Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #17) reviewed for resident rights, in that: The facility failed to ensure CNA AD and CNA AE completely closed Resident #17's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #17's face sheet, dated 09/10/2024, revealed an admission date of 07/01/2022 and, a readmission date of 01/06/2023, with diagnoses which included: Dementia (decline in cognitive abilities), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hypertension (High blood pressure), Chronic kidney disease (gradual loss of kidney function)and, Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #17's Quarterly MDS assessment, dated 08/07/2024, revealed the resident had a BIMS score of 03, indicating she was severely cognitively impaired. Resident #17 was always incontinent of bladder and frequently incontinent of bowel and, required extensive assistance with her ADLs. Record review of Resident #17's care plan, dated 07/22/2022, revealed a problem of has an ADL self-care performance deficit related to Activity Intolerance, Fatigue, with an intervention of TOILET USE: The resident requires extensive assist from (2) staff for toileting. Observation on 09/10/24 at 09:20 a.m. revealed CNA AD and CNA AE did not completely close the privacy curtains while they provided incontinent care for Resident #17, exposing the resident who could be seen from the room's door. Further observation revealed Resident #17's roommate was in the room. During an interview with CNA AD and CNA AE on 09/10/2024 at 9:28 a.m., they confirmed the privacy curtains was not completely closed while they provided care for Resident #17 but it should have been. They confirmed they received resident rights training within the year. During an interview with the DON on 09/10/2024 at 9:30 a.m., the DON confirmed privacy must be provided during nursing care and Resident #17's privacy curtains should have been closed completely. He confirmed the staff had received training on resident rights within the year and the training was provided by the ADONs and himself. They also check the staff skills annually and as needed. The DON revealed they had no policy regarding the privacy curtain being closed during care. Review of Facility's Resident rights sign posted in the facility revealed You have the right to privacy, including privacy during visits and telephone calls and while attending to personal needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 18 residents (Residents #40 and #9) whose assessments were reviewed, in that: 1. The facility failed to ensure Resident #40's quarterly MDS, dated [DATE], correctly documented the resident as receiving an anticoagulant medication. 2. The facility failed to ensure Resident #9's, who was a smoker, annual MDS, dated [DATE], did not reflect the resident did not use tobacco. These failures could place residents at-risk for inadequate care and services. The findings were: 1. Record review of Resident #40's face sheet, dated 09/10/2024, revealed an admission date of 03/09/2018 and, a readmission date of 05/12/2024 with diagnoses that included: Type 2 diabetes mellitus (high level of sugar in the blood), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Heart failure (impairment in the heart's ability to fill with and pump blood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hypertension (High blood pressure), Peripheral vascular disease (Blood circulation disorder affecting the vessels outside of the heart and brain) and, Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #40's Quarterly MDS assessment, dated 06/17/2024, revealed the assessment indicated Resident #40 received an anticoagulant and an antiplatelet. Record review of Resident #40's Physician orders and Medication administration record for June 2024 revealed orders for: Aspirin 81 (antiplatelet) oral tablet chewable. Give 1 tablet by mouth one time a day related to encounter for orthopedic aftercare following surgical amputation and an order for Clopidogrel Bisulfate (antiplatelet) oral tablet 75 mg. Give 1 tablet by mouth one time a day related to peripheral vascular disease. Record review of Resident #40's Medication Administration Record for the month of June 2024 revealed Resident #40 received Clopidogrel Bisulfate Tablet 75 MG and Aspirin 81 mg everyday, as per order, between 06/10/2024 and 06/17/2024. During an interview with MDS Coordinator AF on 09/10/2024 1:05 p.m., MDS Coordinator AF verbally confirmed Resident #40's quarterly MDS was coded as the resident having received an anticoagulant and an antiplatelet when Resident #40 had received Clopidogrel (an antiplatelet) and Aspirin (an antiplatelet) . She verbally confirmed Clopidogrel was an antiplatelet and should not have been coded as an anticoagulant. She revealed she did not know Aspirin was an antiplatelet but should have been coded as an antiplatelet. The MDS nurse stated the RAI was used as reference for the MDS and she had access electronically to the RAI on her computer. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual,Version 1.18.11, October 2023, revealed, N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Record review of Resident #9's face sheet, dated 09/11/2024, revealed the resident was [AGE] years old female and an original admission date of 02/02/2013 and re-admission date of 01/20/2015 with diagnoses that included: type 2 Diabetes mellitus (high level of sugar in the blood), muscle wasting and atrophy (muscles to decrease in size and strength), chronic kidney disease stage 3 (kidney damage unable to filter waste from the blood), hypertension (high blood pressure), and cerebral infarction (low blood flow to the brain). Record review of Resident #9's annual MDS assessment, dated 03/22/2024, indicated her BIMS score was 15 of 15 reflecting she was cognitively intact. Further record review indicated the question of J1300: Current tobacco use in the Section J (Health Conditions) was answered No. Record review of Resident #9's comprehensive care plan, dated initiated 10/08/2020, reflected [Resident #9] is a smoker, and the intervention was instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Record review of Resident #9's smoking assessment, dated 03/15/2024, reflected Resident #9 was a smoker and smoking at the facility smoking area under supervision. Observation on 09/11/2024 at 11:00 a.m. indicated Resident #9 was smoking at the facility smoking area under supervision. Interview on 09/08/2024 at 3:34 p.m. with Resident #9 revealed the resident had been smoking cigarettes for long time, and five times a day at the facility smoking area. Interview on 09/11/2024 at 10:39 a.m. with MDS nurse-AG acknowledged Resident #9's annual MDS dated [DATE]'s question of Current tobacco use in the Section J (Health Conditions) was answered No, and it was mistake because Resident #9 had been smoking since she was admitted to the facility. Further interview with the MDS nurse revealed the question of current tobacco use should have been answered Yes, MDS nurse had responsibility for accurate MDS, and the potential harm was an inaccurate MDS might cause incorrect care to the resident. Interview on 09/11/2024 at 1:03 p.m. with the DON revealed the facility did not have the policy regarding MDS accuracy. The facility was following CMS MDS 3.0 Manual. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual,Version 1.18.11, October 2023, revealed, N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder for level II resident review for 1 (Resident #68) of 18 residents reviewed for resident assessments. The facility failed to refer Resident #68 for re-evaluation of PASARR level I review following a diagnosis of schizoaffective disorder-bipolar type, added on 01/05/2024. This failure could place residents at risk of not having their mental health needs met by the facility and could place all residents at risk of harm by mentally unstable residents. Findings Included: Record review of Resident #68's face sheet, dated 09/10/2024, revealed the resident was [AGE] years old male and an admission date of 11/08/2021 with diagnoses that included: cirrhosis of liver (scar tissue replaces healthy liver tissue), hypertension (high blood pressure), atherosclerotic heart disease (plaque buildup in artery walls), and schizoaffective disorder-bipolar type (chronic mental illness that causes symptoms of both schizophrenia and a mood disorder). Record review of Resident #68's quarterly MDS assessment completed on 08/16/2024 Section C revealed a BIMS score of 10 which indicated moderate cognitive impairment. Section I (Active diagnoses) indicated Resident #68 had diagnoses of Schizophrenia (schizoaffective and schizophreniform disorders). Section N (Medications) indicated Resident #68 was taking antidepressant and antipsychotic medications. Record review of Resident #68's care plan, dated 05/27/2024, revealed Resident #68 had the potential to be physically aggressive related to schizoaffective disorder-bipolar type. He was receiving antidepressant and antipsychotic medications, and the interventions were Monitoring behaviors, notify medical doctor of new or worsening behaviors, and monitor/document/report as needed for any adverse reactions. Record review of Resident #68's diagnosis report, dated 01/05/2024, revealed the diagnoses of schizoaffective disorder-bipolar type had an onset date of 01/05/2024. Record review of Resident #68's physician order, dated 01/05/2024, revealed the physician prescribed Zyprexa 5 mg every day at hour of sleep by mouth for schizoaffective disorder-bipolar type. Further record review revealed Resident #68's physician increased Zyprexa from 5 mg to 10 mg. Record review of Resident #68's medical record from 01/05 2024 to 09/11/2024 revealed there was no referral to a local authority regarding re-evaluation of PASARR by the resident's new mental status (new diagnosis of schizoaffective disorder-bipolar type). Interview on 09/10/2024 at 11:50 a.m. with the DON revealed if a resident came from a home, the facility had the responsibility to conduct the PASARR evaluation, but if a resident came from an acute hospital, the hospital had responsibility to conduct PASARR evaluation. Resident #68 came from an acute hospital on [DATE] with a negative result of PASARR Level I evaluation, and the facility just followed the evaluation. Interview on 09/10/2024 at 11:58 a.m. with MDS Coordinator-AF and MDS nurse-AG revealed because Resident #68 received a new diagnosis of schizoaffective disorder-bipolar type and taking antipsychotic medication (Zyprexa) on 01/05/2024, the facility should have referred Resident #68 to a local authority because Resident #68 had a significant change in his mental status assessment. Further interview with two nurses revealed they started working as MDS nurses in three months. They did not know what reason the facility did not refer Resident #68 to a local authority for re-evaluation of PASARR. MDS nurses had responsibility for re-evaluating residents regarding changing of condition, and the potential harm was Resident #68 might not receive PASARR benefits that he should take. Interview on 09/11/2024 at 1:03 p.m. with DON stated the facility did not have the policy regarding PASARR re-evaluation. The facility was following CMS regulations.

