**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Residents #25) reviewed for care plans in that: Resident #25 did not have a Care Plan addressing his vape use/smoking. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included the following: Review of Resident #25's admission Record dated 6/26/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] and a re-admission dated of 5/7/25, with diagnoses including unspecified dementia without behavioral disorder. Review of Resident #25's admission MDS assessment, dated 5/10/25, revealed: He had a mental status score of 7 of 15 (indicating his cognition was severely impaired) He was not identified as a current tobacco user. Review of his care plan revealed there was no care plan for his nicotine use. Review of Resident #25's Baseline Care Plan dated 5/7/25 revealed Does the resident smoke? No Review of Resident #25's assessments revealed no smoking assessments. Review of Resident #25's Nurse's Notes dated 5/27/2025 at 6:03 p.m. revealed: Note Text: Resident attempted to elope from facility thru the front door. Nurse and DON stopped resident at door. Resident stated that he was going to the head shop to go get a vape. Resident was educated that he cannot leave facility on his own. Resident verbalized understanding. A wander guard was placed on resident to monitor elopement risk. Interview and observation on 06/24/25 at 2:43 PM revealed Resident #25 had several vapes on the bedside table, smoking times posted. Resident #25 said he went outside for smoking times but did not on 6/24/25 because he hurt too much. Interview and observation on 06/26/25 at 10:37 AM, Resident #25 stated he was not vaping in the building. Resident #25 said he had to take a vape from another resident and forgot to turn it into the lady. The vape was in same place as 6/24/25. In an interview on 06/26/25 11:23 AM, the DON and Corporate RN stated smoking was assessed on admission and quarterly. The Corporate RN said people who vaped were also assessed. The DON said she talked to Resident #25 and assessed him for pain, and he had two vapes on the bedside table which she took away. The DON said the Administrator was with her where she took them away. The DON checked Resident #25's electronic record and stated he had no assessments and it did not look like he had a care plan for vaping. She said she did not know why he did not. The DON said it should pop up under the initial care plan for nursing and the MDS nurse was responsible for completing the care plan after that. Review of the facility's policy and procedure on Comprehensive Care Plan, revised 4/25/21, revealed: Every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of Admission. The Interdisciplinary Team will continue to develop the place in conjunction with the Resident Assessment Instrument completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after Admission. The Care Plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process. To assure that the resident's immediate care needs are met and maintained, the baseline care plan will be developed with forty-eight hours of the residents' Admission. It will be utilized until the Comprehensive Care Plan is developed. The Comprehensive Care Plan is developed within 21 days of Admission. Care Plan Meeting and Care Plan Summary will be completed by the IDT after each Care Plan Review. The resident and their representative will be provided a summary at their request of the baseline care plan that includes but not limited to: Any services and treatment to be administered by the community and personnel acting on the community. Review of the facility's policy and procedure on Smoking, effective 3/1/17, revealed: It is the policy to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. IDT will develop an individualized plan for safe storage, use of smoking materials assistance and required supervision for residents who smoke. This is documented on the Resident Smoking Assessment, the residents' Plan of Care, and discussed with the resident and Responsible Party at resident care conference meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 3 residents (Resident #34) reviewed for nutrition. The facility failed to provide care and services to maintain acceptable parameters of nutritional status for Resident #34. This failure could place residents who are dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life. The findings included: Review of Resident #34's admission Record, dated 6/25/25, revealed he was admitted to the facility on [DATE] with diagnoses including partial intestinal obstruction, unspecified cause, unspecified dementia, fecal impaction, malnutrition, stroke with paralysis on left side, and need for assistance with personal care. Review of Resident #34's re-admission MDS Assessment, dated 6/20/25, revealed: He had a mental status score of 5 of 15 (indicating severe cognitive impairment). He had range of motion impairment of the upper and lower extremity on one side. He needed supervision for eating. Review of Resident #34's Care Plan, revised 6/24/25, revealed: Resident #34 was on a large portion diet with regular texture, regular consistency diet. All food should be in a divided plate or in bowls to prevent Resident #34 from throwing and breaking dishes. Fortified cereal for breakfast. The goal was Resident #34 would have adequate nutrition and fluid intake throughout the review date and receive 2 cups per meals of juice and water, coffee and milk in the morning, and water and fruit punch at lunch and supper. Interventions included to monitor and document intake and offer snacks within diet. Review of Resident #34's Care Plan, revised 6/20/25, revealed: Resident #34 was at risk for nutritional risk related to recent weight loss, Body Mass Index was 16.8 (underweight is below 18.5). The goal was Resident #34 will consume 75% or more of meal with no associate weight loss through next quarter, is large portion now and receives sandwiches on tray as well for lunch and supper. Interventions include Provide and serve diet as ordered. Review of Resident #34's Care Plan, revised on 11/27/23, revealed: Resident #34 had an ADL self-care performance deficit related to hemiplegia. The goal was Resident #34 was status would be maintained through the review date. The identified intervention for Eating was the resident required staff set-up or clean-up assistance with meals. Review of Resident #34's Care Plan, revised, 12/7/23 revealed: Resident #34 had a psychosocial well-being problem related to being dependent, behavior and ineffective coping. The identified goal was Resident #34 would demonstrate adjustment to nursing home placement by review date. Interventions included encouraging participation from the resident who depended on other to make his own decisions and to provide opportunities for the resident to participate in care. Review of Resident #34's weights revealed on 4/5/25 his weight was 130.6. On 6/5/25 his weight was 127.0. This was a 2.76% difference in two months that is only significant due to Resident #34 already being below the recommended Body Mass Index. Observation and interview beginning on 6/24/25 of the lunch meal at 11:42 a.m., it was noted Resident #34 had his tray. Resident #34 was placed in a geri-chair with his right side against the table (the dominant side that had movement). Resident #34's divided plate was observed in the center of the table when Resident #34 was at the corner of the table. Observation at 11:59 a.m. revealed Resident #34 was eating the salad which he could reach, but he could not reach the divided plate with the meat and potatoes on it. Observation at 12:06 p.m. revealed the DON offered Resident #34 a sandwich but did not notice his plate was out of reach. In an interview on 6/24/25 at 12:08 p.m., Resident #34 said he was hungry, and he did not eat his plate because he could not reach it. Resident asked surveyor for the plate to be moved. Surveyor moved the plate. Observation after the interview revealed Resident #34 could reach his plate, he immediately started eating the mashed potatoes. Observation at 12:16 p.m., the DON sat to assist Resident #34 to eat. At 12:28 p.m. Resident #34 got his sandwich and the DON pulled the table closer to where Resident #34 was so he could put the sandwich down. n an interview on 11:37 a.m., the DON stated she identified weight loss as an issue at the facility when she took over the facility a month prior and she was making plans every four weeks to see if there was improvement. The DON said that was currently her main clinical focus. The DON stated she just finished assessing what she thought was the issue and sent her recommendations to the Medical Director, changed the appetite stimulant used, is offering a different supplement and more double portions at meals. The DON said she struggled with the kitchen. In an interview on 6/26/25 at 11:53 a.m., the Regional RN stated there was no policy that addressed placing food within reach of the resident. The MDS Coordinator who was present stated, it's like going to a restaurant and they put the food on the other side of the table. In an interview on 6/26/25 at 11:57 a.m., the Administrator and VP of Regional Operations was informed of the meal observation of Resident #34 not having his plate for over half and hour and no one noticing. They were informed Resident #34 could eat food independently and was hungry. The two were told Resident #34 experienced weight loss and there was no policy addressing leaving the food out of reach. The VP of Regional Operations stated it was common sense for the aides to leave it within reach. In an interview on 6/26/25 at 12:05 PM, the Administrator stated weight loss did flag with the facility's Quality Assurance committee and was currently the DON's pet project.

**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 1 (Resident #21) of 3 residents reviewed for infection control. CNA B failed to change her gloves and wash her hands after they became contaminated during incontinent care while assisting Resident #21. This failure could place resident's risk for cross contamination and the spread of infection. Finding include: Record review of Resident #21's admission record dated 06/25/2025 indicated he was admitted to the facility on [DATE] with diagnoses of dementia and muscle weakness. He was [AGE] years of age. Record review of Resident #21's MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision [NAME] = Severely impaired - never/rarely made decisions. Urinary continence = Always incontinent. Bowel continence = Frequently incontinent. Record review of Resident #21's care plan dated 06/03/2025 indicated in part: Focus: The resident has occasional bladder incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Clean peri-area with each incontinence episode. During an observation on 06/24/25 at 03:16 PM, CNA A and CNA B performed incontinent care for Resident #21. CNAs assisted the resident to his bed, put on some gloves and then removed the residents brief which was wet with urine. CNA B took some wet wipes and wiped the resident's penis, scrotum and rectal area and her gloved hands which were observed to come in contact with the Resident #21's skin. CNA B then fastened the resident's brief, and put a pair of clean pants on the resident while still wearing the same gloves. During an interview on 06/24/25 at 03:24 PM, CNA B said she should have changed her gloves after she had performed the incontinent care and assisted with putting Resident #21's brief and pants on him. CNA B said not changing her gloves could lead to cross contamination which could lead to infections such as urinary tract infections. During an interview on 06/26/25 at 10:36 AM, the Administrator was made aware of the observation of incontinent care performed by CNA B. The Administrator said the CNA not changing her gloves after they had become contaminated could lead to cross contamination, and also could lead to the transmission of illnesses. The Administrator said they would have to conduct more training and in-services on infection control. During an interview on 06/26/25 at 10:50 AM, the DON said staff were expected to change their gloves once they became contaminated. The DON said the staff had to do that to prevent cross contamination. The DON said they would have to conduct more training and in-services on glove changes and handwashing, and also conduct more walk through rounds to monitor staff. Record review of the facility's policy titled Perineal Care dated 10/01/2021 indicated in part: To provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition. Steps in the Procedure - Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. Wash and dry your hands thoroughly. Put on gloves. Wash perineal area, wiping from front to back Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Record review of the facility's policy titled Infection Control and dated 01/15/2022 indicated in part: This communities' infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. This communities' infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteers, works and the public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status or payor source. The objective of our infection control policies and practices are to: prevent, detect, investigate and control infections in the community. Maintain a safe, sanitary and comfortable environment for personnel, residents, visitors and the public. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 7 residents (Resident #25, #32 and #37) reviewed for quality of care in that: 1. The facility failed to assess and care plan Resident #25 for safe vaping, 2. The facility failed to keep Resident #25's vape secure when it was not a supervised smoking time 3. CNA E and CNA D incorrectly transferred Resident #32 the shower chair to the bed by incorrectly applying the gait belt too loosely and hooking under Resident #32's arms. 3.CNA A and CNA B incorrectly transferred #37 from her wheelchair to the bed by grabbing her from the back of her pants and her under arms. These failures could put residents at risk of accidents and serious injuries which could result in a reduced quality of life. Findings included: RESIDENT #25 Review of Resident #25's admission Record dated [DATE], revealed he was an [AGE] year-old male admitted to the facility on [DATE] and a re-admission dated of [DATE], with diagnoses including unspecified dementia without behavioral disorder. Review of Resident #25's admission MDS assessment, dated [DATE], revealed: He had a mental status score of 7 of 15 (indicating his cognition was severely impaired) He was not identified as a current tobacco user. Review of his care plan revealed there was no care plan for his nicotine use. Review of Resident #25's Baseline Care Plan dated [DATE] revealed Does the resident smoke? No Review of Resident #25's assessments revealed no smoking assessments. Review of Resident #25's Nurse's Notes dated [DATE] at 6:03 p.m. revealed: Note Text: Resident attempted to elope from facility thru the front door. Nurse and DON stopped resident at door. Resident stated that he was going to the head shop to go get a vape. Resident was educated that he cannot leave facility on his own. Resident verbalized understanding. A wander guard was placed on resident to monitor elopement risk. Interview and observation on [DATE] at 2:43 PM revealed Resident #25 had several vapes on the bedside table, smoking times posted. Resident #25 said he went outside for smoking times but did not on [DATE] because he hurt too much. Interview and observation on [DATE] at 10:37 AM Resident #25 stated he was not vaping in the building. Resident #25 said he had to take vape from another resident and forgot to turn it into the lady. The vape was in same place as [DATE]. Interview on [DATE] at 11:23 AM the DON and Corporate RN stated smoking was assessed on admission and quarterly The Corporate RN said people who vaped were also assessed. The DON said she talked Resident #25 and he had two vapes on the bedside table which she took away. The DON checked Resident #25's electronic record and stated he had not assessments and it did not look like he had a care plan for vaping. She said she did not know why he did not. The DON said it should pop up under the initial care plan for nursing and the MDS nurse was responsible for completing the care plan after that. The DON stated no one has caught him vaping in the building. The DON stated Resident #25 was usually up and about and compliant with the smoking policy. Resident #32 Review of Resident #32's admission Record, dated[DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia and gait abnormalities. Review of Resident #32's Annual MDS Assessment, dated [DATE], revealed She had a mental status score of 5 of 15 (indicating severe cognitive impairment) She was totally dependent on staff for transfers. Review of Resident #32's Care Plan, revised [DATE], revealed: Resident #32 had an ADL Self-care performance deficit related to disease process, dementia. The goal was Resident #32 would maintain her current level of function through the review date. Identified interventions included: Transfer: The resident is dependent on staff for assistance with transferring. Observation on [DATE] at 1:46 PM Resident #32 gave permission to watch the transfer. CNA E put the gait belt on Resident #32. CNA E and CNA D stood on either side of Resident #32, hooked their arms under her arms and grabbed the back of the gait belt. While lifting Resident #32, the gait belt slid up Resident #32's chest, Resident #32 did not straighten her legs so all of her weight was hanging by her arms. The aides put Resident #32 in the low bed and removed the gait belt. At that time CNA D said aides were trained on transfers but she did not know why they put the gait belt on when Resident #32 had pants on but Resident #32 being in a shower chair threw her off. CNA E stated Resident #32 could straighten her legs but frequently did not so the majority of the time Resident #32 was not weight bearing because she would not straighten her legs. CNA E said she was pretty sure the charge nurses were aware of that. CNA D said Resident #32 got skin tears easily. Both aides said they would not do anything differently and had check-offs done pretty frequently and that the DON had checked them off for two-person gait-belt transfer. Neither aide was aware of an increased risk of injury to Resident #32 to hooking their arms under her arms since she was non-weight bearing. Interview on [DATE] at 11:08 AM the DOR stated a 2-person transfer from the wheelchair would be 1 person put the gait belt on while the other steadied the resident. The DOR said one person should stand in front of the resident while the other guides from the back. The DOR stated after the wheelchair was locked the resident should be cued, stood and then pivoted to sit. The DOR stated if the gait belt slid up it was not a safe transfer. The DOR said if the resident's feet did not touch ground it was not a safe transfer if the resident's feet were not touching ground there was a potential for falls. The DOR stated the potential outcome for the resident was a fall. The DOR stated the gait belt could cause skin tears, the staff could get injured if someone got off balance. The DOR stated potential injuries to hooking under a resident's arms were shoulder injury from stretching and instability which could cause the resident pain. Interview on [DATE] at 11:16 AM the DON and Regional RN stated a safe 2-person gait belt transfer looked like each staff took a side of the resident, grab back and front of the gait belt, come up at the same time and move the resident from one surface to the other. The DON said staff should not grab under resident's arms. The Corporate RN stated non-weight bearing resident was not a safe two-person transfer. The DON stated staff must not have been checking the Kardex (where the resident's ADL status is kept in the electronic monitoring system). The DON looked up Resident #32's status and read the Kardex documented Resident #32 was dependent on staff for transfer so it had to be updated. The Corporate RN asked about the care plan. The DON said it would be easier for staff and safer for resident to be a lift resident. Interview on [DATE] at 12:00 PM the Administrator and [NAME] President of Regional were informed there was an issue with safe two-person transfers for Resident #32. Neither had questions. RESIDENT #37 Record review of Resident #37's admission record dated [DATE] indicated she was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and muscle weakness. She was [AGE] years of age. Record review of Resident #37's MDS dated [DATE] indicated in part: For cognitive Skills for Daily Decision Making, the resident's was severely impaired. Transfers - (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) the resident required extensive assistance;resident was involved in the activity, staff provide weight-bearing support, and two+ persons were required for physical assistance. Record review of Resident #37's care plan dated [DATE] indicated in part: Focus: I have an ADL self-care performance deficit r/t disease processes Alzheimer's. Goal: The resident will maintain current level of function through the review date. Interventions: Transfer: The resident requires limited to extensive staff assistance with transferring. During an observation and interview on [DATE] at 12:20 PM in the secure unit, CNA A and CNA B transferred Resident #37 from her wheelchair to her bed. Both CNAs took the resident from underneath her armpits and by the back of her pants. The resident was unable to assist with the transfer and the staff had to manually perform the transfer for her. CNA A said she was not sure what the transfer status was for Resident #37, but that they usually did two person transfers on all the residents on the secure unit. CNA B said she believed the transfer status was listed on their POC (plan of care) tablet they charted on but was not sure. During an observation and interview on [DATE] at 03:06 PM, CNAs A and B were seen wearing gait belts around their waists. The CNAs said the gait belts had recently been brought to them so they could use them to transfer residents. The CNAs were asked about the transfer they had performed on Resident #37. The CNAs acknowledged that they should have used a gait belt for Resident #37 but that at the time they did not have the gait belts. The CNAs said if they transferred the residents from under their arms and the back of their pants it could lead to injuries. CNAs said they documented on their POC tablet and that was where the transfer status was listed. During an observation on [DATE] at 03:10 PM, the CNAs POC tablet indicated for Resident #37 transfer self-performance - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. Total dependence - full staff performance. During an interview on [DATE] at 09:40 AM, the DOR (Director of Rehab) was made aware of the transfers made by the CNAs. The DOR said it was expected for the staff to use a gait belt for all transfers for safety. The DOR said taking the resident's from under their arms could lead to injuries. The DOR said if the resident's care plan indicated to use a mechanical lift, then staff should have used the lift. The DOR said she would do in-services with staff on safety transfers. During an interview on [DATE] at 10:40 AM, the Administrator was made aware of the transfers performed by the CNAs by taking the residents from their armpits and the back of their pants. The Administrator said transferring the residents like that could lead to injuries. The Administrator said the staff should have used a gait belt or the mechanical lift to transfer the residents. The Administrator said they would conduct training and in-services regarding the use of gait belts and the mechanical lift. The Administrator said she believed the DON conducted monitoring rounds of the facility and observed how staff performed tasks. During an interview on [DATE] at 10:45 AM, the DON said the staff was expected to use a gait belt for transferring residents. The DON said the staff were not supposed to transfer the residents by taking them from their underarms and clothing. The DON said if the staff transferred the resident from under their arms, that could lead to injuries. The DON said they would be conducting more training and getting together with the DOR to work together and conduct some training with the staff. The DON said they planned on conducting more observations of staff to make sure staff were following the correct steps. Review of the facility's policy and procedure on Smoking, effective [DATE], revealed: It is the policy to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. Procedure: Incendiary devices will be stored by facility staff. Resident will not be allowed to possess any lighters, cigarettes, or other smoking materials. All vaping material will also be secured. Electronic cigarettes will follow the same rules as tobacco. IDT will develop an individualized plan for safe storage, use of smoking materials assistance and required supervision for residents who smoke. This is documented on the Resident Smoking Assessment, the president's Plan of Care, and discussed with the resident and Responsible Party at resident care conference meetings. Record review of the facility's policy titled Safe lifting and movement of residents and dated [DATE] indicated in part: In order to protect the safety and well-being of staff and residents and to promote quality care this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Manual lifting of residents shall be eliminated when feasible. Nursing staff in conjunction with the rehabilitation staff, shall assess individual residents needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: Resident mobility, Weight-bearing ability. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured the accurateacquiring, receiving, labeling, dispensing, safe and secure storage of medications for 2 of 2 medication carts(200 hall and 300 hall) checked for storage of medications. - The 200 hall medication cart had a bottle of milk of magnesia with dried drippings on the lid of the bottle. - The 300 hall medication cart had an empty bottle of Pro Stat liquid collagen with dried drippings on the side of the bottle - The 300 hall medication cart had two open undated insulin pens for Resident #7 and Resident #14 These failures could affect residents that received medications at the facility by placing them at risk of cross contamination and receiving ineffective insulin therapy. Finding included: Resident # 7 Review of Resident #7's face sheet dated [DATE] revealed a [AGE] year-old female with an original admission date of [DATE] and a readmission date of [DATE]. Review of Resident #7's history and physical dated [DATE] revealed Type 2 diabetes mellitus with hyperglycemia. Review of Resident #7's quarterly MDS assessment dated [DATE] revealed a BIMS score of 05, indicating severe cognitive impairment. Review of Resident #7's Care Plan dated [DATE] revealed resident has Diabetes Mellitus and received oral medications and insulin to control blood glucose levels. Record review of Resident #7's physician orders reflected the following order: Tresiba FlexTouch Subcutaneous Solution Pen-injector 200 UNIT/ML (Insulin Degludec) Inject 40 unit subcutaneously in the morning for Diabetes Mellitus. Resident # 14 Review of Resident #14's admission record dated [DATE] revealed a [AGE] year-old female with an admission date of [DATE]. Review of Resident #14's history and physical dated [DATE] revealed Type 2 diabetes mellitus with unspecified complication and diabetic polyneuropathy. Review of Resident #14's admission MDS assessment dated [DATE] revealed a BIMS score of 07, indicating severe cognitive impairment. Review of Resident #14's Care Plan dated [DATE] revealed resident has Diabetes Mellitus and received insulin to control blood glucose levels. Record review of Resident #14's physician orders reflected the following order: Basaglar KwikPen 100 Unit/ml solution pen-injector 200 UNIT/ML (Insulin glargine) Inject 27 units subcutaneously once a day. An observation on [DATE] at 10:38 am revealed LVN G's medication cart had an empty bottle of pro stat liquid collagen with dried drippings running down the side of the bottle. An observation on [DATE] at 10:40 am revealed two opened, undated insulin injection pens for two residents (Residents #7 and Resident#14) in LVN G's medication cart. An observation on 06 25/2025 at 11:17 am revealed a bottle of milk of magnesia with dried drippings around bottle cap in LVN F's medication cart. An interview with the DON on [DATE] at 08:40 AM revealed that all insulin pens were dated upon opening. The DON stated that insulin should have been dated upon opening because insulin expired after 28 days putting residents at risk for receiving expired insulin, which could have led residents to receiving ineffective insulin treatment. The DON stated that medication bottles needed to be wiped down after use to prevent bottles from being stored with dried drippings. The DON stated that it was important for bottles to be stored clean to prevent cross contamination. The DON stated that nurses and med aides were responsible for ensuring bottles were clean when being stored. The DON stated that the last in-service done regarding medication storage was done last Friday. An interview with LVN F on [DATE] at 11:27 pm revealed that insulin pens should be dated as soon as they were opened for first use. LVN F stated the nurses were responsible to make sure that all pens were dated. A negative outcome for the resident would be using an old pen that was out of the range of the 28 days and ineffective insulin therapy. LVN F stated that all medication bottles were supposed to be cleaned prior to storing them back into the medication cart to prevent cross contamination. An interview with LVN G on [DATE] at 2:47 pm revealed that the insulin pens were dated as soon as they were opened. LVN G stated that all nurses were responsible to make sure all dates were printed clearly on the insulin pen. A negative outcome of using an undated pen would be not knowing how long ago it was opened thus leading to medication being less effective. LVN G stated that medication bottles were to be cleaned after use and before being stored in medication cart to prevent cross contamination. Review of facility's policy titled Storage of Medications revised [DATE] revealed, . the nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening unless the manufacturer recommends another date or regulations/ guidelines require different dating .The nurse will check the expiration date of each medication before administering it, no expired medication will be administered to a resident.

