**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with an indwelling urinary catheter received treatment and services for 1 of 5 residents (Resident's #1, #2, and #3) reviewed for indwelling urinary catheters. 1. The facility failed to have a physician's order for Resident #2's urinary catheter. 2. The facility failed to ensure Resident #1, Resident #2, and Resident #3's urinary catheter bags were inside a privacy cover while inside and outside of their rooms. This deficient practice could affect any resident with an indwelling urinary catheter and place them at risk of increased UTI's, discomfort, and decreased quality of life. The findings included: Review of Resident #1's comprehensive MDS assessment dated [DATE] reflected an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included stroke (poor blood flow to part of the brain causing cell death), high blood pressure, diabetes, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. In an observation on 05/16/2025 at 9:37 AM, Resident #1 was wheeling down the hallway with her urinary catheter bag clipped to the side of her wheelchair and approximately ¼ of the way full of bright yellow urine. In an interview on 05/16/2025 at 9:45 AM with Resident #1, she stated that she almost never had a privacy cover on her catheter bag, and that it just hung off the side of her wheelchair for anyone to see. In an interview on 05/16/2025 at 10:52 AM with Resident #1's FM, they stated that Resident #1's catheter bag was not usually covered with a privacy bag when they visited the resident. The FM stated that they visited almost daily and that on (5/16/25) was the first time a CNA went in and put a privacy bag over the Resident's catheter bag. Review of Resident #2's closed record comprehensive MDS assessment dated [DATE] reflected an-[AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included heart failure, high blood pressure, obstructive uropathy (a blockage that prevents urine from flowing naturally through the urinary system), hyperlipidemia (high levels of fats in the blood), osteoporosis (bones disease), aphasia (impairment in speech production, comprehension, reading and/or writing), non-Alzheimer's dementia (memory impairment), depression (sadness), and encounter for surgical aftercare following surgery on the digestive system. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. Review of Resident #2's care plan dated closed on 05/09/2025 due to discharge reflected no indication the resident had an indwelling catheter. Review of Resident #2's physician's orders dated active as of 4/11/2025 reflected no orders for an indwelling urinary catheter. Review of Resident #3's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included heart failure, high blood pressure, urinary tract infection, diabetes, depression, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In an observation and interview on 05/16/2025 at 3:00 PM of Resident #3 in her room revealed she thought her catheter was coming out and that the bag needed to be changed because it felt full. Observation of her bag hanging on the side furthest from the door revealed an almost full plastic container in front of an almost empty catheter bag that was not inside of a privacy bag. In an interview on 05/16/2025 at 10:33 AM with CNA B she stated that the importance of having a privacy cover on the catheter bag is so other residents don't see the urine. In an interview on 05/16/2025 at 11:30 AM with the DON, she confirmed that the orders for Resident #2's Foley catheter could not be located in the EHR. Additionally, it was confirmed that she was not care planned for a Foley catheter. She stated that she could not understand why the orders were not showing up nor why the care plan would not be showing catheter care, because 'How else would MDS know to mark it?' Regarding catheters having a privacy bag, she stated that those were just there for residents' dignity and that any of the direct care staff can put a privacy cover over a catheter bag. Review of the facility's Catheter Care policy last reviewed December 2023 reflected, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Residents #1, #2, #3, and #4) of 7 residents reviewed for comprehensive care plans. The facility failed to care plan the use of Residents #1, #2, #3, and #4's urinary catheters. This failure placed residents that had urinary catheters at risk of not having their need for assistance met and increased susceptibility to UTI's. The findings included: Review of Resident #1's comprehensive MDS assessment dated [DATE] reflected an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included stroke (poor blood flow to part of the brain causing cell death), high blood pressure, diabetes, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. Review of Resident #1's initial care plan dated 04/23/2025 reflected no indication the resident had an indwelling catheter. In an observation on 05/16/2025 at 9:37 AM, Resident #1 was wheeling down the hallway with her urinary catheter bag clipped to the side of her wheelchair and approximately ¼ of the way full of bright yellow urine. In an interview on 05/16/2025 at 9:45 AM with Resident #1, she stated that she almost never had a privacy cover on her catheter bag, and that it just hung off the side of her wheelchair for anyone to see. Review of Resident #2's closed record comprehensive MDS assessment dated [DATE] reflected an-[AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included heart failure, high blood pressure, obstructive uropathy (a blockage that prevents urine from flowing naturally through the urinary system), hyperlipidemia (high levels of fats in the blood), osteoporosis (bones disease), aphasia (impairment in speech production, comprehension, reading and/or writing), non-Alzheimer's dementia (memory impairment), depression (sadness), and encounter for surgical aftercare following surgery on the digestive system. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. Review of Resident #2's care plan date closed on 05/09/2025 due to discharge reflected no indication the resident had an indwelling catheter. Review of Resident #2's physician's orders revealed no orders for a Foley catheter or catheter care. Review of Resident #2's hospital record dated 04/07/2025 reflected, Patient placed on Foley catheter by urology, plan to DC with Foley catheter and follow-up with urology. Hydronephrosis (a condition where a kidney swells due to urine buildup caused by an obstruction) significant improvement of right hydronephrosis after manual reduction. -Foley catheter. Renal Function okay. Follow-up with urology. Review of Resident #3's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included heart failure, high blood pressure, urinary tract infection, diabetes, depression, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In Section H - Bladder and Bowel, the resident was marked as having none of the above when asked if the resident had an indwelling catheter, external catheter, ostomy, or intermittent catheterization. Review of Resident #3's care plan last revised 05/14/2025 reflected no indication that the resident had an indwelling catheter or intermittent catheterization. Review of Resident #3's physician's orders revealed an order for Foley Catheter Care every shift, ordered 3/19/25. An order for Indwelling Foley catheter (16F 30cc) to continuous drainage, ordered 3/19/25. An order for Secure catheter tubing with anchor every shift, ordered 3/19/25. An order for Change the Foley catheter every 30 days, ordered 3/19/25. In an observation and interview on 05/16/2025 at 3:00PM of Resident #3 in her room revealed she thought her catheter was coming out and that the bag needed to be changed because it felt full. Observation of her bag hanging on the side furthest from the door revealed an almost full plastic container in front of an almost empty catheter bag that was not inside of a privacy bag. Review of Resident #4's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included high blood pressure, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. Review of Resident #4's care plan last revised 04/29/2025 reflected no indication that the resident had an indwelling catheter. In an interview on 05/16/2025 at 10:33 AM with CNA B she stated that she recalled Resident #2 often yanking on her catheter, asking why she had it, and demanding it be removed from her body. She stated that the importance of having a privacy cover on the catheter bag is so other residents don't see the urine. In an interview on 05/16/2025 at 2:00 PM with the MDSC, she stated that Resident #3's MDS assessment would be updated to reflect a catheter during her next assessment unless she had a significant change before then, and that becoming catheterized did not call for an SCSA. She stated that the resident previously had a catheter, had it removed, had it replaced at another time, and it was failed to be care planned during the most recent insertion. As for the other residents, she stated that she could not provide an answer as she maintained the long-term residents' assessments, and the short term MDSC was out of office for an extended period. In an interview on 05/16/2025 at 3:46 PM with LVN A, she stated that she knew to provide catheter care to Resident #2 because she could see the resident had a catheter. She recalled that the resident would frequently ask for the catheter to be removed and asked the staff why she had it. She stated that she knew what hygienic care to provide because with any resident that has a Foley, they are to provide a standard practice of cleanliness and hygiene when providing incontinent care, including cleaning the pubic area and the tubing surrounding the outside of the pubic area. She stated that she can recall multiple times providing incontinent care to Resident #2 and they also began the toileting program with her. Review of the facility's Care Plans, Comprehensive Person-Centered dated last revised 03/2022 reflected, . The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for one (Resident # 21) of eight residents reviewed for PASRR services. The facility failed to refer Resident #21 for a PASRR level II evaluation to the State-designated authority. This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being. Findings included: Record review of Resident #21's face sheet, dated 09/18/24, reflected the resident had a primary diagnosis of chronic obstructive pulmonary disease (common lung disease that makes it difficult to breathe) and other diagnoses were listed as dementia, schizoaffective disorder, bipolar disease. Record review of Resident #21's quarterly MDS Assessment, dated 07/03/24, revealed she was admitted to the facility on [DATE] with diagnoses which included non-Alzheimer's dementia, schizophrenia, and bipolar disorder. Resident #21's BIMs score of 15 indicated the resident's cognition was intact and she was able to make decisions for herself. Record review of Resident #21's PASRR Level I screening, dated 03/27/23, reflected the resident did not have a history of mental illness. Record review of Resident #21's Form 1012, Mental Illness/Dementia Resident Review , dated 01/24/20, reflected the resident had a primary diagnosis of dementia. An observation and interview on 09/17/24 at 10:50 AM with Resident #21 revealed she was lying in bed. She was awake, alert, and oriented. She said she did not receive PASRR services and she did not know what PASRR was. An interview on 09/18/24 at 9:53 AM with MDS Nurse B revealed she had worked at the facility since 2008. She said