**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing and mental and psychosocial needs for 1 (Resident #1) of 3 residents reviewed for care plans. -The facility failed to ensure Resident #1 's pacemaker was addressed on her care plan. This failure placed the resident at risk for not having their individual needs met in a timely manner and could result in injury and a decline in physical well-being. Findings included. Review of Resident #1 face sheet, dated 03/19/2025, reflected an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of presence of cardiac pacemaker. Review of Resident #1's Quartely MDS assessment, dated 01/22/2025, reflected Resident #1 had a Brief interview for mental status score of 04 indicating severe cognitive impairment. Presence of pacemaker was listed under her diagnoses. Review of Resident # 1's comprehensive Care plan dated 3/1/25 did not reflect anything relating to her pacemaker. Interview with LVN A on 3/19/25 at 1:20 p.m. revealed that the purpose of the care plan was to make anyone aware of changes and details what kind of care the resident needs. She stated that she had not reviewed the care plan for the resident, and she was not aware that her pacemaker was not on the care plan. She stated that she is not a part of care plan meetings, and if there was a change to any resident's care plan, staff is notified via the DON and ADON verbally in meetings and in-services. She stated that she looked at residents' orders to see if anything changed throughout the day. The risk of the pacemaker not being care planned included missed communication and missed potential changes to care. Interview on 3/19/25 at 1:43 p.m. with the DON , revealed that whatever care area was triggered on the MDS would be on the care plan,. She stated if it was not triggered, then it would not show up on the care plan. She stated that nurses had to use their nursing judgment when it came to caring for a resident with a pacemaker. She stated that the nurses would report low pulse to Doctor or NP, monitor for dizziness or fainting. She stated that CNAs do not read care plans, because they did not have the time to do so. She stated that she and ADON would inform them and staff nurses of resident care plan, and the care that residents needed. Interview with ADON nurse on 3/19/25 at 2:07 p.m. revealed that the pacemaker was not included in care plan because MDS did not trigger that care area. She stated that Resident #1's pacemaker should have been included in the care plan to ensure continuity of care and prevent the resident going to hospital. She stated that any changes to resident care was verbally told to staff (nurses and CNAs) via meetings and in-services. Review of the facility's policy entitled Care Plans - Comprehensive revised December 2010 read in part, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each resident.The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS .

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 3 (CNA A) staff reviewed for EMR. The facility did not have CNA A's EMR on file upon hire. This failure could place residents at risk of abuse, neglect, and misappropriation of property. Findings included: Record review of Abuse and Neglect policy (not dated) read in part All personnel will be screened before hiring criminal history record, background checks, and reference. The licensing board will ne contacted for all licensed personnel to determine if any sanctions have been assessed against the applicant's license. In addition, all nurse aides conduct will be verified through employee misconduct registry. Record review of CNA A's employee files revealed her hire date was 07/19/24. Record review of CNA A's criminal background dated 07/19/24 revealed no findings. Record review of CNA A's employee file revealed no EMR was noted. Interview on 11/18/24 at 11:18 am, the Secretary stated she was the one responsible for running EMR's upon hire and the Administrator would be the one to follow up to ensure it was completed and a copy was placed in the employee files. The Secretary stated she had run CNA A's EMR but she could not find it on her file. The Secretary stated copies of EMR were required to be filed in the employee files and failure to do so, the facility would not be able to provide copy to verify the EMR was completed. The Secretary stated the DON and Administrator would be unable for interview due to a family emergency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to accommodate residents needs and preferences and accommodation of needs, for 1 (Resident #2) of 13 residents reviewed for dignity. The facility failed to ensure Resident #2's call light was within reach. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. Findings included: Record review of Resident #2's face sheet dated 09/12/2024 revealed an [AGE] year-old female admitted on [DATE] with the following diagnoses: dementia, anxiety disorder, hypertension (high blood pressure), and falls. Record review of Resident #2's Quarterly MDS dated [DATE] revealed: Section C -Cognitive Patterns BIMS score of 00, which indicated she had severe cognitive impairment. Section GG: Functional Abilities and Goals revealed Resident #2 required assistance with transfers and when out of bed did not ambulate on her own and was in wheelchair. Record review of Resident #2's most recent Care plan reviewed on 09/12/2024 revealed: Be sure her call light is within reach and encourage her to use it for assistance as needed. She needs prompt response to all requests for assistance. During an observation on 09/10/24 at 11:30 AM, Resident #2 was laying in her bed. The call light was not within reach of Resident #2. The call light was hanging on the wall at the foot of Resident #2's bed. During an observation on 09/12/24 at 2:51 PM, Resident #2 was laying in her bed. The call light was not within reach of Resident #2. The call light was hanging on the wall at the foot of Resident #2's bed. During an interview on 09/12/2024 at 3:15 PM, the DON stated when a resident was in bed in their room, the call light should have been placed within reach of the resident. The DON stated the nursing staff and CNA's were responsible to ensure that call lights were in reach of residents. The DON stated residents might not have had their needs met if the call light was not within reach. The DON stated what led to the failure was staff forgetting to check to make sure the call light was within reach of resident when they left the room. During an interview on 09/12/2024 at 3:45 PM, the ADMN stated his expectation was that call lights be within reach of residents. The ADMN stated the DON was responsible to monitor staff to ensure call lights were within reach of residents. The ADMN stated the effect on resident's not having the call light within reach could have been resident could have fallen or not have their needs met in a timely manner. The ADMN stated staff not paying attention and/or forgetting to check call light placement could have led to failure of call light not being in reach. Record review of Call Lights not dated, revealed: Each resident will have a call light, Call light will be placed within reach of resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 2 (Resident #46 and Resident #198) of 13 residents reviewed for care plan completion. 1. The facility failed to complete Resident #46 and Resident #198's baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings included: Record review of Resident #46's face sheet dated 09/12/2024 revealed the resident was an [AGE] year-old male admitted on [DATE] with the following diagnoses: chronic kidney disease, renal dialysis, hypertension (high blood pressure), and Type 2 diabetes. Record review of Resident #46's admission MDS dated [DATE] revealed: Section C- Cognitive Patterns revealed Resident #46 had a BIMS score of 00, which indicated he had severe cognitive impairment. Record review of Resident #46's medical record revealed no evidence of the completion of a baseline care plan. Record review of Resident #198's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, pain, type 2 diabetes mellitus with diabetic chronic kidney disease (kidney disease resulting from type 2 diabetes), and malignant neoplasm of prostate (prostate cancer). Record review of Resident #198's admission MDS assessment dated [DATE] revealed: BIMS score of 07 which indication severe cognitive impairment. Record review of Resident #198's medical record revealed no evidence of the completion of a baseline care plan. During an interview on 09/11/2024 at 4:38 PM, the MDS Coordinator stated she was responsible for completing the baseline care plans and that baseline care plans were supposed to be completed within the first 24 hours of admission. The MDS Coordinator stated that what led to the failure of baseline care plans not being completed, within time frame, was that she had to work the floor sometimes and if she worked the floor over the weekend, she would take off during the week. The MDS stated when she worked the floor those duties took priority over her other duties, that was what caused the delay in completing baseline care plans. The MDS Coordinator stated she did not feel residents were affected by not having baseline care plans completed. During an interview on 09/12/2024 at 3:15 PM the DON stated the MDS coordinator was responsible for completing the baseline care plan. The DON stated she did not feel there was an effect on residents for not having a baseline care plan completed. The DON stated that staff don't look at the care plan, it was just more paperwork to complete. The DON did not provide a reason for the failure of baseline care plans not being completed. Record review of facility policy titled, Care Plans-Preliminary dated August 2006, revealed: To assure that the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of the resident's admission. The Interdisciplinary Team will review the Attending Physician's order (e.g., dietary needs, medications, and routine treatment, etc.), and implement a nursing care plan to meet the resident's immediate care needs. The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 2 residents (Resident #3 and Resident #32) reviewed for respect and dignity. The facility failed to ensure staff treated Resident #3 and Resident #32 with respect and dignity, with staff removing residents' trays prior to being completed. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. The findings included: Resident #3 Record review of Resident #3's face sheet dated 09/12/2024 revealed an [AGE] year-old male admitted on [DATE], with the following diagnoses: Vitamin-D deficiency, type 2 diabetes, constipation, mood disturbance, and chronic kidney failure. Record review of Resident #3's Comprehensive MDS dated [DATE] revealed that Section C- Cognitive Patterns had a BIMS score of 06 (severe cognitive impairment ). Resident #32 Review of Resident #32's face sheet dated 09/12/2024 revealed a [AGE] year-old male admitted on [DATE] with the following diagnoses: type 2 diabetes, Vitamin D Deficiency, gastritis, and major depressive disorder. Record review of Resident #32's Comprehensive MDS dated [DATE] revealed that Section C- Cognitive Patterns had a BIMS score of 06 (severe cognitive impairment ). During an interview on 09/11/2024 at 2:30pm, CNA G stated she was in the dining room with CNA H at breakfast time. She stated CNA H pulled the unfinished tray from Resident #32. CNA G stated Resident #32 asked CNA H Why are you taking my tray if I'm not finished with it? CNA G stated that CNA H ignored Resident #32 and only brought him back a juice and half of a banana. CNA G stated at lunchtime, CNA H repeated her same actions, taking Resident #32's tray away from him prior to finishing, once again caused him to yell out for his food. CNA G stated she felt the resident was left hungry at the end of the day and also resulted in her 3-day suspension for taking up for a resident from the ADMN. During an interview on 09/12/24 at 10:18 AM Resident #3 stated he ate in his room. He stated staff often brought his trays and placed them on his table taking the top off without waking him up. Resident #3 stated his food would get cold and resulted in him not wanting to eat it. He stated at times staff would come in and take his tray away telling him the kitchen needed to clean the dishes before leaving at a certain time, which resulted in him not finishing his meals. Resident #3 stated that Resident #32 was his roommate and he had witnessed staff taking his food/tray away before he finished as well. He stated he had spoken to staff about this with nothing being done. During an interview on 09/12/2024 at 11:57 AM the ADMN stated he had not known of this situation prior to this day. He stated all residents should be given enough time to eat everything that was provided on their plates and felt the CNA's would not have done that . During an interview on 09/12/2024 at 5:26 PM the Dietician stated that all residents have the right to be served and as well as given ample time to eat their food on their tray. She stated if the residents were not given enough time to eat what was provided, it could cause the resident to not get the nutritional value they needed. She stated it would have been the actions of the floor staff to monitor and oversee that the residents received and were given time to eat. She stated the ADMN should have monitored meal services as well. During exit conference on 09/12/2024 at 5:45 PM the facility stated they did not have a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #2, Resident #27, Resident #28, and Resident #36) of 13 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #2's comprehensive care plan addressed Resident's code status and fall mat. The facility failed to ensure Resident #27's comprehensive care plan addressed Resident #27's code status and PASRR services. The facility failed to ensure Resident #28's comprehensive care plan was resident specific and person centered. The facility failed to ensure Resident #36's comprehensive care plan was resident specific and person centered. These failures could affect the residents by placing them at risk for not receiving care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Findings included: Resident #2 Record review of Resident #2's electronic face sheet dated 09/12/2024 revealed an [AGE] year-old female admitted on [DATE] with the following diagnoses: dementia, anxiety disorder, hypertension (high blood pressure), and falls. Record review of Resident #2's Quarterly MDS dated [DATE] revealed: Section C -Cognitive Patterns BIMS score of 00, which indicated she had severe cognitive impairment. Section GG: Functional Abilities and Goals revealed Resident #2 required assistance with transfers and when out of bed did not ambulate on her own and was in wheelchair. Record review of Resident #2's physician orders dated 09/12/2024 revealed Resident #2 had a code status of DNR. Record review of Resident #2's most recent comprehensive care plan reviewed on 09/12/2024 revealed no evidence of Resident #2's code status or the use of a fall mat. During an observation on 09/10/2024 at 11:30 AM, Resident #2 was laying in her bed with the fall mat laying on the floor beside the bed. Resident #27 Record review of Resident #27's electronic face sheet dated 09/12/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses: type 2 diabetes, paranoid schizophrenia , major depressive disorder, and elevated blood pressure. Record review of Resident #27's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns BIMS score of 9, which indicated she had moderate cognitive impairment. Record review of Resident #27's physician orders dated 09/12/2024 revealed Resident #27 had a code status of DNR. Record review of Resident #27's PASRR Comprehensive Service Plan dated 11/14/2023 revealed Resident #27 received routine case management and training skills under PASRR services . Resident #28 Record review of Resident #28's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: osteoarthritis (when the cartilage that cushions and protects the ends of bones gradually wears away). Record review of Resident #28's quarterly MDS assessment dated [DATE] revealed: BIMS score of 15 meaning cognition was intact. Record review of Resident #28's comprehensive care plan last revised on 09/10/2024 revealed: Goal: Falls: the resident has had an actual fall with (SPECIFY: no injury, minor injury, serious injury) Unsteady gait Date .Interventions: The resident will have improved mood state (SPECIFY: happier, calmer appearance, no s/sx of depression, anxiety, or sadness) through the review date . Resident #36 Record review of Resident #36's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility most recently on 01/19/2024 with diagnoses to include: visual hallucinations, altered mental status, and insomnia. Record review of Resident #36's significant change MDS dated [DATE] revealed: BIMS score of 00 which indicated severe cognitive impairment. Record review of Resident #36's most recent comprehensive care plan reviewed on 09/12/2024 reviewed: Goal: ADL: The resident has an ADL self-care performance deficit r/t weakness. Intervention: BATHING/SHOWERING: The resident requires transfer assistance by (1) staff with (SPECIFY bathing/showering) 3 times a week and as necessary . During an interview on 09/11/2024 at 4:38 PM, the MDS Coordinator stated she was responsible for completing the comprehensive care plans. The MDS Coordinator state she did not think code status needed to be incorporated in the care plan because it was in the orders and there was flag on residents' electronic chart that stated code status of residents. The MDS Coordinator stated the DON was responsible to monitor the care plans. The MDS coordinator stated she did not feel the residents were affected by not having comprehensive care plans not being completed. The MDS Coordinator did not have a response to what led to the failure . During an interview on 09/12/2024 at 3:15 PM, the DON stated the MDS coordinator was responsible for completing the comprehensive care plan. The DON stated she did not feel that residents were affected by the missing information, that staff did not look at the care plans. The DON stated care plans were just more paperwork that had to be completed. The DON did not provide a reason for the failure of comprehensive care plans not being completed . Record review of facility titled, Care Plans- Comprehensive dated December 2010, revealed Each resident's comprehensive care plan is designed to: Incorporate identified problem areas; incorporate risk factors associated with identified problems; build on the resident's strengths; Reflect the resident's expressed wishes regarding care and treatment goals; Identify the professional services that are responsible for each element of care.

Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 5 (04/13/2024; 05/11/2024; 05/12/2024; 05/25/2024; 06/08/2024) of 91 days reviewed for RN coverage. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 04/13/2024; 05/11/2024; 05/12/2024; 05/25/2024; and 06/08/2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Review of facility's Direct Care Staff Daily Report from 04/01/2024 to 06/30/2024 revealed on 04/13/2024; 05/11/2024; 05/12/2024; 05/25/2024; and 06/08/2024 there was no evidence of RN coverage. During an interview on 9/12/2024 at 3:15 PM, the DON stated her expectation was to have RN coverage daily. The DON stated she was on call on weekends and can be contacted when there was not a RN working. The DON stated they have a RN that worked on the weekends and then her and the MDS Coordinator work Monday and Friday. The DON stated the MDS Coordinator filled in on the weekends when needed. The DON stated if there were dates on the weekends that were reported with no RN coverage, she did not work those weekend dates, but she would have been available by phone to come to pronounce if a resident had passed away. The DON stated she did not feel there was an effect to residents when there was no RN coverage. The DON stated what led to failure was not being able to hire additional RNs. During an interview on 9/12/2024 at 3:45 PM, the ADMN stated his expectation was to have 8 hours of RN coverage 7 days per week. The ADMN stated the DON was responsible for ensuring there were 8 hours of RN coverage daily. The ADMN stated the effect on residents was the discontinuity of care. The ADMN did not have a response to what led to the failure of not having 8 hours of RN coverage. Record review of facility policy titled; RN Coverage dated 06/26/24 revealed: It is the policy of facility to provide 7-day RN coverage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities, which involved 2 of 6 residents (Resident #28 & Resident #198) reviewed for medication errors. 1. The facility failed to ensure MA administered the correct dose of calcium and vitamin D to Resident #28 according to the physician orders. 2. The facility failed to ensure MA administered olmesartan medoxomil (for blood pressure) and amlodipine besylate (for blood pressure) to Resident #198 according to physician orders. These failures could place residents at risk of inadequate therapeutic outcomes. Findings included: Resident #28 Record review of Resident #28's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: osteoarthritis (when the cartilage that cushions and protects the ends of bones gradually wears away). Record review of Resident #28's quarterly MDS assessment dated [DATE] revealed: BIMS score of 15 meaning cognition was intact. Record review of Resident #28's comprehensive care plan last revised on 09/10/2024 revealed Resident #28 had arthritis with interventions that included to encourage adequate nutrition. Record review of Resident #28's Physician Orders revealed the following order dated 03/28/2024: Citracal Maximum Oral Tablet 315-6.25 mg-mcg (Calcium Citrate-Vitamin D) Give 2 tablet by mouth two times a day for supplement. Further review of orders revealed the following order dated 03/25/2022 May crush and cocktail medications/open capsules if appropriate for medication administration in food or liquids unless contraindicated. Record review of Resident #28's electronic September 2024 MAR revealed Citracal Maximum Oral Tablet 315-6.25 mg-mcg (Calcium Citrate-Vitamin D) Give 2 tablet by mouth two times a day for supplement. Start Date- 03/29/2024. During an observation on 09/10/2024 at 10:08 a.m., MA administered Calcium 630mg - Vitamin D 12.5mcg 2 tablets crushed and mixed with water to Resident #28. During an interview on 09/12/2024 at 9:52 a.m., MA stated she did not give the correct dose of Calcium - Vitamin D. She stated she should have only given 1 tablet instead of 2 tablets to Resident #28. She stated she gave the wrong dose because the directions in order were confusing and had half the dose of Citracal than what was available . Resident #198 Record review of Resident #198's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, pain, type 2 diabetes mellitus with diabetic chronic kidney disease (kidney disease resulting from type 2 diabetes), and malignant neoplasm of the prostate (prostate cancer). Record review of Resident #198's admission MDS assessment dated [DATE] revealed: BIMS score of 07 which indicated severe cognitive impairment. Record review of Resident #198's physician orders revealed the following order dated 09/03/2024: amlodipine besylate oral tablet 10mg. Give 1 tablet by mouth one time a day for HTN related to hypertensive heart and chronic kidney disease without heart failure. Further review of physician orders revealed the following order dated 09/03/2024: olmesartan medoxomil oral tablet 40mg. Give 1 tablet by mouth one time a day for hypertension related to hypertensive heart and chronic kidney disease without heart failure. No evidence of hold parameters observed on either of these orders. Record review of Resident #198's electronic September 2024 MAR on 09/12/2024 revealed amlodipine besylate 10mg had been held by MA on 09/10/2024 with code 5 meaning hold see progress notes. Further review of September 2024 MAR on 09/12/2024 revealed olmesartan medoxomil 40mg had been held by MA on 09/03/2024 with code 9 meaning other see progress notes, on 09/09/3034 with code 5 meaning hold see progress notes, and on 09/10/2024 with code 5 meaning hold see progress notes. Record review of Resident #198's progress notes reviewed on 09/10/2024 at 4:22 p.m. revealed no notes entered about holding amlodipine besylate and olmesartan medoxomil on 09/03/2024, 09/09/2024, or 09/10/2024. During an observation and interview on 09/10/2024 at 10:44 a.m., MA obtained Resident #198's blood pressure and it revealed a reading of 132/56. The MA went to LVN D and reported the blood pressure reading. LVN D instructed MA to not give amlodipine besylate and olmesartan medoxomil. MA gave Resident #198's medications without amlodipine besylate and olmesartan medoxomil. During an interview on 09/10/2024 at 3:27 p.m., LVN D stated she had been instructed by the NP in the past to not give blood pressure medication if the blood pressure was less than 110/60. She stated the current medication order did not have any parameters to hold medication. During a telephone interview on 09/10/2024 at 4:11 p.m., the MD stated Resident #198 was a new resident into the nursing facility. He stated he expected for his physician orders to be followed. The MD stated physician orders for blood pressure medications should have hold parameters for when the blood pressure was below 130 and the resident was of the age of Resident #198. He stated he should have been notified if his orders needed clarification. He stated no negative impact occurred from medication being held. He stated he would monitor resident's vital signs when he performed his visits by reviewing medical records and make order adjustments then as part of his process for monitoring orders. He stated he had not performed a visit for Resident #198 because he was a new resident in the facility and instructed staff to continue medication orders as written from the hospital discharge until he was able to see the resident. During an interview on 09/11/2024 at 4:23 p.m., the DON stated there were no hold parameters for Resident #198's blood pressure medications. She stated she expected for nurses to hold medications per the nurse's judgement. She stated the facility does not call the doctor often. She expected for the doctor to be notified if the staff held medication more than 2 to 3 times per the nurse's judgement. The DON stated she did not know the BON's expectation of nurses holding medications based on nurse's judgement because the BON changed their rules all the time. She stated MA's do not write progress notes and felt the code was selected by the MA because of program restrictions. She did not answer the question on who monitors that physician orders were written appropriately, but stated the order was written appropriately. She stated no negative effect occurred to resident by medications being held and stated the medications would have lowered blood pressure even more. During a follow up interview on 09/12/2024 at 9:36 a.m., the DON continued to state that the facility acted appropriately by holding the blood pressure medication without notifying the MD and no parameters specified in the order. She stated she did expect for correct doses of Calcium and Vitamin D to be administered to the resident. She stated giving the incorrect dose had no negative effect on Resident #28. She stated that pharmacy monitored the MA administering the medications quarterly and they had not found that medications were being administered incorrectly. She did not know why the incorrect dose had been administered. Record review of the facility's policy titled Medication Administration Policy with no date revealed: 1. Must use five rights: the right patient, the right drug, the right dose, the right route, and the right time to reduce risk of medication errors. 2. Must have a basic understanding of any drug that he/she is administering i.e. what the drug is intended to treat, adverse effects and contradictions, expected outcomes and usual route. 3. Must obtain vitals such as blood pressure, heart rate, blood glucose, respirations, oxygen saturation, and pain may be indicated for administration of certain medications. 4. If vital signs are not within parameter, the nurse must hold medication according to physician orders. 5. Nurses may hold doses of medications per nursing judgement if the patient is at risk of suffering from medication administration. Must notify MD of assessment findings promptly. 6. Must document in MAR. According to the Texas Board of Nursing website, https://www.bon.texas.gov/pdfs/publication_pdfs/Scope%20of%20Practice%20Decision-Making%20Model%20-%20DMM.pdf, accessed on 09/12/2024 revealed Scope of Practice Decision-Making Model dated April 2019: 2. Is the activity or intervention authorized by a valid order If there is any question about the accuracy or appropriateness of an order, clarification must be sought [Board Rule 217.11(1)(N)] According to the Texas Board of Nursing website, https://www.bon.texas.gov/rr_current/217-11.asp.html, accessed on 09/12/2024 revealed Board Rule 217.11(1)(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious, or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the menu was followed for 3 of 6 (Resident #2, Resident #25, and Resident #33) residents who received a pureed meal reviewed during the lunch meals served reviewed for food and nutrition services. The facility failed to ensure residents, receiving a puree texture diet, were provided the food according to the menu, included a dinner roll on 09/10/2024 and a dinner roll and ice cream on 09/11/2024. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance, and/or weight loss. The findings included: Resident #2 Record review of Resident # 2's Quarterly MDS dated [DATE] revealed an [AGE] year-old female admitted on [DATE]; Section C- Cognitive Patterns had a BIMS score of 0 (severe cognitive impairment); Section I-Active Diagnosis with following diagnosis of Non-Alzheimer's Dementia; Section K- Swallowing/Nutritional Status Resident #2 had a mechanically altered diet. Record review of Resident #2's Care Plan dated 08/07/2024 revealed: Focus-Nutrition: The resident had recent weight loss during hospitalization. Goal- The resident will maintain adequate nutritional status. Interventions- Provide and serve diet as ordered. Record Review of Resident #2's orders dated 06/30/2024 revealed High calorie diet, Pureed texture, regular consistency. Resident #25 Record review of Resident #25's Quarterly MDS dated [DATE] revealed a [AGE] year-old female admitted on [DATE]; Section C- Cognitive Patterns had a BIMS score of 10 (moderate cognitive impairment); Section I-Active Diagnosis with following diagnosis of non-Alzheimer dementia; Section K- Swallowing/Nutritional Status Resident #25 had a mechanically altered diet. Record review of Resident #25's Care Plan date 06/19/2024 revealed: Focus-Nutritional Status: the resident had a nutritional problem poor intake. Goal-The resident will maintain adequate nutritional status through review date. Record Review of #25's orders dated 04/03/2024 revealed High calorie diet, Pureed texture, regular consistency. Resident #33 Record review of Resident # 33's Quarterly MDS dated [DATE] revealed a [AGE] year-old female admitted on [DATE]; Section C- Cognitive Patterns had a BIMS score of 0 (severe cognitive impairment); Section I-Active Diagnosis with following diagnosis of Non-Alzheimer's Dementia; Section K- Swallowing/Nutritional Status Resident #2 had a mechanically altered diet. Record review of Resident #33's Care Plan dated 08/27/2024 revealed: Focus-Nutrition: The resident had recent weight loss during hospitalization. Goal- The resident will maintain adequate nutritional status. Interventions- Provide and serve diet as ordered. Record Review of #33's orders dated 08/23/2024 revealed High calorie diet, Pureed texture, regular consistency. Record review of facility menu week 3 dated 2024 revealed: On Tuesday September 10th, 2024, Lunch included a dinner roll. On Wednesday September 11th, 2024, Lunch included a dinner roll and Ice Cream. During observation on 09/10/2024 at 11:30 AM, the bread was not provided on the pureed diet trays . During an observation and interview on 09/11/2024 at 11:34 AM, the bread was not provided on the pureed diet trays. CNA G stated she felt all residents should have been provided with what was offered on the menu. CNA G asked Resident #33 if she would like to have bread, she stated yes she would. During an interview on 09/12/2024 at 11:57 AM, the ADMN stated the pureed diet came directly from the main menu and did not know if there was a policy for that exact scenario. He stated if there were missing items on the pureed trays, there could be decreased nutritional value for the resident if not replaced appropriately. The ADMN stated the DM monitored the resident diets as well as the Dietician. He stated the residents should have been getting their bread, so they can get their nutritional value of the carbs, and it was an oversight of the DM. During an interview 09/12/2024 at 5:26 PM, the Dietician stated that all residents should have been served everything listed on the menu as that was how they received their balanced diet and nutritional value. She stated the residents that presented with lower cognitive abilities should still have been served what was on the menu. The Dietician stated the CNA's and nurses on the floor should have been monitoring that residents get everything listed on the menu as well as the DM. She stated that miscommunication on the Interdisciplinary Team led to the failure and her expectations were that all residents get everything listed on the menu. Record review of facility policy Therapeutic diets undated, revealed: Policy: It is the policy to serve therapeutic diets according to doctor's orders and need of the resident. Definition: A therapeutic diet is a meal plan that controls the intake of certain foods or nutrients. It is part of the treatment of a medical condition and are normally prescribed by a physician and planned by a dietician. A therapeutic diet is usually a modification of a regular diet. It is modified or tailored to fit the nutrition need of a particular person. Therapeutic diets are modified for nutrients texture, and/or food allergies or food intolerances. Reasons for therapeutic diets; To maintain nutritional status next line to restore nutritional status. To correct nutritional status. To provide extra calories for weight gain. To balance amounts of carbohydrates, fat and protein for control of diabetes. To provide a greater amount of a nutrient . To provide texture modifications due to problems with chewing and slash or swallowing .Increased fiber should come from a variety of sources including fruits, resumes, vegetables whole breads, and cereals.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled. The facility failed to ensure that persons serving food handled food properly. These failures could place residents at risk for food borne illnesses and cross-contamination. The findings included: During an observation on 09/10/2024 at 09:00 AM, the dry storage pantry had: 1. 8 oz. beneprotein powder, no received date 6 total. 2. 4 oz. individual orange juice had no received date. 3. 2 large (size unknown) bottles of ReaLemon juice. 4. 3-7.25 cans of chicken Noodle soup, no received date. During an observation on 09/10/2024 at 9:24 AM, freezer #2 had: 6-1 lb. bags of frozen mixed vegetables with no received date. During observation on 09/10/2024 at 9:27 AM the refrigerator had: 1. 7 gallons of milk had no received date. 2. 2 opened bags labeled red apples had no opened date and no received date. 3. 3 large opened clear bags of what appeared to be jalapenos were not labeled and had no received date. 4. 1 clear gallon bag, of what appeared to be lemons, had no received date. 5. 1 large clear bag of what appeared to be broccoli, had not been labeled and no received date. 6. 3 unbagged bunches of celery was in the bottom drawer of the refrigerator was unlabeled and undated. 7. 12 unbagged, bell peppers, were placed in the bottom drawer of the refrigerator and was unlabeled and undated. 8. 1 large clear bag of cucumbers, not labeled with no received date. 9. 10 heads of lettuce with no received date. 10. One large clear unlabeled and undated box of tomatoes. During an observation on 09/10/2024 at 9:37 AM, there were 2 opened bags of bread on the kitchen shelf, with no opened date or received date. During an interview on 09/10/2024 at 10:00 AM, the DM stated all products were to be dated when received to the facility, as well as labeled if taken out of the product's original boxes. He stated he did not feel it was a big deal as they use the products up fast with no dates needed. The DM stated it was his job to monitor his staff and felt they were complying. He stated there was no failure on his part . During an observation and interview on 09/12/2024 at 9:55 AM, the follow up visit to the facility kitchen revealed there were still vegetables undated in the refrigerator. The DM stated they still did not have dates because they were not in the packages and could not apply dates to the raw vegetables that were in the clear plastic bin. During an interview on 09/12/2024 at 11:52 AM, the ADMN stated all products in the facility kitchen should have had received dates and if opened and out of the original containers should have been labeled of what the product was. The ADMN stated it was the DM who monitored the process. He stated he could not say what led to the failure nor what his expectations were, as he was unfamiliar with the kitchen policies at this time . During an interview on 09/12/2024 at 5:26 PM, the Dietician stated her expectations were for all products to be labeled and dated as the policy stated . During an observation on 09/10/2024 at 9:00 AM, DA E had not performed hand hygiene and had not applied gloves prior to touching and preparing pineapple for the resident lunch service. During an interview on 09/12/24 9:45 AM, the DM stated he could not provide staff in-services for handwashing. He stated he felt the Hand Hygiene instructions posted on the walls in front of the handwashing sink provided enough information for his staff. The DM stated he monitored his staff but could not state how often or when he monitored as life was too busy. He stated if staff did not wash and sanitize their hands, that it would cause contamination with infecting the residents, which would have made them sick. He stated if they did not wash their hands it was a mistake. During an interview on 09/12/2024 at 11:48 AM, the ADMN stated it was in the policy that all staff were to wash their hands before food being prepped. He stated if staff left the kitchen, they should have washed their hands again. The ADMN stated if staff touched food without being gloved, they should have washed their hands as well, and then gloved. He stated he knew they had plenty of gloves in the kitchen. The ADMN stated in not doing so it could have led to cross contamination with the residents being sick. He stated the DM should have monitored infection control for his kitchen staff, while himself as the ADMN, monitored the DM. He stated that staff had been in-serviced and the documentation was in his office. The ADMN stated his expectations were for the staff to comply with washing their hands. He stated the failure occurred with not washing their hands as well as not and seeking more training. During an interview 09/12/2024 at 5:26 PM the Dietician stated the DM should have monitored his staff better for hand hygiene. The Dietician stated the improper training led to the failure with her expectations, for all staff to follow all policies and procedures with hand hygiene. She stated the negative impact could have been cross contamination and passed to the residents. Record Review of facility policy Food Storage from the Policy and Procedure Manual 82, dated 2008, revealed: Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared by methods designed to prevent contamination. Procedure: .7. Hands must be washed after unloading supplies and prior to handling food items. 8 . c. Food should be dated as it is placed on the shelves .15. Refrigeration: . .e. All foods should be covered, labeled and dated .16. Frozen foods: .c. Foods should be covered, labeled, and dated. Review of Texas food Establishment Rules FDA Food Code 2022: Full Document accessed 09/19/2024 revealed Green et al (JFP, March 2007) found that handwashing was more likely to occur in restaurants whose food workers received food safety training, had more than one handwashing sink, and had a handwashing sink in the observed worker's sight. This suggests that improving food worker hand hygiene requires more than food safety education. Noroviruses are environmentally stable, able to survive both freezing and heating (although not thorough cooking), are resistant to many common chemical disinfectants, and can persist on surfaces for up to 2 weeks. Proper hand hygiene and exclusion of food employees exhibiting symptoms of norovirus disease (i.e., diarrhea or vomiting) are critical for norovirus control. Record review of the United States Food and Drug Administration https://www.fda.gov/food/retail-food-industryregulatory-assistance-training/program-information-manual-retail-food-protection-storage-and-handling-tomatoes accessed on 09/19/2024, revealed: Fresh-cut tomatoes and other produce have already been washed before processing and should be considered ready-to-eat with no further need for washing unless the label says otherwise.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (CNA B and LVN D) of 4 staff observed for infection control practices. 1. The facility failed to ensure CNA B removed gloves and performed hand hygiene at the appropriate time while providing resident incontinent care. 2. The facility failed to ensure LVN D sanitized hands at appropriate times when changing gloves during wound care. 3. The facility failed to ensure LVN D sanitized rubber tip of insulin flex pen prior to applying needle to insulin flex pen during administration of insulin to resident. These failures place residents at risk for unnecessary infections while in facility. Finding included: During an observation on 09/10/2024 at 9:43 a.m., CNA B performed incontinent care. CNA B sanitized her hands and put on gloves prior to setting up supplies needed for incontinent care. She removed shirt from closet and assisted the resident to change from sweater into a shirt. She placed the sweater on the dresser. CNA B then asked the resident to stand with the walker while she lowered the resident's pants and removed the urine soiled brief. She wiped the resident front to back with a new wipe every time and disposed of the wipes into the trash. She placed a dry brief onto the resident and assisted with him pulling up the resident's pants. CNA B assisted the resident to sit back into the wheelchair. She then placed the sweater onto a hanger and hung it in the closet. She gathered up all the trash and left the resident's room with gloved hands and trash. She walked down the hall to the shower room and disposed of the trash. CNA B did not remove her gloves or perform hand hygiene until she reached the shower room with the soiled trash and disposed into the trash bin . During an observation on 09/10/2024 at 11:18 a.m., LVN D administered insulin using multi dose flex pen. LVN D performed hand hygiene, removed the lid from the used flex pen, and then placed a new needle onto the flex pen. She did not sanitize the rubber tip of the flex pen prior to applying the needle. During an interview on 09/10/2024 at 3:27 p.m., LVN D stated she had never been told to sanitize the flex pen prior to applying needle and stated the facility policy did not state to sanitize the flex pen prior to applying the needle. During an observation and interview on 09/11/2024 at 9:49 a.m., LVN D performed wound care. LVN D sanitized her hands and gathered her supplies for wound care onto a tray outside of the resident's room. She then sanitized bedside table in the resident's room with sanitizing wipe. She sat tray with wound care supplies onto bedside table and washed hands prior to applying gloves. She cleansed wound to the left ankle with saline and gauze