**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System, within 14 days, upon a resident's transfer, reentry, discharge, and death, for 1 of 8 residents (Resident #25) reviewed for transmitted MDS data to the CMS System. The facility failed to transmit a discharge MDS assessment to the CMS system for Resident #25. This failure could place residents at risk for not having their assessments transmitted timely which could cause a delay in treatment. The findings included: A record review of Resident #25's admission record dated 10/03/2024, revealed an admission date of 05/06/2024 and a discharge date of 06/18/2024 with diagnoses which included heart disease and hypertension (high blood pressure). A record review of Resident #25's medical record revealed an admission MDS assessment dated [DATE] which revealed Resident #25 was a [AGE] year-old male admitted for care and assessed with a BIMS score of 15 which indicated no impairment to his cognition. Further review of Resident #25's medical record revealed no other MDS assessment and or transmittal to the CMS system. During an interview on 10/03/2024 at 06:44 PM, LVN C stated she was the MDS coordinator and began her position on 06/01/2024. LVN C stated Resident #25 had discharged to an assisted living facility on 06/18/2024 and she had not recognized the discharge and did not initiate an MDS discharge assessment to transmit to the CMS system. LVN C stated the electronic record system would prompt her to initiate discharge assessments for residents MDS transmittals to the CMS system for discharges within 14 days post discharge. LVN C stated she did not see Resident #25's discharge alert and did not produce the discharge assessment. LVN C stated the DON was her supervisor and was responsible for oversight of residents' discharges. During an interview on 10/04/2024 at 03:00 PM, the DON stated Resident #25 was discharged to an assisted living facility due to his improved health status and she had failed to have oversight to ensure Resident #25's MDS discharge assessment was captured and transmitted to the CMS system. The DON stated the failure to transmit accurate and timely MDS assessments could place residents at risk for harm by inaccurate records reported to the CMS system. A policy for MDS transmittals to the CMS system was requested on 10/4/2024 at 12:46 PM and the administrator stated the facility had no policy and followed and adhered to the HHSC guidelines at Resident assessments related to MDS assessments and reporting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 3 the residents (Resident # 3) reviewed for oxygen in that: The Facility failed to ensure Residents #3's, nebulizer tubing was bagged. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications. The findings were: Record review of Resident # 3's face sheet dated 10/1/24 revealed an 84-year female admitted to the facility on [DATE] with the diagnoses that included: Chronic Obstructive Pulmonary Disease [disease is characterized by breathlessness] ,Gastroesophageal reflux disease [condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach] and Major Depressive Disorder [mood disorder that causes a persistent feeling of sadness and loss of interest] . Record review of Resident # 3's Quarterly MDS dated [DATE] revealed a BIMS of 15, which indicated intact cognition. Record review of Resident #3's Physician monthly orders dated October 2024 revealed an order start date of 04/01/24: Albuterol Sulfate Inhalation Solution for nebulization 0.5 mg -3mg twice a day as needed for shortness of breath. Observation on 10/01/24 at 11:45 a.m. revealed that Resident # 3 's nebulizer tubing was unbagged on the bedside table. In an interview with Resident # 3 on 10/01/24, at 12:01 p.m., she stated they only bag the nebulizer tubing at this facility every once in a while, depending on the nurse. In an interview with RN A on 10/01/24, at 1:38 p.m., she stated she was the assigned RN to Resident # 3. It was revealed that it was every nurses responsibility to change nebulizer tubing weekly and bag them. However, she did not know why the nebulizer tubing was not being bagged. RN A stated that the Resident was at risk of possible respiratory infection due to the nebulizer tubing being undated and unbagged. During an interview with the (DON) on 10/01/24 at 3:55 p.m., it was revealed that Resident #3 should have had their nebulizer tubing changed and bagged by the night shift. The DON mentioned that she needed to determine why the nebulizer tubing was not bagged for Resident #3. She also stated that she oversaw this task and assured that she would monitor it for compliance. The DON stressed that Resident #3 was at risk of a possible respiratory infection due to the outdated and unbagged nebulizer tubing and unfortunately, she had no policy indicating that the nebulizer should be bagged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for 1 of 3 residents (Resident #150) reviewed for pharmacy services . The facility failed to ensure Resident # 150 had a stop date for PRN Lorazepam 0.5 mg (a medicine used to treat the symptoms of anxiety) This failure could affect residents who received antipsychotic/psychoactive medications and could place residents at risk of receiving unnecessary psychotropic medications. The findings included: Record review of Resident # 150's face sheet dated 10/02/24, reveled a 98- year old female admitted to the facility on [DATE] with diagnosis that included : [Anxiety] a feeling of fear, dread, and uneasiness , Type II Diabetes [ condition that happens because of a problem in the way the body regulates and uses sugar as a fuel and Depression [ a mood disorder that causes a persistent feeling of sadness and loss of interest. Record review of Resident #150 's most recent comprehensive MDS assessment, dated 9/19/2024 revealed the resident was moderately cognitively impaired for daily decision-making skills and was treated with anti-anxiety medications. Record review of Resident #150's comprehensive care plan dated 9/09/24 revealed the resident had a diagnosis of anxiety and used antianxiety medication as ordered by the physician with interventions monitor and document reactions to antianxiety medication such as confusion, and disorientation. Record review of Resident #150s Order Summary Report, dated 10/02/24 revealed the following: - Lorazepam Oral Tablet 0.50 MG, give 1 tablet by mouth every 4 hours as needed for anxiety disorder, with start date 9/20/24 and no stop date. Record review of Resident #150's Medication Administration Record for October 2024 revealed the following: - Lorazepam 0.50 mg was not administered PRN all month in September 2024. During an observation and interview on 10/02/24 at 1:30 p.m., Resident #150 was observed in wheelchair awake and alert. Resident # 150 stated she needed the anxiety medication at times but does not recall when she last had it . On 10/2/2024 at 1:25 p.m., during an interview, RN A disclosed that she had previously given lorazepam to Resident # 150 to help with anxiety. RN A explained that psychotropic medications like Lorazepam should be used for a limited time, not to exceed 14 days. After 14 days, the nurse is required to contact the physician to reassess the resident's need for the medication. RN A was unsure why the order for Lorazepam for Resident #150 was written for an indefinite period, and she expressed concern that the resident was at risk of confusion and disorientation by taking the medication for more than 14 days. During an interview and record review on 10/3/2024 at 2:30 p.m., the (DON) revealed that Resident #150 required the use of Lorazepam as recommended by the physician due to the resident's diagnosis. The DON stated that if the medication was taken all the time, it could result in Resident # 150 being overmedicated. After reviewing Resident # 150's order summary, the DON confirmed that there was no stop date on the order for prn Lorazepam. The DON revealed that the order for Lorazepam was possibly overlooked, The DON stated that she was currently responsible for overseeing that psychotropic drugs are limited to only 14 days, and she would start monitoring this monthly moving forward to prevent this from occurring again. Record review of the facility policy and procedure undated, Titled Medication Drug Review Regimen ,revealed in part, When possible irregularities or unnecessary drugs are identified , the pharmacist shall prepare a drug irregularity report and submit the report to the DON .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 8 residents (Resident #16) reviewed for the ability to call for staff assistance. The facility failed to ensure Resident #16's call light was within reach while she was positioned in her wheelchair. This failure could place residents at risk for delay in care and services, and increased risk of falls and injuries. The findings included: A record review of Resident #16's admission record dated 10/03/2024 revealed an admission date of 12/09/2023 with diagnoses which included Parkinson's disease (a movement disorder of the nervous system that worsens over time. Parkinson's symptoms may include tremors, slowed movement, rigid muscles, and poor balance), spinal stenosis (a condition that narrows the spaces in your spine, squeezing your spinal cord and nerves.), and incontinence without sensory awareness. A record review of Resident #16's quarterly MDS assessment dated [DATE] revealed Resident #16 was an [AGE] year-old female admitted for long term care and assessed as medically complex with a BIMS score of 09 out of a possible 15 which indicated a mild cognitive impairment. Resident #16 was assessed as totally dependent on staff for activities of daily life (toileting, positioning, and hygiene) and required a wheelchair. A record review of Resident #16's care plan dated 10/03/2024 revealed, (Resident #16) is High risk for falls r/t Gait/balance problems, Hypotension r/t Parkinson's Disease. She had a fall 5/1/24 . Anticipate and meet The resident's needs . Be sure The resident's call light is within reach and encourage the resident to use it CNA for assistance as needed. The resident needs prompt response to all requests for LPN assistance. During an observation and interview on 10/03/2024 at 09:17 AM, revealed Resident #16 was seated in her wheelchair in her room, alone without staff, approximately 4- 6 feet away from her call light. The call light was dangled off of the bed, above the floor. Resident #16 requested help from the surveyor and stated she was uncomfortable due to her position in the wheelchair. Resident #16 stated her lower back was in pain with some clothing and or adult brief binding her. Resident #16 stated if she attempted to stand she would fall. The surveyor alerted staff and CNA E stated Resident #16's call light was out of Resident #16 reach. CNA E repositioned Resident #16 and repositioned her call light to be at Resident #16's side. During an interview on 10/04 2024 at 03:45 PM the DON stated her expectation, and the facility policy was for residents to have their call lights within their reach when in their rooms. The DON stated the inability for residents to call staff for assistance could lead to falls. A record review of the facility's Call Light use of policy dated 2005, revealed, BASIC RESPONSIBILITY; Licensed Nurse and Nursing Assistant, all Facility Staff. PURPOSE; To respond promptly to resident's call for assistance. To assure call system is in proper working order. EQUIPMENT; Bedside call light in functioning order . When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 24%, based on 6 errors out of 25 opportunities which involved 1 of 3 residents (Resident #7) reviewed for medication administration and medication errors. 1. RN B crushed pills and capsules, 3 medications; bisacodyl 5mg delayed release, duloxetine 60mg delayed release, and divalproex 125mg delayed release, which should not be crushed per professional standards, and administered the crushed medications to Resident #7. 2. RN B administered acetaminophen 650mg, whole pill, to Resident #7 who was ordered by her physician to have crushed medications due to her swallowing difficulties. 3. RN B administered medication Carvedilol 6.25mg on 10/03/2024 at 10:01 AM, 1 hour late. 4. RN B administered medication acetaminophen 650mg on 10/03/2024 at 10:01 AM, 1 hour late. These failures could place residents at risk for not having the intended therapeutic benefit or an adverse reactions from the medication. The findings included: A record review of Resident # 7's admission record dated 10/03/2024 revealed an admission date of 05/28/2024 with diagnoses which included dysphasia pharyngoesophageal phase (a medical term for difficulty swallowing. Dysphagia can be a painful condition. In some cases, swallowing is impossible), heart failure, dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), and constipation. A record review of Resident #7's quarterly MDS assessment dated [DATE] revealed Resident #7 was an [AGE] year-old female Resident admitted for long term care and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. Resident #7 was assessed as having medical problems which included, a swallowing disorder, heart and respiratory debility, and a seizure disorder. A record review of Resident #7's care plan dated 10/03/2024 revealed, The resident has Congestive Heart Failure . Give cardiac medications as ordered . The resident has hypertension (HTN) r/t CHF. She is taking Coreg (carvedilol) two times daily . Give anti-hypertensive medications as ordered . has impaired cognitive function/dementia or impaired thought processes r/t Difficulty making decisions, Impaired decision-making, long-term memory loss, Short term memory loss . Administer medications as ordered uses antidepressant medication Cymbalta (duloxetine) r/t Depression . Administer antidepressant medications as ordered by physician A record review of Resident #7's physicians orders, dated 10/04/2024, revealed on 06/14/2024, the physician ordered for Resident #7 to receive crushed medications. Further review revealed the physician ordered on 12/01/2021 for Resident to have medications, may alter medication by crushing, opening caps, or administering in foods or fluids. (Only open or crush if manufacture allows) A record review of Resident #7's physicians orders dated 10/04/2024 revealed Resident #7 was ordered to receive, bisacodyl 5mg delayed release (a stool softener), duloxetine 60mg delayed release (an anti-depressant), divalproex 125mg delayed release (anti-seizure medication) twice a day at 09:00 and at 06:00 PM, acetaminophen 650mg (a non-steroidal pain relief medication) three times a day at 08:00 AM, 01:00 PM, and at 08:00 PM, and carvedilol 6.25mg (a medication to treat high blood pressure) at 08:00 AM and at 05:00 PM. During an observation on 10/03/2024 at 10:01 AM, RN B prepared and administered bisacodyl 5mg delayed release pill, duloxetine 60mg delayed release pill, and divalproex 125mg delayed release pill by crushing the medications. Further observation revealed RN B administered acetaminophen 650mg enteric coated delayed release pills whole without crushing and 1 hour late. Further observation revealed RN B administered carvedilol 6.25mg 1 hour late. During an interview on 10/03/2024 at 10:10 AM, RN B stated she had administered the bisacodyl, duloxetine, and the divalproex by crushing the medications because she believed she could crush those medications