Based on interviews, and record reviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff, consistent with their expected roles. The facility failed to ensure Abuse, Neglect and Exploitation Training, Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures, and Dementia Training were completed upon hire for 2 of 5 employees (Marketing/Admissions Coordinator and CNA A) reviewed for required trainings. Based on interviews, and record reviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff, consistent with their expected roles. The facility failed to ensure Abuse, Neglect and Exploitation Training, Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures, and Dementia Training were completed upon hire for 2 of 5 employees reviewed for required trainings. The facility failed to ensure the Marketing/Admissions Coordinator and CNA A received required training in Abuse, Neglect and Exploitation, Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures and Dementia upon hire and prior to providing care for or working with residents. This failure could cause a lack of understanding and skill needed to provide adequate care of residents with varying conditions and levels of care.Findings included:Record review of the Marketing/ admission Coordinator's employee file on 07/15/2025 at 1:50PM reflected she had not been trained in Resident Abuse, Neglect and Exploitation, Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures or Dementia prior to or on her first day of employment, which was 06/17/2025.Record review of CNA A's employee file on 07/15/2025 at 2:09PM reflected she had not been trained in Resident Abuse, Neglect and Exploitation, Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures or Dementia prior to or on her first day of employment, which was 06/04/2025.An interview on 07/15/2025 at 4:00PM revealed the BOM/HR was aware employees completed their required trainings on a computer, but she did not know much about the trainings themselves. She stated she assigned the trainings to employees upon hire, but I needed to speak with the DON to see when the trainings took place and what they were about.An interview on 07/15/2025 at 4:20PM revealed the DON was not aware required training had not been provided to the Marketing/Admissions Coordinator and CNA A prior to them working with residents. The DON stated the BOM/HR assigned all of the required trainings to employees through a computer-based learning system. She stated the negative outcome of not being trained would be staff members might not have all of the skills and understanding needed in order to work with and care for residents, especially those with Dementia, Alzheimer's Disease or behavioral issues.An interview with the Administrator on 07/15/2025 at 4:42PM revealed it was his second day on the job, and he had a lot of cleanup work to do. He stated he would ensure the BOM was assigning all trainings before employees started their first day of resident care.The facility provided no policy on required trainings at hire.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to refer all residents with newly evident or possible serious mental disorder for level II resident review for 2 (Resident #5 and Resident #11) of 12 residents reviewed for PASRR. 1. The facility failed to refer Resident #5 for PASRR level II review following a diagnosis of bipolar disorder one day after he was admitted to the facility. 2. The facility failed to refer Resident #11 for PASRR level II review following a diagnosis of psychotic disorder almost 6 years after he was admitted to the facility. These failures could place residents at risk of not having their mental health needs met by the facility and could place all residents at risk of harm by mentally unstable residents. Findings Included: 1. Record review of Resident #5's admission record dated 07/28/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings) current episode mixed, bipolar disorder current episode depressed severe without psychotic features, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #5's diagnosis report dated 07/28/24 revealed the diagnoses of bipolar disorder current episode mixed, and major depressive disorder had an onset date of 07/19/23. Resident #5's diagnosis of bipolar disorder current episode depressed severe without psychotic features had an onset date of 07/20/23. Record review of Resident #5's annual MDS completed on 06/20/24 Section C revealed a BIMS score of 15 which indicated intact cognition. Section E indicated Resident #5 rejected evaluation or care 1-3 days of the look back period. Section I indicated Resident #5 had diagnoses of depression and bipolar disorder. Section N indicated Resident #5 was taking antidepressant and antipsychotic medications. Record review of Resident #5's care plan completed on 05/13/24 revealed Resident #5 had a psychosocial well-being problem r/t bipolar disorder. He was receiving trazadone, Seroquel, and lithium to treat bipolar disorder. Resident #5 was noted to have a mood problem r/t DEPRESSION. He was noted to have verbal behaviors in that, [Resident #5] exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner. Behaviors are related to: Mental/Emotional illness. The care plan contained the following focus area initiated on 07/19/23 [Resident #5] uses psychotropic medications . related to depression, bipolar disorder. Record review of Resident #5's order report date 07/28/24 revealed the following orders: Order start date 07/19/23 Lithium (antipsychotic medication) Carbonate Oral Tablet 300 MG (Lithium Carbonate) Give 300 mg by mouth three times a day related to BIPOLAR DISORDER CURRENT EPISODE MIXED . Order start date 08/09/23 SEROquel (atypical antipsychotic medication) Oral Tablet (Quetiapine Fumarate) Give 300 mg by mouth in the evening related to BIPOLAR DISORDER, CURRENT EPISODE MIXED . Order start date 01/11/24 trazodone (antidepressant medication) HCI Oral Tablet 50 MG (Trazodone HCI) Give 1 tablet by mouth at bedtime related to BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, SEVERE . Record review of Resident #5's PASRR Level 1 Screening revealed it was completed on 07/19/23 by an acute care facility employee. Resident #5 was noted to have no evidence or indicator of a mental illness. 2. Record review of Resident #11's admission record dated 07/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, diffuse traumatic brain injury (a severe type of traumatic brain injury that occurs when the brain rapidly shifts inside the skull) with loss of consciousness of unspecified duration, injured in unspecified motor-vehicle accident, restlessness and agitation, anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), irritability and anger, and psychotic disorder with hallucinations (severe mental illness including seeing things that are not there). Record review of Resident #11's diagnosis report dated 07/29/24 revealed the onset date for the diagnosis of psychotic disorder with hallucinations was 10/13/23. Record review of Resident #11's quarterly MDS completed on 05/01/24 section C revealed no BIMS score as Resident #11 was rarely to never understood. The staff assessment for mental status revealed Resident #11 had severely impaired cognition. Section E revealed no behaviors. Section I revealed active diagnoses of depression, anxiety disorder, and psychotic disorder. Section N revealed Resident #11 received antipsychotic, antianxiety, and antidepressant medications. Record review of Resident #11's care plan completed on 07/04/24 revealed Resident #11 had a behavior of sliding out of his w/c in the dining room and raising his voice for attention. Interventions listed included resident having no injuries due to behaviors and psychiatrist following behaviors. Resident #11 had sexually inappropriate behaviors r/t grabbing staff as well as physical behaviors r/t anger and poor impulse control. The care plan indicated he had psychosocial well-being and mood problems r/t anxiety and depression. Record review of Resident #11's order summary report dated 07/28/24 revealed the following orders: Order start date 10/13/23 busPIRone (antianxiety medication) HCI Tablet (Buspirone HCI) Give 10 mg by mouth three times a day related to ANXIETY DISORDER . Order start date 01/25/22 Depo-Provera Suspension (birth control used in males to control inappropriate or unwanted sexual behavior in males by lowering testosterone, reducing sex drive, discouraging sexual fantasies, and eradicating sexual obsessions) (medroxyPROGESTERone Acetate) Inject 150 mg intramuscularly one time a day every 14 day(s) related to PERSONALITY CHANGE DUE TO KNOWN PHYSIOLOGICAL CONDITION . Order start date 09/14/22 Paxil (antidepressant medication) Tablet 30 MG (PARoxetine HCl) Give 1 tablet by mouth one time a day for depression. Order start date 03/01/22 Vortioxetine (antidepressant medication) HBr Tablet 20 MG Give 20 mg by mouth in the evening related to PERSONALITY CHANGE DUE TO KNOWN PHYSIOLOGICAL CONDITION . Record review of Resident #11's PASRR Level 1 Screening revealed it was completed on 12/01/17 by a social worker from an acute care facility. Resident #11 was noted to have no evidence or indicator of a mental illness. During an interview on 07/28/24 at 09:46 AM ADM and ADON stated MDS LVN was a remote employee, in that she did not visit the facility or live in the region. During an interview on 07/29/24 at 11:08 AM ADON stated she was responsible for completing PASRRs. During an interview on 07/29/24 at 11:20 AM ADON stated the facility thought MDS LVN was completing PASRRs but when they found out she was not, ADON took back the responsibility for PASRRs. She stated she has been responsible for PASRRs off and on for the past year. ADON stated PASRRs were to be done immediately. She stated she did not know Resident #5 had a mental illness. ADON stated, He came (to the facility) from home. We didn't know about that (bipolar disorder) until later. She stated she could not think of a negative outcome of not referring a resident for a PASRR level II when a new diagnosis of mental illness was made. During an interview on 07/30/24 at 09:45 AM LVN A stated if a resident had a new diagnosis of mental illness and was not referred for a PASRR level II the facility might not have proper care for the mental health of the resident. During an interview on 07/30/24 at 09:47 AM ADM stated not having a resident referred for a PASRR level II following a new diagnosis of mental illness could cause harm to the resident. Record review of facility policy titled admission Criteria and dated 2019 revealed the following: . Our facility admits only residents whose medical and nursing care needs can be met. 1. The objectives of our admission criteria policy are to: . b. admit residents who can be cared for adequately by the facility; . e. assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission. 5. Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident, including orders covering at least: . b. medication orders, including (as necessary) a medical condition or problem associated with each medication; . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to perform preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 3 (Resident #21, Resident #22, and Resident #31) of 12 residents reviewed for preadmission screenings. The facility failed to perform a PASRR for Resident #31 until 27 days after he was admitted . This failure could place residents at risk of receiving inadequate care. Findings Included: Record review of Resident #31's admission record dated 07/28/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities) recurrent, and hemiplegia (partial paralysis) affecting right dominant side. Record review of Resident #31's diagnosis report dated 07/29/24 revealed his diagnosis of major depressive disorder had an onset date of 08/09/23. Record review of Resident #31's quarterly MDS completed 02/18/24 section C revealed no BIMS score as Resident #31 was rarely to never understood. The staff assessment for mental status revealed Resident #31 had severely impaired cognition. Section E revealed Resident #31 had verbal behavioral symptoms directed toward others as well as behavior of rejecting care which occurred 1-3 days of the 7-day look back period. Section I revealed Resident #31 had a diagnosis of depression. Section N revealed Resident #31 was not receiving any antidepressant medication. Record review of Resident #31's care plan completed on 06/06/24 revealed Resident #31 had a diagnosis of Major Depression and was receiving two antidepressant/psychotropic medications. Record review of Resident #31's order summary report revealed the following orders: Order start date of 08/09/23 traZODone HCI Oral Tablet 50 MG (Trazodone HCI) Give 50 mg by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT . Order start date of 04/23/24 Zoloft Oral Tablet 50 MG (Sertraline HCI) Give 1 tablet by mouth one time a day for depression. Record review of Resident #31's PASRR Level 1 Screening revealed it was completed by ADON on 09/05/23. During an interview on 07/28/24 at 09:46 AM ADM and ADON stated MDS LVN was a remote employee, in that she did not visit the facility or live in the region. During an interview on 07/29/24 at 11:08 AM ADON stated she was responsible for ensuring PASRRs on new admits were completed. During an interview on 07/29/24 at 11:20 AM ADON stated the facility thought MDS LVN was completing PASRRs but when they found out she was not, ADON took back the responsibility for PASRRs. She stated she has been responsible for PASRRs off and on for the past year. ADON stated PASRRs were to be done immediately. She stated she could not think of a possible negative outcome of Resident #31 being admitted prior to PASRR completion. During an interview on 07/30/24 at 09:45 AM LVN A stated if a PASRR was not completed prior to or at admission the resident might not receive proper care for mental health. During an interview on 07/30/24 at 09:47 AM ADM stated not having a PASRR completed prior to or at admission could cause harm to the resident. Record review of facility policy titled admission Criteria and dated 2019 revealed the following: . Our facility admits only residents whose medical and nursing care needs can be met. 1. The objectives of our admission criteria policy are to: . b. admit residents who can be cared for adequately by the facility . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level 1 PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. Based on record review and interview the facility failed to perform preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 1 (Resident #31) of 12 residents reviewed for preadmission screenings. The facility failed to perform a PASRR for Resident #31 until 27 days after he was admitted . This failure could place residents at risk of receiving inadequate care. Findings Included: Record review of Resident #31's admission record dated 07/28/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities) recurrent, and hemiplegia (partial paralysis) affecting right dominant side. Record review of Resident #31's diagnosis report dated 07/29/24 revealed his diagnosis of major depressive disorder had an onset date of 08/09/23. Record review of Resident #31's quarterly MDS completed 02/18/24 section C revealed no BIMS score as Resident #31 was rarely to never understood. The staff assessment for mental status revealed Resident #31 had severely impaired cognition. Section E revealed Resident #31 had verbal behavioral symptoms directed toward others as well as behavior of rejecting care which occurred 1-3 days of the 7-day look back period. Section I revealed Resident #31 had a diagnosis of depression. Record review of Resident #31's care plan completed on 06/06/24 revealed Resident #31 had a diagnosis of Major Depression and was receiving two antidepressant/psychotropic medications. Record review of Resident #31's PASRR Level 1 Screening revealed it was completed by ADON on 09/05/23. During an interview on 07/29/24 at 11:08 AM ADON stated she was responsible for ensuring PASRRs on new admits were completed. During an interview on 07/29/24 at 11:20 AM ADON stated the facility thought MDS LVN was completing PASRRs but when they found out she was not, ADON took back the responsibility for PASRRs. She stated she has been responsible for PASRRs off and on for the past year. ADON stated PASRRs were to be done immediately. She stated she could not think of a possible negative outcome of Resident #31 being admitted prior to PASRR completion. During an interview on 07/30/24 at 09:45 AM LVN A stated if a PASRR was not completed prior to or at admission the resident might not receive proper care for mental health. During an interview on 07/30/24 at 09:47 AM ADM stated not having a PASRR completed prior to or at admission could cause harm to the resident. Record review of facility policy titled admission Criteria and dated 2019 revealed the following: . Our facility admits only residents whose medical and nursing care needs can be met. 1. The objectives of our admission criteria policy are to: . b. admit residents who can be cared for adequately by the facility . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level 1 PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #5) of 12 residents who were reviewed for accuracy of medical records. The facility failed to recognize Resident #5's PASRR level 1 was incorrect in that he was positive for mental illness due to his diagnosis of bipolar disorder. This failure could place residents at risk of harm by mentally unstable residents and/or at risk of not having their mental health needs met. Findings Included: Record review of Resident #5's admission record dated 07/28/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings) current episode mixed, bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings) current episode depressed severe without psychotic features, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #5's diagnosis report dated 07/28/24 revealed the diagnoses of bipolar disorder current episode mixed, and major depressive disorder had an onset date of 07/19/23. Resident #5's diagnosis of bipolar disorder current episode depressed severe without psychotic features had an onset date of 07/20/23. Record review of Resident #5's annual MDS completed on 06/20/24 Section C revealed a BIMS of 15 score which indicated intact cognition. Section E indicated Resident #5 rejected evaluation or care 1-3 days of the look back period. Section I indicated Resident #5 had diagnoses of depression and bipolar disorder. Section N indicated Resident #5 was taking antidepressant and antipsychotic medications. Record review of Resident #5's care plan completed on 05/13/24 revealed Resident #5 had a psychosocial well-being problem r/t bipolar disorder. He was receiving trazadone, Seroquel, and lithium to treat bipolar disorder. Resident #5 was noted to have a mood problem r/t DEPRESSION. He was noted to have verbal behaviors in that, [Resident #5] exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner. Behaviors are related to: Mental/Emotional illness. The care plan contained the following focus area initiated on 07/19/23 [Resident #5] uses psychotropic medications . related to depression, bipolar disorder. Record review of Resident #5's order report date 07/28/24 revealed the following order: Order start date 07/19/23 Lithium (antipsychotic medication) Carbonate Oral Tablet 300 MG (Lithium Carbonate) Give 300 mg by mouth three times a day related to BIPOLAR DISORDER CURRENT EPISODE MIXED . Record review of Resident #5's PASRR Level 1 Screening revealed it was completed on 07/19/23 by an acute care facility employee. Resident #5 was noted to have no evidence or indicator of a mental illness. During an interview on 07/28/24 at 09:46 AM ADM and ADON stated MDS LVN was a remote employee, in that she did not visit the facility or live in the region. During an interview on 07/29/24 at 11:08 AM ADON stated she was responsible for completing PASRRs. She stated the facility did not have a PASRR level II on Resident #5. During an interview on 07/29/24 at 11:20 AM ADON stated the facility thought MDS LVN was completing PASRRs but when they found out she was not, ADON took back the responsibility for PASRRs. She stated she has been responsible for PASRRs off and on for the past year. ADON stated PASRRs were to be done immediately. She stated she did not know how she missed Resident #5 had a mental illness at the time he was admitted . During an interview on 07/30/24 at 09:45 AM LVN A stated if a resident was positive for mental illness and the PASRR level I was not coded as such, resulting in the resident not receiving a PASRR level II, the facility might not provide proper care for the mental health of the resident. During an interview on 07/30/24 at 09:47 AM ADM stated not having a resident referred for a PASRR level II could cause harm to the resident. Record review of facility policy titled admission Criteria and dated 2019 revealed the following: . Our facility admits only residents whose medical and nursing care needs can be met. 1. The objectives of our admission criteria policy are to: . b. admit residents who can be cared for adequately by the facility; . e. assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission. 5. Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident, including orders covering at least: . b. medication orders, including (as necessary) a medical condition or problem associated with each medication; . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 (LVN B, CNA C, CNA D, and CNA E) of 4 staff members. -LVN B did not don PPE gown before or during performing ordered Wound Care to unstageable pressure ulcer to sacral area of Resident #187 who also had a Foley Catheter. -CNA C did not don PPE gown before or during assisting ordered Wound Care to unstageable pressure ulcer to sacral area of Resident #187 who also had a Foley Catheter. -CNA D did not don PPE gown before or during performing ordered Foley Catheter Care to Resident with unstageable pressure ulcer to sacral area on Resident #187. -CNA E did not don PPE gown before or during observation of Foley Catheter Care to Resident with unstageable pressure ulcer to sacral area on Resident #187. These deficient practices have the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, and communicable diseases. Findings included: Record review of Resident #187's admission record dated 07/29/24 revealed a [AGE] year-old male admitted to facility on 7/9/24 with diagnoses of essential (primary) hypertension, diabetes mellitus due to underlying condition without complications, retention of urine, unspecified, type 2 diabetes mellitus with diabetic neuropathy, unspecified, hyperlipidemia, unspecified, single subsegmental pulmonary embolism without acute cor pulmonale (a pulmonary embolism occurs when a clump of material, most often a blood clot, gets stuck in an artery in the lungs, blocking the flow of blood.), pressure ulcer of sacral region, unstageable. Record review of Resident #187's Care Plan revealed that it stated Resident #187 needed x1 person assist with ADL's. Resident has a Foley Catheter for urine drainage and wears a Depends for bowel movements. Receives daily wound care to unstageable sacral pressure ulcer. Record review of Resident #187's active order summary report dated 07/29/24 revealed the following orders: Order start date 07/21/24 Cleanse wound to coccyx with [brand name wound cleanser], pack with [brand name wound cleanser] soaked gauze, cover with dry gauze and ABD pad, secure with tape. Change q shift and PRN. Every shift related to PRESSURE ULCER OF SACRAL REGION, UNSTAGEABLE . Order start date 07/29/24 Cleanse wound to coccyx with wound cleanser, pack with wound cleanser soaked gauze, cover with dry gauze and ABD pad, secure with tape. Change q shift and PRN. every 1 hours as needed related to PRESSURE ULCER OF SACRAL REGION, UNSTAGEABLE . Order start date 07/29/24 Cleanse wound to coccyx with wound cleanser, pack with wound cleanser soaked gauze, cover with dry gauze and ABD pad, secure with tape. Change q shift and PRN. every shift related to PRESSURE ULCER OF SACRAL REGION, UNSTAGEABLE . Order start date 07/11/24 Protein Oral Liquid (Protein) Give 30 ml by mouth one time a day for wound healing. Order start date 07/10/24 Vitamin C Oral Tablet (Ascorbic Acid) Give 500 mg by mouth two times a day for wound healing. Order start date 07/11/24 Zinc Oral Tablet (Zinc) Give 220 mg by mouth one time a day for wound healing. Order start date 07/09/24 Foley care q shift every shift Foley catheter care each shift. Order start date 07/09/24 Foley catheter: ensure Foley catheter is anchored to resident's leg so as to prevent injury every shift. Order start date 08/09/24 Foley Catheter: Insert 16 French catheter with 30 cc balloon. Every day shift starting on the 9th and ending on the 10th every month Foley Catheter: Insert 16 French catheter with 30 cc bulb to closed bedside drainage. Change monthly on the 9th. Observation on 7/28/24 at 11:35 AM revealed LVN B and CNA C did not don a PPE gown before or during performing wound care to an unstageable pressure ulcer to the sacral area of Resident #187. The PPE gown was not present inside the room or in the hallway outside the door of Resident #187's room. Observation on 7/29/24 at 9:58AM revealed CNA D and CNA E did not don a PPE gown before or during performing ordered Foley Catheter care to Resident #187 who had an unstageable pressure ulcer to his sacral area. The PPE gown was not present inside the room or in the hallway outside the door of Resident #187's room. In an interview on 7/29/24 at 10:06AM with CNA D she stated she had never been told to wear a gown as part of PPE when giving Foley Catheter care. She did not know what Enhanced Barrier Precautions (EBP) were. When asked what a negative outcome could be from not donning a PPE gown she stated, You could get something on patient like bacteria. In an interview on 7/29/24 at 10:11AM with CNA E he stated he hand never heard of EBP. He had never been told to wear gown while doing any type of care to Residents. When asked what a negative outcome could be from not donning a PPE gown he stated, Could cause cross contamination. In an interview on 7/29/29 at 10:28AM with LVN A, facilities Infection Preventionist, she stated she had never heard of Enhanced Barrier Precautions (EBP). When asked what a negative outcome could be from not donning a PPE gown she stated, I haven't taught anyone about this. We didn't know. A negative outcome could be cross contamination. In an interview on 7/29/24 at 10:32AM with the ADON she stated she hadn't heard of Enhanced Barrier Precautions (EBP) until today. When asked what a negative outcome could be from not donning a PPE gown she stated, Carrying germs from one resident to another. In an interview on 7/29/24 at 10:44 AM with the ADM she stated she had never heard of Enhanced Barrier Precautions (EPB). She stated, Our best practice act person has been here twice and didn't tell us about it. When asked what a negative outcome could be from not donning a PPE gown she stated, Infection control. Getting germs on you and contaminate another resident. In an interview on 7/29/24 at 11:31AM with CNA C by phone, she stated she had never been told to wear a gown when performing any kind of personal care to residents. She stated she was never told about Enhanced Barrier Precautions (EBP.) When asked what a negative outcome could be from not donning a PPE gown she said, It could spread infection or germs. In an interview on 7/29/24 at 5:29PM with LVN B by phone, she stated no one told her to wear a gown when giving care to residents and had not been informed of Enhanced Barrier Precautions (EPB). When asked what a negative outcome could be from not donning a PPE gown she stated, Giving an infection to a resident. Record review of CMS QSO-24-08-NH dated 03/20/24 revealed the following, . In July 2022, the CDC released updated EBP recommendations for 'Implementation of PPE Use in nursing homes to prevent spread of MDROs,' and therefore, CMS is updating its infection prevention and control guidance accordingly. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. Record review of facility provided policies and procedures for Infection Prevention and Control Program dated 12/2023 states: Policy Interpretation and Implementation .2. The program is based on accepted nation infection prevention and control standards. 4. Policies and procedures are reviewed and revised as necessary: a. When changes in regulations or professional standards of practice necessitate revisions: 7. Prevention of Infection a. 3. educating staff and ensuring that they adhere to proper techniques and procedures; 7. implementing appropriate enhanced barrier and transmission-based precautions . Record review of facility provided policies for Infection Preventionist dated 9/2022 states: .Responsibilities; 3. The infection preventionist monitors, changes in infection prevention and control guidelines and regulations to ensure that policies, practices, and protocols remain current and aid in preventing and controlling the spread of infection . No In-services on Enhanced Barrier Protection (EPH) were done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to assess a resident using the quarterly review instrument specified by the state and approved by CMS not less frequently than once every 3 months for 5 (Residents #4, #11, #18, #21, and #31) of 12 residents reviewed for quarterly MDS assessments. 1. The facility failed to complete a quarterly MDS for Resident #4 with ARD 06/13/24. 2. The facility failed to complete a quarterly MDS for Resident #11 with ARD 05/24/24. 3. The facility failed to complete a quarterly MDS for Resident #18 with ARD 05/07/24. 4. The facility failed to complete a quarterly MDS for Resident #21 with ARD 06/14/24. 5. The facility failed to complete two quarterly MDS' for Resident #31 with ARDs 05/20/24 and 06/14/24. These failures could lead to residents not receiving necessary/complete/correct care due to lack of current information for care plans. Findings included: 1. Record review of Resident #4's admission record dated 07/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement), type 2 diabetes (insufficient production of insulin, causing high blood sugar), and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #4's MDS tab in the EHR revealed his last completed annual had an ARD of 04/30/24 and he had an incomplete quarterly with ARD of 06/13/24. The annual MDS was created by the previous DON and the quarterly MDS was created by MDS LVN. Record review of Resident #4's annual MDS completed on 04/06/24 section C revealed a BIMS score of 12 which indicated moderately impaired cognition. Record review of Resident #4's care plan revealed a completion date of 06/10/24. 2. Record review of Resident #11's admission record dated 07/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, diffuse traumatic brain injury (a severe type of traumatic brain injury that occurs when the brain rapidly shifts inside the skull) with loss of consciousness of unspecified duration, injured in unspecified motor-vehicle accident, restlessness and agitation, and irritability and anger. Record review of Resident #11's MDS tab in the EHR revealed his last completed quarterly had an ARD of 04/30/24 and he had an incomplete quarterly with ARD of 05/24/24. These quarterly MDS' were created by MDS LVN. Record review of Resident #11's quarterly MDS completed on 05/01/24 section C revealed no BIMS score as Resident #11 was rarely to never understood. The staff assessment for mental status revealed Resident #11 had severely impaired cognition. Record review of Resident #11's care plan revealed it was completed on 07/04/24. 3. Record review of Resident #18's admission record dated 07/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, non-st elevation (NSTEMI) myocardial infarction (damage to the heart muscle caused by a loss of blood supply due to blockages of the arteries), anxiety disorder, major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and suicide attempt. Record review of Resident #18's MDS tab in the EHR revealed his last completed quarterly had an ARD of 02/05/24 and he had an incomplete quarterly with ARD of 05/07/24. The complete quarterly was completed by ADON and previous DON. The incomplete quarterly was created by MDS LVN. Record review of Resident #18's quarterly MDS completed on 02/21/24 section C revealed no BIMS score as Resident #18 was rarely to never understood. The staff assessment for mental status revealed Resident #18 had moderately impaired cognition. Record review of Resident #18's care plan revealed it was completed on 07/12/24. 4. Record review of Resident #21's admission record dated 07/29/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and hypertension (high blood pressure). Record review of Resident #21's MDS tab in the EHR revealed her last completed quarterly had an ARD of 05/04/24 and she had an incomplete quarterly with ARD of 06/14/24. The complete quarterly was completed by previous DON. The incomplete quarterly was created by MDS LVN. Record review of Resident #21's quarterly MDS completed on 05/17/24 section C revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident #21's care plan indicated it was completed on 06/18/24. 5. Record review of Resident #31's admission record dated 07/28/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and hemiplegia (partial paralysis) affecting right dominant side. Record review of Resident #31's MDS tab in the EHR revealed his last completed quarterly had an ARD of 02/18/24 and he had two incomplete quarterly MDS' with ARDs of 05/20/24 and 06/14/24. The complete quarterly was completed by ADON and previous DON. The incomplete quarterlies were created by MDS LVN. Record review of Resident #31's quarterly MDS completed 02/18/24 section C revealed no BIMS score as Resident #31 was rarely to never understood. The staff assessment for mental status revealed Resident #31 had severely impaired cognition. Record review of Resident #31's care plan revealed a completion date of 06/06/24. During an interview on 07/28/24 at 09:46 AM ADM and ADON stated MDS LVN was a remote employee, in that she does not visit the facility or live in the region. During an interview on 07/29/24 at 10:31 AM MDS LVN stated she was responsible for all resident MDS'. She stated she used the RAI Manual as the policy for MDS completion. She stated she had 14 days after the ARD to complete a quarterly MDS. She stated she knew several MDS' in the facility were past the 14-day mark because she was working on finding some information to ensure she was coding correctly. She stated she was not sure of a negative outcome to residents of not completing MDS' timely. MDS LVN stated, I mean for compliance we need to try to get them done timely. She stated MDS assessments determined the funding the facility received. MDS LVN stated not having the correct funding could affect care of resident. She stated ADON did the actual interviews with residents in the facility and she (MDS LVN) used that information to complete the MDS'. During an interview on 07/29/24 at 11:20 AM ADON stated she was responsible for the MDS' in the facility for a short time, but she felt overwhelmed by doing both jobs. She stated of MDS LVN, She should look at my assessments and do MDS' from there. ADON said a possible negative outcome of not completing MDS' timely was, We won't get paid and it could affect resident care because we couldn't pay our staff. During an interview on 07/30/24 at 09:45 AM LVN A stated not completing MDS' timely would affect our funding. She stated she was not sure what impact the affected funding would have on residents. During an interview on 07/30/24 at 09:47 AM ADM stated resident care was based on the information in the care plan which was based on the information in the MDS. She asked, How do we know what care we are providing because the care plan is built off of the MDS? ADM stated the MDS' not being completed timely would also affect the funding of the facility. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.18.11 dated October 2023 revealed the following regarding quarterly MDS': . The MDS completion date must be no later than 14 days after the ARD.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen observed for food storage, preparation, and distribution. A. The DM did not perform hand hygiene appropriately when preparing pureed foods. This failure could place residents who ate food served by the kitchen at risk of food-borne illness from cross-contamination. Findings included: During an observation and interview on 7/28/24 at 10:55 am, the DM was observed preparing the pureed foods. The DM changed her gloves then touched various kitchen surfaces including the prep table and the blender. The DM went to the stove and used a ladle to put gravy into the blender. The DM walked back to the prep table and used her hands to remove the chicken from the bone and then placed the chicken into the blender with her gloved hands. The DM picked up the lid for the blender and began to puree the chicken. The DM did not change her gloves or wash her hands. The DM stated she just realized she did not wash her hands or change her gloves. My bad. During an observation and interview on 7/28/24 at 11:05 am, the DM washed her hands and changed her gloves and continued with the pureeing. The DM touched the prep table and picked up the blender lid, and container after it was washed. The DM took the container to the prep able. The DM carried the container to the stove and ladled the corn into the blender container. The DM carried the blender to the prep table, put the lid on the blender container and turned the blender on, The DM pureed the corn then picked up a carton of milk, took the lid off the milk and poured the milk into the corn. The DM put the lid back on the milk and set the container down on the prep table. The DM walked to the shelf and picked up a loaf of bread. The DM opened the loaf of bread and took out a piece of bread from the wrapper with her gloved hand. The DM folded the piece of bread in half with her gloved hands and put the bread into the blender with the corn. The DM did not change her gloves or wash her hands. When asked if she realized she touched the bread with her contaminated hands she stated Dadgum I did it again I should have changed my gloves. The DM stated she was not supposed to touch the food with her hands and was supposed to change gloves between tasks. She stated this could cause cross contamination. During an interview on 7/29/24 at 2:05 pm, the DM, stated she was aware she did not wash her hands between tasks. The DM stated she should have washed her hands and changed her gloves when switching tasks. The DM stated not changing gloves and washing hands could cause food borne illness. The DM stated she trained the staff in hand washing techniques. Record review of facility policy titled, Preventing Foodborne Illness, dated November 2022, revealed, in part: all employees who handle prepare serve food are trained in the practice of safe food handling and preventing food borne illness. Employees must wash hands before coming into contact with any food surfaces, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Gloves are considered single use items and must be discarded after completing the task for which they are used. Gloves are removed, hands re washed and gloves are replaced. Gloves are worn when directly touching ready to eat foods. Food service employees are trained in the proper use of utensils such as tongs gloves deli paper and spatulas as tools to prevent foodborne illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 6 residents reviewed for comprehensive care plans. Resident #1 required partial/moderate and substantial assistance in self-care activities which were not documented in his care plan. Resident #1 had diagnoses of depression, anxiety and dementia(loss of memory)which were not documented in his care plan. Resident #1 had a diagnosis of cardiac pacemaker(devise that helps manage irregular heartbeats) which was not documented in his care plan. Resident #1 had physician orders for physical therapy which was not documented in his care plan. Resident #1 had physician orders for speech therapy which was not documented in his care plan. Resident #1 had bowel and urinary incontinence which was not documented in his care plan. These failures could place residents at risk of receiving inadequate care due to inaccurate care planning. Findings included: Record Review of Resident #1's face sheet dated November 20, 2023, revealed, in part, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Dementia, major depressive disorder-recurrent severe without psychotic features(mood disorder that affects the mind), Alzheimer's disease(brain disorder that causes problems with memory, thinking and behavior) with late onset, presence of cardiac pacemaker. Record review of