**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 that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 18 residents (Resident #17) reviewed for comprehensive care plans, in that: The facility failed to ensure Resident #17, who was always incontinent of bladder and bowel, had a care plan regarding bowel incontinence care. This deficient practice could place residents at risk for not receiving proper care and services. The findings included: Record review of Resident #17's face sheet, dated 09/11/2024, revealed the resident was [AGE] years old female and an original admission date of 07/01/2022 and re-admission date of 01/16/2023 with diagnoses that included: Dementia (decline in cognitive ability), major depressive disorder (loss of interest in activities), hypertension (high blood pressure), muscle wasting and atrophy (muscles to decrease in size and strength), and chronic kidney disease (kidney damage unable to filter waste from the blood). Record review of Resident #17's quarterly MDS assessment completed on 08/07/2024 Section C (Cognitive Patterns) revealed a BIMS score of 03which indicated severe cognitive impairment. Section GG (Functional Abilities and Goals) indicated Resident #17 required substantial/maximal assistance (helper dose more than half the effort) to toilet hygiene, sit to stand, chair/bed-to-chair transfer, and not attempted due to medical condition or safety concern to toilet transfer. Section H (Bladder and Bowel) indicated Resident #17 was always incontinent to bladder and bowel. Record review of Resident #17's care plan, date revised 02/10/2023, revealed Resident #17 had problem: the resident has bladder incontinence, and interventions: clean peri-area with each incontinence episode, encourage fluids during the day to promote prompted voiding responses, and ensure the resident had unobstructed path to the bathroom. Further record review of the resident care plans indicated no care plans regarding bowel incontinence. Interview on 09/10/2024 at 2:25 p.m., CNA-AH acknowledged Resident #17 was always bowel incontinent, so CNAs checked the resident every 2 hours and provided bowel incontinent care. Interview on 09/10/2024 at 2:28 p.m., MDS Coordinator RN-AF acknowledged Resident #17 was always bowel incontinent and needed to have a care plan for bowel incontinence. However, Resident #17's care plan addressed only bladder incontinence. There was no a care plan regarding bowel incontinent care. Further interview with MDS Coordinator RN-AF revealed they did not know what reason Resident #17's bowel incontinence care plan was missing because they were hired three months ago. MDS nurse had responsibility for care plan, and the potential harm was the resident might have skin breakdown because of a lack of care by no care plans. Interview on 09/11/2024 at 1:03 p.m. with the DON Was trevealed the facility did not have the policy regarding care plan. The facility was following CMS regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #79) of 3 residents reviewed for quality of care. The facility failed to ensure Resident #79, who was receiving Glucerna at a rate of 55 ml/hour via tube feeding on 09/08/2024, coincided with the physician order that indicated providing Glucerna at a rate of 60 ml/hour to the resident. This failure could place residents at risk of not receiving the proper tube feeding requirements prescribed by the physician. Findings included: Record review of Resident #79's face sheet, dated 09/08/2024, revealed the resident was [AGE] years old female and an original admission date of 06/05/2023 and re-admission date of 12/23/2023 with diagnoses that included: Dementia (decline in cognitive ability), surgical aftercare following surgery on the digestive system, dysphagia (swallowing difficulties), muscle wasting and atrophy (muscles to decrease in size and strength), hypertension (high blood pressure), and type 2 Diabetes mellitus (high level of sugar in the blood). Record review of Resident #79's quarterly MDS assessment completed on 06/17/2024 Section C (Cognitive Patterns) revealed a BIMS score of 00 which indicated severe cognitive impairment. Section GG (Functional Abilities and Goals) indicated Resident #79 required dependence (full staff performance every time) for chair/bed-to-chair transfer and eating. Section K (swallowing/nutritional status) indicated Resident #79 had a feeding tube. Record review of Resident #79's care plan, date revised 03/05/2024, revealed Resident #79 had problem: the resident requires tube feeding related to dysphagia, and interventions: the resident needs total care with tube feeding and water flushes. See medical doctor orders for current feeding orders. Record review of Resident #79's physician order, dated 09/04/2024, revealed Enteral feed order - every shift Glucerna 1.5 at 60 ml/hour x 18 hours via gastrostomy tube stationary pump. Observation on 09/08/2024 at 11:11 a.m. revealed Resident #79 was on the bed and receiving Glucerna 1.5 via gastrostomy tube stationary pump, and the rate was set up at 55ml/hour on the pump machine. Interview on 09/08/2024 at 11:28 a.m., LVN-AI acknowledged Resident #79 was receiving Glucerna 1.5 with the rate of 55 ml/hour via tube feeding pump, but the physician order indicated providing Glucerna 1.5 with the rate 60 ml/hour to the resident. LVN-AI stated Resident #79's physician increased the rate from 55 ml/hour to 60 ml/hour on 09/04/2024, but the nurse forgot it and set the rate to 55 ml/hour. The potential harm was Resident #79 might not have enough calories and could have weight loss. Interview on 09/10/2024 at 4:20 p.m. with the DON revealed Resident #79 should have been receiving Glucerna 1.5 with the rate of 60 ml/hour via tube feeding pump, instead of 55 ml/hour because the physician gave the order of 60 ml/hour on 09/04/2024. Nurses should follow physician orders, and the potential harm was the resident could have weight loss. Record review of the facility's policy, titled Medication Administration, including tube feeding, dated 10/24/2022, revealed Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physician in accordance with professional standards of practice. 14. Administer medication as ordered in accordance with manufacturer specifications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 2 residents (Residents #63) reviewed for quality of care in that: The facility failed to ensure Resident #63's nebulizing mask and tubing, that were observed on 09/08/2024, were not covered in a plastic bag dated on 07/21/2024. This failure could affect residents who received nebulizing treatment and place them at risk for respiratory infections. The findings included: Record review of Resident #63's face sheet, dated 09/09/2024, revealed the resident was [AGE] years old female and an original admission date of 07/02/2021 and re-admission date of 02/15/2022 with diagnoses that included: Alzheimer's disease (damages memory and thinking skills), hypertension (high blood pressure), muscle wasting and atrophy (muscles to decrease in size and strength), dysphagia (swallowing difficulties), and cardiac arrhythmia (irregular heartbeat). Record review of Resident #63's quarterly MDS assessment with an ARD of 07/26/2024 reflected the resident scored an 00 on her BIMS which signified the resident had severe cognitive impairment, and the resident needed to have substantial/maximal assistance (helper dose more than half the effort) to eating, shower/bathing, and dressing, but not attempted due to medical condition or safety concern to toilet and sit to stand transfer. Record review of Resident #63's physician orders, dated 07/20/2024, reflected Albuterol Sulfate Nebulization Solution 2.5 mg/0.5 ml one (1) application inhale orally via nebulizer every 4 hours as needed for congestion. Observation on 09/08/2024 at 10:22 a.m. revealed Resident #63's nebulizer was on the nightstand connected to tubing and mask. The tubing and mask were covered in a plastic bag. The mask was dated on 07/21/2024. Observation and interview on 09/08/2024 at 10:28 a.m. with LVN-AI, revealed she saw Resident #63's tubing and mask and acknowledged the tubing and mask connected to Resident #63's nebulizer were covered in a plastic bag, and the mask was dated on 07/21/2024. LVN-AI stated Resident #63 sometimes used the nebulizer and mask for breathing treatments. LVN-AI stated, per the facility policy, nurses should have changed the tubing and mask for breathing treatments weekly, and LVN-AI did not know why nurses did not change them weekly. The potential harm was Resident #63 might have respiratory infection due to old tubing and mask. Interview on 09/09/2024 at 5:26 p.m. with the DON revealed facility nurses should have changed Resident #63's tubing and mask for breathing treatment weekly. The potential harm was the resident could have respiratory infection. Record review of the facility's policy, titled Small Volume Nebulizer, undated, reflected . 10. Assemble small volume nebulizer and label with the date the nebulizer was set up. Nebulizers are to be changed after 7 days of use.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: The facility failed to ensure three packets of bread, observed in the freezer on 09/08/2024, were labeled and dated, and that one of packets was not opened in the freezer because the plastic bag was torn. This failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 09/08/2024 at 9:59 a.m. in the kitchen revealed there was one freezer in the dry storage room, and inside the freezer there were three packets of bread. Two packets were covered in plastic bags but not labeled and dated. The other packet was French toasted bread, covered in a plastic bag, but the packet was opened because the plastic bag was torn. The packet of French toasted bread was also not labeled and dated. Interview on 09/08/2024 at 10:01 a.m., Kitchen Supervisor-N saw the three packets of bread inside the freezer located in the dry storage room and acknowledged the three packets of bread were not labeled and dated, and the French toasted bread was opened in the freezer because the plastic bag was torn. The kitchen supervisor stated she did not know when they were opened, and the staff should have labeled and dated on the packets and changed the torn plastic bag to new one to prevent food infection. Interview on 09/10/2024 at 12:40 p.m. with Registered Dietitian-Y revealed kitchen staff should have labeled and dated on the packets and changed the broken plastic bag to a new one for food safety. The potential harm was residents might have gotten food poison. Record review of the facility's policy, titled Food Storage, date revised 06/01/2019, revealed To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes and HACCP guidelines, and Freezer . e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, 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 disease and infection for 2 of 6 residents (Residents #83 and #63) reviewed for infection control, in that: 1. The facility failed to ensure CNA AD used the proper technique to sanitize her hands while providing incontinent care for Resident #83. 2. The facility failed to ensure CNA-AD and CNA-AE wore a gown while performing incontinent care for Resident #63 who was on EBP (Enhanced Barrier Precautions) on 09/10/2024. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: 1. Record review of Resident #83's face sheet, dated 09/10/2024, revealed an admission date of 01/17/2024 and, a readmission date of 06/21/2024 with diagnoses which included: Dementia (decline in cognitive abilities), Epilepsy (Neurological disorder characterized by seizures) and History of traumatic brain injury (Injury to the brain caused by an external force). Record review of Resident #83's Quarterly MDS assessment, dated 07/05/2024, revealed Resident #83 had a BIMS score of 7, which indicated severe cognitive impairment. Resident #83 was indicated to always be incontinent of bowel and bladder. He required extensive assistance with his ADLs. Record review of Resident #83's care plan, dated 07/24/2024, revealed a problem of SKIN INTEGRITY: The resident is at risk for impaired skin integrity related to:Braden score indicating moderate risk, liver d disease, incontinence of bowel and bladder, with a goal of The resident will remain free from alterations in skin integrity. Observation on 09/10/2024 at 11:00 a.m. revealed while providing incontinent care for Resident #83 CNA AD changed her gloves and used sanitizer but did not rub the sanitizer between her fingers. During an interview on 09/10/2024 at 11:10 a.m. CNA AD confirmed she should have rub the sanitizer between her fingers to sanitize the entire surface of her hands. She forgot. She confirmed receiving infection control and hand washing training within the year During an interview with the DON on 09/10/2024 at 11:20 a.m., the DON confirmed that the correct technique to use sanitizer was to sanitize the whole hand, including between the fingers. The DON revealed improper hand hygiene could present a risk of infection by cross contamination for the residents. The facility was doing annual infection control and incontinent care training and annual skills checks. Review of facility policy, titled Hand Hygiene, dated 10/24/2022, revealed Hand hygiene technique when using an alcohol-based hand rub: a. Apply to palm of one hand the amount of product recommended by the manufacturer. b. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. c. This should take about 20 seconds. 2. Record review of Resident '63's face sheet, dated 09/09/2024, revealed the resident was [AGE] years old female and an original admission date of 07/02/2021 and re-admission date of 02/15/2022 with diagnoses that included: Alzheimer's disease (damages memory and thinking skills), hypertension (high blood pressure), muscle wasting and atrophy (muscles to decrease in size and strength), dysphagia (swallowing difficulties), and cardiac arrhythmia (irregular heartbeat). Record review of Resident #63's quarterly MDS assessment with an ARD of 07/26/2024 reflected the resident scored a 00 on her BIMS which signified the resident had severe cognitive impairment, and the resident needed to have substantial/maximal assistance (helper does more than half the effort) for eating, showering/bathing, and dressing, but not attempted due to medical condition or safety concern to toilet and sit to stand transfer. Record review of Resident #63's care plan, date initiated 07/16/2021, revealed problem: the resident has bladder incontinence related to Alzheimer's disease, and intervention: Brief use - the resident uses disposable briefs. Change every 2 hours and as needed. Observation on 09/10/2024 at 8:42 a.m. indicated there was a sign on the door of Resident #63's room, and the sign said Gown and gloves only for high- contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care) and observed a container with three compartments for gown and gloves in front of Resident #63's room. Observation on 09/10/2024 at 8:43 a.m. indicated CNA-AD and CNA-AE put on only gloves after washing their hands, entered to Resident #63's room, and provided incontinent care to Resident #63 without putting on a gown. Interview on 09/10/2024 at 8:58 a.m., CNA-AD and CNA-AE acknowledged they did not put on a gown when they provided incontinent care to Resident #63 and stated they should have put on a gown when providing incontinent care because Resident #63 was on EBP, and incontinent care was one of the high-contact resident care activities. They were nervous so they forgot to put on a gown. The potential harm was Resident #63 could have infections. Interview on 09/10/2024 at 4:20 p.m. with the DON revealed CNA-AD and CNA-AE should have put on a gown when providing incontinent care because Resident #63 was on EBP, and incontinent care was one of the high-contact resident care activities. The potential harm was Resident #63 might be infected. Record review of the facility's policy, titled Enhanced Barrier Precautions, dated 04/05/2024, revealed It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multiple-resistant organisms. Enhanced Barrier Precaution (EBP) refers to an infection control intervention designed to reduce transmission of multiple-resistant organism that employes targeted gown and gloves use during high contact resident care activities. 