Based on interviews and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 3 of 4 quarterly meetings reviewed for QAPI. The facility did not ensure the MD, or a representative attended quarterly QAPI meetings. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings included: Interview during the Entrance Conference on 6/24/25 at 9:56 a.m. the Administrator identified the Medical Director. The Administrator stated the QA meetings were held monthly with all department heads, a corporate representative, and a representative from the hospital district that owned the facility. The Administrator stated the Medical Director attended occasionally. When asked to specify what occasionally meant, the Administrator stated the Medical Director only attended the QA meetings one time in the last year. The Administrator said the Medical Director was in the building monthly to see residents and his Nurse Practitioner was in the building two times a month. The Administrator stated the facility constantly remained in communication with them. Review of the Quality Assurance Performance Improvement Attendance Sign-In forms revealed: Quarter 1: 6 (June)/2024: The Medical Director attended. Quarter 2: 7/9/24, 8/13/24 - The Medical Director did not attend Quarter 3: 9/10/24, 10/8/24, 11/12/24 - The Medical Director did not attend. (undated 12/??/.24 - staff were the staff that were there in 2024), 1/14/24 (error), 2/11/25 - The Medical Director did not attend. Quarter 4: 3/11/25, 4/8/25, 5/13/25- The Medical Director did not attend. 6/1/25 - The Medical Director did not attend. In an interview on 6/26/25 at 10:48 p.m., the Regional RN Consultant stated the facility policy on Medical Director attendance was that every Department Head should participate monthly and the Medical Director should attend quarterly. The RN Consultant stated she was unaware of when the last time the Medical Director attended the QA meeting at the facility. When informed he attended one QA Meeting in the last 12 months, the RN Consultant stated she did not know why the Medical Director only attended one time because he should have at least attended over the phone. Review of the facility's policy and procedure on Quality Assurance and Performance Improvement, effective 3/1/17, revealed: This facility shall develop, implement, and maintain and ongoing facility wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care, quality, and resolve identified problems. Authority: The owner and/or governing board (body) of our facility shall be ultimately responsible for the QAPI program. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure allegation of abuse, the facility had evidence that alleged violation was thoroughly investigated but failed to report the results of investigation to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 resident (Residents #1) reviewed for investigating alleged violation of abuse. The facility failed to report evidence that a thorough investigation was conducted, failed to complete a provider investigative report (Form 3613A), and failed to report the results of the investigation when Resident #1 alleged abuse from CNA A which did not result in injury to Resident #1. These failures could place residents at risk for allegations of abuse and neglect not being thoroughly investigated by the facility and reported as required. Findings include: Record review of Resident #1's face sheet, dated 6/25/24, revealed Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure with Hypercapnia (arterial oxygen, carbon dioxide, or both cannot be kept at normal levels), Ventricular Fibrillation (abnormal heart rhythm), Opioid dependence, Schizophrenia (mental disorder), Muscle Weakness, Muscle Wasting and Atrophy (wasting away of body part or tissue). Record review of Resident #1's MDS, dated [DATE], revealed Resident #1 had a BIMS score of 11 (moderate cognitively impaired), impaired visual functioning, fall risk, un-aware of safety risks. Record review of Resident #1's Care Plan, dated 4/7/24, revealed Resident #1 had impaired visual functioning and is at risk for decrease in ADLs and injuries. Resident #1 has behavior problems (refuses to listen to staff about smoke break times, redirection unsuccessful, low frustration tolerance. Schizoaffective disorder, Depression, high risk for falls and fractures, requires assistance with decision making, potential to be verbally aggressive towards staff, poor impulse control, limited physical mobility, elopement risk. Record review of Resident #1's progress notes, dated 5/26/24 at 2:40pm revealed, LVN B documented, this nurse witnessed resident verbally aggressive with CNA due to his smoke break. This resident bad-mouthing CNA because resident demanding to be taken out for a smoke CNA stated he would take him out to give him a minute to finish doing what he was doing resident then became loud demanding to be taken out, came around nurse's station and grabbed his cigarettes' and stated he would take himself. This nurse heard door alarm from smoking door, upon walking down hallway noted residents and staff down the hallway, this resident noted to be in the middle of the hallway, when he noticed this nurse he came towards me, upset, stating he wanted to report the male CNA A because he had put his hands on him, this nurse and resident continued on to the nurses station where resident stating he wanted to call the police, resident taken aside and assessment done, no bruising, no redness, no swelling noted to resident, then proceeded to report what had occurred, this nurse notified abuse coordinator and DON, resident then noted to go up to the CNA stating he would make sure and take his job from him, resident redirected and relocated, assisted outside by this nurse to take a smoke break and calm down, attempted to notify resident's family member of incident, no answer, resident stated he is on a cruise but that he does not want his family to know of incident. Record review of facility incident intake #506758, reported to HHSC on 5/26/24 by facility Administrator, incident category: Abuse. Narrative of incident intake #506758, 'Resident #1 asked to be taken out to smoke break, CNA A told Resident #1 that he would, but he needed to finish his charting before he went, and he would need a couple of minutes to finish it. CNA A turned and asked LVN C to take the smokers out to smoke. LVN C began to take the smokers down the hall while CNA A finished his charting. When CNA A was finished, he went down the smoker's hallway and Resident #1 stands up on his scooter to confront CNA A. Resident #1 told CNA A I will get our license and When I get done with you won't have anything left. CNA A said that he saw Resident #1 stand up on his scooter and become unsteady on his feet. CNA A put his hand under Resident #1's elbow to support him in sitting down in his chair. Resident #1 then began to say that CNA A had abused him. During an interview on 6/25/24 at 1:00pm with Resident #1 stated the facility and staff were good this was a good place, and they take care of them. Resident #1 did re-call incident on 5/26/24 at 2:30pm, Resident #1 stated he was ready to go smoke, and CNA A told him that he was not taking resident outside to smoke with the other residents. Resident #1 stated he had no idea why CNA A was not letting him go with them. Resident #1 stated for no reason CNA A pushed him back into his wheelchair, Resident #1 denied yelling or cussing at CNA A. Resident stated that CNA A was in front of him and grabbed him under his arms and pushed him. Resident #1 stated he was not hurt but was angry. Resident #1 stated he told the charge nurse, and the nurse checked him out and he was fine, he did not get hurt. Resident #1 stated he has never had any problems with CNA A before and has never seen or heard of any problems in the facility, Resident #1 stated this was a good facility and staff. Resident #1 stated that the DON and Administrator sent CNA A home and he has not come back. On 6/25/24 at 4:10pm Resident #1 approached surveyor and stated he (Resident #1) went a little overboard on 5/26/24 and acted out, Resident #1 stated sometimes he can't control his anger and yells at people. Record review of CNA A's statement dated 5/26/24 (CNA A did not return to facility after incident and self-terminated and did not reply to phone calls by surveyor). CNA A stated he told Resident #1 that he will take out residents to smoke in a few minutes. CNA A stated Resident #1 started yelling and calling him names, then Resident #1 stood up in his scooter and yelling at CNA A and began to fall forward, and CNA A grabbed Resident #1 and put him back in his scooter. LVN B came down hall, Resident #1 stated I pushed him, and he want to file abuse charges. CNA A denied allegations. Interview on 6/26/24 at 10:30am LVN B stated she witnessed Resident #1 yelling at CNA A to take them out to smoke. LVN B stated she was walking down hall towards CNA A and Resident #1, they were by the smoking exit door, LVN B stated she did not see CNA A grab or touch Resident #1. LVN stated Resident #1 came rolling up towards LVN stating CNA had pushed him and he wants to report abuse. LVN B stated she assessed resident found no redness or bruising, no injuries, Resident #1 stated he was not injured. LVN B stated she called Administrator and DON to report incident, notified resident's physician and tried to contact resident's family member but had no answer, resident stated they were on a cruise. Record review on 6/25/24 at 2:25pm Resident #2, [AGE] year-old male, BIMS of 11 (moderately cognitive impaired) stated he witnessed the incident. He stated Resident #1 stood up and got in CNA A's face saying you don't know who you are missing with. Resident #2 stated CNA A did not put his hands on Resident #1, Resident #1 did almost fall, and CNA A grabbed him and kept him from falling. Resident #2 did not know why Resident #1 was upset. Resident #2 stated he has never seen or heard of CNA being disrespectful to anyone, all the staff were nice. Interview on 6/25/24 at 1:55pm Administrator stated she self-reported incident on 5/26/24 to HHSC. In-service was conducted by DON on 5/26/24 over Abuse and who to report it to. The Administrator stated she did the investigation, took statements but did not know why she did not complete and turn in the 3613A Provider Investigation Report form as required in 5 days. The Administrator stated she and the DON discussed and decided the incident was inconclusive, but CNA A did not come back to facility, self-terminated. Record review of facility's Abuse/ Neglect Policy for Reporting: Abuse Reporting Policy date 1/1/23 Page 4, 'The abuse coordinator with the Director of Nursing/designee will investigate all allegations and use the appropriate forms to document the investigation and turn it into HHS within 5 calendar days.'

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident representative when the resident had a change in his psychosocial status for one (Resident #1) of four residents reviewed for changes in condition. The facility failed to inform Resident #1's responsible party when he ran out of the medication Risperidone or of his ongoing aggressive behavior. The facility failed to inform Resident#1's physician that when he ran out of the medication Risperidone and get a new order for the medication at the family's request. This failure could place residents at risk for not having their representative notified or not receiving relevant medical information when there is a change of condition. Findings included: Review of Resident #1's admission Record, dated 5/16/24, revealed he was a [AGE] year-old male who was a respite resident originally admitted to the facility on [DATE] with a most recent admission date of 4/12/24 with a diagnosis which included Traumatic Brain Injury and Quadriplegic Cerebral Palsy. Resident #1 was discharged on 5/1/24. Review of Resident #1's Order Summary Report, dated, 5/16/24, revealed orders including Risperidone 1 mg in liquid form twice a day for traumatic brain injury. Resident #1 was not in the facility long enough for a Minimum Data Set to be completed. Review of Resident #1's Care Plan revealed: Dated 9/2/21: Focus that Resident #1 may have adverse consequences from the use of psychotropic medications as evidenced by disease process Traumatic Brain Injury and take Risperidone as ordered. The identified goal was Resident #1 would remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension (low blood pressure), gait disturbance, constipation/impaction, or cognitive/behavioral impairment through the review date. Identified interventions included Administer psychotropic medications as ordered by physician. Dated 12/15/23: Focus The resident is on an antipsychotic medication Risperidone related to Traumatic Brain Injury. The goal was the resident will remain free from adverse reactions related to antipsychotic medication therapy. Interventions included: administer medications as ordered and obtain consent from resident or responsible party prior to medication use. Dated 12/17/23 The resident has a behavior problem. Hits/grabs staff or residents related to low frustration tolerance. The identified goal was: the resident will have fewer episodes of hitting or grabbing by review date. Identified interventions included: administer medications as ordered. Dated 4/14/24 Focus: The resident has the potential to be physically aggressive (hits, kicks, throws things) related to poor impulse control. The goal was the resident will demonstrate effective coping skills through the review date. Interventions included: Administer medications as ordered Dated 4/17/24 The resident has a psychosocial well-being problem related to Quadriplegic Cerebral Palsy. The identified goal was: the resident demonstrate adjustment to the nursing home placement through review date. Identified interventions included: increase communication between resident/ family/ caregivers about care and living environment. Explain all procedures and treatments, medications, condition, all changes, rules, options and provide opportunities for the resident and family to participate in care. Review of Resident #1's April 2024 MAR revealed: Saturday 4/13/24 at 8 p.m. = (Administration note Time 4:58 p.m. revealed: med aide approach resident for meds, he swung left arm and knock meds out of hand, spit, and hitting table with fist. Med aide informed nurse. Sunday 4/14/24 at 8 a.m. = (Administration note time 3:38 p.m. meds refused, resident very combative and informed nurse) 4/14/24 at 8 p.m. = resident refused the medication Wednesday 4/17/24 at 8 p.m. = resident refused the medication Thursday 4/18/24 at 8 p.m. = resident refused the medication Sunday 4/21/24 at 8 am. = resident refused the medication Tuesday 4/23/24 at 8 a.m. = (administration note, time 8:54 a.m. administration note - notified family for meds) 4/23/24 at 8 p.m. = 9 Wednesday 4/24/24 at 8 a.m. = 9 4/24/24 at 8 p.m. = (administration note, time 8:37 p.m. awaiting from family) Thursday 4/25/24 at 8 p.m. =9 (administration note, time 9:09 p.m. awaiting from the family) Friday 4/26/24 at 8 p.m. = (administration note, time 8:25 p.m. awaiting from the family) Sunday 4/28/24 at 8 a.m. = (administration note, time 1:45 resident not very cooperative not taking meds and combative, informed nurse) Monday 4/29/24 at 8 a.m. = resident refused the medication (administration note, time 8:16 p.m. awaiting from family) 4/29/24 at 8 p.m. = (no note given for why resident did not get the medication) Review of Resident #1's Clinical Notes revealed: 4/13/24 5:55 p.m. Behavior Note: Resident refused to eat all meals. Refused medications. Threw medications on MA. Slamming hand onto table and swing fist at staff. 4/20/24 10:47 a.m. Behavior Note: Staff approached this nurse voiced resident is being combative, instructed staff to sit resident alone this nurse approached resident with bilingual nurse the second nurse spoke to him in Spanish offered him breakfast and coffee. Resident took his hat off and began to swing at second nurse. Attempted to give him lorazepam (an anti-anxiety medication) as needed. Resident Refused and knocked cup out of the nurse's hand. At this time staff stepped back and allowed resident to sit alone in front of tv in common area. Other residents kept at a distant. (no documentation of family notified of behavior) 4/26/24 7:38 a.m. Behavior Note: Resident being aggressive with staff. Hit CNA in the stomach as she walked by resident. When this nurse walked by punched cart with fist. When medication aide went to give medications, resident flipped off by resident. 4/27/24 12:06 p.m. Nurse's Note: Resident admitted for respite care. Resident admitted with medication from home. Risperidone on hand depleted (facility out of medication). Attempted to notify parent. No answer. notified Care Giver of needed medication stated can't you order it? The pharmacy here closes at noon, we can't get it. Advised that typically respite residents supply their own meds and long-term care residents' medications are supplied by facility pharmacy. Also advised that resident will miss multiple doses until medication is able to be obtained which will be more difficult to obtain a liquid medication. replied, ok then. Review of the 24-hour report showed no documentation that the family was notified of Resident #1's ongoing behaviors or that he was running out of Risperidone. On 4/12/24 (day of admission) it documented he was admitted for respite care for three weeks. Review of the Discharge summary dated [DATE] at 1:15 p.m. revealed Resident discharged home with family. Took belongings with resident and medications. Review of the CNA behavior monitoring [NAME] revealed Resident #1 demonstrated multiple physical and/or disruptive behaviors daily. Review of Resident #1's admission Contract signed by the Resident/Family revealed the family signed they gave consent for the Medical Director to be the resident's physician for the duration of the resident's stay and for the facility to be in charge of pharmacy service. (The family signed the same contract every other admitting resident signed.) Interview on 5/15/24 at 12:29 p.m. the Administrator stated Resident #1 was a private pay resident and there were issues with his medications. She stated his family was supposed to bring his Risperidone and they were not able to bring it. The Administrator stated Resident #1 used the liquid version of the medication and the facility's pharmacy did not provide that. The Administrator stated they explained to the family they would have to bill the family for the medication if they ordered it. The Administrator stated Resident #1 was frequently aggressive to staff and would not eat or drink. The Administrator said on the last day he was at the facility; Resident #1 tore the arm and tip back bar off his wheelchair. The Administrator said Resident #1 was a TBI and was a respite resident. She stated the facility had had him prior, but this visit was a bit longer than previous stays. During an interview on 5/16/24 at 1:42 p.m. CNA A said there was a resident on her hall that would hit them. She stated the expectation was for 2 people to go into the room to assist the resident and explain what you were doing. CNA A said if that did not work to step away and come back when the resident was calmer. CNA A said Resident #1 would refuse to take his medication and all the nurse would say was not to agitate him. She said he was only at the facility for a few weeks. CNA A said he was calmer with the girls who would speak Spanish to him and explain everything they were doing, every time they were doing it. During an interview on 5/16/24 at 2:45 p.m. MA B stated the ordering process for medications was the MA would make a list of medications they were running out of and give it to the nurse and the nurse would follow up with it. MA B stated the facility would usually get the medication the next day unless it was a narcotic they needed to go to the doctor for or the resident was hospice and hospice needed to bring the medication. MA B said she did not know why a resident would go without medication because she believed the pharmacy was open on the weekends. MA B said she did not know of any special circumstances that would prevent a resident from getting medications. Interview on 5/17/24 at 12:47 p.m. Resident #1's family stated they used the facility for respite care for years without issue, so they continued that. She said the facility called one time to say he had behaviors and she said she told them to put him to bed with his cards and he would calm down. The family stated the facility dealt with it and Resident #1 started eating. The family member said the following day Resident #1 did fine and the family did not hear anything from the facility, so they thought things were fine. The family said the family visited to check on Resident #1 and he was happy, and they were fine and he was eating; then that Saturday they called and said he was out of his Risperidone. Resident #1's family member said they thought why was the facility calling the family now when the drug store was closed and the family lived several hours away. The family said when they went to pick up Resident #1 no one told them anything about how Resident #1 did at the facility. Interview on 5/17/24 at 3:47 p.m. the Administrator stated the respite contract was different from the regular contract in that the facility did not provide the resident's medications. The DON said she did not know where it documented in the respite contract, only that was what she was told. The Administrator said if a resident was private pay they were still under their doctor's care so if they needed anything they would be seen by the doctor. The DON added the facility's doctor did see Resident #1 while he was at the facility. The DON said they facility did reorder Resident #1's Risperidone but the pharmacy did not provide the liquid. The DON said the facility could have got an order for the Risperidone and crushed the medication. The Administrator explained the family visited twice and Resident #1 was very happy they visited. The Administrator said Resident #1 said when the family came the second time Resident #1 thought he was going to go home and when he did not his behavior escalated. The DON said that Saturday they called the and notified the caregiver the facility was out of the Risperidone. The DON stated the said they lived in a town 3 hours away and the pharmacy there was closed so the facility needed to get the medication. The DON said if the family said if Resident #1 got combative to give him flash cards and put to bed. The DON said this did not work to calm him down. The DON stated the visited the first weekend and brought him a milkshake. The DON said Resident #1 drank all of it and they told the family he was not eating, was being aggressive, and not taking his medication, and the family said that was fine (there is no documentation of this communication). The DON stated the family visited a second time and Resident #1 became so excited because he thought he would be going home so when he did not go home he threw a fork at staff and that Saturday he was getting all out. The DON said the nurses called the said the city's pharmacy was closed so the facility needed to get the medication. The DON said the facility got the medication, but it took their pharmacy a while to get the medication which was not perfect. The DON stated there was no order to crush the Risperidone and Risperidone was not in the facility's emergency medication system. The DON said Resident #1 was not hurting himself or other so did not need the antipsychotic medication they did have in the emergency medication system. The DON said the nurses did not document they called the family. The DON said the nurses were encouraged to call the family and talked to them twice. The DON agreed the family should have been contacted more often and she did not know why they were not. She said the family should have been contacted when Resident #1 stopped eating again and when his behavior escalated. The Administrator stated she was not sure of the exact policy but the family should have been notified when the medication was low and not out and when Resident #1 stopped eating. The Administrator said there were a lot of behaviors, behaviors, he's a repeat respite, I don't know if it's continued decline. The Administrator added Resident #1 never got comfortable at the facility with the respite visits. The DON said nothing worked to calm Resident #1 down and the facility did not know the family was upset with the facility's care until the family contacted them two days after the discharge. Review of the facility's policy and procedure on Change in a Resident's Condition or Status, Revised May 2017, revealed: Policy Statement: our facility shall promptly notify the resident, his or her Attending Physician, an representative (sponsor)(of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, residents rights etc.) Policy Interpretation and Implementation The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): refusal of treatment or medications two (2) or more consecutive times. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: there is a significant change in the resident's physical, mental, or psychosocial status. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of one (Resident #1) of four residents reviewed for availability of medications. The facility failed to obtain and administer the antipsychotic Risperidone fifteen (15) times between 4/23/24 and 5/1/24 per physician's orders to Resident #1. This failure puts residents at risk of not receiving prescribed medications and experiencing behaviors or other symptoms of diagnosed conditions. Findings included: Review of Resident #1's admission Record, dated 5/16/24, revealed he was a [AGE] year-old male was originally admitted to the facility on [DATE] for respite services with a most recent admission date of 4/12/24 with a diagnosis which included Traumatic Brain Injury and Quadriplegic Cerebral Palsy. Resident #1 was discharged on 5/1/24. Review of Resident #1's Order Summary Report, dated, 5/16/24, revealed orders including Risperidone 1 mg in liquid form twice a day for traumatic brain injury beginning 6/7/23. Review of Resident #1's Care Plan revealed: Dated 9/2/21: Focus that Resident #1 may have adverse consequences from the use of psychotropic medications as evidenced by disease process Traumatic Brain Injury and take Risperidone as ordered. The identified goal was Resident #1 would remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through the review date. Identified interventions included Administer psychotropic medications as ordered by physician. Dated 12/15/23: Focus The resident is on an antipsychotic medication Risperidone related to Traumatic Brain Injury. The goal was the resident will remain free from adverse reactions related to antipsychotic medication therapy. Interventions included: administer medications as ordered and obtain consent from resident or responsible party prior to medication use. Review of Resident #1's April 2024 MAR revealed: Tuesday 4/23/24 at 8 a.m. = (administration note, time 8:54 a.m. administration note - notified family for meds) 4/23/24 at 8 p.m. = (no explanation on why medication not given) Wednesday 4/24/24 at 8 a.m. = (no explanation on why medication not given) 4/24/24 at 8 p.m. = (administration note, time 8:37 p.m. awaiting from family) Thursday 4/25/24 at 8 p.m. = (administration note, time 9:09 p.m. awaiting from the family) Friday 4/26/24 at 8 p.m. = (administration note, time 8:25 p.m. awaiting from the family) Sunday 4/28/24 at 8 a.m. = (administration note, time 1:45 resident not very cooperative not taking meds and combative, informed nurse) Monday 4/29/24 at 8 a.m. = resident refused the medication (administration note, time 8:16 p.m. awaiting from family) 4/29/24 at 8 p.m. = (no explanation on why medication not given) Review of Resident #1's Clinical Notes revealed: 4/27/24 12:06 p.m. Nurse's Note: Resident admitted for respite care. Resident admitted with medication from home. Risperidone on had depleted (the facility ran out of medications). Attempted to notify the paren. No answer. Caregiver notified of needed medication. stated can't you order it? The pharmacy here closes at noon, we can't get it. Advised Caregiver that typically respite residents supply their own meds and long-term care residents' medications are supplied by facility pharmacy. Also advised caregiver that resident will miss multiple doses until medication is able to be obtained which will be more difficult to obtain a liquid medication. Caregiver replied, ok then. Review of the 24-hour report showed no documentation that the family was notified of Resident #1's running out of Risperidone. On 4/12/24 (day of admission) it documented he was admitted for respite care for three weeks. 5/1/24 1:15 p.m. Discharge Summary Resident discharged home with family. Took belongings with resident and medications. Review of Resident #1's Admissions Contract signed by the Resident/Family on 9/2/21 revealed the family signed they gave consent for the Medical Director to be the resident's physician for the duration of the resident's stay and for the facility to be in charge of pharmacy service. (The family signed the same contract every other admitting resident signed.) Interview on 5/15/24 at 12:29 p.m. the Administrator stated Resident #1 was a private pay resident and there were issues with his medications. She stated his family was supposed to bring his Risperidone and they were not able to bring it. The Administrator stated Resident #1 used the liquid version of the medication and the facility's pharmacy did not provide that. The Administrator stated they explained to the family they would have to bill the family for the medication if they ordered it. The Administrator stated Resident #1 was frequently aggressive to staff and would not eat or drink. The Administrator said on the last day he was at the facility; Resident #1 tore the arm and tip back bar off his wheelchair. The Administrator said Resident #1 was a TBI and was a respite resident. She stated the facility had had him previously, but this visit was a bit longer than previous stays. During an interview on 5/16/24 at 2:45 p.m. MA B stated the ordering process for medications was the MA would make a list of medications they were running out of and give it to the nurse and the nurse would follow up with it. MA B stated the facility would usually get the medication the next day unless it was a narcotic they needed to go to the doctor for or the resident was hospice and hospice needed to bring the medication. MA B said she did not know why a resident would go without medication because she believed the pharmacy was open on the weekends. MA B said she did not know of any special circumstances that would prevent a resident from getting medications. Interview on 5/17/24 at 12:47 p.m. Resident #1's family stated they used the facility for respite care for years without issue, so they continued that. She said the facility called one time to say he had behaviors and she said she told them to put him to bed with his cards and he would calm down. The family stated the facility dealt with it and Resident #1 started eating. The family member said the following day Resident #1 did fine and the family did not hear anything from the facility, so they thought things were fine. The family said the family visited to check on Resident #1 and he was happy, and they were fine, and he was eating; then that Saturday they called and said he was out of his Risperidone. Resident #1's family member said they thought why was the facility calling the family now when the drug store was closed, and the family lived several hours away. The family said when they went to pick up Resident #1 no one told them anything about how Resident #1 did at the facility. Interview on 5/17/24 at 3:47 p.m. the Administrator stated the respite contract was different from the regular contract in that the facility did not provide the resident's medications. The DON said she did not know where it documented in the respite contract, only that was what she was told. The Administrator said if a resident was private pay, they were still under their doctor's care so if they needed anything they would be seen by the doctor. The DON added the facility's doctor did see Resident #1 while he was at the facility. The DON said they facility did reorder Resident #1's Risperidone but the pharmacy did not provide the liquid. The DON said the facility could have got an order for the Risperidone and crushed the medication. The DON said that Saturday they called the and notified the Caregiver the facility was out of the Risperidone. The DON stated the said they lived in a town 3 hours away and the pharmacy there was closed so the facility needed to get the medication. The DON said if the family said if Resident #1 got combative to give him flash cards and put him to bed. The DON said this did not work to calm him down. The DON stated the visited the first weekend and brought him a milkshake. The DON said Resident #1 drank all of it and they told the family he was not eating, was being aggressive, and not taking his medication, and the family said that was fine (there is no documentation of this communication). The DON said the nurses called the said the city's pharmacy was closed so the facility needed to get the medication. The DON said the facility got the medication, but it took their pharmacy a while to get the medication which was not perfect. The DON stated there was no order to crush the Risperidone and Risperidone was not in the facility's emergency medication system. The DON said Resident #1 was not hurting himself or others so did not need the antipsychotic medication they did have in the emergency medication system. The DON said the nurses did not document they called the family. The DON said the nurses were encourage to call the family and talked to them twice. The Administrator stated she was not sure of the exact policy but they family should have been notified when the medication was low and not out. Review of the facility's policy and procedure on Unavailable Medications, revised August 2020, documented: Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, or manufacturer's shortage of an ingredient, or may be a permanent situation due to the medication no longer being produced. The facility must make every effort to ensure that medications are available to meet the needs of each resident. Procedures: The pharmacy staff shall: Notify nursing staff that the order product(s) is/are unavailable. Notify nursing staff of when it is anticipated that the drug(s) will become available Suggest alternative, comparable drug(s) and dosage of drug(s) that is/are available. The nursing staff shall: Notify the attending physician (or on-call physician when applicable of the situation and explain the circumstance, expected availability, and alternative therapy(ies) available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. Obtain a new order and cancel/discontinue the order for the non-available medication. Notify the pharmacy of the replacement order.