Resident #1's admission MDS assessment completion date of 10/25/2023, revealed a BIMS of 06 out of 15 indicating severe cognitive impairment. In Section GG0130 of the MDS revealed that Resident #1 had impairment of upper extremities and required partial/moderate assistance with eating, oral and personal hygiene. It also revealed that Resident #1 required substantial/maximal assistance with toileting hygiene, shower/bath, upper body dressing and lower body dressing. In Section GG0170 revealed that Resident #1 required substantial/maximal assistance with rolling left and right and sit to lying, lying to sitting on side of bed, sit to stand and chair/bed to chair transfer. In Section H0100 revealed that Resident #1 had bowel and urinary incontinence. In Section I0020 revealed that Resident #1 had diagnoses of Dementia, anxiety and depression, and presence of cardiac pacemaker. In Section O0400 revealed that Resident #1 was receiving physical and speech therapy. Record review of Resident #1's physician orders revealed that physical therapy was ordered on 10/12/2023 and speech therapy was ordered on 10/13/2023. Physician orders dated 11/17/2023 revealed Resident #1 had a prescription for Buspirone HCL oral tablet 15 mg three times a day for dementia. Record review of Resident #1's nursing notes dated 11/11/2023 revealed resident was taking Buspirone HCL oral tablet 10 mg by mouth three times a day related to dementia. Nursing notes dated 11/17/2023 revealed that the physician increased Buspirone from 10mg to 15 mg three times a day. Record review of Resident #1's care plan dated 10/30/2023 revealed no evidence of documentation related to self-care activities which required partial/moderate and substantial assistance, no evidence of documentation of Resident #1's diagnoses of depression, anxiety or dementia, no evidence of documentation of Resident #1's diagnosis of presence of cardiac pacemaker, no evidence of documentation of physical or speech therapy and no evidence of documentation of Resident #1's urinary and bowel incontinence. During an interview and observation on 11/20/2023 at 9:54 AM, Resident #1 was sitting in his room eating his breakfast. His appearance was clean and his room was homelike. Resident #1 stated he had no concerns about his care at the facility and his needs were being met. During an interview and observation on 11/20/2023 at 2:25 PM, ADON reviewed Resident #1's care plan and MDS Assessment via EHR. ADON stated that she was sorry that the care plan was not completed and that she was going to fix the care plan immediately. During an interview on 11/20/2023 at 2:35 PM, DON stated she was responsible for completing Resident #1's care plan. When asked about the negative outcome for an incomplete or inaccurate care plan, DON stated that holes in communication in care can cause the resident's needs not to be met. DON stated a verbal report is given at each shift and that is how they keep track of what each resident needs and the care plan is just a paper trail. During an interview on 11/20/2023 at 2:39 PM, LVN A stated that she is familiar with all her residents, so she is aware of their needs, LVN A said she is given a verbal report at each shift on any changes with the residents. When asked about a possible negative outcome for a missed or inaccurate verbal report, LVN A stated that a resident could get hurt. During an interview and observation on 11/20/2023 at 2:53 PM, ADM reviewed Resident #1's care plan via EHR and acknowledged that Resident #1's care plan was not completed . When asked about inaccuracies or incomplete care plans, ADM stated that it was a problem and that she couldn't argue that it was not filled out accurately. Record Review of Care plan policy(no date) revealed .It will be consistent with the medical plan of care and those disciplines that have direct involvement with the resident's care. The care plan will contain information about the physical, emotional, psychological, psychosocial, spiritual, education and environmental needs as appropriate. It is the purpose to ensure that each resident is provided with individualized, goal directed care, which is reasonable, measurable and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete an assessment that accurately reflected the resident's status for 1 of 12 residents (Resident #4) reviewed for accuracy of MDS assessments. The facility failed to identify Resident #4's administration of Humalog Solution (insulin lispro) injections on his annual MDS assessment. This failure to ensure accurate assessments could affect residents by placing them at risk and could result in residents not receiving correct care and services. Findings include: Record review of Resident #4's face sheet on May 31, 2023 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease, chronic pain, covid-19, encounter for immunization, hypoosmolality(electrolytes, proteins and nutrients in the blood are lower than normal) and hyponatremia(low levels of sodium in blood), anemia, mild cognitive impairment of uncertain etiology, Parkinson's disease, unspecified displaced fracture of surgical neck of right humerus, subsequent encounter for fracture with routine healing, unspecified fracture of upper end of right humerus, subsequent encounter for fracture with delayed healing, other abnormalities of gait and mobility, repeated falls, cognitive communication deficit, other osteoporosis with current pathological fracture(broken bone spread by disease), muscle weakness, age-related osteoporosis without current pathological fracture, need for assistance with personal care, unspecified nondisplaced fracture of surgical neck of left humerus, subsequent encounter for fracture with routine healing, low back pain, major depressive disorder, vitamin D Deficiency, gastro-esophageal reflux disease without esophagitis, vitamin efficiency, overactive bladder, hyperlipidemia, hypothyroidism, essential hypertension, type 2 diabetes, tremors, drug induced subacute dyskinesia(condition affecting the nervous system), schizoaffective disorder, and depressive type. Record review of Resident #4's physician's orders revealed active orders dated 08/23/2022 to administer Humalog Solution (insulin lispro) on a sliding scale. Record review of Resident #4's Medication Administration Record for the month of March 2023 revealed that 2 units of Humalog Solution was administered on 03/16/2023 at 8 PM, on 03/18/2023 at 7:30 AM, and on 03/21/2023 at 4:30 PM. Record review of Resident #4's MDS assessment dated [DATE] revealed the resident had a BIMS(brief interview for mental status) score of 9 out of 15. The MDS also indicated in Section N0300 (Injections) that Resident #4 received 0 Humalog Solution (insulin lispro) injections from the 7 days during the MDS look back period to check for medications administered to the resident. Record review of Resident #4's Care plan dated 04/03/2023 indicated a focus on diabetes as the resident was at risk for unstable blood sugars related to Type II Diabetes with interventions to administer diabetes medication as ordered by the physician. During an interview with Resident #4 on 05/30/2023 at 2:45 PM, the resident was identified as a Type II diabetic. Resident #4 stated he was checked by staff twice a day and was given insulin when needed. During an interview with the MDS Coordinator on 05/31/2023 at 10:26 AM, the MDS Coordinator stated the look back period for medication was 7 days for the MDS Assessment. The MDS Coordinator also said he looked to the Resident Assessment Instrument when he has questions regarding MDS Assessments. When asked about policies regarding MDS Assessments, the MDS Coordinator showed surveyor the MDS Coordinator Manual. During an observation and interview with the MDS Coordinator on 05/31/2023 at 2:00 PM, the MDS Coordinator reviewed Resident #4's MDS assessment dated [DATE] and observed that there was no indication of any insulin injections given to resident in section N0300 (Injections). The MDS Coordinator also reviewed the Medication Administration Record for Resident #4 and observed 2 units of Humalog Solution was administered on 03/16/2023 at 8:00 PM, 03/18/2023 at 7:30 AM and 03/21/2023 at 4:30 PM. After reviewing the MDS Assessment and the MAR the MDS Coordinator said, I made a mistake. It is not accurate and I will correct it now. When asked about the negative outcome for inaccurate MDS Assessments the MDS Coordinator did not provide an answer. During an interview with LVN B on 06/01/2023 at 9:56 AM concerning Resident #4 and the process of checking Resident #4's blood sugar, LVN B stated Resident #4's blood sugar was checked in the mornings, before meals and in the evenings. Record review of Resident Assessment Instrument dated October 2023 via the CMS website revealed the Steps for MDS Assessment were as follows: 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Review documentation from other health care locations where the resident may have received injections while a resident of the nursing home (e.g., flu vaccine in a physician's office, in the emergency room - as long as the resident was not admitted ). 3. Determine if any medications were received by the resident via injection. If received, determine the number of days during the look-back period they were received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep resident environment free of accidents and hazards and assistance devices to prevent accidents for 1 of 12 residents (Resident #19) reviewed. The facility failed to provide a fall mat for Resident #19. This failure can increase the risk of injury for residents requiring assistance due to history of falls. Findings include: Record review of Resident #19's face sheet dated 05/30/23 revealed he is a [AGE] year-old male originally admitted to the facility on [DATE] with a readmission on [DATE]. Resident #19 has diagnoses including non-st elevation (NSTEMI), myocardial infarction (Heart attack), aphagia (inability or refusal to swallow), anxiety disorder, iron deficiency anemia, unspecified, other abnormalities of gait and mobility, heart failure, Pneumonia, unspecified organism, insomnia, dementia in other diseases classified elsewhere, unspecified severity with other behavioral disturbance, major depressive disorder, recurrent severe without psychotic, hyperlipidemia, unspecified, gastro- esophageal reflux disease without esophagitis (irritation of the esophagus caused by stomach acid, muscle weakness (generalized), ataxic gait (unsteady or uncoordinated walk), cognitive communication deficit, aphasia (language disorder, other reduced mobility, need for assistance with personal care, problem related to care provider dependency, unspecified, moderate protein calorie malnutrition, essential (primary) hypertension (high blood pressure), chronic atrial fibrillation (fast heart beat), unspecified, other malaise, traumatic hemorrhage of cerebrum (stroke), unspecified with loss of consciousness of unspecified duration, sequela (conditions or diseases that follow another, suicide attempt (sequela). Record review of Resident #19's care plan revealed Resident #19 had a goal of potential for falls related to cognitive impairment with initiation date of 7/20/22 and a revision date of 4/24/23. Intervention associated with goal reflected Floor mat while in bed. Resident #19's care plan reflected the resident had a recent fall on 4/22/23. Record review of Resident #19 MDS (no date) indicated a BIMS of 01. On 05/31/23 at 3:44 PM, observation revealed Resident #19 in bed with no fall mat located next to resident's bed. On 6/1/23 at 8:35 AM, observation revealed Resident #19 was in bed with no fall mat on floor next to resident bed. An interview on 5/31/23 at 2:55 PM with CNA F revealed charge nurse oversees assistive devices and CNA F was not sure how often the residents were assessed. CNA F indicated that going to nurses or therapy would provide assistive devices and types of assistive devices included hi-lo beds, fall mats, and rails. CNA F stated that if assistive devices are ordered, orders would be in the charting system of each person's chart. CNA F identified negative outcomes as the resident would fall and hurt themselves if resident fell with no fall mat or had a hi-lo bed that was not to the ground. An interview on 5/31/23 at 3:02 PM with CNA G revealed: Who is responsible for fall assessments and assistive devices? Nurse of physical therapy. Go to nurse first if you have a fall. How often are residents assessed? CNA G stated, I don't know that. Where would you go if any assistive devices are needed? CNA G indicated, First nursing or go to therapy. What assistive devices are used for fall prevention? CNA G responded, Fall mats, beds lowered all the way to the ground, no cords or wires, walkers, canes, wheelchair. When would you get a new assessment for assistive device orders? CNA G indicated, Through our nurse of the ADON would if is like a big need or we go get them. Is there a certain area that you would need to go get the assistive devices? CNA G stated, A lot of the times we keep fall mats in the shower room to sanitize and in our clean utility room. What is a negative outcome if fall preventions are not place such as a floor mat not being in place? CNA G responded, Them falling and breaking a hip and hurting themselves. On 5/31/23 at 3:44 PM, interview with RN A revealed: Who is responsible for fall assessments and assistive devices? RN A advised that a licensed nurse should do the fall assessment. This should go into the care plan when the pop up on the screen and need an evaluation. RN A advised that administration should be asked about timelines of assessments as they (RN A) was new to the facility. RN A