4. High-contact resident care activities include: F. Changing briefs or assisting with toileting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 6 residents (Resident #6) reviewed for advanced directives in that: Resident #6 did not have advance directives documented in the admission agreement or electronic medical record from the date of admission, [DATE], to discharge date , [DATE]. This deficient practice could affect residents admit to the facility and place them at risk of not having their wishes known, which could delay emergency treatment. Findings included: Review of Resident #6's face sheet dated revealed he was a [AGE] year-old male was admitted into the facility on [DATE] with diagnoses including Alzheimer's Disease. Review of Resident #6's consolidated orders for [DATE] revealed resident had an order for Full Code status, initiated [DATE]. Review of Resident #6's admission care plan, initiated [DATE], revealed the resident had no advanced directives and no advanced directive care planning had been scheduled with the resident's representative. Review of Resident #6's record revealed the resident's representative did not sign the facility admission agreement that discusses advanced directives prior to admission or after the resident's admission to the facility. Interview on [DATE] at 10:22 a.m. with the Admissions Director revealed she met with the resident representative prior to admission and told the representative the admissions packet needed to be completed. She said she did not get the admission agreement signed prior to or during the residents stay at the facility. She said she tries to complete admissions packets with residents or their representatives prior to admission or the day they admit. She said the importance of doing this is so the facility has consent to treat and to establish advanced directives. She stated the company policy is to have admission agreement completed within 24 to 48 hours of admission. She further stated the advanced directive declination page of the admissions agreement is provided to nursing and the facility Social Worker once completed. Interview on [DATE] at 10:40 am with the facility Social Worker revealed an advanced directive discussion was not completed with the resident representative. The Social Worker stated he was on vacation the week the resident admitted , and the resident was discharged prior to his return from vacation. The Social Worker stated the MDS Nurse may be responsible for his duties when he was not at the facility. The Social Worker stated the importance of discussing advanced directives with the resident or their representative was to respect each resident's rights. Furthermore, he stated he has received training on advanced directives from his corporate Social Worker. Interview on [DATE] at 3:00 pm with the facility DON revealed the facility Social Worker and Admissions Director are responsible for discussing advanced directives with the resident or the representative prior to or at the time of admission. He stated the nursing department was notified about a resident's advanced directive preferences from the admission Director or Social Worker. He stated if the Social Worker was not at the facility, one of the nurse managers should address advanced directives. He stated the MDS Nurse just started the week before and acknowledged none of the nurse managers discussed advanced directives with the resident or his representative. Review of the facility's admission policy, revised [DATE], revealed a document titled Facility Internal Patient Self-Determination Checklist Texas . The checklist reflects a list of advanced directive types along with checkboxes for resident has, provided a copy to the facility and would like to obtain. Review of the facility advanced directives care planning policy, revised 08/2007, stated, this facility respects the rights of individuals to make their own end-of-life treatment decisions regarding health care and this facility will document in the resident's clinical record whether the resident has executed an Advance Directive. Copies of executed directives shall be maintained in the resident's clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Residents have the right to formulate an advance directive for 1 of 9 resident (Resident # 73) reviewed for advanced directive in that: The facility failed to have the physician's signature recorded on the Out of Hospital Do Not Resuscitate (OOHDNR), which made the advanced directive invalid. This deficient practice could place residents at risk of not having their wishes known, which could affect whether they receive emergency medical treatment. Findings: Record review of Resident #73 face sheet, dated 08/10/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to the following: cerebral infarction (stroke) due to unspecified to occlusion or stenosis of right middle cerebral artery, acute respiratory failure with hypoxia, type 2 diabetes (high blood sugar), hyperlipidemia (high cholesterol), pneumonia, dysphagia following a cerebral infarction, muscle wasting and atrophy, lack of coordination, and aphasia (loss of ability to understand or express speech, caused by brain damage). Record Review of Resident #73's care plan with a print date of 08/10/2023 revealed a DNR status, additional review of the Resident's chart revealed an incomplete DNR signed on 06/29/2023 by spouse and on 06/30/2023 by two witnesses, (one unidentified in relationship to the Resident and the second signature was that of the Social Services Director. The OOHDNR was not signed by a physician. Record Review of the facility order summary report with a print date of 08/10/2023 revealed an active DNR (Do Not Resuscitate Order) dated 06/29/2023. Interview on 08/10/2023 at 3:57 p.m. with the Social Services Director, revealed the Social Services Director was aware Resident # 73's OOHDNR had not been signed by the physician. The Social Services Director, stated the OOHDNR must be signed by a physician for a OOHDNR to be valid, I was told by the corporate social worker that if we have the family's signature or POA on the OOHDNR form and a doctor's verbal order then the patient is considered a DNR, I present the OOH DNR's to the physician however sometimes it takes a while to get them back even with multiple follow ups requesting the document, it should be signed and in the EHR but it is not. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated 12/2020, accessed 08/22/2023 revealed, Out-of-Hospital Do-Not-Resuscitate Form section D requires the patient's attending physician to sign and date the form, print or type his/her name and give his/her license number. No policy was provided regarding OOHDNR's prior to exit.

Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 or 2 residents (#73). Resident #73's oxygens was administered at 2 Liters Per Minutes instead of 1 Liter Per Minute via nasal cannula as ordered by the physician. This deficient practice could affect 2 residents who received oxygen continuously and result in residents receiving incorrect or inadequate oxygen support and could result in decline in health. The findings were: Record review of Resident #73 face sheet, dated 08/10/2023, revealed the resident was admitted the facility on 06/29/2023 with diagnoses that included but not limited to the following: cerebral infarction due to unspecified to occlusion or stenosis of right middle cerebral artery, acute respiratory failure with hypoxia, type 2 diabetes (high blood sugar), hyperlipidemia (high cholesterol), pneumonia, dysphagia following a cerebral infarction, muscle wasting and atrophy, lack of coordination, and aphasia (loss of ability to understand or express speech, caused by brain damage). Record of review of Resident #72's August 2023 Order Summary Report revealed Resident #73 ordered Oxygen at 1 L in Place Connected, originally ordered on July 25, 2023. Observation on 08/10/2023 at 11:34 a.m. of Resident #73 revealed she was lying in bed with the oxygen concentrator was turned on and was being worn by the Resident while she was lying in the bed oxygen administered at 2 liters per minute instead of 1 liter per minute. Interview and Observation with LVN C at 08/10/2023 at 11:40 a.m. revealed Resident #73 was lying in bed while wearing the nasal canula and utilizing the oxygen at 2 liters per minute. LVN stated, it is my responsibility to make sure the oxygen was set at 1 liter per minute as directed by the doctor's order and it was not at that time. LVN C said she did not think there were any negative consequences for Resident's oxygen being set at 2 liters per minute but would let the DON know to make sure. Interview with Interim DON, on 08/10/2023 at 3:23 p.m., the DON stated, staff made me aware Resident #73 was receiving Oxygen at 2 liters per minute and the physician's order indicated the oxygen was to be administered at 1 liter per minute. The Interim DON, further stated, The physician's order should have been followed but I do not think it had any negative effect on the Resident in my opinion. When asked for a policy during this interview, the Interim DON stated she was not sure if there was a policy for oxygen administration, that is a general nursing practice to follow physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 18 residents (Resident #55 and #64) reviewed for infection control practices, in that: During the medication pass, LVN B: -placed clean gloves in her pocket -did not perform hand hygiene prior to care and between glove changes -did not sanitize the digital wrist blood pressure cuff between resident use These failures could place residents at risk for infection, transmission for communicable diseases and/or a decline in health. The findings included: 1. Record review of Resident # 55's face sheet, dated 8/11/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included muscle wasting and atrophy (wasting or thinning of muscle mass), hypertension (high blood pressure), hyperlipidemia (elevated cholesterol) and gastrostomy status (a tube inserted through the wall of the stomach; can be used to give drugs and liquids.). Record review of Resident #55's most recent quarterly MDS assessment, dated 6/29/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and required a feeding tube. Record review of Resident #55's comprehensive care plan, revision date 8/9/23 revealed the resident had impaired tissue perfusion (lack of oxygenated blood flow to areas of the body) related to hypertension with interventions that included to administer anti-hypertensive medications as ordered and to monitor for side effects of medication and the resident was at risk for narrowing of arteries related to hyperlipidemia with interventions that included to give all cardiac medications as ordered by the physician and to monitor blood pressure. 2. Record review of Resident #64's face sheet, dated 8/11/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hyperlipidemia (elevated cholesterol), hypertension (high blood pressure), muscle wasting and lack of coordination. Record review of Resident #64's most recent quarterly MDS assessment, dated 5/9/23 revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #64's comprehensive care plan, revision date 5/16/23 revealed the resident had hypertension related to lifestyle choices with interventions that included to administer anti-hypertensive medications as ordered and to monitor for side effects and effectiveness. Observation on 8/10/23 at 7:24 a.m., during the medication pass revealed LVN B took a digital wrist blood pressure cuff from the medication cart and took several disposable gloves from the glove box and placed the gloves in her pocket. LVN B then went into Resident #55's room, took out a pair of gloves from her pocket and put them on without performing hand hygiene. LVN B then obtained Resident #55's blood pressure with the digital wrist blood pressure cuff. LVN B, after obtaining Resident #55's blood pressure and after checking Resident #55's feeding tube, washed her hands and returned to the medication cart. LVN B then prepared Resident #55's medications by crushing each medication and returned to Resident #55's bedside. LVN B then removed a pair of gloves from her pocket and put them on without performing hand hygiene. LVN B, after completing medication pass to Resident #55 was summoned to Resident #64's room because the resident had been complaining of pain. LVN B took the digital wrist blood pressure cuff used on Resident #55, did not sanitize the digital wrist blood pressure cuff, and obtained Resident #64's blood pressure. During an interview on 8/10/23 at 10:46 a.m., LVN B revealed the digital wrist blood pressure cuff was her own personal blood pressure cuff and the only one used during the shift. LVN B revealed she realized after she was made aware by the surveyor that she had not been performing hand hygiene between glove changes and putting the gloves in her pocket could potentially result in cross contamination and was considered an infection control issue. LVN B stated, it is cross contamination, and the resident could get sick. LVN B revealed she had forgotten to sanitize the digital wrist blood pressure cuff between Resident #55 and Resident #64 and stated, that is also cross contamination, and I could be passing an infection from one resident to the other. During an interview on 8/10/23 at 3:43 p.m., the Interim DON revealed, staff must wash or sanitize hands between glove changes because you don't know what's in your hands and what if that glove breaks. What if you coughed in your hand, your hands brushed up against something and it could be passed to the resident and cause them to become ill. The Agency DON revealed it was not good nursing practice to place gloves in pockets. The Agency DON revealed, no hand hygiene between gloves changes, putting gloves in pockets and not sanitizing the blood pressure cuff between residents was considered an infection control issue and cross contamination. Record review of the competency training for LVN B, dated 5/2/23 revealed LVN B had satisfied the requirements for hand hygiene and infection control procedures. Record review of the facility policy and procedure titled, Hand Hygiene, date implemented 10/24/22 revealed in part, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .This applies to all staff working in all locations within the facility .Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub .The use of gloves does not replace hand hygiene .If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Record review of the facility policy and procedure titled, Infection Prevention and Control Program, date implemented 5/13/23 revealed in part, .This facility has established and maintains 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 as per accepted national standards and guidelines .All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services .All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment .

Based on interview and record review, the facility failed to ensure that its activities program was directed by a qualified professional. The Activity Director was not currently qualified to direct the activities program. This failure could result in not meeting the assessed activity needs of each resident. The findings were: Review of the staff roster on 08/11/2022 revealed the current Activity Directors hire date was 09/25/2015. Interview on 08/11/2023 at 03:25 p.m. with the Activity Director revealed the Activity Director had been in the current position since January 2022, stating I was the Activity Assistant before, when the Activity Director left I took over the position. The Activity Director stated, I am not a certified Activity Director, I haven't had any classes, they haven't ever told me that I need a certificate or anything, I do good at my job, and I don't think I need any training . The Activity Director further stated, if I need help I just as the Regional Nurse. Interview on 08/11/2023 at 03:29 p.m. the Interim Administrator stated, the facility does not have a certified activity director, I am aware it is a deficiency. The Interim Administrator further stated, I have been here a short period and I was unaware the Activity Director was not certified, I am aware that is a requirement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #44) reviewed for dialysis in that: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #44. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings were: Record review of Resident #44's face sheet, dated 8/11/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] and 7/17/23 with diagnoses that included hypoglycemia (low blood sugar), hyperlipidemia (elevated cholesterol), cognitive communication deficit, end stage renal disease (condition in which the kidneys cease functioning on a permanent basis) and dependence on renal dialysis. Record review of Resident #44's most recent admission MDS assessment, dated 7/19/23 revealed the resident was severely cognitively impaired for daily decision-making skills and required dialysis treatments. Record review of Resident #44's comprehensive care plan, revision date 7/11/23 revealed the resident had end stage renal disease and was provided dialysis on Tuesday, Thursday, and Saturday. Record review of Resident #44's Order Summary Report, dated 8/11/23 revealed the following: -Dialysis provided Tuesday, Thursday, and Saturday at 6:00 a.m. with order date 7/19/23 and no end date. Record review of Resident #44's Dialysis Communication Form, Resident Assessment and Observation Post-Dialysis revealed incomplete documentation by the facility for 7/20/23, 8/5/23 and 8/8/23. The Post-Dialysis section of the Dialysis Communication form for the aforementioned dates were blank. The facility failed to provide Daily Communication Forms for Resident #44 for the following dates: 7/18/23, 7/22/23, 7/25/23, 7/27/23, 7/29/23, 8/3/23 and 8/10/23 During an interview on 8/11/23 at 10:42 a.m., ADON A revealed Resident #44 received dialysis treatments on Tuesdays, Thursdays, and Saturdays. ADON A further revealed, the facility provided the Dialysis Communication Form to the dialysis clinic and the form was given to the transportation driver or to the resident if the resident was competent. ADON A revealed it was the facility nurse's responsibility to ensure the Dialysis Communication Form's top portion was completed by the facility nurse prior to dialysis and the middle portion was filled out by the dialysis staff. ADON A revealed, after the resident returned from dialysis, the facility nurse was supposed to fill out the bottom portion, Resident Assessment and Observation Post-Dialysis section of the Dialysis Communication Form. ADON A revealed it was important the Dialysis Communication Forms were completed and filed because Resident #44 needed to be monitored for possible adverse effects from dialysis treatments. During an interview on 8/11/23 at 11:01 a.m., LVN B revealed Resident #44 received dialysis treatments on Tuesdays, Thursdays, and Saturdays. LVN B revealed, the facility nursing staff were responsible for completing the top portion of the Dialysis Communication Form, the dialysis clinic staff were responsible for completing the middle portion of the Dialysis Communication Form and upon return to the facility, the facility nurse was supposed to complete the bottom portion, Resident Assessment and Observation Post-Dialysis section of the Dialysis Communication Form. LVN B revealed, once the Dialysis Communication Form was completed, it was placed in a file bin at the nurse's station where the medical records clerk picked it up and uploaded it into the resident's electronic record. During an observation and interview on 8/11/23 at 1:23 p.m., Resident #44 revealed she received dialysis treatments on Tuesdays, Thursdays and Saturdays and had last been to the dialysis clinic on Thursday, 8/10/23. Resident #44 revealed the area on the right upper arm was the access for dialysis treatments. Resident #44 revealed she was not aware of any paperwork when she went to the dialysis clinic. During a follow up interview on 8/11/23 at 1:31 p.m., LVN B revealed she had completed a general assessment of Resident #44 when she returned from her dialysis treatment on Thursday, 8/10/23. LVN B revealed she had obtained Resident #44's vital signs, wrote them down on a piece of paper, but did not document the results in the electronic record. LVN B revealed Resident #44 was provided with the Dialysis Communication Form, but the resident did not come back with the form on 8/10/23. LVN B stated, we were pretty busy, and when Resident #44 came back from dialysis I did the general head to toe (assessment), Resident #44 looked stable and comfortable, then we got real busy and the (Dialysis Communication Form) was overlooked. During an interview on 8/11/23 at 1:43 p.m., the Interim DON revealed it was the expectation of the facility nurses to ensure the Dialysis Communication Forms were completed because we gotta know if something happened to the resident while at dialysis. Record review of the facility policy and procedure titled, Hemodialysis, revision date 7/2015 revealed in part, .Purpose .Hemodialysis devices may only be accessed by the dialysis center by medical personnel who have received training and demonstrated clinical competency regarding use of these devices .Documentation .The general medical nurse should document in the resident's medical record as follows .4. Any pertinent information from dialysis nurse post-dialysis being given .5. Observations post-dialysis .

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, on 5 days during the look back period from April 1, 2023, to August 8, 2023 (99 calendar days). The facility failed to maintain RN coverage on: April 1,2023, April 2, 2023, April 5, 2023, May 12, 2023, and May 13, 2023. This failure could affect all 82 residents of the facility by placing them at risk for not having their nursing and medical needs met. Findings included: Review of the 'Timecard Review (Department Report)' for all of the facility's RNs from 04/01/2023 - 08/08/2023 revealed there was no RN coverage on the following dates: April 1, 2023 April 2, 2023 April 5, 2023 May 12, 2023 May 13, 2023 During an interview on 08/11/2023 at 8:38 a.m. the Interim Administrator stated, I began my employment at this facility on July 13, 2023, I was not here on any of the days reported as not having the required RN coverage, I did check with the Regional Nursing Consultant to make sure she was not in the building and she was not. I have not been able to find any information to support there was an RN in the building for 8 hours on April 2, April 5, or May 13 of 2023. All of the information I have researched shows there was not 8 hours of RN coverage on those days. I am aware that is a requirement, however I do not feel that affected resident care because there were qualified staff in the building and the Regional Consultant was on call for the facility in case, they needed her assistance. Review of the form CMS-672 dated 08/07/2023 revealed a census of 82 residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours if the alleged violation involved abuse to HHSC for 3 of 4 residents (Residents #1, Resident #2, and Resident #3) reviewed for reporting of alleged violations of abuse. The facility failed to report immediately or within 2 hours an allegation of abuse when Resident #1 pulled Resident #3's hair causing her to fall to the ground and hit her head; and when Resident #1 hit Resident #2 on the side of the head with his fist. This failure could place residents at risk for continued abuse, undetected abuse, neglect and/or decline in feelings of safety and well-being. The findings included: 1. Record review of Resident #3's face sheet dated 06/04/2023 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease (progressive form of dementia which affects memory and thinking), high blood pressure, anxiety disorder (significant and uncontrollable feelings of restlessness, irritability) and dementia (decreased blood flow to the brain which affects memory, thinking skills, behavior, and personality). Record review of Resident #3's MDS Quarterly assessment dated [DATE] revealed a BIMS score of 3 (on a scale of 1-15) which indicated her cognitive skills for daily decision making were severely impaired, no behaviors towards others, and was ambulatory without assistance. Record review of Resident #3's Progress Note dated 05/04/2023 at 4:23 p.m. by RN C revealed she was passing by Resident #3's room when she heard a loud scream and a banging noise. Upon entering Resident #3's room she saw Resident #3 on the floor, Resident #1 in the entrance of the room and another male resident (Resident #4) in the room. RN C asked Resident #3 what happened, and Resident #3 stated Resident #1 had pulled her hair causing her to fall on the floor. Resident #3 further stated she was in her bathroom, as she came out of the bathroom Resident #1 pulled her hair until she fell and hit the floor. Resident #3 denied any exchange of words between her and Resident #1. Resident #1 was removed immediately from the area and the nurse assessed Resident #3 for injuries with no signs of trauma and initiated neuro checks. 2. Record review of Resident #2's face sheet dated 06/04/2023 revealed he was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (progressive form of dementia which affects memory and thinking), high blood pressure, anxiety disorder (significant and uncontrollable feelings of restlessness, irritability) and arthritis (joint pain). Record review of Resident #2's MDS Significant Change assessment dated [DATE] revealed a BIMS score of 3 (on a scale of 1-15) which indicated his cognitive skills for daily decision making were severely impaired, no behaviors towards others, required 2-person assistance to transfer from his bed to the wheelchair and could propel himself in the wheelchair. Record review of Resident #2's Progress Note dated 05/31/2023 at 4:39 p.m. by LVN A revealed an unidentified staff member saw Resident #2 on the 400 hallway when another resident [Resident #1] in the hallway started hitting Resident #2 several times in the face and Resident #2 attempted to block the punches. Staff immediately ran to the residents and separated them. A head-to-toe assessment was done on Resident #2 with noted redness to left cheek and ear. Resident #2 denied being in distress and was given pain medication. Resident #2's physician and Responsible Party were notified. Record review of Resident #2's Skin Audit, dated 05/31/2023, revealed redness to the resident's left cheek and ear. 3. Record review of Resident #1's face sheet dated 06/03/2023 revealed he was admitted to the facility 11/16/2022 with diagnoses which included cerebral infarction (stroke), diabetes (chronic elevated blood sugar levels which can damage other organs), vascular dementia (decreased blood flow to the brain which affects memory, thinking skills, behavior, and personality), high blood pressure, hemiplegia, and hemiparesis (partial weakness and paralysis to one side of the body). Record review of Resident #1's MDS Assessment, a Quarterly Assessment, dated 03/23/2023 revealed a BIMs score of 7 (on a scale of 1-15) which indicated his cognitive skills for daily decision making were severely impaired, no behaviors towards others, required assistance of 2 persons with transfer to a wheelchair and he could propel himself in the wheelchair. Record review of Resident #1's Care Plan for the problem area of Resident with physical aggression related to anger, dementia towards another resident with a start date of 03/24/2023 and was revised on 05/04/2023, 05/26/2023, and 05/31/2023. Interventions initiated on 03/23/2023 were moving the resident to a different hall and medication review. Revised interventions initiated on 05/04/2023 included an outside hospitalization for psych evaluation, the resident was placed on one-on-one monitoring upon return to the facility and his medications were reviewed. Revised interventions initiated on 05/26/2023 involved a trial discontinuation of the one-on-one monitoring due to no recent behavior noted. Revised interventions initiated 05/31/2023 were to send the resident to the hospital for a psych evaluation, the local mental health authority was contacted to seek assistance with placing the resident in another facility, and the one-on-one monitoring was resumed due to the resident struck out at another resident. Record review of Resident #1's Critical Behavior Monitoring Logs (one-on-one monitoring) from 05/05/2023 to 05/26/2023 revealed the last time the resident had aggressive behavior was on 05/16/2023 and his behavior was calm from 05/17/2023 to 05/26/2023. Record review of Resident #1 Care Plan Collaboration and Review meeting notes, dated 05/26/2023, revealed an interdisciplinary team meeting was held regarding Resident #1 with no behaviors noted and the one-on-one monitoring would be discontinued on a trial basis with continued monitoring for behaviors. Record review of Resident #1's Progress Note dated 05/31/2023 at 6:05 p.m. by LVN A revealed: Resident was on the hallways and another resident [Resident #2] was passing by, he turned aggressive to the resident and started punching him several times in the face, staff removed them apart. A. Record review of HHSC Form 3613A Provider Investigation Report for Intake #422661 revealed on 05/04/2023 at 4:30 p.m. when the Administrator was walking down the hall, she heard a scream from Resident #3's room. As the Administrator approached the room, Resident #1 was observed wheeling himself out of the room. As the Administrator walked into the room she saw Resident #3 on the floor with RN C next to the resident and a male resident (Resident #4) in the middle of the room in a wheelchair. Resident #4 was redirected to his room and the nurse assessed Resident #3 with no injuries noted. Resident #3 stated Resident #1 had pulled her to the floor by her hair. The residents' physician and responsible parties were notified. Resident #1's medications were reviewed, and he was placed on one-on-one monitoring. The incident was reported to HHSC on 05/05/2023 at 3:30 p.m., 23 hours later. The undated typed statement from the Social Worker from the facility's investigation revealed he interviewed Resident #1 in Spanish immediately after the event on 05/04/2023, asked why the event occurred and Resident #1 stated in Spanish To put her in her place. The Social Worker reinterviewed Resident #1 on 05/05/2023, asked him why the events transpired on 05/04/2023, and Resident #1 stated it was because Resident #3 was speaking to another male resident (Resident #4). During an interview with the Social Worker on 06/02/2023 at 3:45 p.m. he revealed Resident #1 had developed a romantic interest in Resident #3 and would react aggressively when he felt jealous or intimidated. The Social Worker stated Resident #3 had a male resident (Resident #4) who was her friend, in her room visiting. The Social Worker thought the other male resident might have sparked some jealousy in Resident #1 and he grabbed Resident #3 by her hair and pulled her to the ground. During an interview on 06/02/2023 at 4:19 p.m. with Resident #3, with Spanish translation by the Social Worker, revealed Resident #3 stated Resident #1 was well behaved with her and she did not remember the incident with Resident #1. The Social Worker asked her if her hair was pulled which she said it was pulled by Resident #1, but she did not remember what happened. The Social Worker asked Resident #3 if she felt safe in the facility and the resident stated she did. Observation on 06/02/2023 at 4:19 p.m. of Resident #3 revealed she resided on the secured unit, was ambulatory, had long black hair and was well dressed wearing a coordinating skirt, blouse, and hat. During an interview on 06/03/2023 at 7:59 a.m. with RN C revealed Resident #1 was placed on one-on-one monitoring after the incident with Resident #3. During an interview on 06/03/2023 at 9:12 a.m., RN C stated on the day of the incident with Resident #1 and Resident #3, she was in the hallway when she heard a female scream and a thump on the floor. When she entered Resident #3's room she saw Resident #3 on the floor by the foot of her bed, Resident #4 was in the center of the room and Resident #1 was near the door. RN C stated she removed Resident #1 from the room. RN C asked Resident #4 what happened, he stated Resident #3 came out of the bathroom and Resident #1 grabbed Resident #3's long hair and pulled her to the ground. RN C assessed Resident #3 with no injuries noted and the resident did not have any physical complaints or emotional distress after the incident. RN C stated Resident #3 liked to be around Resident #1 and after the incident staff would try to keep them apart. During an interview on 06/03/2023 at 9:35 a.m. with Resident #4, with Spanish translation by MA F, revealed Resident #3 was in her bathroom and he was in Resident #3's room waiting for Resident #3 to come out of the bathroom. While Resident #3 was in the bathroom Resident #1 came by the room and waited for Resident #3 to come out of the bathroom. As Resident #3 walked out of the bathroom, Resident #1 (who was in a wheelchair) grabbed her hair and pulled her down to the floor. In an interview on 06/04/2023 at 11:32 a.m. the Interim DON she was not aware of any problems between Resident #1 and Resident #3 before the incident on 05/04/2023. The Interim [NAME] stated after the 05/04/2023 incident, Resident #1 was placed on one-on-one monitoring which continued until 05/26/2023 when it was decided in an Interdisciplinary Team meeting to stop the one-on-one monitoring on a trial basis because there was no further outburst toward other residents. The Interim DON stated the facility continued to monitor Resident #1's behavior after the one-on-one monitoring was stopped. The Interim DON stated Resident #1 was very pleasant to talk with, but he could be very possessive and protective about Resident #3. During an interview on 06/04/2023 from 11:59 a.m. to 12:46 p.m., the Administrator stated she was in her office when she heard a commotion on 05/04/2023 and walked down towards the sound which came from the hall where Resident #3 resided. The Administrator stated she observed Resident #1 in the hallway in his wheelchair. When she entered Resident #3's room, RN C was in the room next to Resident #3 who was on the floor and Resident #4 was in the center of the room. Resident #3 was assessed for injuries with none noted and she refused to go to the hospital for further evaluation. The Administrator stated she asked Resident #1 in Spanish why he pulled Resident #3's hair until she fell, and he stated in Spanish that he was upset that Resident #3 allowed another man (Resident #4) to be in her room. Resident #1 was sent to the hospital for a psych evaluation and was placed on one-on-monitoring when he returned. The Administrator stated the one-on-one monitoring continued until 05/26/2023, when the Interdisciplinary Team decided to stop the one-on-one monitoring on a trial basis, and continued to monitor Resident #1's behavior which there was none until the incident on 05/31/2023 with Resident #1 and Resident #2. During an interview on 06/04/2023 at 2:27 p.m., the Administrator stated the incident between Resident #1 and Resident #3 was reported to HHSC within 24 hours instead of 2 hours because she considered it to be a behavior and not abuse, and Resident #3 did not have any injuries or bruising noted. The Administrator stated she could not think of any harm that could happen to a resident by not reporting the incident to HHSC within 2-hours of the incident and stated the facility started their internal investigation right away. B. Record review of the facility's confirmation email dated 06/01/2023 at 4:19 p.m., from TULIP (the state website to notify HHSC of incident) to the Administrator revealed HHSC received information on the self-report for the 05/31/2023 incident between Resident #1 and Resident #2, 24 hours after the event; and the intake number for the self-report was #427905. Record review of the facility's partially completed investigation for Intake #427905 revealed a typed, undated/untitled summary page that indicated on 05/31/2023, the DOR observed Resident #1 and Resident #2 exchanged words followed by Resident #1 hit Resident #2. The DOR attempted to stop the incident but was unsuccessful, called for help and was assisted by the Medical Records Clerk in separating the residents. When Resident #1 was asked what had occurred, he stated no one was going to take his woman from him so he proceeded to punch Resident #2. When Resident #2 was asked what happened, he said Resident #1 told him No one was going to take his woman and then Resident #1 hit him. Both residents' physicians were notified, Resident #2's responsible party was notified, Resident #1 was his own responsible party. Both residents were assessed for injuries. Resident #1 was sent to the hospital for further evaluation, the local mental health authority was notified, and the police were contacted. The undated typed statement from the Medical Record Clerk revealed on 05/31/2023 at around 4:30 [p.m.] the Medical Records Clerk was in the Administrator's office when she heard a staff member yell for help. She ran towards the sound and saw Resident #1 hitting Resident #2 on his face and assisted the DOR with separating the two residents. During an interview with the Social Worker on 06/02/2023 at 3:45 p.m. he revealed he thought the incident that occurred on 05/31/2023 with Resident #1 and Resident #2 was related to Resident #3. The Social Worker stated Resident #1 was on the hall where Resident #3 resided looking for her when he saw Resident #2 on the same hall near her room. Resident #1 reacted stating that no one was going to take his woman to Resident #2, and he struck Resident #2 which was witness by the DOR. After the incident Resident #1 was placed back on one-on-one monitoring and the facility was seeking another facility to transfer him to. During an interview on 06/02/2023 at 4:06 p.m. with Resident #2, with Spanish translation by the Social Worker, the resident stated he had backed up and scrapped his ear. The Social Worker asked Resident #2 in Spanish if he remembered being hit and the resident did not and did not remember the incident in the hallway. The Social Worker asked Resident #2 if he felt safe in the facility and the resident stated he did. Observation on 06/02/2023 at 4:06 p.m. of Resident #2 revealed he was sitting on his bed in a room by himself with a wheelchair by the bed and no visible injuries or redness to his face. During an interview on 06/02/2023 at 4:47 p.m. with Resident #1, with Spanish translation by the Social Worker, the resident stated he had a problem with Resident #2 because the resident would run his mouth a lot and stated Resident #2 hit him first and he returned the hit. Observation on 06/02/2023 at 4:47 p.m. revealed Resident #1 was sitting in a wheelchair in the activity room with slight weakness noted to his left arm and leg. Resident #1 was able to propel himself around in the wheelchair. HA D was monitoring Resident #1 and had papers in his hand. Resident #1 started to propel himself out of the activity area and HA D followed Resident #1. Observation on 06/02/2023 at 5:16 p.m. of Resident #1's room revealed he was the only resident in the room. Observation on 06/03/2023 at 8:08 a.m. of Resident #1 revealed he was asleep in bed and in the doorway Receptionist E was sitting in a chair monitoring the resident. During an interview on 06/03/2023 at 8:10 a.m., Receptionist E stated he was doing one-on-one monitoring of Resident #1. He said every 15 minutes he would record on the monitoring sheets what activity Resident #1 was doing, his location, and what his behavior was. During an interview on 06/03/2023 at 10:00 a.m., Medical Records Clerk stated on 05/31/2023 she was in the administrator's office around 4:30 in the afternoon when she heard someone yelling on the 400 Hall. She ran over to 400 Hall, saw Resident #1 hit Resident #2 on his face with his fist and assisted with separating the two residents along with the DOR. During an interview on 06/03/2023 at 3:41 a.m., DOR stated on 05/31/2023, she had left the therapy gym open and when she returned around 3:30 p.m she found Resident #1 and Resident #3 in the gym. The DOR stated she directed both residents out of the gym and she walked with Resident #3 to her room to ensure she was safe since the DOR was aware of the previous incident with Resident #3 and Resident #1. The DOR stated Resident #1 was not moody at all when she saw him in the gym with Resident #3. The DOR stated around 4:30 p.m. she was coming out of the therapy room near the dining room and saw Resident #1 and Resident #2 raise their upper bodies in a posturing motion, each leaning forward in their wheelchairs. They exchanged words with each other which she could not hear, and Resident #1 appeared to be upset. The DOR stated she yelled for assistance, ran towards Resident #1 and Resident #2 but before she could reach them, Resident #1 struck out at Resident #2. The DOR stated Resident #1 hit Resident #2 several times on his left side of his face and Resident #2 hit Resident #1 twice. The DOR stated she tried to separate the two residents but could not do it by herself, yelled for assistance and the Medical Records Clerk came and assisted her. During an interview on 06/03/2023 at 4:02 p.m., LVN A stated on 05/31/2023 she saw Resident #1 shortly before the incident in his wheelchair heading towards 400 hall and he appeared calm and was not agitated. LVN A stated she did not witness the incident between Resident #1 and Resident #2, but she did assess both residents after the incident with no injuries noted to Resident #1 and Resident #2 had some redness on his left jaw and ear. LVN A stated there had not been any altercations, hostility, or anger between Resident #1 and Resident #2 before the incident on 05/31/2023. During an interview on 06/04/2023 at 11:32 a.m., Interim DON stated on 05/31/2023 she was in the conference room, heard some screams and headed towards the sound. When she arrived on the 400 hall, the DOR and Medical Records Clerk had separated Resident #1 and Resident #2 who were both in wheelchairs and were close to Resident #3's room. The Interim DON stated Resident #1 appeared to be calm like nothing had happened. The Interim DON stated she assessed Resident #2 for injuries with a faint dime-size reddish discoloration on his jaw and the resident stated he was fine. The Interim DON stated the one-on-one monitoring of Resident #1 was restarted after the incident on 05/31/2023 and would continue indefinitely; his medications were reviewed and the facility was looking for placement for Resident #1. During an interview on 06/04/2023 from 11:59 a.m. to 12:46 p.m., the Administrator stated on 05/31/2023 she was in her office, heard a yell, ran over to the hall where the yelling was coming from and saw the DOR holding the back of Resident #1's wheelchair and the Medical Records Clerk was holding the back of Resident #2's wheelchair. The Administrator stated she asked Resident #1 what happened, and he responded in Spanish that no one was going to take his woman away. The Administrator stated Resident #3 was not in the hallway by the two residents but both residents were near Resident #3's room. The Administrator stated Resident #1 might have seen Resident #2 propel himself in the direction of Resident #3's room and might have thought he was going that way. The Administrator stated she asked Resident #2 what happened, and he said in Spanish that Resident #1 stated to him that no one is going to take away my woman. Resident #1 was sent to the hospital for