and administered the acetaminophen whole because Resident # 7 could tolerate some pills whole. RN B stated she did administer the carvedilol and the acetaminophen 1 hour late, RN B stated she had not reported to her supervisor, the DON, any potential late medication administrations . During an interview on 10/03/2024 at 01:00 PM, the DON stated RN B had not reported any potential late medication administrations. The DON stated Resident #7's bisacodyl, duloxetine and divalproex medications were delayed release formulations and should not be crushed and were inappropriate formulations for Resident #7. The DON stated Resident #7 was prescribed crushed medications due to Resident #7's swallowing difficulties and should not be administered whole pills. The DON stated her expectations and facility policy was for residents to receive their medications as ordered and within 1 hour of their scheduled administration. The DON stated the nurse was counseled and received re-enforced training on safe medication administration, Resident #7 was assessed without injury, and the physician received a report of the medication errors and Resident #7 did not receive any new orders. The DON stated medication error could place residents a risk form harm by adverse effects of the medication administration errors. A record review of the Institute for Safe Medication Practices website; https://www.ismp.org/sites/default/files/attachments/2018-02/tasm.pdf Accessed 10/04/2024, titled ISMP Acute Care Guidelines for Timely Administration of Scheduled Medications revealed, Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, q4h, q6h) Administer these medications within 1 hour before or after the scheduled time. A record review of the facility's undated Medication Error policy revealed, It is the policy of (facility), Inc. to be free of significant medication errors and error rates. A medication error report (see next page for example) will be filled out for each medication or treatment error. PURPOSE: To define error, investigate error, determine reason for error and consider preventative measures. MEDICATION ERROR: Federal regulations state a medication error is a discrepancy between what the physician ordered and what is actually administered. Significant medication error causes the resident discomfort or jeopardizes his or health and sample. Example are listed below: o Omissions o Unauthorized drugs (drugs administered without a doctors order) o Wrong Dose o Wrong route of administration o Wrong dosage form o Wrong time including AC's give PC or vice versa or drug administered 60 minutes earlier or later than scheduled time. Any medication error must immediately be reported to the resident's attending physician, a medication error form completed, and the immediate supervisor notified. A record review of the bisacodyl manufactures website; https://healthy.kaiserpermanente.org/health-wellness/drug-encyclopedia/drug.dulcolax-bisacodyl-5-mg-tablet-delayed-release.297753 Accessed 10/04/2024, titled Drug Encyclopedia Ducolax (bisacodyl) 5mg tablet, delayed release revealed, How to use: Take this medication by mouth as directed by your doctor. If you are self-treating, follow all directions on the product package. If you have any questions, ask your doctor or pharmacist. Swallow this medication whole. Do not crush, chew, or break the tablet or take it within 1 hour of antacids, milk, or milk products. Doing so can destroy the coating on the tablet and may increase the risk of stomach upset and nausea. A record review of the United States of America's Food and Drug Administrations website; https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022516lbl.pdf accessed 10/04/2024, titled Cymbalta (duloxetine hydrochloride) Delayed-Release Capsules for Oral revealed, DOSAGE AND ADMINISTRATION Cymbalta should be swallowed whole and should not be chewed or crushed, nor should the capsule be opened and its contents sprinkled on food or mixed with liquids. All of these might affect the enteric coating. A record review of the United States of America's Food and Drug Administrations website; https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/018723s037lbl.pdf , accessed 10/04/2024 titled Depakote (divalproex sodium) Tablets for Oral use revealed, Swallow Depakote ER tablets or DEPAKOTE delayed-release tablets whole. Do not crush or chew them. Tell your healthcare provider if you cannot swallow Depakote ER tablets or DEPAKOTE delayed release tablets whole. You may need a different medicine. A record review of the acetaminophen manufactures website; https://healthy.kaiserpermanente.org/health-wellness/drug-encyclopedia/drug.tylenol-8-hour-650-mg-tablet-extended-release.450881 , accessed 10/04/2024, titled Tylenol (acetaminophen) 8 Hour 650 mg tablet, extended release revealed, How to use . Do not crush or chew extended-release tablets. Doing so can release all of the drug at once, increasing the risk of side effects. Swallow the tablets whole.

Based on observations, interviews, and record reviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 of the facility's laundry department reviewed for patient care equipment in safe operating condition. The facility presented 4 installed dryers of which 2 were inoperable and the facility presented with 3 washers of which 2 were inoperable. These failures could place residents at risk for harm by the facility's inability to provide clean sanitary linens. The findings included: A record review of the facility's census Resident List Report dated 10/01/2024 revealed a census of 50 residents. During an observation on 10/01/24 at 09:59 AM, the facility's laundry department revealed 3 commercial washers of which 1 of the 3 was operational. Further review revealed 4 commercial dryers of which 2 were operational. During an interview on 10/03/2024 at 10:10 AM, laundry Aide D stated she had been the laundry attendant for the past year and of the 3 washers only 1 worked and of the 4 dryers only 2 worked. Laundry Aide D stated the dryers and washers had been inoperable for months. Laundry Aide D stated she was able to provide clean linens for the facility's residents with the current operational equipment but could be challenged to provide clean laundry if the demand increased with an increased census . During an interview on 10/04/2024 at 01:30 pm, the Administrator stated she had been attempting to secure BIDS and funding for the repair and or replacement of the dryers and washers and had not yet secured the equipment repairs or replacement. The administrator stated the facility had just bought the 1 operational commercial washer . A policy for maintaining essential equipment for resident care was requested on 10/4/2024 at 12:46 PM and the administrator stated the facility had no policy and followed and adhered to the HHSC guidelines at maintaining essential equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or serious bodily injury for 1 (Resident #4) of 4 residents reviewed for freedom from abuse, neglect, and exploitation. The nursing staff of the facility failed to report an allegation of resident abuse made by Resident #4, which occurred on 09/10/24, to the administrator immediately, per facility policy. This failure could place all residents at increased risk for potential neglect due to unreported allegations of neglect. The findings included: Record review of Resident #4's admission record, dated 09/20/24, reflected a [AGE] year-old male who was re-admitted on [DATE] with no relevant diagnoses. Record review of Resident #4's quarterly MDS assessment, dated 07/20/24 reflected no BIMS score and had modified independence (some difficulty in new situations only) with cognitive skills for daily decision making. Record review of a late entry for a Health Status Note, dated 09/09/24 at 10:45 PM, authored by LVN B, reflected, This nurse went to check on [Resident #4], he had drank water and had no blood in mouth at present. [Resident #4] has trouble with canker sores and bad teeth. Asked him if he said the CNAs hit him and he said No I was joking, informed him that was not something to joke about and to not make False statements like that unless it really happened he said okay. Record review of Behavior Note, dated 09/09/24 at 10:55 PM, authored by LVN B, reflected, [10:30 PM]- [CNA D] went into room for last round and resident asked for a drink of water, [CNA D] handed him his water and noticed he had a little blood in mouth, so [CNA D] asked resident what happened, and he replied you hit me, [CNA D] said no I didn't, don't say that because I can get in trouble for you lying about something like that, resident Laughed then [CNA D] made sure he had his call light and said if you need something just call. Resident then said your going to leave when I have blood in my mouth, [CNA D] stated she was going to report it to this nurse. He then said oh my gosh and laughed. [CNA D] exited room. Record review of Behavior Note, dated 09/09/24 at 11:03 PM, authored by LVN B, reflected, [10:35 PM] - [CNA D] went and asked [CNA C] to go in room with her to check on resident status. [CNA C] said resident has canker sores a lot. They both went into resident's room, [CNA C] asked him what happened in Spanish, he then told [CNA C] you hit me and [CNA C] replied no I didn't, don't say stuff like that because we can get into trouble for stuff that's not true. He then replied well who hit me then, CNA's said no one, he stated well I'm going to tell them in the morning then. During an interview on 09/19/24 at 01:20 PM, Resident #4 revealed he was joking around when he said a CNA hit him. He revealed he feels safe at this facility and had never experienced any abuse at this facility. During an interview on 09/19/24 at 03:11 PM, LVN B revealed she worked shift 6PM to 6AM for a couple of years. She said she did not want to bother anyone about the abuse allegation involving Resident #4. She revealed it was important to report allegations according to protocol for resident safety. During an interview on 09/19/24 at 04:30 PM, the DON revealed CNA D reported to DON that Resident #4 accused CNA D and CNA C of hitting him . The DON was told Resident #4 said he was joking, and the nurse found the resident was bleeding due to a canker sore. The DON revealed she learned about this at about 06:00AM on 09/10/24 from CNA D. The DON further revealed this did not need to be reported to the administrator because it was not an abuse allegation because they found the source of why Resident #4 was bleeding. The DON further revealed after reading LVN B's progress note she thought this incident needed to be reported because of how it was documented. The DON revealed the documentation did not include the nursing staff found why the resident was bleeding and the progress note read as an abuse allegation. She revealed she reported this abuse allegation at around 03:00 PM on 09/10/24. During an interview on 09/19/24 at 04:43 PM, the administrator revealed the incident where Resident #4 accused 2 CNAs of hitting him should have been reported to the administrator immediately. She revealed she let staff know that she didn't care when they contact her or how many people contact her. She revealed this would allow her to decide if this would be something to report to state. She revealed because the resident accused someone of hitting him, even if he was joking, the CNAs, nurse, and DON should've reported this incident to her. During an interview on 09/19/24 at 05:18PM, CNA D revealed Resident #4 was bleeding in his mouth. CNA D asked Resident #4 why he was bleeding and he accused her of hitting him. CNA D requested CNA C to speak with Resident #4 to confirm or deny Resident #4's accusations. CNA D said CNA C was now accusing CNA C of hitting him. CNA D revealed she should have reported this incident to the administrator. CNA D revealed she told LVN B before she left the facility because her shift ended. CNA D further revealed she was going to call the DON because it was an abuse allegation, however, CNA D was told by LVN B not to bother the DON. CNA D revealed she listened to her coworkers as they worked at the facility longer than her. CNA D revealed it was important to report right away even though Resident #4 was joking about being hit, because it could be a possibility, he was remembering someone else at the facility was hitting him. She further revealed she made a mistake and realized it the next day. She further revealed she should've called the administrator because I know better. Record review of the facility's policy Resident Abuse, Neglect or Mistreatment, undated, reflected Any alleged violation involving mistreatment, misappropriation of property, abuse, exploitation or neglect of a resident shall be reported to the administrator immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to review and revise Resident Care Plans after each assessment for 2 of 4 Residents (Resident #1 and Resident #3) whose records were reviewed for care plan revision/timing, in that:. 1. Resident #1's Care Plan was not updated after her annual MDS assessment reflected she was dependent on staff for ADL care . 2. Resident #3's Care Plan was not updated after she had a significant change and required a mechanical lift for transfers. These deficient practices could affect any resident and contribute to Residents not receiving the care and services they needed. The findings were: 1. Record review of Resident #1's admission record, dated 09/18/24, reflected a [AGE] year-old female who was admitted on [DATE] with diagnoses to include Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and weakness. Record review of Resident #1's annual MDS assessment dated [DATE] reflected a BIMS score of 6 out of 15, indicating severely impaired cognition. It further reflected Resident #1 required dependent (helper does all the effort) for lying to sitting on side of bed, sit to lying, sit to stand, and chair/bed-to-chair transfer. Record review of Resident #1's care plan, undated, reflected [Resident #1] has an ADL self-care performance deficit r/t confusion, dementia with an intervention TRANSFER: [Resident #1] is totally dependent on x1 staff for transferring., revised 10/08/22. 