identified that fall prevention devices included walkers, wheelchairs, fall mats and beds in lowest position. RN A identified a negative outcome of if fall mat is on a care plan and not in place it could be a possible injury and a tag if not following care plans On 5/31/23 at 3:53 PM, an interview with the ADON revealed that nurses do the fall assessments if there is a fall, but they are assessed during QOL. It is discussed if they need something new and it can be the DON, the MDS Coordinator, or whoever I can catch. ADON revealed that residents are always assessed if a fall occurs and any assistive devices go through ADON and ADM to put assistive device in place. ADON stated that hi-lo bed, assisted rails, fall mats are all assistive devices but unsure if the facility has any right now. ADON stated that a negative outcome would be an injury to the resident and the team is responsible for assistive devices being in place. Record review of the undated Policy/Procedure titled Comprehensive Resident Centered Care plan revealed that the care plan will contain information about the physical, emotional/psychosocial, spiritual, educational, and environmental needs as appropriate. It is our purpose to ensure that each resident is provided with the individualized, goal-directed care, which is reasonable, measurable, and based on resident's needs. Record review revealed that in-service training was provided for Fall Prevention completed on 2/21/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 3 (Resident #22, Resident #31, and Resident #32) of 12 residents reviewed for DNR orders. Resident #22 had an OOH-DNR order that was not completed as it was not dated by the physician, did not have the printed name of the physician, and was not signed a second time by one of the witnesses. Resident #31 had an OOH-DNR order that was not completed as it was not dated by the physician, one of the witnesses did not sign a second time, and it was not dated in the final section titled, ALL PERSONS MUST SIGN HERE:. Resident #32 had an OOH-DNR order that was not completed as it was not dated by the physician, did not have the printed name of the physician, was not dated by one of the witnesses, one of the witnesses did not sign a second time, and it was not dated in the final section titled, ALL PERSONS MUST SIGN HERE:. These failures could place residents with DNR orders at risk for receiving, or not receiving, life-saving measures that align with their medical preferences. Findings included: 1. Record review of Resident #22's face sheet, dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), a need for assistance with personal care, and hypertensive chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). Resident #22's face sheet revealed an advance directive of DNR. Record review of Resident #22's MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated intact cognition. Record review of Resident #22's care plan, dated [DATE] revealed, in part: Resident has physician's orders that include an order for DNR. Do not resuscitate orders will be honored per resident or legally appointed guardian's wishes. Record review of Resident #22's physician's orders revealed an active order for DNR with a revision date of [DATE]. Record review of Resident #22's EHR revealed a document titled TEXAS DEPARTMENT OF HEALTH STANDARD OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER, dated [DATE], which revealed in Section 4 PHYSICIAN'S STATEMENT: I, the undersigned, am the attending physician of the patient named above. I have noted the existence of this order in the patient's medical records, and I direct out-of-hospital heath care professionals to comply with this order as presented. There was no physician printed name, or date in the section; the lines were left blank. The last section of the document revealed, ALL PERSONS WHO SIGNED MUST SIGN HERE: This document has been properly completed. There was no signature of one of the witnesses in the section; the line was left blank. 2. Record review of Resident #31's face sheet, dated [DATE], revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), hyperlipidemia (high cholesterol), presence of cardiac pacemaker, personal history of malignant neoplasm of breast (breast cancer), and hypertension (high blood pressure). Resident #31's face sheet revealed an advance directive of DNR. Record review of Resident #31's MDS, dated [DATE], revealed a BIMS score of 2 out of 15 which indicated severely impaired cognition. Record review of Resident #31's care plan, dated [DATE] revealed, in part: [Resident #31] has physician's orders that include a status of full code .[Resident #31]/legally appointed guardian's wishes will be followed daily and ongoing. Monitor for changes in resident's code status and update as needed. Review at least quarterly. Resident #31's care plan did not mention DNR. Record review of Resident #31's physician's orders revealed an active order for DNR with a revision date of [DATE]. Record review of Resident #31's EHR revealed a document titled TEXAS DEPARTMENT OF HEALTH STANDARD OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER, dated [DATE], which revealed in Section 4 PHYSICIAN'S STATEMENT: I, the undersigned, am the attending physician of the patient named above. I have noted the existence of this order in the patient's medical records, and I direct out-of-hospital heath care professionals to comply with this order as presented. There was no date in the section; the line was left blank. The last section of the document revealed, ALL PERSONS WHO SIGNED MUST SIGN HERE: This document has been properly completed. There was no date or signature of one of the witnesses in the section; the lines were left blank. 3. Record review of Resident #32's face sheet dated, [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), other stimulant dependence, major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and insomnia Resident #32's face sheet revealed an advance directive of DNR. Record review of Resident #32's MDS, dated [DATE], revealed a BIMS score of 2 out of 15 which indicated severely impaired cognition. Record review of Resident #32's care plan, dated [DATE] revealed, in part: Resident has physician's orders that include an order for DNR. Do not resuscitate orders will be honored per resident or legally appointed guardian's wishes. Record review of Resident #32's physician's orders revealed an order for DNR with a discontinued date of [DATE] and an original revision date of [DATE]. The order was discontinued following an interview with ADM regarding the validity of the OOH-DNR form on [DATE]. Record review of Resident #32's EHR revealed a document titled TEXAS DEPARTMENT OF HEALTH STANDARD OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER, dated [DATE], which revealed in Section 3 WITNESSES: . We have witnessed all of the above signatures there was no date next to the second witness' signature; the line was left blank. Section 4 of the document revealed PHYSICIAN'S STATEMENT: I, the undersigned, am the attending physician of the patient named above. I have noted the existence of this order in the patient's medical records, and I direct out-of-hospital heath care professionals to comply with this order as presented. There was no physician printed name, or date in the section; the lines were left blank. The last section of the document revealed, ALL PERSONS WHO SIGNED MUST SIGN HERE: This document has been properly completed. There was no date in the section; the line was left blank. During an observation and interview on [DATE] at 08:27 AM RN A stated nurses could carry forth orders and put them in the EHR if it is a new order for DNR. She pointed out on the EHR where a resident is listed as DNR or full code. RN A retrieved a binder from the nurses' station and explained that the binder contained a plastic page protector for each resident with their face sheet. RN A explained if the resident was DNR, a copy of the DNR was in the back side of their plastic page protector. If they were full code, there was nothing in the back side. Observation revealed the residents were in the binder in alphabetical order. During an observation and interview on [DATE] at 08:32 AM the ADM was shown the OOH-DNR forms for Resident #31 and Resident #32. She was unable to identify what was wrong with the forms. She took the forms into the ADON/DON's office and asked who was responsible for DNR forms. The DON raised her hand. During an interview on [DATE] at 09:11 AM the ADON and the DON were asked for a possible negative outcome of having an incorrectly filled out OOH-DNR. They stated they would have assumed the DNR's for Resident #31, Resident #32, and Resident #22 were filled out correctly. The ADON stated they could be in legal danger even resulting in jail time if they did not render life-saving aid and the family decided to get upset about that. During an interview on [DATE] at 09:13 AM RN A stated a possible negative outcome of a an incorrectly filled out OOH-DNR was, We would assume they are DNR and there would be all kinds of legal ramifications from that. The patient's wishes might not be followed. Record review of a portion of the facility's admission packet titled, Advance Directives revealed the following: .What is an Out-of-Hospital Do Not Resuscitate Order (OOHDNR)? This form is for use when you are not in the hospital. It lets you tell health care workers, including Emergency Medical Services (EMS) workers, NOT to do some things if you stop breathing or your heart stops. If you don't have one of these forms filled out, EMS workers will ALWAYS give you CPR or advanced life support even if your advance care planning forms say not to. You should complete this form as well as the Directive to Physicians and Family or Surrogates and the Medical Power of Attorney form if you don't want CPR. Record review of a document titled, Out-of-Hospital DNR instructions revealed the following: .The form must be signed and dated by two witnesses .The original standard Texas Out-of-Hospital must be completed and properly executed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 3 of 12 residents (Residents #15, #22, and #29) reviewed for PASRR compliance. The facility failed to ensure that an initial PASRR screening (Level I screen) was completed for Resident #15 prior to admission to the facility. The facility failed to ensure that an initial PASRR screening (Level I screen) was completed for Resident #22 prior to admission to the facility. The facility failed to ensure that an initial PASRR screening (Level I screen) was completed for Resident #29 prior to admission to the facility. These failures could place residents at risk of not receiving specialized and/or habilitative services as needed to meet their needs and as required by law due to an inability to identify potential mental disorders or intellectual disabilities. Findings Included: 1. Record review of Resident #15's face sheet, dated 05/31/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), dementia (a group of thinking and social symptoms that interferes with daily functioning), Alzheimer's (a progressive disease that destroys memory and other important mental functions), and psychotic disorder with delusions (a condition of the mind that results in difficulties determining what is real and what is not real accompanied by an unshakable belief in something that is untrue). Record review of Resident #15's MDS, dated [DATE], revealed a BIMS score of 00 out of 15 which indicated severe cognitive impairment. Record review of Resident #15's care plan, dated 04/17/23, revealed no documentation regarding PASRR status or services received. Record review of a document from Resident #15's EHR titled PASRR Level 1 Screening indicated the assessment was completed on 12/26/22, 97 days after she was admitted to the facility. 2. Record review of Resident #22's face sheet, dated 05/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and a need for assistance with personal care. Record review of Resident #22's MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated intact cognition. Record review of Resident #22's care plan, dated 05/05/23 revealed no documentation regarding PASRR status or services received. Record review of a document from Resident #22's EHR titled PASRR Level 1 Screening indicated the assessment was completed on 08/24/22, 14 days after she was admitted to the facility. 