psych evaluation and the local mental health authority was contacted to assist with placement of Resident #1. The administrator stated Resident #1 was placed back on one-on-one monitoring when he returned to the facility which would continue until while the facility searched for another facility to care for Resident #1. The Administrator reported Resident #1 was his own responsible party and the Responsible Party for Resident #2 was notified of the incident along with the residents' physician. Observation on 06/04/2023 at 12:49 p.m. with the Administrator showed the surveyor where the incident between Resident #1 and Resident #2 occurred, which was in middle of the hallway near Resident #3's room. During an interview on 06/04/2023 from 11:59 a.m. to 12:46 p.m., the Administrator stated abuse could be verbal or physical abuse and would be reported to HHSC between 2 to 24 hours after the incident occurred. The Administrator stated she refers to the HHSC provider letter to determine which incidents would be reported within 2 hours such as abuse or neglect incidents. The Administrator stated the incident between Resident #1 and Resident #2 on 05/31/2023 was reported within 24-hours and was not reported within 2-hours because Resident #2 did not have serious bodily injury and Resident #1 had been sent to the hospital for evaluation, so he was not a further threat to Resident #2 or any other resident. The Administrator stated she felt the incident with Resident #1 and Resident #2 was a behavior incident and not abuse because the incident occurred close to Resident #3's room, because there was no serious injury to Resident #2 when Resident #1 struck him, and because of the statement Resident #1 had made, therefore she did not report it within 2 hours. The Administrator stated she was still working on completing the HHSC Form 3613A Provider Investigation Report as it had not yet been five working days from the incident date. During an interview on 06/04/2023 at 2:27 p.m., the Administrator stated she could not think of any harm that could happen to a resident by not reporting the incident to HHSC within 2-hours of the event and stated the facility started their internal investigation right away. Record review of the facility's Abuse, Neglect and Exploitation policy, dated 08/15/2022, revealed 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .VII. Reporting/Response. A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes; a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to review and revise the person-centered comprehensive care plan to reflect the resident's current condition for 1 of 6 residents (Resident #2) reviewed for care plans, in that. The facility failed to update Resident #2's care plan to reflect the resident having an indwelling urinary catheter in place. This deficient practice could place the resident at risk for not receiving appropriate care and intervention to meet their current needs. The findings were: Record review of Resident #2's face sheet, undated, revealed the resident was initially admitted on [DATE], readmitted [DATE] and 4/23/2023. Resident #1 diagnoses included Parkinson's Disease, unspecified intellectual disabilities, atherosclerotic heart disease of native coronary artery without angina pectoris (arteries that deliver blood to the heart can cause chest pain), hyperlipidemia(a condition that incorporates various genetic and acquired disorders that describe elevated lipid levels within the human body.), gastro-esophageal reflux disease without esophagitis(occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of your esophagus.), unspecified dementia,(a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life. )dehydration, protein-calorie malnutrition, cerebral palsy(group of disorders that affect movement and muscle tone or posture.). Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 0 (cognitively impaired-unable to process thoughts). The functional status indicated the resident required total dependence for bed mobility, transfers, dressing, eating, toilet use, and personal care. Bed mobility, transfers, dressing, eating, and toilet use required two or more persons physical assistance and personal hygiene required one person assist. Resident #2's bladder and bowel indicated had always urinary and bowel incontinent . All needs to be anticipated by staff. The MDS did not indicate Resident #2 had an indwelling urinary catheter. Record review of Resident #2's Care Plan, date initiated 4/4/2022 with revision scheduled 5/30/2022, The resident had bladder incontinence r/t cerebral hypoxia (a form of hypoxia (reduced supply of oxygen), specifically involving the brain. The goal reflected: The resident would remain free from skin breakdown due to incontinence and brief use through the review date, date initiated 4/28/2022, revision date: 3/23/2023, target date 6/6/2023. The interventions included brief use: change every 2 hours and as needed. No indication of an indwelling catheter in place . During an observation on 4/26/2023 at 11:20 a.m. of Resident #2 observed she had an indwelling urinary catheter in place. Interview on 04/27/23 at 10:15 a.m. ADON 2 confirmed Resident #2 did not have a care plan for an indwelling urinary catheter. She revealed a care plan should have been added to her electronic medical record care plan when she returned from the hospital on 4/23/2023. During an interview on 4/27/2023 at 2:30 p.m. the Administrator stated, We do not have a specific policy. When a care plan policy was requested.

**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 is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections, based on the resident's comprehensive assessment for 1 of 6 residents (Resident #2) whose records were reviewed. Nursing staff failed to properly place Resident #2's indwelling urinary catheter bag off of the floor while she was in bed. This deficient practice could affect any resident with an indwelling catheter and could result in avoidable UTI's(urinary tract infection) and trauma to the urethra. The findings were: Record review of Resident #2's face sheet, undated, revealed the resident was initially admitted on [DATE] readmitted [DATE] and 4/23/2023. Resident #1 diagnoses included Parkinson's Disease, unspecified intellectual disabilities, atherosclerotic heart disease of native coronary artery without angina pectoris (arteries that deliver blood to the heart can cause chest pain), hyperlipidemia(a condition that incorporates various genetic and acquired disorders that describe elevated lipid levels within the human body.), gastro-esophageal reflux disease without esophagitis(occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of your esophagus.), unspecified dementia,(a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life. )dehydration, protein-calorie malnutrition, cerebral palsy(group of disorders that affect movement and muscle tone or posture.). Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 0 (unable to determine (cognitively impaired-unable to process thoughts). The Functional status indicated the resident required total dependence for bed mobility, transfers, dressing, eating, toilet use, and personal care. Bed mobility, transfers, dressing, eating, and toilet use required two or more persons physical assistance and with personal hygiene required one person assist. Resident #2's bladder and bowel indicated had always urinary and bowel incontinent . All needs to be anticipated by staff. The MDS did not indicate Resident #2 had an indwelling urinary catheter. Record review of Resident #2's Care Plan, date initiated 4/4/2022 with revision scheduled 5/30/2022, The resident had bladder incontinence r/t cerebral hypoxia (a form of hypoxia (reduced supply of oxygen), specifically involving the brain. The goal reflected: The resident will would remain free from skin breakdown due to incontinence and brief use through the review date,. date initiated 4/28/2022, revision date: 3/23/2023, target date 6/6/2023. The interventions included brief use: change every 2 hours and as needed. No indication of an indwelling catheter in place. Observation on 4/27/2023 at 9:50 a.m., revealed Resident #2 was lying in bed. Resident #2 non interviewable. Observation of Residents #2 's indwelling urinary catheter bag revealed it was lying on floor under the bed, along with tubing on floor. During an observation and interview on 4/27/2023 at 11:45 a.m. revealed ADON 1 confirmed Resident #2's indwelling urinary catheter bag was lying on floor under the bed, along with the tubing on the floor. ADON 1 stated the staff should not allow the resident's indwelling urinary catheter bag or tubing to be on the floor. She stated, That is not clean practice, and the resident could get an infection. A request for a policy for indwelling urinary catheters was made on 4/27/2023 at 2:30 p.m. to the Administrator prior to exit from the facility, resulted in the Administrator informing the surveyor that there was not a policy. She stated, We should be following infection control practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that a resident needs respiratory care, is provided such care, consistent with professional standards of practice for 2 of 6 residents (Resident #2 and Resident #5) reviewed for respiratory care in that: Resident #2 and Resident #5's oxygen concentrator bottle's and nasal canula's were not dated. This deficient practice could affect residents who receive oxygen and result in infection and respiratory compromise. The findings were: Record review of Resident #2's face sheet, undated, revealed the resident was initially admitted on [DATE] readmitted [DATE] and 4/23/2023. Resident #1 diagnoses included Parkinson's Disease, unspecified intellectual disabilities, atherosclerotic heart disease of native coronary artery without angina pectoris (arteries that deliver blood to the heart can cause chest pain), hyperlipidemia(a condition that incorporates various genetic and acquired disorders that describe elevated lipid levels within the human body.), gastro-esophageal reflux disease without esophagitis(occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of your esophagus.), unspecified dementia, (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life. ) dehydration, protein-calorie malnutrition, cerebral palsy(group of disorders that affect movement and muscle tone or posture.). Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 0(cognitively impaired-unable to process thoughts). The functional status indicated the resident required total dependence for bed mobility, transfers, dressing, eating, toilet use, and personal care. Bed mobility, transfers, dressing, eating, and toilet use required two or more persons physical assistance and personal hygiene required one person assist. Resident #2's bladder and bowel indicated had urinary and bowel incontinent. All needs to be anticipated by staff. The MDS did not indicate Resident #2 had an indwelling urinary catheter. Oxygen use. Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 0 (unable to determine). Functional status indicated resident required total dependence for bed mobility, transfer, dressing, eating, toilet use, and personal care. Bed mobility, transfers, dressing, eating, and toilet use required two or more persons physical assistance with personal hygiene required one person assist. Bladder and bowel indicated always urinary and bowel incontinent. All needs to be anticipated by staff. No documentation for oxygen use. Record review of Resident #2's physician's orders dated 4/26/2023 revealed O2 @ 2L/Min via NC (nasal canula) for shortness of breath related to hypoxia. (loss of oxygen to brain) Record review of Resident #2's Care Plan, date initiated 4/27/2023 did not have oxygen usage on the current care plan. Observation on 4/27/2023 at 9:50 a.m., revealed Resident #2 was lying in bed. The resident was non interviewable. Resident #2 had a nasal canula with oxygen at 2 lpm on. Resident #2's oxygen concentrator water bottle and nasal canula were not dated. During an interview on 4/27/2023 at 12:00 p.m. ADON 1 confirmed Resident #2's oxygen concentrator water bottle and nasal canula did not have a date on it, indicating when it had been opened or placed. ADON 1 stated the oxygen bottles and nasal cannulas should have a date written on them to indicate when they were opened. ADON 1 further revealed night shift change the oxygen bottles and nasal cannulas weekly on Sundays or when they are empty or dirty, and the date is to be written on the bottles and nasal cannulas. ADON 1 further revealed this is to prevent infection or bacteria build up. Record review of Resident #5's face sheet computer dated 4/27/2023 with an original admission date of 11/16/2018 and an updated admission date of 3/19/2023 with diagnoses to include epilepsy, anoxic brain damage (damage to the brain caused by lack of oxygen), acute and chronic respiratory failure with hypoxia, and tracheostomy (a small surgical opening that is made through the front of the neck into the windpipe, or trachea). Record review of Resident #5's care plan date initiated 4/6/2021 updated 3/30/2023 Problem The resident has a tracheostomy of risk for hypoxia. Goal the resident will have clear and equal breath sounds bilaterally through the review date. The resident will have no signs and symptoms of infection through the review date. Interventions: Apply oxygen at 2 liters per minute for oxygen saturations below 90%. Use universal precautions as indicated. Record review of Resident #5's Quarterly MDS dated [DATE], revealed Resident #5's BIMS score was 00 indicating severe cognitive impairment. Further record review of Quarterly MDS section O, documentation of oxygen use. Observation on 4/27/23 11:25 a.m. revealed Resident #5 was lying in bed. Oxygen tubing was connected to a nebulizer device with no date on it, to indicate when it had been changed. During an interview and observation on 4/27/2023 at 10:20 a.m. revealed ADON 1 confirmed Resident #5's oxygen tubing was connected to a nebulizer device with no date on it, to indicate when it had been changed. ADON 1 stated the oxygen tubing should have a date written on it to indicate when it was opened. ADON 1 further revealed night shift changes the oxygen tubing weekly. During an interview on 4/27/2023 at 2:40 p.m. with Administrator stated, We do not have a policy for changing or dating the oxygen bottles or nasal cannulas.