Resident #21 did not have a PASRR Level II screening. She said the PASRR Level 1 screening reflected the resident did not have mental illness. MDS Nurse B said instead of completing a new PASSR Level 1 screening, she filled out a form 1012. She said she did not know she had to do a new PASSR Level 1 screening if the first one was incorrect. She said the form 1012 was a paper form that was not sent to the mental health authority and she did not think that it needed to be sent to them. She said she was the only person in the facility who completed PASRR forms. She said there was a risk that the resident could miss services she was entitled to if the PASRR forms were not filled out correctly. An interview on 09/18/24 at 12:52 PM with the DON revealed she had worked at the facility for the last 6 years. She said MDS Nurse B was responsible for completing PASRR forms and the DON did not oversee the work that she did. The DON said she did not know a whole lot about PASRR. She said she did not know what the PASRR policy said until 09/18/24. An interview on 09/19/24 at 2:24 PM with the Administrator revealed MDS Nurse B was responsible for ensuring PASRR assessments were correct. He said there was no one in the facility who reviewed the work of MDS Nurse B. Record review of the facility policy PASSR Policy and Procedure revised January 2024, reflected: Policy It is the policy of our company to ensure that all PASRR requirements are followed as set forth and regulated by The Texas Department of Health and Human Services and Centers for Medicaid and Medicare Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames that met the residents clinical and psychosocial needs that were identified in the comprehensive assessment for 2 (Resident #19 and Resident #22) out of 8 residents reviewed for care plans. The facility failed to ensure that Resident #19's comprehensive care plan included her diagnosis of pain. The facility failed to ensure that Resident #22's Care Plan was updated to reflect that he no longer had an indwelling catheter. This failure could place residents at risk of having received inadequate interventions not individualized to their care needs and diagnoses. Findings Included: 1.) Record Review of Resident #19's quarterly MDS assessment dated [DATE], revealed she was an [AGE] year-old male who admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (disease of the lungs that makes it difficult to breathe). The resident was receiving scheduled and as needed pain medication. Resident #19 had a BIMS score of 15 indicating no cognitive impairment. Record review of Resident #19's Order Summary Report, dated 09/18/24, reflected: 1. 07/11/23 Biofreeze external gel 4 % (Topical pain medicine). Apply to mid back topically every 8 hours as needed for pain. 2. 04/16/24 Lidocaine external kit 4 % (Topical pain medicine). Apply to both shoulders topically in the morning for right shoulder pain and remove per schedule. 3. 05/20/24 Lidocaine external patch 4 % (Topical pain medicine). Apply to right foot topically as needed for pain. 4. 07/11/23 Mobic oral tablet 15 milligrams (pain medicine). Give 1 tablet by mouth at bedtime for pain. 5. 03/14/24 Tizanidine HCl oral tablet 2 milligrams (pain medicine.) Give 1 tablet by mouth two times a day for pain/muscle spasms. 6. 03/21/24 Tramadol HCl oral tablet 50 milligrams (pain medicine). Give 1 tablet by mouth two times a day for pain. An observation and interview with Resident #19 on 09/17/24 at 12:55 PM revealed she was lying in bed. She said she suffered with chronic pain and took scheduled pain medication. Record Review of Resident #19's comprehensive care plan, no date reflected, reflected she did not have a care plan for pain. An interview on 09/19/24 at 1:55 PM with MDS Nurse D revealed she did not know why Resident #19 did not have a care plan for pain. She said she and the managers were responsible for creating care plans. She said there was a risk to the resident of having increased pain if she did not have a care plan for pain. An interview on 09/18/24 at 4:12 PM with the DON revealed she did not know why Resident #19 did not have a care plan for pain. She said MDS Nurse D was responsible for creating the care plan. The DON said care plans were important because they directed care. 2.) Review of the Resident Face Sheet dated 09/19/24 revealed Resident #22 was an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #22's active diagnoses include: dysphagia (difficulty swallowing), acute cough, allergies, type 2 diabetes mellitus with diabetic polyneuropathy (a complication of diabetes that causes nerve damage in the hands, legs, feet, and arms), chronic obstructive pulmonary disease (ongoing lung condition caused by damaged lungs), acute and chronic respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing low levels of oxygen in the bloody tissues), mood disturbance, psychotic disturbance, dementia, heart failure, heart disease, cataract (a cloudy area in the eye), acute kidney failure, hypokalemia (occurs when the amount of potassium in the blood was low), pulmonary fibrosis (scarring and thickening of the tissue around in the lung between the air sacs), vitamin b deficiency, other retention of urine, abnormalities of gait and mobility, and falls. Review of the admission MDS assessment dated [DATE] revealed Resident #22's cognition was moderately impaired. Resident #22 required limited assistance with the support of one staff for bed mobility and extensive assistance with the support of one staff for transfers. Resident #22 used a wheelchair for mobility. Resident #22 had an indwelling catheter (including suprapubic catheter and nephrostomy tube - a thin, flexible tube that drains urine directly from the kidney into a bag outside the body). Review of the Care Plan dated 01/12/18 revealed Resident #22 had an indwelling Foley catheter: Neurogenic bladder. Date Initiated: 11/16/2023 Revision on: 05/28/2024 Resident #22's Goal: Resident #22 will be/remain free from catheter-related trauma through review date. Date Initiated: 05/28/2024 Target Date: 05/21/2024 Resident #22's Interventions: Catheter: The resident has 16F 30cc balloon foley catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Date Initiated: 11/16/2023 Revision on: 05/28/2024 Monitor/document for pain/discomfort due to catheter. Date Initiated: 11/16/2023 Monitor/record/report to MD for s/sx UTI: 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. Date Initiated: 11/16/2023 Record review of Resident #22's Physician's Order for 06/05/2024 stated, May replace foley catheter for leaking every 24 hours as needed for leaking. Record review of Resident #22's Progress Notes for 08/20/2024 written by LVN G reflected, Nurse talk to Hospice nurse. Regarding catheter reinsertion. Nurse informed her that resident didn't tolerated reinsertion attempt well, even though he was premedicated with Morphine. [Staff] informed nurse that Resident #22's family member was fine with resident remaining in brief for the night and she would come out to attempt reinsertion on 8/21/2024 in am. If reinsertion isn't possible hospice would send him to ER for reinsertion. Record review of Resident #22's Progress Notes for 08/20/2024 written by LVN H revealed, This nurse notifed residents hospice nurse when returned phone call of residents [NAME] on penis from catheter being possible pulled out. This nurse explained to hospice nurse of [NAME] and blood and that the penis was torn. This nurse also explained when trying to insert another catheter resident grimcing in pain. Hospice nurse asked if this nurse could try again to insert another catheter. At 07:00, Nurse was notified by aide that resident was up and walking and catheter on floor. When tried to replace catheter with a new one, resident had no urine returne, small spots of blood. This nurse stopped the catheter insurtion and notified DON and notified hospice . [sic] Record review of Resident #22's Progress Notes for 08/21/24 - 09/05/2024 reflected the resident did not have a catheter. During an observation of Resident #22 on 09/19/24 at 12:55 PM revealed he was sitting on his bed and eating lunch. Resident #22 was observed without a catheter. In an interview on 09/19/2024 at 12:59 PM, Resident #22 stated that he no longer had a catheter. Resident #22 stated that he currently wore underwear, and he no longer needed a catheter. Resident #22 stated that he had some issues with his catheter, and it was causing some pain. He stated that he did not know what kind of issues he was having with his catheter, but it was causing him pain, therefore the staff decided to remove the catheter. In an interview on 09/19/24 at 1:07 PM with CNA F, she confirmed that Resident #22 no longer had an indwelling catheter. She reported approximately 2 months ago Resident #22 had an indwelling catheter and he was getting up from his bed and held onto his wheelchair and he used his bedside table for support and his indwelling catheter ripped out. She stated that staff at the facility attempted a few times to reinsert Resident #22's indwelling catheter but were unsuccessful. CNA F stated that Resident #22's hospice nurse was contacted and stated that she would try to reinsert Resident #22's indwelling catheter and if unsuccessful, she would have Resident #22 sent to the emergency room at the hospital to have his indwelling catheter reinserted. CNA F stated that Resident #22's incontinence hadimproved, and he no longer needed his indwelling catheter, and she did not remember how long Resident #22 had been without his indwelling catheter. She stated that she was unaware that Resident #22's Care Plan and MDS Assessment reflected him still having the indwelling catheter. CNA F stated that the risk the facility's medical records being improperly coded on Resident #22's Care Plan , which reflected that he currently had an indwelling catheter could be a form of neglect. She further stated that if someone was to review Resident #22's Care Plan in PCC (a cloud-based healthcare software provider for long-term and post-acute care) to inquire about his incontinence and the system said that he had an indwelling catheter, it could lead to him having infections. In an interview on 09/19/24 at 1:21 PM with the DON, she stated that Resident #22 had a medical diagnosis of neurogenic bladder, which was a urinary condition that lacked bladder control due to a brain, spinal cord or nerve problem. The DON reported that Resident #22 was on hospice and that he had an incident (unknown timeframe) in which his catheter was accidently ripped out by the resident. She stated that the staff attempted to replace Resident #22's catheter but were unsuccessful and his hospice nurse was notified. She reported that after the incident Resident #22 was wearing briefs and had been without his catheter for 3-4 days and the staff were excited. She stated that Resident #22 was doing well with his incontinence, therefore his hospice provider decided to remove his physician order for the catheter. She stated that the MDS Nurses are responsible for the revisions of residents Care Plan. She stated that she was unaware that Resident #22's Care Plan was not updated. She stated that she did not feel as though there were any risk or harm that could have been done with Resident #22's Care Plan reflecting that he had a catheter. She stated that it would not hurt him and there would be more hurt to Resident #22 if he needed or required a catheter and did not have one. In an interview on 09/19/24 at 1:56 PM, MDS Nurse D, she stated that she was responsible