3. Record review of Resident #29's face sheet, dated 05/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cirrhosis of the liver (impaired liver function caused by the formation of scar tissue), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), and chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue). Record review of Resident #29's MDS, dated [DATE], revealed a BIMS score of out of 12 out of 15 which indicated moderate cognitive impairment. Record review of Resident #29's care plan, dated 05/26/23, revealed no documentation regarding PASRR status or services received. Record review of a document from Resident #29's EHR titled PASRR Level 1 Screening indicated the assessment was completed on 02/15/23, two days after she was admitted to the facility. Record review of a document from Resident #29's EHR titled PASRR Level 1 Screening indicated the assessment was completed on 02/27/23, 14 days after she was admitted to the facility. During an interview on 05/31/23 at 04:17 PM the MDS Coordinator stated PASRR level 1 screenings were done within 24 hours of admission of a resident. He stated he was responsible for ensuring the PASRR level 1 screening were completed on or before the day of admission. He stated a possible negative outcome of completing the PASRR level 1 screenings after admission was residents who were PASRR positive would not get the specialized services they needed. When asked why Resident #15's PASRR level 1 screening was completed 97 days after her admission to the facility, the MDS Coordinator stated he did not know why as he was not employed at that time. When asked why Resident #22's PASRR level 1 screening was completed 14 days after her admission to the facility he stated, She came from home or something. I'm not sure. When asked why Resident #29's PASRR level 1 screening was completed either 2 or 14 days after her admission to the facility he stated, She came from home too. When asked why Resident #29 had two PASRR level 1 screenings in her EHR he stated he did not know. When asked who was responsible for completing PASRR level 1 screenings when a resident is admitted to the facility from home, the MDS Coordinator stated he was. On 06/01/23 a policy governing PASRR was requested from, but not provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 5 of 12 residents (Residents #19, #22, #31, #32, #33) whose care plans were reviewed. The facility failed to develop a comprehensive person-centered care plan indicating services as follows: 1. Failure to complete goals related to smoking for Residents #22, #32, #33 2. Failure to create goals of services being provided such as hospice care for Resident #31 3. Failure to reflect accurate advance directives in care plan Resident #31 These failure could place residents at risk of receiving care that is substandard, unable to meet their needs, or inadequate to prevent complications such as fall preventions and smoking. Findings included: Resident #22 Record review of Resident #22's face sheet on 05/30/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to congestive heart failure, major depressive disorder, hypokalemia, retention of urine, anemia in chronic kidney disease, hypercholesterolemia, other idiopathic peripheral autonomic neuropathy, hypertension, chronic kidney disease stage 1-4, old myocardial infarction, abnormalities of gait and mobility, repeated falls, reduced mobility, assistance with personal care, long term use of anticoagulants, history of other venous thrombosis and embolism, and obstructive and reflux uropathy. Resident has a brief mental status interview of 15 labeled as cognitively intact. Record review of the facility's smokers list (no date) provided by ADM revealed that Resident #22 was a smoker. Record review of Resident #22's care plan dated 5/5/23 indicated no focused goal for smoking. Resident #32 Record review of Resident #32's face sheet 05/31/23 dated revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), other stimulant dependence, major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and insomnia. Record review of Resident #32's evaluations revealed Resident #32's smoking assessment dated [DATE] was completed. No additional smoking assessments were completed after admission. Record review of the facility's smoker's list (no date provided) provided by ADM mentions Resident #32 as a smoker. Record review of Resident #32's care plan dated 4/3/23 indicated resident did not have a focus goal related to smoking. Resident #33 Record review of Resident #33's face sheet dated 5/31/23, revealed [AGE] year-old female admitted to the facility on [DATE] with a brief mental interview status of 02. Resident #33's current diagnoses included but were not limited to: Anxiety, hyperlipidemia (high cholesterol), polycythemia (blood cancer), nicotine dependence, sever protein-calorie malnutrition, essential hypertension (high blood pressure), acute ischemic heart disease, heart failure, gastro-esophageal reflux disease without esophagitis (inflammation of the esophagus due to stomach acid), osteoporosis (bone weakness), and moderate dementia. Record review of Resident #33's evaluation assessments face sheet (no date) revealed no smoking assessment completed upon admission. The smoking assessment was not completed until 5/30/2023 with no prior assessments completed since admission. Record review of the facility's smokers list (no date) provided by ADM indicated that Resident #33 is a smoker with occasional written in parentheses beside resident's name. Record review of Resident #33 care plan initiated on 01/06/2023 revealed that no goal was identified for smoking. Interview on 05/31/23 at 02:23 PM with LVN B revealed if someone was a smoker, should it be included in the goals/care plan? LVN B responded with, Yes. Asked LVN B indicated that smoking assessment should be with goals/care plan. LVN B indicated RN should be responsible for completing assessments and should be on the initial intake. LVN B stated a negative outcome could be as far as to the resident, may not be mentally capable of smoking, burn themselves, burn others, burn the house down. If they go out and smoke, some of them you have to go out there with. LVN indicates that they (pointing to ADON) do assessments more often but unaware of timeline. Interview on 05/31/23 at 02:31 PM with the DON revealed if someone is smoker, they (the resident) should they have something in their care plan as well as a smoking assessment. DON confirmed that MDS coordinator was responsible for completing the smoking assessment. DON stated that a negative outcome would be oxygen could not be monitored and if symptoms were present then knowledge of smoking has to be documented. DON also stated that smoking assessments are done every month when care plans are done and every resident is assessed for smoking. Record review of Resident #31's face sheet, dated 05/30/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), hyperlipidemia (high cholesterol), presence of cardiac pacemaker, personal history of malignant neoplasm of breast (breast cancer), and hypertension (high blood pressure). Resident #31's face sheet revealed an advance directive of DNR. Record review of Resident #31's MDS, dated [DATE], revealed a BIMS score of 2 out of 15 which indicated severely impaired cognition. Record review of Resident #31's care plan, dated 04/17/23 revealed, in part: [Resident #31] has physician's orders that include a status of full code .[Resident #31]/legally appointed guardian's wishes will be followed daily and ongoing. Monitor for changes in resident's code status and update as needed. Review at least quarterly. Resident #31's care plan did not mention DNR. Record review of Resident #31's physician's orders revealed an active order for DNR with a revision date of 03/06/23. Record review of Resident #31's EHR revealed a document titled TEXAS DEPARTMENT OF HEALTH STANDARD OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER, dated 03/03/23, which revealed in Section 4 PHYSICIAN'S STATEMENT: I, the undersigned, am the attending physician of the patient named above. I have noted the existence of this order in the patient's medical records, and I direct out-of-hospital heath care professionals to comply with this order as presented. There was no date in the section; the line was left blank. The last section of the document revealed, ALL PERSONS WHO SIGNED MUST SIGN HERE: This document has been properly completed. There was no date or signature of one of the witnesses in the section; the lines were left blank. Record review of the undated Policy/Procedure titled Comprehensive Resident Centered Care plan revealed that the care plan will contain information about the physical, emotional/psychosocial, spiritual, educational, and environmental needs as appropriate. It is our purpose to ensure that each resident is provided with the individualized, goal-directed care, which is reasonable, measurable, and based on resident's needs. Record review of the undated Policy/Procedure titled Comprehensive Resident Centered Care Plan, under section Developing Care Plan: Line 2- The services provide or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of quality. Line 3 (c) Each planned intervention will be specific and include parameters for frequency and time schedule. Line 4-Each discipline will check or add expected outcomes and goals. Expected outcomes describe the realistic short-range goals to be achieved by the resident within a specific time frame. Line 5-These activities will be completed for each patient problem. Line 6- The care plan will be maintained in the care plan section of the resident medial record. Record review of the undated Policy/Procedure titled Comprehensive Resident Centered Care Plan under section Updating Care Plans reveals: Line (1) Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems and goals. Line 3 (a) significant change in the resident's condition. Line 5- Revisions involving the care of other disciplines are done through consultative and collaborative efforts and documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (CNA D, RN A and CNA E) of 3 staff observed for infection control practices. -CNA D failed to use proper hand hygiene techniques when providing incontinent care to Resident #30. -RN A failed to use proper hand hygiene when delivering meals in dining area. -CNA E failed to use proper hand hygiene when assisting resident with meal tray in resident room. This failure may place resident at an increased risk for transmissible diseases. Findings include: Record review of Resident #30 face sheet dated 5/30/23 revealed a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, traumatic brain injury with loss of consciousness (violent bow or jolt to the head or body), intermittent explosive disorder (repeated, sudden episodes of impulsive, aggressive, violent behavior or angry verbal outbursts), local infection of the skin and subcutaneous tissue (any type of microorganism, bacterial, viral or fungal that enters any break in the skin), anxiety disorder (persistent feeling of anxiety or dread which can interfere with daily life), candidiasis (fungal infection caused by a yeast called Candida), major depressive disorder (causes persistent feeling of sadness and loss of interest), extrapyramidal and movement disorder (variety of movement disorders) , alcohol dependence, essential hypertension (high blood pressure), stage 4 pressure ulcer of sacral region (full-thickness skin loss extending through the fascia with considerable tissue loss, this might involve muscle, bone, tendon or joint), dysphagia (swallowing difficulties), ataxic gait (awkward, uncoordinated walking), and pedestrian injured in traffic accident. Record review of Resident #30's last quarterly MDS dated [DATE] revealed a BIMS score of 00 out of 15 which indicated he was severely impaired. Resident #30 required extensive assist with 2 persons assist with all ADL's. Resident #30 utilized a wheelchair for ambulation with limited assist with 1 person assist. Record review of Resident #30's care plan dated 5/8/23, revealed in part: Problem: Resident has mixed bladder incontinence r/t loss of peritoneal tone Goal: Resident will decrease frequency of urinary incontinence through next review date. Interventions: Check frequently for wetness and soiling every two hours and change as needed. Briefs or incontinence products as needed for protection. Apply barrier cream to skin after incontinent episodes. Assist to toilet as needed. Monitor for and report MD signs/symptoms urinary tract infections: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Weekly skin checks to monitor for redness, circulatory problems, breakdown, or other skin concerns, Report any new skin conditions to the physician. Registered dietician to evaluate resident's nutritional status as needed. Problem: Resident has bowel incontinence related to immobility, medications. Goal: Resident will have less than two episodes of incontinence per day through the review date. Intervention: Check resident every two hours and assist with toileting as needed. Observe pattern of incontinence and initiate toileting schedule if indicated. Provide bedpan/bedside commode. Provide loose fitting, easy to remove clothing. Provide peri care after each incontinent episode. Take resident to toilet at same time each day resident usually has bowel movement. During an observation on 5/30/23 at 09:25 AM of incontinence care for Resident #30 revealed CNA C and CNA D entered the room and introduced selves to Resident #30. The door to resident #30 room was closed and the privacy curtain was closed. All supplies were assembled before the procedure. CNA C explained to Resident #30 they were going to change his brief. Both CNA C and CNA D washed their hands with soap and water prior to starting care. Both CNA C and CNA D placed gloves on and completed the incontinent care. CNA C changed her gloves and utilized ABHR throughout incontinent care with each removal of wipes and wiping from dirty to clean. CNA C applied ABHR and changed gloves with each cleaning of Resident #30 and grabbing a new wipe. CNA C and CNA D turned Resident #30 over and cleaned the anal region. CNA D removed the dirty brief, did not remove her gloves, and did not wash her hands. CNA C changed her gloves, applied ABHR and applied new gloves, placed a new brief on Resident #30 and CNA D grabbed the new brief assisting with applying the new brief without changing her gloves or washing her hands. An observation on 05/30/23 at 12:40PM, revealed RN A was observed at the pick-up window by the kitchen placing hands on face and near mouth. RN A then obtained a tray to deliver to resident. RN A then handled residents' silverware without proper hand hygiene. RN A proceeded to take a napkin and pen out of her pocket, wrote on the napkin, and delivered a drink to a resident by taking the cellophane off top of glass. No hand hygiene was practiced prior to