Based observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure 1 medication cart (used by nurse for treatments performed on 200 and 400 halls was locked when unattended. This failure could place residents at risk of having access to unauthorized medications, wound care, and medical supplies leading to possible harm or drug diversions. Findings included: During an observation on 04/23/2024 at 6:23 p.m., an unlocked medication cart seen unattended by the nurses' station in between 200 and 400 halls with one resident approximately 6 feet away. There were medications including Nystatin (prescription anti-yeast) powders, Voltaren and hydrocortisone (over the counter topical) creams. Over the counter medication bottles including Aspirin, Tylenol, and colace (stool softener). Prescription medications including Zoloft (anti-depressant), trazodone (anti-depressant), Singulair (anti-inflammatory), Buspar (anti-anxiety), Baclofen (muscle relaxant), Keppra (anti-seizure), lactulose (anti-constipation), Sinemet (dopamine precursor), and Megace (appetite stimulant) in the cart. During an interview on 04/23/2024 at 6:25 p.m., RN A stated that she was responsible for the unlocked medication cart. She stated she had left it unlocked since counting medications during shift change. She stated that being nervous and distracted led to her not locking cart. RN A stated that she knew medication carts were to be locked when left unattended. She stated that she had not taken any in-services with the facility but had education through her agency as she was an agency nurse. She stated that the negative impact of leaving the cart unlocked could be possible adverse reactions leading to death if a resident were to take some medication out of cart. She stated the failure was the locking mechanism not being pushed in that would have locked the cart. During an interview on 04/23/2024 at 6:30 p.m. the DON stated medication carts should always be locked when unattended. She stated the negative impact would be residents could possibly have an allergic reaction and/or death if they took medications out of the medication cart. The DON stated all nursing staff should monitor the medication carts to make sure they are always locked. She stated she had not done any in-services herself, but had found in-services of June 2023, prior to her hire date. She stated the failure occurred when the nurse left the cart unlocked with her expectations being keeping all carts locked and to follow protocol. Record review of the facility policy titled Storage of Medications revised on 08/2020 revealed Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident records were maintained with accepted professional standards and practices for completeness and accurately documented for 1 of 17 residents (Resident #64) reviewed for resident records. The facility failed to obtain physician's order prior to placing Resident #64 in secure unit. The facility failed to obtain consent from resident or representative prior to placing Resident #64 in secure unit. These failures could place residents at risk of being separated against their will , without orders or the representative's consent. Findings include: Record review of the Resident #64's face sheet dated 04/21/2024 revealed she was a [AGE] year-old female admitted to the facility initially on 03/06/2024 and most recently on 03/30/2024 with a diagnosis of acute posthemorrhagic anemia (low iron from blood loss), unspecified dementia (brain disorder that interferes with memory with unknown severity), anxiety, and diabetes. Record review of Resident #64's quarterly MDS dated [DATE], revealed: Section C - Cognitive Patterns a BIMS score of 05 (severe cognitive impairment); Section P- Restraints and Alarms revealed no restraint use; Section E- Behavior revealed she had wandering and rejection of care behaviors. Record review of Resident #64's care plan dated 03/31/2024 revealed she had impaired cognitive function and impaired decision-making abilities but no evidence of residing on secure unit. Record review of Resident #64's physician orders dated 04/21/2024 revealed quetiapine/Seroquel (antipsychotic medication) 25mg give 1 tablet by mouth one time a day for preventative; quetiapine/Seroquel (antipsychotic medication) 25 mg give 2 tablets by mouth one time a day for preventative; quetiapine/Seroquel (antipsychotic medication) 25mg give 3 tablets by mouth at bedtime for preventative, but no orders to be placed on secured unit at this facility. During an interview on 04/24/2024 at 10:46 a.m., the DON stated residents needed to have a physician's order and consent prior to being admitted into the locked unit. She stated she was unsure why physician's order was not obtained but felt that consent was obtained on paper. She was not able to locate where the paper form would have been stored and stated she would prefer those consents be uploaded into resident's electronic record. She stated that she monitored consents and orders were obtained. During an interview on 04/24/2024 at 11:11 a.m., the RRN stated her expectation would be for physician's order and consent obtained from the resident or their representative, prior to resident admitting into the secure unit. She stated she felt consent was obtained and paper lost. She stated she did not know why physician's order was not obtained. She stated that the DON and ultimately herself monitors those consents and physician orders were obtained. She stated the effect not having would have on the resident was possible involuntary seclusion of the resident. Review of facility's policy titled admission Screening for Placement on Memory Care Unit and Consent for Placement on Memory Care Unit last revision date on 05/25/2021 revealed Pre-admission: Identification of the individuals whose needs necessitate placement on the Memory Care Unit prior to their admission to the facility requires the following: 1. Assessment of the potential resident by admission staff and DCO (director of clinical operations) is required prior to admission to the nursing facility to determine if the potential resident exhibits the flags listed in section (3) a,b,c,d,e,f,g. 2. If yes, upon admission of the Resident to the facility, admission member will Complete the admission Screening for Placement on Memory Care Unit. Meet with the responsible party to complete the Consent for Placement on Memory Care Unit. admission Screening form and consent for placement will be generated in Document Manager in Point Click Care. Social worker will prepare a care plan to reflect the need for placement on the Memory Care Unit and follow up with the resident to assess psychosocial well-being for adjustment issues. Charge nurse will notify the physician to obtain an order for placement on the Memory Care Unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents had the right to choose their schedule for 2 of 6 residents (Residents #12 and #63) reviewed for self-determination preferences. The facility failed to allow Resident's #12 and #63 to smoke more than one cigarette while on their smoke break. This failure could place residents at risk of diminished feeling of self-worth, depression, and or diminished quality of life. Findings include: Resident #12 Record Review of Resident #12's Face Sheet dated 04/24/2024, revealed he was a [AGE] year-old Male, admitted to the facility on [DATE], with a Diagnoses of muscle weakness and wasting, difficulty walking, depression and tobacco use and heart disease. Resident #12's MDS, dated [DATE], Section C revealed a BIMS score of 11 (moderately impaired cognition). Resident #12's Care Plan dated 10/10/2023 revealed: Focus- The resident has coronary artery disease related to Hypertension, lifestyle choices, Smoking. Goal-The resident will be free from/sx (signs) of complications of cardiac problems through the review date. Interventions-Educate the resident/family/caregivers about: factors which might precipitate irregular heart rate: Alcohol, Caffeine, Stress, Activity. Encourage compliance to treatment regimen and follow up with physician. Encourage resident to refrain from smoking. Resident #12's smoking assessment dated [DATE] revealed, he can independently light smoking materials safely dispose of ashes and other tobacco-related residue appropriately. Resident #12 can also extinguish smoking materials completely in an appropriate receptacle. Resident #12 orders revealed no evidence of having only one cigarette during the 15-minute break. Interviews during a confidential meeting on 04/22/2024 at 10:02 AM, Resident #12 wanted to know if there were a policy that stated he can only have 1 cigarette during smoke breaks for himself and other smoking residents. During an interview on 04/24/24 at 11:23 AM, Resident # 12 voiced that he was upset that he was only allowed 1 cigarette per smoke break. He stated that he had smoked 2 packs prior to admission and does not feel that 1 cigarette was enough. He voiced that he would have no problem smoking 2-3 cigarettes in the 15 minutes that were allotted to him during the smoke breaks provided. Resident #63 Record Review of the resident #63's Face Sheet dated 04/25/2024, revealed he was a 63 yr. old male, admitted to the facility on [DATE], with a Diagnoses of Major Depressive Disorder, Anxiety Disorder, tobacco use and insomnia. Resident 63's MDS, dated [DATE], Section C revealed a BIMS score of 11 (moderately impaired). Resident #63's Care Plan dated 08/10/2023 revealed: Focus-The resident is a smoker. Goal-The resident will not smoke without supervision through the review date. Interventions-Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Observe clothing and skin for signs of cigarette burns. Resident #63's smoking assessment dated [DATE] revealed, he can independently light smoking materials safely and can the resident dispose of ashes and other tobacco-related residue appropriately. Resident #63's Orders revealed no evidence of having only one cigarette during the 15-minute break. During an interview on 04/23/24 at 11:30 AM, HK-J stated that she had worked there since 2021. She stated that she performed the smoke breaks on the days she worked approximately 3-4 days a week. She stated she took the resident's out to smoke on those days. She stated the rules were for residents to have only 1 cigarette during a 15-minute smoke break. HK-J stated she did not know what the policy was about smoking. She stated at one time they had a red box with a sign that had said, only one cigarette a break. During an interview on 04/25/2024 at 11:15 AM, the SW stated the residents were only allowed to have 1 cigarette per smoke break every three hours. She stated there were two safe smokers that had been given smoke breaks at night due to these two residents only able to have one cigarette throughout the day with each smoke break. The SW stated in doing that, it had helped them sleep but inconvenient for them as it was at 12:30 AM and 3:30 AM. She stated even at those times, Resident #12 and Resident #63 were still to only have one cigarette. The SW stated the rules were in the corporate facility policy. She stated the department heads had a meeting with the smokers about what the violations would be if they did not adhere to those rules. The SW stated she was unaware the facility policy showed no evidence that the residents could only have one cigarette. She stated she had previously been told that it was the way it had always been done the past three years. The SW stated the residents received $60 a month and stated that was another reason they ration the residents cigarettes. During an interview on 04/25/2024 at 11:35 AM, the ADMN stated there was a limit to only one cigarette while the residents were out on smoke break. She stated it was corporate policy and the Department Heads (ADMN, DON, and AD), had a smoking RC meeting as well, to let the residents know what the rules were. The ADMN stated the residents were told that if they violated the smoking policy, they would get written up with a smoking violation. The ADMN stated it was the Department Heads that had that specific RC so they (Dept. Heads and smoking Residents) would be on the same page. She stated once having read the smoking policy at that time, there was no mention of residents only could have one cigarette per smoke break. She stated the Department Heads had decided it kept the residents on their budget as well as not having residents stealing cigarettes from other residents who smoked. The ADMN stated it would also prevent them from running out of money at the end of each month. She stated, it was not fair to the residents, but it kept them on the same level and in reality, it was not fair, but the one cigarette is in all fairness to all who smoke. The ADMN stated she made the determination across the board with that being the best for the community. She stated she thought it was fair to make a blanket rule. She stated if someone asked her if they could have another cigarette with plenty of time left in that smoke break, she would have always told them No because it was based on the situational needs of all residents. She stated the failure was that the residents did not like to be monitored and was the reason that certain residents had brought it up. The ADMN stated she thought the negative impact were the residents health if they smoke more than one. The ADMN stated her expectations were for the residents on only have one cigarette per break. She stated that ultimately it was her decision. During an interview on 04/25/2024 at 2:34 PM, the RRN stated she was unaware the residents were being told they could only smoke 1 cigarette. She stated it was not in their facility policy that the residents could only have 1 cigarette during their 15-minute scheduled smoking times. She stated they had the right to smoke as many as they wanted if it were during that scheduled time. Review of facility Resident Smoking Council Meeting Minutes, dated 02/16/2024 revealed no evidence of advising residents they could have only one cigarette during their 15-minute break. Review of facility's policy titled Risk Management, Smoking Policy, dated 06/11/2018 revealed .Standard of Practice Explanation and Compliance Guidelines Self Determination the Resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to a. The resident has a right to choose activities, schedules (including sleeping and waking times) . The facility policy showed no evidence the residents could have only one cigarette during their 15-minute smoke break. Review of facility's policy titled Resident Rights, dated 08/2009 revealed; Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. .k. Retain and use personal possessions to the maximum extent that space and safety permit; 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, clean, and homelike environment for 3 of 17 (Resident #4, #22, and #32) resident rooms reviewed for resident rights. 1. The facility failed to ensure the hot water faucet worked in Resident #4's and #22's rooms. 2. The facility failed to ensure hot water in room was above 100? in Resident #32's room sink. 3.The facility failed to ensure hand washing sink drained water without resident holding up drain with hand by reaching into used water in Resident #32's room. 4. The facility failed to ensure closets had doors that would enclose resident's clothing. These failures could place residents at risk for infection and diminished clean, homelike environment. Findings included: Resident #4 Record review of Resident #4's face sheet dated 04/24/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE], with a diagnosis of chronic obstructive pulmonary disease (lung disease interfering with airflow), dementia, major depressive disorder, anxiety, tobacco use, diabetes, and acquired absence of right and left leg (leg amputations). Record Review of Resident #4's quarterly MDS assessment dated [DATE], Section C - Cognitive Patterns revealed a BIMS score of 09 (moderate cognitive impairment); Section GG- Functional Abilities and Goals revealed resident needed setup or cleanup assistance with eating, needed supervision with oral hygiene, toilet hygiene, upper body dressing, lower body dressing, and personal hygiene, and needed partial assistance with bathing. During an observation and interview on 04/21/2024 at 3:53 p.m., the sink in Resident #4's room, hot water faucet, would not turn on and left closet door not present leaving resident's clothing exposed. Resident #4 stated that he would like to have warm or hot water available in his room. He voiced he washed his hands and face with the water from sink. He stated that he had told staff his hot water did not work, and nothing had been done about it. Resident #22 Record review of Resident #22's face sheet dated 04/24/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of seizures, diabetes, morbid obesity, muscle weakness, and lack of coordination. Record review of Resident #22's admission MDS dated [DATE] Section C - Cognitive Patters revealed a BIMS score of 12 (moderate cognitive impairment); Section GG- Functional abilities and Goals revealed resident needed setup or cleanup assistance with eating and oral hygiene, needed supervision with upper body dressing, and needed partial assistance with toileting hygiene, bathing, lower body dressing, putting on or taking off footwear and personal hygiene. During an observation and interview on 04/24/2024 at 12:19 p.m., the sink in Resident #22's room only had cold water. Resident #22 stated she would like to have warm or hot water in her room and had not had it since she moved into the facility. Resident #32 Record review of Resident #32's face sheet dated 04/24/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of encephalopathy (damage or disease that effects the brain), dementia, unsteadiness of feet, hypertension (high blood pressure), and lack of coordination. Record review of Resident #32's quarterly MDS dated [DATE], Section C revealed a BIMS score of 10 (moderate cognitive impairment); Section GG- Functional abilities and Goals revealed resident needed setup assistance with eating, supervision with bathing, and was independent with oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. During an observation and interview on 04/21/2024 at 10:48 a.m., the sink in Resident #32's room would not drain water without resident putting hand down in used water and holding up the drain plug. Hot water temperature obtained with thermometer, read 92.4 ?. Resident stated that she did not mind water not being hot. She stated she was not sure how long the drain had not functioned without her holding the plug up. Record review of resident council minutes from January and February of 2024 revealed concerns with hot water on 500 hall. Record review of maintenance log on 04/21/2024 revealed no evidence that 500 hall's hot water concerns were addressed or that Resident #32's drain not draining. During an interview on 04/23/2024 at 10:39 a.m., AD stated she was who made notes in the resident council minutes. She stated hot water concern on 500 hall meant some sinks did not have hot enough water or no hot water at all. During an observation on 04/24/2024 at 3:33 p.m., room [ROOM NUMBER] right closet door missing leaving resident's clothing exposed. During an observation on 04/24/2024 at 12:19 p.m., room [ROOM NUMBER] had only cold water available in the only sink in the room and closet doors leaving resident's clothing exposed. During an observation on 04/21/2024 at 11:45 a.m., room [ROOM NUMBER] had left closet door sitting on floor on A side of room and lying against the wall. Left closet clothing left exposed. During a follow up interview on 04/25/2024 at 8:33 a.m., the AD stated when a concern was brought up in resident council then she would take the concern to the responsible department head for that concern. She stated DPP would be notified if there were issues with maintenance such as plumbing. She stated that she was unsure if the current DPP worked in January or February of 2024 and was unsure who concern was brought up to during that time. She stated the facility discussed concerns during their scheduled QAPI meetings also. She was not able to state whether the hot water concern was corrected. During an interview on 04/25/2024 at 8:38 a.m., the ADMN stated it was her expectation that resident rooms had working water. She did not voice any negative outcome to residents when faucets and drains were not in working order. She would not state her expectation about closet doors adding that some people would not mind having no closet doors. She did not voice any negative outcome to residents. She stated DPP was responsible for monitoring that items in the room were working. ADMN stated verbal discussions were made when items needed to be fixed. She did not provide any evidence that verbal communication had occurred. During an interview on 04/25/2024 at 10:20 a.m., the DPP stated he had ordered parts to fix hot water faucets in the sinks that he knew were not working. He stated it was hard to obtain parts due to facility's location and no stores close by, so he had to have parts shipped. He stated that he did not have computer access to order supplies until two to three weeks ago which delayed his ability to correct issues. He stated he had been attempting to find [NAME] brackets to fix closet doors, but they were no longer available to order. He stated he had been verbally told about some items not working but felt that he forgot some of the items that were told to him when he became busy during his workday. Review of facility's policy titled Maintenance Service dated December 2009 revealed: The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .Functions of maintenance personnel include but are not limited to .maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. Review of facility's policy titled Work Orders, Maintenance revised in April 2010 revealed: Maintenance work orders shall be completed in order to establish a priority of maintenance service .In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the Maintenance Director .It shall be the responsibility of the department directors to fill out and forward such work orders to the Maintenance Director .A supply of work orders is maintained at each nurses' station .Work order requests should be placed in the appropriate file basket at the nurses' station. Work orders are picked up daily .Emergency requests will be given priority in making necessary repairs. Review of facility's policy titled Quality of Life - Homelike Environment revised in May 2017 revealed: Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include Clean, sanitary and orderly environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide appropriate treatment and services to prevent urinary tract infections for residents who are incontinent of bladder, for 2 of 18 (Resident #17 and Resident #38) residents reviewed for incontinent care. The facility failed to ensure no cross-contamination occurred when CNA B failed to wash hands prior to, during, or after performing peri-care and failed to follow peri-care standards of practice when wiping in a zig-zag motion instead of front to back and when going from dirty to clean for Resident #17. The facility failed to ensure no cross-contamination occurred when CNA C failed to wash hands prior to, during, or after performing peri-care and failed to follow peri-care standards of practice when wiping in a zig-zag motion instead of front to back and when going from dirty to clean for Resident #38. These failures could place residents at risk of development and transmission of communicable diseases and infections. Findings included: Resident #17 Review of Resident #17's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: major depression, dementia, and psychotic disorder. Record review of Resident #17's Quarterly MDS assessment dated [DATE] revealed: BIMS score of 05 which indicated severe cognitive impairment. Further review of the MDS Section GG Self-Care revealed toileting hygiene of substantial/maximal assistance. Further review of the MDS Section H Bladder and bowel revealed frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #17's Care plan revised on 10/17/2023 revealed: Focus: The resident has mixed bladder incontinence and is at risk for skin breakdown r/t incontinence of urine r/t Dementia, Impaired Mobility. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. The resident's risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through the review date. Interventions: Clean peri-area with each incontinence episode. Establish voiding patterns. Monitor/document/report PRN any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects. Resident #38 Review of Resident #38's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: dementia, pain, Alzheimer's, and fatigue. Record review of Resident #38's Significant Change MDS dated [DATE] revealed: BIMS not completed. Further review of the MDS Section GG Self-Care revealed toileting hygiene of dependent. Further review of the MDS Section H Bladder and Bowel revealed always incontinent of bowel and bladder. Record review of Resident #38's Care plan revised on 02/05/20 revealed: Focus: The resident has bladder incontinence and is at risk for skin breakdown r/t incontinence of urine dx of Alzheimer's. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Clean peri-area with each incontinence episode. Encourage fluids during the day to promote prompted voiding responses. Ensure the resident has unobstructed path to the bathroom. Establish voiding patterns. Limit fluids 2-3 hours prior to bedtime. Monitor and document intake and output as per facility policy. During observation on 04/21/24 at 11:31 AM, CNA B performed peri-care on Resident #38 with the assist of CNA C. CNA B did not wash her hands prior to beginning. CNA B wiped perineal area in a zig-zag motion with one wipe. CNA B did not separate the labia and clean that area. CNA B did not change gloves or sanitize between removing dirty brief and applying clean brief. CNA B finished peri-care, removed gloves, and did not wash hands. CNA C assisted with turning of resident. CNA C then performed peri-care on Resident #17 with the assist of CNA B for turning. Neither CNA C nor CNA B washed their hands. CNA C wiped perineal area in a zig-zag motion with one wipe. CNA C did not separate the labia and clean that area. CNA C did not change gloves or sanitize between removing dirty brief and applying clean brief. CNA C finished peri-care, removed gloves, and did not wash hands. During an interview on 04/21/24 at 1:15 pm, CNA C stated she should have washed her hands prior to peri-care and after peri-care. She stated she was just nervous. CNA C stated she did not know she should have changed gloves between dirty and clean. She stated she had not been trained or checked off on peri-care since she had worked at the facility. During an interview on 04/21/24 at 1:30 pm, CNA B stated she did not wash her hands because the resident bathrooms were either too full to get into or they do not have hot water. She stated she felt that she cleaned the resident thoroughly. CNA B stated she had not performed any skills competencies. Record review of personnel files showed no evidence of skill competency checkoffs or peri-care training for CNA B hired on 12/12/2023. Record review of personnel files showed no evidence of skill competency checkoffs or peri-care training for CNA C hired on 01/13/2020. During an interview on 04/25/24 at 2:00 PM, the DON stated hands should be washed before, during, and after peri-care. She stated the perineal should be cleaned from front to back not a zig-zag motion and a new wipe should be used after each swipe. DON stated the labia should be separated and cleaned thoroughly. The DON stated she had not performed any staff competencies since she had been DON starting in February 2024. She stated she had called the previous DON to see if she had record of competencies but at that time, she had no record of when competencies were last performed. She stated she did not know how often staff performance should be evaluated or anything about their required annual training. Review of facility's policy titled Perineal Care not dated revealed: Steps in Procedure: .2. Wash and dry your hands thoroughly .6. Put on gloves 8. For a female resident a. use wipes and apply skin cleansing agent. B. wash perineal area, wiping from front to back. 1. Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to attempt to use alternatives prior to installing a side or bed rail and assess the resident for risk of entrapment from bed rails prior to installation for 3 of 3 residents (Resident #26, Resident #59, and Resident #68) reviewed for bed rails. 