insomnia 8. Unsocialability 9. Indifference to surroundings 10. Fidgeting 11. Nervousness 12. Uncooperativeness, or agitative behaviors which do not represent a danger to the patient/resident or others .Monitor and report side effects to the physician and document in the patient's medical record. 7. Physician and consulting pharmacist will review the progress of the patient/resident and advise the nursing staff of goal, plan to maintain the patient/resident at the lowest possible dose necessary to control symptoms. 8. Monitoring and evaluation of the patient/resident for the potential of antipsychotic medication is an ongoing progress through the Standards of Care Meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure Dietary Aide O had an effective hair restraint during breakfast meal serving on 01/23/24. This failure could place residents at risk for food-borne illness and food contamination. Findings include: Observations on 01/24/24 from 8:37 AM to 9:01 AM during breakfast meal preparation revealed Dietary Aide O did not have a hair restraint covering the front of her hair about 1 inch on forehead and 1/2 inch in front of both ears while she plated food for resident hall trays. Interview on 01/24/24 at 9:08 AM with Dietary Aide O revealed she was unaware her hair restraint was not covering [NAME] her hair in the front. She stated she had been in-serviced on wearing effective hair restraint when in kitchen. Interview on 01/24/24 at 9:11 AM with the Dietary Manager revealed he expected all dietary staff to wear effective hair restraints to cover all hair. He stated not wearing an effective hair restraint can cause food contamination. Review of facility's in-service dated 10/2/23 on dress code reflected Dietary Aide O was in-serviced along with all dietary staff. Record review of the facility's policy titled Employee Sanitary Practices, undated, reflected All employees shall: 1. Wear restraints .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (600 hall nurses' medication cart and 400 hall nurses' medication cart) of 4 medication carts reviewed for pharmacy services in that: The facility failed to ensure: 1- The 600 Hall medication cart had 2 insulin pens for Resident #18 without an opened date. 2- The 400 Hall medication cart had 1 insulin pen for Resident #54 without an opened date. These failures could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. The findings include: 1- Record review of Resident #18's Quarterly MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, elevated blood pressure, and hyperlipidemia (too many lipids and fats in the blood). She had a BIMS score of 09 indicating her cognition was cognitively moderately impaired. Record review of Resident #18's physician's orders dated January 2024 revealed an order for Humulin 70/30 U-100 insulin 100 unit/ml subcutaneous suspension. Inject 52 units subcutaneously every morning. Humulin R Regular U-100 insulin 100 unit/ml injection solution units per sliding scale. Subcutaneous before meals and at bedtime 0-149=0 units, 150-199=2 units, 200-249=4 units, 250-299=6 units, 300-349=8 units Observation on 01/23/2024 at 3:05 PM revealed the 600-hall nurse's medication cart had a pen of Humulin 70/30 U-100 insulin 100 unit/ml, and a pen of Humulin R Regular U-100 insulin 100 unit/ml for Resident #18, did not have an opened date. Interview on 01/23/2024 at 3:08 PM, LVN A stated the 2 pens of insulin belong to Resident #18 did not have an open date. LVN A stated she used both pen in the morning. She stated she forgot to check if there was an open date on the pens. LVN A stated the purpose for putting an open date was for expiration purposes because the insulin was only good for 28 days. 2- Record review of Resident #54's Comprehensive MDS, dated [DATE], revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, elevated blood pressure, and hyperlipidemia (too many lipids and fats in the blood). He had a BIMS score of 10 indicating her cognition was cognitively moderately impaired. Record review of Resident #54's physician's orders dated January 2024 revealed an order for Lantus Solostar U-100 insulin 100 unit/ml (3ml) subcutaneous pen (insulin glargine, human recombinant analog) 45 units subcutaneous at bedtime. Observation on 01/23/2024 at 3:15 PM revealed the 400-hall nurse's medication cart had a pen of Lantus Solostar U-100 insulin 100 unit/ml (3ml), did not have an opened date. Interview on 01/23/2024 at 3:17 PM, LVN B stated the pen of insulin belong to Resident #54 did not have an open date. LVN B stated he did not give the insulin yet because it was due at bedtime. LVN B stated he did not know when the pen was opened and he stated the nurse who opened the pen supposed to put the open date, because the insulin was good only for 28 days after it was opened. LVN B stated the risk would be giving ineffective insulin to resident. Interview on 01/24/24 at 12:20 PM, the DON stated the insulin flex pens, once opened, needed to be dated because each insulin pen had a 30 or 40 days shelf life and if not thrown out before that time the insulin could lose its effectiveness. The DON stated the Assisted DON and the DON were supposed to do random check of the medication carts for monitoring. Record review of the facility's policy titled Storage of Medication, dated September 2018, revealed in part .12. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide food with appetizing temperature for one (01/24/24 breakfast) of one meal reviewed for appetizing temperature. The facility failed to serve eggs and oatmeal that had a palatable texture during the breakfast meal on 01/24/24. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life. Findings included: Review of Resident #7's quarterly MDS assessment dated [DATE] reflected Resident #7 was an [AGE] year old female admitted to the facility on [DATE]. Resident #7 had a BIMS of 9 indicating she was moderately cognitively impaired. Interview on 01/23/24 at 9:25 AM with Resident #7 revealed breakfast was late today and her eggs were cold. She stated hall trays get served last if they chose to eat in their rooms. Review of Resident #10's quarterly MDS dated [DATE] reflected Resident #10 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #10 had a BIMS of 11 indicating he was moderately cognitively impaired. Interview on 01/23/24 at 12:17 PM with Resident #10 revealed his food was cold for his meals and eggs were cold at breakfast for his meals. He stated he ate in his room for meals and ate in his room. Observation on 01/24/24 at 8:10 AM reveal breakfast trays for secure unit were brought to secure unit by Dietary Aide. Observation on 01/24/24 at 8:12 AM revealed Resident #86 was sleeping in her room lying down. Observation on 01/24/24 at 9:12 AM revealed Resident #86 was sleeping in her room lying down. Observation on 01/24/24 at 9:15 AM revealed dining room breakfast trays for secure unit were being put on cart after breakfast in dining room and staff assisted residents out of secure unit after breakfast. Observation and Interview on 01/24/24 at 9:16 AM revealed MA M was in Resident #86's room feeding Resident #86 with head of bed elevated. MA A stated she had just started feeding Resident #86 her eggs and was on vegetarian diet. She had eggs and toast on her breakfast plate. MA A stated Resident #86 was sleeping so she waited to assist her after done in dining room with other residents. She stated Resident #86 would grab and eat other residents' food so she feed her in her room. MA M stated the eggs were barely warm. Observation on 01/24/24 at 9:22 AM revealed facility staff passing out hall breakfast trays to residents on 600 hall and test tray was on cart. Observation at 9:31 AM revealed last hall tray was served to resident room [ROOM NUMBER]. Observation on 01/24/24 at 9:33 AM of breakfast test tray revealed plate had cover and oatmeal was covered with plastic lid. Test tray revealed eggs were cold to touch and tasted cold. Test tray revealed oatmeal was covered with plastic lid with no steam and tasted cold. Follow-up interview with Resident #7 on 01/24/24 at 9:46 AM revealed her breakfast was usually cold. She further stated her eggs this morning were cold and would have liked them warmer. She stated she ate her breakfast in her room for meals. Confidential group interview with six of six residents on 01/24/24 at 10:00 AM revealed breakfast was cold. One of the residents in group stated the eggs were cold this morning. Record Review of Resident Council Minutes for the November 2023, December 2023 and January 2024 did not mention about cold food. Interview on 01/24/24 at 9:42 AM with the Dietary Manager revealed he expected breakfast to be served to residents warm. He stated the eggs and oatmeal should not be cold when served. He stated hall trays were the last to be served for meals. He stated secure unit got their meal trays first, then dining room and last were hall trays for the nonsecure unit halls. The Dietary Manager stated he was aware of Resident #10 complaining of cold breakfast food. Review of facility's policy Hot and Cold Food Temperatures dated 08/01/18 reflected The temperatures of the food items will be managed to conserve maximum nutritive value and flavor .All hot food items must be served to the resident at a palatable temperature.

Based on observations and interviews, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents, for two (500 Court and 600 Court nurse medication carts) of five medication carts observed for medication storage. 1. LVN A failed to ensure medications were secured or attended to by authorized staff when LVN A did not lock the nurse medication cart on 600 Court. 2. LVN A failed to ensure medications were secured or attended to by authorized staff when LVN A did not lock the nurse medication carton 500 Court. This failure could place residents at risk of resident accessed and ingested medications or drug diversion. Findings Included: 1. In an observation on 12/02/22 at 10:23 AM revealed a medication cart on the 600 Court was unattended and not under direct observation of authorized staff. The lock was in the out position and the drawers were able to be opened and left the medications accessible. Various multi-dose bottles of OTC medications to be used for more than one resident were organized in the top drawer of the medication cart. Residents' routine and PRN medication blister packs, residents' inhalers, six insulin pens, five multi-dose insulin vials, two blood glucose meters, syringes, and lancets were organized in other drawers of the medication cart. One resident was ambulating back and forth in the hallway of 600 Court during observation. In an observation and interview on 12/02/2022 at 10:31 AM, LVN A returned to the medication cart. LVN A said she does not normally leave the medication cart unlocked when she walked away. LVN A stated she does not usually work 600 Court, it was her fault, and knew that leaving the medication cart should not happen. LVN A said she received training during new hire orientation. LVN A stated a resident could get medications and have an allergic reaction. 