then removed her gloves. She placed new gloves without performing hand hygiene then applied silver cream to wound bed with wooden applicator, covered wound with gauze, and secured gauze to skin with tape. She removed gloves and disposed into trash and applied new gloves without performing hand hygiene. She cleansed wound to the right ankle with saline and gauze then removed her gloves. She placed new gloves without performing hand hygiene, then applied silver cream to the wound bed with a wooden applicator, covered the wound with gauze, and secured gauze to skin with tape. She removed her gloves and disposed into trash, then washed her hands with soap and water. She carried trash out of the resident's room and placed it into the trash bin on the treatment cart and sanitized her hands again. LVN D stated she should have performed hand hygiene in between glove changes. She stated that she had been nervous due to being watched and forgot to perform hand hygiene . During an interview on 09/11/2024 at 4:23 p.m., the DON stated she expected the nurse to sanitize the insulin flex pen rubber tip prior to placing the needle onto the insulin flex pen. She stated the pharmacy would watch medication passes about once a quarter and she expected for nurses to know how to sanitize the insulin flex pen because they had a nurse's license. She stated she could not supervise nurses all the time. The DON stated she did not know why LVN D failed to sanitize the insulin flex pen and not sanitizing could cause skin infection to the resident. The DON stated she expected for nurses to follow procedure during wound care. She stated LVN D was probably nervous from being watched and forgot to follow procedure. She stated no infection risk due to gloves were a barrier and wounds had not been infected already. The DON stated she expected her staff to change gloves and perform hand hygiene after performing incontinent care and before touching clean areas in residents room including clothing. She stated she monitored staff for hand hygiene and had just had skills check off for hand hygiene either July or August of 2024. She stated she felt staff being rushed and nervous led to the failure. She stated not performing hand hygiene appropriately could cause infection. Review of the facility's policy titled Use of Hand Antiseptic dated 2008 revealed: Hand antiseptics may be used between hand washing as long as hands are not soiled. Hand antiseptics are not to take the place of hand washing. Review of facility's policy titled Policy: Flex Pen Insulin Administration with no date revealed: Pull the pen cap straight off. Wipe the rubber seal with alcohol swab. Check the liquid in the pen. Do not use if cloudy, colored, or has particles or clamps. Select a new needle. Pull off the paper tab from the outer needle shield. Push the capped needle straight on the pen and twist the needle on until it is tight. Review of facility's policy titled Incontinent Care with no date revealed: Disposable diapers are used for incontinent residents. Check every two hours. Change as necessary. Use wipes or washcloth and make sure that the resident is properly cleaned. Discard disposable diaper properly. Review of facility's policy titled Policy: Infection Control Program with no date revealed: C. Handwashing: Single most effective way to control spread of infection. 1. Wash hands in between patient care. 2. Wash hands after using bathroom. 3. Wash hands before and after feeding residents. 4. Wash hands after handling soiled material. 5. Wash hands after using gloves. D. Gloves: 1. Change gloves in between patient care. 2. Wash hands after discarding gloves. 3. Wear gloves when handling soiled materials. 4. Discard in designated containers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #30) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #9's that reflected as needed oxygen therapy. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings include: Resident #30's face sheet dated 08/09/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Resident #30's history and physical dated 05/03/23 revealed a [AGE] year-old female diagnosed with chronic obstructive pulmonary disease, general weakness, and dementia. Resident #30's significant change MDS dated [DATE] revealed a diagnosis of asthma/ chronic obstructive pulmonary disease, muscle weakness, and history of covid-19. Resident marked down for oxygen therapy. Resident #30's care plan dated 01/06/23 revealed resident was on oxygen therapy for poor oxygen absorption. Oxygen via nasal cannula at 2 liters per minute continuous. Resident #30's order recap dated 03/29/23 revealed supplemental oxygen at 1 liter per minute by nasal cannula as needed as tolerated to keep oxygen saturation 92% or above every shift . Interview on 08/09/23 at 2:01 PM with the ADON. The ADON stated she did not know much about care plans. The ADON stated the doctors' orders needed to match the care plan. Interview on 08/09/23 at 3:20 PM with the DON stated she completed the care plans for the residents. The DON stated she oversees that the care plans are being completed correctly. The DON stated Resident #30 had doctors' orders for oxygen as needed oxygen. The DON stated the care plans were not correct because it did not reflect the doctors' orders. The DON stated, we go by doctors' orders. Record review of the facility care planning - interdisciplinary team policy dated 2014 revealed our facility's care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The care planning/interdisciplinary team were responsible for the review and updating of care plans. Record review of facility's using the care plan policy dated 2006 revealed the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Changes in the resident's condition must be reported to the MDS assessment coordinator so that a review of the resident's assessment and care plan can be made.

**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 fed by enteral means receives the appropriate treatment and services for 1 of 10 residents (Resident #9) reviewed for enteral feeding. Resident #9 was on continuous feeding and while feeding. The facility failed to ensure Resident #9's head of the bed was elevated at a 45-degree angle per care plan These failures could place residents receiving enteral feedings at risk of aspiration. Findings include: Resident #9's face sheet dated 08/09/23 revealed admission on [DATE] to the facility. Resident #9's history and physical dated 03/08/22 revealed an [AGE] year-old female diagnosed with dementia, debility (physical weakness), aspiration pneumonia, and dysphagia (difficulty swallowing). Resident #9's care plan not dated revealed feeding tube - resident has an alteration in gastro-intestinal status with dysphagia. Avoid lying down for at least one hour after PEG (percutaneous endoscopic gastrostomy) feeding. Keep HOB (head above bed) elevated at all times. Resident #9 requires tube feeding due to dysphagia and requires/needs the HOB (head above bed) elevated 45 degrees during and thirty minutes after tube feeding. Observation on 08/08/23 at 4:30 PM of Resident #9 in bed with HOB top of mattress level with the plane of the headboard indicating level of bed was low and not at 45 degrees. Observation on 08/09/23 at 1:16 PM of Resident #9 in bed with head of bed elevated past the headboard top plane indicating 30 degrees. Interview and observation on 08/09/23 at 12:03 with RN A revealed she administered 120ml (mililter) water bolus to Resident #9 as scheduled via G-tube . Resident #9 was lying in bed with head of bed slightly elevated. When RN A completed administration of water bolus Resident #9 was left with head of the bed slightly elevated. RN A stated head of bed needed to be at about a 30-degree angle. RN A stated the head of the bed and mattress where at the same level indicating the resident was in a 30-degree angle . RN A proceeded to elevate the head of the bed to a 40-45-degree angle. RN A stated resident needed to be with the head of the bed at a higher angle to prevent aspiration at 45 degrees. Interview and observation on 08/09/23 at 1:20 PM RN A stated that earlier Resident #9 was too low in her bed and was not elevated according to doctors' orders. At 1:27 PM Resident #9 was in bed and a range scale was applied to the frame of the bed indicating 30 degrees. RN A stated that Resident #9 was not elevated correctly as she needed to be 45 degrees as per doctors' orders. RN A stated not having the resident at 45 degrees can be a risk for her. RN A stated the Resident #9 could aspirate. Record review of facility tube feeding policy not dated indicated elevate HOB (head above bed) 30-45 degrees to prevent aspiration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #30) of 4 residents observed for oxygen management. Resident #30 was on oxygen which did not have an oxygen sign posted outside of her bedroom. Resident #30 was outside in the front patio of the facility with an oxygen tank that was in the red indicating refill oxygen. These failures could place residents on oxygen therapy at risk of an explosion or fire, injury, incorrect or inadequate oxygen support, and decline in health. Findings include: Resident #30's face sheet dated 08/09/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Resident #30's history and physical dated 05/03/23 revealed a [AGE] year-old female diagnosed with chronic obstructive pulmonary disease, general weakness, and dementia. Resident #30's significant change MDS dated [DATE] revealed a diagnosis of asthma/ chronic obstructive pulmonary disease, muscle weakness, and history of covid-19. Resident was marked down for receiving oxygen therapy. Resident #30's care plan dated 01/06/23 revealed resident was on oxygen therapy for poor oxygen absorption. Oxygen via nasal cannula at 2 liters per minute continuous. Resident #30's order recap dated 03/29/23 supplemental oxygen at 1 liter per minute by nasal cannula as needed as tolerated to keep oxygen saturation 92% or above every shift. Observation on 08/07/23 at 9:43 AM revealed Resident #30's oxygen tank hanging of the back of the wheelchair was on red and had no oxygen. There was an oxygen concentrator in Resident #30's room and resident was not using the oxygen at that moment. No oxygen sign was posted outside of resident's room. Observation on 08/08/23 at 9:54 AM revealed Resident #30's room did not have an oxygen sign posted outside of the bedroom. Resident #30 was not in her room. One oxygen tank was in the corner of the room and indicated green, meaning it had oxygen. Interview on 08/08/23 at 10:11AM with RN A stated oxygen signs state that oxygen was being used by a resident in the room. RN A stated oxygen signs also lets everyone know not to smoke. RN A stated the facility had the signs up and they were remodeling the hallway and forgot to put them back up . RN A stated the nurses notify the Director of Nursing that they need an oxygen sign for the residents who are on oxygen. RN A stated not having oxygen signs posted in rooms where residents are using oxygen can be a risk for the residents. RN A stated the risk could be an explosion. RN A stated no residents in the facility have oxygen signs posted and the risk still exists. Interview on 08/08/23 at 10:20 AM the ADON stated oxygen signs mean that a resident was using oxygen. The ADON stated it meant precautions of no smoking. The ADON stated the risk to the resident of not having oxygen signs posted was an explosion. The ADON stated since they are remodeling the halls it was the maintenance and nursing department responsibility to ensure the oxygen signs were posted. Observation on 08/08/23 at 10:32 AM - revealed Resident #30 was outside in the front patio area of the building in her wheelchair. Resident #30 had an oxygen tank in the back of her wheelchair. The meter read - arrow was on red indicating the tank was empty. Resident #30 was not seen having breathing problems. Observation and interview on 08/08/23 at 10:38 AM the ADON observed Resident #30 sitting in her wheelchair outside in the front patio area. Resident #30's oxygen tank was on red. The ADON stated that the arrow on red indicated that the oxygen tank was empty. The ADON stated it was the nurse's responsibility for ensuring the residents tanks are full. The ADON stated there could a be a risk to Resident #30 if she needed oxygen. The ADON immediately requested for a replacement oxygen tank and took the resident back to the room. Interview on 08/08/23 at 4:02 PM with the ADON stated the DON had notified her that oxygen sign postings were not required outside of the resident bedrooms because the facility was a no smoking facility and was not required. Record review of facility emergency preparedness (facility Disaster Plan) policy not dated revealed storage and use of oxygen must have an oxygen sign posted.