1. The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails. 2. The facility failed to obtain informed consent prior to installation of bed rails. These failures could place residents at risk for injury and restricted movement. The findings include: Resident #26 Record review of Resident #26's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Alzheimer's, dementia, and depression. Record review of Resident #26's quarterly MDS assessment dated [DATE] revealed: BIMS score of 06 which indicated severe cognitive impairment. Further review of the MDS Section P Restraints and Alarms revealed no bed rails used and Section GG- Functional Abilities and Goals revealed resident needed partial assistance with rolling left and right in the bed, ability to move from sitting to lying, ability to move from lying on the back to sitting on the side of the bed, and ability to move from bed to chair. Record review of Resident #26's care plan initiated on 03/07/2024 revealed no evidence of side rails. Record review of Resident #26's electronic physicians Orders revealed no evidence of order for side rails. Record review of Resident #26's electronic medical record revealed no evidence that risk for entrapment was performed, less restrictive measures were attempted, or informed consent was obtained prior to installation of bed rails. During an observation on 04/25/24 at 1:53 p.m., Resident #26 was resting in bed with bilateral half side rails up. Resident was not able to be interviewed or answer questions. Resident #59 Record review of Resident #59's electronic face sheet dated 04/24/2024 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: major depressive disorder, dementia, insomnia, muscle weakness, psychotic disorder with delusions, and anxiety. Record review of Resident #59's quarterly MDS dated [DATE] revealed: BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS Section P Restraints and Alarms revealed no bed rails used and Section GG- Functional Abilities and Goals revealed resident needed substantial assistance to roll left and right in the bed, and helped does all of the effort with ability to move from sitting to lying, ability to move from lying on the back to sitting on the side of the bed, and ability to move from bed to chair. Record review of Resident #59's Care plan initiated on 01/04/2024 revealed: Focus: Resident requires the use of 1/2 side rails to assist with bed mobility. Goal: Dignity will be maintained, and no occurrence of injury will occur throughout the review date. Interventions: Evaluate and Re-evaluate for 1/2 side rail use quarterly and PRN. Explain reason and risks of 1/2 side rails using terms the resident and responsible party can understand. Monitor for proper positioning and circulatory concerns report any significant changes to MD promptly. Record review of Resident #59's electronic physicians orders revealed no evidence of an order for side rails. Record review of Resident #59's electronic medical record revealed no evidence that risk for entrapment was performed, less restrictive measures were attempted, or informed consent was obtained prior to installation of bed rails. During an observation on 04/21/2024 at 11:15 a.m., Resident #59 was sitting in the dining area of the secured unit. Resident 59's room [ROOM NUMBER]-A had bilateral half side rails present and the left side was in the up position. Attempted phone interview on 04/21/2024 at 6:20 p.m. with Resident #59's responsible party who refused interview at this time. Resident #68 Review of Resident #68's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: blindness, depression, autistic disorder, and Down's syndrome. Record review of Resident #68's admission MDS dated [DATE] revealed: BIMS not completed that indicated resident was unable to complete related to resident is rarely or never understood. Further review of the MDS Section P Restraints and Alarms revealed no bed rails used, and Section GG- Functional Abilities and Goals revealed partial assistance needed for resident to roll left and right in the bed and ability to move from sitting to lying and needed substantial assistance with ability to move from lying on the back to sitting on the side of the bed, and ability to move from bed to chair. Record review of Resident #68's Care plan initiated on 03/04/2024 revealed: Focus: Resident requires the use of 1/2 side rails to assist with bed mobility. Goal: Dignity will be maintained, and no occurrence of injury will occur throughout the review date. Interventions: Evaluate and Re-evaluate for 1/2 side rail use quarterly and PRN. Explain reason and risks of 1/2 side rails using terms the resident and responsible party can understand. Monitor for proper positioning and circulatory concerns report any significant changes to MD promptly. Record review of Resident #68's electronic physicians orders revealed: MAY USE SIDE RAILS FOR POSITIONING, dated 03/04/2024. Record review of Resident #68's electronic medical record revealed no evidence that risk for entrapment was performed, less restrictive measures were attempted, or informed consent was obtained prior to installation of bed rails. During an observation on 04/25/2024 at 01:59 p.m. Resident #68 was lying in bed with bilateral half rails in the up position. Resident unable to be interviewed or answer questions. During an interview on 04/25/2024 at 12:03 p.m., LVN I stated the facility did not use bed rails to keep residents in their beds but used them as mobility aides. She stated that a consent should be obtained, and a physician's order was needed prior to bed rails being installed. She stated that she would perform a mobility device assessment in the electronic medical record when a resident had bed rails and would know to perform when UDA (un-documented assessments) triggered. She was unsure who scheduled out the assessment on the UDA. LVN I stated the effect of placing bed rails on a resident's bed that did not have orders, consent, or appropriate assessment could cause resident to potentially fall or get caught in the rail. During an interview on 04/25/2024 at 12:05 p.m., CNA F stated the facility did not use bed rails to keep residents in their beds but for mobility. She stated that Resident #59 had recently moved into room [ROOM NUMBER] and felt that the bed may have had rail prior to her being in the room. During an observation and interview on 04/25/2024 at 1:10 p.m., Resident #59's bed had bilateral half rails with left rail (closest to the wall) in the up position. The ADON stated that facility did not use bed rails to keep residents in their beds. She stated that she did not know the facility's policy on bed rails. During an interview on 04/25/2024 at 1:15 p.m., the DON stated her expectation would be for physician orders to be obtained and consent obtained prior to installing bed rails on a resident's bed. She felt that the failure had occurred due to Resident #59 had recently changed rooms and bed rails being present prior to room change. She stated that she and the RRN were responsible for monitoring that proper items were in place prior to bed rails being installed on the beds. She was not aware of any assessment that needed to be performed for bed rails. She stated that the effect to the resident could be having an injury from a fall. During an interview on 04/25/2024 at 1:18 p.m., the RRN stated she expected for a physician's order, informed consent, an entrapment risk assessment, and an assessment of bed to make sure bed rail fit properly prior to bed rails being used. She stated that both her and the DON were responsible to make sure those tasks were performed. During a follow up interview on 04/25/2024 at 1:37 p.m., the DON stated the assessment that should have been performed was titled Bed Rail Entrapment Assessment and the DPP should have been performing. She stated that the DPP would be in-serviced then he could start to perform assessments. Review of facility's policy titled Bed Safety dated 04/2021 revealed: Focused Communities will strive to provide a safe sleeping environment for the resident. Procedure 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. An inspection should be done by the Director of Plant Operations at installation/before use and quarterly thereafter of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement, or bed position. c. Ensure that when bed system components are worn and need to be replaced, they are replaced with compatible components that meet manufacturer's specifications; d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.). 3. The Director of Plant Operations shall provide a copy of inspections to the Executive Director of Operations and report results to the QA Committee recommendations shall be maintained by the Executive Director of Operations and/or Safety Committee. 4. The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment. 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 7. After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed). 8. Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. 9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. 10. When using side rails for any reason, the staff shall take measures to reduce related risks. 11. Side rails shall not be used as protective restraints. Should a protective restraint be used, communities' protocol for the use of restraints shall be followed. 12. The use of physical restraints on individuals in bed shall be limited to situations where they are needed to treat a resident's medical symptoms, and only after being reviewed by authorized individuals. 13. The staff shall report to the Director of Clinical Operations and Executive Director of Operations any deaths, serious illnesses and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The Executive Director of Operations shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Device Act.

Based on interview and record review, the facility failed to review the work of each Certified Nurse Aid (CNA) every 12 months for 4 (CNA-D, CNA-E, CNA-F and CNA G) of 5 CNAs reviewed for nursing services. The facility failed to provide CNA competency evaluations at least every 12 months after hire. This failure could result in inadequate CNA performance while providing care for residents. Findings include: Record Review of Personnel Files revealed: - Employee record for CNA-D revealed a hire date of 10/04/2021 and had no evidence of a competency evaluation at least every 12 months after hire. - Employee record for CNA-E revealed a hire date of 10/19/2021 and had no evidence of a competency evaluation at least every 12 months after hire. - Employee record for CNA-F revealed a hire date of 11/15/2021 and had no evidence of a competency evaluation at least every 12 months after hire. - Employee record for CNA-G revealed a hire date of 10/14/2021 and had no evidence of a competency evaluation at least every 12 months after hire. During an interview on 04/25/2024 at 2:00 PM, the DON stated she had not performed any staff competencies since she had been hired as DON, February 2024. She stated she had called the previous DON to see if she had the records of CNA competencies, but she had no records. She stated she did not know how often staff performances should have been evaluated or their required annual training. The DON stated she was supposed to have monitored the CNA competency trainings. She stated the negative impact to residents could have been them not performing their duties correctly and possibly not giving them the proper care they deserved. She stated the failure was that she had not followed up with making sure the CNA's had all been trained correctly with documentation. The DON stated her expectations were for them to have had all of the competencies they needed and have the proper training and to take care of the residents as required. Record Review of the facility's policy titled Nurse Aide Education, dated 08/16/17, revealed the following: - Competency will be evaluated initially and annually. - Facility will conduct a performance review of each nurse aide at least once every 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days for 6 (Resident #45, Resident #10, Resident #18, Resident #58, Resident #2, and Resident #52) of 11 residents reviewed for pharmacy services. The facility failed to ensure Resident #45, Resident #10, Resident #18, Resident #58, Resident #2, and Resident #52 had stop dates for PRN Lorazepam (medicine used to treat the symptoms of anxiety). This failure could place residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Resident #45 Review of Resident #45's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, diabetes, depression, dementia, and Alzheimer's. Record review of Resident #45's Quarterly MDS assessment dated [DATE] revealed: BIMS score of 04 which indicated severe cognitive impairment. Further review of the MDS Section N Medications revealed antianxiety medications taken in the last 7 days during the look back period (assessment period). Record review of Resident #45's Care plan revised on 10/24/2023 revealed: Focus: The resident uses antianxiety Medication. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Monitor/record occurrence of for target behavior symptoms (SPECIFY pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. Record review of Resident #45's electronic Physicians Orders revealed: Lorazepam Concentrate 2 MG/ML Give 0.5 ml sublingually every 4 hours as needed for restlessness/agitation/anxiety, dated 02/11/2022 with no stop date. Record review of Resident #45's MAR, dated April 2024, revealed no evidence of Lorazepam being administered. Review of Resident #45's physician progress notes from January 2024- April 2024 revealed no documented rationale for the continued provision of lorazepam. Resident #10 Review of Resident #10's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: bipolar disorder, difficulty swallowing, and anxiety. Record review of Resident #10's Significant Change MDS dated [DATE] revealed: BIMS score not completed. Further review of the MDS Section N Medications revealed antianxiety medication taken in the last 7 days during the look back period (assessment period). Record review of Resident #10's Care plan revised on 10/17/2023 revealed: Focus: The resident uses antianxiety Medication. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Record review of Resident #10's electronic Physicians Orders revealed: Lorazepam Intensol Oral Concentrate 2 MG/ML Give 0.5 ml by mouth every 4 hours as needed for restlessness/agitation/anxiety, dated 02/06/2024 with no stop date. Record review of Resident #10's MAR, dated April 2024, revealed Lorazepam was administered on 04/23/24 at 11:53 am and 04/24/24 at 11:49 am. Review of Resident #10's physician progress notes from January 2024- April 2024 revealed no documented rationale for the continued provision of lorazepam. Resident #18 Review of Resident #18's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: paralysis, diabetes, irregular heartbeat, and difficulty swallowing. Record review of Resident #18's Quarterly MDS dated [DATE] revealed: BIMS score 00 which indicated severe cognitive impairment. Further review of the MDS Section N Medications revealed antianxiety medication taken in the last 7 days during the look back period (assessment period). Record review of Resident #18's Care plan revised on 12/20/2023 revealed: Focus: The resident uses antianxiety Medication. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Record review of Resident #18's electronic Physicians Orders revealed: Lorazepam Injection Solution 2 MG/ML (Lorazepam) Give 0.5 ml sublingually every 4 hours as needed for restlessness/agitation/anxiety, dated 12/29/2023 with no stop date. Record review of Resident #18's MAR, dated April 2024, revealed no Lorazepam had been administered. Review of Resident #18's physician progress notes from January 2024- April 2024 revealed no documented rationale for the continued provision of lorazepam. Resident #58 Review of Resident #58's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: diabetes, liver failure, and high blood pressure. Record review of Resident #58's Quarterly MDS dated [DATE] revealed: BIMS score 10 which indicated moderate cognitive impairment. Further review of the MDS Section N Medications revealed no antianxiety medications taken in the last 7 days during the look back period (assessment period). Record review of Resident #58's Care plan revised on 12/20/2023 revealed: Focus: The resident uses antianxiety Medication. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Record review of Resident #58's electronic Physicians Orders revealed: Lorazepam Solution 2 MG/ML (Lorazepam) Give 0.5 ml by mouth every 4 hours as needed for restlessness/agitation/anxiety, dated 12/15/2022 with no stop date. Record review of Resident #58's MAR, dated April 2024, revealed no Lorazepam had been administered. Review of Resident #58's physician progress notes from January 2024- April 2024 revealed no documented rationale for the continued provision of lorazepam. Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: depression, anxiety, brain bleed, and Parkinson's disease. Record review of Resident #2's Quarterly MDS dated [DATE] revealed: BIMS score 10 which indicated moderate cognitive impairment. Further review of the MDS Section N Medications revealed no antianxiety medication taken in the last 7 days during the look back period (assessment period). Record review of Resident #2's Care plan revised on 12/20/2023 revealed: Focus: The resident uses antianxiety Medication. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Record review of Resident #2's electronic Physicians Orders revealed: Lorazepam Solution 2 MG/ML (Lorazepam) Give 0.5 ml by mouth every 4 hours as needed for restlessness/agitation/anxiety, dated 12/15/2022 with no stop date. Record review of Resident #2's MAR, dated April 2024, revealed no Lorazepam had been administered. Review of Resident #2's physician progress notes from January 2024- April 2024 revealed no documented rationale for the continued provision of lorazepam. Resident #52 Review of Resident #52's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: prostate cancer, anxiety, and respiratory failure. Record review of Resident #52's admission MDS dated [DATE] revealed: BIMS score 08 which indicated moderate cognitive impairment. Further review of the MDS Section N Medications revealed antianxiety medication taken in the last 7 days during the look back period (assessment period). Record review of Resident #52's Care plan revised on 03/22/2024 revealed: Focus: The resident uses antianxiety Medication. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Record review of Resident #52's electronic Physicians Orders revealed: Lorazepam Intensol Oral Concentrate 2 MG/ML Give 0.5 ml by mouth every 1 hours as needed for Anxiety/Agitation/Restless, ordered 03/22/2024 with no stop date. Record review of Resident #52's MAR, dated April 2024, revealed: lorazepam was administered on 04/21/2024 at 2:59 am and 6:48 am, 04/23/2023 at 1:00 pm and 2:42 pm, and 04/24/2024 at 4:12 am, 10:10 am, 11:53 am, and 7:14 pm. Review of Resident #52's physician progress notes from January 2024- April 2024 revealed no documented rationale for the continued provision of lorazepam. During an interview on 04/24/2024 at 10:45 AM, the DON stated she was aware of the regulation on PRN psychotropic medications. She stated it was her responsibility to monitor and ensure all PRN psychotropic medications had a stop date no longer than 14 days. The DON stated she had been the DON since February and had been very busy and she just missed the orders. She stated she did not know the possible negative outcome other than not following the regulation. Review of facility policy titled, Psychotropic Medication Review not dated revealed: Policy: IDT will emphasize the importance of seeking an appropriate dose and duration of each psychotropic medication, with careful assessment as to whether the medication is necessary and pharmacologically appropriate. Standards: 1. The community will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications, to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. 2. The community supports the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness. 3. The community supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, mental, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident. 4. Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation. 5. Psychopharmacological medications will never be used for purpose of discipline or convenience. Procedures: 1. Monitors psychotropic drug use noting any adverse effects. 2. Reviews of the use of the medications with IDT on monthly basis, during Standard of Care Meeting to determine the continued presence of target behaviors and or the presence of any adverse effects of the medications. 3. Monitors psychotropic drug use to ensure that medications are not used in excessive doses or for excessive duration. 4. Monitor psychotropic drug use for gradual dose reduction (GDR) potential. 5. Monitor GDR for success or failure, related to targeted behaviors. Review of Drugs.com for Lorazepam accessed on 04/29/2024 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services in that: The facility failed to ensure the dry food storage was not past their use by dates. This failure placed residents at risk for food borne illnesses. Findings include: During an observation on 04/21/2024 at 9:45 AM, the dry storage pantry revealed: 1. 6 packages of 16 oz. sealed marshmallows in the original packaging with an use by date of 02/15/2024. 2. 1 opened box of shredded coconut with the in date of 07/12/2022 and an opened date of 07/13/2022. 3. 1 sealed 20 lb. box of black-eyed peas with an use by date of 08/31/2023. During an interview on 04/23/24 at 10:44 AM, the DM stated there should have been no expired food in the pantry. She stated the product dates should have been checked on a weekly basis as well as when the truck came in with products. She stated she had previously given in-services for food safety to her kitchen staff on 03/22/2024. She stated she should have monitored the stored food as well as what came in on the trucks to the kitchen more closely. The DM stated the failure occurred with the kitchen department head and having not paid attention to the expired products and dates. She stated the negative impact was it could have possibly made residents sick, and her expectations would have been that all products were checked correctly daily. During an interview on 04/25/2024 at 11:45 AM, the ADMN stated the expiration dates on food products should have been checked every day and updated weekly as well as rotating food products. She stated she would only go into the kitchen when she needed to. She stated she the DM monitored products to make sure there were no outdated products, but that ultimately the ADMN monitored the DM. The ADMN stated the negative impact to residents were that they could get sick. She stated the failure occurred with the chain of command with trainings not being adhered to. She stated her expectations were that the products be labeled and dated as they come in off the truck and rotating and using the oldest dated products before their expired date. Record review of facility's food manager training, Food Safety Articles, First In, First Out (FIFO), undated, revealed; FIFO organizes food by expiration or use-by date Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 05/08/2024 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act § 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 11 (Resident #45, Resident #10, Resident #18, Resident #58, Resident #2, Resident #52, Resident #26, Resident #19, Resident #21, Resident #35, and Resident #34) of 11 residents reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness to ensure Resident #45, Resident #10, Resident #18, Resident #58, Resident #2, Resident #52, Resident #26, Resident #19, Resident #21, Resident #35, and Resident #34 received adequate end-of-life care. The facility failed to have physicians' orders for Hospice Care for Resident #10, Resident #58, Resident #2, Resident #52, Resident #21, and Resident #35. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Resident #45 Review of Resident #45's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, diabetes, depression, dementia, and Alzheimer's. Record review of Resident #45's Quarterly MDS assessment dated [DATE] revealed: BIMS score of 04 which indicated severe cognitive impairment. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. Record review of Resident #45's Care plan revised on 09/01/2023 revealed: Focus: The resident has a terminal prognosis r/t Alzheimer's Disease. On Hospice Services. Goal: The resident's comfort will be maintained through the review date. Interventions: Assess resident coping strategies and respect resident wishes. Consult with physician and Social Services to have Hospice care for resident in the facility. Encourage resident to express feelings, listen with non-judgmental acceptance, compassion. Encourage support system of family and friends. Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near. Record review of Resident #45's electronic Physicians Orders revealed: Admit to Hospice, dated 02/11/2022. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #45. Resident #10 Review of Resident #10's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: bipolar disorder, difficulty swallowing, and anxiety. Record review of Resident #10's Significant Change MDS dated [DATE] revealed: BIMS score not completed. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. Record review of Resident #10's Care plan revised on 02/07/2024 revealed: Focus: The resident has a terminal prognosis r/t DX: Huntington's. On hospice Services. Goal: The resident's dignity and autonomy will be maintained at highest level through the review date. The resident's comfort will be maintained through the review date. Interventions: Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review of Resident #10's electronic Physicians Orders revealed no evidence of an order for Hospice Care. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #10. Resident #18 Review of Resident #18's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: paralysis, diabetes, irregular heartbeat, and difficulty swallowing. Record review of Resident #18's Quarterly MDS dated [DATE] revealed: BIMS score 00 which indicated severe cognitive impairment. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. Record review of Resident #18's Care plan revised on 12/20/2023 revealed: Focus: The resident has a terminal prognosis HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING RIGHT DOMINANT SIDE. On Hospice services. Goal: The resident will be free of depression and anxiety through the review date. The resident's comfort will be maintained through the review date. Interventions: May oral suction PRN. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Work with nursing staff to provide maximum comfort for the resident. Record review of Resident #18's electronic Physicians Orders revealed: Admit to Hospice ., dated 12/29/23. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #18. Resident #58 Review of Resident #58's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: diabetes, liver failure, and high blood pressure. Record review of Resident #58's Quarterly MDS dated [DATE] revealed: BIMS score 10 which indicated moderate cognitive impairment. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. Record review of Resident #58's Care plan revised on 09/29/2023 revealed: Focus: The resident has a terminal prognosis r/t liver failure. HOSPICE. Goal: The resident's comfort will be maintained through the review date. Interventions: Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Assess resident coping strategies and respect resident wishes. Consult with physician and Social Services to have Hospice care for resident in the facility. Encourage support system of family and friends. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Review resident's living will and ensure it is followed. Involve family in discussion. Work with nursing staff to provide maximum comfort for the resident. Record review of Resident #58's electronic Physicians Orders revealed no evidence of an order for Hospice Care. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #58. Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: depression, anxiety, brain bleed, and Parkinson's disease. Record review of Resident #2's Quarterly MDS dated [DATE] revealed: BIMS score 10 which indicated moderate cognitive impairment. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. Record review of Resident #2's Care plan revised on 09/29/2023 revealed: Focus: The resident has a terminal prognosis r/t liver failure. HOSPICE. Goal: The resident's comfort will be maintained through the review date. Interventions: Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Assess resident coping strategies and respect resident wishes. Consult with physician and Social Services to have Hospice care for resident in the facility. Encourage support system of family and friends. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Review resident's living will and ensure it is followed. Involve family in discussion. Work with nursing staff to provide maximum comfort for the resident. Record review of Resident #2's electronic Physicians Orders revealed no evidence of an order for Hospice Care. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #2. Resident #52 Review of Resident #52's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: prostate cancer, anxiety, and respiratory failure. Record review of Resident #52's admission MDS dated [DATE] revealed: BIMS score 08 which indicated moderate cognitive impairment. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. Record review of Resident #52's Care plan revised on 03/22/2024 revealed: Focus: The resident has a terminal prognosis r/t DX: C61 Malignant neoplasm of prostate. On Hospice Services. Goal: The resident will be free of depression and anxiety through the review date. The resident's comfort will be maintained through the review date. Interventions: Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Encourage resident to express feelings, listen with non-judgmental acceptance, compassion. Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review of Resident #52's electronic Physicians Orders revealed no evidence of an order for Hospice Care. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #52. Resident #26 Review of Resident #26's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Alzheimer's, dementia, and depression. Record review of Resident #26's Quarterly MDS dated [DATE] revealed: BIMS score 06 which indicated severe cognitive impairment. Further review of the MDS Section P Restraints and Alarms revealed no bed rails used. Further review of MDS Section O Special Treatments, Procedures, and Programs revealed hospice care. Record review of Resident #26's Care plan initiated on 03/07/2024 revealed: Focus: The resident has a terminal prognosis r/t DX: Alzheimer's. On hospice services. Goal: The resident will be free of depression and anxiety through the review date. The resident's comfort will be maintained through the review date. Interventions: Assess resident coping strategies and respect resident wishes. Encourage resident to express feelings, listen with non-judgmental acceptance, compassion. Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near. Record review of Resident #26's electronic Physicians Orders revealed: May admit to hospice ., dated 03/07/24. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #26. Resident #19 Review of Resident #19's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: pneumonia, diabetes, and dementia. Record review of Resident #19's Quarterly MDS dated [DATE] revealed: BIMS score not completed. Further review of MDS Section O Special Treatments, Procedures, and Programs revealed hospice care. Record review of Resident #19's Care plan revised on 03/28/2024 revealed: Focus: The resident has a terminal prognosis r/t DYSPHAGIA FOLLOWING CEREBRAL INFARCTION. On hospice services. Goal: The resident will be free of depression and anxiety through the review date. The resident's comfort will be maintained through the review date. Interventions: Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Encourage support system of family and friends. Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near. Suction as needed due to excess secretions. Record review of Resident #19's electronic Physicians Orders revealed: May admit to hospice ., dated 11/21/23. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #19. Resident #21 Review of Resident #21's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, dementia, and bipolar disorder. Record review of Resident #21's Quarterly MDS dated [DATE] revealed: BIMS score not completed. Further review of MDS Section O Special Treatments, Procedures, and Programs revealed hospice care. Record review of Resident #21's Care plan initiated on 02/02/2024 revealed: Focus: The resident has a terminal prognosis r/t DX: Huntington's Disease. admitted to Hospice. Goal: The resident's dignity and autonomy will be maintained at highest level through the review date. The resident's comfort will be maintained through the review date. Interventions: Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review of Resident #21's electronic Physicians Orders revealed no evidence of orders for hospice care. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #21. Resident #35 Review of Resident #35's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Alzheimer's, depression, anxiety, and dementia. Record review of Resident #35's Significant Change MDS dated [DATE] revealed: BIMS score 05 which indicated severe cognitive impairment. Further review of MDS Section O Special Treatments, Procedures, and Programs revealed hospice care. Record review of Resident #35's Care plan initiated on 04/20/2024 revealed: Focus: The resident has a terminal prognosis r/t DX: ALZHEIMER'S DISEASE WITH LATE ONSET On hospice services. Goal: The resident will be free of depression and anxiety through the review date. The resident's comfort will be maintained through the review date. Interventions: Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review of Resident #35's electronic Physicians Orders revealed no evidence of orders for hospice care. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #35. Resident #34 Review of Resident #34's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: heart failure, dementia, and back fracture. Record review of Resident #34's Quarterly MDS dated [DATE] revealed: BIMS score 06 which indicated severe cognitive impairment. Further review of MDS Section O Special Treatments, Procedures, and Programs revealed hospice care not claimed. Record review of Resident #34's Care plan initiated on 04/20/2024 revealed: Focus: The resident has a terminal prognosis r/t DX: Heart failure, unspecified. On Hospice Services. Goal: The resident will be free of depression and anxiety through the review date. The resident's comfort will be maintained through the review date. Interventions: Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Encourage resident to express feelings, listen with non-judgmental acceptance, compassion. Encourage support system of family and friends. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review of Resident #34's electronic Physicians Orders revealed: ADMIT TO HOSPICE ., dated 11/29/2023. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #34. During an interview on 04/24/2024 at 10:46 AM, the DON stated that hospice communicated with the facility by writing orders. She stated she could not find the binder or any hospice information for any residents on hospice services. She stated that she did not know that hospice was supposed to provide information to the facility. During an interview on 04/24/24 at 10:49 AM, the RRN stated that she expected for facility to have hospice documentation either in a binder or in the medical record that included the hospice plan of care and certificate of terminal illness. She stated that facility did have hospice contact information and she called one of the hospice agencies and asked them to send over the binder with required information. She stated that she did not know why the facility did not have that information. She stated that the effect of not having the information could cause the resident to not get the care they needed because of not having continuity of care. During an interview on 04/24/24 at 11:16 AM, the SSD voiced that the 2 hospice charts at the nurses' station were for resident's that are no longer in the facility. She voiced that she did not find any hospice binders at the nurses' station for any of the current residents on hospice. Record review of the facility's Hospice Services Agreement dated effective November 27, 2023, between the nursing facility and Hospice revealed: .4. Hospice Services A. Hospice will: .6. Provide the facility with the following: 1. The most recent Hospice Plan of Care; 2. The Hospice election form and any advance directives specific to each Patient; 3. Physician certification and recertification of the Terminal , Illness specific to each Patient; 4. Names and contact information for Hospice personnel involved in the delivery of Hospice Services for each Patient; 5. Instructions on how to access Hospice's twenty-four hour on- call system; 6. Hospice medication information for each Patient; and 7. Hospice physician and Attending Physician, if any, orders for each Patient .8. Medical Records: a. Facility and Hospice will prepare and maintain medical records for each Hospice Patient. Such records will be prepared and maintained in conformity with federal and state law, rules, regulations, procedures, policies, guidelines, and generally accepted medical record practices .

Based on interview and record review, the facility failed to ensure 4 of 5 (CNA-D, CNA-E, CNA-F, CNA-G) employees whose in-service records were reviewed had received the required minimum 12 hours annual in-service. The facility failed to provide the required annual performance care training to CNA-D, CNA-E, CNA-F, and CNA-G. This failure placed residents at risk for unmet needs due to untrained staff. Findings include: Record review of Personnel Files revealed: - Employee record for CNA-D revealed a hire date of 10/04/2021 and had no evidence of the required minimum 12 hours annual in-service. - Employee record for CNA-E revealed a hire date of 10/19/2021 and had no evidence of the required minimum 12 hours annual in-service. - Employee record for CNA-F revealed a hire date of 11/15/2021 and had no evidence of the required minimum 12 hours annual in-service. - Employee record for CNA-G revealed a hire date of 10/14/2021 and had no evidence of the required minimum 12 hours annual in-service. During an interview on 04/25/2024 at 2:00 PM, the DON stated she was responsible for nursing staff competencies and she had not performed any staff in-service competencies since she had been hired as DON, February 2024. She stated she had called the previous DON to see if she had the records of CNA required in-services, but she had no record. She stated she did not know how often staff in-service competencies should have been evaluated or their required annual training. The DON stated she was supposed to have monitored the CNA competency trainings. She stated the negative impact to residents could have been them not performing their duties correctly and possibly not giving them the proper care they deserved. She stated the failure was that she had not followed up with making sure the CNA's had all been trained correctly with documentation. The DON stated her expectations were for them to have had all of the competencies they needed and have the proper training and to take care of the residents as required. Record Review of the facility policy titled Nurse Aide Education, dated 08/16/17, revealed the following: - Competency will be evaluated initially and annually. - Facility will conduct a performance review of each nurse aide at least once every 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an ongoing program of activities designed to meet the interests and support the physical, mental, and psychosocial well-being for 12 of 12 residents (#10, #11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24) on the Memory Care Unit reviewed for activities, in that 1. 12 of 12 residents in the Memory Care Unit did not have an ongoing activity program designed to meet their interest. This deficient practice could place residents at risk for isolation, low self-esteem, and decline in mental status. Findings include: Face sheet review reflected Resident #15, was a female 69 diagnosed with Alzheimer's disease. MDS dated [DATE] for Resident #15 reflected a BIMS of 00 (severely impaired cognition), Care Plan dated 5/9/23 for Resident #15 reflected for Activities it stated activities in room [ROOM NUMBER] times per week, nails, reading and music. Observation on 6/20/23 at 10:35 am revealed Resident #15 sitting on bed in room [ROOM NUMBER]-A, and there was no activity calendar posted in the room. Observation on 6/20/23 at 1:45pm revealed Resident #15 sitting in a chair in the hallway. Observation on 6/21/23 at 9:12 am revealed Resident #15 was sitting in the TV room watching TV. Face Sheet review reflected Resident #16 was a female aged 71 and was diagnosed with Alzheimer's disease. MDS dated [DATE] for Resident #16 reflected a BIMS of 10 (moderately impaired cognition) Care Plan dated 3/31/23 for Resident #16 reflected for Activities it stated attends activities 3 times per week. Interview on 6/21/23 at 9:20 am, Resident #16 stated she does not know when the activities are or what time they start. Resident #16 does not recall doing any activities in her room. Observation 6/21/23 at 9:22am, revealed Resident #16 does not have an Activity Calendar posted in room. Face Sheet review reflected Resident #17 was a Female aged 83 and was diagnosed with Major depression. MDS dated [DATE] for Resident #17 reflected a BIMS of 4 (severely impaired cognition) Care Plan dated 3/15/23, reflected for activities, Resident #17 will attend activities 3 times per week, and an Activity calendar will be posted in room. Observation on 6/21/23 at 9:30 am revealed Resident #17 sitting on her bed. There was no Activity calendar posted in room. Face Sheet reflected Resident #18 was a female aged 74 and was diagnosed with Dementia. MDS dated [DATE] for Resident #18 reflected a BIMS of 2 (severely impaired cognition) Care Plan dated 5/2/23, reflected for Activities, Resident #18 will attend activities 3 times per week, nails, music, reading, and an Activity calendar will be posted in room. Observation on 6/21/23 at 9:35 am revealed Resident #18 was in bed sleeping, and no activity calendar was posted in room. Face Sheet reflected Resident #19 was a female aged 80 and was diagnosed with Congestive Heart Failure. MDS dated [DATE] for Resident #19 reflected a BIMS of 3 (severely impaired cognition) Care Plan dated 5/29/23, reflected for Activities Resident #19 will have an Activity calendar posted in room. Observation on 6/21/23 at 9:38 am, revealed Resident #19's room did not have an Activity calendar posted. Face Sheet reflected Resident #20 was a female aged 87 and was diagnosed with Dementia and anxiety. MDS dated [DATE] for Resident #20 reflected a BIMS of 2 (severely impaired cognition) Care Plan dated 6/3/23, for Resident #20 reflected for activities, in room activities. Face Sheet, reflected Resident #21 was a female aged 75 and was diagnosed with Alzheimer's disease, MDS dated [DATE] for Resident #21 reflected a BIMS of 00 (severely impaired cognition) Care Plan dated 6/5/23, for Resident #21 reflected for activities, in room activities, nails, music and reading. Face Sheet, reflected Resident #24 Female aged 78 was diagnosed with encephalopathy, MDS dated [DATE] for Resident #24 reflected a BIMS of 6 (severely impaired cognition) Care Plan dated 4/13/23, for Resident #24 reflected, for activities, in room activities, and Activity calendar posted in room. Observation on 6/21/23 at 9:45 am, revealed Resident #24 room [ROOM NUMBER]-A in bed watching TV, and no Activity Calendar was posted in room. Face Sheet, reflected Resident #22 Female aged 92 was diagnosed with Alzheimer's disease, MDS dated [DATE] reflected a BIMS of 00 (severely impaired cognition) Care Plan dated 3/31/23, reflected for activities, Activity calendar posted in room. Observation on 6/21/23 at 9:49 am, revealed Resident #22 lying in bed sleeping, and no Activity calendar posted was in room. Face Sheet, reflected Resident #10 Female aged 81 was diagnosed with Alzheimer's disease, MDS dated [DATE] reflected a BIMS of 10 (moderately impaired cognition) Care Plan dated 4/13/23, reflected for activities, can attend activities in main activity room. Observation on 6/21/23 at 9:55 am, revealed Resident #10 sitting in room [ROOM NUMBER]-B. There was no Activity calendar posted in room. Interview on 6/21/23 at 9:55 am, Resident #10 stated that they have no activities for the residents in this unit. Resident #10 stated she must go in the main area for BINGO or any other type of activity. Resident #10 stated sometimes she misses activities and would like to have a calendar in her room. Interview on 6/21/23 at 10:21 am family member of Resident #10 stated that he has no problem with the facility, is involved in Care plan, and the facility contacts him if something happens. The family member stated that the facility does not provide any activities for the residents in the memory care unit. The family member stated Resident #10 sometimes will go into the main facility and play BINGO if she knows about it. Face Sheet, reflected Resident #23 Female aged 79 was diagnosed with Dementia, MDS dated [DATE] reflected a BIMS of 6 (impaired cognition) Care Plan dated 4/19/23, reflected for activities, Activity calendar posted in room. Observation on 6/21/23 at 10:05 am, revealed Resident #23 sitting in the TV room looking out the window. Observation of Resident #23's room [ROOM NUMBER]-A, revealed no Activity calendar was posted in the room. Face Sheet, reflected Resident #11 Female aged 66 was diagnosed with encephalopathy, MDS dated [DATE] reflected a BIMS of 8 (moderately impaired cognition) Care Plan dated 6/6/23, reflected for activities, Activity calendar posted in room, and main room activities. Observation on 6/21/23 at 10:16 am, revealed Resident #11 room [ROOM NUMBER]-A sitting on bed, and no Activity calendar was posted in room. Interview on 6/21/23 at 10:17 am, Resident #11 stated that there is nothing to do in this unit. Resident #11 stated she goes out into the main activity room for activities. Resident #11 stated she does not know when the activities are or when the activities start. Resident #11 stated she would like to have a calendar in her room. Observation on 6/21/23 at 10:25 am, revealed a Large Activity calendar was posted in the TV room. Interview on 6/21/23 at 10:25 am, LVN C stated no activities are done on a regular basis. LVN C stated that they have no one to do the activities in the memory care unit. LVN C stated a couple of residents (residents #10 and #11) go out to the main facility for activities when they can, but most do nothing. LVN C stated sometimes they have someone from outside the facility come in and sing but generally nothing other than coloring or the TV is the only activity they have. LVN C did not know how residents are informed of activities other than the one posted in the TV room. LVN C said she did not know if the residents were to have an activity calendar posted in their rooms. Interview on 6/21/23 at 10:34 am CNA D stated sometimes she sings to residents, but they do not do activities. CNA D stated they do not have anyone to help with activities. CNA D did not know how residents were to know of activities, CNA D did not know residents were to have activities calendars posted in rooms. Interview on 6/21/23 at 11:25 am, the AD stated the activity calendar was only posted in the TV room of the Memory unit. The AD stated she did not know that activity calendars were to be posted in the resident's room per the resident's Care Plans. The AD stated she was aware of the activities not being performed in the Memory unit. The AD stated she has tried to encourage the staff to do activities and has told them what to do. The AD stated she knows that some of the equipment or items to do activities come up missing, and sometimes they find the missing items in the resident's room. The AD stated she has not in-serviced or tried hard enough to help staff with activities in the Memory unit. Review of facility's 'Life Enrichment Activity Guidelines' date 04/2020 reflected: The community will provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. The Life Enrichment Director/Coordinator is responsible for maintaining appropriate departmental documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after being hospitalized for 1(Resident # 230) of 8 residents reviewed for transfer/discharge in that: The facility did not allow Resident #230 to return to the facility after she was sent out to psychiatric center for an evaluation and treatment. This deficient practice could place 74 residents at risk of being discharged and not allowed to return to the facility causing a disruption in their care and services and potential decline in health. Findings included: Review of Resident #230's face sheet dated 02/23/23 revealed an [AGE] year-old female with an admission date to the facility of 08/10/22 . She had a diagnosis of dementia. Review of progress note dated 01/05/23 revealed Resident #230 was exhibiting behaviors of aggression towards staff and residents. Resident #230 was hitting and throwing items around. It showed physician had to be called and orders were placed for 1:1 supervision until referral to psychiatric facility was made. On 01/06/23 Resident #230 was transferred to psychiatric facility for evaluation and treatment. Review of physician orders dated 01/05/23 revealed Resident #230 was to be referred to psychiatric facility due to resident being at risk for harming self and others. Review of Discharge MDS assessment dated [DATE] revealed return was anticipated after discharge. Review of comprehensive care plan dated 02/21/23 read in part .Discharge has been determined to not be feasible based on DEMENTIA, PSYCHOSIS, (severe mental disorder where emotions are impaired) SCHIZOAFFECTIVE (mental disorder causing hallucinations and delusions), BIPOLAR, (severe mood swings) MDD (major depression). Resident, physician, Resident Representative, agree on long-term care placement. Goal: Resident and Resident Representative will express satisfaction with community .Interventions: Discuss placement goals for staying in community and redefine and adjust as needed . Review of notification of discharge date d 01/27/23 revealed the nursing home facility would be discharging Resident #230 due to residents needs not being met by facility, and the safety and health of individuals would be affected by Resident #230's presence. The discharge notification did not specify why her needs could not be met. Review of Psychiatric facility medical record dated 01/25/23 revealed Resident #230 was taking her medications but was being aggressive with staff members. Review of Psychiatric facility medical record dated 01/26/23 revealed nursing home had refused to take resident back and a care plan meeting would be made to figure out a plan for her. Review of Psychiatric facility medical record dated 01/27/23 revealed Resident #230 was taking her medications and had received a Haldol injection that could be adjusted depending on her symptoms and behaviors. Resident #230 was still being agitated with staff members. Review of Psychiatric facility medical record dated 01/30/23 revealed there had been a care plan meeting with the nursing home to determine plan for resident. Resident #230 had been taking her medications, would sleep throughout the night, and was not being aggressive with other residents. The discharge plan had not been made as the nursing home was refusing to take Resident #230 back to facility. Review of Psychiatric facility medical record dated 01/31/23 revealed Resident #230 was ready to be discharged . Her behavior had improved, and she was no longer being aggressive towards other patients. She could be redirected by staff and was able to answer questions. The nursing home had refused to take Resident #230 back into nursing home. In an interview on 02/21/23 at 3:29 PM with the DON, she said Resident #230 had not been allowed back at the facility because the resident had been given a court ordered Haldol shot and that could not be given at the facility. She said from the notes that she had received from facility via fax, Resident #230 had not improved and she was still aggressive with others. She said the Psychiatric facility had told her that Resident #230 had been taking her medications, but they had still given her a Haldol injection. She said the Psychiatric facility was giving her different information. In a follow-up interview on 02/24/23 at 10:31 AM with the DON, she said the nursing home had sent Resident #230 to the Psychiatric facility anticipating that she would return. She said from the information that she knew, Resident #230 had been having behaviors, and she was not taking her medications. She stated she had spoken to the social worker at the Psychiatric facility and requested updated notes, but that they had not been available. She said the set discharge date for Resident #230 was for 01/30/23, and that she had not participated in the last care plan meeting. She stated she did not have updated medical records because she had been working night shift around the time of the meeting and was not involved in the process. She was not aware of the updated physician notes after 01/26/23 from the psychiatric facility showing Resident #230 had improved since admission. She said based on that, Resident #230 seemed fit to return to facility and said the physician at the nursing home could have adjusted her medications (Haldol injection). In an interview on 02/24/23 at 10:56 AM with Social Worker designee, she said the facility was going to bring Resident #230 back to the facilit y. She said she heard that Resident #230 was still having aggressive behaviors and had been given a Haldol shot, but she did not know why she had not returned. (At this time, she was shown the progress notes from psychiatric facility) She said based on the updated notes from Psychiatric facility, Resident #230 should have returned to nursing home. In an interview on 02/24/23 at 11:09 AM with the Regional [NAME] President, he said the facility had tried to call the psychiatric facility to get updates on Resident #230. He said the only medical records they had were up to date 01/26/23, which the DON had requested. He said after that, they had no records. He said they had not emailed, but only called the facility. He said they had made the decision to discharge on [DATE] because of what they had seen on the medical record. He said during the care plan meeting, the psychiatric facility only wanted to discuss the discharge plan and had given no updates on resident. On 02/24/23 at 11:30 AM, the facility was asked to provide documentation of attempts made to the psychiatric facility to gather medical records. The facility was also asked for notes from the last care plan meeting with the psychiatric facility. This could not be provided, as no additional information or documentation was provided prior to survey exit. Review of facility policy titled Bed Hold Reservation Agreement undated read in part .This facility permits residents to return to the facility after hospitalization or therapeutic leave if their needs can be met .they require the services provided by the facility .the facility will remain in contact with the resident and the representative while the resident is absent from the facility and arrange for return .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid including referring residents with newly evident or possible serious mental disorders for level II resident review upon a significant change in status assessment for one (Resident #10) of 6 resident reviewed for PASARR, in that: Resident #10 was admitted with a Level 1 PASARR indicating resident did not have a mental illness and or intellectual disability or related condition resulting in the facility failing to coordinate a Level II PASARR during resident screening. This failure could place residents at risk of not receiving specialized services that may assist them in attaining and or maintaining their highest practicable level of psychosocial functioning. Findings Include: Record review of Resident #10's Face Sheet indicates resident was admitted on [DATE] and readmitted on [DATE]. Record review of Resident #10's Annual MDS completed by MDS Nurse dated 02/08/2023 stated A1500 - Preadmission Screening and Resident Review (PASARR) entered code was a 0. This indicated resident did not have a mental illness and or intellectual disability or related condition. A1510 - Level II Preadmission Screening and Resident Review was not conducted. Record review of Resident #10's medical diagnosis indicates resident had Unspecified Intellectual Disabilities on 02/22/2023 but was unable to determine if Resident #10 had a PASARR Level II completed upon admission or readmission. Record review of Resident #10's H&P (History and Physical) dated 02/25/2019 Annual Physical Examination under history has had a signature documenting mental retardation signed by the examining physician. Record review of Resident #10's view diagnosis dated 02/22/2023 indicates unspecified intellectual disabilities with a comment - mental retardation. Interview on 02/23/23 at 3:31 p.m., the DON stated the PASARR was to be completed during admission. The DON stated PASARR would be triggered if the resident had altered cognitive mental status. The DON stated MDS would conduct the PASARR which was then placed in a specified website the facility uses. The DON stated she was not 100 percent sure the PASARR was being done. The DON stated it was done for incoming or leaving residents. The DON stated her understanding of a PASARR would indicate if a resident would need referrals to see doctors and services to meet the needs of the resident. Interview on 02/23/2023 at 3:36 p.m., the MDS Nurse stated that a PASARR can be done with a change of condition and upon admission. The MDS Nurse stated the PASARR follow the online guidelines which were completed online. The MDS Nurse stated she would follow up on making sure the change of the conditions was inputted into the MDS. The MDS Nurse stated the residents receiving services would depend on the PASARR. The MDS Nurse stated that Resident #10's screening and assessments should have been looked at. The MDS Nurse stated she knew about the PASARR concern and did not mention it until it was time to do the audit. The MDS Nurse stated that Resident #10 was none verbal and because he was none verbal, he should have been evaluated. The MDS Nurse stated she did not believe there was a risk if the PASARR was being overlooked. The MDS Nurse stated she believed the residents would have benefited from the extra services the PASARR provided.