2. In an observation on 12/02/22 at 10:45 AM revealed a medication cart on the 500 Court was unattended and not under direct observation of authorized staff. The lock was in the out position and the drawers were able to be opened and left the medications accessible. Four multi-dose bottles of OTC vitamins and a plastic medicine pill bottle with a label that identified the medication Ondansetron 8 mg and the specific resident for whom it was prescribed were organized in the top drawer of the medication cart. Residents' routine and PRN medication blister packs, gauze dressing with adhesive borders, residents' routine and PRN topical medications, and multi-dose liquid oral medications to be used for more than one resident were organized in other drawers of the medication cart. During an interview on 12/02/22 at 12:31 PM, the DON identified LVN A as the nurse responsible for the medication cart on 500 Court. The DON stated that it was not acceptable to leave medication carts unlocked and unattended or not within direct line of site and arms reach for resident safety and to prevent drug diversion. The DON said if residents could access the medications, swallow a medication that they are allergic to, or have an adverse reaction. The DON said she held a one-to-one verbal session with LVN A about medication storage and drug diversion to prevent reoccurrence. The DON stated surveillance of locked medication carts are conducted regularly for quality assurance. Review of the facility's policy Medication Storage - Storage of Medication, dated 05/16, reflected: - In order to limit access to prescription medication, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications are allowed access to medication carts. medication supplies should remain locked when not in use or 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 ensure residents had a right to personal privacy for 1 of 5 residents (Resident #5) reviewed for personal privacy. CNA A failed to provide privacy for Resident #5 when completing incontinent care and the resident was visible to her roommate, Resident #9. This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to lack of privacy during a care. Findings include: Review of Resident #5's face sheet dated 11/09/22 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia and recurrent depressive disorders. Review of Resident #5's quarterly MDS dated [DATE] reflected she was severely cognitively impaired. Further review reflected she was totally dependent on two staff for toilet use and was always incontinent of bowel and bladder. Review of Resident #5's care plans, dated 11/09/22, reflected she required extensive assistance for toileting and had a severely impaired cognitive status. Interventions included assisting with toileting as needed, checking resident every two hours, monitoring bowel movements daily, providing pericare after each incontinent episode, and using briefs with the resident. In an observation and interview on 11/08/22 at 10:05 AM, Resident #9 was lying in her bed, and was awake and alert. CNA A was at Resident #5's bedside providing incontinent care, but she did not draw the privacy curtain. Resident #5's perineal region was visible. Resident #5 was not able to answer questions and only made unintelligible noises. In an interview on 11/08/22 at 10:15 AM, CNA A said it was her first day at the facility. CNA A said she should have drawn the privacy curtain when providing care to Resident #5 because there was another resident in the room. In an interview on 11/09/22 at 10:05 AM, DON E said privacy should be provided during incontinent care by closing the room door, pulling the curtains, and making sure the blinds were closed. DON E said if privacy was not provided, this could be an issue with residents' rights or dignity. Review of the facility's policy titled Perineal Care, dated 02/12/20, reflected the procedure included providing privacy for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good nutrition for 1 of 9 (Resident #56) residents reviewed for ADLs. The facility failed to ensure Resident #56 meal was set up and within his reach. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for weight loss and a decreased quality of life. Findings include: Review of Resident #56's face sheet dated 11/10/22 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia, UTI, hypernatremia (elevated sodium), and constipation. Resident #56's quarterly MDS dated [DATE] reflected he had a BIMS score of 4 which indicated a severe cognitive impairment. The assessment of his functional status reflected he required limited physical assistance from one person with eating. Review of Resident #56's care plans dated 11/10/22 reflected Resident #56 had a hearing, visual, and speech deficit. He had a self-care deficit and required total assistance. Resident #56 had an altered nutritional status due to being bedridden and dementia. Interventions included assisting him with eating and providing the necessary assistance with food and fluids. Resident #56's nutritional assessment dated [DATE] completed by RD G observed his lunch on 11/01/22. She documented Resident #56 was in bed and appeared to have slight muscle wasting. She also documented Resident #56 had slid down, was leaning to his left side, and was unable to reach his food and fluids. RD G documented once he was repositioned, he was able to finish his meal. RD G documented nursing was to consult PT and/or OT to evaluate for proper positioning during mealtimes. In an observation on 11/10/22 at 8:40 AM, Resident #56 was lying in bed, awake and alert. His breakfast meal tray was in his room, on his bedside table, covered. A fall mat was on the floor between the resident and his bedside table, and his meal was out of his reach. In an observation and interview on 11/10/22 at 9:20 AM, Resident #56's breakfast tray was still out of his reach. He stated he had not eaten breakfast and wanted cereal. HHSC Surveyor intervened and asked the Regional Nurse if she could help Resident #56. The Regional Nurse said she did not want to assume staff had left the meal tray and would not be back to assist Resident #56 with his breakfast. LVN D arrived to Resident #56's room and stated Resident #56 was able to feed himself but required his meal be set up. LVN D and CNA F repositioned Resident #56 higher in his bed, placed his bedside table and breakfast over his bed and opened his drinks. Resident #56 was then able