for managing resident Care Plans. She stated that the management at the facility have weekly meetings on Mondays and sometimes Thursdays to discuss the changes that needed to be made, if any to residents Care Plans. She stated that Care Plan meetings were conducted at the facility to ensure that residents Care Plans were accurate or needed to be changed. MDS Nurse D stated that she was unsure when the Care Plan meetings are conducted at the facility, but she knew that they were done. MDS Nurse D stated that she was unaware that Resident #22's Care Plan reflected that he still had a catheter. She stated that she was responsible for documenting the discontinuation of the catheter on Resident #22's Care Plan. She stated that a risk of Resident #22's Care Plan not being properly documented to reflect that he no longer had a catheter would be that he could be overlooked for incontinence checks. She stated that the error on Resident #22's Care Plan could possibly cause harm due to skin breakdown if the staff did not regularly check on him because they thought he had a catheter. In an interview on 09/19/2024 at 2:24 PM, the Administrator stated that he had 2 MDS Nurses (MDS Nurse B and MDS Nurse D) that were responsible for inputting and revising the residents' adjustments made to the Care Plan. The Administrator stated that MDS Nurse B was responsible for the revisions of the residents Care Plan for residents who were at the facility for short term. He stated that MDS Nurse D was responsible for the revisions of the residents Care Plan and for residents who were at the facility for long term, including Resident #22. He stated that there were not a person that oversees the MDS Nurses work, but the facility had QRM a company that helps them oversee the duties that the MDS Nurses perform. He stated that the facility reviewed the recommendations and changes in QA and LOC meeting in which management reviewed things that they covered and caught in the meetings, which could include the oversights from QRM. He stated that both MDS Nurses looked over each other's work to cover themselves. The Administrator stated that he was unaware that Resident #22's Care Plan were not updated to reflect that he no longer had a catheter. He stated that he did not feel as though there were any risks or harm to Resident #22 due to his Care Plan not being updated to reflect that he no longer had a catheter. He confirmed that Resident #22's Care Plan should have been updated to reflect the changes for Resident #22 no longer having a catheter. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered Care Plans, dated March 2022 revealed the following elements: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. b. identify individuals or roles to be included; c. request meetings; d. request revisions to the plan of care; e. participate in establishing the expected goals and outcomes of care; f. participate in determining the type, amount, frequency and duration of care; g. receive the services and/or items included in the plan of care; and h. see the care plan and sign it after significant changes are made. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma-informed. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. 13. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 8 residents (Resident #4) reviewed for quality of care. The facility failed to ensure Resident #4 was not misdiagnosed with schizoaffective disorder. This failure could place residents at a risk of being misdiagnosed and receiving incorrect treatment. Findings included: Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old-female admitted to the facility on [DATE]. The resident had a BIMS score of 3 indicating severe cognitive impairment. The resident's diagnoses included hip fracture, non-Alzheimer's dementia, and schizophrenia. Record review of Resident #4's comprehensive care plan, dated 07/19/24, reflected: Resident uses psychotropic medications related to behavior management, schizoaffective/bipolar type, and dementia with psychotic disturbance. Record review of Resident #4's History and Physical, dated 04/05/24, and completed by Physician E reflected: Patient seen and examined in bed with family present. Per the patient's family, she has had short-term memory issues for the past few months that have been markedly worse since anesthesia following her knee operation. She was given Geodon and Ativan at the hospital and became psychotic. She has a history of poor reaction to these medications in the past. We discussed the need to discontinue Seroquel. Family says that she has never been formally diagnosed with dementia though she clearly exhibits the signs. Admit History: [AGE] year-old female with past medical history of high blood pressure, depression, and advanced dementia who presented to the emergency room on [DATE] following a ground level fall onto her left side. She underwent surgery which markedly worsened her psychosis from her dementia and possible urinary tract infection. She was treated for urinary tract infection and given Seroquel. She does not have a history of borderline personality disorder or schizophrenia. Psychologic: Normal mood/affect, Insight Impaired. Cognitive Status: Forgetful, confused, dementia. Record review of Resident #4's Behavioral Health Organization Diagnostic Assessment, dated 04/15/24, and completed by the Psychologist reflected: New referral: Patient has a history of depression and schizoaffective disorder. She also has a history of dementia. Patient was referred to determine her ability to benefit from psychological services at this time. Patient denies history of psychiatric hospitalization, depression, and schizoaffective disorder. Patient was a poor historian due to the severity of her cognitive impairment. Clinical Assessment: Based upon clinical interview, brief symptom screening, and a review of records, resident currently meets criteria for major depressive disorder, recurrent episode, mild. In addition, she qualifies for unspecified dementia, moderate, with agitation. Lastly, patient has a historic diagnosis of schizoaffective disorder. Service Plan: No therapy recommended. Record review of Resident #4's Psychiatric Subsequent Assessment, dated 09/05/24, and completed by the Psychiatric-Mental Health Nurse Practitioner reflected: Reason for referral: Agitation, Irritability, Psychosis, Confusion, Short Term Memory Problems, Long Term Memory Problems, Verbal Aggression, Physical Aggression, Medication Evaluation. Psychosis: Staff reports no current symptoms of auditory hallucinations, delusions or disorganized speech. Assessment/Plan: 1. Recurrent depressive disorders is being treated with Zoloft 25 milligrams daily. 2. Dementia in other diseases classified elsewhere, unspecified severity, with agitation is being treated with Namenda 5 milligrams two times a day. 3. Unspecified psychosis being treated with Seroquel 12.5 milligrams every night. No overt symptoms of psychosis noted or reported, will monitor closely. There was no diagnosis of schizoaffective disorder. An observation on 09/17/24 at 10:23 AM revealed Resident #4 was lying in bed asleep. An interview on 09/17/24 at 12:04 PM with the representative party for Resident #4 revealed the resident did not have a history of schizoaffective disorder. An interview on 09/18/24 at 3:09 PM with MDS Nurse B revealed Resident #4 had a diagnosis on the MDS assessment for schizoaffective disorder because it was listed on a psychologist note dated 04/15/24. She said the resident did not have the diagnosis when she was admitted . An interview on 09/18/24 at 3:40 PM with the Medical Director revealed Resident #4 did not have a history of schizophrenia or schizoaffective disorder. An interview on 09/19/24 at 12:14 PM with the Psychologist revealed he documented the resident as having schizoaffective disorder in his note for 04/15/24. He said he later found out it was a false diagnosis and he said he notified an unknown facility staff about the error on unknown date. An interview on 09/19/24 at 2:18 PM with the DON revealed she signed the MDS assessment dated [DATE] for Resident #4. She said that she signed all MDS assessments but did not review every single one and could not remember if she reviewed Resident #4's MDS. She said for Resident #4, the misdiagnosis did not affect the resident. Record review of the facility policy, Antipsychotic Medication Use, dated 2001, reflected: 4. The attending physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions. Record review of the facility policy, MDS Completion and Submission Timeframes, revised July 2017, reflected: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #62 and Resident #188) of 8 residents observed for infection control. 1. LVN A failed to clean the blood pressure cuff after using it on Resident #188 who was on enhanced barrier precautions. LVN A used the same blood pressure cuff on Resident #62. 2. The facility failed to post signage on Resident #188's that he was on enhanced barrier precautions. The failures could place residents at risk for healthcare associated cross contamination and infections. Findings included: Record review of Resident #188's face sheet dated 09/17/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included 3rd degree burns on his left leg and malignant neoplasm of the brain (brain cancer). Record review of Resident #62's face sheet dated 09/17/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (brain dysfunction). An observation and interview on 09/17/24 at 9:23 AM with LVN A revealed she was administering medications. She said it was her first day as an employee at the facility, but she had worked at the facility before as an agency nurse. LVN A prepared medications for Resident #188. There was no signage or PPE in front of Resident #188's room. LVN A did not wear PPE in Resident #188's room. LVN A took the medications and blood pressure cuff into Resident #188's room and set the medications and blood pressure cuff on the resident's lap tray. LVN A took the resident's blood pressure and administered his medications. LVN A took the blood pressure back to the medication cart and laid it on top of the cart. An observation on 09/17/24 at 9:42 AM revealed two therapy staff put on full PPE and entered Resident #188's room. An observation and interview on 09/17/24 at 9:47 AM revealed LVN A took the blood pressure cuff, that she did not sanitize, and used it on Resident #62. LVN A said she was supposed to clean the blood pressure cuff between using it on residents but forgot to. She said she was supposed to clean it to prevent infection. LVN A left and said she would return shortly. An observation and interview on 09/17/24 at 9:50 AM revealed LVN A returned to the medication cart. She said she found out Resident #188 was supposed to be on enhanced barrier precautions because he had a Foley catheter. She said she did not know because there was no signage on the door and there was no PPE outside of his room. She said she should have worn PPE (gown and gloves) before entering Resident #188's room. A follow-up interview on 09/17/24 at 1:03 PM with LVN A revealed she completed infection control check-offs while she was an agency nurse at the facility. She said she did not know why Resident #188 did not have signage on the door. She said she did not know who was responsible for making sure signage on resident doors. She said she did not know of any other residents who did not have signage and PPE available for enhanced barrier precautions. She said it was important to don PPE for residents on enhanced barrier precautions to prevent the spread of infection. An interview on 09/18/24 at 11:14 AM with the ADON revealed she was able to identify all residents who were on enhanced barrier precautions. She said she did not know why Resident #188 did not have his signage posted on his door. She said it was possible that other residents were taking them down. She said she and the DON were responsible for making sure that residents on enhanced barrier precautions had the proper signage and PPE available. The ADON said there was a risk of infection to residents if PPE was not worn as needed. She said medical equipment was supposed to be cleaned between each resident used to prevent exposure to infection. An interview on 09/18/24 at 1:06 PM with the DON revealed Resident #188 was on enhanced barrier precautions because he had leg wounds. She said she did not know why Resident #188 did not have the signage on his door. She said the facility was going to order a different type of device to hold the signs so that the residents could not take them down. The DON said it was everyone's responsibility to ensure signage was posted on the resident's door. Record review of the facility policy, Infection Control, dated November 2017, reflected: c. Standard and transmission-based precautions to be followed to prevent the spread of infections .