Based on observation and interview, the facility failed to ensure in accordance with State and Federal laws, to store all drugs and biological's in locked compartments when not in attendance by staff for 1 of 1 medication rooms observed, in that: The medication storage room at the central nursing station was left unlocked and the door was open and not in attendance by staff. This deficient practice could allow residents access to the main medication room and place them at risk for a drug diversion, mishandling of medication, and or injury to residents. The findings were: During an observation on 4/26/23 at 11:13 a.m. revealed the medication storage room door, located at the central nurse's station, was open, left unlocked and unattended by a staff member. Further observation revealed there were no visible staff at the nurse's station. Further observation revealed the main medication room contained a variety of accessible prescriptions medications, insulin, and stock medications. During an observation and interview on 4/26/2023 at 11:15 a.m. LVN A stated the medication room door should always be locked and the door closed whenever there were no staff present. She stated she did not know why the medication room door was left unlocked and opened. When asked what type of medications were kept in the medication room that could be accessible to residents, LVN A stated, there are multiple medications like stock medications such as aspirin, vitamins, different stomach medications. During an interview with ADON 1 on/4/26/2023 at 12:00 p.m. ADON 1 confirmed the main medication room door had been left unlocked with no staff in attendance. ADON 1 stated she did not know why the door the medication room was left open as it had a lock on the door with a keypad, that when closed should automatically lock. She stated the nurses were the ones who should enter the medication room. She further revealed it was her expectation to have the medication room door closed and locked when a staff member nurse is not in the medication room as residents could go into the medication room and potentially take medication by mouth causing injury. She further revealed the medication room mainly is stocked with vitamins, Tylenol, eye drops, stomach medications like Maalox or medicines for indigestion. A request to the Administrator on 4/27/2023 at 2:30 p.m. for a policy for locking or securing doors resulted in Administrator saying We do not have a policy for locking or securing doors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 each resident for 2 of 3 residents (Resident #1 and #2) reviewed for pharmacy services in that: 1. RN A and LVN B failed to administer Resident #1's insulin as ordered. 2. LVN B failed to administer Resident #2's insulin as ordered. These deficient practices could affect residents who received medications and place them at risk for not receiving a therapeutic effect and could result in a decline in health. The findings were: 1. Record review of Resident #1's face sheet, dated 3/14/23 revealed an [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with diagnoses that included mood disturbance, psychotic disturbance, anxiety, type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), hypertension (high blood pressure) hyperlipidemia (high cholesterol) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks). Record review of Resident #1's comprehensive care plan, revision date 3/9/23 revealed the resident was at risk for alteration in blood sugar levels related to type 2 diabetes with interventions that included diabetes medication as ordered by doctor. Record review of Resident #1's Order Summary Report, dated 3/14/23 revealed the following: -Levemir Solution (insulin) 100 Units/ML (milliliter), inject 15 units subcutaneously one time a day for diabetes with start date 1/21/22 and no end date -Novolin Solution (insulin) 100 Unit/ML, inject as per sliding scale subcutaneously two times a day for diabetes, with additional orders to notify the physician if the blood sugar was less than 60 mg/dl (milligrams/deciliter) or more than 400 mg/dl with order date 1/21/22 and no end date Record review of Resident #1's MAR (medication administration record) for March 2023 revealed the following: -3/2/23 Levemir Solution 100 Unit/ML and the blood sugar levels scheduled at 6:00 a.m. were marked 9=Other / See Progress Notes written by RN A. -3/2/23 Novolin Solution 100 Unit/ML and the blood sugar levels scheduled at 6:00 a.m. were marked 9=Other / See Progress Notes written by RN A. -3/2/23 Novolin Solution 100 Unit/ML and the blood sugar levels scheduled at 4:00 p.m. were marked NA under BS (blood sugar) and 9=Other / See Progress Notes written by LVN B. Record review of Resident #1's progress note dated 3/2/23 at 5:49 a.m. written by RN A revealed, Supplies unavailable to perform blood glucose check. Record review of the progress note dated 3/2/23 at 5:29 p.m. written by LVN B revealed, unable to do accu check on resident and unable to administer insulin due to not having correct glucose strips for glucometer. An attempt at an interview on 3/14/23 at 10:29 a.m. of Resident #1 was unsuccessful as the resident was not interviewable and appeared pleasantly confused. 2. Record review of Resident #2's face sheet, dated 3/15/23 revealed a [AGE] year old male admitted on [DATE] and re-admitted on [DATE] and 6/19/22 with diagnoses that included type 2 diabetes, peripheral vascular disease (a slow and progressive circulation disorder, narrowing, blockage, or spasms in a blood vessel), acquired absence of left leg below knee, hypertension (high blood pressure), hyperlipidemia (high cholesterol), heart disease and long-term current use of insulin. Record review of Resident #2's most recent comprehensive MDS assessment, dated 1/20/23 revealed the resident was cognitively intact for daily decision-making skills and was diagnosed with type 2 diabetes and was treated with insulin injections 7 times during the last 7 days or since admission/entry or reentry if less than 7 days. Record review of Resident #2's comprehensive care plan, revision date 2/10/23 revealed the resident was at risk for hyperglycemia (high blood sugar)/hypoglycemia (low blood sugar) related to diabetes with interventions that included to administer medications as ordered by the doctor and glucose monitoring. Record review of Resident #2's Order Summary Report, dated 3/15/23 revealed the following: -Humalog Solution 100 Unit/ML inject as per sliding scale subcutaneously two times a day related to type 2 diabetes with additional order to notify the physician if the blood sugar was less than 60 mg/dl or more than 401 mg/dl with order date 8/4/22 and no end date. Record review of Resident #2's MAR for March 2023 revealed the following: -3/2/23 Humalog Solution 100 Unit/ML and the blood sugar levels scheduled for 6:30 a.m. were marked NA under BS and 9=Other/See Progress Notes written by LVN B. Record review Resident #2's progress note dated 3/2/23 at 7:18 a.m. written by LVN B revealed, unable to check glucose due to not having glucose strips. During an interview on 3/14/23 at 12:50 p.m., Resident #2 stated he received insulin injections 3 times a day and each time he received an insulin the nurses did an accu check. Resident #2 stated he recalled an unknown male nurse told him, about a week ago that he could not have an accu check because there were no supplies and since the accu check could not be obtained Resident #2 could not get the prescribed insulin. Resident #2 stated he understood, I would not be able to get my insulin because you would need to know what my sugar level was. Resident #2 stated, I did not feel sick or get sick from not getting the insulin. During an observation and interview on 3/14/23 at 2:21 p.m., the DON stated, if a resident did not receive a medication, the electronic MAR would prompt you to enter a code and forces you to write a progress note and provide an explanation. The DON stated the code 9 indicated either the medication was refused by the resident, or the medication was not administered for some reason or other. The DON stated she had been out of the facility due to personal reasons for about two weeks and only returned to work on 3/14/23. The DON stated the nursing staff were not provided with the access code to get into the supply room because of issues with missing supplies in the past. The DON stated she recalled receiving a phone call from RN A about not having any test strips for the accu check. The DON stated she had assumed RN A had found the test strips in the supply room because RN A never called her back. The DON stated, the ADON was in charge of keeping supplies stocked for the nurses but left on vacation the day after the DON was out, meaning there were no nursing staff in charge of ensuring the staff were being provided with supplies. The DON stated, regardless, nursing staff could call me if they needed anything. The DON stated, residents who did not get their scheduled medications could affect the resident in a negative way, such as Resident #1 and Resident #2 not receiving the scheduled insulin could result in hypoglycemia or hyperglycemia. During an interview on 3/14/23 at 3:35 p.m., the Administrator stated she had been in charge of ordering supplies because the central supply person no longer worked for the facility as of 1/23/23. The Administrator stated the facility had not run out of supplies because she was assuming that responsibility. An attempt at an interview with RN A on 3/14/23 at 4:14 p.m. and 3/15/23 at 8:55 p.m. was unsuccessful. LVN B was no longer employed by the facility. Record review of the facility's policy and procedure titled, Medication Administration, dated 10/24/22 revealed in part, .Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice .

**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 meets professional standard of quality care for 1 (Resident #118) of 13 residents reviewed for baseline care plans in that: Resident #118's breathing treatments were not reflected in his baseline care plan. This deficient practice could affect newly admitted residents and could result in missed care. The findings included: Review of Resident #118's electronic face sheet dated 6/23/22 revealed he was admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia (lung problems affecting breathing with low oxygen levels in blood). Review of Resident #118's Initial Baseline/Advanced Care Plan dated 6/10/22 revealed it did not reflect Resident #118's respiratory issues or physician ordered breathing treatments. Review of Resident #118's physician orders dated 6/23/22 revealed the resident was to receive Levalbuterol HCl Nebulization Solution (medicine that relaxes muscles in the airways to increase air flow to the lungs)0.63 MG/3 ML 1 dose inhale orally via nebulizer four times a day for acute respiratory-Start Date-06/10/2022 1600 (4PM). FAILURE Review of Resident #118's MAR for June 2022 revealed Levalbuterol HCl Nebulization Solution 0.63 MG/3 ML 1 dose inhale orally via nebulizer four times a day for acute respiratory failure -Start Date-06/10/2022 1600 (4PM) Resident #118's first dose of Levalbuterol was given on 6/11/22 at 08:00 a.m. Observation and interview on 6/21/22 at 10:00 p.m., Resident #118 revealed he was lying in his bed. His family member was at the bedside and stated he was not interviewable. A nebulizer machine (device for producing a fine spray of liquid used for inhaling a medicinal drug) and mask were at his bedside. Interview on 6/21/22 at 10:10 p.m., with Resident #118's family member revealed Resident #118 had just received his breathing treatment and was ordered to have them four times a day. Interview on 6/24/22 at 08:00 a.m., the DON stated the regional MDS person was doing the MDS's and care plans. She stated Resident #118's respiratory condition and his need for breathing treatments should have been in his baseline care plan. She stated it was important for the nursing staff to have a good idea of the resident needs, even in the first 48 hours. She stated she did not know how the nurse missed it in her assessment and it did not appear on the company form. The DON said the form provided enough room for all the resident's needs to be addressed. She stated a regular care plan form could have been initiated as a continuation of the baseline form to address the resident's needs. Interview on 6/24/22 at 08:10 a.m., the RMC revealed he would address the issue of the baseline care plan. He stated Resident #118's respiratory status and treatments ordered at the time of admission needed to be address to make sure he had the required and necessary care. Review of the facility's policy and procedure, Care Planning revised November 2017 revealed 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for 2 (Residents #11 and #14) of 16 residents reviewed for comprehensive care plans in that: 1. Resident #11's comprehensive person-centered care plan inaccurately reflected she had an in-dwelling urinary catheter. 2. Resident #14's comprehensive person-centered care plan did not reflect her grip spoon or two handled cups required to assist her in eating. These deficient practices could affect residents with specific care needs and could result in missed care. The findings included: 1. Review of Resident #11's electronic face sheet dated 6/23/22 revealed she was admitted to the facility on [DATE] with diagnoses of fracture of the left femur (broken left thigh bone), dementia (cognitive impairment), psychotic (mental disorder with disturbance of thought) and anxiety disorder (nervousness), schizophrenia (bipolar mental disorder) and dysphagia (problem swallowing). Review of Resident #11's significant change MDS dated [DATE] revealed she scored a 5/15 on her BIMS which indicated she was moderately cognitively impaired. She had a catheter, and was always incontinent of bowel. She required extensive assistance with her ADL's and care. Review of Resident #11's physician orders dated April 2022 revealed her indwelling urinary catheter was discontinued on 4/5/22. Review of Resident #11's comprehensive person-centered care plan revised on 4/27/22 revealed under Problem .has 16 FR 10 ML indwelling catheter. Observation on 6/21/22 at 11:00 a.m., Resident #11 was in her room on her bed, and she did not have an indwelling urinary catheter. She was not interviewable. 