to feed himself. In an interview on 11/10/22 at 9:45 AM, NS H said she helped pass Resident #56's meal tray. NS H said she was not aware which residents required assistance with their meals or the type of assistance they required. NS H said the nurse would tell her what to do. In an interview on 11/10/22 at 2:28 PM, LVN D said Resident #56's breakfast should have been placed at his bedside because he could eat by himself. She said the containers also needed to be opened for him. LVN D said it was her responsibility to tell the nursing students the type of assistance residents required for meals. LVN D said she should have told NS H she needed to set up Resident #56's meal, but she thought she knew. In an interview on 11/10/22 at 3:12 PM, DON E said it was the floor nurses' responsibility to give the nursing students instructions on how to provide care for a resident. DON E said it was her expectation CNAs and the nurses on the hall should be passing out the trays with the nursing students. DON E said if a resident did not get the assistance they needed with meals that could cause weight loss. Review of the facility's policy titled, Assisting Residents with Eating, dated 02/12/20, reflected the policy did not address assisting residents who required meal set up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #56) of 3 residents reviewed for quality of care. The facility failed to ensure Resident #56's heels were offloaded and a dressing was in place to his arterial wound. This failure placed residents with wounds at risk for worsening wounds, infections, bleeding, or pain. Findings included: Review of Resident #56's face sheet dated 11/10/22 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia. Resident #56's quarterly MDS dated [DATE] reflected he had a BIMS score of 4 which indicated a severe cognitive impairment, he required extensive assistance from two staff for bed mobility, dressing, and personal hygiene. The skin section reflected he did not have any pressure wound, ulcers, or skin problems and treatments included a pressure reducing device for his bed and application of dressings to his feet. Review of Resident #56's care plans dated 11/10/22 reflected Resident #56 had osteomyelitis to his heel, a hearing, visual, and speech deficit. He had a self-care deficit and required total assistance. Resident #56 had an altered nutritional status due to being bedridden and dementia. Interventions included IV antibiotics, inspecting his skin daily with care and bathing, offloading his heels, positioning the resident properly, and treatments and dressings as ordered. Review of Resident #56's orders dated 11/10/22 reflected his diagnosis of acute osteomyelitis (infection in the bone) to the right ankle and foot and the following orders: 1. 10/26/22- May have multi-podus boot (device that alleviates pressure to heel and supports leg position) to bilateral feet every shift. 2. 11/09/22- Treatment to left heel arterial wound every morning shift; cleanse with normal saline, pat dry, apply skin prep, and leave open to air. 3. 11/09/22- Treatment to right heel arterial wound every morning shift; cleanse with normal saline, pat dry, apply Santyl, apply calcium alginate with silver, and cover with superabsorbent silicone border and faced dressing. An observation and interview on 11/08/22 at 10:39 AM reflected Resident #56 was lying in bed with his eyes closed. He did not respond to questions. His heels were not offloaded, and he had slid down in bed. His heels were resting on top of the foot board. There was one foot pillow on the resident's bed lying to the left of him, but not applied. An observation and interview on 11/10/22 at 9:09 AM reflected Resident #56 was lying in bed, awake and alert. He had slid down in bed and the bottom of his feet, including his wounds, were pressed up against the foot board. There was not a dressing in place to the wounds to his left or right heels. There was a streak of dry, rust colored substance on his sheet by his right leg which appeared to be dry blood. Resident #56 denied pain and said he was not aware he was supposed to get a treatment to his legs. An observation and interview on 11/10/22 at 9:20 AM reflected Resident #56 had slid down in his bed and his heels were on top of the foot board. LVN D and CNA F entered and repositioned Resident #56 higher in bed and he began to eat his breakfast. LVN D said Resident #56 had a treatment ordered for both his heels and she said she had not been notified Resident #56's dressing to his heel was not in place. His heels were not offloaded when he was repositioned. An observation on 11/10/22 at 09:47 AM, reflected Resident #56 had again slipped down in bed and his right heel was on the foot board, his left foot was crossed over his right foot. There was not a dressing in place. In an observation on 11/10/22 at 10:29 AM, LVN D entered Resident #56's room and completed the treatment to both his heels. A dressing was applied to both heels, his feet were offloaded on a pillow, and a foot pillow was applied to his right foot. LVN D also inserted a foam wedge between Resident #56's mattress and foot board. In an interview on 11/10/22 at 2:28 PM, LVN D said Resident #56's wounds to his heels were getting smaller. LVN D said any staff who observed there was not a dressing to his heels or his heels were not offloaded should notify the nurse. LVN D said interventions for Resident #56's wounds included nutritional supplements, the foam wedge to keep his feet off the foot board, checking on him at least every 2 hours to make sure he was positioned appropriately, and she said he only had one foot pillow for his right foot. LVN D stated if the wound treatment for Resident #56 and offloading his heels were not done, his wounds could get worse. In an interview on 11/10/22 at 3:12 PM DON E said Resident #56 moved