Based on the observations, interviews, and record reviews the facility failed to dispose of garbage and refuse properly for 1 of 1 (Dumpster) garbage dumpster containers reviewed for food safety requirements. 1. One dumpster in the back alley of the facility had trash on the floor outside and around the dumpsters. 2. One dumpster had its lid open. This failure could affect residents by placing them at risk of food borne illness, illnesses, or be provided an unsafe, unsanitary and uncomfortable environment. Findings include: Observation and Interview on 08/07/23 with the Dietary Supervisor beginning. at 8:18 AM revealed one dumpster had both side lids open exposing the trash. The Dietary Supervisor stated the maintenance department handles the trash outside. The Dietary Supervisor stated anybody throwing the trash had to close the lids after throwing the trash. The Dietary Supervisor stated the lids need to be closed due to contamination. At 8:23 AM on the right side of the dumpster was a paint can, plastic water bottle, and varies other pieces of trash on the floor. Behind the dumpster was a brown cardboard box, napkins, plastic waters bottles in the edges of the concrete floor mixed with vegetation and other unidentifiable pieces of trash. The Dietary Supervisor stated if trash was on the floor around the dumpster, they did not have to let maintenance know because maintenance was always outside cleaning. The Dietary Supervisor stated not picking up the trash that was on the floor around the dumpster and closing the dumpster lids would attract animals and pests. Interview on 08/07/23 at 11:16 AM the Maintenance Supervisor. stated the kitchen was responsible for the dumpster outside. The Maintenance Supervisor stated maintenance was responsible for everything within the facility fence. The Maintenance Supervisor stated the city goes out to clean the alley way once in a while. The Maintenance Supervisor stated that the dumpster lids needed to be closed after the trash was thrown and then picked up by whoever saw it. The Maintenance Supervisor stated trash on the floor and the lids open could attract animals like cats and be an infection control issues. Interview on 08/08/23 at 9:04 AM [NAME] B stated when throwing out the trash in the dumpster the dumpster lids need to remain closed. [NAME] B stated it was so the trash did not come out of the dumpster and contaminate the area round the dumpster. [NAME] B stated the lids were to remain closed to not attract animals. [NAME] B stated maintenance was responsible for picking up the trash area the dumpster area but if she saw trash, she would pick it up. Interview on 08/08/23 at 9:20 AM Dishwasher C stated when throwing trash, they must keep lids closed. Dishwasher C stated she does not know why the dumpster lids need to be closed but it had always been done that way. Dishwasher C stated if she saw trash on the floor, she would pick it up. Dishwasher C stated the trash on the floor would attract animals and would breed bacteria. Interview on 08/08/23 at 9:38 AM the Dietary Supervisor stated the trash bags needed to be tied well and thrown in the dumpster with the dumpster lids closed. The Dietary Supervisor stated the lids being opened attracted animals. The Dietary Supervisor stated if he sees harmless trash, he picks it up and if not, they let maintenance know to go pick it up. Record review of the facility environmental services policy not dated revealed area around dumpster shall be kept clean to ensure that the dumpster can be accessed by both employees and waste disposal company.

Based on interview, and record review, the facility failed to implement its written polices, and procedures that prohibit abuse, neglect and exploitation for 10 of 16 staff (Dietary Supervisor, Activities Director, CNA D, CNA E, CNA F, Nurse Aide G, CNA H, CMA K, CMA L, and [NAME] B) reviewed for neglect and abuse policies . The facility failed to conduct annual EMR/NAR screening for staff. This failure could put residents at risk of receiving services from employees who with a history of misconduct and/or were ineligible to provide services in this setting. Finding include: Record review of personnel files revealed the following staff (Dietary Supervisor, Activities Director, CNA D, CNA E, CNA F, Nurse Aide G, CNA H, CMA K, CMA L, and [NAME] B) did not have current annual screening of the employee misconduct registry/nurse's aide registry completed: Dietary Supervisor, Activities Director, CNA D, CNA E, CNA F, Nurse Aide G, CNA H, CMA K, CMA L, and [NAME] B. Interview on 08/09/23 at 9:52 AM with the Secretary stated she was of responsible for completing the annual EMR/NAR screenings. The Secretary stated it was mandatory to conduct annual screenings for EMR/NAR by the state. The Secretary stated the reason screenings are conducted was so staff are eligible to keep an eye on the residents and to ensure the residents are not being abused or neglected by the staff. The Secretary stated not keeping up with the annual mandatory screenings could be a risk to the residents leaving them open to abuse or neglect. The Secretary stated she keeps forgetting to do the annual screening for EMR/NAR and this years was completed on 08/08/23 for the staff. The Secretary stated the Administrator was responsible for overseeing that she was doing the annual mandatory screening. Interview on 08/09/23 at 3:55 PM the Administrator who stated that facility employees are screened for EMR/NAR upon hire and annually. The Administrator stated the purpose of screening annually was to make sure nothing had changed with any employee and that they are still eligible to work for the facility. The Administrator stated there could be a risk if screening was not done annually. The Administrator stated there was potential for abuse and neglect . Record review of the facility employees (Dietary Supervisor Date of hire 09/14/16, Activities Director Date of hire 11/14/16, CNA D Date of hire 06/08/21, CNA E Date of hire 01/14/20 , CNA F Date of hire 10/24/17, CNA H Date of hire 03/29/22, CMA K Date of hire 09/28/18, CMA L Date of hire 08/07/19, [NAME] B Date of hire 09/07/07). for EMR/NAR documentation revealed the EMR/NAR screening was conducted on 08/08/23. Record review of the facility abuse, and neglect policy dated 09/01/14 revealed employee misconduct registry - all personnel will go through the employee misconduct registry before hire and yearly thereafter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record reviews the facility failed to ensure that the residents environment remains free of accidents hazards for 1 (Resident #9) of 20 residents and to ensure 7 of 10 facility rooms were safe from hazards reviewed for accident hazards. 1. The facility failed to ensure that 5 resident-use bathroom sinks had hot water temperatures below 110 degrees F and did not put residents at risk of injury. 2. The facility failed to make sure the Resident #9's fall mat was placed according to plan of care 3. The facility failed to ensure that 1 utility closet and 1 housekeeping storage room remained closed/locked due to chemicals being stored in the housekeeping room and industry equipment/pipes in the utilizes closet. These failures could place residents at risk of injury. Findings include: Water Temperatures Observation on 08/07/2023 at 9:30 AM in the resident-use bathroom between rooms 14/16 using surveyor's thermometer revealed a hot water temperature of 127 degrees F. In observation and interview on 08/07/23 beginning at 10:15 AM the Maintenance Supervisor said two of five hot water heaters supplied hot water to the resident-use bathrooms on the facility's two wings (East Hall and [NAME] Hall). He said that the hot water heater for the [NAME] Hall provided hot water for all bathrooms on the [NAME] Hall and a communal shower located near the [NAME] Hall nurse's station. He said the hot water heater located to the right of the Administrator's office provided hot water for all the bathrooms and communal shower located in the East Hall. He said three other hot water heaters provided hot water to the laundry and kitchen only. Observation by the Maintenance Supervisor and surveyor of the resident-use bathroom sink between rooms [ROOM NUMBERS] (West Hall) revealed a hot water temperature of 118 degrees F using the Maintenance Supervisor thermometer. Observation by the Maintenance Supervisor and surveyor of the sink in the bathroom next to room [ROOM NUMBER] (West Hall) revealed a hot water temperature of 118 degrees F using the Maintenance Supervisor thermometer. The Maintenance Supervisor said that he checked water temperatures in the resident-use bathrooms for the whole facility every week and recorded the temperatures on a written log. Observation of the hot water temperature in the sink in a communal bathroom to the left of room [ROOM NUMBER] (West Hall) revealed a water temperature of 157 degrees F using the Maintenance Supervisor thermometer. The Maintenance Supervisor stated that the water temperatures might be high because morning baths had been done for some time. He said that typically when the showers were in use earlier in the morning all the hot water got used up so water temperatures would go down all over the facility. Observation of the sink in the private bathroom in room [ROOM NUMBER] (West Hall) revealed that there was no hot water because the hot water valve under the sink was off. The Maintenance Supervisor opened the hot water valve, and the hot water in the sink measured 130 degrees F using the Maintenance Supervisor thermometer. The Maintenance Supervisor was observed turning off the hot water valve saying that the water was too hot. In observation and interview on 08/07/23 at 10:27AM with the Maintenance Supervisor the [NAME] Hall hot water heater gauge reflected a hot water temperature of 141 degrees F. Maintenance Supervisor said the water was too hot and he would have to drain the hot water heater. In observation and interview on 08/07/23 at 10:34 AM with the Maintenance Supervisor the East Hall hot water heater gauge reflected a hot water temperature of 100 degrees F. In observation on 08/07/23 at 10:42 AM with the Maintenance Supervisor of the hot water from the sink in the East Hall bathroom for room [ROOM NUMBER] revealed a hot water temperature of 130 degrees F. In an interview on 08/07/23 at 10:59 AM the ADON said she had not received any complaints about resident-use water being too hot. She said that there were no incidents of scalding or burns from hot water for the past year. She said if CNAs noticed the water was too hot the nurse would be notified, and it would be reported to the facility Administrator. She did not know if there was a schedule for Maintenance to check water temperatures in resident bathrooms. Incident reports for the past six months were requested. Record review of incident reports dated from February to August of 2023 revealed no incident reports for burns or scalding. In an interview on 08/07/23 at 11:05 AM the DON was informed of the hot water temperatures being observed in resident use areas. She stated she did not know what the top water temperature for resident use should be, but that if the water temperature was too high residents could get scalded. In an interview on 08/07/23 at 12:03 PM the Maintenance Supervisor said he was draining the hot water heater for the [NAME] Hall and would set it at 100 degrees F. He stated he would also drain the East side hot water heater since there were rooms on the East side with high water temperatures. Water temperature logs for the past six months were requested. Record review on 08/07/2023 of the facility document Weekly Hot Water Temps 2023 dated from 01/02/2023 to 05/29/2023 documented that hot water temperatures were being checked once a week in all resident rooms. The document revealed no instances when the water temperature was higher than 103 degrees F. The document noted Safe water temperature between 100 [degrees] F - 110 [degrees] F. There were no water temperatures documented for the months of June 2023, July 2023 or August of 2023. In an interview on 08/07/23 at 5:03 PM the Administrator said that around 10:00 AM the facility had lowered the temperatures on both hot water heaters to lowest setting and drained hot water from both hot water heaters. In observation on 08/07/23 beginning at 5:09 PM with the Administrator and Maintenance Supervisor observation in the resident-use sink in the bathroom between Rooms 14/16 (West Hall) revealed a hot water temperature of 126 degrees F. Observation of the resident-use sink in communal shower room for the [NAME] side revealed a hot water temperature of 137 degrees F. Observation of the resident-use sink in room [ROOM NUMBER] (East Hall) revealed a hot water temperature of 118 degrees F. In an interview on 08/07/23 at 5:28 PM the Administrator and Maintenance Supervisor said they had called a plumber to inspect and adjust hot water heaters in the morning . In an interview on 08/07/23 at 5:31 PM the ADON said excessive hot water temperatures could put residents at increased risk of scalding and burns. She said she had in-serviced all CNAs to check water temperatures on their bare skin, then have the residents also check the water temperature before using the water for resident care. Observation and interview on 08/08/2023 at 8:16 AM with the Maintenance Supervisor and the facility President (Co-owner) in the bathroom between rooms [ROOM NUMBERS] (West) revealed that the hot water temperature in the sink was 120 degrees F. The facility President stated there were several ways to adjust the hot water temperature and that water temperature at the point of use would be 4 to 6 degrees lower than the temperature showing on a hot water