2. Record review of Resident #3's admission record, dated 09/19/24, reflected a [AGE] year old female who was admitted on [DATE] with diagnoses to include dementia (a group of symptoms affecting memory, thinking and social abilities), weakness, cognitive communication deficit, unsteadiness on feet, and other lack of coordination. Record review of Resident #3's quarterly MDS assessment, dated 08/24/24 reflected no BIMS score with a short-term and long-term memory problem. It further reflected resident #1 required dependent (helper does all the effort) for lying to sitting on side of bed, sit to lying, sit to stand, and chair/bed-to-chair transfer. Record review of Resident #3's care plan, undated, reflected there was no section in her care plan that reflected ADLs or transfers. During an interview and observation on 09/19/24 at 05:49 PM, CNA H revealed Resident #1 required a mechanical lift for transfers. CNA H revealed she was not able to access resident care plans from her POC screen. When CNA H clicked on the care plan tab, which would show a resident's care plan, there was a blank window with no care plan shown. CNA H revealed she knew how to transfer residents from other CNAs' verbal report and POC documentation. She further revealed she adjusted her transfers based on how the resident responded to assistance or what was needed due to resident's possible physical limitations. CNA H revealed Resident #3 did not require a mechanical lift and she was able to transfer Resident #3 without a mechanical lift. She further revealed the morning shift liked to use a mechanical lift for Resident #3. CNA H further revealed there was no note that Resident #1 or Resident #3 required a mechanical lift for transfers on her POC screen or [NAME] report. During an interview on 09/20/24 at 10:25 AM, Physical Therapist G revealed Resident #1 and Resident #3 needed the mechanical lift for transfers. She revealed the nursing staff were in charge of updated the residents' care plans for type of transfers. During an interview with CNA I on 09/20/24 at 10:35 AM revealed Resident #1 and Resident #3 were transferred by Mechanical lifts and required 2 people. She revealed she knew this information from the DON or other nursing staff that shared this information. She did not look at care plans for this information. She revealed it was important to lift resident appropriately for resident safety. During an observation and interview on 09/20/24 at 10:45 AM, the MDS nurse revealed when Resident #1 came back from 09/08/24 hospitalization, Resident #1's care plan should have been updated to reflect resident #1 needed to be transferred by a Mechanical lift. She further revealed any nurse had access to the care plan and could have updated how the resident got transferred. She further revealed there were no details on how Resident #3 was transferred. She further revealed there was not a section in Resident #3's care plan that explained the ADL care for Resident #3. The MDS nurse further revealed a lot of staff were involved in the care plans. The DON or the admitting nurse oversaw the initial care plan which would include details on how a resident was to be transferred. She revealed the DON or the MDS nurse oversaw ensuring care plans are updated as needed. She revealed CNAs had access to the [NAME] report, where data came from the residents' care plan, to see if a resident required a Mechanical lift for transfers. She revealed the CNAs should have access to resident care plans to give appropriate resident care. She reviewed the [NAME] report and care plans for Resident #1 and Resident #3 and confirmed Resident #1 did not have a Mechanical (2-person) transfer in her care plan but had a 1-person transfer and Resident #3 did not have an ADL section in her care plan that specified any transfers. She further revealed care plans needed to be updated with an ADL section, so the nursing staff knew how to take care of resident. She further revealed if the transfers in the care plans were not updated appropriately, this could lead to an injury or fall. During an interview on 09/20/24 at 01:46 PM, the DON revealed Resident #1 and Resident #3's care plans should be updated to include they needed to be transferred via Mechanical lifts with 2 people. She revealed they worked with physical therapy to update transfers because of safety issues for staff and residents. She further revealed this information was exchanged verbally in between all nursing staff. Record Review of facility's policy Care plan/comprehensive interdisciplinary, dated 2005, reflected, The comprehensive care plan will periodically be reviewed and revised by the interdisciplinary team after each resident assessment, assessment review, or significant change in condition. The care plan will be otherwise updated as warranted by changes in medication, treatment or other changes in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 8 residents (Resident #188 and #33), reviewed for comprehensive care plans in that: 1. The advance directive code status was not updated for (Resident #188's care plan; and 2. The diet order was not updated for Resident #33's care plan. These deficient practices could affect residents with comprehensive care plans and could result in missed or delayed continuity of care. The findings included: 1. Record review of the admission record dated 8/24/2023 revealed Resident #188 was an [AGE] year-old female admitted on [DATE]. Diagnosis information included: heart failure; hypertension [high blood pressure]; mixed hyperlipidemia [combined high cholesterol, triglycerides and other lipids in the blood] and history of malignant neoplasm [cancerous tumor] of the breast. Advance Directive section indicated DNR [do not resuscitate]. Record review of the admission MDS assessment, dated 8/21/2023, revealed a BIMS Summary Score of 10 for Resident #188, indicative of moderate cognitive impairment. Record review of the order summary report for Resident #188 dated 8/24/2023 revealed a physicians' order for DNR with an order date of 8/16/2023. Record review of progress note dated 8/14/2023 at 3:11 PM, authored by LVN F, revealed, Resident #188, is DNR per report from [redacted]. No physical copy available. Record review of miscellaneous forms revealed signed, Out of Hospital Do Not Resuscitate form for Resident #188 dated 8/16/2023. Record review of the care plan for Resident #188, initiated 8/14/2023, with the most recent revision date on 8/24/2023, revealed no advance directive status listed for either previous full code status or current DNR status. 2. Record review of the admission record dated 8/24/2023 revealed Resident #33 was an [AGE] year-old female originally admitted on [DATE]. Record review of the comprehensive MDS assessment, dated 8/06/2023, revealed Resident #33 had a summary BIMS score of 05, indicative of severe cognitive impairment. Under Section G, Functional Status, eating was coded as supervision of the activity with set up assistance. Under Section GG, Functional Abilities and Goals, eating was coded as set up or clean up assistance for eating. Under Section I, the resident's primary medical condition category for primary reason of admission was non-traumatic brain dysfunction related to unspecified dementia. Under Section K, Swallowing/Nutritional Status, 'none of the above' was selected for swallowing disorder [a. loss of liquids/solids; b. holding food in mouth/cheeks; c. coughing or choking during meals or when swallowing medications; d. complaints of difficulty or pain with swallowing]. 'None of the above' was selected, under the subheading for Nutritional Approaches that included, mechanically altered diet. Under Section L, Oral/Dental Status, 'none of the above' was selected, indicative of no dental issues. Record review of the order summary report dated 8/24/2023 revealed Resident #33 had active physician orders, if resident eats less than 50% of meal then offer nutritional substitute and may alter medication by crushing, opening caps, or administering in food or fluids; dated 7/26/2023. No active dietary order listed. Record review of progress notes dated 7/29/2023 at 8:02 AM, authored by LVN E, revealed under Nutrition subheading, diet Regular, see chart for full diet order. Progress note dated 7/29/2023 at 4:25 PM authored by FSS, revealed, Resident #33 admitted on a regular diet, regular texture, thin liquid diet. [Resident #33] Tells me she has no issues with chewing or swallowing; Record review of the care plan for Resident #33 revealed a focus area of malnourished as evidenced by nutritional screening tool, initiated 7/26/2023. Care plan did not address liquid consistency or food texture in a focus area and no associated interventions were listed. In an observation on 8/21/2023 between 11:45 AM and 12:32 PM, Resident #33 was observed to be seated in a high backed, wheelchair at a round table with her peers in the common dining area, receiving staff assistance from the AD to eat. Resident #33 was served a regular diet texture with thin liquids. In an interview on 8/24/2023 at 12:21 PM, the DON stated she was responsible for updating care plans as situations change. The DON stated she expects care plans to be updated within 72 hrs. The DON stated she was not aware diet plan changes were not on care plans for Resident #33; and was not aware code status was not updated on care plan for Resident #188. The DON stated going from a full code status to a DNR status would be considered a significant change. In an interview on 8/24/2023 at 2:14 PM, the DON stated recommendations and changes were submitted by the RD in writing in triplicate, entitled Status Report. The DON stated each Status Report is routed to the appropriate discipline for action. The DON stated she did not keep copies of the status report half sheet. The DON stated she had the sheets shredded upon immediately acting upon the status report. In an interview on 8/24/23 at 2:33 PM, the Med Rec clerk stated she had contacted the FSS for instructions on where to find the Status Report sheets. The Med Rec clerk stated, after searching for the Status Reports, the facility had no other documentation regarding notification that diet orders were missing from electronic health record from the RD. Record review of Care Plan/Comprehensive Interdisciplinary policy, dated 2005, revealed, periodically be reviewed and revised by the interdisciplinary team; otherwise updated as warranted by changes in medication treatment or other changes in condition. Record review of Nutrition and Mealtime policy, undated, revealed, 2. When a change in nutritional status is noted, nursing personnel will consult with the dietitian and or physician to determine the causes and response to the change; 3. Documentation of changes in nutritional status will be made in the residents' medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administration of all drugs and biologicals, to meet the needs of two of 6 residents reviewed for pharmacy services (Residents #12 and #1), in that: 1. The facility failed to ensure vital signs were obtained immediately prior to the administration of medication, metoprolol [a medication for high blood pressure], for Resident #12. 2. The facility failed to ensure that liquid medications were dispensed into a graduated receptacle for accuracy of dosing for Resident #1. These deficient practices could place residents at risk of not receiving the intended therapeutic benefit of the medications, could result in a worsening or exacerbation of chronic medical conditions, hospitalization and or a diminished quality of life. The findings included: 1. Record review of the admission record dated 8/24/2023, revealed Resident #12 was a [AGE] year-old female with an original admission date of 01/20/2015. Active diagnoses included essential (primary) hypertension [high blood pressure without an identifiable secondary cause]. Record review of the care plan for Resident #12 revealed a focus area of hypertension, takes lisinopril and metoprolol for medication management; with the following associated interventions and tasks: give antihypertensive medications as ordered; monitor for side effects such as orthostatic hypotension [a significant drop in blood pressure when changing position from supine to sitting or standing], increased heart rate and effectiveness with a date initiated of 8/01/2022. Record review of order summary report dated 8/24/2023, revealed Resident #12 had an active order for metoprolol 50 milligrams: give one tablet by mouth two times a day related to essential (primary) hypertension with a start date of 11/16/2021. In an observation on 8/23/2023 at 7:11 AM, LVN F administered metoprolol, a medication for hypertension that required vital signs to assess if parameters are met for safe administration, to Resident #12. In an interview on 8/23/2023 at 7:15 AM, LVN F stated Resident #12's vital signs were measured at approximately 6:15 AM, at the start of her shift. LVN F stated Resident #12's blood pressure was 147/76 and heart rate was 62; LVN F stated those numbers were within the parameters, so it was safe to administer the medications as ordered. In an interview on 8/24/2023 at 12:51 PM, the DON stated she expected vital signs to be taken just prior to medication administration for any medication that requires parameters such as blood sugar, heart rate, or blood pressure. The DON stated staff were trained upon orientation, annually, and as needed, thereafter, that vital signs should be measured immediately prior to preparing the medications for administration. Record review of metoprolol contraindications, accessed 9/12/2023 from https://www.drugs.com/monograph/metoprolol.html, revealed: metoprolol is contraindicated in patients with a heart rate less than 45-60 beats per minute, systolic blood pressure less than 100 mm Hg [millimeter of mercury, measurement used to record blood pressure]. Record review of an undated Medication Administration, Oral policy revealed, under the heading, Remember: .Note any medications that need vital signs taken before being given and take them and hold the medication if necessary. 2. Record review of the admission record dated 8/24/2023, revealed Resident #1 was a [AGE] year-old female with an original admission date of 9/23/2017. Active diagnoses included anemia [deficiency of healthy red blood cells in blood]. Record review of the care plan for Resident #1 revealed a focus area of, resident has anemia; with the following associated interventions: give medications as ordered; monitor, document, report PRN [as needed] signs and symptoms of anemia, with a date initiated of 11/20/2022, and revision on 8/13/2023. Additional focus area of Regular, mechanical soft, thin liquids diet; with the following associated interventions: give supplements as ordered - med pass and mighty shakes; alert nurse and dietitian if not consuming on a routine basis with a date initiated of 4/06/2022, revision on 5/10/2023. Record review of order summary report dated 8/24/2023 revealed Resident #1 had an order for Med Pass 2.0 [a liquid supplement] 60 milliliters: three times a day for prophylaxis [prevention and treatment for malnutrition and anemia] with a start date of 11/21/2021. In an observation on 8/23/2023 at 7:28 AM, LVN F poured Med Pass 2.0 [a liquid medication] directly into an opaque, white Styrofoam cup that was not graduated for measurements for Resident #1. LVN F administered the liquid without assessing the accuracy of the dose. In an interview on 8/24/2023 at 12:51 PM, the DON stated the opaque, white Styrofoam cups are used to administer liquids during medication administration. The DON stated she expected liquid medications to be measured into the clear plastic graduated medicine cup on a flat stable surface and the nurse should move down so that she is at eye level to assess at the meniscus (the lowest point of the curve of liquids) to determine accurate dosing. The DON stated the nurse may need to pour 2 or three medicine cups of liquid in to the larger opaque, white Styrofoam cup, if the volume is larger than a single clear plastic graduated medicine cup. The DON staff were trained upon orientation, annually thereafter, and as needed on preparing medications for administration. Record review of an undated Medication Administration, Oral policy revealed necessary equipment as, 6. Medicine cups to put medicine into (supply and disposable plastic 30CC [milliliter] cups); 7. drinking cups. under the title Preparing Liquid Medications: .5. Pour liquid medication for non-unit dose medication as follows: shake bottle, if directed to do so; medication cup at eye level; pour away from the label; pour until meniscus of liquid is level with dosage mark on cup.