a lot in bed and he had a history of falls. She said staff should be making rounds on him every 2 hours to ensure he was positioned appropriately. DON E did not state the risk of Resident #56's heels and wounds not being offloaded. Review of the facility's policy, Treatment of Wounds: Dressing Changes . dated 07/2018, reflected the policy did not include interventions for the prevention of pressure wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that one (Resident #91) of 2 residents reviewed for urinary catheters received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The facility failed to care for Resident #91 indwelling urinary catheter when it was found with a large amount of pale-yellow sediment in the tube and murky amber urine in the urinary drainage bag and the drainage bag was on the floor. This deficient practice could affect residents in the facility with indwelling urinary catheters and place them at risk for infection and not receiving services as needed. Findings included: Review of Resident #91's face sheet dated 11/10/22 reflected he was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia, chronic kidney disease, urine retention, and history of UTI. Review of Resident #91's MDS dated [DATE] reflected he had a BIMS score of 8 which indicated a moderate cognitive impairment. The assessment of his functional status reflected he required extensive 2-person physical assistance with toileting. The bowel and bladder assessment reflected he had an indwelling catheter and was frequently incontinent of bowel. Review of Resident #91's care plans dated 11/10/22 reflected he had a urinary catheter and complications can include an increased risk if UTI, blockage of the catheter . Interventions were to care/change of urinary catheter as ordered . monitor urine appearance, amount, odor, clarity. Review of Resident #91's consolidated orders dated 11/10/22 the following orders: 1. 07/26/22- change foley catheter as needed (clogged, dislodged, or as clinically indicated). CDC recommendation: Change catheters and drainage bags based on clinical indications such as infection, obstruction, and when the closed system is compromised. 2. 08/01/22- Check output every shift. 3. 11/10/22- Check foley catheter and urine every shift for appearance (clear/yellow, amber, cloudy/sediment) Notify physician if any abnormalities. Check patency. Document abnormal findings in nurses' notes and notify physician. 4. 11/10/22- Suprapubic flush as needed every 24 hours with 30mL of sterile water for urinary retention and sediment. 5. 11/10/22- Foley catheter 16 FR every shift to continuous gravity drainage and catheter care. Privacy bag checked and placement of leg strap verified every shift. Review of Resident #91's nurses' note dated 08/01/22 reflected his foley catheter was changed on 08/01/22 because the catheter was coated with white sediment, draining sluggishly, and was not patent. In an interview and observation on 11/08/22 at 10:42 AM Resident #91 was lying in bed. He had an indwelling foley catheter which was hanging off the bed. The drainage bag was covered with a privacy bag, but the drainage tubing was coated with pale yellow sediment. Resident #91 said he had a foley catheter due to a stroke. Resident #91 said his foley catheter was last changed on 06/01/22 and the nurse told him the catheter would be changed when the nurse thought it needed to be changed. In an interview and observation on 11/10/22 at 8:40 AM Resident #91 was lying in bed. His foley catheter drainage bag did not have a privacy bag and was on the floor. The drainage tubing was coated with pale yellow sediment and there was a large clot of sediment in the tubing. The urine in the drainage bag was dark amber and contained a large amount of pale-yellow sediment. ADON B entered the room. She stated the foley drainage bag should not be on the floor. ADON B stated Resident #91's foley catheter tubing and drainage bag had sediment and stated she would call the physician. ADON B said CNAs were responsible for emptying the catheter drainage bags every shift and as needed. In an interview on 11/10/22 at 9:15 AM, ADON B said she received an order from the physician to flush Resident #91's foley catheter and obtain urine to test for a UTI. In an interview on 11/10/22 at 9:40 AM, DON C said she was at the facility helping out and said Resident #91's foley catheter would be flushed as ordered by the physician. DON C said per the CDC, foley catheters were only changed as needed, not routinely. DON C said a foley catheter would be changed if the resident displayed signs of infection, such as sediment in their urine. DON C then said Resident #91's foley catheter would be replaced and then flushed. In an interview on 11/10/22 at 2:28 PM, LVN D said she was assigned to Resident #91 on 11/07/22, 11/08/22, 11/09/22, and 11/10/22 on the 6AM to 2PM shift. LVN D said she observed residents' foley catheters every day in the morning, at the end of her shift, and as needed. LVN D said she had not noted Resident #91 had sediment in his foley catheter tube. LVN D said CNAs emptied the catheter drainage bags, gave her the amount, and were supposed to tell her if there was a change in the urine color or clarity. LVN D said sediment could be an indication of a resident not getting enough fluids or an infection. LVN D said indwelling catheters were not changed unless there's a problem, like if he's had a change in condition like the sediment today. Review of the facility's policy titled, Care and Removal of an Indwelling Catheter, dated revised 01/12/20 reflected the policy did not address routine care, monitoring, and placement of foley catheters and drainage system nor indications of when a foley catheter should be replaced. Review of the CDC's recommendations for urinary catheters accessed at https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html on 11/16/22 reflected: .Do not rest the bag on the floor . Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised .

**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 fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 (Resident #8) of 2 residents reviewed for enteral nutrition. The facility failed to ensure Resident #8's feeding bag was labeled. This failure could result in complications of enteral feedings such as receiving the wrong feeding or outdated feeding. Findings included: Review of Resident #8's face sheet dated 11/10/22 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia and difficulty swallowing following a stroke. Review of Resident #8's MDS dated [DATE] reflected she had a severe cognitive impairment, was totally dependent on staff for eating, she had a feeding tube, and she received 51% or more of nutrition and fluids through her tube feeding. Review of Resident #8's care plans, dated 11/09/22, reflected she had altered nutrition due to enteral feeding. Interventions included keeping the head of bed elevated, monitoring tolerance of tube feeding, providing water flush as ordered, providing water flushes at medication pass per nursing policy, and providing tube feedings as prescribed. Review of Resident #8's orders dated 11/09/22 reflected an order for Isosource (type of enteral formula) at 55mL per hour over 22 hours. In an observation and interview on 11/08/22 at 10:15 AM, Resident #8 was lying in bed. She could not answer questions. Resident #8 had an enteral feeding pump at her bedside which was running into her g-tube. The feeding pump had 2 bags hanging; one had a clear liquid, and the second had a tan colored liquid. Neither bag had labels with contents, date it was hung, or the resident's name. In an observation and interview on 11/09/22 at 7:22 AM, LVN D and ADON B were in Resident #8's room to administer her medication. Resident #8 had an enteral feeding pump at her bedside which was running into her g-tube. The feeding pump had 2 bags hanging; one had a clear liquid, and the second had a tan colored liquid. Neither bag had labels with contents, date it was hung, or the resident's name. LVN D said she had not noted Resident #8's feeding bag was not labeled. LVN D said the feeding bag should be labeled with the formula, date it was hung, the rates, and the resident's name. In an interview on 11/09/22 at 10:05 AM, DON E said enteral feeding bags should have a label which included the date, initials of nurse who hung it, and the time. DON E said Resident #8's feeding did not run for a long period so she did not believe there would be an issue with the feeding hanging longer that indicated if it was not labeled. Review of the facility's policy titled Enteral Nutrition . dated 01/12/20, reflected the procedure included labeling the formula container with the resident's name, room, date, starting time, rate, and the initials of the person setting it up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #8) of 6 residents reviewed for pharmaceutical services. The facility failed to ensure LVN D flushed Resident #8's g-tube between medications as ordered. This failure could lead to medication interactions for residents who receive their medications enterally. Findings included: Review of Resident #8's face sheet dated 11/10/22 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia and difficulty swallowing following a stroke. Review of Resident #8's MDS dated [DATE] reflected she had a severe cognitive impairment, was totally dependent on staff for eating, she had a feeding tube, and she received 51% or more of nutrition and fluids through her tube feeding. Review of Resident #8's care plans, dated 11/09/22, reflected she had altered nutrition due to enteral feeding. Interventions included keeping the head of bed elevated, monitoring tolerance of tube feeding, providing water flush as ordered, providing water flushes at medication pass per nursing policy, and providing tube feedings as prescribed. Review of Resident #8's orders dated 11/09/22 reflected an order entered on 09/05/21 to flush her g-tube with 30mL of water before and after medications and with 15mL of water between each medication administered. In an observation and interview on 11/09/22 at 7:22 AM, LVN D administered Resident #8's medications via her g-tube. LVN D flushed Resident #8's g-tube with 30mL of water before medications and after all medications. LVN D did not flush Resident #8's g-tube between each medication. LVN D said she did not flush Resident #8's g-tube between each medication because Resident #8 did not have an order to flush between each medication. In a follow-up interview on 11/09/22 at 9:42 AM, LVN D said she misread Resident #8's flush orders and thought it was to only to flush before and after, but not in between each medication. LVN D said water flushes in between medications were to ensure the medication was cleared through the tube and there were not any medication interactions. In an interview on 11/09/22 at 10:05 AM, DON E said she expected nurses to review physician's orders prior to medication administration. DON E said the purpose of flushing the g-tube between each medication was to make sure it the medication went all the way through the g-tube. Review of the facility's policy titled Medication Administration Enteral Tubes, dated 09/18, reflected, .Enteral tubes are flushed with at least 15mL of water before administering any medications and after all medications have been administered. Each medication is administered separately to avoid interaction and clumping. The enteral tubing is flushed with water between each medication to avoid physical interaction of the medications .