**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 baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission for 1 of 8 residents (Resident #181) reviewed for baseline care plans. The facility failed to develop a baseline care plan within 48 hours of Resident #181 admission. This failure could place recently admitted residents at risk of not receiving care and services to meet their needs. Findings include: Record review of Resident #181 face sheet dated 2/23/23 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #181 history and physical dated 2/16/23 revealed a diagnoses of dementia, psychotic behavior, and generalized anxiety. Record review of Resident #181 physician order dated 2/14/23 revealed to be placed in secure unit due to risk for elopement. Record review of Resident #181 Memory Care Unit: admission Screening for placement dated 2/13/23 reveled section A. admission review the following were checked off: A. Resident has Alzheimer's or related dementia diagnosis. B. Resident habitually wanders or would wander out of the building, and would not be able to find their way back. F. Resident is able to ambulate independently. Section B: Special concerns or needs revealed a note Resident was eloping from previous facility and while out on pass at home with family. Section C: admission decision revealed Resident meets the criteria for the Memory Care Unit was checked off. Record review of Resident #181 baseline care plan revealed one had not been completed. Observation and interview on 2/21/22 during initial rounds Resident # 181 was in the memory care secured unit. She was wandering around the hallway saying she did not know why she was at the facility. Resident #181 appeared pleasantly confused. Interview on 2/23/22 at 11:45 AM the DON stated baseline care plan were created by the admitting nurses. The DON stated nurses received training regarding developing baseline care plans upon hire, annually and as needed. The DON stated nurses used physician orders and diagnosis to develop a baseline care plan. The DON stated by not creating a baseline care plan could affect monitoring and needs been being met . Record review of Resident Assessment: Baseline Care Plan policy dated 11/1/19 revealed A baseline care plan is required to be completed within 48 hours of admission. The baseline care plan must include: initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and passar.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences in 1 resident (Resident #68) out of 8 reviewed for oxygen care in that: -Nursing staff administered oxygen to Resident #68 without a physician's order. This deficient practice could cause a decline in health for residents receiving O2 without a physician order and who are not being monitored accurately. Findings included: Observations on 02/21/23 at 10:30 AM revealed Resident #68 was wearing nasal canula with 3 liters of oxygen. Review of Resident #68's face sheet dated 02/23/23 revealed an [AGE] year-old male with and admission date of 12/02/22. He had a diagnosis of Chronic Respiratory failure, meaning he had trouble breathing and required oxygen. Review of Progress notes dated 02/13/23 revealed Resident #68 supplemental o2 tank that remains in in his w/c was replaced by this nurse. Encouraged staff to ensure Resident #68 is on continuous o2 via N/C. Review of physician orders revealed there were no orders for oxygen or oxygen monitoring. Review of Resident #68's vital signs revealed his pulse oximetry had not been monitored or taken since 02/15/23. Review of comprehensive care plan dated 01/05/23 revealed ineffective breathing pattern related to COPD and CHF. (COPD is a lung disease that causes airflow limitation. CHF is a heart disease that causes shortness of breath due to overload of fluid). Goal was that Resident #68 would demonstrate effective breathing rate through interventions such as monitoring respiratory rate, and administer oxygen as ordered. Review of admission MDS assessment dated [DATE] revealed Resident #68 had a BIMS score of 5; indicating he was severely cognitively impaired. That meant he may have had impaired memory and difficulty with decisions. Section O revealed that Resident #68 had oxygen therapy. In an interview on 02/23/23 at 10:36 AM with DON, she said Resident #68's oxygenation had been monitored when they had COVID assessments, but it had not been assessed since. She said she did not know why the nurses were not monitoring his oxygen saturations. She said it was not good nursing practice to not monitor the oxygen saturations and said that if it was not documented then it was not done. She said the nurses knew how to monitor for pulse oximetry (oxygenation percentage in the blood), regardless of having an order. She stated Resident #68 did not have an order for oxygen and said it was the nurses' job to ensure oxygen order was in place if resident was receiving oxygen. In a follow-up interview on 02/23/23 at 10:51 AM , DON reported there was no oxygen policy for the facility. In an interview on 02/24/23 at 10:12 AM with LVN F, she said was responsible for Resident #68 for that day. She said she knew Resident #68 had oxygen and said she had documented his pulse oxygenation on his chart. (At this time, she was asked to look at his vital signs and find his pulse oxygenation). She said, since he did not have an order to check his pulse oxygenation, it was not checked. She said it was important to monitor and check his oxygenation because he had COPD, and his oxygen could drop. She said she had been trained, but it had been a while.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 drugs/biologicals reviewed for labeling in that: -Resident #10's tube feeding was unlabeled with feeding rate and time it was hung. This deficient practice could cause a decline in health in residents due to labeling errors/issues. Findings included: Review of Resident#10's face sheet dated 02/23/23 revealed a [AGE] year-old male with an admission date of 02/07/20. Review of Resident #10's History and Physical revealed he had a PEG tube and was receiving tube feedings. It also revealed he had dysphagia, which is difficulty swallowing. Review of physician orders dated 05/04/18 revealed Change feeding bag, tubing and syringe every 24 hours. Every night shift. It also showed his feeding formula to be Jevity 1.5 75 ml an hour. Review of Resident #10's Quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 3; meaning he was severely cognitively impaired. That meant he had difficulty with decision making and memory impairment. Section K of the MDS assessment revealed he had a feeding tube. Review of comprehensive care plan dated 03/02/21 revealed Resident #10 required PEG tube feeding related to aphasia (difficulty speaking). Goal was for Resident #10 to maintain adequate nutritional and hydration status through interventions such as providing full assistance with tube feeding. Observations on 02/21/23 at 10:28 AM revealed tube feeding formula was not labeled with time and date it was hung by the nurse. It was also missing the rate that the formula was running at per physician order. In an interview on 02/21/23 at 11:36 AM the DON stated the feeding tube formula had not been labeled correctly. She said it did not have the time or date it had been hung or the rate that the formula was running at. She said the feeding formulas were changed at midnight and changed by the night nurses. She said the nurses had been trained upon hire and annually. She said it was important to label the feeding correctly to ensure the proper feeding was obtained and given to the resident. In an interview on 02/22/23 at 10:55 AM with LVN E, she said the tube feeding formula had to be labeled correctly with date, time it was hung and the rate the formula was ordered for. She said the nurses had been trained to do so during orientation. She could not state a risk for the resident. Review of facility policy titled General Guidelines for Medication Administration dated 08-2020 read in part .Select the medication, check the label, container and compare against the MAR .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain a safe, clean, and homelike environment for 2 of 4 shower rooms (200 hall and 400 hall) reviewed for environment. 1. The facility failed to ensure shower room in 200 and 400 hall was free from black mold. 2. Resident #55 and Resident #76 voiced concerns with dirty shower rooms. This failure could place residents at risk for infection and a diminished clean, homelike environment. Findings included: 1.Observation on 2/22/23 beginning at 6:15 PM revealed 200 hall and 400 hall shower rooms had black debris mold along the edges of the shower area. Observation and interview on 2/22/23 at 6:29 PM the DON stated the black debris on the 200 hall shower room floor was black mold . The DON stated the Administration has known about the black mold since back in December of 2022. The DON stated all the residents in the 200 hall get showered in that shower room. The DON stated maintenance was responsible to clean the common areas. The DON stated there was a delay in maintenance disinfecting and cleaning due to the new Maintenance Director taking over not long ago. The DON stated she has voiced concerns to the Administration and even removed mold herself from the 200 hall shower room on the higher surfaces herself . The DON stated the mold could expose the residents at risk of infection. Observation and interview on 2/22/23 at 6:34 PM the DON stated the black debris on the 400 shower room floor was mold. 2.Record review of Resident #55 face sheet dated 2/24/23 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #55 history and physical dated 2/13/22 revealed diagnosis of dementia. Record review of Resident #55 Quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, which indicated moderate cognitive impairment. Interview on 2/23/22 at 10:29 AM revealed Resident #55 was in bed and stated she gets assistance from staff for her shower. Resident #55 stated she gets a bath at least 3-4 days a week. Resident #55 stated staff shower her in the shower room out in the hallway (200 hall) because she doesn't have a shower in her room. Resident #55 stated she has seen the shower room floor dirty several times and wished they would clean it more often. Record review of Resident #76 face sheet dated 2/24/23 revealed an [AGE] year-old female admitted on [DATE]. Record review of Resident #76 Quarterly MDS assessment dated [DATE] revealed a BIMS of 10, which indicated moderate cognitive impairment. Observation and interview on 2/23/23 at 10:41 AM Resident #76 stated she uses the shower room on the 400 hall. Resident #76 walked over to shower room in 400 hall and pointed at the black mold in the shower area. Resident #76 stated she wished the facility did better cleaning. Resident #76 stated the staff tend to run the water along the edges but the black debris does not come off and fears that it just spreads in the area she stands while she showers. Record review of Centers for Disease Control and Prevention: Mold last reviewed November 14, 2022 revealed Mold can cause many health effects. For some people, mold can cause a stuffy nose, sore throat, coughing or wheezing, burning eyes, or skin rash. People with asthma, immune compromised people and people with chronic lung disease may get infections in their lungs from mold. Record review of Publications / SHIB 03-10-10 A Brief Guide to Mold in the Workplace last updated on 11/08/13 revealed Introduction: Concern about indoor exposure to mold has increased along with public awareness that exposure to mold can cause a variety of health effects and symptoms, including allergic reactions. Mold Basics: Indoors, mold growth should be avoided. Problems may arise when mold starts eating away at materials, affecting the look, smell, and possibly, with the respect to wood-framed buildings, affecting the structural integrity of the buildings. Molds can grow on virtually any substance, as long as moisture or water, oxygen, and an organic source are present. Health Effects: The onset of allergic reactions to mold can be either immediate or delayed. Allergic responses include hay fever-type symptoms such as runny nose and red eyes. Molds may cause localized skin or mucosal infections but, in general, do not cause systemic infections in humans, except for persons with impaired immunity, AIDS, uncontrolled diabetes, or those taking immune suppressive drugs. Molds can also cause asthma attacks in some individuals who are allergic to mold. In addition, exposure to mold can irritate the eyes, skin, nose and throat in certain individuals. Symptoms other than allergic and irritant types are not commonly reported as a result of inhaling mold in the indoor environment. Prevention: Moisture control is the key to mold control. When water leaks or spills occur indoors - act promptly. Any initial water infiltration should be stopped and cleaned promptly. A prompt response (within 24-48 hours) and thorough clean-up, drying, and/or removal of water-damaged materials will prevent or limit mold growth. Record review of Quality of Life: Homelike Environment policy dated May 2017 revealed Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: A. clean, sanitary and orderly environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation; which included but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat residents medical symptoms for 5 of 19 residents (Resident #50, Resident #71, Resident #42, Resident #180, Resident #62) reviewed for abuse. A. 5 residents (Resident #50, Resident #71, Resident #42, Resident #180, Resident #62) were residing in the secure memory unit without physician orders and medical symptoms. These failures could place residents at risk of being separated against their will, without orders or the representatives consent. Findings include: Record review of Resident #50 face sheet dated 2/23/23 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #50 history and physical dated 1/13/23 revealed diagnoses of dementia with mild behavior disturbance. Record review of Resident #50 active physician orders for February 2023 revealed no orders to be placed on secured memory unit. Record review of Resident #50 Memory Care Unit: admission Screening for Placement was not completed. Record review of Resident #50 care plan dated 2/21/23 revealed Resident is an elopement risk/wanderer and is at risk for possible injury related to impaired safety awareness and diagnosis of dementia and resides in memory lock down unit due to elopement risk. Record review of Resident #71 face sheet dated 2/23/23 revealed a [AGE] year-old female who was admitted to facility on 5/18/22. Record review of Resident #71 history and physical dated 5/25/22 revealed diagnoses of depression and dementia. Record review of Resident #71 active physician orders for February 2023 revealed no orders to be placed on secured memory unit . Record review of Resident #71 elopement assessment dated [DATE] revealed score of 5, which indicated medium risk. Record review of Resident #71 Memory Care Unit: admission Screening for Placement was not completed. Record review of Resident #42 face sheet dated 2/23/23 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #42 history and physical dated 5/6/22 revealed a diagnosis of dementia. Record review of Resident #42 active physician orders for February 2023 revealed no orders to be placed on secured memory unit. Record review of Resident #42 elopement assessment dated [DATE] revealed a score of 11, which indicated high risk. Record review of Resident #42 Memory Care Unit: admission Screening for placement dated 5/13/22 revealed section A. admission review the following were checked off: A. Resident has Alzheimer's or related dementia diagnosis. B. Resident habitually wanders or would wander out of the building, and would not be able to find their way back. F. Resident is able to ambulate independently. If no, please explain below in special concern/needs section below. G. Resident is able to benefit from a structured environment with specialized activities. Section C, admission decision revealed Resident meets the criteria for the Memory Care Unit. Was checked off. Record review of Resident #42 Memory Care Unit: Continue stay assessment dated [DATE] revealed section A. Continued stay review had the following checked off: A. Resident habitually wanders or would wander out of the building, and would not be able to find their way back. B. Resident has significant behavior problem that seriously disrupts the rights of other residents. C. Resident is a serious danger to self or others. F. Resident continues to benefit from a structured environment with specialized activities. Section C. continued stay determination revealed Resident continues to meet the criteria for placement on the Memory Care Unit was checked off. Record review of Resident #180's face sheet dated 02/23/23 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. She had a diagnosis of dementia, depression and anxiety. Record review of Resident #180 History and Physical was not provided by facility at time of exit. Record review of Resident #180 physician orders revealed there were no orders for placement in the locked unit. Record review of Resident #180 Memory Care Unit: admission Screening for Placement dated 02/06/23 revealed Section A. admission Review the following sections were checked off: A. Resident has Alzheimer's or related dementia diagnosis. B. Resident habitually wanders or would wander out of the building and would not be able to find their way back. F Resident is able to ambulate independently. G. Resident is able to benefit from a structured environment with specialized activities. Record review of Resident #180's medical record revealed there was no re-assessment for Memory Care Unit Placement done. Record review of Resident #180 admission elopement risk assessment on PCC dated 02/20/23 revealed Elopement risk score was high at a 11.0. Section A. Resident Evaluation factors was documented Poor decisions, Dementia, Anxiety, Depression. History of leaving the facility marked with a note new admit, facility where she came from, she took off wander guard and walked out of facility. Record review of Resident #62's face sheet dated 02/23/23 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. She had a diagnosis of Alzheimer's, Dementia, Major Depressive disorder and psychotic disorder that would cause delusions. Record review of Resident #62 History and Physical was not provided by facility at time of exit. Record review of Resident #62 physician orders revealed there was no order for placement in the locked unit. Record review of Resident #62 's Medical Record revealed there was no admission Screening for Placement or Re-assessment for Continued Stay. Record review of Resident #62 last elopement risk assessment on PCC dated 02/08/23 revealed Elopement risk score was medium at a 5.0. Section A. Resident Evaluation factors was documented Alzheimer's, Dementia, Depression, Mood Disorder,. History of leaving the facility was marked with a no. Interview and record review on 2/23/23 at 11:43 AM the DON stated residents are assessed for elopement risk upon admission and as needed if they attempt to leave the facility. The DON stated if a resident is exit seeking, wandering and score high on elopement risk assessment, they place the resident on a wander guard first. The DON stated once a resident is on a wander guard and still seen attempting to leave the facility and succeed then they evaluate for [NAME] secure unit placement. The DON stated elopement risk and memory care unit admission assessment are tools they use to determine if a resident meets the criteria. The DON stated if a resident comes with history of elopement from a previous facility they are automatically placed in the facility's secured unit. The DON stated once they have determined a resident meets criteria to be placed on the secured unit they are to obtain a physician order from MD for placement. The DON reviewed Memory Care Unit Education in-service and stated they use that as a policy and guide for placement guidelines. The DON stated that the in-service read a physician order is required to have a medical reason. The DON stated elopement and safety were not considered a medical reason. The DON stated all residents who were currently placed in memory care unit required to have a physician order. The DON stated with no physician order and the physician orders that read elopement and safety that were not considered a medical reason, the residents residing in secured unit were not properly placed. Interview and record review on 2/23/23 at 12:27 PM the DOC stated residents were assessed with elopement and memory unit admission assessments to determine if they meet criteria for placement. The DOC stated residents were placed in secured unit for safety concerns. The DOC stated residents who had wandering behaviors and history of elopement would first be provided with wander guard then if that didn't appear to help, they would be considered for secured unit placement. The DOC stated if residents meet criteria to be placed in secured unit, they would obtain physician order to be placed in secured unit. The DOC reviewed Memory Care Unit Education in-service and stated it was a tool they used as guide to follow assessments to determine placement in secured unit. The DOC stated elopement and memory care unit admission assessment and continued stay were completed upon admission, quarterly and as needed if there was a change in condition by floor nurses. The DOC stated elopement and safety were not considered a medical reason to be placed, they were considered behavior concerns. The DOC stated if residents did not have a physician order to be placed in secured unit they should not be residing in secured unit. The DOC stated by orders not indicating a medical reason and not having any orders and residents residing in the secured unit was considered improper placement . The DOC reviewed Resident Rights policy and stated it could be considered involuntary seclusion. The DOC stated there were no consents obtained from family members. Interview on 2/23/23 at 1:23 PM the MD stated residents were placed on secured units because they have tendencies to escape and required a more controlled environment. The MD stated nurses and nursing administration conducted the elopement assessments and trusted their judgement. The MD stated when facility had a resident that met the criteria to be placed, they would call her and review the case and then come to a decision of placement. The MD stated after it was determined that a resident met criteria for secured unit placement, she would give a verbal order for the resident to be placed in secured unit. The MD stated she did not know if elopement and safety were considered a medical reason but that was what she and the facility were using. The MD stated if residents did not have a physician order to be placed in the secured unit, they should not be residing in the secured unit. Record review of Risk Management: Signaling Device policy dated 04/2020 revealed At times, the community admits and retains residents that are confused and have the tendency to wander about the community. If the community is equipped with a secured unit, these residents will normally be secured on this unit. The community must ensure the residents safety while utilizing the least restrictive means available. To meet this need, the community will obtain information pre-admission or admission conferences with the resident's and family regarding any history of wandering or the potential for wandering. All instances of wandering or attempted elopement will be recorded in the medical record. Record review of Memory Care Unit Education, not dated, revealed Evaluation of memory care units: 1. Residents are assessed upon admission or with changes in condition by the IDT using the Memory Care Unit admission Screening form in order to determine the need for memory unit placement. Residents will receive ongoing evaluations using the Memory Care Unit Continued Stay Review quarterly, annually, and with significant changes in condition to determine continued need for placement. 2. Residents will have physicians order stating the medical reason for secured unit placement. Record review of Resident Rights policy dated 12/2016 revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the residents' medical symptoms. Record review of Abuse policy dated 1/27/2020 revealed The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/ Confinement, and or Misappropriation of Property. The facility will adhere to policies and procedures and will follow the guidelines in the written policy and procedure. Residents will not be subjected to abuse, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents family members or legal guardians, care taker, friends, or other individuals. This includes physical, verbal, sexual, physical/ chemical resyrtaint.