heater gauge. Observation and interview on 08/08/2023 at 8:26 AM with the Maintenance Supervisor, the facility President (Part Owner) and the Administrator in room [ROOM NUMBER] (East) revealed that the hot water temperature was 118 degrees F using the Maintenance Supervisor thermometer. The Administrator said that the plumber had determined that the temperature gauge on the East side water header heater was broken and stuck at 100 degrees F. He said that the East side water heater was currently set on hot. In observation and interview on 08/08/2023 at 11:22 AM a plumber and the Maintenance Supervisor were observed working on the East side water heater. The plumber said the water heater was set at low which would yield a maximum water temperature of 120 degrees. When asked he said that he had not been advised as to the acceptable temperature for hot water for the facility. He explained that the mixing valve on the water heater could be adjusted to mix hot and cold water to the desired temperature. In observation on 08/08/2023 beginning at 2:52 PM with the Maintenance Supervisor and Administrator, six resident-use bathroom sinks on the [NAME] Hall had hot water temperatures below 110 degrees F. It was observed that the resident-use bathroom sink in room [ROOM NUMBER] (East Hall) had a hot water temperature of 116 degrees F. The Administrator said that the hot water for room [ROOM NUMBER] went directly into the bathroom sink and did not pass through the water heater mixing valve. He said the occupant of room [ROOM NUMBER] wanted to stay in that room with the understanding that the hot water to the sink would be turned off. In an interview on 08/09/2023 at 8:11 AM the facility Administrator said the mixing valve on the East Hall water heater had been adjusted to lower the temperature of water delivered to resident's rooms. He did not state to what temperature the water temperature had been lowered. Record review of the undated facility policy Water Temperature documented it was the policy of the facility to maintain a water temperature suitable for the comfort of the residents in resident-use areas. It stated to check temperature in resident's room, shower and restroom. Water temperature must not be higher than 110 degrees Fahrenheit. Temperature log must be done at least once a week by maintenance. Fall Risk Resident #9's face sheet dated 08/09/23 revealed admission on [DATE] to the facility. Resident #9's history and physical dated 03/08/22 revealed an [AGE] year-old female diagnosed with dementia, debility (physical weakness), spondylosis (abnormal wear on the cartilage and bones of the neck (cervical vertebrae)), aspiration pneumonia, and dysphagia (difficulty swallowing). Resident #9's quarterly MDS dated [DATE] revealed ADLs for resident for bed mobility was one person assist with total dependence and transfers as total dependence with two-person assistance. Resident #9's care plan dated 02/03/23 revealed the resident was low risk for falls due to dementia and limited mobility. Place the floor mat to minimize the injury in case resident falls. Resident #9's quarterly fall risk assessment for 02/05/23 indicated resident was a high risk for falling and had a history for falling before. Resident's gait was weak and impaired. Fall risk assessment dated [DATE] revealed low risk for falling and was marked as no for history of falling . Observation on 08/09/23 at 1:16 PM revealed Resident #9 was in bed with head of bed elevated past the headboard top plane and floor mat was underneath the resident's bed. Observation on 08/09/23 at 2:13 PM in Resident #9's room. The resident's floor mat was underneath the resident's bed while resident was lying in bed. Interview on 08/09/23 at 1:20 PM RN A stated Resident #9's fall mat needed to be placed next/near the resident's bed and not underneath Resident #9's bed so if resident fell she would not get hurt. RN A stated anyone placing the resident in bed was responsible for putting the fall mat back in place next to the bed. RN A stated the risk to Resident #9 was falling possibly getting fractures because she was older and had brittle bones. Interview on 08/09/23 at 2:01 PM with the ADON. The ADON stated Resident #9 was not high risk for falls. The ADON stated Resident #9 has never had a fall during her time at the facility. The ADON stated the fall mat needed to be placed back next to the bed so if the resident fell she would not get hurt. The ADON stated Resident #9 would be at risk for injuries since the fall mat was not placed correctly. Utilities Closet & Housekeeping Storage Room Observation on 08/07/23 at 4:55 PM revealed the in the main corridor hallway in the building, the utilities closet was not closed all the way shut. By pulling the door it opened and inside was a water heater, a ladder, boiler, piping on the walls, and other large industry appliances with metal piping running down at ankle level running through the room. The utilities closet was located in a high traffic area where residents were passing by. Interview on 08/07/23 at 4:47 PM the ADON stated the utilities room needed to be secured, closed, and locked due to the water heater and other industrial equipment being housed in the room. The ADON stated it was to be closed and locked so resident would not get into the room. The ADON stated there was a risk to the residents because there was a water heater, boiler, and other appliances in the room in which the residents could have hurt themselves with. Observation on 08/07/23 at 5:03 PM revealed in the main corridor on the other side of the hallway in the building the housekeeping storage room was left open. Inside the room there were various chemicals in spray bottles and containers, brooms, mops, boxes. Interview on 08/07/23 at 5:05 PM the ADON stated the housekeeping door needed to remain closed and locked so residents don't get in. The ADON stated the risk to the residents where that they could get the chemicals risking injury. Interview on 08/08/23 at 1:25 PM with the Dietary Supervisor stated he was also in charge of the housekeeping department. The Dietary Supervisor stated the housekeeping storage room door was not supposed to be opened and unlocked. The Dietary Supervisor stated there was a risk to the resident if they got into the room if they ingested any of the chemicals. Interview on 08/08/23 at 1:45PM AM the Maintenance Supervisor stated the utilities closet needed to be closed and locked at all times. The Maintenance Supervisor stated it was a hazard for the residents because there was industrial appliances in the room and pipes were low to the ground. The Maintenance Supervisor stated if the residents had gotten into the room they could have fallen or gotten hurt. Interview on 08/09/23 at 3:55 PM with the Administrator stated the utilities closet and housekeeping storage room were to remain closed and locked. The Administrator stated they were putting locks at the top of the doors to make sure they locked and where residents were not able to reach them. The Administrator stated the residents going into the utilities or housekeeping rooms could be a risk of something dangerous happening to them. The Administrator stated the facility employees are responsible for making sure that the doors are closed and locked for the utilities and housekeeping rooms. Facility policy of accidents and supervision and falls were not obtained. Record review of the facility dietary safety awareness policy not dated revealed to keep bathroom doors and utility doors closed.

Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation/storage, in that: 1. Foods in dry store, walk in, and freezer were not dated or labeled properly. 2. Food containers and food bags were not properly sealed in the kitchen and walk-in. 3. Hot food had been placed in the refrigerator while hot. 4. A dented can was not removed from shelf rotation. 5. the dish washer temperature was not at or above 140 degrees. These failures could affect residents by placing them at risk of food borne illness. Findings include: Observation and interview on 08/07/23 beginning at 8:15 AM with the Dietary Supervisor revealed in the freezer door was a bag of Chile rellenos with no expiration date noted. On the first shelf in the freezer there was a closed package of sausage not labeled, on the bottom self were (x6) closed bags of potatoes not labeled. At 8:32 AM on in the seconded freezer on the door was a closed bag of chicken nuggets not labeled, underneath on the door were French toast packages not labeled. At 8:41 AM in the refrigerator on the seconded shelve was a small metal pan labeled breakfast and not labeled correctly and very hot. The Dietary Supervisor stated the hot pan of breakfast puree was not to be in the refrigerator and needed to cool down first before being put in to the refrigerator. On the right side of the refrigerator on the top shelve was a container of orange juice not labeled correctly , an open bag of cheddar cheese slices in a zip lock bag and not labeled correctly, a zip lock bag that was not sealed properly of white cheese and not labeled correctly. At 8:45 AM across the refrigerator and freezer the shelves had a container of creamy of wheat that was open and not sealed. The Dietary Supervisor stated the creamy of wheat had to be sealed or closed to prevent cross contamination. Observation and interview on 08/07/23 at 8:50 AM in the basement revealed there was a dented can of pears in the rotation shelves. The Dietary Supervisor stated the dented can of pears should not have been placed in the rotation shelves and should have been placed in the discarded box to return to the supplier. The Dietary Supervisor stated dented cans are not used because they are contaminated, grow bacteria like e-coli and if served to residents can hurt their stomachs. All the cans on the shelve were not dated. Observation on 08/07/23 at 9:00 AM in the kitchen in the prep area were two spice containers (Lemon pepper & Black pepper) that has the lids open. The Dietary Supervisor stated the lids need to be closed to prevent bugs from going into the containers and causing contamination. Observation on 08/08/23 at 8:55 AM of the dish machine temperature gauge for the water as dishes were moving through it read 128 degrees F indicating the water was not being heated to 140 degrees F. Interview on 08/08/23 at 9:04 AM with [NAME] B stated she waits for cooked foods to cool down before putting them in to the refrigerator. [NAME] B stated the hot foods are not supposed to go into the refrigerator hot. [NAME] B stated if served to the residents it could hurt their stomachs. [NAME] B stated open foods need to be labeled correctly with date, name, and expiration date. [NAME] B stated the dish machine's water needed to be at 140 degrees to be able to kill the germs. [NAME] B stated not being at 140 degrees runs the risk of germs not being killed. [NAME] B stated she lets her supervisor know if there are any dented cans. [NAME] B stated she does not use dented cans because it can cause e-coli. [NAME] B stated at her house she does not use dented cans because of bacterial growth that can get you sick. [NAME] B stated the residents could get sick if served. Interview on 08/08/23 at 9:20 AM with the Dishwasher C stated foods need to be labeled correctly with name, date, and expiration date. Dishwasher C stated she received training with temperature, labeling, and cooking foods from her Dietary Supervisor as well as through the food handler's course. Dishwasher C stated the water in the dish machine needed to be at 140 degrees to kill the bacteria and if it was not at 140 then it would not kill the bacteria. Dishwasher C stated running dishes through the dish machine not at 140 degrees and using the dishes could get resident's sick. Dishwasher C stated if she sees dented cans, she notifies her Dietary Supervisor. Dishwasher C stated dented cans are not good to use but does not know why they are not good to use. Interview on 08/08/23 at 9:38 AM the Dietary Supervisor stated that they do not put an expiration date on foods because they know that the food will not last pass seven days. The Dietary Supervisor stated mislabeled foods that are served to residents can get them sick. The Dietary Supervisor stated dented cans cannot be used because organisms can grow inside of the can . The Dietary Supervisor stated the dish water needed to be at 140 degrees to be able to kill the bacteria and not being at that temperature could get resident's sick. Recorded review of the facility dietary policies/procedures not dated revealed food storage - open food items must be dated when opened. Open frozen foods must be dated. Use dishwashing machine to wash utensils at 140-degree temperature. Record review of the facility dietary safety awareness policy not dated revealed outdated, dented goods must be discarded. Record review of facility in-service report on diet and nutrition dated 05/12/23 revealed dietary staff were trained with the understanding the importance of nutrition care. Record review of facility in-service report for food temperatures dated 06/24/23 revealed dietary staff were trained on people review and learn to drive the correct and different kind of temperature on the food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement its written policies and procedures that prohibit abuse and neglect for 1 (Resident #140) of 6 residents reviewed for abuse and neglect. A. The facility failed report allegation of abuse reported by Resident #140 RP regarding staff member being physically abusive to appropriate authorities as stated on their abuse policy. This failure could place residents at risk for abuse and neglect. Findings included: Record review of Abuse and Neglect Policy