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 18 residents (Resident #24) reviewed for call lights in that: Resident #24's call light was not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #24's admission record dated 07/27/23 documented a [AGE] year-old female admitted on [DATE]. Resident #24 documented diagnoses included: Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing (fracture of left leg), non st elevation (NSTEM) myocardial infarction (type of heart attack that usually happens when your heart's need for oxygen can't be met), candidiasis (Vaginal yeast infection), lack of coordination (coordination impairment or loss of coordination), type 2 diabetes mellitus without complication (body doesn't make enough insulin or can't use it as well as it should), and age related osteoporosis with current pathological fracture (deterioration in bone mass with increasing risk to fragility fractures. Record review of Resident #24's MDS assessment dated [DATE] revealed the resident had a BIMS score of 12 indicating the resident was cognitively moderately impaired. The MDS also revealed the resident required extensive assistance in various areas of activities of daily living such as bed mobility, dressing, and toilet use. Record review of Resident #24's care plan dated 07/27/23 revealed Resident #24 was care planned for her impaired physical mobility and ADL self-care performance deficit r/t s/p L femur fx. Resident #24's care plan did not reveal call light assistance/placement or interventions. Observation and interview of Resident #24 on 07/25/23 at 11:52am revealed her right hand was contracted and had a splint on it. Her call light was pinned to her upper right shoulder and out of her reach. Resident #24 stated that she can only reach her call button if it is pinned in the middle of her shirt or the middle of her blanket. Resident #24 stated that her call button is often out of reach. Resident #24 stated that if she needs assistance when her call button is out of reach, she yells so someone can come assist her. Observation of Resident #24 on 07/25/23 at 12:52pm revealed her call light was pinned to her upper right shoulder and out of her reach. An interview with CNA #A on 07/26/23 at 2:27 pm, revealed CNAs make rounds at least every two hours or as needed. CNA #A stated during the CNAs' rounds they look to see if the resident's call light is in reach. CNA #A stated Resident #24 likes to have her call button to be placed on her left side on the inside of her shirt. CNA #A stated resident #24 told him that she like her call button on the inside of her shirt on the inside . CNA #A stated if Resident #24's call button was placed in any other position then it would be hard for her to access. CNA #A stated if a resident's call button was not in reach, then a resident would not be able to get assistance or the care they may be in need of. An interview with the DON on 07/27/23 at 11:05am. The DON stated anyone that goes into the resident's rooms is responsible for ensuring call buttons are in reach. DON stated if a resident's call button is not in reach then the resident will not be able to ask for assistance when needed. Record review of the facility's Call System policy not dated revealed Policy statement Residents are provided with a means to call staff for assistance through a communication system that directly call a staff member or a centralized work station. Policy interpretation and implementation 1. Each resident is provided with a means to call staff directly of assistance from his/her bed, for toileting/bathing facilities and from the floor. 4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to not admit any new residents with a mental disorder unless the State mental health authority has determined based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission that because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility for (Resident #38) of one of four resident reviewed for PASARR screenings. The facility failed to ensure Resident #38 PASARR Level One screening accurately reflected their diagnoses of mental illness. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Review of Resident #38's admission Face Sheet dated July 26, 2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included Type 2 Diabetes Mellitus without Complications (a chronic disease that causes a person's blood glucose levels to rise too high), Essential (Primary) Hypertension (abnormally high blood pressure that's not the result of a medical condition), Unspecified Dementia, Mild, without behavioral disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), Unspecified Psychosis not due to a substance or known Physiological condition (Psychosis is a mental state characterized by a loss of touch with reality and may involve hallucinations, delusions, disordered thinking, and behavioral changes), Generalized Anxiety Disorder (a mental condition characterized by excessive or unrealistic anxiety about two or more aspects of life (work, social relationships, financial matters, etc.), accompanied by symptoms such as increased muscle tension, impaired concentration, and insomnia), Anxiety disorder (people frequently have intense, excessive and persistent worry and fear about everyday situations. Often, anxiety disorders involve repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks)). Review of the most recent MDS assessment dated [DATE] reflected Resident #38 had a BIMS score of 6. In an interview on 7/27/2023 with MDS Coordinator she stated admission imports the PL1 from the hospital. If it is a negative then it is scanned into the resident chart, input into Simple (which is a program the facility uses). If the PASSAR is positive, once it is in Simple, it notifies the PASSAR to do an evaluation. She stated she is not sure if admission has been trained to do anything else with the PASSAR. admission inputs whatever comes from the hospital. If the resident is coming from home, she will contact the family and ask them the questions needed to complete the PASSAR. She stated sometimes they get a few PASSAR forms that are not correct and the MDS coordinator will fill out a 1012 correction form. The MDS coordinator stated if the resident's PASSAR is not completed correctly, they will not get the services they may qualify for. MDS coordinator stated if there is a change in diagnosis like psych, another evaluation is completed. MDS coordinator stated if the resident goes to the hospital and they aren't gone more than 30 days, a new evaluation will not need to be completed. MDS coordinator was asked why resident #38 did not have a PASSAR II, she stated she guess she must have overlooked the resident psychosis. She stated she will put in another evaluation in for the Resident #38. In an interview on 7/27/2023 with Admissions Coordinator she stated the resident must come from the hospital with a PASSAR. AC stated she enters the PASSAR once she receives it. AC stated she has not been trained on reading the PASSAR. She stated once she enters the information, the MDS coordinator will catch the corrections and fill out a form to have corrections done. If the resident must have a special care plan, they will assess the resident and provide additional services. The AC stated if a PASSAR is not completed correctly, the resident can miss the additional services they may qualify for. The AC stated but if it is missed, she feels the facility has adequate services within in the building they can provide to the resident. Interview on 7/27/2023 with DON stated the AC must upload the PASSAR into Simple, it then alerts Pecan Valley, and they must come out and evaluate the residents. If the PASSAR is negative, it is uploaded with nothing further. If there is an error, the AC uploads the PASSAR, and a correction form will be done. DON stated the AC and the MDS coordinator are trained to do PASSAR's. DON stated if there is a mistake on the residents PASSAR and not corrected, they cannot get the treatment or services they need or qualify for. Review of the facility's PASSAR clinical policy dated March 2019 read in part, 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. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source to determine if the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (1) the admitting nurse notifies the social services department when a resident I identified as having a possible (or evident) MD, ID, o RD. (2) the social worker is responsible for making referrals to the appropriate state-designated authority.) c. Upon completion of the level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. the state PASARR representative provides a copy of the report to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for two of two residents (Residents #3 and #125) reviewed for respiratory care. A) The facility failed to ensure Resident #3's oxygen concentrator filter was clean and her CPAP and nebulizer masks and tubing were covered and dated. B) The facility failed to ensure Resident #125's oxygen concentrator filter was clean and her oxygen tubing were dated. This failure could place all residents who use respiratory equipment at risk for respiratory infections. Findings included: A) Record review of Resident #3's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of acute and chronic Respiratory Failure with Hypoxia (impairment of gas exchange between the lungs and the blood causing shortness of breath, anxiety, confusion). Observation on 07/25/2023 at10:40 AM in Resident #3's room revealed she had an oxygen concentrator with a filter full of white dust. Her CPAP mask and nebulizer mask (used to deliver breathing treatments) were unbagged. Observation on 07/26/2023 at 8:43 AM in Resident #3's room revealed her nebulizer mask and tubing were still unbagged and on her bedside table. The tubing was not dated. Record review of Resident #3's Treatment Administration Record dated 07/02/2023 reflected an order to change O2 tubing and date every night shift every 7 days at 6:00 PM. This order was signed as having been completed on 07/24/2023. There was an order to clean the O2 concentrator filters every night shift every 7 days at 6:00 PM. This order was initialed as having been completed