Based on observation, interviews and record review, the facility failed to keep drug records to account of all controlled drugs to be maintained and periodically reconciled for 1 out of 4 (400 hall) narcotic count sheets and 1 out of 1 medication storage room reviewed for controlled medications in that: -Narcotic count sheet for 400 hall was missing staff signatures for 3 days (2/20, 2/21 and 2/22). -An unemptied open vial of Haldol medication was found inside the medication storage room and had not been wasted. This deficient practice could result in inaccurate count and destruction of controlled medications which could lead to a decline in health to residents receiving controlled medications. Findings included: Observations on 02/22/23 at 10:03 AM revealed Haldol medication vial was found in biohazard container uncovered without a lid or lock, inside the medication room. Haldol vial had about 0.25 ml of medication in it. Observations on 02/22/23 at 10:22 AM revealed the narcotic count sheet for the in 400 hall had nursing staff signatures missing for 2/20 night shift 2/21 day and night shift and 2/22 day shift. In an interview with the DON on 02/22/23 at 10:07 AM, she said the procedure for wasting medication was to have 2 nurses waste the medication in the medication room. Wasting medication meant discarding the remaining dose of medication. She said the vial should have not been in the Biohazard container because it was a controlled substance, and it should have been wasted. She said the nurses knew how to waste medication because she was responsible for training the nurses during on-hire orientation. In an interview with LVN E on 02/22/23 at 10:28 AM, she said she had counted the narcotics with the night shift nurse but had not signed the narcotic count sheet because she forgot to do so. She said she had been trained to complete the narcotic count check during on-hire training. She said the reason it should have been done was because there could be a discrepancy in the medications, and the staff could be short on medications for the residents. In an interview with LVN F on 02/24/23 at 10:20 AM, she said the nursing staff had to sign off on the narcotic sheet at the beginning and the end of the shift. She said that was done to ensure that the narcotic count was correct. In a follow-up interview with the DON on 02/24/23 at 10:28 AM, she said the nurse knew that part of their duties was to count the narcotics and sign off on the narcotic count sheet. She said it was important to do so in case some of the medications could be missing and the count could be off. She said the nurses had been trained on doing so before beginning their duties. Record review of staff training undated read in part .Narcotic sheets must be done after every shift and signed by nurses . Record review of facility policy titled Controlled Substance Disposal dated 08-2020 read in part .When a dose of a controlled substance is removed from the container .it is destroyed in the presence of two licensed nursing personnel, and in accordance with facility policy and state regulations, and the disposal is documented on the accountability record . Record review of facility policy titled Storage of Controlled Substances dated 08-2020 read in part .At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel and its documented .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services, in that: 1. Food products in dry storage, freezer, and in refrigerator were not correctly labeled, wrapped, or were expired. 2. Staff were not wearing hairnets properly or not at all while in the kitchen. 3. Sanitation Bucket Log (Is used to check the part per million of cleaning solution mixed with the water to make it is disinfecting) was not filled out every day. This these failures could affect residents by placing them at risk of food borne illness. Findings include: Observation on 02/21/2023 beginning at 9:38 a.m., with Dietary Manager in the dry storage revealed there was a 106 oz can of crushed pineapples on the roller shelf with a two-inch dent in the middle of the can. A 96 oz can of Apples slices in water was in on the roller shelve shelf which had on its left side squashed causing a fold around two to three inches in length. The upper and lower seals of the can were dented in. In the walk-in refrigerator sitting in the mid shelf was a red tray with four mugs/cups filled with a red substance. The first red cup to the left by itself had no covering or lid and was not dated. The two other cups lined up in a row had no proper seals or lids to properly cover the mugs/cups and the forth cup was in the back covered. In the walk-in was a clear sealed zip lock bag with celery inside of it with no label or date. In the walk-in on the bottom was a large metal sheet pan that was used for cheesecake that was not cover properly. On the left side of the cheesecake that was in the sheet; from top to bottom (2 feet length) and around two inches in width was not covered by the Saran Wrap. In the freezer there was a box big box of lasagna closed sideways around three inches off the floor sitting on a bag of ice jammed in between the racks and the freezer wall covered in ice. In the freezer underneath the big box of lasagna was a cup of ice cream on the icy floor next to two bags of ice. In the freezer on the bottom shelf was an undated/labeled clear sealed bag of sweet potato fries. In a white refrigerator (1 of 1 white Refrigerator) a clear plastic container possibly two inches in dept, had a cellophane wrap that was not providing a proper seal. In the white refrigerator in the door on the second shelf was a zip locked bag of lettuce the was looking slimy wet with the condensation on the zip lock and had parts that were dark green and brown. In the white refrigerator on the door on the top shelf was a sandwich that was left open squashed together with other sandwiches. It was left open in a clear see-through sandwich bag. On the shelf in the side prep area next to the front servicing area was containers. There was a large container of parsley that were not sealed. On the shelf in the side prep area next to the front servicing area was a metal container filled with thickener but it was not properly sealed. The Saran wrap was not grabbing then container and was hanging downwards on both sides. Observation and Record Review on 02/21/2023 at 11:04 a.m., facility Sanitation Bucket Log (Is used to check the part per million of cleaning solution mixed with the water to make it is disinfecting) for 2023 was not filled out for February 18th lunch and dinner and on the February 20th for breakfast and lunch and indicated the buckets are to be refilled after each meal and as needed. The above log is to be completed after each refill. Observation on 02/21/2023 at 12:20 p.m., Administrator walked into the kitchen with no hair net on heading towards the Dietary Manager's Office. Record review on 02/22/2023 at 3:54 p.m., of facility Sanitation Bucket Log for 2023 had the February 18th for lunch and dinner filled out and for the February 20th breakfast and lunch filled out. Interview on 02/21/2023 at 12:22 p.m., the Dietary Manager stated the facility policy stated that anyone coming into the kitchen needs to have a hair net on. The Dietary Manager stated the risk to the resident would be hair in the food. The Dietary Manager stated eating the hair could be gross, could cause choking, and get the resident's sick. The Dietary Manager stated all staff are trained on labeling, temps, and food preparation. The Dietary Manager stated the dented cans are separated from the good cans. The Dietary Manager stated dented cans could have particles inside of them and if used could get resident's sick. The Dietary Manger stated foods should be labeled and if they are not labeled staff will not know if the food is good to use. The Dietary Manager stated the under covered cheesecake that was on the bottom uncovered could have had particles or other unwanted foreign object falling into the cheesecake. The Dietary Manger stated these objects could potentially get the resident's sick. Interview on 02/23/2023 at 9:15 a.m., the Dietary Manager stated dietary staff are trained to document on logs and are shown how to fill them out. Dietary The Manager stated she checks daily and makes sure that the sanitation logs are filled out. The Dietary Manager stated she was out on the February 18th and did not oversee that the log was being filled out but instead Food Service Manager C was supposed to be checking it was being done. The Dietary Manager stated she did not have the answer as to who filled the sanitation log on 02/22/2023. The Dietary Manager stated the consequences of false reporting is a write up. The Dietary Manager stated they did not know if the sanitation fluid was actually sanitizing and don't know if that was correct. Dietary Manager stated the residents can get sick if they are not checking that the sanitation fluid making sure it was effectively sanitizing correctly. Interview on 02/23/2023 at 9:36 a.m., Food Service Manager C stated she makes sure when at work that the labels are done, temps, and sanitation logs are done. Food Service Manager (Picture of can dented was shown) stated the dented can should be in the area where they keep all the dented cans. Food Service Manager C stated the dented cans can be contaminated and have pieces of the metal inside that can go into the food. Food Service Manager C stated it can choke the resident and or cause botulism (food poisoning caused by a bacterium (botulinum) growing on improperly sterilized canned meats and other preserved foods). Food Service Manager C stated foods are supposed to be labeled and the facility ensures this by using the FIFO (First In First Out Method). Food Service Manager C stated dietary staff are to make sure they are not expired. Food Service Manager C stated the kitchen conducts in-services on labeling of foods. Food Service Manager C stated if foods are not labeled than then a resident can get sick form food borne illness if we are using expired foods. Food Service Manager C stated even if they were busy, staff were trained to do dishes and the log and were supposed to fill out the log. Food Service Manager C stated the risk is that the sanitation was not being checked on properly to make sure it was sanitizing. Food Service Manager C stated residents can get sick. Food Service Manager C stated I cannot explain how the logs were filled out I was not here the last two days. Food Service Manager C stated she considered it to be false documentation. Food Service Manager C residents could get sick and become ill. Food Service Manager C stated she and or her supervisor when they are at the facility make sure they logs are being done. Food Service Manager C state when both supervisors are on shift, they try to make sure the dietary staff are doing their temps and logs correctly. Observation on 02/23/2023 at 9:57 a.m., Dietary Aide A was touching her exposed hair that was outside of the hair net with her hands. The hairnet was not covering up all of her exposed hair from the lower back left and right sides and in the front left and right sides where the sideburns come down. Interview on 02/23/23 09:57 a.m., with Dietary Aide A stated she received training from this facility and the food handlers training. Dietary Aid A stated working in the kitchen you need a hairnet and to cover all of your hair. Dietary Aide A stated the exposed hair could fall into the food of the residents and could contaminate the food causing the residents can get sick. Dietary Aide A stated no she would not be okay with people doing food for me that had exposed hair. Dietary Aide A stated if hair come came out in the food that she was eating she would not want to eat food. Dietary Aide A stated in labeling the dietary staff have to write the name, date, time, initials of staff. Dietary Aide A stated the purpose of labeling is to know how long the food has been there or when it was prepared. Dietary Aide A stated using the unlabeled food could not be good and or contaminated; it should be thrown away. Dietary Aide A stated it could have effects on residents if used because it could be spoiled and could get them sick. Dietary Aide A stated dented cans are not used because there could be pieces of metal inside of it. Dietary Aide A stated the risk to the residents could be food poisoning if used. Dietary Aide A stated the dietary staff have a place where all the dented cans go and later are discarded disregarded. Dietary Aide A stated the containers are to be closed well and covered well. Dietary Aide A (Picture was shown of the cheesecake) stated the cheesecake needed to be closed and sealed. Dietary Aide A stated the cheesecake being on the bottom shelf shelve, stuff could have fallen on it. Dietary Aide A stated the dietary staff have been trained on how to fill out the temps, sanitization logs and it was overseen by the Dietary Manager. Dietary Aide A (Picture was shown both sanitation logs from both different days) stated it is not appropriate to fill out the log on 02/22/2023 if dietary staff had not filled it out on 02/21/2023. Dietary Aide A stated dietary staff do keep notes or recording on the sanitation log anywhere else. Dietary Aide A stated dietary staff are not doing what they are supposed to because they filled it out the following day. Dietary Aide A stated filling out the sanitation log the next day was not right because no one not sure if the staff was changing the bucket out. Dietary Aide A stated she would consider it false documentation because the one before had it blank and this one had it filled out. Dietary Aide A stated the buckets not being properly checked could contaminate wherever you prep food, dihes, and utensils which could result in residents getting sick. Record review of Dietary Staff certification of completion Learn2Serve Food Handlers Training Course. Completion dates vary from dietary staff. Record review on of all Dietary Staff certification of completion ServSafe and Dietary Manger Food Production Manager Certification Examination dated 03/22/2022. Record review of facility in-service dated 04/12/2021 What to expect, Health Inspection Reading at all times. Page 2 talks about food storage: Food is kept at least 6 inches off the ground, Food is stored in a clean, dry location that is not exposed to contamination, containers are labeled with the food name and delivery date, Freezer and Refrigerator Maintenance, all food items are correctly labeled and dated. Sanitation: The sanitizer is mixed to the correct concentration, sanitizing buckets changed out as needed to temp. Employee Hygiene: Employees wear hairnets, and male employees cover facial hair. Record review of facility policy dated 11/01/2019 - Food Service Uniforms stated it is the policy of that all employees wear a uniform that reflect the professional image of the Department of Food and Nutrition Services for Focused Post-Acute Care Partners. Procedure - Hair: All hair will be covered prior to entering the kitchen with a hairnet (men/women) or optional skull cap (men; women will wear hairnet and skull cap). Record review of facility policy dated 10/2017 - Food Receiving and Storage stated foods shall be received and stored in a manner that complies with safe food handling practices. Line 7. Dry foods that are stored in bins will be removed form original packaging, labeled and dated (use by dated). Line 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Line E. Other open containers must be dated and sealed or covered during storage. Record Review of facility policy dated 10/2017, Preventing Foodborne [NAME] - Employee Hygiene and Sanitary Practices stated Food and Nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Line 1. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and presenting foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. Line 12. Hair nets or caps and/or beard restraints must be worn to keep hair form contacting exposed food, clean equipment, utensils and lines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain medical records on each resident that are complete, accurately document and readily accessible for 11 of 16 residents (Resident #180, 62, 50, 71, 42, 62, 47, 15, 53, 41, and 8) reviewed for medical records. A. The facility failed to maintain physician orders that were complete and accurately documented for Resident # 180, 62, 50, 71, and 42. B. The facility failed to have history and physicals readily accessible for Resident #39, 38, 52, 180, 62, 47, 15, 53, 41, and 8. C. Resident #68 was receiving oxygen with no physician order. These failures placed residents at risk of not receiving necessary care due to inaccurate and or incomplete medical records. Findings include: Record review of Resident #39 History and Physical was not provided by facility at time of exit. Record review of Resident #38 History and Physical was not provided by facility at time of exit Record review of Resident #52 History and Physical was not provided by facility at time of exit Record review of Resident #180 History and Physical was not provided by facility at time of exit. Record review of Resident #62 History and Physical was not provided by facility at time of exit Record review of Resident #47 History and Physical was not provided by facility at time of exit. Record review of Resident #15 History and Physical was not provided by facility at time of exit. Record review of Resident #53 History and Physical was not provided by facility at time of exit. Record review of Resident #41 History and Physical was not provided by facility at time of exit. Record review of Resident #8 History and Physical was not provided by facility at time of exit. Record review of Resident #62 physician orders revealed there was no order for placement in the locked unit. Record review of Resident #180 physician orders revealed there were no orders for placement in the locked unit. Record review of Resident #50 active physician orders for February 2023 revealed no orders to be placed on secured memory unit. Record review of Resident #71 active physician orders for February 2023 revealed no orders to be placed on secured memory unit. Record review of Resident #42 active physician orders for February 2023 revealed no orders to be placed on secured memory unit. Observations on 02/21/23 at 9:05 AM revealed Resident # 62 was in secured locked unit. Observations on 02/21/23 at 9:12 AM revealed Resident #180 was in secured locked unit. Observations on 02/21/23 at 9:35 AM revealed Resident #50 was in secured locked unit. Observations on 02/21/23 at 9:40 AM revealed Resident #71 was in secured locked unit. Observations on 02/21/23 at 9:45AM revealed Resident #42 was in secured locked unit. Observations on 02/21/23 at 10:30 AM revealed Resident #68 was wearing a nasal canula with 3 liters of oxygen. Review of Resident #68's face sheet dated 02/23/23 revealed an [AGE] year-old male with and admission date of 12/02/22. Review of Progress notes dated 02/13/23 revealed Resident #68 supplemental o2 tank that remains in in his w/c was replaced by this nurse. Encouraged staff to ensure Resident #68 is on continuous o2 via N/C. Review of physician orders revealed there were no orders for oxygen or oxigenation monitoing. Review of comprehensive care plan dated 01/05/23 revealed ineffective breathing pattern related to COPD and CHF. (COPD is a lung disease that causes airflow limitation. CHF is a heart disease that causes shortness of breath due to overload of fluid). Goal was that Resident #68 would demonstrate effective breathing rate through interventions such as monitoring respiratory rate, and administer oxygen as ordered. Review of admission MDS assessment dated [DATE] revealed Resident #68 had a BIMS score of 5; indicating he was severely cognitively impaired. That meant he may have had impaired memory and difficulty with decisions. Section O revealed that Resident #68 had oxygen therapy. In an interview on 02/23/23 at 10:36 AM with the DON, she said Resident #68 did not have order for oxygen or oxygenation monitoring . She said her nurses had to make sure there were orders for oxygen if the resident was on oxygen in order to ensure the residents were receiving getting oxygen and being monitored . Interview on 2/24/23 at 8:40 AM requested History and Physicals from DON. In an interview on 02/24/23 at 10:12 AM with LVN F, she said she was responsible for Resident #68 for that day. She said she knew Resident #68 had oxygen and said he had an order for it. (At this time, she was asked to look at his physician orders.) She said, he did not have orders for oxygen or pulse oximeter monitoring. She said part of her job was to look through all the orders, but she had not noticed it. She said it was important for Resident #68 to have an order for oxygen and pulse oximeter monitoring because he had COPD, and his oxygen could drop. She said she had been trained, but it had been a while. On 02/23/23 at 10:41 AM, the DON reported there was no oxygen policy for the facility. Interview on 2/24/23 at 12:30 PM the DON stated history and physicals and physician orders should be readily available either on PCC or in the resident chart. The DON stated the facility was going through an all-electronic transition and it has been taking her a long time to obtain physician orders and history and physicals because Medical Records had boxes full of documents and she was needing to go through each one of them. Observation and interview on 2/24/23 at 12:50 PM revealed the Medical records room had approximately more than 10 big boxes filled with medical records, not sealed. Medical Records was on the phone with MD, stated she was trying to obtain history and physicals. Medical Records stated that new admissions history and physicals should be either on resident chart or PCC. Medical Records stated residents who had been residing in the facility long term should have history and physicals and physician orders in resident charts or PCC. Medical Records stated the facility was transitioning to all-electronic and had to go through boxes to file them. Medical Records stated there had been a set back when the pandemic hit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A. The facility failed to ensure Nasal Cannulas were placed in a bag when not in use for Resident #130, 11, 13, 70, 24, and 12. B. The facility failed to ensure clean linen was distributed in a covered linen cart, all four edges were torn exposing clean linen. C. The facility failed to keep urinals clean. D. The facility failed to ensure soiled linens were properly handled. These failures could place residents at risk of cross contamination. Findings include: Observation on 2/21/23 at 8:57 AM revealed the linen cart was on 200 hall. The linen cart was ripped on all 4 corners exposing clean linen. Observation on 2/21/23 at 10:02 AM revealed Resident #130 was not in the room; the nasal cannula was not bagged and on the floor. The urinal was at the top of the fridge at bedside next to a slightly opened bag of popcorn. The urinal was not in a bag and the rim and bottom was dark yellow, urine odor noted. Observation on 2/21/23 at 10:44 AM revealed Resident #11 was not in the room; the nasal cannula was on the floor not bagged, carpeted area. Observation on 2/21/23 at 10:49 AM revealed Resident #13's oxygen mask was not bagged; it was located hanging off behind the bedside dresser in the room. Observation on 2/21/23 at 10:54 AM revealed a dusty urinal was in on the restroom floor of room [ROOM NUMBER]. Observation on 2/21/23 at 11:22 AM revealed Resident #70's nasal cannula was on the floor and not bagged in the room, carpeted area. Observation on 2/21/23 at 11:53 AM revealed Resident #24's nasal cannula was not bagged and on the floor. Yankauer suction (a firm plastic suction tip with a large opening surrounded by a bulbous head and is designed to allow effective suction) was not bagged. Both located in Resident #24 room. Observation on 2/21/23 at 3:13 PM revealed the urinal was hanging off the towel rack next to the toilet, the urinal had yellow stain at the bottom . Observation on 2/22/23 at 11:40 AM revealed a ripped linen cart was being used to transport linen to the 200 hall, exposing clean linen. Observation on 2/22/23 at 5:04 PM revealed Resident #12's nasal cannula was not bagged and on the floor, caprpeted area. Yankauer suction was not bagged. Both located in Resident #12 room. Observation and interview on 2/22/23 at 6:34 PM revealed wet towels and sheets were on the floor of the 400 hall shower room. The DON stated the CNA's were trained to place all dirty, wet linen in the dirty bin. The DON stated they staff usually have dirty linen bin right outside the shower room for easy access to place dirty linen. The DON stated nursing staff were trained upon hire and annually . Interview on 2/23/23 at 11:25 AM the DON stated nasal cannulas and yankauer were required to be placed in bags when not in use. The DON stated all nursing staff were in charge of ensuring nasal cannulas and yankauer suction were properly stored while not in use upon hire and annually. The DON stated nursing staff were trained to check at least every two hours during rounds. The DON stated by not ensuring they were bagged when not in use could potentially put residents at risk of respiratory infection due to cross contamination. The DON stated urinals were required to be bagged when not in use and if seen dirty to be discarded. The DON stated by not cleaning urinals properly and storing them in bags when not in use could expose residents to infection due to cross contamination. The DON stated the facility did not have a policy on oxygen monitoring or infection control. Record review of Environmental Services: laundry and Linen processing policy dated 10/24/22 revealed page 1- The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. Bagging and Handling Soiled Linen: 1. All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. Page 2-Washing Linen and other Soiled Items: 7. Clean linen will remain hygienically clean (free from pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. Record review of Elimination: Ben Pan/ Urinal-Use policy dated 04/2021 revealed Page 1- Policy: It is the policy of this community to provide the bedpan/ urinal in a manner which is safe and promotes the resident's dignity. Page 2- Emptying Urinal or Bedpan: 5. Empty, rinse, clean, and replace urinal or bedpan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 facility reviewed for environment. The facility failed to ensure housekeeping and maintenance services were provided for resident living areas. This failure could affect residents placing them at risk of living in an unsafe, uncomfortable environment, infection and disease, and decreased