delivering the drink. An observation on 05/31/23 at 07:54 AM, observed CNA E serving Resident #3 a tray of food in Resident #3's room. CNA E placed the tray on the table, took off the lid, asked the resident if they would like for the bed to be raised, touch the bed buttons on the right lower side of the bed to elevate head area. CNA E asked the resident if they would like for the toast to have jam on it, grabbed a kitchen utensil and then picked up the resident's toast (2 pieces). CNA E grabbed the resident's drink, removed the cellophane and grabbed the top of the cup with 3 fingers around the edge of the glass. No hand hygiene was practiced during observation. During an interview on 5/30/23 at 09:55 AM with CNA D, when asked about removing the dirty brief and not changing her gloves after, CNA D stated she should have changed her gloves, washed her hands, and placed new gloves on. When asked what a negative outcome could be for not changing her gloves and washing her hands, CNA D stated cross-contamination. An interview on 05/31/23 at 01:26 PM, RN A was asked about proper hand hygiene when delivering meals. RN A stated, Know now that for nursing but wash hands before donning gloves. Wash after taking after gloves. During sterile dressings. Change between patients and wash hands. Gloves before administering glucose checks or ointments. Don't touch food with bare hands. If something happens should wash. Should use alcohol when delivering trays. Forgot to do it during mealtime. RN A was asked what a negative outcome could be if hand hygiene was not practiced correctly when delivering meals. RN A stated, It can make residents sick if not doing hand hygiene. In an interview on 05/31/23 at 01:30 PM, CNA G was asked what the handwashing policy was. CNA G stated, Wash hands as soon as you enter the room. All the way up to wrists. Dining room sanitize hands between each tray while serving. An interview on 06/01/23 at 09:53 AM with the DON, it was asked what is the hand washing policy for dining room and delivering food to residents? During dining we are to gel when they get to the window to grab the tray. They delivery the tray then gel again after completing the delivery. Cross contamination can be a negative outcome of not doing hand hygiene during meal delivery services. Record review of facility policy titled, Handwashing/Hand Hygiene revised April 2012, revealed the following: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . n. Before and after assisting a resident with toileting (hand washing with soap and water) . 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: f. Before moving from a contaminated body site to a clean body site during resident care . g. After contact with a resident's intact skin . Record review of facility policy titled Peri care Competency, undated, revealed the following: 4: Washes hands: -Before donning gloves -After removing gloves -Between cleaning the front and back -When heavily soiled . 7. Always washes clean to dirty . Record review of the Food Code through the Food and Drug Administration, dated January 18th, 2023 indicates code 2-301.14 When to Wash that food employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single use and single-use articlesp and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen and 1 of 1 kitchen storage room reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure foods were sealed properly. 3. The facility failed to properly sanitize thermometer to check food temperatures. 4. The facility failed to ensure proper thawing procedures. 5. The facility failed to ensure proper infection control measures. 6. The facility failed to check expiration dates on foods. 7. The facility failed to properly cover/seal foods. These deficient practices could expose residents who consume food prepared in the facility's kitchen to food-borne illnesses. Findings Include : Observation of the dry storage area on 5/30/23 at 8:41 AM revealed the following: 1. 2- 5-pound tubs of potato granules with no lid. lid on the third tub had written in black marker Do not throw away lid with a date of 5/9. 2. 1 gallon of vegetable oil sealed with a piece of tin foil. There was no date and labeled in black marker around the edge Do not throw away. 3. Fancy [NAME] Mousse package -not dated. 4. 7 1-pound packages of Instant Pudding Mix not dated 5. 3 clear containers with condiment packages of (1) mustard (2) mixture of condiment packages (3) mayonnaise- no label or date 6. 2 18-ounce packages of Strawberry Presweetened soft drink mix- no dates 7. Gallon size zip top bag labeled Fruit Loops dated 5/28 with no expiration date. 8. A gallon size zip top bag labeled Corn Flakes dated 5/20 with no expiration date. 9. A box of opened 16-ounce lasagna located in a bigger brown box- opened, not properly sealed, and not dated with an open date. 10. A brown box containing 8 boxes of 16-ounce boxes of lasagna noodles- not dated 11. A gallon size zip top bag with a cream of wheat box with no expiration date. 12. Small Jelly packets - not labeled with a received date 13. Clear Liquid Fry Shortening 35 pounds - No date opened- No use by date 14. 40 7.25 oz individual [NAME] Chicken Noodle Soup - No received date 15. 7 individual glass Agues Fresca Powder Strawberry with no received date 16. Oatmeal in zip top bag- No expiration date 17. Graham cracker crust- No expiration date 18. Light corn syrup bottle 16oz- no open date 19. 7 2.5 oz Ms. Dash Original seasonings- no received/open date 20. 5 pound pancake mix - No expiration date 21. 9 cherry gelatins with no received date 22. 5 pound seasoning salt that was not in a secured container open to air Observation of small refrigerator/freezer on 5/30/23 at 8:56 AM revealed the following: 1. 2 blocks of margarine-wrapped with no dates 2. Gallon jug in Red Diamond container with a brown substance and black markings that reflected, Do not throw away. 3. 16-ounce lemon juice opened on 3/2 with no expiration date 4. 4.5 fluid ounce of Trappey's Peppers opened 4/19- no expiration date or use by date 5. Italian Dressing bottle- opened- no date open 6. 22-ounce Nesquik chocolate syrup- opened with no date 7. 8-ounce [NAME] turkey breast in gallon size plastic bag- not labeled and not dated- no expiration date or use by date 8. A storage container box of oranges in a juice substance- no open date/ no expiration date 9. Small margarine cups in a plastic container- open date- no expiration date. 10. 12.75 oz Heinz Mustard that expired on 1-29-23 11. Sausage Patties in a bag-o expiration date 12. A 1 liter bottle with a label indicating Dr. Pepper. in the freezer- not labeled or dated. 13. 2 12fl oz canisters of concentrated apple juice- no received date Observation of the shelving unit on 5/30/23 at 9:05 AM revealed the following: 1. Nixtamal Corn Tortillas that were not refrigerated indicated to refrigerate after opening and opened with no open date 2. Tender Crust [NAME] Bread- opened with no open date and no received date 3. 2.12-ounce spice jar labeled Nutmeg dated 11/7/21- no use by date or expiration date 4. 3.12-ounce spice jar labeled Garlic Powder- not dated 5. 6.50-ounce plastic jar labeled [NAME] on lid- opened 2/28 with no expiration date 6. 1 pound box of baking soda- no open date 7. 12-ounce [NAME] baking powder - opened 2/9 - expired 9/4/22 8. 17 oz Restaurant Pride oil exposed to air opened 4/28 9. 1 pound 2-ounce plastic container labeled Light Chili Powder and labeled on the back side with a post it note that reflected SALT written in black marker 10. 7 fluid ounces plastic container of Dawn Dish soap located on the bottom shelf stored with food items 11. [NAME] Homestyle Beef Flavored Base- no expiration date- no received date- no open date 12. 2.5 oz Ms. Dash Original spice - opened with no open date 13. A 0.4 oz organic cilantro - opened with no open date- expired 10-30-21 14. 8 fl oz imitation vanilla flavor - expired 4/2023 15. 16 oz cornstarch- no expiration date on the bag 16. 13 oz oregano- expired 4-4-2023 17. Light chili powder- no expiration date 18. Silver canister shaker with a powdery white substance- no label/no date Observation on 5/30/23 at 9:15 AM revealed a frozen ham in a metal pan on the counter located in the middle of the kitchen. Observation of freezer in kitchen storage room the left side of room at 9:23 AM revealed the following: 1. 5 frozen drink cups- no label 2. 2 2 lblb. bags containing frozen okra 2lb - no use by date 3. 6 frozen coconut cream Pies - no use by date 4. 6 16 oz classic jumbo frank hot dogs- no receive date 5. A clear bag containing frozen items- no use by date and not labeled 6. A white bag unopened- no label 7. 6 12 oz frozen peas - no receive date 8. 4 vegetable stir fry- expired 5/2/2023 9. A clear bag containing egg rolls in a cylinder shape- no label- no expiration date 10. A clear bag containing a shredded substance- no label and no dates 11. Frozen Diced Chicken- no use by date Observation of the refrigerator in room [ROOM NUMBER] on the left side of room at 5/30/23 at 9:25 AM revealed the following: 1. A green plastic tub labeled Potato Salad dated 5/29- no use by or expiration date 2. 4 bags labeled Nestle Tollhouse semi-sweet chocolate chips- no date 3. A gallon size bag holding two pieces of cut meat labeled Ham with no dates 4. 2 pints of Food Club Heavy Whipping Cream- no dates 5. 1 gallon Best Made pickles- opened 5/9 no expiration date 6. 19- 1-pound units of individually wrapped margarine- not dated 7. 1 gallon of Kikkoman Teriyaki marinade- opened 9/27- expired 1/15/23 8. 12-ounce plastic container of cottage cheese- dated 5/19 9. A plastic bag containing 6 green bell peppers not labeled, not dated, and located in a box that contained and was labeled tomatoes Observation of the freezer in room [ROOM NUMBER] on the right side of room on 5/30/23 at 9:35 AM revealed the following: 1. 9 bags of Flour tortillas 24 count Frozen - expired 5/16/23- no receive date An observation on 5/30/23 at 12:08 PM revealed DM H did not follow proper protocol with sanitizing the food thermometer between food items. DM H did not sanitize temperature thermometer prior to taking temperatures. DM H placed the thermometer in cooked ham. DM H placed the thermometer in ice and moved the thermometer around. DM H removed the thermometer from the ice and placed the thermometer in mashed potatoes. DM H removed thermometer from mashed potatoes, placed thermometer in ice and moved thermometer around. DM H removed thermometer from ice and placed thermometer in Brussels sprouts. DM H removed thermometer from Brussels sprouts, placed thermometer in ice and moved thermometer around. DM H removed thermometer from ice and placed thermometer in mechanical (finely chopped) ham. DM H removed thermometer from mechanical ham, placed thermometer in ice, and moved around. DM H removed thermometer from ice and placed thermometer in mechanical corn. DM H removed thermometer from mechanical corn, placed in ice and moved thermometer around. DM H removed thermometer from ice and then placed thermometer in pureed ham. DM H removed thermometer from pureed ham and placed in ice. DM H removed thermometer from ice and placed in pureed corn. DM H removed thermometer from pureed corn, placed in ice and moved thermometer around in ice. DM H removed thermometer from ice and placed thermometer in coconut cream pie. An observation on 5/30/23 at 12:32 PM revealed DM H did not wash her hands prior to putting on gloves. DM H continued to wear same gloves when touching the refrigerator, a thick container (powder substance to make liquids thick), a sink handle for water, plastic wrap, and meal card tickets prior to the meal service. DM H then began preparing plates for residents and assembling trays without hand hygiene and changing gloves. An interview with DM H on 5/30/23 at 3:24PM, DM H stated she had been employed at the facility for 15 years. DM H stated she supervised 5 staff. DM H said that her RD trained her on policy and procedures. DM H stated the date received should be written on each food item when it is received. DM H said that they check-in the trucks and are responsible for writing the date received on the food that they get. DM H stated the date open should be written on each food item when it is opened. DM H said the expiration policy for expired foods is 3 days to throw it away. DM H said their handwashing policy is to sing happy birthday and to wash their hands upon entering and exiting the kitchen. DM H stated staff are trained on policy and procedures every 3 months. An interview with [NAME] J on 5/30/23 at 3:17 PM revealed that [NAME] J had been employed at the facility since November 2022. [NAME] J stated training is from videos and DM H. [NAME] J stated the date and name should be on all food when it is received. [NAME] J said when a product is opened that the date it is opened should be written on it. [NAME] J said that the expiration policy is 3 days. [NAME] J stated the handwashing policy is to wash their hands every time staff enters the kitchen from the outside. [NAME] J stated that food is thawed by putting food in the fridge the day before to thaw. An interview with [NAME] K on 5/30/23 at 3:14 PM, [NAME] K stated that [NAME] K had been employed with the facility since April. [NAME] K said DM H trains staff on policies and procedures. [NAME] K stated food should have the date received written on it when it is received. [NAME] K stated when a product is opened that the date should be written on the outside of the item. [NAME] K said the facility's expiration policy is 3 days. [NAME] K stated the handwashing policy is for staff to wash hands when entering the kitchen and before gloves are put on. [NAME] K said