on 07/23/2023. B) Record review of Resident #125's undated Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing related problems). Observation on 07/25/2023 at 10:16 AM in Resident #125's room revealed her oxygen tubing was not dated and her oxygen concentrator filter was covered in white dust. Observation on 07/26/2023 at 12:05 PM revealed Resident #125's oxygen concentrator filter was still covered with white dust and debris. Surveyor ran her finger across the filter and white debris fell from it. Record review of Resident #125's Treatment Administration Record dated 07/16/2023 reflected an order to change O2 tubing and date every night shift every 7 days at 6:00 PM. This order was signed as having been completed on 07/23/2023. There was an order to clean the O2 concentrator filters every night shift every 7 days at 6:00 PM. This order was initialed as having been completed on 07/23/2023. Observation and Interview on 07/26/2023 at 02:14 PM RN E stated he had worked in the facility as needed off and on for 2 years. RN E looked at the concentrator filter and stated It's dusty. I can see where it could cause allergy issues. He stated he was not trained how to clean the oxygen filters and there was always a risk of respiratory infection, and he thought the night staff was trained to clean the filters. He stated the nebulizer masks were supposed to have a bag on them and the night shift was supposed to make sure it was done. Interview on 07/27/2023 at 1:45 PM LVN C stated not bagging the respiratory equipment or cleaning the concentrator filters could cause a respiratory or sinus infection. She stated she did not check on the respiratory equipment while she was doing rounds on her patients. Interview 07/27/2023 at 2:29 PM ADON B stated nursing staff were supposed to change oxygen tubing and date them every Sunday evening and change the concentrator filters. She stated staff should put the nebulizer mask and extra concentrator tubing in a bag to keep it from getting contaminated. She further stated the risk of not doing these things was respiratory infections. Not cleaning or changing the filters could affect the life of the concentrator, the quality of air for the resident and could reduce the amount of air coming through. Interview on 07/27/2023 at 2:40 PM the DON stated, The tubing to respiratory equipment should be changed on Sundays and the filters washed on Sunday nights. She stated the risk to the resident if these procedures were not followed was respiratory infections, decreased air flow from dirty filters, and more pathogens introduced to the residents. She further stated it was their policy to change tubing and clean filters. Record review of a facility policy and procedure titled Departmental (Respiratory Therapy) Prevention of Infection dated 2001 and revised in November 2011 reflected, Change the oxygen cannula and tubing every seven days or as needed. Keep the oxygen cannula and tubing used prn (as needed) in a plastic bag when not in use. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. Infection control considerations related to medication Nebulizers/continuous Nebulizers. Store the circuit in plastic bag, marked with date and residents name between uses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident had a right to secure and confidential personal and medical records for 5 of 10 residents (Residents #273, #270, #271, #34 and #272) reviewed for medical record confidentiality. The facility failed to ensure confidential medical information was kept private by leaving the computer screen open on the medication cart and leaving the 24-hour report (a report with resident names, diagnoses, and vital signs) on top of the cart and exposed where passersby could read it. This failure could place Residents at risk for breach of confidential information possibly impairing the dignity of the resident by others having pertinent medical information regarding residents' health status. Findings included: Record review of Resident #273's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar), Pure Hypercholesteremia (high amounts of cholesterol a waxy substance in the blood), Nicotine (a naturally produced alkaloid in the nightshade family of plants, tobacco, and widely used as a stimulant) Dependence, Sleep Apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), and Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems). Record review of Resident #270's undated Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Displaced Bimalleolar Fracture (ankle fracture) of right lower leg, Pressure induced deep tissue damage of left heel, and Pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left heel. Record review of Resident #271's undated Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), Unspecified Dementia (a group of thinking and social symptoms that interferes with daily functioning characterized by memory loss and judgement ), Anxiety (mental health disorder characterized by feelings of worry, anxiety or fear strong enough to interfere with one's daily activities) Depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and Hypertension (high blood pressure). Record review of Resident #34's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Acute Kidney Failure (kidneys suddenly become unable to filter waste products from the blood), Pleural effusion (buildup of fluid between the tissues that line the lungs and the chest), and Covid-19 (infectious illness caused by the SARS-CoV-2 virus). Record review of Resident #272's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Essential Primary Hypertension, Emphysema (lung disease that causes breathlessness), Primary Osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down causing pain and stiffness), Syncope and collapse (fainting or passing out leading to loss of consciousness and a fall down or over), unspecified Fracture of Sacrum (break in the sacrum bone a large triangular bone that forms the last part of the vertebral column, or spine). Observation on 07/26/2023 at 07:24 AM revealed while RN D was administering medication to Resident #273 whose bed was on the far side of the room, the medication cart was at an angle to the door and the computer screen with the resident's confidential information was visible from the hallway. Observation on 07/26/2023 at 7:50 AM revealed RN C's 24-hour report (a report with resident names, diagnoses, and vital signs) was on top of the medication cart with resident information for Residents #270, #271, #34 and #272 visible to onlookers. The 24-hour report reflected Resident #270 had a full code (if a person's heart stops beating and /or they stopped breathing, all resuscitation measures will be used to keep them alive) status, had an indwelling urinary catheter (flexible tube that passes through the urethra and into the bladder to drain urine), and new orders for a tall boot (for pressure relief) at all times. Resident #271 had a full code status, with diagnoses of Atrial Fibrillation, Hypertension (high blood pressure), Anxiety and a Urinary Tract (body's drainage system for removing urine) Infection. Resident #34 was noted to be a full code status with diagnoses of Pleural Effusion, Acute Kidney Failure, Covid and was to be discharged home that day at 3:45 PM. Resident #272 was noted to be a full code status, with diagnoses of a Sacral Fracture (break in the sacrum bone a large triangular bone that forms the last part of the vertebral column, or spine) and Syncope (fainting). Resident #272 was also noted to be receiving an antibiotic, Cefdinir. Interview on 07/26/2023 at 10:42 AM with RN D who stated by leaving the computer screen and the 24-hour report open with resident information, it was breaking HIPAA (Health Insurance Portability and Accountability Act) privacy regulations and someone who was unauthorized could see it and obtain private information on the resident. In an interview on 07/27/2023 at 1:42 PM, LVN C stated nurses are trained in privacy and cannot tell just anyone a resident's information. Nurses must check the chart for the responsible party, be aware when talking in hallway, lock screen on medication cart computer, and keep books with confidential information closed. In an interview on 07/27/23 at 2:20 PM, ADON B stated staff are educated on confidentiality, closing the computer screen, and not leaving paperwork visible on a desk or cart. She stated nurses are taught in nursing school first, and with yearly training and the risk of not maintaining confidential resident information is that private information could be viewed resulting in a loss of dignity, could be used in criminal ways, or to belittle someone. In an interview on 07/27/2023 at 2:45 PM, the DON stated that there was a tab on the computers to close them where confidential information cannot be seen when not in use. She stated if a nurse is more than 5 feet from the medication cart, they should close the computer as it would be a HIPAA violation to leave it open. She further stated the risk to a resident would be impaired dignity and leaving the 24-hour report open on top of the cart would be HIPAA violation as well. In a Record review of an undated facility policy titled Health Insurance Portability and Accountability Act, reflected whether the resident health information is on a computer, in an electronic health record, on paper, or in other media providers have the responsibility for safeguarding the information by meeting the requirements of the rules.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to ensure Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for 2 of 2 residents reviewed. B) Resident #24's comprehensive care plan did not address the resident's right-hand contracture, and call lights assistance C) Resident #35's comprehensive care plan did not address the resident receiving hospice services. This failure could place Residents at risk by failing to meet the resident's preferences, choices, and goals during their stay at the facility. Findings included: A) Record review of Resident #24's admission record dated 07/27/23 documented an [AGE] year-old female admitted on [DATE]. Resident #24's documented diagnoses included: Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing (extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter), non st elevation (NSTEM) myocardial infarction (type of heart attack that usually happens when your heart's need for oxygen can't be met), candidiasis (Vaginal yeast infection), lack of coordination (coordination impairment or loss of coordination), type 2 diabetes mellitus without complication (body doesn't make enough insulin or can't use it as well as it should), and age related osteoporosis with current pathological fracture (deterioration in bone mass with increasing risk to fragility fractures. Record review of Resident #24's MDS assessment dated [DATE] revealed resident had a BIMS score of 12 indicating the resident was cognitively moderately impaired. The MDS also revealed the resident required extensive assistance in various areas of activities of daily living such as bed mobility, dressing, and toilet use. Record review of Resident #24's care plan dated 07/27/23 revealed. Resident #24's care plan did not reveal her right-hand contracture, call light assistance/placement or use of insulin. Observation of Resident #24 on 07/25/23 at 11:52am revealed her right hand was contracted and had a splint on it. Her call light was pinned to her upper right shoulder and out of her reach. Resident #24 stated that she can only reach her call button if it is