undated revealed it is the duty of all personnel to report any incident pertaining to abuse and neglect to proper authorities and failure to report is subject to criminal prosecution. Record review of face sheet dated 6/29/22 revealed Resident # 140 was a [AGE] year old male admitted on [DATE]. Record review of Resident # 140's History and Physical from local nursing home dated 3/20/22 noted diagnosis of early dementia and anxiety. Record review of Resident # 140's MDS admission assessment dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment. Active diagnosis included Alzheimer disease and non-Alzheimer's dementia. Record review of Facility Complaint Form dated 6/4/22 noted person making complaint was Resident # 140's RP and complaint revealed patient's RP accused staff nurse of hitting patient in the face. Complaint was referred to DON and comments noted patient left against medical advice 6/6/22, patient has Alzheimer's, dementia with behavioral disturbance. Facility Complaint Form was signed by DON and dated 6/7/22. Record review of Tulip on 6/29/22 revealed no self-reports related to Resident # 140 regarding abuse allegation. Interview on 6/29/22 at 10:47 AM, the DON reported Resident # 140 had been in facility for a short period of time and had diagnosis of dementia, Alzheimer's, and behavioral disturbance. The DON reported she was out on vacation for few days at the time the incident happened, and when she returned Resident # 140 had left against medical advice. The DON reported she conducted investigation, got statements from all staff involved in his care. The DON reported that findings were inconclusive due to several staff witnessing Resident #140 aggressive behavior towards staff. The DON reported she did not report the incident to State Office. The DON did not have an answer for failure. Interview on 06/29/22 at 10:55 AM, the Administrator reported he had been notified of abuse allegation the day it happened by charge nurse. The Administrator reported Resident # 140 had left against medical advice a day or two after allegation was made. The Administrator reported he did not report the abuse allegation to State Office. The Administrator did not have answer for failure. Interview and record review on 06/29/22 at 2:51 PM, the Administrator reported he was the Abuse Prohibition Coordinator. He stated he was required to report any allegation of abuse within 24 hours to State Office. Record review of Abuse and Neglect Policy undated revealed it is the duty of all personnel to report any incident pertaining to abuse and neglect to proper authorities. The Administrator stated that proper authorities meant State Office. Administrator stated by not reporting allegations of abuse could pace residents at risk of abuse and neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all allegations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation was made to state survey agency for 1 of 6 residents (Resident #140) reviewed for abuse. A. The facility failed to report allegation of physical abuse to Resident #140 to State Survey Agency. This failure could place residents at risk for abuse and neglect. Findings included: Record review of Abuse and Neglect Policy undated revealed it is the duty of all personnel to report any incident pertaining to abuse and neglect to proper authorities and failure to report is subject to criminal prosecution. Record review of face sheet dated 6/29/22 revealed Resident # 140 was a [AGE] year old male admitted on [DATE]. Record review of Resident # 140's History and Physical from local nursing home dated 3/20/22 noted diagnosis of early dementia and anxiety. Record review of Resident # 140's MDS admission assessment dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment. Active diagnosis included Alzheimer disease and non-Alzheimer's dementia. Record review of Facility Complaint Form dated 6/4/22 noted person making complaint was Resident # 140's RP and complaint revealed patient's RP accused staff nurse of hitting patient in the face. Complaint was referred to DON and comments noted patient left against medical advice 6/6/22, patient has Alzheimer's, dementia with behavioral disturbance. Facility Complaint Form was signed by DON and dated 6/7/22. Record review of Tulip on 6/29/22 revealed no self-reports related to Resident # 140 regarding abuse allegation. Interview on 6/29/22 at 10:47 AM, the DON reported Resident # 140 had been in facility for a short period of time and had diagnosis of dementia, Alzheimer's, and behavioral disturbance. The DON reported she was out on vacation for few days at the time the incident happened, and when she returned Resident # 140 had left against medical advice. The DON reported she conducted investigation, got statements from all staff involved in his care. The DON reported that findings were inconclusive due to several staff witnessing Resident #140 aggressive behavior towards staff. The DON reported she did not report the incident to State Office. The DON did not have an answer for failure. Interview on 06/29/22 at 10:55 AM, the Administrator reported he had been notified of abuse allegation the day it happened by charge nurse. The Administrator reported Resident # 140 had left against medical advice a day or two after allegation was made. The Administrator reported he did not report the abuse allegation to State Office. The Administrator did not have answer for failure. Interview and record review on 06/29/22 at 2:51 PM, the Administrator reported he was the Abuse Prohibition Coordinator. He stated he was required to report any allegation of abuse within 24 hours to State Office. Record review of Abuse and Neglect Policy undated revealed it is the duty of all personnel to report any incident pertaining to abuse and neglect to proper authorities. The Administrator stated that proper authorities meant State Office. Administrator stated by not reporting allegations of abuse could pace residents at risk of abuse and neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure they completed a PASRR evaluation on newly admitted residents prior to admission for 1 of 4 residents (Resident #38) reviewed for PASRR screenings. Resident #38, who had an MI diagnosis, was admitted to the facility under a waiver based on the assumption that she would be in the facility fewer than 30 days, and so was not referred to the local MI authority for PASARR evaluation. When Resident #38 stayed beyond the 30 days, the facility failed to refer her for PASARR evaluation. This failure puts residents with MI diagnoses at risk of not receiving specialized services as needed to meet their needs. Findings included: Record review of Resident #38's admission Record dated 06/30/2022 documented that she was originally admitted to the facility on [DATE], and her current admission began on 08/31/2021. She was [AGE] years old. Her diagnoses included Schizoaffective Disorder, Bipolar type; Major Depressive Disorder, Recurrent, Unspecified; Anxiety Disorder, unspecified; and Schizophrenia, unspecified. Review of Resident #38's Progress Note, interval assessment dated [DATE] documented in part that she had diagnoses including Schizophrenia with auditory hallucinations, Bipolar disorder, anxiety, and dementia. Record review of Resident #38's quarterly MDS dated [DATE] documented that she had severely impaired cognitive skills for daily decision making. She had signs and symptoms of delirium including fluctuating inattention and altered level of consciousness. Her diagnoses included anxiety disorder, depression and schizophrenia. Record review of Resident #38's Care Plan dated 05/01/2021 documented in part that she was using psychotropic medications relative to a diagnosis of schizophrenia. Record review of Resident #38's electronic diagnoses listing accessed on 06/28/2022 revealed diagnoses of schizoaffective disorder, bipolar type; Hallucinations, unspecified; Major Depressive Disorder, recurrent, unspecified; Anxiety disorder, unspecified; and Schizophrenia, unspecified. Record review of Resident #38's PASARR Level 1 Screening document dated 05/03/2021 revealed that she was assessed on 04/30/2021 to have evidence or indictors of mental illness. Her admission Category was classified as F0100 Exempted Hospital Discharge because a physician certified that she was likely to require less than 30 days of nursing facility services. In an interview on 06/30/2022 at 11:22 AM, the MDS Nurse said that it was her responsibility to coordinate determination of resident's PASARR status with the local authority. She said that the reason Resident #38 was not re-screened after 30 days was because the resident was insured by a PACE program and the PACE Program might change resident's status without informing the facility. The MDS Nurse said that the PACE program did not provide specialized services to people with MI. In an interview on 06/30/2022 at 11:27 AM, the DON said that if Resident #38 was not rescreened for eligibility for PASSAR services, the resident would not be affected because if the Local Authority rescreened her, they would say the resident was in a secure environment and so not provide any services. In interview and record review on 06/30/22 at 2:01 PM the MDS Nurse provided a PASSAR PL1 document for Resident #38 dated 6/30/2022 that showed that resident had evidence of MI. The PASSAR PL1 document showed No for Exempted Hospital Discharge. In an interview on 06/30/22 at 3:12 PM the MDS Nurse said that changes in Resident #38's PASARR eligibility were missed because she [the MDS Nurse] was new to the facility and thought that the PACE program was responsible for coordinating PASARR evaluations with the local authority, so the paperwork that the facility had was sufficient. The MDS Nurse said that the facility did not have a system for tracking PASARR changes because changes in resident PASSAR status was not normal. The MDS Nurse said she would need to work out a process for tracking resident's PASARR status with the DON. She said that she did not know what the potential impact of an incorrect PASARR might be and had not known of a person with MI who received PASARR services. Record review of the undated facility policy PASSAR documented in part that the facility would do a PASSAR screening on every resident. The policy stated PASARR is done on admission for every resident no more than 14 days. The policy did not describe processes for monitoring for or responding to changes in resident's PASARR status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary treatment and services based on the comprehensive assessment and, consistent with professional standards of practice, to prevent pressure ulcers for one (Resident #7) of one resident reviewed for pressure ulcers in that: Resident #7 was not provided heel protectors at all times as ordered by the physician. This failure could place residents who are at risk for pressure ulcer formation at increased risk of developing pressure ulcers. Findings included: Record review of Resident #7's admission Record dated 06/30/2022 revealed that she was [AGE] years old. She was originally admitted to the facility on [DATE] and her current admission began on 03/23/2022. Her diagnosis included Alzheimer's Disease with late onset, other psychotic disorder not due to a substance or known physiological condition, Unspecified Dementia without behavioral disturbance, cachexia (unintentional weight loss) and gastrotomy status (she had a feeding tube). Record review of Resident #7's history and physical dated 01/18/2022 revealed that she had advanced dementia, was completely bed/chair dependent, and a mechanical lift was needed for transfers. Record review of Resident #7's quarterly MDS dated [DATE] revealed that she had severely impaired cognitive skills for daily decision making. She had continuous difficulty focusing attention, continuous disorganized thinking, and continuous altered level of consciousness. She required extensive assistance from one person to move around in bed, to move around the facility, to dress, eat, use the toilet and for personal hygiene. She was totally dependent on two people to transfer between surfaces. She did not walk. She was always incontinent of bowel and bladder. According to the MDS she was not at risk for developing pressure ulcers and had none at the time the assessment was performed. Record review of Resident #7's Care Plan revised on 04/29/2021 documented that the resident had a potential for pressure ulcer development. An intervention initiated on 06/01/2022 documented that she was to wear Spenco boots (for relief of pressure for the feet, heels and ankles) at all times. Record review of Resident #7's physician order dated 06/01/2022 documented that she was to wear Spenco boots at all times. Observation on 06/28/22 at 9:10 AM of Resident #7 revealed, that she was seated in a wheelchair in her room and was wearing yellow non-slip socks. Nothing else was on her feet. An interview was attempted but the resident did not respond to verbal stimuli in English or Spanish. Observation on 06/28/22 at 2:23 PM of Resident #7 revealed, that she was seated in a wheelchair. She was wearing yellow socks with non-slip strips and had nothing else on her feet. Observation 06/28/2022 at 3:38 PM of Resident #7 revealed, that she was lying in bed. She was wearing yellow socks and had nothing else on her feet. Observation on 06/29/2022 at 8:01 AM of Resident #7 revealed, that she was dressed and in her wheelchair in her room. An interview was attempted but the resident did not respond to verbal stimuli. She had yellow socks and nothing else on her feet. Observations on 06/30/2022 at 7:55 AM and at 9:18 AM revealed that on both occasions Resident #7 was dressed and in her wheelchair