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the dry storage, refrigerator, and freezer were labeled, dated, and sealed properly. These failures could affect residents by placing them at risk for food-borne illness. Findings included: Observation of dry storage goods area on 11/08/22 at 9:45 am revealed what appeared to be flour in a large plastic container with the lid pushed back half-way exposing the food substance, and 4 packs of hamburger buns not dated/labeled. Observation of the walk-in refrigerator on 11/08/22 at 9:55 am revealed what appeared to be the following items: * green peas in a large plastic bin with lid that was not sealed/dated, *Baked beans in large container not labeled/dated, * A plastic bag of pound cake that had been opened with no dates, * A large baggie of chicken with a use by date 11/05/22 (expired) * A large baggie of ham sandwich meat unsealed/opened/exposed to the air and not dated/labeled, * A large baggie of yellow shredded cheese not labeled/dated, * A large baggie of yellow cheese slices not labeled/dated, and * A large baggie of shredded white cheese not labeled/dated. Observation of the walk-in freezer on 11/08/22 at 10:10 am revealed the following items: * A bag of carrots opened/unsealed/and not labeled, *A large baggie of an unknown frozen food item with a use by date of 8/16/2022, and *A large baggie of an unknown frozen food item with a used by date of 11/05/2022. Observation on 11/09/22 at 10:15 am revealed in the dry storage 3 large bags of ketchup not dated/labeled. Observation on 11/09/22 at 10:20 am in the stand-alone refrigerator there were approximately 35 small individual containers stored in a large metal container with shredded cheese, butter, mustard, and other unidentified condiments not labeled/dated. Interview with the Dietary Manager and Regional Dietitian on 11/09/22 at 2:00 pm revealed they are aware all food items must be sealed, labeled, and dated appropriately. The Dietary Manager stated he was responsible for making sure all tasks are completed in the kitchen by his staff including all food items in the dry storage, refrigerator, and freezer being sealed, labeled, and dated appropriately. He also stated if all food items are not sealed, labeled, dated, and expired items not thrown out, it could put residents at risk for food-borne illness. Review of the facility's policy titled Food Storage, dated August 1, 2018 reflected .Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination .Procedure: 1. Storeroom: Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened .canned and dry foods without expiration dates are used within six months of delivery .2. Refrigerator: All foods are covered, labeled, and dated .3. Freezer: Foods are covered, labeled, and dated .Any item out of the original case must be properly secured and labeled.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control policy and procedure designated to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 ( CNA A and CNA F) of 8 staff observed for infection control. The facility failed to ensure CNA A and CNA F doffed their dirty gloves after incontinent care. These failures placed residents at risk for spread of infection through cross-contamination. Findings included: In an observation on 11/08/22 at 10:05 AM, CNA A was at Resident #5's bedside providing incontinent care. CNA A did not doff her dirty gloves after cleaning the buttocks or before applying the clean brief. CNA A then took the dirty brief to the restroom and disposed of it in the trash can. CNA A, still wearing the dirty gloves, touched Resident #5's sheets and pulled them over her, touched the bed control and adjusted the head of the bed, and touched Resident #9's bedside table, moving it closer to Resident #9. In an interview on 11/08/22 at 10:15 AM, CNA A said it was her first day at the facility. CNA A said she should have doffed her dirty gloved after she disposed of the dirty brief because she could infect the clean stuff with the dirty gloves. In an observation on 11/10/22 at 10:31 AM, CNA F provided incontinent care for Resident #56. After incontinent care, using the same gloves she had used to clean the resident's genitals, CNA F placed the clean brief on Resident #56. CNA F then placed a pillow under Resident #56's feet, pulled the blanket over him, and touched the bed controller to lower the bed. CNA F then left the room with the trash and wearing one dirty glove to hold the trash. In an interview on 11/10/22 at 11:22 AM, CNA F said she was an agency aide, and it was her first shift at the facility. CNA F said she should have doffed her dirty gloves after incontinent care and before touching clean items because she could spread germs and cause contamination. In an interview on 11/09/22 at 10:05 AM, DON E said hand hygiene should be done prior to incontinent care, if hands get soiled, and after they are finished. DON E said dirty gloves should not be used to touch clean items for infection control and said they did not want to spread germs. Review of the facility's policy titled Hand Hygiene for Staff and Residents, dated 07/2018, reflected hand hygiene should be done after contact with soiled or contaminated articles (such as articles that were contaminated with body fluids), resident contact, and removal of medical gloves. The policy did not indicate when staff should remove gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, and serve water in accordance with professional standards for a sanitary environment and water safety for two (600 hall hydration ice chest and nourishment room ice machine) of two locations reviewed for sanitary conditions. 