meat and food are thawed in the fridge the night before. Record review of the Policy of Storage of Dry Food and Supplies, origination 4/2017; review date 7/2018 revealed, under Procedure headline, line (5)- Chemicals will be kept separate from food and paper . (In a separate storeroom or mop closet) Do not intermingle food and paper supplies, keep in separate areas of the storeroom. Line (6)- Use FIFO (First In, First Out). All foods will be dated on the day of deliver and rotated so that the oldest product is to the front for the first use. Line (7)- For products that will be removed from their original container, use metal or plastic food grade safe plastic containers with tight fitting lids. Label both top and sides of containers. Plastic food grade storage bags may also be used, must be sealed tight and clearly labeled. Line (8)- Use only National Safety Foundation (NSF) approved containers and food grade storage bags for food storage. Line (10)-All opened product will be resealed effectively. Product from open bags, boxes, etc. that cannot be resealed are placed in an appropriate container, labeled, and dated. Record review of the policy Food Safety and Sanitation Plan, origination 4/2015; review date 4/2018, revealed, under line (13) Personal Hygiene Practiced (a) thorough hand washing is required (but not limited to) the following situations: (b) starting the work shift and (e) After coughing, sneezing, or touching hair or face. Record review of the policy Food Safety and Sanitation Plan, origination 4/2015; review date 4/2018, revealed, under Procedure, line (4) Potentially hazardous foods shall be kept at safe temperatures, line (b) Under potable running water at temperature of 70 degrees F below, with sufficient water velocity to agitate and float off loose food particles. Record review of the Policy of Food Inventory, Ordering, Receiving and Stocking, originated 4/2015; review date 4/2018, revealed, under heading of Stock Rotation to date stock with date of delivery (other systems for stock rotation visibility may be used if approved by consultant dietician) place your procedure in this manual. Record review of the policy Storage of Frozen and Refrigerated Food, originated 8/29/2005; review date 10/2017, revealed under the heading Procedure: line (8) Thaw potentially hazardous food on a try on the bottom shelf of the refrigerator. Label to date removed from the freezer, use by date. (7 days from the date removed form the freezer.) This includes meats, fish, poultry, vegetables, and frozen shakes, and all thawing potentially hazardous foods. Line (9) Refrigerate foods in shallow containers to speed the cooling process. Label to date placed in the refrigerator, time, expiration or use by date. Once a product has been opened the date opened shall be written on the product and use by date is 3 days from the date opened. Food prepared in the building and properly cooled will be dated as to the date prepared and use by date which will be 3 days from the date prepared. Line (11) Items to be stored in the refrigerator upon delivery are to be dated to delivery date and expiration date- 7 days following delivery date. The only exception to expiration dating is items containing an expiration date form the manufacturer, ex. Milk, sour cream, cottage cheese, etc. Line (12) Manufactured refrigerated items such as cooked eggs, cheese, lunch meat, when opened are to be placed in a sealed container, labeled to opened date and use by date (7days). Line (14) All refrigerated and Frozen items will contain proper labeling of at least the common name of the product and dated as noted above. Record review of the Dietary Policy Hand Washing origination date: 4/2017; review date 9/2018, revealed, under the heading Fundamental Information- Dietary employees will wash their hands before starting work and after or in-between the following activities: (3) Touching the hair, face, or body; (11) Before donning gloves for working with food. Under heading Procedure: (3) Wet hands and forearms with warm water .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 14 (Resident #13) residents reviewed for PASARR. Resident #13 was not referred for a PASARR Level II assessment when diagnoses of generalized anxiety disorder, major depressive disorder, recurrent severe without psychotic features, psychotic disorder with delusions due to known physiological condition (mental health problem that causes people to perceive or interpret things differently from those around them) and psychotic disorder with hallucinations due to known physiological condition was identified after admission. This failure could affect residents with mental illnesses by placing them at risk of not being assessed to receive needed services. Findings include: Record review of Resident #13's face sheet, dated 05/11/22, revealed an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included rash, heartburn, constipation, chronic pain, shortness of breath, hypertension, restless legs syndrome, type 2 diabetes (high sugar levels for prolonged periods of time), and hypothyroidism (decreased production of thyroid hormones.) The face sheet also revealed on 06/26/20, Resident #13 was diagnosed with generalized anxiety disorder, major depressive disorder, recurrent severe without psychotic features, psychotic disorder with delusions due to known physiological condition and psychotic disorder with hallucinations due to known physiological condition. Record review of Resident #13's Annual MDS, dated [DATE], revealed in Section A1500, Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition? with an answer marked, no. Section C of the MDS revealed a BIMS score of 13 out of 15 which indicated her cognition was intact. Section G revealed she required extensive one-person assistance with bed mobility, dressing, toilet use and personal hygiene, extensive two-person assistance with transferring and supervision with set-up help only with eating. Record review of Resident #13's Care Plan, revealed, in part, [Resident #13] has impaired cognitive function with impaired thought processes related to Psychotic disorder with delusions and hallucinations with a revision date of 03/02/22. The same Care Plan revealed, [Resident #13] uses psychotropic medications with a revision date of 05/09/22. Record review of Resident #13's PASARR Level 1 Screening, dated 07/17/2015, revealed, in part, C0100 Mental Illness .No .C0200 Intellectual Disability .No .C0300 Developmental Disability .No. During an observation and interview on 05/09/22 at 9:00 AM, Resident #13 was sitting a wheelchair, in her room, watching a video on a computer. Her right leg was atrophied (wasted away body tissue or organ). Resident #13 stated she had a hemangioma (non-cancerous reddish tumor formed of excess blood vessels) as a child and has had 21 surgeries. During an interview on 05/11/22 at 8:38 AM with DON and MDS Coordinator, DON stated herself and MDS Coordinator were responsible for assisting with PASARR, though they both just started at the facility March 2022. When asked about Resident #13's diagnoses of generalized anxiety disorder, major depressive disorder, psychotic disorder with delusions and psychotic disorder with hallucinations dated 06/26/20, after she was admitted and after her original PASARR Level 1 was completed, MDS Coordinator stated that he had contacted the local authority for PASARR in the past and was told a PASARR only had to be resubmitted if a resident was discharged from the facility and then readmitted . DON stated, I've been doing this for six years and have never done that before [resubmitted a PASARR after resident admission). During an interview on 05/11/22 at 1:35 PM with DON and ADM, DON stated MDS Coordinator had contacted the local authority for PASARR and was told that because of Resident #13's diagnosis codes, a PASARR did need to be resubmitted. DON stated she was not sure why a PASARR was not resubmitted when Resident #13 was diagnosed with the previously discussed diagnoses on 06/26/20. DON stated on Resident #13, there would have been no negative outcomes related to not resubmitting a PASARR due to new qualifying diagnoses. DON stated, PASARR offers them everything we offer them. DON stated she had PASARR training in 2019 and since then, she had received intermittent training from a State Quality Monitoring Nurse. DON stated diagnoses that would warrant a PASARR evaluation included, schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), it depends on if it is for ID (Intellectual Disability) or MI (Mental Illness). It has to be a combination. No bipolar (serious mental illness characterized by extreme mood swings; can include extreme excitement episodes or extreme depressive feelings) by itself. They say Tourette's (neurological condition that causes unwanted, involuntary muscle movements and sounds known as tics.) DON stated she had used the Resident Assessment Instrument as a guide regarding PASARR. ADM stated Resident #13 would not have had any negative outcomes related to not resubmitting a PASARR due to new qualifying diagnoses. She stated that Resident #13 was alert and oriented and could communicate. DON stated she did not think the facility had a PASARR policy, but she would look. During an interview on 05/11/22 at 2:13 PM, MDS Coordinator stated he spoke with the local authority for PASARR that day and was told he did need to resubmit another PASARR for Resident #13. He stated he was not really told why, I assumed they (a resident) get a new diagnosis like psychosis, just to be safe (resubmit a PASARR.) When asked what diagnoses could qualify a resident for a PASARR evaluation, MDS Coordinator stated psychoses, Tourette's, schizophrenia, bipolar, and any intellectual disabilities. MDS Coordinator stated he had only been at the facility a month. MDS Coordinator was asked what negative outcome could arise if a resident obtained a diagnosis after admission that could qualify them for PASARR services but they did not have a PASARR resubmitted and MDS Coordinator replied if a resident was entitled to PASARR services, they would not be getting those services. MDS Coordinator stated he has had no PASARR training, just what he had learned over the years. During an interview on 05/11/22 at 3:00 PM, DON stated the facility did not have a PASARR policy.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of one medication carts reviewed for medication labeling and storage. The South Hall medication cart contained one vial of Lantus insulin for Resident #1 that had an open date of 04/05/22 and no expiration date, one Novolog Flexpen insulin for Resident #13 that had an open date of 04/05 (no year) and no expiration date and one vial of Lispro insulin for Resident #7 that had an open date of 03/17 (no year) and no expiration date. This failure could place residents who receive insulin at risk of exposure to medications and/or biologicals that are expired and/or contaminated. Findings include: During an observation and interview on 05/09/22 at 10:01 AM of the South Hall medication cart with LVN A, a vial of Lantus insulin was found for Resident #1 with an open date of 04/05/22 and with no expiration date after being opened. LVN A stated 04/05/22 was the open date and that the insulin expired 20-30 days after it was opened. A Novolog Flexpen for Resident #13 was found dated 04/05 (no year) and with no expiration date after being opened. LVN A stated 04/05 was the open date and that the insulin expired 20-30 days after it was opened. A vial of Lispro insulin for Resident #7 was found dated 03/17 (no year) and with no expiration date after being opened. LVN A stated 03/17 was the open date and that the insulin expired 20-30 days after it was opened. LVN A stated she thought all insulins had an expiration date of 20-30 days after they were opened. She stated all nurses were responsible for checking the medications carts for expired medications. LVN A stated administering an expired medication to a resident could cause a reaction. During an interview and record review on 05/11/22 at 1:44 PM with DON and ADON, when asked what the expiration date was for an open vial of Lantus, DON stated she did not know and ADON stated 30 or 31 days. When asked what the expiration date was for an open pen of Novolog, DON did not answer and ADON stated 28 days. ADON stated all nurses were responsible for checking the medication cart for expired medications and DON stated the night nurses were also responsible for checking the medication carts for expired medications. DON stated the pharmacy consultant would also audit the medication carts and check for expired medications monthly. DON stated there could have been no negative outcomes to administering expired insulins. DON stated there could have been a negative outcome if the insulin was administered past the factory expiration date on the bottle, but no negative outcomes if administered past the expiration date based on the open date. ADON stated nurses underwent new hire competencies upon hire at the facility and one of the competencies included medication administration which, upon review, revealed, .19. Seven right of administration are observed .compliance with manufactures specifications. DON stated, regarding checking for expired mediations, that's what you learn in nursing school. Record review of facility provided policy titled, Storage of Medications, undated, revealed, in part, .Purpose .The purpose of this procedure is to ensure that medications are stored in a safe, secure, and orderly manner .General Guidelines .3. No discontinued, outdated, or deteriorated medications are available for use in this facility. All such medications are destroyed.