Based on observation, and interview, the facility failed to store all drugs and biologicals in locked compartments for one of four medication carts (200-wing treatment cart) reviewed for medication storage, in that: The facility failed to ensure the 200-wing treatment cart was unlocked and unattended at the nurses' station. This deficient practice could affect residents who have medications in the medication cart and could result in lost medications, drug diversion, or harm due to accidental ingestion or misuse of unprescribed treatments. The findings included: In an observation on 8/24/2023 at 2:00 PM, the 200-wing treatment cart was observed unlocked and unattended at the nurses' station. Staff, visitors, and ambulatory residents were in the immediate vicinity. The cart included both over the counter and prescription medications along with diabetic testing supplies, specifically lancets, and glucometer control testing solutions. The cart was next to the open door of the unoccupied nurses' station. In a group interview on 8/24/2023 at 2:11 PM with the DON, LVN D and LVN E, LVN E stated the 200-wing treatment cart was her responsibility. LVN E stated she did not know that the treatment cart needed to be locked since it was not a medication cart. LVN D stated she locked the cart within the previous 5 minutes when she noticed it was unlocked and unattended. LVN E stated she had just unlocked the cart within the last two to three minutes to obtain supplies. LVN E then proceeded to the resident's room, leaving the cart unlocked, and unattended at the nurses' station. LVN E stated she had left it unlocked and unattended for less than 2 minutes before realizing she had the wrong size dressing then and came back to the location of the treatment cart to obtain the correct sized dressing that she needed. The DON stated carts were to be locked when not in active use. In an interview on 8/24/2023 at 4:02 PM, the DON stated she did not have a policy on medication storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to designate a member of the facility's interdisciplinary team who was responsible for working with hospice representatives to coordinate care and failed to obtain documentation and information from the hospice company for 2 of 4 residents (Resident #7 and Resident #26) who received hospice services reviewed, in that: 1. There was not a designated member of the facility's interdisciplinary team who was responsible for working with hospice representatives to coordinate care. 2. The facility did not obtain documentation and information from the hospice company for Resident #7 and Resident #26 regarding their hospice services. This deficient practice could place residents who receive hospice services at risk of not having their needs met due to lack of communication and coordination between the facility and the provider of hospice services. The findings were: 1. During an interview with the Social Worker on 08/22/2023 at 10:15 a.m. the Social Worker stated she worked part-time at the facility and was not the designated hospice liaison. The Social Worker further stated the liaison was the Medical Records Director. During an interview with the Medical Records Director, on 08/22/2023 at 1:12 p.m., the Medical Records Director stated she was not the hospice liaison and stated the liaison was probably the Administrator. During an interview with the Administrator on 08/23/2023 at 3:36 p.m., the Administrator stated the DON was the hospice liaison. During an interview with the DON on 08/24/2023 at 3:18 p.m., the DON stated the facility liaisons were hospice staff members. The DON further stated all document and information regarding Resident #7 and Resident #26 were either located in their paper medical charts or electronic medical charts. 2. Record review of Resident #7's face sheet, dated 08/24/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Right Bundle Branch Block, Bilateral Primary Osteoarthritis of Knee, and Age-Related Physical Debility. Record review of Resident #7's Quarterly MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #7's care plan, revised 04/16/2023, revealed, [Resident #7] has a terminal prognosis [related to] Right Sided Heart Failure on [hospice company] services. Record review of Resident #7's order summary report, dated 08/24/2023, revealed a physician order to admit to hospice care dated 03/22/2023. Record review of Resident #7's paper and electronic medical charts revealed the most recent hospice plan of care, the hospice election form, and the current physician re-certification of terminal illness were not present. Record review of Resident #26's face sheet, dated 08/24/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease, Anemia in Neoplastic Disease, and Other Chronic Pain. Record review of Resident #26's Quarterly MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #26's care plan, revised 03/01/2023, revealed, [Resident #26 has] a terminal prognosis [related to] Malignant Neoplasm of Parotid Gland. [Resident #26] is on [hospice company] services. Record review of Resident #26's paper and electronic medical charts revealed the most recent hospice plan of care, the hospice election form, and the current physician re-certification of terminal illness were not present. During an interview with the DON on 08/24/2023 at 4:02 p.m., the DON stated there was no facility policy regarding coordination of hospice services.

Based on observation, interview, and record review, the facility failed to ensure the residents' right to right to a safe, clean, comfortable and homelike environment for 3 of 3 communal shower rooms (shower room A located near the small dining room, shower room B located near conference room, and shower room C on 200 Hall) reviewed, in that: Barrels containing soiled linens and barrels containing trash were stored in three communal shower rooms, and equipment in Shower Room C was in disrepair. This deficient practice could place residents who utilize communal shower rooms at risk of psychosocial harm due to feeling disrespected or uncomfortable, with decreased self-esteem and quality of life. The findings were: Observation on 08/21/2023 at 10:42 a.m. revealed barrels containing soiled linens and barrels containing trash were in communal shower room A on the resident hallway near the small dining room. During an interview with the Social Worker on 08/21/2023 at 10:48 a.m., the Social Worker confirmed barrels containing soiled linens and barrels containing trash were in the communal shower room on the resident hallway near the small dining room. Observation on 8/21/2023 at 11:41 a.m., on the 200-wing Shower Room C, on the right side of the hallway from the nurses' station, the wall next to the toilet was observed to have a missing toilet paper holder exposing the drywall behind the tiled wall. Additionally, the toilet seat had multiple gouges in the finish, mostly centered around the front of the toilet seat, which exposed the rough wood like material underneath. The toilet seat lid had deterioration in the finish, in the area where it attached to the toilet seat and toilet, which exposed the rough wood like material underneath. The screws embedded in the toilet seat appeared to have a reddish-brown material seeping on to the bracket. There were two large plastic bins on wheels with lids, that contained dirty and visibly soiled clothes which emanated a malodorous smell that permeated the entire shower room. Observation on 08/24/2023 at 3:12 p.m. revealed barrels containing soiled linens and barrels containing trash were in the communal shower room B on the resident hallway near the conference room. During an interview with the DON, at the same time as the observation, the DON confirmed barrels containing soiled linens and barrels containing trash were in the communal shower room on the resident hallway near the conference room and stated it was the usual practice for the barrels with soiled linen and trash to be stored in communal shower rooms. During an interview with the DON on 08/24/2023 at 4:02 p.m., the DON stated there was no facility policy regarding resident dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 halls (disused hall near therapy gym and hall near conference room), and 1 shower room (Shower Room C) reviewed for environment, in that: Hazardous materials, sharp tools, and equipment in disrepair were found in areas accessible by facility residents. This deficient practice could place all residents at risk of injury due to exposure to hazardous materials, sharp tools, and equipment in disrepair. The findings were: Observation on 8/21/2023 at 11:41 a.m., on the 200-wing shower room (Shower Room C) on the right side of the hallway from the nurses' station, the wall next to the toilet was observed to have a missing toilet paper holder exposing the drywall behind the tiled wall. Additionally, the toilet seat had multiple gouges in the finish, mostly centered around the front of the toilet seat, which exposed the rough wood like material underneath. The toilet seat lid had deterioration in the finish, in the area where it attached to the toilet seat and toilet, which exposed the rough wood like material underneath. The screws embedded in the toilet seat appeared to have a reddish-brown material seeping on to the bracket. Observation on 08/21/2023 at 12:02 p.m. of the Maintenance Closet located on the hall near the conference room, revealed it was unlocked and contained: four containers of cleaning materials, each with a label which stated the material was harmful if it came into contact with eyes and/or harmful if swallowed. During an interview with RA A and CNA B on 08/21/2023 at 12:05 p.m., RA A and CNA B confirmed the Maintenance Closet was unlocked and contained bottles labeled as hazardous. Observation on 08/24/2023 at 2:14 p.m. revealed the shower room next to the therapy gym was used for therapy sessions and contained a sink which was loosely affixed to the wall and a toilet which was loosely affixed to the floor. During an interview with the Office Manager on 08/24/2023, at the same time as the observation, the Office Manager confirmed the presence of a sink which was loosely affixed to the wall and a toilet which was loosely affixed to the floor in the therapy shower room. Observation on 08/24/2023 at 2:17 p.m., in the disused hallway near the therapy gym, revealed the bathroom of room [ROOM NUMBER] had a toilet which was loosely affixed to the floor and contained a bottle of cleaning material with a label which stated the material was harmful if swallowed. Further observation revealed a room labeled Hopper Room, in which was a toilet with no seat which contained brown liquid with a foul odor. Further observation revealed a communal shower room which contained three gallon sized containers of cleaning material with labels which stated the material was harmful if swallowed. During an interview with the Office Manager on 08/24/2023, at the same time as the observation, the Office Manager confirmed the presence of hazardous materials and equipment in disrepair on the disused hallway near the therapy gym. The Office Manager further confirmed that residents could access the disused hallway from resident halls which were in use, and that residents could also access the disused hallway from the therapy gym. Observation of the Maintenance Room, located next to snack and drink dispensers in the disused resident hall, revealed it contained numerous tools with sharp edges. Further observation revealed the presence of containers of cleaning and maintenance materials each with a label which stated the material was harmful if it came into contact with eyes and/or harmful if swallowed. During an interview with the Office Manager on 08/24/2023, at the same time as the observation, the Office Manager confirmed the presence of sharp tools and hazardous materials in the Maintenance Room located next to snack and drink dispensers, and confirmed the room was accessible by residents. During an interview with the Administrator on 08/24/2023 at 4:00 p.m., the Administrator stated all staff were responsible for storing hazardous materials behind locked doors. The Maintenance Director was not available for interview. During an interview with the DON on 08/24/2023 at 4:02 p.m., the DON stated there was no facility policy regarding accident hazards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 3 of 8 residents (Resident #188, #28, and #33), reviewed for resident records, in that: 1. The facility failed to ensure the Advance Directive code status was updated for Resident #188's care plan; 2. The facility failed to ensure the diet order was updated for Resident #28's care plan and physician orders; and 3. The facility failed to ensure the care plan was updated for Resident #33 to include diet orders. This deficient practice could affect all residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: 1. Record review of the admission record dated 8/24/2023 revealed Resident #188 was an [AGE] year-old female admitted on [DATE]. Diagnosis information included: heart failure; hypertension; mixed hyperlipidemia [familial combined high cholesterol, triglycerides and other lipids in the blood] and history of malignant neoplasm [cancerous tumor] of the breast. Advance Directive indicated DNR [do not resuscitate]. Record review of the admission MDS assessment, dated 8/21/2023, revealed a BIMS Summary Score of 10 for Resident #188, indicative of moderate cognitive impairment. Record review of progress note dated 8/14/2023 at 3:11 PM, authored by LVN F, revealed, Resident #188, is DNR per report from [redacted]. No physical copy available. Record review of the order summary report for Resident #188 dated 8/24/2023 revealed a physicians' order for DNR with an order date of 8/16/2023. Record review of miscellaneous forms revealed signed, Out of Hospital Do Not Resuscitate form dated 8/16/2023. Record review of the care plan for Resident #188, initiated 8/14/2023, with the most recent revision date on 8/24/2023, revealed no advance directive status listed for either previous full code status or current DNR status. 2. Record review of the admission record dated 8/24/2023 revealed Resident #28 was a [AGE] year-old female originally admitted on [DATE]. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #28 was rarely/never understood with short-term and long-term memory problems and severely impaired cognitive skills for daily decision making. Under Section G, functional status, Resident #28 was coded as total dependence with one-person physical assist in the ADL [Activity of daily living] category of eating. Under Section I, Active Diagnosis, Resident #28 was admitted with the primary medical category of other neurological conditions, and aphasia [speech and language disorder caused by damage to the brain]. Under section K, swallowing/nutritional status, Resident #28 if you don't utilize a mechanically altered diet as a nutritional approach for swallowing difficulties. Record review of the care plan revealed Resident #28 had a focus area of, swallowing problem related to dysphagia; with the following interventions: all staff to be informed of the residents' special dietary and safety needs; diet to be followed as prescribed. Record review of the order summary report dated 8/24/2023 revealed Resident #28 had active physician orders, if resident eats less than 50% of meal then offer nutritional substitute and may alter medication by crushing, opening caps, or administering in food or fluids; dated 2/04/2023. No active dietary order listed. Record review of progress notes: dated 2/28/2023 at 12:52 PM authored by the RD, revealed under the Note Text, Diet - no diet ordered in PCC; with recommendations to, 1. Add diet order to [electronic health record]; dated 4/02/2023 at 6:32 PM authored by the RD, revealed under the Note Text, Diet - Not in [electronic health record]; with interventions: , 1. Add diet order to [electronic health record]; dated 7/11/2023 at 3:40 PM authored by FSS, revealed under the Note Text, [Resident #28] is currently on a regular, mech[anical] soft, thin liquid diet. Record review of Dietary Profile dated 8/6/2023 at 5:49 PM, authored by unidentified staff, revealed Resident #28's current diet order and current texture of food as Reg[ular]. In an observation on 8/21/2023 between 11:45 AM and 12:32 PM, Resident #28 was observed in the communal dining area, being assisted by various staff with eating. 3. Record review of the admission record dated 8/24/2023 revealed Resident #33 was an [AGE] year-old female originally admitted on [DATE]. Record review of the comprehensive MDS assessment dated [DATE] revealed Resident #33had a summary BIMS score of 05; indicative of severe cognitive impairment. Under Section G, Functional Status, eating was coded as supervision of the activity with set up assistance. Under Section GG, Functional Abilities and Goals, eating was coded as set up or clean up assistance for eating. Under Section I, the residents primary medical condition category for primary reason of admission was non-traumatic brain dysfunction related to unspecified dementia. Under Section K, Swallowing/Nutritional Status, none of the above is selected for swallowing disorder [a. loss of liquids/solids; b. holding food in mouth/cheeks; c. coughing or choking during meals or when swallowing medications; d. complaints of difficulty or pain with swallowing]. None of the above is selected, under the subheading for Nutritional Approaches that included, mechanically altered diet. Under Section L, Oral/Dental Status, none of the above is selected, indicative of no dental issues. Record review of progress notes dated 7/29/2023 at 8:02 AM authored by LVN E, revealed under Nutrition subheading, diet Regular, see chart for full diet order; dated 7/29/2023 at 4:25 PM authored by FSS, revealed, Resident #33 admitted on a regular diet, regular texture, think liquid diet. [Resident #33] Tells me she has no issues with chewing or swallowing; Record review of the order summary report dated 8/24/2023 revealed Resident #33 had active physician orders, if resident eats less than 50% of meal then offer nutritional substitute and may alter medication by crushing, opening caps, or administering in food or fluids; dated 7/26/2023. No active dietary order listed. Record review of the care plan for Resident #33 revealed a focus area of malnourished as evidenced by nutritional screening tool, initiated 7/26/2023. Care plan did not address liquid consistency or food texture in a focus area and no interventions were listed. In an observation on 8/21/2023 between 11:45 AM and 12:32 PM, Resident #33 was observed to be seated in a high backed, wheelchair at a round table with her peers in the common dining area, receiving staff assistance from the AD to eat. Resident #33 was served a regular diet texture with thin liquids. In an interview on 8/24/2023 at 12:21 PM, the DON stated she is responsible for updating care plans as situations change. The DON stated she expects care plans to be updated within 72 hrs. The DON stated she was not aware diet plan changes were not on care plans for Resident #33; and was not aware code status was not updated on care plan for Resident #188. In an interview on 8/24/2023 at 2:14 PM, the DON stated recommendations and changes are submitted by the RD in writing in triplicate, entitled Status Report. The DON stated each Status Report is routed to the appropriate discipline for action. The DON stated she did not keep copies of the status report half sheet. The DON stated she had the sheets shredded upon immediately acting upon the status report. In an interview on 8/24/23 at 2:33 PM, the Med Rec clerk stated she had contacted the FSS for instructions on where to find the Status Report sheets. The Med Rec clerk stated, after searching for the Status Reports, the facility had no other documentation regarding notification that diet orders were missing from electronic health record from the RD. Record review of Care Plan/Comprehensive Interdisciplinary policy, dated 2005, revealed, periodically be reviewed and revised by the interdisciplinary team; otherwise updated as warranted by changes in medication treatment or other changes in condition. Record review of Nutrition and Mealtime policy, undated, revealed, 2. When a change in nutritional status is noted, nursing personnel will consult with the dietitian and or physician to determine the causes and response to the change; 3. Documentation of changes in nutritional status will be made in the residents' medical record.

Based on interview and record review, the facility failed to utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week and the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 3 of the 13 months reviewed, in that: The facility did not employ a Director of Nursing and did not employ sufficient full-time registered nurses to utilize their services for at least eight consecutive hours per day, seven days per week from July 2022 to October 2022. This deficient practice could place all residents in danger of not receiving adequate care. The findings were: During an interview with the Administrator on 08/23/2023 at 3:36 p.m., the Administrator stated the DON began working in October 2022 and prior to that, the facility had not employed a Director of Nursing since before the time of the previous re-certification survey in July 2022. The Administrator further stated the facility had not employed sufficient full-time registered nurses to utilize their services for at least eight consecutive hours per day, seven days per week from July 2022 to October 2022. Record review of the facility document, Staff List, undated, revealed the DON was hired in October 2022. During an interview with the DON on 08/24/2023 at 3:18 p.m., the DON confirmed she began her tenure as Director of Nursing in October 2022 and worked full-time. During an interview with the DON on 08/24/2023 at 4:02 p.m., the DON stated there was no facility policy regarding the employment of a registered nurse for at least eight consecutive hours per day, seven days per week and the designation of a registered nurse to serve as the director of nursing on a full-time basis.

Based on interview and record review, the facility failed to include as part of its QAPI program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program, for 20 of the 25 staff members reviewed for mandatory training, in that: Twenty of the twenty-five staff members reviewed for mandatory training had not received training regarding the facility's QAPI program. This deficient practice could place residents at risk of receiving inadequate care from staff who are unfamiliar with the facility's QAPI program. The findings were: Record review of LVN E's employee file revealed LVN E was hired on 07/27/2023 and had not received training regarding the facility's QAPI program. Record review of RN H's employee file revealed RN H was hired on 08/10/2023 and had not received training regarding the facility's QAPI program. Record review of RN I's employee file revealed RN I was hired on 06/13/2023 and had not received training regarding the facility's QAPI program. Record review of LVN J's employee file revealed LVN J was hired on 05/22/2023 and had not received training regarding the facility's QAPI program. Record review of 's Dietary Aide K's employee file revealed Dietary Aide K was hired on 05/18/2023 and had not received training regarding the facility's QAPI program. Record review of Restorative Aide L's employee file revealed Restorative Aide L was hired on 02/09/1994 and had not received training regarding the facility's QAPI program. Record review of CNA M's employee file revealed CNA M was hired on 02/06/1996 and had not received training regarding the facility's QAPI program. Record review of CNA N's employee file revealed CNA N was hired on 11/20/2022 and had not received training regarding the facility's QAPI program. Record review of CNA B's employee file revealed CNA B was hired on 12/07/2009 and had not received training regarding the facility's QAPI program. Record review of CNA O's employee file revealed CNA O was hired on 09/20/2017 and had not received training regarding the facility's QAPI program. Record review of PTA P's employee file revealed PTA P was hired on 03/28/2019 and had not received training regarding the facility's QAPI program. Record review of RA A's employee file revealed RA A was hired on 07/06/2009 and had not received training regarding the facility's QAPI program. Record review of OTA Q's employee file revealed OTA Q was hired on 03/30/2020 and had not received training regarding the facility's QAPI program. Record review of LVN R's employee file revealed LVN R was hired on 04/26/2021 and had not received training regarding the facility's QAPI program. Record review of LVN G's employee file revealed LVN G was hired on 11/23/2022 and had not received training regarding the facility's QAPI program. Record review of MDS/LVN S's employee file revealed MDS/LVN S was hired on 02/13/2023 and had not received training regarding the facility's QAPI program. Record review of LVN D's employee file revealed LVN D was hired on 10/24/1994 and had not received training regarding the facility's QAPI program. Record review of PT T's employee file revealed PT T was hired on 02/22/2019 and had not received training regarding the facility's QAPI program. Record review of OT U 's employee file revealed OY U was hired on 02/22/2019 and had not received training regarding the facility's QAPI program. Record review of ST V's employee file revealed ST V was hired on 07/18/2023 and had not received training regarding the facility's QAPI program. During an interview with the Office Manager and the Administrator on 08/24/2023 at 3:42 p.m., the Office Manager and Administrator stated they were jointly responsible for ensuring staff members completed mandatory training. The Administrator stated she was unaware of the requirement that all staff receive training regarding the facility's QAPI program. The Administrator further stated there was no facility policy regarding staff training and the QAPI program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to inform the resident or resident representative of their right to establish advance directives as set forth in the laws of the State and provide assistance if the resident wishes to execute one or more directive(s)for 1 (#6) out of 20 residents reviewed for advanced directives in that: Resident #6 was not provided information when she was admitted to the facility to have an option to formulate an advance directive. This failure could place residents who are admitted to the facility and could result in a resident's advanced care wishes not being noted or complied with. The findings included: Review of Resident #6's electronic face sheet dated 7/8/22 revealed she was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of rheumatoid arthritis (inflammation of one or more joints), age related osteoporosis (weakening of bone strength related to age), fibromyalgia (chronic muscle pain, tenderness and fatigue), major depressive disorder (major health disorder having episodes of psychological depression), unspecified open-angle glaucoma(increased pressure in the eye) and chronic pain syndrome ( ongoing pain). She was listed as her own responsible party. Review of Resident #6's physician orders Active as of 7/6/22 revealed she had no orders for advanced directives. Review of Resident #6's quarterly MDS comprehensive assessment with an ARD of 4/7/22 revealed she scored a 15/15 on her BIMS which indicated she was cognitively intact and required minimal assistance with her ADL's. Further review in Section F-Preferences for Customary Routine and Activities revealed it was very important for her to make her own choices. Review of Resident #6's base line care plan dated 6/21/22 revealed it did not contain any information on advanced directives. Review of Resident #6's admission packet paperwork dated 6/21/22 which included Advanced Directives was not completed. Review of Resident #6's clinical charts, both electronic and hard cover reviewed on 7/6/22 revealed no information on advanced directives. Observation and interview on 7/5/22 at 9:10 a.m. of Resident #6 revealed she was lying on her bed clean and well groomed, and there were two bottles of medicated eye drops sitting on her nightstand beside her bed. When asked if she gave herself the eye drops, she stated yes, that was very important to her. Observation and interview on 7/8/22 at 10:30 a.m. of Resident #6 revealed she was lying on her bed and was watching television. Interview with Resident #6 revealed she did not recall anyone had discussed code status when she was admitted . She was not provided information about code status. Interview on 7/7/22 at 1:28 p.m. with the NC revealed that code status needed to be done when Resident #6 was admitted because staff needed to know what the resident's wishes were and the paperwork and orders needed to be completed. She stated it was important that staff knew what Resident #6 wanted for advanced directives. She stated without advanced directives residents were considered to be full code and they only had 4 residents in the facility with that preference. Interview on 7/7/22 at 2:30 p.m. with LVN C (the admitting nurse of Resident #6) revealed that when Resident #6 was admitted she did not notice she did not have an advanced directive or code status in her orders and so it was totally missed. She stated that when she admitted residents a temporary care plan was created from the assessment and that the code status was something that should be reflected. Interview on 7/8/22 at 10:35 a.m. with Resident #6 revealed she could not recall if anyone discussed code status upon admission, and she had always wanted to be a full code, but since her family member passed away in May, she was not sure anymore and may want to have DNR status. She stated she did not want to discuss the issue further, but that it was very important for her to make a decision about advanced directives. Interview on 7/8/22 at 10:16 a.m. with the ADM revealed that she went to Resident #6's family member when Resident #6 was admitted , and she said she was on her way out of town. She wanted her left as a full code, and it did not get put inside the chart. She stated if we don't have a copy of a DNR, we treat residents as a full code. The ADM stated there was nothing noted about code status in Resident #6's charts, and no one picked up on it. It would've probably got picked up in care plans and she wasn't due for a care plan meeting and the Social Worker may have caught it but we don't have a Social Worker. The nurses don't look at the code status on admission, it is up to the admissions people. We missed this on Resident #6, and it was important because staff needed to know Resident #6's wishes when it came to advanced directives. She stated she was responsible, and it was missed. Review of the facility policy and procedure titled Advanced Directive/Critical Care Choice dated 2005 revealed Procedure .1. Upon admission the social worker, DON or their designee will approach the resident, POA or legal guardian and explain the choices of Full Code or DNR. 2. During this period, the resident or significant other will be asked to document their choice on the appropriate form .4. A summary of this discussion and the names and individuals present during the discussion will be documented by social service, administration, or other participating professional in that department's section of the chart or on interdisciplinary notes. 5. Nursing administration or medical records will enter the critical care choice on the physician consolidated orders for physician's signature. 6. The category of critical care choice/DNR will be documented in the care plan. 7. The signed critical care choice form/DNR will be placed in the front of the clinical record. 8. The front of the chart will be flagged with a Red Dot to signify Do Not Resuscitate if permission is given. 9. Nursing staff will notify all other departments of the critical care choice. Review of the facility Advanced Care Planning Protocol dated 6/5/18 revealed Purpose .To ensure that the clinical care of individuals in long term care is consistent with each person's preferences and values, particularly when he/she is unable to participate in the decision-making process .Protocol .Provide the individual or his/her representative with a copy of the HHSC Advance Care Planning educational material, frequently asked questions about advanced care planning, the individual rights under Texas law to make decisions concerning medical care and to formulate advance directives, and facilities policies respecting the implementation of advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to have an accurate assessment for 2 (Resident #1 and #21) of 10 residents reviewed for assessments in that: 1. Resident #1 was receiving hospice services however it was not coded on the resident's MDS. 2. Resident #21 was receiving hospice services however it was not coded on the resident's MDS. This failure could affect residents who receive assessments and result in inaccurate care and treatments. The findings included: 1. Review of Resident #1's face sheet dated 7/8/2022 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included senile degeneration of brain (an elder's decline in mental health that leads to physical changes such as a change in posture, loss of vision or hearing, weakness in strength and stiff joints), dysphagia (difficulty swallowing food or liquids), essential hypertension (abnormally high blood pressure often due to obesity, family history or an unhealthy diet) and peripheral vascular disease (a slow, progressive circulation disorder usually caused by plaque buildup inside the artery wall). Review of Resident #1's July 2022 Consolidated Physician Orders revealed an order for hospice services, with a start date of 3/23/2022. Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE], in section O, under the heading of Hospice Care revealed the MDS did not indicate the resident was on hospice services. In an interview on 7/8/2022 at 1:27 p.m. with the MDS Nurse she stated Resident #1 had an order for and was receiving hospice services. After reviewing the resident's admission MDS she stated the MDS did not indicate Resident #1 was receiving hospice services. The MDS Nurse stated Resident #1 admission MDS was completed prior to her employment as the MDS Nurse. 2. Review of Resident #21's face sheet dated 5/22/2022 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's disease (a progressive neurologic disorder that causes the brain to shrink/atrophy and brain cells to die), type 2 diabetes mellitus (a chronic condition that results in too much sugar in the bloodstream and can lead to circulatory, nervous and immune system disorders), essential hypertension and dementia with behavioral disturbance. Review of Resident #21's July 2022 Consolidated Physician Orders revealed, Admit to hospice dated 4/27/2022. Review of Resident #21's admission MDS dated [DATE], in section O, under the heading of Hospice Care revealed the MDS did not indicate the resident was on hospice services. In an interview on 7/8/2022 at 11:45 a.m. with the MDS Nurse she stated Resident #21 was on hospice services. After reviewing Resident #21's Annual MDS she stated the MDS did not indicate Resident #1 was receiving hospice services. The MDS Nurse reported it was on oversight on her part. The MDS Nurse reported if the MDS was not coded correctly it could affect the resident's plan of care and/or not be addressed in the resident's plan of care. In an interview on 7/8/2022 at 11:57 a.m. with the DON she stated both Residents #1 and #21 were on hospice services. The DON reported the MDS Nurse was in training and it was a clerical error when she omitted coding hospice services for Resident #21. The DON reported if the MDS were not coded correctly it could have implications on the residents' plan of care. In an interview on 7/8/2022 at 3:36 p.m. the DON reported they cited to the Resident Assessment Instrument (RAI) manual for hospice coding of the MDS. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's [NAME], Version 1.17.1, October 2019, Section O: Special Treatments, Procedures, and Programs revealed, The intent to the items in this section is to identify any special treatments, procedures and programs that the resident received during the specified time periods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #6) of 6 residents reviewed for base line care plans in that: Resident #6's preference to self-medicate her prescribed eye drops and to keep them at bedside were not reflected on her baseline person-centered plan of care. This failure could affect residents admitted to the facility and could result in not respecting their rights or preferences of care. The findings included: Review of Resident #6's electronic face sheet dated 7/8/22 revealed she was readmitted to the facility on [DATE] with diagnoses of rheumatoid arthritis (inflammation of one or more joints), age related osteoporosis (weakening of bone strength related to age), fibromyalgia (chronic muscle pain, tenderness and fatigue), major depressive disorder (major health disorder having episodes of psychological depression), unspecified open angel glaucoma(increased pressure in the eye) and chronic pain syndrome ( ongoing pain). Review of Resident #6's quarterly MDS with an ARD of 4/7/22 revealed she scored a 15/15 on her BIMS which indicated she was cognitively intact and required minimal assistance with her ADL's. Further review in Section F-Preferences for Customary Routine and Activities revealed it was very important for her to make her own choices. Review of Resident #6's physician orders Active as of 7/6/22 revealed Latanoprost Solution 0.005 % (used to treat high pressure inside the eye) Instill 1 drop in both eyes at bedtime related to UNSPECIFIED OPEN ANGLE GLAUCOMA, STAGE UNSPECIFIED (H40.10X0) unsupervised self-administration PrescriberWritten Active 06/21/2022 2000 .Timoptic Solution 0.5 %(Timolol Maleate) (used to treat high pressure inside the eye) Instill 1 drop in right eye two times a day related to UNSPECIFIED OPEN ANGLE GLAUCOMA,STAGE UNSPECIFIED(H40.10X0) unsupervised self-administration-Start Date-06/21/2022 1600. Review of Resident #6's MAR's dated June 2022 and July 2022 revealed when she was admitted on [DATE] and she had self-administered her Timoptic Solution eye drops twice a day and her Latanoprost Solution eye drops at bedtime. Review of Resident #6's baseline care plan dated 6/21/22 revealed it did not contain any information on the resident self administering her eye drops. Review of the facility competence to self-administer medication form completed by the NC for Resident #6 was dated 7/6/22. Observation and interview on 7/5/22 at 9:10 a.m. of Resident #6 revealed she was lying on her bed clean and well groomed, and there were two bottles of medicated eye drops sitting on her nightstand beside her bed. When asked if she gave herself the eye drops she stated yes, that was very important to her. Interview on 7/7/22 at 1:28 p.m. with the NC revealed that Resident #6's self-medicating of eye drops needed to be on the baseline care plan because staff needed to know what her preferences were and it was in her admission physician orders. She stated she recently found out about Resident #6's self-medicating eye drops order and needed to do a self-medicating assessment on Resident #6 to ensure she used the eye drops as ordered and followed professional standards of administration. Interview on 7/7/22 at 2:30 p.m. with LVN C (the admitting nurse of Resident #6) revealed that when Resident #6 was admitted she self-medicated and that information needed to be in her baseline care plan so that others knew what her care needs and preferences were. She stated she missed putting that information on self-medicating of eye drops into Resident #6's person-centered baseline plan of care, and she did not know why it was missed. Review of the facility policy and procedure titled Care Plan/Comprehensive Interdisciplinary dated 2005 revealed A temporary care plan will be completed by the admitting nurse for every new patient to the facility. Review of the facility form titled Temporary Care Plan (undated) revealed it did not include under SELF-HELP an area for self-medicating. Review of the facility policy and procedure titled Self-Administration of Medications (undated) revealed Upon admission the resident or their legal representative documents the acceptance/refusal of self-administration of medication on the appropriate sheet .If the resident wishes to self-administer medications, they will be assessed by the facilities interdisciplinary Care Plan Committee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to review and revise the person-centered comprehensive care plan after each assessment for 2 (residents #12 and #30) of 12 residents reviewed for care plan revisions in that: 1. Resident #12's comprehensive person-centered care plan was not revised to address his high risk for skin breakdown, new skin breakdown areas, and preventive measures and treatments ordered. 2. Resident #30's comprehensive person-centered care plan was not revised to address his recent fall and preventive measures placed. These failures could affect residents with MDS assessments and could result in additional care needs being missed. The findings included: 1. Review of Resident #12's electronic face sheet dated 7/8/22 revealed he was admitted to the facility on [DATE] with diagnoses of diabetes mellitus (inability to regulate blood sugar), dementia (cognitive impairment), hemiplegia and hemiparesis (paralysis to one side and half of body), cerebral infarction (stroke in the brain), and pressure ulcer (skin breakdown resulting from pressure) of unspecified site, unspecified stage. Review of Resident #12's quarterly MDS assessment with an ARD of 4/15/22 revealed he scored a 13/15 on his BIMS which indicated he was cognitively intact. He required extensive assistance with his ADL's. He was coded to be at risk of developing pressure ulcers, had a pressure reducing device in bed, and application of dressings to feet. Review of Resident #12's comprehensive person-centered care plan dated 4/29/22 revealed under Focus .I have a ulcer to the left heel .interventions .dietary to D/C liquid protein and start juven tid on meal trays .will be provided cottage cheese with breakfast. No other skin issues, interventions or treatments were noted. Review of Resident #12's Active Orders as Of: 7/8/22 revealed CHANGE DRESSING TO BILATERAL HEELS EVERY TUESDAY AND FRIDAY BEGINNING 07-01-2022 AND AS NEEDED WITH DRESSING FAILURE OR COMPROMISE. REMOVE DRESSINGS AND CLEANSE RIGHT HEEL WOUND WITH WOUND CLEANSER. APPLY PURACOL PLUS AG (Collagen Gel) TO WOUND AND COVER WITH MEPILEX HEEL DRESSING. APPLY MEPILEX BORDER HEEL DRESSING TO LEFT HEEL FOR PROTECTION every 8 hours as needed for wound care prn Prescriber Written Active 06/29/2022 .PREVALON BOOTS ON WHEN IN BED every shift for DECREASE PRESSURE IN BED Prescriber Written Active 05/17/2022. Review of Resident #12's MAR dated July 2022 revealed nurses signed that he received the treatment ordered above to his bilateral heels every Tuesday and Friday. Review of facility incident reports revealed Resident #12 had an incident on 2/24/22, where he bumped his toe, had a blood blister/bruise to the top of his third toe on his left foot. and on 4/18/22, Resident #12 had a toenail come off on right fifth toenail and on 5/2/22, Resident #12 had a toenail come off left third toe. Review of Resident #12's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] revealed he scored a 12 which indicated he was at high risk for skin breakdown. Review of Resident #12's progress note dated 5/11/22 revealed: Has superficial open area left heel 1.8 cm length by 2 cm width by 0.2 cm depth. Pink tissue in wound bed noted right outer heel with superficial open area 0.8 cm width by 1 cm width by 0.1 cm depth. Pink tissue in wound bed, cleansed both open areas with wound cleanser and protective dressing applied. DH2 shoe on left foot. Bilateral tubigrip to lower legs from toes to bend of knee. Encouraged resident not to use heels to propel self in wheelchair. Float heels in bed. Observation on 7/5/22 at 09:20 a.m. of Resident #12 revealed he was sitting in his room in a wheelchair, he had mutipodus boots on both his feet. A set of prevalon boots could be seen near his bed. His toes were exposed and had scabbed areas on them. Interview on 7/5/22 at 09:30 a.m. with Resident #12 revealed he had problems with his feet and he had areas on his heels that needed treatments. He stated his treatments were usually done at the wound care clinic, but that now they were being done also at the facility. 