pinned in the middle of her shirt or the middle of her blanket. Resident #24 stated that her call button is often out of reach. Resident #24 stated that if she needs assistance when her call button is out of reach, she yells so someone can come assistance her. Observation of Resident #24 on 07/25/23 at 12:52pm revealed her call light was pinned to her upper right shoulder and out of her reach. B) Record review of Resident #35's admission record dated 07/27/23 documented an [AGE] year-old female admitted on [DATE]. Resident #35's documented diagnoses included: Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), gastro-esophageal reflux disease without esophagitis (GERD that does not involve inflammation of the esophagus), neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problems) Record review of Resident #35's MDS assessment dated [DATE] revealed resident had a BIMS score of 03 indicating the resident was severely cognitively impaired. The MDS also revealed the resident required extensive assistance in various areas of activities of daily living such as bed mobility, transfers, dressing, eating, toilet use and hygiene. Record review of Resident #35's care plan dated 07/27/23 did not reveal she was receiving hospice services. Record review of Resident #35's physician orders dated 07/27/23 revealed Resident #35 was receiving hospice services. There was no start date but a revision date on 06/15/23. Record review of Resident #35's hospice notes revealed that Resident #35 started receiving hospice services on 06/08/23. Resident #35 is receiving the following services from hospice: Changing Linen 3x a week, restock incontinent supplies weekly, report changes in skin, falls, or RNCM when noted, Brush teeth every visit, complete bed bath 2x a week, foot care every visit, Nail care clean, oral care every visit, perineal care every visit, shampoo weekly shower 3 times week, skin care every visit. An interview with the MDS Coordinator on 07/27/23 at 10:50am. MDS Coordinator stated the purpose of the care plan is to know how to take care of the resident. MDS Coordinator stated that residents with contractures should be care planned. MDS Coordinator stated it would be for the resident's care and to be available for staff to see what they should be doing. MDS Coordinator stated if a resident needed a call button to be in a specific location, then that should be care planned. If the resident call button was not care planned, then the resident's call button may not be placed in the location for it to be reached. MDS Coordinator stated care plans are updated when things happen or as needed. An interview with the DON on 07/27/23 at 11:05am. DON stated that care plans are to plan care for residents and available for staff to see what they should be doing for the residents' care. DON stated that contractures should be care planned but it would be up to therapy. DON stated call buttons should not be care planned because call buttons are more of a safety issue. An interview with DON on 07/27/23 at 12:15pm. DON stated that a resident receiving hospice should be care planned for it. DON stated that CNAs could be confused about what care the facility was providing if the resident was not care planned for hospice services. An interview with MDS Coordinator on 07/27/23 at 12:15pm. MDS Coordinator stated that a resident receiving hospice should be care planned for it. MDS Coordinator stated that someone may not know if a resident was receiving hospice services if it was not indicated on the care plan. Record review of facility policy Care Plans, Comprehensive Person-Centered dated 2016 in paragraph 4 and 7, reflected: 4. Each resident comprehensive person-centered care plan will be consistent with the residents' rights to participate in the development and implementations of his or her plan or care, including the right to. 1. Participate in the planning process 2. Identify individual roles to be included 3. Request a meeting 4. Request revisions to the plan of care 5. Participate in the determining the type amount and frequency and duration of care 6. Receive the services and/or items included in the plan of care 7. See the care plan and sign it after significant changes are made 7. The care plan process will: Facilitate residents and /or representative involvement Include an assessment of the residents' strengths and needs Incorporate the residents personal and cultural preferences in developing the goals of care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to them for 2 of 2 residents (Residents #371 and #12) reviewed for medication administration and 1 of 4 medication carts (the 200 Hall Nurses Medication Cart) reviewed for medication storage. A) The facility failed to ensure over-the-counter medications for Residents #371 and #12 were stored in locked compartments. B) The facility failed to ensure the medication cart was locked when it was left unattended in the common area of the 200-hallway. These deficient practices could place residents at risk of medication misuse or drug diversion. Findings included: A) Record review of Resident # 371's undated Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Hyperlipidemia (high level of fats in the blood), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest), Irritable Bowel Syndrome (an intestinal disorder causing pain in the belly, gas, diarrhea and constipation) with Diarrhea (loose watery stools), Essential Primary Hypertension (high blood pressure), Unspecified (systolic) Congestive Heart Failure (chronic condition in which the heart doesn't pump as well as it should) and acute Kidney Failure (kidneys suddenly become unable to filter waste products from the blood). Record review of Resident # 371's Annual MDS dated [DATE] reflected a BIMS score of 13 indicating intact cognitive status. Record review of Resident # 371's chart reflected there were no Physicians orders for self-administration of medications and no assessments for self-administration of medication. In an observation and interview on 07/26/2023 at 09:38 AM Resident #371 had a bottle of Tylenol 500mg (a medication used to treat aches, pains, and fever) and an empty bottle of Ibuprofen PM 200/20mg (a combination medication used to treat occasional insomnia and pains) on a chest of drawers in his room. Resident #371 stated he had not been trained on those medications and wouldn't remember it if he was trained. Resident #371 stated the medications were obtained from a local grocery store. In an interview on 07/26/2023 at 2:23 PM RN E stated residents having medications in their rooms is not a normal practice. He observed the medication bottles in Resident # 371's room and informed him the nurse would need to put them in a safe place until he could speak with his Physician regarding prescribing them. Record review of Resident # 12's undated Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Unspecified Dementia (a group of thinking and social symptoms that interferes with daily functioning characterized by memory loss and judgement) unspecified severity, Dysphagia (difficulty swallowing), Cognitive Communication Deficit (difficulty with thinking and how someone uses language), Unspecified Macular Degeneration (loss in the center of the field of vision), Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety or fear strong enough to interfere with one's daily activities), and Essential Primary Hypertension (high blood pressure). Record review of Resident # 12's quarterly MDS dated [DATE] reflected a BIMS score of 6 indicating severe cognitive impairment. Record review of Resident # 12's chart reflected there were no Physicians orders for self-administration of medications and no assessments for self-administration of medication. Observation and interview on 07/25/2023 at 11:33 AM in Resident #12's room revealed three opened bottles of over-the-counter saline nasal spray, a bottle of rectal suppositories, an opened tube of ointment with Vitamins A and D, and an unopened tube of triple antibiotic cream on the bedside table. Resident #12 stated she did not know what the tube of antibiotic cream was for, and she had not used it yet. In an interview on 07/26/2023 at 2:23 PM RN E stated We don't normally go through a resident's stuff. I don't know how (Resident #12) accumulated all this stuff. No resident has any medications in their room, not even eye drops or nasal spray. The biggest risk is they could overmedicate. (Resident #12) won't remember when she took her medications. If resident are taking meds in their rooms, they could interact with other meds they are taking. In an interview on 7/27/2023 at 1:42 PM, LVN C stated there were not any residents in the facility that had any Doctors orders to administer their own medications. She further stated if medications were found in rooms, the nurse or staff should remove medications, lock them up, notify the family, place the resident's name on the bottle and have family come get the medications. If the resident was currently taking the unprescribed medication, then they should notify the doctor and get an order for the medication. She stated the risk for residents included overdosing, adverse reactions, another resident could get into the medications, or the resident could administer the medication using the wrong route, for example a nose spray could be put into the mouth. In an interview on 07/27/2023 at 2:35 PM, ADON A stated, We don't currently have anyone who should have any medications in their room. We observe for medications in rooms by making room checks daily either by certified nurse's aide or nurse. She further stated, nurses should go into residents' rooms daily and staff are trained to remove medications if they see them. She stated the risk for medications that were not approved for self-administration included interactions with other medications, adverse reactions, overuse, and residents could become ill. In an interview on 07/27/2023 at 2:29 PM ADON B stated no one with a diagnosis of Dementia should be approved to self-administer medications and the nurse should take any medications found in rooms and notify the family. She stated there were residents who wandered around and if they got the medications, they could be allergic to them. She stated the staff are educated to tell nursing if there are any medications in rooms, however, she couldn't say there was any formal education. She stated there was common sense and word of mouth training between CNAs. In an interview on 07/27/2023 at 2:45 PM, DON stated there are residents' assessment for self-administration of medication. Nurses are instructed to remove medications found in rooms and staff do not go into rooms and look around if residents are not in their rooms. If medications are sitting on top of a bedside table, the nurse should remove them. She further stated the risk to residents of self-administering medications without prior assessment include doubling up on medications and if the resident is educated but cannot remember. She stated Ibuprofen PM and Tylenol can be harmful to residents. Record review of facility policy titled Self-Administration of Medications dated February 2021 and review date of 2/2023, reflected Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment the interdisciplinary team assesses each resident cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. B) Observation on 07/26/2023 at 07:36 AM revealed RN D's medication cart was left unlocked and unattended with the top drawer slightly open. The cart was sitting at a 45-degree angle, easily accessible from the