in her room and was wearing yellow non-slip socks, with nothing else on her feet. In an interview and observation on 06/30/2022 at 8:03 AM, CNA A said that she had worked with Resident #7 since the resident moved into the facility. CNA A said she helped Resident #7 dress that morning (06/30/2022) and had put yellow non-slip socks on her. She said that the resident had been wearing special boots since when she moved into the facility, but that she forgot to put the boots on Resident #7 that morning. CNA said that she had dressed Resident #7 the mornings of 06/28, 06/29 and 06/30/2022 and forgot those mornings to put the boots on the resident. CNA said that the boots were to prevent pressure ulcers and that if the resident did not wear the boots, she might get pressure ulcers. She said that the resident did not have pressure ulcers on her feet at that time (06/30/2022). CNA A was observed to look briefly in Resident #7's room and then went immediately to a linen closet in the hallway where she found some large black boots labeled Foot Drop. She said that the boots did not belong to Resident #7 but that they were clean. She was observed to put the boots on Resident #7. In an interview and observation on 06/30/2022 at 8:10 AM, LVN B said that the CNAs were responsible for putting ulcer prevention devices on residents. She said that she was responsible for confirming that pressure relief devices were being used and being that they were being used properly. She said she confirmed this by going down the hall and looking at residents. She said that Spenco boots were used to prevent deep tissue injuries (a type of pressure ulcer). LVN B was observed to go to Resident #7's room and look at the large black boots that the resident had on her feet. LVN B stated that these were the wrong boots for the resident and that the correct boots were small and shaped like a taco. LVN B stated that without the boots the resident was at risk of developing ulcers on her heels. In an interview and observation on 06/30/2022 at 8:15 AM, the MDS nurse said that Spenco boots were for ulcer prevention, and that the order for Resident #7 to wear Spenco boots was received on 06/01/2022. She said that the CNAs had a list indicating which residents were to have pressure-relieving devices. The MDS Nurse observed going to Resident #7's room to look at the boots the resident had on. Resident #7 was still wearing the large black boots with foot drop printed on them. The MDS nurse said that she did not know if the boots on the resident served the same purpose as the small boots for pressure relief. In an interview on 06/30/2022 at 10:55 AM, the DON said that there was not a problem with Resident #7 not having the Spenco boots on because the resident did not have pressure ulcers. She said that the boots were ordered by the PACE program of which Resident #7 was a member in order to prevent pressure ulcers. The DON said that the PACE program liked to put a lot of devices on the resident and that she (the DON) was always telling the PACE program that the facility wanted to use the least restrictive interventions with residents. She said that although the use of the Spenco boots was ordered by the resident's physician, it was at the nurses' discretion whether to use them or not. Review of the facility's undated policy Heel Protectors' documented in part that it was the facility policy to prevent pressure sores on residents that were bed bound. Heel protectors were devices that are cushioned and placed underneath the heels as preventive measure for pressure sores.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that PRN orders for psychotropic drugs are limited to 14 days for one (Resident #7) of seven residents reviewed for unnecessary medications. Resident #7 had an order for Lorazepam (an anti-anxiety medication) PRN, with no end date. This failure could place residents at risk of receiving unnecessary psychotropic medications. Findings included: Record review of Resident #7's admission Record dated 06/30/2022 revealed that she was [AGE] years old. She was originally admitted to the facility on [DATE] and her current admission began on 03/23/2022. Her diagnosis included Alzheimer's Disease with late onset, other psychotic disorder not due to a substance or known physiological condition, Unspecified Dementia without behavioral disturbance, cachexia (unintentional weight loss) and gastrotomy status (she had a feeding tube). Record review of Resident #7's history and physical dated 01/18/2022 revealed that she had advanced dementia and was completely bed/chair dependent. She was receiving quetiapine (an anti-psychotic medication) and had diagnoses of Alzheimer's dementia late onset with behavioral disturbance, and Dementia with psychotic features. Record review of Resident #7's quarterly MDS dated [DATE] revealed that she had severely impaired cognitive skills for daily decision making. She had continuous difficulty focusing attention, continuous disorganized thinking, and continuous altered level of consciousness. She had not received any antianxiety medication over the seven-day look-back period. Record review of Resident #7's Care Plan revised on 04/29/2021 documented in part that the resident had a mood problem and that she would have no signs of symptoms of anxiety through 07/26/2022. Medication would be administered as ordered. Record review of Resident #7's physician's medication order dated 03/14/2022 documented that she was to receive .05 ML of 2 MG/ML Lorazepam Intensol Concentrate (an anti-anxiety medicine) every four hours as needed for Anxiety/ Restlessness which could be repeated in 30 minutes if the first dose was ineffective. Review of Resident #7's MAR for the months March, April, May, and June of 2022 documented that no doses of .05 ML of 2 MG/ML Lorazepam Intensol Concentrate were administered. In an interview on 06/30/2022 at 11:00 AM, the DON said that Resident #7 had PRN orders for lorazepam exceeding 14 days because the resident received hospice care from a PACE program, and it was standard procedure for the PACE program to order PRN lorazepam without an end date for its hospice patients. She said that although the facility was responsible for the care provided to its residents, and the PACE program came into the facility to provide services, ordering PRN Lorazepam exceeding 14 days was how the PACE hospice program always did it. Review of the facility's undated policy PRN Psychotropics documented in part that it was the policy of the facility to monitor the use of PRN psychotropic medications. It documented that the facility would use psychotropic medication on a PRN basis for 14 days only. If the prescribing physician wanted to continue to prescribe the psychotropic medication on a PRN basis, the physician would have to re-evaluate for another 14 days or prescribe it on a routine basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs in 1 of1 medication room reviewed for medication storage. The narcotic locked box in the refrigerator 1 of1 medication room was not permanently affixed and secured to the refrigerator. This failure could result in drug diversion of controlled meds. Findings included: During observation on 06/30/2022 at 8:20AM of medication room [ROOM NUMBER] revealed that the narcotic locked box in the refrigerator was not permanently affixed and secured to the refrigerator. The contents of the narcotic box included the following meds: Medication for Resident #12- Dronabinol (Marinol) During an interview and observation on 06/30/22 at 8:20AM the refrigerator was opened by DON, which revealed two small locked boxes on the right side of refrigerator. The DON stated those were for controlled meds. Observation revealed those boxes were affixed to the refrigerator and did not come out. Observation revealed one large box with combination on left of refrigerator with one medication inside. The DON stated that that med was a probiotic. Surveyor asked why the probiotics were locked up. The MDS Nurse came into the medication room and stated, no, those are not probiotics, those meds are a controlled substance and have to be locked in a box. Surveyor then asked why this box was not affixed to the refrigerator like the others, surveyor picked up the box and showed the DON that the box was not affixed. The DON stated that because the med packet was too big to fit in the other smaller boxes, they put it in the larger locked box, but we will affix it to the refrigerator right now. The DON called the maintenance man and when he arrived, she instructed him to affix the box to the refrigerator like the other boxes. Record review of the facility's policy section 4.1 titled Medication Storage: Storage of Medication dated 2007 indicated in part: Controlled medications must be stored separately from non-controlled medications. The access system used to lock Schedule II medications and other medications subject to abuse, cannot be the same access system used to obtain the non-scheduled medications. Schedule II medications and preparations must be stored in a separately locked permanently affixed compartment. See section 4.2, Storage of Controlled Medications. Schedule III-IV and non-controlled medications that have been identified by the nursing care center, as having the potential for abuse may also be stored with Schedule II medications. Record review of the facility's policy section 4.2 titled Controlled Medication Storage dated 2007 indicated in part: Medications listed in Schedule II, including those requiring refrigeration, are stored under separately locked affixed compartments, non-controlled medications that have been identified by the nursing care center, as having the potential for abuse may also be stored with controlled substances. Record review of Pharmacy Consult Log: Med Room Audit Form by consultant dated 01/05/2022 revealed Criteria not met controlled box is free standing, needs to be attached to fridge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident # 27) of 1 resident's reviewed for Foley catheter care. A. Resident # 27's Foley catheter was on the floor and tubing was over the oxygen concentrator. B. DON grabbed the Foley catheter with no gloves. These failures placed the residents at risk for infection due to cross contamination. Findings included: Record review of Resident #27's Face sheet dated 6/29/22 revealed Resident # 27 was a [AGE] year-old female admitted on [DATE]. Record review of Resident # 27's History and Physical dated 2//15/22 revealed a diagnosis of anemia Record review of Resident # 27's MDS quarterly assessment dated [DATE] revealed a BIMS score of 11, indicating she was cognitively intact. Observation and interview on 06/30/22 at 9:43 AM revealed, Foley catheter was on the floor and tubing was over the oxygen concentrator. Resident # 27 stated nurse had placed a new catheter yesterday evening. Resident # 27 stated she had not noticed Foley catheter was still in the room and on the floor. The DON reported the Foley catheter should have been disposed of in the biohazard waste after it had been replaced. The DON picked the Foley catheter with no gloves and Resident # 27 told her she needed to wear gloves. The DON walked to the front of the room to get gloves and Resident # 27 told DON she needed to wash her hands. Resident # 27 reported that Foley catheter on the floor and failure to wash hands after picking up Foley catheter with no gloves was a cross contamination issue. The DON reported the Foley catheter on the floor was considered cross contamination and she should have washed hands after picking up the Foley catheter and before going for gloves. The DON reported she should have worn gloves prior to picking up Foley catheter. The DON reported training regarding infection control and Foley catheter care were done upon hire and as needed. The DON reported the Infection Preventionist nurse and herself were in charge of overseeing staff were following infection control guidelines. The DON did not have answer for not wearing gloves before picking up Foley catheter and Foley catheter not been properly disposed of. Interview on 06/30/22 at 1:20 PM, LVN C reported she had placed a new Foley catheter bag on Resident # 27 yesterday evening. LVN C stated when she was asked by Resident # 27 to replace new Foley catheter, the old one was not at sight and assumed someone else had thrown it out. LVN C stated that Foley catheter should have been disposed of in red biohazard bin as soon as it was removed. LVN C stated that leaving the Foley catheter on the floor was considered cross contamination and potential infection control issue. LVN C reported she received training regarding biohazard disposal upon hire. Interview on 06/30/22 at 1:45 PM the Administrator reported Foley catheters were required to be disposed of in red biohazard container. The Administrator reported the nurses were required to use gloves when caring for Foley catheters. The Administrator reported old Foley catheter bags were required to be disposed of in a red biohazard bag and in the red biohazard bin. The Administrator reported by not disposing of Foley catheter appropriately ad not wearing gloves when handling Foley catheter was a cross contamination issue. The Administrator reported this failure was a potential infection control concern. The Administrator reported staff were trained regarding infection control and Foley catheter care upon hire and as needed by the DON and Infection Preventionist nurse. Record review of Infection Control- Environmental Infection Control: Waste Disposal dated April 2012 revealed All infectious and regulated waste destined for disposal shall be placed in closable leak-proof containers or bags that are color-coded or labeled as herein described.