2. Review of Resident #30's electronic face sheet dated 7/8/22 revealed he was admitted to the facility on [DATE] with diagnoses of senile degeneration of brain (cognitive impairment and dysfunction), vascular dementia (cognitive impairment), macular degeneration (loss of vision), depressive disorders (decreased mood), Parkinson's disease (a disease affecting movement) and insomnia (difficulty sleeping). Review of Resident #30's quarterly MDS assessment with an ARD of 6/10/22 revealed he was not a candidate for a BIMS which indicated he was severely cognitively impaired. He required extensive assistance with his ADL's. He was always incontinent of bladder and frequently incontinent of bowel. He was coded to have had a fall since admission or the prior assessment. Review of Resident #30's comprehensive person-centered care plan dated 6/9/22 did not reflect he was at moderate risk for falls, had a fall and had interventions in place such as a mat on the floor by the bed. Review of Resident #30's fall risk assessment dated [DATE] revealed he scored a 14 which indicated he was at moderate risk for falls. Review of the facility incident report for Resident #30 dated 4/30/22 revealed he had an unwitnessed fall which resulted in a bruise to the top of his scalp. Review of Resident #30's orders Active as Of July 8, 2022 revealed written above in the heading space FLOOR MAT AT BEDSIDE WHEN IN BED. Has physician's orders for 1/2 bedrail at top of bed, fall mat at bedside when in bed DX: Frequent falls, dated 8/31/21. Observation on 7/6/22 at 9:30 a.m. of Resident #30 revealed he was lying in bed with a floor mat by the side of the bed. He was not interviewable. Interview on 7/8/22 at 2:48 pm. with the MDS nurse revealed that she had only been at the facility for a few months and that she was also over other programs She stated she was also working at the sister facility in town. She stated that she tried to keep up with the care plans but that the MDS accuracy was her focus. She stated she had the NC as a resource, and she helped her when she could. She stated that it was important for Resident #12's and #30's care plans to be revised after each assessment and updated with changes so that it is person-centered and that it reflected their needs, services, care requirements, physician orders and preferences. She said the care plans were important because it communicated to other staff what care requirements are needed for each resident. Interview on 7/8/22 at 3:00 p.m. with the NC revealed that the MDS's were her priority, to check them and make sure they were accurate, so the care plans were not a priority. She stated she and the MDS nurse needed to work on them. She stated that it was important for Residents #12's and #30's care plans to be revised after an MDS assessment or with changes in care so that it was person-centered and reflected their needs, services, care requirements, physician orders and preferences. She said the care plans were important because it communicated to other staff what care requirements were needed for each resident. She stated that she was ultimately accountable for the resident's care. Review of the facility policy and procedure titled Care Plan/Comprehensive Interdisciplinary dated 2005 revealed A comprehensive care plan will be developed for each resident within (7) days of completion of resident admission assessment and then quarterly thereafter. The care plan must include measurable objectives and timetables to meet a resident's medical, nursing and psychosocial needs as identified in the comprehensive assessment .The care plan will periodically be reviewed and revised by the interdisciplinary team after each resident assessment, assessment review, or significant change in condition. the care plan will be otherwise updated as warranted by changes in medication, treatment or other changes in condition.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There was a hard-boiled egg in a plastic container that was passed the use by date. 2. There was a 5-pound container of cottage cheese that was passed its use by date. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 7/7/2022 at 10:39 a.m. in the facility kitchen revealed a facility refrigerator located near the main entrance into the kitchen. Observation inside the refrigerator revealed a plastic container holding one hard boiled egg. Located on the lid of the container revealed hand-written dates, 5/16/22 and 6/24/22. Interview on 7/7/2022 at 10:39 a.m. with the Food Service Supervisor (FSS) revealed she did not know why there were 2 different dates on the container lid. The FSS revealed they ordered hard boiled eggs that come in a large plastic bag that was dated. The FSS reported that must have been the last egg from their most recent order of hard-boiled eggs but was uncertain why there were 2 different dates. The FSS stated the egg should have been thrown out because of the conflicting dates. 2. Observation and interview on 7/7/2022 at10:41 a.m. in the kitchen refrigerator revealed an unopened 5-pound container of cottage cheese with a use by date of 6/24/22. The FSS reported the cottage cheese should have been thrown out because it was passed the used by date. In an interview on 7/8/2022 at 9:30 a.m. with the FSS revealed she found out from her staff why the container with the egg had 2 dates. She reported the first date for 5/16/2022 was the date that was on the bag the eggs came in and the second date for 6/24/2022 was the date the egg was placed in the plastic container. The FSS stated she checked the kitchen refrigerators 2 times a week on Mondays and Fridays for any expired food items. The FSS reported any food that was served beyond its use by date or beyond the time limit they could store open food items, which she thought was 7 days, placed the residents at risk for food born illnesses. Review of information provided by the FSS titled, Refrigerated Foods, not dated, revealed, 2. Hard cheese keeps well at room temperature, but soft cheeses (cottage cheese) spoil quickly. Eggs will keep several days, depending on freshness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (#18, #19 and #30) of 4 residents reviewed for incontinent or catheter care and for the improper handling of dirty linen in 1 out of 1 shower room observed for infection control, in that: 1. CNA D put dirty wipes and dirty gloves onto Resident #18's clean bedspread during incontinent care for the resident. 2. CNA A took off her dirty gloves during incontinent and catheter care for Resident #19 and put them onto the top of Resident #19's clean bedspread. 3. CNA A did not change her dirty gloves after she cleaned Resident #30's bottom after he had a bowel movement and did not sanitize her hands after she completed Resident #30's incontinent care. 4. CNA B brought dirty linen out of a shower room unbagged and carried the soiled linen with her bare hands. These failures could affect residents who receive incontinent or catheter care and showers and could result in the spread of bacteria and infections. The findings included: 1. Review of Resident #18's electronic face sheet dated 7/8/22 revealed she was admitted to the facility on [DATE] with diagnoses of senile degeneration (cognitive and memory loss), chronic pain), (ongoing discomfort, anemia (low iron in blood) and weight loss. Review of Resident #18's quarterly MDS assessment with an ARD of 5/7/22 revealed she was not a candidate for a BIMS which indicated she was severely cognitively impaired. She required extensive assistance with ADL's and was coded 3 on bladder and bowel which indicated always incontinent. Review of Resident #18's comprehensive person-centered care plan dated 5/12/22 did not reflect she was always incontinent of bowel and bladder. Observation and interview on 7/7/22 at 4:20 p.m. of Resident #18 revealed she received incontinent care from CNA D. Resident #18 was incontinent of bladder and bowel. CNA D cleaned the resident and placed the dirty wipes in the plastic bag on the resident's bed. The last three wipes and her dirty gloves were tossed toward the bag, missed and landed on the top of Resident #18's clean bed spread. Interview at the same time with CNA D revealed she should have taken more time and placed the dirty wipes and gloves into the bag to prevent cross contamination. Interview on 7/8/22 at 2:00 p.m. with the NC revealed that CNA D should have been more careful and placed the dirty items in the bag and not on Resident #18's clean bed. She stated that CNAs had training on infection control and incontinent care. She stated that not following proper procedures could lead to an increase in infections. Review of CNA D's Nurse Aide Skills Performance Checklist dated 9/20/21 revealed she was signed off on provide male perineal care and provide female perineal care. Review of CNA D's Certificate of Completion dated 5/24/22 revealed she completed the Infection and Infection Control module provided by Texas Health and Human Services. Review of the facility policy and procedure titled Perineal Care/Incontinent Care dated 2005 revealed Female Perineal Care .If resident is soiled with feces .discard each wipe after use .change gloves. 2. Review of Resident #19's electronic face sheet dated 7/8/22 revealed she was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease (hardening and occlusion of the arteries), anxiety (nervousness), diabetes mellitus (inability to regulate blood sugar in the blood), chronic pain (ongoing pain), bladder disorder and urine retention (bladder holding urine). Review of Resident #19's admission MDS assessment with an ARD of 5/8/22 revealed she scored an 8/15 on her BIMS which indicated she was moderately cognitively impaired. She required extensive assistance with ADL's. She was coded to have a urinary catheter. Review of Resident #19's comprehensive person-centered care plan dated 5/16/22 revealed she had an indwelling urinary catheter. Review of Resident #19's Active Orders As of 7/8/22 revealed Foley catheter to be changed only under .Hospice direction. Foley catheter to be left in place: DX: Urine retention/bladder prolapse .start date: 5/5/22. Observation on 7/7/22 at 4:15 p.m. of CNA A as she performed catheter and incontinent care for Resident #19 revealed CNA A took off her dirty gloves after doing incontinent care and put them on Resident #19's clean bedspread. Interview on 7/7/22 at 4:20 p.m. with CNA A she stated she knew better and had been trained on how to do peri care and that the dirty gloves she took off needed to go in the plastic bag which was sitting atop of Resident #19's bed. Interview on 7/8/22 at 2:00 p.m. with the NC revealed that CNA A should have been more careful and placed the dirty items in the bag and not on Resident #19's clean bed. She stated that CNAs had training on infection control and incontinent care. She stated that not following proper procedures could lead to an increase in infections. She stated that CNA A was an agency CNA and she did not have any paperwork to support her training, but she did get in-serviced while at the facility on infection control. Review of the facility policy and procedure titled Catheter Care, Indwelling Catheter, dated 2005 revealed .remove gloves and discard in appropriate container. 3. Review of Resident #30's electronic face sheet dated 7/8/22 revealed he was admitted to the facility on [DATE] with diagnoses of senile degeneration of brain (cognitive impairment and dysfunction), vascular dementia (cognitive impairment), macular degeneration (loss of vision), depressive disorders (decreased mood), Parkinson's disease (a disease affecting movement) and insomnia (difficulty sleeping). Review of Resident #30's quarterly MDS assessment with an ARD of 6/10/22 revealed he was not a candidate for a BIMS which indicated he was severely cognitively impaired. He required extensive assistance with his ADL's. He was always incontinent of bladder and frequently incontinent of bowel. Review of Resident #30's comprehensive person-centered care plan dated 6/9/22 revealed Focus .resident has mixed bladder incontinence r/t disease process of dementia .clean peri-area with each incontinent episode. Observation on 7/7/22 at 10:00 a.m. of CNA A who performed incontinent care for Resident #30 in the shower room where he was being lifted with a standing lift revealed she did not change gloves after she cleaned Resident #30's bottom after he had a bowel movement and did not sanitize her hands after she completed his incontinent care and removed her gloves. She then continued to get his chair and continue with his transfer. Interview on 7/7/21 at 10:20 a.m. with CNA A, she stated she knew better, and she did not know why she didn't change gloves after cleaning Resident #30 and she stated she should have sanitized her hands after taking off her gloves when she was finished. Interview on 7/8/22 at 2:00 p.m. with the NC revealed that CNA A should have changed her gloves after cleaning Resident #30 and sanitized her hands when she had finished the care. She stated that CNAs had training on infection control and incontinent care. She stated that not following proper procedures could lead to an increase in infections. She stated that CNA A was an agency CNA and she did not have any paperwork to support her training, but she did get in-serviced while at the facility on infection control. Review of the facility policy and procedure titled Perineal Care/Incontinent Care dated 2005 revealed Male Perineal Care .If resident is soiled with feces .discard each wipe after use .change gloves. 4. Observation on 7/5/22 at 9:30 a.m. of CNA B revealed she came out of a shower room and carried unbagged dirty linen with her bare hands. Interview on 7/5/22 at 09:35 a.m. with CNA B she stated that she had gloves in her pockets and did not know why she brought the dirty linen out without putting it in a bag and wearing gloves. She stated she could spread bacteria that way, and that she was trained on how to properly handle dirty linen. Interview on 7/8/22 at 2:00 p.m. with the NC revealed that CNA B needed to have the soiled linen bagged and she needed to have worn gloves when she removed the soiled linen from the shower room. She stated that CNAs had training on infection control and incontinent care. She stated that not following proper procedures could lead to an increase in infections. She stated that CNA A was an agency CNA and she did not have any paperwork to support her training, but she did get in-serviced while at the facility on infection control. Review of CNA B's Nurse Aide Skills Performance Checklist dated 5/18/22 revealed she was checked off on hand washing and handling soiled linens. Review of the facility policy and procedure titled Hand Washing/Hygiene dated 2005 revealed Purpose .to prevent the spread of infection .Indications for Performing Hand Hygiene (Including Alcohol Gels) revealed .after contact with soiled objects .after removing gloves. Review of facility staff in-service training titled PPE, dated 5/23/22, Universal Precautions dated 2/22/22, Infection Control dated 1/7/22 and Infection Control: Breaking the Chain. dated 1/21/22 revealed CNA's A and B were in attendance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a medical, nursing, and mental and psychological needs, that are identified in the comprehensive assessment for 6 (#9, #11, #18, #19, #21 and #27) of 20 residents reviewed for comprehensive person-centered care plans in that: 1. Resident #9's PASRR comprehensive person-centered care plan did not address detailed information about the specialized services being provided. 