hallway and not flush with a resident's door. Observation on 07/26/2023 at 07:44 AM revealed RN D's medication cart was left unlocked as he went into a room to administer medications and had his back to the door. Interview on 07/26/2023 at 10:42 AM RN D stated by leaving his medication cart open and unlocked someone could get the wrong medications and take them. He stated they might be allergic or could get heart or blood pressure medications leading to illness or death. Interview on 07/27/2023 at 1:45 PM LVN C stated she had worked at the facility since March of 2023. She stated the laptop computer on top of the medication cart should be locked and the medication carts should be kept locked. She stated the cart should be pulled up to the doorway before entering a resident's room and they are trained to keep them locked when they are not with them. She further stated the risk if the medication cart was left open and unattended was a resident or staff could get into it and take medications. She stated the resident could be confused and be allergic to the medication and suffer an injury and they would not know what if anything they took out of the cart. Interview on 07/27/2023 at 2:11 PM ADON A stated she had worked at the facility one year in May of 2023. She stated every time a nurse steps away from their medication cart they should lock the cart and secure the computer too. She further stated residents, other staff or family could access the medications and there are also sharps in the cart. She stated there was a risk of overuse of medication, adverse reactions and people could take things they are not supposed to take. Interview on 07/27/2023 at 2:40 PM the DON stated she had worked at the facility for five years. She stated staff are trained on medication passes a minimum of three days and the cart should be locked unless the nurse is right there. She further stated anyone could get into the cartsa and if medications are consumed there could be an allergic reaction, and overdose, and other adverse reactions. She stated visitors, other nurses, CNAs, or anyone who wanted to steal drugs could get into the unlocked cart. Record review of a facility policy titled Administering Medications dated 2001 and revised August 2019 reflected, During administration of medication, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

**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 to help prevent the development and transmission of communicable diseases and infections for 3 of 16 (#273, #272, and #24) Residents reviewed for infection control practices. A. RN D placed his ungloved fingers into medication cups prior to administration for Resident's #273 and #272. B. CNA F failed to use proper urinary catheter care techniques when proving perineal hygiene for Resident #24. These failures had the potential to affect all residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: A) Record review of Resident #273's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar), Pure Hypercholesteremia (high amounts of cholesterol a waxy substance in the blood), Nicotine (a naturally produced alkaloid in the nightshade family of plants, tobacco, and widely used as a stimulant) Dependence, Sleep Apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), and Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems). Record review of Resident #272's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Essential Primary Hypertension, Emphysema (lung disease that causes breathlessness), Primary Osteoarthritis (type of arthritis that occurs when flexible tissue a the tends of bones wear down causing pain and stiffness), Syncope and collapse (fainting or passing out leading to loss of consciousness and a fall down or over), unspecified Fracture of Sacrum (break in the sacrum bone a large triangular bone that forms the last part of the vertebral column, or spine). Observation on 07/26/2023 at 07:25 AM of RN D preparing medications for Resident #273 revealed he touched the inside of the pill cup with his ungloved finger. Observation on 07/26/2023 at 07:49 AM of RN D preparing medications for Resident #272 revealed he placed his ungloved left thumb in the pill cup. Interview on 07/26/2023 at 10:42 AM RN D stated by putting his fingers into the medication cups he could have had bacteria and microorganisms on his fingers and then transferred those to the residents' medications and then the resident when they took the medications. Interview on 07/27/2023 at 1:45 PM LVN C stated nurses should not touch the inside of medication cups with their bare hands as it increases the risk of infection to the resident. She further stated there could be something going around that could be spread bacteria especially if the nurse didn't wash their hands properly. Interview on 07/27/2023 at 2:11 PM ADON A stated during medication administration the nurse should not touch the inside of the medication cup or around where the resident's mouth touches as the risk is giving them an infection and unnecessary illness. Interview on 07/27/2023 at 2:40 PM the DON revealed it is not standard practice to put our fingers in the medication cups. The risk to the resident is dirty fingers from dirty hands. Hopefully they (nurse) would have washed their hands. Fingers should never be put in med cups. Record review of a facility policy and procedure titled Administering Medications dated 2001 and revised in April 2019 reflected, Staff follows facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. B) Record review of Resident # 24's undated Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of displaced intertrochanteric fracture of left femur (type of hip fracture involving the thigh bone and the pelvis), and unspecified Escherichia-coli (E. Coli bacteria commonly found in the lower intestine) as the cause of diseases. Observation and Interview on 07/26/2023 at 12:43 PM of urinary catheter care performed on Resident #24 revealed CNA F used a bathing wipe on the catheter tubing away from the resident's body and then using the same wipe cleaned up and down the tubing several times. CNA F stated he had been at the facility for 2.5-3 years and stated an ADON had trained him on catheter care. He stated by wiping up and down the tubing with the same wipe there was a risk of introducing infection to the resident and causing a urinary tract infection. Interview on 07/27/2023 at 1:45 PM LVN C stated when performing urinary catheter care a new wipe should be used each time to wipe away from the insertion site. She stated going back up and down with the same wipe could introduce bacteria into the resident. Interview on 07/27/2023 at 2:11 PM ADON A stated regarding urinary catheter care the staff are trained with demonstration and return demonstration if needed, however, she was unsure if they were checked off annually. She stated staff should wipe away from the catheter insertion site and use one wipe at a time. She stated by wiping up and down with the same wipe they could bring bacteria back up which could cause a urinary tract infection and an avoidable illness. Interview on 07/27/2023 at 2:40 PM the DON stated Staff is trained and checked off on catheter care. They should use soap and water or use wipes from the top and away from the body. They could introduce other pathogens on the way up including e-coli which could cause purulent urine, a urinary tract infection and confusion as a result of sepsis. Record review of a facility policy and procedure titled Catheter Care, Urinary dated 2001 and revised in August 2022 reflected The purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections. Use a clean washcloth with warm water and soap (or bathing wipe) to cleanse and rinse the catheter from insertion site to approximately four inches outward.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. There were 17 expired jello cups and an opened carton of expired cranberry juice stored in the reach-in refrigerator. 2. There was a tray of jello that spilled on top of a box of cooked ham stored in the walk-in refrigerator. 3. There were 24 cans of expired cranberry juice stored in the pantry. 4. There was a box of bananas that was not stored in a dry food storage area. 5. There were two small buckets filled with chemicals stored next to a box of bananas. These failures could place residents who received meals, snacks, and/or beverages from the kitchen at risk of foodborne illness. The findings included : Observation on 07/25/2023 at 9:23 a.m. underneath a food preparation table across from the pantry revealed there was a small green plastic bucket next to a carboard box of bananas. The bucket was filled halfway with a liquid and had a blue towel in it. The box of bananas was open, and there was one bundle of five bananas sticking out on top of the box, exposing the bananas to potential contaminants. Observation on 07/25/2023 at 10:12 a.m. underneath the food preparation table across from the pantry revealed there was a small red plastic bucket between the green bucket and cardboard box of bananas. The red bucket was filled halfway with a liquid. Observation on 07/26/2023 at 9:47 a.m. underneath the food preparation table across from the pantry revealed there was a small green plastic bucket and small red plastic bucket next to a carboard box of bananas. The green bucket was filled halfway with a liquid and had a blue towel in it. The red bucket was between the green bucket and cardboard box of bananas. The red bucket was filled halfway with a liquid and had a blue towel in it. The box of bananas was open. There was plastic wrap covering the bananas. Observation on 07/26/2023 at 9:47 a.m. in the reach-in refrigerator revealed: a. There was a carton of thickened cranberry cocktail juice that was opened. The carton had a date indicating it was opened on 06/26/2023 and an expiration date indicating it was best if used by 06/29/2023. b. There were four packs of sugar free snack-size orange-flavored jello cups and three sugar free snack-size orange-flavored jello cups sitting in an open plastic bin. Each pack had four jello cups. There was one pack that had three jello cups. One jello cup had 11 small green spots on the lid. The jello packs had a shelf date indicating 07/17/2023 and expiration date indicating 05/20/2023. Observation on 07/26/2023 at 9:58 a.m. in the walk-in refrigerator revealed there was a silver metal tray filled with red jello stored on a silver metal shelf. The jello was covered with brown paper and labeled, Jello - for Supper. There was also a cardboard box stored on the silver metal shelf below the tray of jello. The cardboard box was labeled, Cooked ham and water product. There was some of the red jello that soaked the top of the box. Observation on 07/26/2023 at 10:39 a.m. in the pantry revealed there were two packs of cranberry juice cans. Each pack had 12 cans of cranberry juice. Each can had an expiration date indicating 08/10/2022. Observation on 07/27/23 at 1:15 p.m. revealed the DM picked up and discarded the cardboard box of bananas underneath the food preparation table across from the pantry. The DM also picked up and discarded the two 12 packs of cranberry juice cans from the pantry. Interview on 07/25/2023 at 9:42 a.m. with the DM revealed there were two types of small plastic buckets stored underneath each table in the kitchen. The DM stated the small green plastic buckets were filled with soap and water and the small red plastic buckets were filled with a sanitizer. Interview on 07/26/2023 at 10:01 a.m. with Dishwasher A revealed the small red