2. Review of Resident #14's electronic face sheet dated 6/21/22 revealed she was admitted to the facility on [DATE] with diagnoses of anemia (low red blood cells), kidney failure, hypothyroidism (thyroid gland disorder, not enough thyroxin), and dysphagia (difficulty swallowing). Review of Resident #14's quarterly MDS dated [DATE] revealed she scored a 5/15 on her BIMS which indicated she was severely cognitively impaired. She required extensive assistance with her ADL's and she had not had any weight loss. Review of Resident #14's physician orders dated 6/24/22 revealed she was ordered a regular diet, pureed texture, fortified foods, 2 handle cups with all meals, grip spoon (spoon with a heavier handle) and a start date of 4/5/22. Review of Resident #14's comprehensive person-centered care plan revised dated 3/25/22 revealed Problem .resident is at risk for imbalance nutrition less than body requires r/t dementia. The residents two handled cup and grip spoon were not reflected in the care plan. Review of Resident #14's lunch meal ticket revealed grip spoon with all meals. Observation on 6/21/22 at 12:40 p.m., Resident #14 revealed she had a two handled cup and 2 large spoons with her tray at lunch time. Staff assisted her on and off with feeding. Interview on 6/21/22 at 12:44 p.m., CNA A fixed Resident #14's lunch tray revealed he did not notice she did not have a spoon with a grip handle. He stated often the kitchen will send only a regular spoon. He stated it was important for her to have a grip handle to help her to comfortably hold the spoon and to eat. He stated he should have mentioned it to the nurse but he didn't. Interview on 6/21/22 at 12:46 p.m. with RN B who supervised the secure unit lunch meal stated they often will not have the spoon with the grip handle .we help her if she needs assistance .I should have told the kitchen but did not. She stated she realized it was important for Resident #14 to keep her functioning as much as possible and to eat independently with minor cueing. She stated it should also be in her comprehensive person-centered care plan. Interview on 6/24/22 at 08:00 a.m., the DON revealed the regional MDS person was doing the MDS's and care plans. She stated Resident #11's indwelling urinary catheter should have been taken out when the care plan was revised on 4/27/22 and Resident #14's two handled cup and spoon with a grip handle needed to be in her care plan during the last revision. She stated that it was important for the nursing staff to have a good idea of the resident's needs. Interview on 6/24/22 at 08:10 a.m. with the RMC revealed that Resident #11's care plan should have been revised on 4/27/22 to remove the indwelling urinary catheter because it was removed on 4/5/22. He stated Resident #14's adaptive equipment, the two handled cup and grip handled spoon needed to be in her comprehensive person-centered care plan. He stated it was important to show and to communicate with the nursing staff what needs the residents have so they get the care they require. Review of the facility's policy and procedure, Care Planning revised November 2017 revealed A comprehensive, person-centered care plan is developed and implemented for each resident to meet the resident's physical, psychosocial and functional needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility must 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 for 2 residents (#10 and #117) out of 4 residents reviewed for respiratory therapy in that, 1. Resident #10's nasal cannula and tubing were looped over the concentrator hanging to the floor not bagged. 2. Resident #117's oxygen concentrator filter on both sides of the unit were both covered with dust. These deficient practices could affect residents on respiratory therapy at risk of infection and the lack of oxygen or infiltration of the lungs. The findings were: 1. Record review of Resident #10's face sheet, dated 06/23/2022, revealed the resident was admitted [DATE] with diagnoses that included: chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs), acquired absence of lung (part of). Record review of Resident #10's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 05 which indicated severe cognitive impairment. Record review of Resident #10's care plan initiated on 11/10/2020 and revised 05/12/2022 revealed a care plan for Problem Resident is at risk for fluid volume overload r/t CHF Interventions O2 as per md orders. Record review of Resident #10's physician's order summary dated 06/23/2022 revealed O2 at 4L/min Via NC prn for shortness of breath, as needed for shortness of breath related to chronic obstructive pulmonary disease and oxygen saturation check every shift for hypoxia. During observation on 06/21/2022 at 11:27 a.m. revealed Resident #10's tubing not bagged at bedside while not being used. During observation and interview on 06/23/2022 at 3:41 p.m. revealed Resident #10's concentrator at bed side with tubing and nasal cannula was not bagged and hanging down the front of the concentrator with tubing touching the floor. Resident #10 stated she used her oxygen when she felt she needed it and would sleep with it on. During an interview on 06/23/2022 at 3:47 p.m. LVN C stated the tubing and nasal cannula should have been bagged and they usually had a bag on the machine for Resident #10 to place it in however, Resident #10 would remove the bag and throw it away. LVN C further stated tubing was changed on Sundays or when needed. LVN C stated they had educated Resident #10 about placing nasal cannula and tubing in the bag, however due to her memory she would still throw the bag away. 2. Review of Resident #117's electronic face sheet dated 6/23/22 revealed he was admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke affecting the brain), diabetes (inability to regulate blood sugar in the body), morbid obesity (extremely overweight), obstructive sleep apnea (condition where breathing is disrupted during sleep), and legal blindness (loss of vision). Review of Resident #117's admission MDS assessment with an ARD of 6/10/22 revealed he scored a 9/15 on his BIMS which indicated he was moderately cognitively impaired. He required extensive assistance with his ADL's. He was checked off to receive oxygen while a resident. Review of Resident #117's physician orders dated 6/23/22 revealed 02@ 2LPM via nasal annular continuous one time a day for SOB .start date 6/4/22. Review of Resident #117's comprehensive person-centered care plan revised 6/22/22 revealed Problem .resident has oxygen therapy r/t ineffective gas exchange .Interventions .OXYGEN SETTINGS: O 2 via nasal prongs @2LPM. Observation on 6/21/22 at 10:30 a.m. Resident #117 was lying in bed with oxygen being infused via nasal annular, his family member was in the room. His oxygen concentrator was set at 2 L/Min. The oxygen concentrator filter on both sides of the unit was covered with dust. Observation on 6/2322 at 3:00 p.m. Resident #117 was lying in bed with oxygen being infused via nasal annular, his family member was on the other side of the bed talking to the resident in Spanish. The oxygen concentrator was set at 2 L/min and the filter on both sides of the unit was covered with dust. Interview on 6/23/22 at 3:10 p.m. Resident #117 stated he really didn't pay much attention to the oxygen concentrator, and he trusted the nurses to check the unit and he couldn't see very good. Interview on 6/23/22 at 3:20 p.m. LVN C revealed Resident #117's filters need cleaning, I will wash them. When asked if the nurses check them daily, she said they should, and she hadn't checked them. She said it was important to have clean filters on the oxygen concentrator because it could impact the functioning of the machine and delivery of oxygen and a resident would have issues breathing. Interview on 6/24/22 at 08:15 a.m. the DON revealed nurses needed to check oxygen units each shift and to make sure the filters are clean. She stated that it was a professional standard of respiratory care, and to ensure the resident was delivered the proper amount of oxygen. She stated oxygen administration was like a medication and the nurse needed to monitor it and the machine. She said Resident #117's oxygen concentrator filters needed to be cleaned or replaced. The facility had no policy or procedure for respiratory therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that PRN (as needed) orders for psychotropic drugs were limited to 14 days and if the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 of 16 residents (Resident #58) reviewed for unnecessary psychotropic medications. Resident #58 had a PRN order for Xanax (an anti-anxiety medication) for more than 14 days without physician documentation re-evaluating the medication to continue its use PRN. This deficient practice could place residents at risk of receiving unnecessary medications. Findings include: Record review of Resident #58's face sheet, dated 6/22/2022, revealed the resident was initially admitted to the facility on [DATE] with diagnoses which included Asperger's syndrome (a developmental disorder affecting ability to effectively socialize and communicate), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), unspecified intellectual disabilities (a diagnosis reserved for children 5 years of age who could not be assessed due to multiple factors, such as physical disability or co-occurring mental illness) and anxiety disorder. Record review of Resident #58's Physician orders revealed an order dated 5/25/2022 for Ativan Tablet 0.5 mg, give 0.5mg by mouth every 8 hours as needed for anxiety disorder with no stop date. Record review of Resident #58's care plan with an initiation date of 11/12/2019 revealed the resident was at risk for agitation related to anxiety with interventions that included to administer anti-anxiety medications as ordered by physician and to monitor for side effects. Record review of Resident #58's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, severely impaired cognitive status Record review of Resident #58's MAR for June 2022 revealed the Ativan PRN was not given in June 2022. In an interview on 6/23/22 at 2:31 p.m. with the DON confirmed Resident #58 had an order for Ativan 0.5mg every 8 hours as needed. The DON reported the resident was receiving a routine order of Ativan and sometimes the resident requires an extra dose. The DON went on to say she did not believe there was any potential for harm or adverse effects for Resident #58's PRN Ativan that did not have a stop date because the resident was already on routine Ativan. Record review of the facility's policy titled Medication Management, revised 10/1/2019, 1, F, revealed, c. PRN orders for psychotropic drugs are limited to 14 days, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rational in the resident's medical record and indicate the duration for the PRN order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for 1 (Resident #14) of 3 residents reviewed for assistive devices in that: Resident #14 was not provided the grip handled spoon she was ordered to have to eat her meals. This deficient practice could affect residents who required assistive devices to eat their meals and could result in malnutrition and weight loss. The findings were: Review of Resident #14's electronic face sheet dated 6/21/22 revealed she was admitted to the facility on [DATE] with diagnosis of dysphagia (difficulty swallowing). Review of Resident #14's quarterly MDS assessment with an ARD of 4/13/22 revealed she scored a 5/15 on her BIMS which indicated she was moderately cognitively impaired. She required extensive assistance with her ADL's and she had not had any weight loss. Review of Resident #14's Active Orders as of: 6/24/22 revealed she was ordered a regular diet, pureed texture, fortified foods, 2 handle cups with all meals, grip spoon (spoon with a heavier handle) and a start date of 4/522. Review of Resident #14's comprehensive person-centered care plan revised dated 3/25/22 revealed Problem .resident is at risk for imbalance nutrition less than body requires r/t dementia. Her two handled cup and grip spoon were not reflected. Review of Resident #14's meal ticket revealed grip spoon with all meals. Observation on 6/21/22 at 12:40 p.m. of Resident #14 revealed she had a two handled cup and 2 large spoons with her tray at lunch time. She had a pureed lunch of chicken and rice, green beans, corn tortillas and strawberries. Staff assisted her on and off with feeding. Interview on 6/21/22 at 12:44 p.m. with CNA A who fixed her tray revealed he did not notice she did not have a spoon with a grip handle. He stated that often the kitchen will send only a regular spoon. He stated it was important for her to have a grip handle to help her to comfortably hold the spoon and to eat. He stated he should have mentioned it to the nurse but he didn't. Interview on 6/21/22 at 12:46 p.m. with RN B who supervised the secure unit lunch time where Resident #14 was eating revealed they often will not have the spoon with the grip handle .we help her if she needs assistance .I should have told the kitchen but did not. She stated that she realized it was important for Resident #14 to keep her functioning as much as possible and to eat independently with minor cueing. Interview on 6/24/22 at 8:00 a.m., the DON revealed Resident #14 was assessed to need the assistive device to help her eat. She stated Resident #14's hands have aged and were not as flexible to hold a regular spoon effectively. She stated staff should have let the kitchen know she needed to have the grip handled spoon and not just have assisted the resident with eating, because the resident needed to be as independent as she could with her eating skills until she declined to a point where she required to be fed more. She stated the staff are trained on assisting residents with ADL's and RN B should have checked Resident #14's tray and then notified the kitchen that the grip spoon wasn't present.