2. Resident #11's comprehensive person-centered care plan did not reflect her indwelling urinary catheter leg strap. 3. Resident #18's comprehensive person-centered care plan did not reflect she was always incontinent of bladder and bowel. 4. Resident #19's comprehensive person-centered care plan did not reflect her indwelling urinary catheter leg strap. 5. Resident #21's comprehensive person-centered care plan did not reflect the resident was receiving hospice services. 6. Resident #27's PASRR comprehensive person-centered care plan did not reflect any specialized services being provided. These failures could affect residents who require specific care and could result in missed or inadequate care. The findings included: 1. Review of Resident #9's face sheet dated 5/4/2022 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included scoliosis (a sideways curvature of the spine that most often is diagnosed in adolescents), trisomy 18 (a genetic condition when a person has an extra copy of chromosome 18 that causes physical growth delays during fetal development) and cerebral palsy (abnormal brain development or damage that affect a persons ability to maintain balance and posture). Review of Resident #9's Annual MDS dated [DATE] revealed the resident did not speak, had severely impaired cognitive status and required extensive to total care with activities of daily living. Review of Resident #9's comprehensive person-centered care plan dated 7/07/2022 revealed the resident was positive for PASRR services (Preadmission Screening and Resident Review-eligible for specialized services due to mental illness or intellectual and developmental disability regardless of funding source or age). Further review of the care plan revealed PT/OT to work with resident 3 X a week and provided no information on the local authority, that the local authority would be contacted for changes or that they would meet quarterly for an interdisciplinary team meeting (IDT) with the local authority. 2. Review of Resident #11's electronic face sheet dated 7/8/22 revealed she was admitted to the facility on [DATE] with diagnoses of diabetes (inability to regulate glucose in the blood), retention of urine (holds urine), dementia (cognitive loss) and rhabdomyolysis (a breakdown of skeletal muscle due to direct or indirect muscle damage which could lead to kidney damage). Review of her Quarterly MDS with an ARD of 3/29/22 revealed she was coded a 9 under bladder which indicated she had an indwelling urinary catheter. She was coded a 3 on bowel which indicated she was always incontinent of bowel. She scored an 8/15 on her BIMS which indicated she was moderately cognitively impaired and required extensive assistance with her care. Review of Resident #11's comprehensive person-centered care plan dated 7/7/22 did not reflect she needed to have a leg-strap with her indwelling urinary catheter. Review of Resident #11's Order Summary Active As Of 7/8/22 revealed Check for placement and function of leg strap every shift every shift related to RETENTION OF URINE, UNSPECIFIED (R33.9) Prescriber Written Active 06/11/2022. Review of Resident #11's MAR for June 2022 and July 2022 revealed nurses initialed off on check for placement and function of leg strap every shift. Observation on 7/5/22 at 09:10 revealed Resident #11 lying in bed, she had an indwelling urinary catheter with a drainage bag. She did not want to talk. Interviews of MDS nurse and NC combined see below. 3. Review of Resident #18's electronic face sheet dated 7/8/22 revealed she was admitted to the facility on [DATE] with diagnoses of senile degeneration (cognitive and memory loss), chronic pain), (ongoing discomfort, anemia (low iron in blood) and weight loss. Review of Resident #18's quarterly MDS assessment with an ARD of 5/7/22 revealed she was not a candidate for a BIMS which indicated she was severely cognitively impaired. She required extensive assistance with ADL's and was coded 3 on bladder and bowel which indicated always incontinent. Review of Resident #18's comprehensive person centered care plan dated 5/12/22 did not reflect she was always incontinent of bowel and bladder. Observation on 7/7/22 at 4:20 p.m. of Resident #18 revealed she received incontinent care from CNA D. Resident #11 was incontinent of bladder and bowel. Interviews of MDS nurse and NC combined see below. 4. Review of Resident #19's electronic face sheet dated 7/8/22 revealed she was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease (hardening and occlusion of the arteries), anxiety (nervousness), diabetes mellitus (inability to regulate blood sugar in the blood), chronic pain (ongoing pain), bladder disorder and urine retention (bladder holding urine). Review of Resident #19's admission MDS assessment with an ARD of 5/8/22 revealed she scored an 8/15 on her BIMS which indicated she was moderately cognitively impaired. She required extensive assistance with ADL's. She was coded to have a urinary catheter. Review of Resident #19's comprehensive person-centered care plan dated 5/16/22 revealed her care plan did not reflect her indwelling urinary catheter leg strap. Review of Resident #19's Active Orders As Of 7/8/22 revealed Check for placement and function of leg strap every shift every shift Prescriber Written Active 04/26/2022. Review of Resident #19's MAR for April 2022, May 2022, June 2022 and July 2022 revealed nurses initialed off on check for placement and function of leg strap every shift. Interviews of MDS nurse and NC combines see below. 5. Review of Resident #21's face sheet dated 5/22/2022 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's disease (a progressive neurologic disorder that causes the brain to shrink/atrophy and brain cells to die), type 2 diabetes mellitus (a chronic condition that results in too much sugar in the bloodstream and can lead to circulatory, nervous and immune system disorders), essential hypertension and dementia with behavioral disturbance. Review of Resident #21's July 2022 Consolidated Physician Orders revealed, Admit to hospice dated 4/27/2022. Review of Resident #21's admission MDS dated [DATE], in section O, under the heading of Hospice Care revealed the MDS did not indicate the resident was on hospice services. Review of Resident #21's comprehensive person-centered care plans dated 7/8/2022 revealed the resident did not have a care plan for hospice services. 6. Review of Resident #27's face sheet dated 12/8/2021 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included essential hypertension (abnormally high blood pressure often due to obesity, family history or an unhealthy diet), mild cognitive impairment and chronic pain. Review of Resident #27's Annual MDS dated [DATE] revealed the resident was eligible for PASRR services due to other related conditions and had a Brief Interview for Mental Status (BIMS) score of 15, cognitively intact. Review of Resident #27's comprehensive person-centered care plans with a start date of 6/13/2022 revealed the resident was PASRR positive and with only one intervention to Maintain communication with PASRR services quarterly, with no information on the local authority or the specialized services being provided by the facility. Review of Resident #27's PASRR IDT meeting notes dated 6/10/2021 revealed the facility was providing rehabilitation services to include physical and occupational therapy. Review of Resident #27's July 2022 Consolidated Physician Orders revealed the resident was receiving physical, occupational and speech therapy. In an interview on 7/7/2022 at 12:02 p.m. with Resident #27 the resident stated she was receiving rehabilitation services 3 times a week. Interview on 7/8/22 at 2:48 pm. with the MDS nurse revealed that she had only been at the facility for a few months and that she was also over other programs She stated she was also working at the sister facility in town. She stated that she tried to keep up with the care plans but that the MDS accuracy was her focus. She stated she had the NC as a resource and she helped her when she could. She stated that it was important for Residents #9's, #11's, #18, #19, #21's and #27's care plans to be person-centered and to reflect their needs, services, care requirements, physician orders and preferences. She said the care plans are important because it communicated to other staff what care requirements are needed for each resident. Interview on 7/8/22 at 3:00 p.m. with the NC revealed that the MDS's were her priority, to check them and make sure they were accurate, so the care plans were not a priority. She stated she and the MDS nurse needed to work on them. She stated that it was important for Residents #9's, #11's, #18, #19, #21's and #27's care plans to be person-centered and to reflect their needs, services, care requirements, physician orders and preferences. She said the care plans are important because it communicated to other staff what care requirements are needed for each resident. She stated that she was ultimately accountable for the residents care. Review of the facility policy and procedure titled Care Plan/Comprehensive Interdisciplinary dated 2005 revealed A comprehensive care plan will be developed for each resident within (7) days of completion of resident admission assessment and then quarterly thereafter. The care plan must include measurable objectives and timetables to meet a resident's medical, nursing and psychosocial needs as identified in the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 2 of 16 resident rooms (room [ROOM NUMBER] and #48) reviewed for physical environment, in that: 1. There were 4 nails sticking out of the wall directly above the bed in room [ROOM NUMBER] bed A. 2. There was a large area of sheetrock that was ripped down to the gypsum plaster in room [ROOM NUMBER] next to bed A. These failures could affect all residents as well as staff and the public by causing them to live, work, and visit a facility with an environment that is not safe, functional, sanitary, and/or comfortable. The findings included: 1. Observation on 7/6/2022 at 9:46 a.m. revealed in room [ROOM NUMBER] the side of bed A was pushed against the wall. Further observation revealed directly above the bed there were 4 nails sticking out of the wall. Located above the 4 nails were family pictures placed above on the wall. In an interview on 7/6/2022 at 4:37 p.m. with the Maintenance Supervisor, after observing the nails sticking out of the wall, reported the resident likely removed the pictures from the wall that was hanging from the nails and placed the pictures elsewhere. The Maintenance Supervisor reported no one had notified him the nails were sticking out of the wall. The Maintenance Supervisor reported the potential outcome with the nails sticking out of the wall was the resident could get a skin tear or injury if the resident was trying to reach for the pictures above the nails. In an interview on 7/6/2022 at 4:48 p.m. with the Administrator reported the family placed the pictures directly above the bed for the resident in room [ROOM NUMBER]A and the resident would remove the pictures from the wall while she was lying in bed. 2. Observation on 7/5/2022 at 4:56 p.m. in room [ROOM NUMBER] revealed the side of bed A was pushed against the wall. Closer observation of the wall revealed a large area measuring about 7 inches wide and 12 inches long where the top paper covering on the sheet rock was ripped off and exposed the gypsum plaster underneath. In an interview on 7/62022 at 4:38 p.m. with the Maintenance Supervisor, after he observed the wall, revealed it was likely caused by the resident's electric bed rubbing the wall when being raised and lowered, causing the paper covering of the sheet rock to tear. The Maintenance Supervisor revealed he was not aware of the damage on the wall. The Maintenance Supervisor reported all the staff were aware where the Maintenance Log, which staff document repairs that need to be done, was kept at the nurses' station. Review of the Maintenance Supervisor Log reveal there was no information regarding the nails sticking out of the wall in room [ROOM NUMBER]A and the damage on the wall in room [ROOM NUMBER]A. In an interview on 7/8/2022 at 3:36 p.m. the DON reported they did not have a policy regarding required repairs needed in residents' rooms.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week from March 19th through, April 2022, May 2022, June 2022, and July 2022. The facility failed to maintain RN coverage 8 hours a day for over 3 months. This failure could affect all residents of the facility and could result in missed resident nursing assessments, interventions, care, and treatment. The findings included: Record review of the time sheets of RN A and the DON's (who was an RN) from 3/18/2022 to 7/8/2022 revealed there was no RN coverage for 8 hours a day from 3/19/22 to 7/6/22. In an interview on 7/06/22 at 2:58 p.m., the Administrator stated the facility did not have an RN in the facility for 8 hours a day from 3/18/22 to 7/6/22. The Administrator said the facility tried hiring RN's, but with the gas prices so high no one wanted to travel, and that the hospital offered the RN's more money, so they had no one who wanted to apply. She stated she knew they needed an RN, and they would continue to try to hire one. The ADM stated If we need an RN to come in and assess something we reach out to our other facility. In an interview on 7/7/22 at 9:07 a.m. with the DON Consultant, revealed that the facility advertised, and they even have used the website. She stated that the facility had been without RN coverage for 8 hours a day since March 2022. She stated The cost of living here is very high, rent is about $3000. Nobody can afford to live here. The hospital hires contract staff, and we can't afford them. The implication of not having RN coverage could be a lack of quality care for high skilled care residents. At present I do not take residents who require high skilled nursing care. I am on call 24 hours a day, and I live 2 blocks away. Further interview on 7/8/22 at 2:00 p.m. the Administrator revealed the facility did not have a policy on RN coverage.