buckets were filled with a sanitizer and the small green buckets were filled with soap and water. Interview on 07/26/2023 at 10:23 a.m. with DA A revealed they were also responsible for stocking the refrigerators. DA A further stated DAs checked the food and beverages stored in the reach-in refrigerator and walk-in refrigerator daily to ensure the items were labeled, dated, and not expired. Interview on 07/26/2023 at 10:40 a.m. with the DM revealed she and the Assistant DM trained the DAs on food storage and safety. The DM stated opened food items were stored in the refrigerators for up to three days. The DM stated the DAs were responsible for checking the expiration dates on the food and beverages stored in the refrigerators and pantry before each shift daily. The DM stated she and the Assistant DM checked the expiration dates on food and beverages every morning and throughout the day daily. Interview on 07/27/2023 at 8:24 a.m. with DA A revealed the afternoon shift DAs were responsible for labeling, dating, and checking the expiration dates on food and beverages stored in the pantry. DA A stated the DM and Assistant DM also checked the food and beverages in the refrigerators and pantry to verify the DAs properly labeled, dated, and checked the expiration dates. Interview on 07/27/2023 at 8:26 a.m. with the DM revealed her and the Assistant DM checked the food and beverages stored in the refrigerators and pantry in the morning and throughout the day to ensure food and beverages were properly labeled, dated, and discarded if expired. Interview on 07/27/2023 at 1:13 p.m. with the DM revealed she was aware there were 17 expired jello cups and an opened carton of expired cranberry juice stored in the reach-in refrigerator. The DM explained she did not conduct her inspection of the food and beverages stored in the reach-in refrigerator at the time the surveyor made the observation. The DM stated she discarded the 17 jello cups and carton of cranberry juice on 07/26/2023. The DM stated she was not aware there were two 12 packs of expired cranberry juice cans stored in the pantry. The DM stated residents were not served the expired jello cups and expired cranberry juice from the carton and cans. The DM stated residents could become sick if they were served expired food and beverages. The DM stated she was aware there was a tray of jello that spilled on a cardboard box of cooked ham in the walk-in refrigerator. The DM explained one of the DAs spilled the jello when they were placing the tray on a shelf in the walk-in refrigerator. The DM stated she discarded the box and inspected and placed the cooked ham in another container. The DM stated she was aware there was a cardboard box of bananas next to a small red bucket filled with sanitizer and a small green bucket filled with soap and water. The DM explained the box of bananas were always covered and placed next to the buckets. The DM stated the sanitizer could not be rinsed off the bananas with water. The DM stated residents could become sick if they ate food contaminated by the sanitizer. Interview on 07/27/2023 at 1:19 p.m. with [NAME] A revealed the small green buckets were filled with sanitizer and the small red buckets were filled with soap and water. [NAME] A stated sanitizer could not be rinsed off the produce with water. [NAME] A stated residents' health could not be safe if they ate food contaminated by the sanitizer. [NAME] A stated DAs aides were also responsible for labeling, dating, and checking and discarding expired food and beverages stored in the refrigerators and freezers. [NAME] A stated dishwashers were responsible for labeling, dating, and checking and discarding expired foods stored in the pantry. [NAME] A stated afternoon shift DAs checked the food stored in the refrigerators and freezers daily. [NAME] A stated she was not aware there were expired food and beverages in the refrigerator and pantry because they were on vacation for the last four days. Interview on 07/27/2023 at 1:27 p.m. with DA A revealed they were not aware there was 17 expired jello cups and an opened carton of expired cranberry juice stored in the reach-in refrigerator. DA A stated they were also not aware there were two 12 packs of expired cranberry juice cans stored in the pantry. DA A stated residents could become sick if they ate expired food or beverages. DA A stated they were not aware a tray of jello spilled on a cardboard box of cooked ham stored in the walk-in refrigerator. DA A stated they were aware there was a cardboard box of bananas next to a small red bucket filled with sanitizer and small green bucket filled with soap and water underneath the food preparation table. DA A stated the box was normally more spaced out from the red and green buckets. DA A stated they were not sure if the sanitizer could be rinsed off produce with water. DA A stated they were also not sure if residents could face adverse consequence if they if they ate food contaminated by the sanitizer. Interview on 07/27/2023 at 1:31 p.m. with the Assistant DM revealed she was not aware there was 17 expired jello cups and an opened carton of expired cranberry juice stored in the reach-in refrigerator. The Assistant DM explained she did not conduct her inspection of the food and beverages stored in the reach-in refrigerator at the time the surveyor made the observation. The Assistant DM stated the jello cups and cranberry juice were not served to residents on 06/26/2023. The Assistant DM stated she was not aware there were two 12 packs of expired cranberry juice cans stored in the pantry. The Assistant DM stated residents could become sick or develop a stomach ache if they ate expired food or beverages. The Assistant DM stated she was not aware there was a tray of jello that spilled on a cardboard box of cooked ham stored in the walk-in refrigerator. The Assistant DM explained she did not conduct her inspection of the food and beverages stored in the walk-in refrigerator at the time the surveyor made the observation. Review of a posting, Daily Kitchen Checklist, week of 07/24/2023 through 07/30/2023, revealed the following tasks were completed daily or after each use: 23. Chemical stored away from food. Staff initialed tasks were completed on 07/24/2023, 07/25/2023, and 07/26/2023. Review of policy and procedure manual, Food Storage, dated 2019 revealed the following: Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure: 4. Chemicals must be clearly labeled, kept in original containers when possible, kept in a locked area and stored away from food. 7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. a. Old stock is always used first (first in - first out method). Supervise the person designated to put stock away to make sure it is rotated properly. d. Foods will be stored and handled to maintain the integrity of the packaging until ready for use. 12. Refrigerated food storage f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. h. Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed. Review of policy and procedure manual, Food Safety and Sanitation, dated 2019 revealed the following: Policy: All local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. Procedure: 1. Food and Nutrition Services Department b. The food and nutrition services department will follow regulations as outlined by other official health agencies and organizations with jurisdiction over the facility. 4. Food Storage a. Stored food is handled to prevent contamination and growth of pathogenic organisms. o Poisonous and toxic materials including cleaning agents should be stored (and secured) outside the food storage area. o When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. o Perishable foods with expiration dates are used prior to the use by date on the package. o Canned or dry foods without expiration dates are used within six months of delivery or according to the manufacturer's guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents #1 & resident #2 the right to participate in other activities, including social, religious, and community activities that did not interfere with the rights of other residents of other residents at the facility for residents #1 & #2 reviewed for resident rights. The facility failed to ensure Residents #1, & #2 had a choice of religion. This failure could place residents at risk for not having the opportunity to exercise their rights of religion. Findings included: A record review of Resident #1's Face Sheet revealed, a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy (A problem in the brain that is caused by an imbalance in the blood), Anxiety Disorder (Excessive and persistent worrying and fear about everyday situations), and Hypothyroidism (Underactive Thyroid) A record review of Resident #1's care plan revealed she liked to participate in church related activities. A record review of Resident 2's Face Sheet revealed, a 82 -years-old, who was admitted to the facility on [DATE] with diagnoses, which included Chronic, Obstructive Pulmonary Disease (A disease that cause airflow blockage and breathing related problems), Bacteria (Bacteria present in blood stream), and Cerebral Infraction (Disrupted blood flow to the brain due to problems with the blood vessels that supply it). A record review of Resident #2's care plan revealed the resident liked to participate in bible study. 01/10/2023 at 10:25 AM, an interview was conducted with the ombudsman who stated resident #1 complained that the facility admin said preacher #1 could not continue preaching because his was not preaching from the traditional bible. The residents stated that the residents were comfortable with the teaching. The Ombudsman stated the residents' rights were violated and gave me additional resident name to speak with about the situation, On 01/10/2023 at 10:45 AM, an interview was conducted with the Resident #1 who stated religion was important to her. Resident #1 stated the Administrator won't let Preacher #1 come back and preach . Resident #1 stated she liked Preacher #1's Sunday services . On 01/10/2023 at 10:45 AM, an interview was conducted with Resident #2 who stated she really enjoyed Preacher #1's service and was upset when he wasn't allowed to preach anymore . On 01/10/2023 at 12:40 PM, an interview was conducted with Preacher #1 who stated he believed his services helped people understand the bible. Preacher #1 stated he voluntarily stopped going to the facility due to the Administrator wanting him to preach from the traditional bible . Preacher #1 stated he preached Baalism. Preacher #1 stated his services had nothing to do with demonic spirts . 01/10/2023 at 1:25 PM, an interview was conducted with the admin who stated Preacher #1 brought off the wall religious bible teaching to the resident at the facility. The admin stated Preacher #1 was asked to teach more traditional bible teachings, but Preacher #1 refused. The admin stated the teaching involved demonic spirts. The admin stated when Preacher #1 was asked to teach more traditional bible teaching Preacher #1 stated he would not comeback. The admin stated residents had the right to bring in whomever they would like to teach a certain religion in private . The admin stated if residents wanted to bring a non-traditional ministry, they could get with the activity director to set up a location to meet. The admin stated a resident not receiving the religion teaching of their choice could make them feel their rights were being violated based on religion. The admin stated all residents had to right to participate in the religion of their choice.