1. The facility failed to ensure the hydration ice chest located on the 600 Hall was clean and free of mold, mildew, grime, spilled juices, and coffee or tea that were served to resident for hydration and consumption. and use of proper ice scoops utensils for ice. 2. The facility failed to ensure the ice machine, in the facility nourishment room was cleaned and free of limescale and lime (chalky white spots) on the inside of the ice machine rims, ice scoop was secure and properly covered to prevent exposure to air borne bacteria, and the ice scoop on the wall was placed in a holder with sitting water. This failure had the potential to place residents at risk for infections, illnesses, and bacteria due to unsanitary conditions. Findings include: An observation on 11/9/2022 at 8:46 a.m. of the ice chest located on the 600-hall revealed brown, red, and black substances on the top, inside, and outside of the ice chest. There were two disposable clear cups located in a zip bag connected to the ice chest that were undated and used to scoop ice for resident cups. The bottom of the ice chest had black or grayish growth occurring around it above the basin catching the water. A white blanket under the ice chest was soiled with brownish debris. The third tier of the cart was found to have brown spots and dirt. In an interview on 11/9/2022 at 8:47 a.m. with LVN- O, it was revealed that CNAs were responsible for cleaning and refreshing the ice chest with fresh ice as needed. He said that the ice machine was in the room where food was served, near the nursing stations for the 500 and 600 halls. An observation on 11/9/2022, at 8:55 a.m. of an ice machine located in the nourishment room located on the 600 hall revealed a dried, white powdery, chalky substance caked around the inside of the ice bin. A large ice scoop lying on top of an ice machine, uncovered, and an ice scoop located to the right of the machine inside a scoop holder sitting in water. In an interview with the administrator, on 11/9/2022 at 9:30 a.m. it was revealed that she expected the staff working in the hall to clean the ice chest as needed. She stated that she would have them clean the ice chest and refill it with ice while she reviewed facility policy on hydration carts and cleaned the ice machine. The administrator stated that residents could become ill from receiving ice from the dispenser's that were not clean and sanitized In an interview on 11/9/2022, at 2:45 p.m., HK A revealed that he was responsible for cleaning the outside of the ice machine located in the nourishment room. He does not know who was responsible for cleaning the inside. In an interview on 11/10/2022, at 8:20 a.m. with Housekeeping Supervisors (HKS), it was revealed that housekeeping staff are not responsible for cleaning the ice chest located on the 600 hall. She stated that housekeeping staff are responsible for cleaning the outside of the ice machine daily. She said that it was the job of the maintenance department to clean the inside of the ice machine. In an interview on 11/10/2022, at 8:30 a.m. the Maintenance Director (MD) stated that he was responsible for cleaning the inside of the ice machine once a month, per the manufacturer's manual. MD stated that he cleaned the caked white chalk substance located in the ice machine today after being notified by the administrator. He claimed to have cleaned and disinfected the ice machine with an Auto Chlor disinfectant solution. MD stated that it was critical to keep the ice scoop covered to avoid exposure to the environment and the growth of bacteria, which could put residents at risk of illnesses and infections. The maintenance director stated he had not noticed anything wrong with the ice machine until it was brought to his attention. In an interview on 11/10/2022 at 10:10 am, CNA -F revealed that she did not observe blackish buildup on the ice chest while on shift. She stated that she has refilled the ice chest with fresh ice when needed. She stated that she did not refill the ice chest on 11/09/2022 and 11/10/2022. She said that when she changes the ice, she cleaned with bleach wipes inside and out, then refills with ice. She denied observing water sitting in the bottom of the scoop holder that held the scoop she uses for ice refills. In an interview with ADON on 11/10/2022 at 12:15 p.m., she revealed she expects the CNAs to clean the ice cart and chest when they are visibly soiled, as the CNAs are the staff that refresh the ice chest with ice when needed. She stated that residents receiving ice from the machine could be at risk of infection and illness if it is not cleaned and sanitized. ADON stated that she had not observed the ice chest until it was brought to her attention by DON and the administrator. In an interview with the DON on 11/1020/22 at 12:20 p.m., she revealed that she expects CNAs to clean the ice chest when it is visibly soiled. She stated that she does not inspect the ice chests in each hall used for hydration at the facility. She stated that she did not observe the blackish-gray substance on the bottom of the ice machine or spilled residue on top until she was notified by the administrator. She stated that she took the ice chest to the kitchen for sanitation. She stated that staff have been trained on the proper sanitation of the ice chest and the protocol of taking the ice chest to the kitchen for sanitation when it is visibly soiled. In a second interview with the Administrator on 11/10/2022 at 12:30 p.m., revealed the health care staff were in charge of cleaning the ice chest. She stated when the ice chest was visibly soiled with stains and spots, it should be taken to the kitchen for sanitation before being refilled and returned to the hall for resident service of ice. She stated that the ice chest has been replaced with a new one, and scoops have been ordered. Review of the facility's Manufactures [NAME] and work log report dated 11/09/22 revealed a list of days that the machine was last cleaned by the MD by disinfecting the machine inside, clean filter and coils once every 30 days. In an interview with MD revealed that the facility doesn't have a policy for how often the machine should be cleaned