quality of life due to poor conditions of the facility interior and exterior. Findings includes: Observation on 02/21/2023 at 9:22 a.m., the back yard green gate between the 200 hall and 400 hall was left wide open. No locks were noted on the gate. The gates were open to the desert. Observation on 02/21/2023 at 9:31 a.m., revealed resident room [ROOM NUMBER] had no doors on the left side of the closet exposing the clothes had no hinges attached. As soon as exiting the hallway to the left at average height level four screw size holes where some object was placed on the wall that were not covered. A thin strip of metal shown through while paint was cracked. Restroom shower had resident personal belongings in two brown boxes, two metal side rails, a white tapware two shelved storage box with a hospital grown on top. Two articles of clothes green and dark green shirts are hung on the shower pole. A picture frame, an elegant box, two hospital clear measuring sample urine containers with a blue ice pack looking object sit on top of the two boxes that are stacked together. On the wall where the call lights were hung, there was exposed wiring. Four orange electrical caps were seen and one blue capped electrical wire was seen. Two inches of the exposed wall to the left of the casing for the call light was exposed. Observation on 02/21/2023 at 9:49 a.m., revealed resident room [ROOM NUMBER] had no closet doors on both closets; the closet to the right did not have any hinges. Resident clothes on both closets were exposed. On the wall opposite side of the restroom there were four holes making a shape of a rectangle with two screws size holes separated a foot away from the other two holes. The window right above was five screw size holes above the window seal about three feet apart and on hole was in the middle. Observation on 02/21/2023 at beginning 10:04 a.m., revealed resident room [ROOM NUMBER] the whole connecting the bathroom and the closet they're all had 3 scratches near the border closest to the floor around 4 feet and name. Two feet above the scratches there was another set of scratches three of them about four feet in length. The scratches on the top cut into the wall exposing the white sheetrock underneath and scratches on the bottom expose sheetrock and had some black markings. As soon as you come out of the hall to your right is two scratches separated around two feet with a depth of 1/8 inch of sheetrock missing. The top scratch was a foot an a half and the bottom scratch was around two feet. The edge or corner of the wall had chips coming off it from the border of the floor approximately three feet upwards towards the ceiling. The restroom wall where the hand soap was attached underneath shows where it was originally located. There are ten holes poked into the wall with paint coming off exposing the brown and white sheetrock underneath. Three holes have yellow dry wall anchors and two have gray dry wall anchors. Wall closet to the resident's bed had four large scrapings with multiple smaller and thinner scratches and lots of dots where paint and sheetrock is exposed. The main large scratch had a dept of around half an inch. Observation on 02/21/2023 at 10:21 a.m., of resident room [ROOM NUMBER] revealed the following: Closet space had no closet door attached exposing the residents' clothes; restroom shower had no turn knob for the hot or cold water. The shower spray hose did not have a sprayer. The floor drain was covered with 4 strips of duct tape with approximately a foot long. Shower floor tile looked dirty/stained and within the borders of the tile there was parts that had grime and dark in color while other areas were white. Observation on 02/21/2023 at 12:25 p.m., the conference room door handle in hallway 200 was dirty and had some unknown substance was light brown with little particles in it. When grabbing the door handle the foreign object was rough and grimy. Observation on 02/21/2023 at 12:28 p.m., in the front of the building the whole outside window screen was off lying sideways on the ground next to the window. Resident's window was closed. Observation on 02/21/2023 at 1:58 p.m., in resident room [ROOM NUMBER] the right-side closet is missing a door and the residents clothes is exposed. Observation on 02/21/2023 at 2:19 p.m., resident restroom [ROOM NUMBER] underneath the rail shows where the toilet paper dispenser was moved. Above it mesh was seen inside of the pinkish wall of the two exposed holes about two inches in diameter. The mesh looks like it is breaking outwards and between the two holes is a smaller hole about a dime size. An unknown material possible insulation is seen encircling some white spackle. Observation on 02/21/2023 at 2:21 p.m., in resident room [ROOM NUMBER] on resident wall had three small sized screw holes. On another wall near the cable cord was another three small sized screw holes. Observation on 02/21/2023 at 2:32 p.m., in resident room [ROOM NUMBER] the left side closet was missing a door and was missing one hinge exposing the residents' clothes. Below near the floor corner the border was gone exposing pieces of material. Observation on 02/21/2023 at 3:26 p.m., in resident room [ROOM NUMBER] the closet did not have any closet doors but instead had curtains that were orange hung up in place of the closet doors. Observation on 02/21/2023 at 4:02 p.m., in the Chapel currently used as the conference room in hall 200. The back door did not latch and remain unlocked. A resident was observed wandering the 200 hall and trying to get into the conference room multiple times with and without staff providing supervision. Observation on 02/22/2023 at 4:27 p.m., with Director of Plant Operations, in hallway 200 in the far back of the hall was a fire door exit that had a box on the top right hand with no covering exposing computer wiring and the mother board. Observation on 02/22/2023 at 4:46 p.m., in resident room [ROOM NUMBER] in the shower was a red luggage and a black larger luggage in the corner. On top of the red medium size luggage was a square blue linen bag and on top of the bag was a plastic hospital urinal with the cap open. The urinal had three doted areas color brown. A foot away to the other side of the shower floor was two wheelchair footrests. Tile on the shower floor looked dirty and in between the borders of the tile looked grimy and had dark area through the shower floor. Observation on 02/22/2023 at 5:06 p.m., with Director of Plant Operations revealed the front of the building porch had one of the support beams that had come off. The long piece of wood was lying on the ground on the side of the porch in the grass. This exposed the beam which was brown, and the plywood which was a grayish color. A foot long string of plywood was dangling in the air. On the side of the beam was approximately a four-foot piece of plywood. Observation on 02/22/2023 at 5:09 p.m., outside on in the front of the building was the outside screen the was bent outwards from the top half and the bottom half and not properly secured in the window frame. The window of the resident is closed. There was a tarantula that was dead with its limbs closed up like a hand making a fist. A large spider that appeared not alive was lying on the window ledge near the window's locking mechanism. Observation on 02/22/2023 at 5:19 p.m., in the back of the facility next to the kitchen was an outside window screen lying on the floor. The sliding window was closed. Observation on 02/22/2023 at 5:20 p.m., in the back gate area of the facility towards the outside of Hall 300 was an outside screen lying sideways on the wall towards the right side of the window. Observation on 02/22/2023 at 5:21 p.m., in the conference room of hallway 500 there are three windows with blinds that are broken, bent, distorted, or missing pieces of the blinds. Observation on 02/22/2023 at 5:25 p.m., in the activity and dining room of hallway 300 in the right corner close to the backyard between 300 and 500 hallways. There was exposed wiring from the border that was popped out exposing wiring around 4 feet from the wall. A residents sat on a reclining chair two or three feet away. Observation on 02/22/2023 at 5:26 p.m., in the back yard area located inside the gate between hallways 500 and 300 there were two blue ACE buckets (one filled with water) stacked on top of each other while a third ACE bucket was lying on its side further down in the grass. - To the left about two feet of the buckets was one white 3 by 4 feet piece of wood with a small 2 by 1 ½ foot piece of white wood leaning next to the wall of the 300 Hall resident room (Unknown whose room it is). - Two feet to the left of the white pieces of wood was a bucket lid from the ACE bucket that was on the ground. - Close to the fence line there was two blue mattresses the one on the bottom was torn and exposed the white inner part of the mattress. Next to it was a large piece of wood around 6 feet in length. Observation on 02/22/2023 at 5:30 p.m., in hallway 300 near the communal shower room wall was a 6-inch by 2-inch rectangle hole in the wall. The mesh is exposed and sheetrock. It is noted that residents are walking up and down the hallway. In the communal shower was two gray trash cans, two shower chairs, on the floor was a large bottle of a unknown chemical unsecured, unattended by staff and accessible to residents. The floor tile looked grimy, and borders had dark material in between them. To the right side of the shower was a laundry holder with a small gray basket underneath, to the side was a clear plastic bag full of clothes and wet shower boots, a white small trash can, and a normal trash can sat close. Above on the wall next to the paper towel dispenser was paint coming off exposing the brown plywood underneath. Observation on 02/24/2023 at 10:08 a.m., in resident room in the 500 hallway. The shower had three brown boxes stacked on top of each other on the floor and a dresser drawer on top of them in the corner. A black ladder that was able to hold items. Underneath behind the black ladder was another small brown box with items and a shoe on it. In front to the side corner was a medium sized brown box with other items. Tile floor was dirty and in between the borders had dark material throughout the floor. Interview on 02/21/2023 at 3:26 p.m., with Resident #76 stated that her son came and bought curtains because the closet did not have doors. Resident #76 stated she liked the curtains but wanted to have the closet doors. Interview on 02/22/2023 4:10 p.m., Director of Plant Operations stated anything the nurses find broken or wrong through the facility must be written down. Director of Plant Operations stated he tried to fix repairs as soon as possible and prioritizes the repairs like if there is no water or the toilets are not working then those issues are worked on first. Director of Plant Operations stated in the maintenance log under descriptions he places what he has done to correct the repair issues. Director of Plant Operations stated some facility staff will verbally come and tell him about the discrepancy instead of writing it down in the maintenance log. Director of Plant Operations stated he does not record discrepancy anywhere else other than the maintenance log. Director of Plant Operations stated he had gone to the nurses and reported telling them verbally to write down any issues in the maintenance logbook. Director of Plant Operations stated he had not in-serviced the facility staff on what to do or how to notify him on where to request work orders. Director of Plant Operations stated the Administrator had reported the conference door not locking a week ago and was not recorded in the maintenance log. Interview on 02/22/2023 at 5:00 p.m., with Director of Plant Operations stated the transport vehicle does not park directly beneath the beam that had repair issues. Director of Plant Operations stated the transport for the resident sparks further away underneath the front porch overhang. Director of Plant Operations stated that a month ago a commercial vendor delivering items had ripped that portion of the overhang and the commercial vendor was going to pay for it but had not yet made the repairs. Director of Plant Operations stated that a lot of the window screen that are off do not fit the windows anymore. Director of Plant Operations stated it was probably due to the frames being warped and bent. Director of Plant Operations stated the outside window screen did not fit. Director of Plant Operations stated that the outside screen was bent and did not properly make a seal to create a barrier from the outside to the inside environment like a lot of other window screens. Director of Plant Operations stated he had not had time to fix the issue because it was only him and he did not have staff and was busy with other tasks. Director of Plant Operations stated the facilities gates need to be closed and locked. Director of Plant Operations stated the gate locks broke and have not been replaced. Director of Plant Operations stated the gate needs to be closed and locked especially since the conference room door does not lock. Director of Plant Operations stated resident room [ROOM NUMBER] shower had resident personal belongings in it and CNAs use it as storage. Director of Plant Operations stated resident room [ROOM NUMBER] hole in the wall with the call light was not repaired properly by contractors the facility has to repair call light systems. Director of Plant Operations stated he oversees that the contractors are properly doing the work right. Director of Operations stated the wires being exposed was an electrical fire hazard and a risk to the residents. Direct of Plant Operations stated he does not do daily checks of rooms throughout the facility. Director of Plant Operations stated resident shower in 508 tile was mold on the floor. Director of Plant Operations stated the Housekeeping Supervisor was supposed to oversee that the housekeepering personnel are cleaning thoroughly all of the rooms and showers. Director of Plant Operations stated the mold could be a hazard to residents by getting them sick. Director of Plant Operations stated that most of the restrooms are dirty. Director of Plant Operation stated he would not want to take a shower in the facility's shower. Director of Plant Operations stated it did not look like housekeeping was cleaning everyday and properly. Director of Plant Operations stated the House keeping Supervisor oversees the and makes sure the cleaning is being done. Director of Plant Operations stated that they do have chemicals that are strong enough to remove and kill the bacteria/strains. Director of Plant Operations stated the housekeepers are trained in their job duties. Director of Plant Operations stated the shower room in resident room [ROOM NUMBER], the duct tape was placed there to keep a resident from urinating into the drain and from stopping the resident from also placing foreign objects into the drain. Director of Plant Operations stated the fire door in hallway 200 had the electrical conjunction box covering missing and was a fire hazard to the residents due to the exposed components. Interview on 02/23/2023 at 8:55 a.m., the Administrator stated regarding the shower in resident room [ROOM NUMBER], he had not seen that the showers were being used as a storage with residents personal belongings. The Administrator stated that it was the right of the resident if they wanted their belongings placed in the shower. The Administrator stated that they have to look at the resident's diagnosis and if the representatives wanted the belongings in the shower. The Administrator stated the shower in resident room [ROOM NUMBER] looked like the tile had mold (Administrator grabbed a wipey and wiped some of the black matter from the tile side wall and floor) and that the housekeeping supervisor needed to make sure the housekeepers were cleaning. The Administrator stated the communal shower room in the 200-hall had water strain on the floor and wall tiles. The Administrator stated the facility had chemicals to be able to remove the mold looking material in the communal shower room. The Administrator stated they are in the process of trying to remodel the restrooms. The Administrator stated the risk to the residents using the shower would be infection. Interview on 02/23/2023 at 8:58 a.m., Resident #20 stated she did not know about her luggage and other personal belongings being stored in her restroom shower. Resident #20 stated no one from the facility staff or during admission told her if she wanted her personal belongings in the shower. Resident #20 stated to the Administrator that she wanted her personal belongings removed from the shower immediately because she did not give permission to have it placed in there. Interview on 02/23/2023 at 9:45 a.m., with Director of Environmental Services stated that all housekeepers have to be trained to conduct housekeeping. Director of Environmental Services stated that for trainings they had a sign in sheet where the housekeeping staff would sign off but not anymore. The Director of Environmental Services stated she was in charge of making sure the housekeepers were cleaning. The Director of Environmental Services stated she does checks on her staff but tries to have confidence in them that they are doing what they are supposed to. The Director of Environmental Services stated that the housekeepers were supposed to be cleaning every day. The Director of Environmental Services stated the restroom and the residents' rooms were to be cleaned. The Director of Environmental services stated every day housekeeping was to be vacuuming. The Director of Environmental Services stated she was conducting her rounds and was finding that at times the housekeeping was not being done right. Director of Environmental Services stated she tells the housekeepers to do a task and ends up having to redo the task because it was done incorrectly. The Director of Environmental Services stated she had not in-serviced the housekeeping staff. The Director of Environmental Services stated there was two housekeepers in the morning and one in the afternoon. The Director of Environmental Services stated she was short staffed. The Director of Environmental Services stated resident shower room in 508, she had not seen it yet. The Director of Environmental Services stated she had been working at the facility for ten years and had seen the way all the showers were and did not voice the uncleanliness to her superiors. The Director of Environmental Services stated the risk to the residents was breathing. The Director of Environmental Services stated that the dark material looked like mold that had mushrooms or spores that could affect the residents with breathing. the Director of Environmental Services stated resident shower in 209 had personal belongings with a urinal container sitting on top of the belongings and did not belong there. The Director of Environmental Services stated if she was a resident there, she would not like the urinal with her personal belongings. The Director of Environmental Services stated she would not have the restrooms dirty like that in her home. Interview on 02/23/2023 at 10:30 a.m., with Housekeeper D stated she had received training to be a housekeeper from two staff that no longer work at the facility. Housekeeper D stated the housekeeper trainers demonstrated how to clean first and then she did. Housekeeper D stated she did receive formal training from the facility where she signed off. Housekeeper D stated the housekeepers clean all the rooms in all the halls. Housekeeper D stated carpets are cleaned every day. Housekeeper D stated the shower in resident room [ROOM NUMBER] does not look clean but she does mop it. Housekeeper D stated she would not shower in the shower but only use the toilet if she was a resident. Housekeeper D stated she had seen how the showers look and had not voiced it out to her supervisors regarding the issue of the mold and dirtiness. Housekeeper D stated regarding resident shower in room [ROOM NUMBER], she would not like that urinal and the luggage do not look good being in the shower. Housekeeper D stated she did not know why the urinal was in the shower since the residents in the room were all female. Record review of facility Maintenance Log reviewed indicated there were only two work orders requested. The orders were for 02/16/2023 for rooms 306 and room closet 300. Record review of Resident #20's face sheet and MDS indicated that resident was her own Representative and had a BIMS of 8.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record reviews the facility failed to dispose of garbage and refuse properly for 6 of 6 dumpster and 1 of 1 oil fryer container reviewed for food safety requirements. 1. Garbage and refuse were observed on the ground near the dumpsters in the back of the facility. 2. 2 dumpsters were observed uncovered with garbage inside and one fry oil container was uncovered with used fry oil in it. This failure could affect residents by placing them at risk of illnesses, or be provided a unsafe, unsanitary and uncomfortable environment. Findings include: Observation on 02/21/2023 at 8:40 a.m., with Dietary Manager, six metal dumpsters and one metal oil (fryer) container were lined up in a row around 50 to 75 feet away from facility. The dumpster lids on most of all six dumpsters do not provide a proper seal as some are bent in various ways allowing access to the outside environment. One dumpster had its left side lid open and the other had its right-side lids open. The dumpsters with its left side lid open had a cardboard box sitting underneath its lower right side exposing 60 % of the cardboard box on the ground. The dumpster with the right-side lid open had a piece of dark grayish bag around a foot hanging in the air from its closed lid. Behind the dumpsters closest to the fryer container in between both dumpsters was a white plastic bag torn and caught on a plant with [NAME] that was approximately a foot away from the dumpsters. Next to the white plastic torn bag on the same plant but on a different branch was a bag string caught in the plant. Further down the behind the dumpsters was another plant with a white plastic bag caught in its [NAME]. Next to the fryer about a foot away was a brown cardboard on the ground. A foot away was another long piece of cardboard paper and a white plastic bag. Leaning to the side of the fryer container was cardboard sheet around 2 foot in diameter. The fryer lid was left opened. On the grill was a caked-on layer of grease. Next to the open lid on the right side was a two-to-three-foot two length by two-inch width piece of wood with white grease or fat particles dusted all over the wood and container. On the left side of the fryer lid was a dirty dusted butter knife. On the third dumpsters in the front was a piece of white paper lying on the ground half a foot diagonal to the dumpster. On the back side of the fryer was a nightstand, a broken pallet, three pieces of wood scattered, a green tea bottle on the ground floor, and four two feet by three-foot sheets of wood lying on the fryer. A white sugar packet and a red piece of possibly candy were on the ground. Dumpster furthers to the medical waste, behind the dumpster on the floor was a white spoon on the ground. Next to the medical waste was a white wooden stand with a blue sheet with hay on top of it. Two feet from it was a four-foot length by one foot width piece of wood lying on the ground. It was also observed that around the general area (grounds) was various kinds of trash scatted throughout the dumpster area grounds further away from the dumpsters. In the back entrance to the kitchen was a pile of cardboard boxes (8 varies sizes of boxes) emptied lying on the ground and on the side of the building. Interview on 02/21/2023 at 9:38 a.m., with Dietary Manager stated maintenance takes care of the upkeep of the grounds and makes sure the grounds are clean. The Dietary Manager stated the dumpster lids are to be closed and not opened. The Dietary Manager stated they have in-serviced and [NAME]-serviced the dietary staff on keeping the dumpsters closed and area clean. The Dietary Manager stated that it is everyone's duty to ensure the dumpster lids are closed and making sure there is no trash around the dumpsters. The Dietary Manager stated the cardboards near the entrance of the kitchen have been on the floor since 02/20/2023 and have not been thrown due to not having staff. The Dietary Manager stated the dietary staff conducting the truck (on 02/21/2023) would throw away the cardboard boxes. Observation on 02/22/2023 at 5:13 p.m., with Director of Plant Operations, 2nd Dumpster closest to the fryer had its right-side lid open. The third dumpsters in the front were a piece of white paper lying on the ground half a foot diagonal to the dumpster that still remained. Observation on 02/22/2023 at 5:20 p.m., with Director of Plant of Operations, behind the kitchen entrance were serval emptied cardboard boxes lying on the ground. Interview on 02/22/2023 at 5:15 p.m., the Director of Plant Operations stated the dumpsters are to be cleaned of any trash everyday by him and by anybody. The Director of Plant Operation stated the dumpster lids are to remain closed and that the lids were in bad condition. The Director of Plant Operations stated he is responsible for taking care of the grounds and making sure the dumpster areas and around the facility are cleaned. The Director of Plant Operations stated he does not have the staff to be able to take care of the task like it should be. The Director of Plant Operations stated the risk to the residents is they could get sick. Record review of facility Related Garbage and Refuse Disposal dated 10/2007 stated food related garbage and refuse are disposed of in accordance with current state laws. Line. All food waste shall be kept in containers. Line 2. All garbage and refuse containers are provided with tight fitting lids or covers and must be kept covered when stored or not in continuous use. Line 5. Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pests. Line 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. Record review of facility Waste Disposal dated 04/2022 stated food and nutrition services will ensure that waste containers are properly maintained. Line 1. Waste containers and dumpsters have lids covering them when not in use and are not overflowing. Line 2. Area around dumpsters are kept clean and odor and rodent free. Line 3. Dumpster plug are to be in place if not a sealed unit. Record review of facility Pest Control dated 05/2008 stated our facility shall maintain an effective pest control program. Line 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily.