**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 4 Residents (Resident #1) reviewed for pharmaceutical services. MA A administered a non-prescribed 5 MG of Buspirone (a medication for anxiety) and non-prescribed 400 MG of Magnesium Oxide (a medication for heartburn, sour stomach, or acid indigestion) to R #1 on 11/14/2024. The noncompliance began on 11/14/2024 and ended on 11/14/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at the facility at risk of medication errors. Findings included: RR of R#1's AR, dated 1/28/2025, reflected a [AGE] year-old woman who admitted to the facility on [DATE]. She was diagnosed with Paroxysmal Atrial Fibrillation (which was a disease of the heart characterized by irregular and often faster heartbeat.) RR of R#1's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 12. A BIMS Score of 12 indicated the resident had moderate cognitive impairment. RR of a complaint, dated 11/15/2024, reflected R #1 was given a non-prescribed medication, in error, on 11/14/2024. The complaint alleged MA A, who was administering medications, was not being watched by the trainer at the time of the alleged medication error. RR of R #1's PN, in the resident's medical record, reflected a telehealth (video conference) visit, dated 11/14/2024 at 6:30 PM. The chief complaint was [R #1 received 5 MG of Buspirone and 400 MG of Magnesium Oxide. Physician subjective view was patient had no complaints, was seen on video, appeared non-distressed, denied chest pain or shortness of breath. Alert and oriented to time and place, following all commands appropriately. All vital signs were stable; BP generally runs lowish (Blood Pressure 100/57, Pulse 78, Oxygen Saturations 95%.) Denied lightheadedness or dizziness. Assessment/Plan inadvertent medication given to the patient, she received 5 MG of Buspirone and 400 MG of Magnesium Oxide about 20 minutes ago, alert, and oriented, non-sedated, no complaints, following all commands, vital signs stable, LVN was asked to monitor Vitals every 2 hours for 6 hours, cardiorespiratory, neuro checks per protocol. Call back if any concerns of cardiopulmonary depression or oversedation. Advised to hold tonight's Remeron (an anti-depressant sometimes used to stimulate hunger) and Melatonin (a medication used to help someone fall asleep) given potential sedation with 5 MG of Buspirone and 400 MG of Magnesium Oxide.] RR of a facility generated Medication Error Report, dated 11/14/2024 at 6:20 PM, reflected R #1 received a medication error on 11/14/2024. MA A administered the incorrect medication. Description of event: MA A was completing final checks on medications; trainer had clicked to next resident to start reviewing medications and MA A thought that was who she was giving medications. What contributed most to this error, was not confirming the 5 rights of medication administration. To prevent an error from happening again, MA A had education provided with additional days of training. The telehealth physician ordered withhold Remeron and Melatonin. RR of a facility generated Confidential Employee Corrective Action Form, dated 11/14/2024, reflected MA A received a coaching. Reason: Employee completed a medication error and gave medications to wrong patient. Conduct that was observed, or substantiated: 5 rights of medication administration were not followed. Areas to improve: MA A to be provided additional days of training. Signed by MA A, and the ADM, on 11/15/2024. RR of MA A's medication aide permit in Tulip (Texas Unified Licensure Information Portal) reflected an issue date of 11/4/2024; Expiration date of 11/4/2025. RR of MA A's medication administration check off form, dated 11/13/2024, reflected the MA met required tasks. INT and OBS on 1/28/2025 at 9:44 AM with R#1 revealed her in her wheelchair about to exit her room. She was fully dressed, appropriately groomed, and easy to engage. R #1 recalled the medication error from 11/14/2024. She stated the facility addressed the medication error when it happened. She did not want to discuss it further and refused further interview. Resident alert, cordial, and lucid. INT and OBS on 1/28/2025 at 9:44 AM with MA B revealed she was trained to be an MA per policy, continuing education, and yearly reviews. She was observed, at med pass, looking at medication packaging and checking the information on the computer. She stated she was making sure the right medication made it to the right resident and was part of the 5 Rs (Rights) of medication administration. She did not recall any medication errors recently; Any medications errors were reported immediately. INT and OBS on 1/28/2025 at 10:07 AM with MA C revealed she went to school, to become an MA, for about three months and participated in supervised clinicals. There was training throughout the year and yearly check offs were performed. She stated she was trained to check the 5 Rs for accurate medication administration. The 5 Rs were right person, right time, right dose, right medication, and right route. She did not recall any medication errors recently; Any medications errors were reported immediately. INT on 1/28/2025 at 11:33 AM with R #1's NP revealed that 5 mg of Buspirone was a small dosage of a gentle anti-anxiety medication. The goal, for this medication, was to take it multiple times a day to build up the anti-anxiety effect. The NP did not think the individual 5 MG of Buspirone would have had much of a negative effect on the resident, if any. She may have had a slight headache, or some nausea, but it was unlikely the medication error caused her any significant harm. The Magnesium 400 MG was a medication for upset stomach, or constipation. The dosage R #1 received, was a normal dosage. The resident may have suffered diarrhea, if she received more of the medication, but the initial, and singular administration, probably did not have any significant effect. The NP did not recall the resident to have had any complaints. INT and RR on 1/28/2025 at 12:11 PM with the DON revealed new medication aides go through orientation, when hired, and all medication aides went through specific training to become authorized to pass medications. After the medication error on 11/14/2024, the DON stated the MA A was taken off nights and went to day shift for an additional 3 more days of training. After the 3 additional days, MA A transitioned back to the night shift. The DON stated there were no medication errors since 11/14/2024. RR of the medication error binder reflected no medication errors since 11/14/2024. The DON felt the incorrectly administered Buspirone 5 MG may have made the resident drowsy, but the resident did not have any significant negative effect. The Magnesium Oxide 400 MG was a normal dosage. The Magnesium Oxide 400 MG could have caused loose stools, but the resident only had one dose and did not exhibit any significant gastrointestinal or bowel concerns. Safeguards in place to avoid medication errors were the MA training, MA skill check offs, and on-the-spot checks by senior staff. INT on 1/28/2025 at 1:15 PM with the ADM revealed facility medication aides were trained to administer medications per policy. The ADM felt the facility medication administration policy and the training MA A received addressed the appropriate information to avoid medication errors. The failure that caused R #1 to receive a non-prescribed medication fell upon communication and human error. Safeguards in place to prevent medication errors were the training program, nurse management monitoring, continued education, and yearly reviews. RR of the facility's Medication Administration Policy, undated, reflected the MA was supposed to have identified the correct resident prior to medication administration; supposed to have read medication orders on medication sheet; remove medication container and compare label with medication sheet; place appropriate dosage in cup; re-read label and medication sheet. Repeat procedure with each resident who was supposed to receive medication. RR of the facility's in-service education for 5 rights of Medication, dated 11/14/2024, reflected 20 staff, from both AM and PM shifts, in attendance. MA A was in attendance, marked by signature.

Based on observations, interviews, and record review , the facility failed to provide sufficient support personnel with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 5 (Dietary A, Dietary B, Dietary C, Dietary D, and Dietary E) of 9 dietary staff. The facility did not ensure 5 (Dietary A, Dietary B, Dietary C, Dietary D, and Dietary E) of 9 dietary staff had a current food handler's certificate from the date of hire until August 13, 2024 . This failure could place all residents who consumed food prepared from the kitchen at risk of foodborne illness. Findings included: Review of records dated 08/13/2024 revealed Dietary Staff A, Dietary Staff B, Dietary Staff C, Dietary Staff D, and Dietary Staff E did not have food handlers' certificates while employed at the facility. In an interview with the DM on 08/13/2024 at 03:25 PM she stated the employees were required to go through Relias (a computer-based education system) training and then work with her for on the job training and onboarding for multiple days, but at minimum 3 days. She acknowledged that it was required for all dietary staff to have an accredited food handlers' certificate before working in the kitchen. She said the last person was hired over 6 months ago. She stated that this could put the residents at risk for foodborne illness if not trained properly. In an interview with the Administrator on 08/13/2024 at 3:35 PM she stated that employees were required to spend the first week of employment completing the Relias training required by their corporate office. She said that she relied on corporate for training policies and a training system to ensure accreditation standards were up to date. She said she knew all kitchen staff needed a food handlers' certification, but thought Relias was accredited because of guidance from her corporate office. She refused to acknowledge the question about any potential negative outcomes due to a lapse in training. She stated that in-service training's were reactionary, and all staff departments were provided in-services after events had happened. She stated that there has been in-service training performed for dietary staff but failed to provide records for in-services. In an interview on 08/13/2024 at 3:40pm with the Relias customer service phone line he stated that Relias was not affiliated with any state level accreditation programs but has objectives that could serve to meet competencies. No in-service training for dietary aids was provided by the time of exit. Requested the policy for dietary new hire training but it was not available.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. The facility failed to ensure Dietary Aide C served food in accordance with professional standards and facility policy. These failures could place residents at risk of foodborne illnesses. Findings included: Observation on 08/13/24 12:00 PM of lunch service on 200 hall bistros. Dietary Aide C used her thumb and index finger on her right hand to pick up the pickles and onions and place them in the residents sandwich. She did not wear gloves or use a utensil for the pickles and onions. Surveyor observed her make 7 trays in this manner. ADON was observing as well and did not try to correct Dietary Aide C. In an interview on 08/13/24 12:48 PM Dietary Aide C stated she should have used utensils when grabbing the pickles and onions because of the risk for cross-contamination and possibly making the residents' sick. She stated it is the policy to use gloves or utensils when serving ready to eat foods. 08/13/24 01:00 PM In an interview ADON stated she observed Dietary Aide C touch the pickles and onions with her fingers, and she should not have done that because it is their policy not to touch the food with hands. She stated it is an infection control issue and she should have used gloves or utensils. In an interview on 08/13/24 at 02:00 PM, the DM stated she trained new kitchen staff herself after they go through general facility orientation which includes proper handling and serving of food, and she also trained all staff with regular in-services. She stated she does not have any documentation of the training. She also stated she was very surprised to hear of the issue with Dietary Aide C during lunch service in the bistro. She stated the crew knows better and she is disappointed. She further stated she tells her staff It only takes one little germ to make the residents sick. She stated the policy regarding plating food is to use utensils or gloves for ready to eat foods and she prefers for her staff to use utensils because there is less room for error. In an interview on 08/13/24 at 02:10 PM, the DON stated during orientation nursing staff were trained on meal service and hand hygiene. Dietary Staff receive their own training by their manager. In an interview on 08/13/24 at 02:15 PM, the Administrator stated all new dietary personnel receive general facility orientation, job specific training through RELIAS, as well as three to five days on the job training with the dietary supervisor. She stated the dietary supervisor worked very closely with new staff and provided ongoing training through in-services. Record Review of RELIAS training on 8/13/2024 for seven dietary staff, including Dietary Aide C, reflected all received training on infection control and prevention, food safety fundamentals, and handling food safely. Record Review on 8/13/202 of in-service training dated 08/12/2024 reflected staff received training on hand hygiene proper policy/procedure and frequency including Dietary Aide C. Record Review on 8/13/2024 of Nutrition Services Indications for Glove Use and Sanitation facility policy dated 01/01/2010 reflected food employees may not contact ready- to-eat food or food that will not be subsequently cooked with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment.

Based on observation, interview, and record review the facility failed to help prevent the development and transmission of communicable disease and infections on 2 of 3 ice chest observed for infection control. Ice chest on hall 100 revealed plastic cup stored inside laying on the ice. Ice chest on hall 400 revealed metal scoop inside laying on the ice. This failure placed residents at risk for cross contamination and/or spread of infection that could cause severe illness and decreased quality of life. Observation on 9/18/23 at 08:59 am of ice chest on hall 100 revealed Large Plastic cup inside lying on the ice. No storage container visible on ice chest. Observation on 9/18/23 at 09:17 am of ice chest on hall 400 revealed metal scoop inside lying on the ice. Scoop holder was attached to cart. Observation on 9/18/23 at 11:29 am of ice chest on hall 100 revealed large plastic cup inside lying on the ice. Interview on 9/18/23 at 10:45 CNA A stated he has been with the facility for 1 day (today is his first full day as a qualified CNA). He stated that the ice scoop should be placed in the holder attached to the cooler, not inside the cooler. Interview on 9/18/23 at 12:55 PM CNA B stated she knew the ice chests scoops were not supposed to be kept in the coolers themselves, but in a holster attached to the cart. Interview on 9/18/23 12:30 pm with DON, stated her expectation was that the proper scoop is used to pass out ice and that is be stored in the attached holster when not in use. She stated not using the proper equipment to pass ice and not properly storing the scoop can put the resident at risk for potential harm from cross contamination. Interview on 9/18/23 100 pm with ADM. Stated her expectations was that staff follow policy and procedures for the ice chest and use the proper equipment. She stated that not following the policy and procedure could potentially place residents at harm for illness duet to cross contamination. Record review on 9/18/23 1:15 pm of Policy Cleaning of Ice machine and scoops dated 1/1/10 states the ice scoop is stored in a clean container that allows water to drain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #24)7 residents reviewed for care plans. The care plans for Residents #24 failed to address her dementia diagnosis and what services would be provided to maintain the resident's needs These failures could affect residents by placing them at risk for not receiving care and services to meet their needs. Findings included: 1. Review of the MDS assessment dated [DATE] revealed Resident #24 was an [AGE] year-old female with BIMS score 12 who was admitted to the facility on [DATE]. The resident's diagnoses included: depression, bipolar (mood) disorder, and non-Alzheimer's dementia (mental decline). Review of Resident #24's Comprehensive Care Plan initiated 11/30/17 revealed it did not address Resident #24's dementia. Interview with REG N on 07/11/23 at 12:00 AM revealed facility staff overlooked Resident #24's MDS and missed the dementia diagnosis. REG N stated that if residents were admitted all their diagnosis should be in the care plan. REG N stated the purpose for the care plan was to put in place interventions so staff could properly manage residents' care. REG N stated that by Resident #24 having an incomplete care plan for dementia she could potentially become more confused. When asked who is responsible for ensuring care plans are complete, Reg N responded LVN A and LVN B are but are on leave. Interview with the DON on 07/11/23 at 12:25 PM revealed facility staff updated how they did care plans by doing standard care meetings. DON stated every week she reviews everything regarding the residents from admission and onwards and documents on a checklist during the standard of care meetings. [NAME] stated that staff has a checklist to use for any changes that occurred with the resident( vitals, med profile, medications). DON stated the facility must have missed the diagnosis for Resident #24 by accident. The DON stated the dementia diagnosis should have been care planned. The DON stated that if Resident #24 was not properly care planned for dementia, that could lead to a decline in care and affect her daily activities. Review of the policy, Care plans, Comprehensive Person-Centered, undated, revealed the following. The facility develops a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan will describe: The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Any services that would otherwise be required but that are not provided due to the resident's exercise of rights, including the right to refuse treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the right to receive written notice of a room change before the change was made for 1 of 2 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1, and his Responsible Party received written notice prior to a room change. This failure could place residents at risk for decrease quality of life being in a new environment. Findings included: Record review of Resident #1's undated face sheet reflected he was a 40 -year-old male admitted to the facility on [DATE]. Diagnosis was not listed on the face sheet. Record review of Resident #1's Medical Diagnosis dated 01/26/2023 reflected resident had a diagnosis other seizure (a burst of uncontrolled electrical activity between brain cells), unspecified dementia without behavior/ psychotic, mood, and anxiety disturbance. The medical diagnosis record was updated on 01/27/2023 with a diagnosis of down syndrome, unspecified (congenital malformations, deformations, and chromosomal abnormalities). Record review of Resident #1's Significant Change MDS assessment dated [DATE] reflected resident usually able to make self-understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time), resident usually understands others (misses some part/intent of message but comprehends most conversations). Resident #1 had a BIMS score of 5 indicated his cognition was severely impaired. Resident did not exhibit any issues with behaviors. Resident was also assessed to require extensive assistance with ADL's and needed two-person assistance. Resident had new diagnosis of hip fracture. He also had frequent pain during the MDS assessment period and received scheduled pain medication regiment. Record review of Resident #1's Comprehensive Care Plan dated 1/27/2023 and revised on 2/17/2023 reflected resident was at risk for psychosocial well-being. Interventions: Observe for psychosocial and mental status changes - document and report as indicated. Record review of Resident #1's nurses notes dated 02/13/2023 at 5:25 AM reflected the resident slept in the common area most of this shift. Resident #1 would not arouse fully when speaking to him. Resident #1 appeared very tired and did not want to go to room. Staff attempted to transfer resident at 0300 into another empty bed on the hall and he woke up and stated that he wanted to get up. Resident #1 was transferred to wheelchair and assisted to the common area. Resident was pleasant with staff. Resident was administered PRN Tylenol for R leg pain. Signed by LVN A. Record review of Resident #1's nurses notes dated 02/13/2023 at 16:12 reflected Resident moved to 208 B; family aware/ consented. Signed by the Director of Nurses. Interview on 02/24/2023 at 7:00 PM, the R/P for Resident #1 stated when she visited Resident #1 on 02/13/2023 approximately 11:00 AM, he was not in his room. She stated she could hear him yelling but could not find him. She stated she asked someone (did not know name of person) and this person explained Resident # 1 had been moved to another room. She stated she could hear him yelling but could not find him. She stated she asked when he was moved, and she was informed by a nurse (did not know the nurses name) he was moved early in AM on 02/13/2023. She stated she was not notified of him being moved by a phone call or any written notice. She stated her son was not given a written notice. She also stated when she asked her son about the room change, he did not understand why he was moved. Interview on 02/25/2023 at 11:05 AM, the Director of Nurses stated Resident #1 did not want to remain in his room related to his roommate yelling. She stated the nurse's documentation on 02/13/2023 was expected to reflect why the staff was attempting to move Resident #1 at 3:00 AM She stated Resident #1 did not want to lay down in another room and preferred to remain up in his wheelchair in the common area near the only nurses' desk in the facility. She stated Resident #1 was awake most of the night, became tired, and was moved to room [ROOM NUMBER] B the morning of 02/13/2023. She stated she did not know the exact time he was moved into that room. She also stated no one documented the time of the exact move or if he was notified, he was being moved. She stated in the morning meeting on 02/13/2023 at 9:30 AM, Resident #1 needed to be moved to another room. She also stated she informed the Administrator, the R/P needed to be contacted concerning Resident #1 moved to another room. She stated no one called the mother (R/P) to inform her he was being moved. She stated Resident #1's Mother entered the facility and was unable to locate Resident #1. She stated the mother was upset and wanted to know where her son was located. She stated she did explain to the mother of the incident with the roommate yelling. She stated the mother was not happy about not being contacted about her son (Resident #1) being moved. She stated all R/P's were to be contacted of any type of room change. She stated there was no excuse of why any of the staff did not contact the mother concerning the room change. She stated they should have decided who was going to contact the mother during the morning meeting and have someone call the mother immediately after the meeting and prior to the room change. She stated she did document the R/P (Mother) was informed and consented in the nurses notes on 02/13/2023. She also stated the R/P (Mother) stated he had already been moved and she thought it would upset him if he was moved again and then she agreed/consented to the move. She stated the R/P (mother) did not sign any type of room change agreement or was notified by any staff prior to Resident #1 being moved. She stated with the R/P not knowing about the move, she was upset and thought something had happened to her Resident #1. She stated with the mother being upset, there was a potential of upsetting the resident. Attempted to contact LVN A via telephone on 02/25/2023 at 12:20 PM and was unable to leave message. In an interview on 02/25/2023 at 4:00 PM, the Administrator stated Resident #1 was moved on 02/13/2023 prior to his R/P visiting him on 02/13/2023. He stated he did not recall the exact time Resident #1 was moved. He stated he thought it was approximately 10:30 AM. He stated he did not remember if it was discussed in morning meeting to call his R/P of moving him to another room. He stated the morning meeting began at 9:30 AM and ended approximately 10:00 AM. He stated the R/P was required to be contacted before resident was moved. He stated if family came in the facility and was not aware their family member was moved to another room, the family had a potential of becoming distraught. He stated the family may believe their loved one was sick, something happened to their loved one and was sent to hospital. He also stated this incident of not notifying R/P of room change had a potential of causing a lot of unnecessary stress. Record review of the Facility Resident Care Policy (not dated) reflected the facility will prepare a written notice which contains: the reason and effective date of the relocation and the room to which the resident is being located to.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment of residents were reported within 2 hours to the state agency for one (Resident #1) of three residents reviewed. The facility failed to timely report an allegation of injury of unknown origin to the State Agency for Resident #1. This failure could affect all residents by placing them at risk of abuse or neglect. Findings included: Record review of Resident #1's undated face sheet reflected he was a 40 -year-old male admitted to the facility on [DATE]. Diagnosis was not listed on the face sheet. Record review of Resident #1's Medical Diagnosis dated 01/26/2023 reflected resident had a diagnosis other seizure (a burst of uncontrolled electrical activity between brain cells), unspecified dementia without behavior/ psychotic, mood, and anxiety disturbance. The medical diagnosis record was updated on 01/27/2023 with a diagnosis of down syndrome, unspecified (congenital malformations, deformations, and chromosomal abnormalities). Record review of Resident #1's Significant Change MDS assessment dated [DATE] reflected resident usually able to make self-understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time), resident usually understood others (misses some part/intent of message but comprehends most conversations). Resident #1 had a BIMS score of 5 indicated his cognition was severely impaired. Resident did not exhibit any issues with behaviors. Resident was also assessed to require extensive assistance with ADL's and needed two-person assistance. Resident had new diagnosis of hip fracture. He also had frequent pain during the MDS assessment period and received scheduled pain medication regimen. Record review of Resident #1's Comprehensive Care Plan dated 1/27/2023 and revised on 2/17/2023 reflected resident was at risk for psychosocial well-being. Interventions: Observe for psychosocial and mental status changes - document and report as indicated. Resident #1 was at risk for injury/immobility due to need for quarter or half side rails to assist with turning and repositioning. Monitor for changes in condition that may indicate a decline in mobility and report to physician. Resident requires assist with ADL's. Resident had limited physical mobility related to right hip fracture. Non-weight bearing to right lower extremity. Resident was non-weight bearing to right lower extremity. Monitor/ document/ report PRN any signs/ symptoms of immobility: contractures forming, worsening, thrombus formation or skin breakdown. PT and OT referrals as ordered, PRN. Resident #1 was at risk for falls due to new environment, down's syndrome, and dementia. Call light in reach. Ensure resident was wearing appropriate footwear when mobilizing in wheelchair. Resident needs a save environment: clutter free and bed in low position at night. Resident had a seizure disorder. Resident was assessed to be at risk for pain. Interview on 02/25/2023 at 11:05 AM, the Director of Nurses stated she notified the Administrator on 02/13/2023 after the facility received results of right fracture hip late in evening on 02/13/2023. She stated she did not know the exact time. She stated the Administrator was the abuse coordinator and at that time no one knew what happened and this is when the investigation began of the interviews with staff. She stated resident was transferred to hospital on [DATE] approximately 5:30 PM. She also stated someone from the hospital called the facility on 02/13/2023 and spoke to a nurse and reported resident had a right hip fracture. She stated the nurse supervisor called her with the information. She stated it was not documented in nurses notes of the phone calls from the hospital, from nurse supervisor, or when I called the administrator. She stated Resident #1 returned to the facility on [DATE]. Interview on 02/25/2023 at 4:00 PM, the Administrator stated he was notified on 02/13/2023 by the DON of the health condition of Resident #1. He stated the DON reported Resident #1 had hip fracture of unknown origin. He stated Resident #1 was in the hospital on [DATE] due to seizures and returned to facility on 02/12/2023. Resident #1 was complaining of some pain and the nurse practitioner ordered an x-ray on 02/13/2023 and it was not going to be as soon as she wanted the x-ray and decided to transfer him to the hospital on [DATE]. He stated this was when it was reported that he had a fractured right hip. He stated someone from hospital called on 02/13/2023 and spoke to one of the nurses (not sure name of the nurse) and reported he had a fracture right hip. He stated he was to report this incident to the Texas State of Human Services within 2 hours of being notified as stated in the federal regulations. He stated he did not attempt to report it until 02/19/2023. He stated he had difficulty with the electronic site with the state website of where to report any type of incidents. He also stated he did not call in the incident to the state of Texas electronic system of reporting incidents. He stated he did not have an intake number. He stated he preferred not to call in incidents he preferred to complete incidents online with the electronic system with the state of Texas. He stated as of 02/25/2023 (at the time of the interview), the incident was not reported to Texas State Department of Health Services. He stated by him not reporting to state in a timely manner, it could become more negative about the situation such as not reporting of what happened and not notifying Texas State Department of Health. He stated it was his responsibility to report, to the State, about any unusual occurrences such as injury of unknown origin. Record Review of Provider self-reporting of LTC incidents dated 02/19/2023 was not completed and was not sent into the electronic records with the Health and Human Services self - reporting incidents. Record Review of Abuse/ Neglect Prohibition Policy (not dated) reflected any bruising or injuries of unknown origin of any resident must be documented upon discovery and reported immediately to their supervisor who in turn will report this immediately to the director of nurses or administrator. All efforts will be made to determine if abuse/neglect could have occurred concerning these bruises of injuries of unknown origin. The administrator or his/her designee will report the alleged abuse/neglect to the Texas Health and Human Services and/or other appropriate agency and /or the appropriate law enforcement agency per regulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one (Resident #1) of 11 residents reviewed for facility-acquired pressure ulcers. The facility failed to ensure Resident #1's skin wound was assessed correctly by a registered nurse which resulted in Resident #1 being incorrectly assessed by the licensed vocational nurse/treatment nurse. The facility failed to ensure the TREATMENT NURSE received training and monitoring to ensure residents wounds were treated within professional guidelines. These failures could result in residents receiving inadequate skin care for wounds, deterioration of wounds and decreased quality of life. Findings included: Review of Resident #1's face sheet dated 11/03/2022 revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of chronic kidney disease, high blood pressure, rheumatoid arthritis, morbid obesity, major depressive disorder and atrial fibrillation (irregular heartbeat that can cause blood clots). Review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 13 to indicate mildly impaired cognition. Resident #1 was noted to require total assistance by two or more staff members for bed mobility. Resident #1 was incontinent of bowel and bladder. Resident #1 was not noted to have any current skin issues and required a pressure relieving device on her bed. Review of Resident #1's care plan dated 11/02/2022 revealed Resident #1 had a stage 3 to left posterior thigh. Interventions included administer medications as ordered, administer treatments as ordered and monitor for effectiveness, follow facilities policies/procedures for skin breakdown and if the resident refuses treatment confer with the resident, IDT, and family to determine why and try alternative methods to gain compliance. Review of Resident #1's physician orders dated 10/26/2022 revealed Resident #1 was ordered wound treatment for Stage 3 pressure ulcer for left posterior thigh, cleanse with normal saline, gently pat dry, calcium alginate AG+, and cover with silicone super-absorbent dressing QD and PRN until resolved as needed for wound care. Review of Resident #1 wound assessment dated [DATE] revealed Resident #1 had a stage 3 pressure ulcer on left thigh (posterior) that was in-house acquired with measurements of 20.0 cm by 18.0 cm with a total area of 360.0 cm and no depth was noted. In an interview on 11/02/2022 at 12:23 PM, ADON A stated Resident #1 had excoriation (skin breakdown due to scratching or picking). on left buttock and thigh as Resident #1 kept scratching it causing open areas. ADON A stated it was first noted on 10/11/2022 and the TREATMENT NURSE likely staged it as a stage 3 pressure ulcer due to the open area caused by the scratching. ADON A stated there was not an open area caused by pressure. ADON A stated the TREATMENT NURSE should not have identified the excoriation as a stage 3 pressure ulcer. Interview on 11/02/2022 at 1:15 PM, Resident #1 stated she had redness on her left thigh on the back of it caused by being wet from brief and the pad underneath not being changed. Resident #1 stated there were times she did not realize she was wet or that the pad was wet and her skin became irritated by the wetness over extended amounts of time. Resident #1 stated sometime the facility was short staffed and it took awhile for staff to get to her to change her wet brief. Resident #1 stated the staff do the best they can and put barrier cream after each change of her brief. Interview on 11/03/2022 at 3:00 PM DON stated the Treatment Nurse was not educated properly on staging wounds. DON stated a couple of the residents were staged as worse than they actually were. DON stated the Treatment Nurse was an LVN with a moderate amount of experience prior to taking this position here as the Treatement Nurse. Observation on 11/02/2022 at 3:10 PM, revealed Resident #1 had a large area of reddened or excoriated skin to her left buttock. The area was 8 x 12 inches long and wide. Two small 0.5 cm areas of open skin were seen to the left buttock. Resident #1's skin had a large area of reddened skin, inflamed looking. She had small skin tears which appeared to be the result of the skin break down. IFollow-up interview on 11/02/2022 at 3:10 PM, DON stated Resident #1's skin had almost healed over and was being treated with barrier cream. DON stated not all the aides were putting on the barrier cream every brief change and Resident #1 skin had reddened again. Follow-up interview on 11/06/2022 at 10:20 AM, DON stated the facility had recognized in October 2022 that the Treatment Nurse needed more training and sent him to another facility to work with a tenured treatment nurse. DON stated there was not another nurse or RN verifying the staged wounds by the Treatment Nurse. DON stated in the October QAPI (Quality Assurance and Performance Improvement) meeting she realized along with the ADON that there was an increase in facility acquired pressure ulcers and planned for training of the Treatment Nurse and evaluation of the current wounds to ensure the information was correct. DON stated they had not completed the full evaluation of all wounds. DON stated there had been staffing issues and when needed the ADON assisted with coverage to ensure residents' needs were met. Interview on 11/06/2022 at 11:00 AM, Treatment Nurse stated he had not had training for staging of wounds or wound care except what he received in nursing school. Treatment Nurse stated he trained at another facility this past week on 11/01/2022 - 11/02/2022. Treatment Nurse stated he realized the assessments needed to be more accurate in that if a new wound or skin issue was discovered it should be on the skin assessment and then wound assessments and physician orders should match the current skin issue. Treatment Nurse stated Resident #1 was incorrectly staged to a stage 3 pressure ulcer due to the open areas caused by her scratching. Treatment Nurse stated the red area was excoriated skin and not a pressure ulcer. Treatment Nurse stated Resident #1 continued to be on the wound care protocol. Review of Resident #1's Total Skin Assessments from 10/10/2022 - 11/01/2022 revealed Resident #1 had no new skin issues. Review of Resident #1's Nursing Progress Note dated 10/10/2022 at 10:35 AM revealed CNA reported resident having an open area to buttock; area is approx. 25cm length by 20cm width presenting as DTI with masceration (deep tissue injury with skin softening). Area does have an open area with slight eschar and will be classified as a Stage 3 pressure ulcer to left posterior thigh. very scant drainage noted; Cleanse with normal saline, gently pat dry, apply anacept (antiseptic) place collagen sheets and cover with hydrocolloid dressing to area QD & PRN until resolved. Review of Resident #1's Wound assessment dated [DATE] revealed Resident #1 had an in-house acquired stage 3 pressure ulcer on her left rear thigh. The measurements were 25.0 cm x 20 cm with a total area of 500 cm squared. No depth was documented. Review of Resident #1's Wound assessment dated [DATE] revealed Resident #1 had an in-house acquired stage 3 pressure ulcer on her left rear thigh. The measurements were 25.0 cm x 20 cm with a total area of 500 cm squared. No depth was documented. Review of Resident #1's Wound assessment dated [DATE] revealed Resident #1 had an in-house acquired stage 3 pressure ulcer on her left rear thigh. The measurements were 20.0 cm x 18 cm with a total area of 360 cm squared. No depth was documented. Review of Resident #1's physician orders dated 10/11/2022 revealed Resident #1 was ordered Arginaid (supplement with amino acids to promote wound healing) two times per day for wound care protocol with instructions for one packet mixed in 4-6 oz of water. Review of Resident #1's physician orders dated 10/11/2022 revealed Resident #1 was ordered a liquid protein supplement 30 cc two times per day for wound care protocol. Review of Resident #1's physician orders dated 10/11/2022 revealed Resident #1 was ordered a lab for measurement of Resident #1's pre-albumin (pre-albumin levels indicate protein levels in the body needed for wound healing). Review of facility Wound Care Protocol dated 05/20/2022 revealed residents with wounds were supplemented with multivitamins and arginaid if stage 2, 3, or 4 pressure ulcer. The residents prealbumin would be checked and the RD would be notified for assessment of resident's protein needs. Review of TREATMENT NURSE'S Competency Check-off dated 07/07/2022 revealed TREATMENT NURSE demonstrated the competencies necessary to measure the wound correctly, stages wound following NPIAP (National Pressure Injury Advisory Panel) guidelines, .and document treatment in the EMR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct an accurate comprehensive assessment of each resident's functional capacity for 1 of 32 residents (Resident #56) reviewed for MDS accuracy. The facility failed to include Resident #56's new onset of hallucinations and delusions when a significant change assessment was completed for her after a functional decline and escalation of schizophrenia/bipolar disorder symptoms occurred. This failure placed residents at risk of not receiving appropriate care or services for their condition(s). Findings Included: Review of Resident #56's clinical face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of major depressive disorder severe with psychotic features, unspecified intellectual disabilities, schizoaffective disorder, and bipolar disorder. Review of Resident #56's significant change MDS dated [DATE] reflected a BIMS of 3 indicating a severe cognitive impairment. Section E 0100. Potential Indicators of Psychosis reflected that she had no hallucinations and no delusions during the lookback period. It also reflected that she had exhibited the behavior of physical aggression. Review of Resident #56's Discharge Return Anticipated MDS dated [DATE] reflected no behaviors. Review of Resident #56's care plan reflected a focus area initiated on [DATE] that revealed, Resident at risk for complications associated w/ routine use of psychotropic medications and an area that reflected the following: The resident has a psychosocial well-being problem r/t Depression. There was no care plan item related to schizoaffective disorder, hallucinations, delusions, or aggression. Review of social services progress notes for Resident #56 dated [DATE] at 9:00 a.m. reflected the following: The administrator and I met with resident today due to an incident that occurred last night between she and her roommate. Her roommate states that resident came into the room and accused roommate of stealing her cell phone, when the roommate repeatedly told her she did not have her cell phone resident became upset and stated she was going to fight her roommate, the two of them were separated last night and Resident went to a different room. Upon this social workers arrival to residents room she was sitting in her wheel chair in the room crying she spoke at a rapid pace and states she does not feel safe here. She said she has been hearing voices and seeing her ex-husband in the facility which he has not been here. She states she mainly sees her ex husband most in the therapy room. She also states she sees people that have died and states 'I do not know why I keep seeing him he is alive as far as I know.' She keeps stating that she is scared she is losing her mind she says she knows the visual hallucinations are not real. She mentioned to me last Friday she has been seeing cats all over her room and in the building she states the auditory and visual hallucinations occur periodically during the day. She further mentioned she is not sleeping through the night as she is paranoid someone is going to get her all of this is impacting her daily functioning especially as it pertains to social relationships. She and her roommate do not have a history of altercations and she continues to obsess over staff member that she thinks is in love with her but no longer wants her. Social worker informed PCP for recommendations at this time. Review of nurse's progress notes for Resident #56 dated [DATE] at 11:44 a.m., reflected the following: Resident noted to continue to have visual and auditory hallucinations, very tearful this morning. Resident reports and confirmed by staff that resident has not slept well in several days. NP notified and orders for Trazodone 50mg qhs received, increase dose of Seroquel at night to 50mg and administer Ativan 0.5mg x1 now [given by this RN]. (Pharmacy) called with new orders, daughter and resident notified of changes, consent for Trazodone completed. Will monitor. Review of a behavioral health hospital assessment dated [DATE] reflected Resident #56 was assessed with schizoaffective disorder bipolar type and major neurocognitive disorder and included the following details: Affect- constricted, blurred, worrisome Appearance- disheveled Motor Activity- hyperactivity Speech- rambling Behavior- bizarre Mood- restless, anxious Thought Process- tangential Hallucinations- auditory, visual Delusions- bizarre, paranoid Observation and interview on [DATE] at 8:34 a.m., revealed Resident #56 sitting in her wheelchair next to her bed, eating breakfast. She stated everything was pretty good. She had no complaints. She stated she was not scared in the facility but sometimes people bother her. She stated that the staff help her when she is feeling anxious or scared. She could not give any examples of how they help her. During an interview on [DATE] at 9:48 a.m., the MDSN stated she had worked at the facility in her position about three years and was the long term care MDS nurse. She stated she had been the MDS nurse who had completed the significant change assessment for Resident #56 in February 2022. She stated that she also completed the Discharge Return Anticipated MDS for Resident #56 when she discharged to the acute care behavioral health facility in March. She stated the significant change MDS was because there was an all over functional decline and onset of psychotic behaviors. She stated that they initially thought the behavior change might have been because of her having COVID or for some other medical reason, and she was tested for various infections and conditions, including UTI, for which she was positive. She stated the resident was treated for the UTI, and there were no other issues detected through diagnostic testing. She stated the behaviors then escalated considerably at the beginning of [DATE]. She stated the resident was discharged to an acute behavioral hospital on [DATE], because she had become extremely paranoid, was hallucinating, and thought people were stealing her things and out to get her or hurt her. She stated that Resident #56's cognition is better since she returned to the facility on [DATE] and her ADLs have improved significantly except she is still not able to walk on her own. The MDSN stated that the behaviors are mostly controlled, but Resident #56 is still having some hallucinations. She stated the resident recently said she saw a little boy in her room. The MDSN stated the Discharge Return Anticipated MDS did not include any behaviors, because the behaviors were covered on the significant change assessment. She looked at the significant change assessment and stated that hallucinations and delusions were not marked on that assessment and should have been. She stated that one outcome for the behaviors not being on the MDS was that the behaviors would not be on the care plan, which they needed to be. She stated she thought the behaviors were care planned under the care plan items for depression and psychotropic drugs. She stated she thought the interventions would be the same for hallucinations and delusions. She stated it probably would not have an impact on the Resident #56, because the staff communicated during their morning meetings and on their 24-hour report book. She stated the process for completing an MDS assessment was that she completed all the sections and then sent it out to the department heads to review. She stated that she is responsible for oversight and monitoring of the system for MDS assessments. She stated the process was in her head, and she used a notebook to write down any new information about her residents that she learned from the other departments and made sure they went into the care plans. She stated they did interviews and went over nurse's notes, progress notes, and hospital records. She stated she still received training yearly from corporate, but she did not remark about what that training entailed with regard to the process of ensuring MDS assessments are accurate and comprehensive. During an interview on [DATE] at 10:16 a.m., the SW stated Resident #56 was having a lot of mental health issues, but she had been pretty good the past week or so. The SW stated she used the care plan to know what was going on with the residents, and it would be important for behaviors such as hallucinations, delusions, and physical aggression to be care planned. During an interview on [DATE] at 10:23 a.m., ADON A stated that, from her understanding, Resident #56 had started having psychotic behaviors a few months ago. She stated that it was hallucinations and paranoia, and she would latch on to a few people she trusted. ADON A stated she never saw aggressive behaviors, but they may have happened. She stated the MDS nurse was definitely aware of the behaviors, because they went over those behaviors every morning during their meeting. She stated she assumed that behaviors like that should have gone into the care plan. She stated the care plans confused her when she opened them, so she did not look at them often. She stated she was not aware of whether or not she was supposed to be reading them. She stated she had never had any training about MDS assessments or care plans. During an interview on [DATE] at 1:49 p.m., the DON stated that around the first of [DATE], Resident #56's behaviors really escalated in a very short period of time. She stated that they treated her for a UTI, it resolved, but the hallucinations and paranoia were still there. The DON stated on the first of [DATE], Resident #56 had visual and audial hallucinations. The DON stated the resident had a traumatic past, and there was a man working in their rehab gym who looked to Resident #56 like her abusive ex-husband. The DON stated that seemed to trigger the behaviors. She stated they had an order for the nurses to document any behaviors, and then they were able to get her into the behavioral hospital very quickly. The DON stated when the resident came back to the facility, she told them and has continued to tell them that she still saw the people she had been hallucinating, but she knew they were not real. The DON stated that Resident #56's hallucinations and delusions were something she would expect to be in the MDS assessment and the care plan. She stated she thought the resident would get the care she needed anyway, though, because the staff relied so heavily on the morning meeting discussions and the 24-hour report. She stated she had no system really in place to look over the MDS and care plans to ensure they are comprehensive and probably needed to create a system. She stated that if the behaviors did not make it into the care plan, it could affect the resident in that she could not get the care she needed. She stated that staff or resident injury could be an outcome to a resident with psychotic behaviors not receiving the treatment he or she needed. The DON stated if no one knew about the hallucinations or aggression, the resident could hurt herself, and there could also be a negative psychological impact. During an interview on [DATE] at 2:35 p.m., the ADM stated that Resident #56 has had hallucinations, delusions, and threats of physical aggression. He stated the behaviors were on and off but did persist, and they should have been on the MDS assessments and in the care plan. He stated the MDS nurses explained that Resident #56 might have had interventions in other areas of her care plan that applied to her behaviors, but he had not looked at that, yet. He stated that the MDS nurses had a corporate MDS nurse who supported and trained them, but she had been working at one of their sister facilities that did not have an MDS nurse, so she had not been able to provide as much oversight recently. He stated he was very well versed in the needs of his residents, but he did not have a specific plan related to oversight of the MDS and care planning processes. He stated he did ask a lot of questions and contribute ideas when discussing MDS and care plans in the morning meeting. He stated that, every now and then he fixated on something that might have needed to be care planned and emailed to make sure it was, but it was not systematic. He stated if there was not a care plan for an issue, staff could not help, intervene, or succeed at calming Resident #56 when she is in distress. He stated another potential impact on residents was that they would not get as much monetary reimbursement for a resident's stay if all his or her issues were not marked on the MDS, and that meant that there might not be enough money to run the facility or meet all resident needs. Review of undated facility policy titled Resident Assessment reflected the following: It is the policy of this facility to conduct a document, initially and periodically, a comprehensive, accurate, standardized, reproducible assessment of a residence functional capacity on all residence admitted to the facility. The assessment will include at least the following: (i) identification and demographic information (ii) customary routine (iii) cognitive patterns (iv) communication (v) vision (vi) mood and behavior patterns (vii) psychological well-being. The assessment must accurately reflect the resident's status. Each resident's comprehensive assessment is conducted or coordinated by a registered nurse with the appropriate participation of health professionals. The registered nurse who conducts her coordinates each assessment she'll sign and certify the completion of the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 32 residents (Residents #56 and #27) reviewed for care plans. The facility failed to ensure - Resident #56's care plan was updated to include goals and interventions for a new onset of behaviors: hallucinations, delusions, and physical aggression. -Resident #27's care plan included goals and interventions for his behavior of picking at his seborrheic dermatitis until it bled. These failures placed residents at risk for not having the specific medical and psychosocial needs met and attaining their highest practicable well-being. Findings included: 1. Review of Resident #56's clinical face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of major depressive disorder severe with psychotic features, unspecified intellectual disabilities, schizoaffective disorder, and bipolar disorder. Review of Resident #56's significant change MDS dated [DATE] reflected a BIMS of 3 indicating a severe cognitive impairment. Section E 0100. Potential Indicators of Psychosis reflected that she had no hallucinations and no delusions during the lookback period. It also reflected that she had exhibited the behavior of physical aggression. Review of Resident #56's Discharge Return Anticipated MDS dated [DATE] reflected no behaviors. Review of Resident #56's care plan reflected a focus area initiated on [DATE] revealed, Resident at risk for complications associated w/ routine use of psychotropic medications and an area that reflected the following: The resident has a psychosocial well-being problem r/t Depression. There was no care plan item related to schizoaffective disorder, hallucinations, delusions, or aggression. Review of social services progress notes for Resident #56 dated [DATE] at 9:00 a.m., reflected the following: The administrator and I met with resident today due to an incident that occurred last night between she and her roommate. Her roommate states that resident came into the room and accused roommate of stealing her cell phone, when the roommate repeatedly told her she did not have her cell phone resident became upset and stated she was going to fight her roommate, the two of them were separated last night and Resident went to a different room. Upon this social workers arrival to residents room she was sitting in her wheel chair in the room crying she spoke at a rapid pace and states she does not feel safe here. She said she has been hearing voices and seeing her ex-husband in the facility which he has not been here. She states she mainly sees her ex husband most in the therapy room. She also states she sees people that have died and states 'I do not know why I keep seeing him he is alive as far as I know.' She keeps stating that she is scared she is losing her mind she says she knows the visual hallucinations are not real. She mentioned to me last Friday she has been seeing cats all over her room and in the building she states the auditory and visual hallucinations occur periodically during the day. She further mentioned she is not sleeping through the night as she is paranoid someone is going to get her all of this is impacting her daily functioning especially as it pertains to social relationships. She and her roommate do not have a history of altercations and she continues to obsess over staff member that she thinks is in love with her but no longer wants her. Social worker informed PCP for recommendations at this time. Review of nurse's progress notes for Resident #56 dated [DATE] at 11:44 a.m., reflected the following: Resident noted to continue to have visual and auditory hallucinations, very tearful this morning. Resident reports and confirmed by staff that resident has not slept well in several days. NP notified and orders for Trazodone 50mg qhs received, increase dose of Seroquel at night to 50mg and administer Ativan 0.5mg x1 now [given by this RN]. (Pharmacy) called with new orders, daughter and resident notified of changes, consent for Trazodone completed. Will monitor. Review of behavioral health hospital assessment dated [DATE] reflected that Resident #56 was assessed with schizoaffective disorder bipolar type and major neurocognitive disorder and included the following details: Affect- constricted, blurred, worrisome Appearance- disheveled Motor Activity- hyperactivity Speech- rambling Behavior- bizarre Mood- restless, anxious Thought Process- tangential Hallucinations- auditory, visual Delusions- bizarre, paranoid Observation and interview on [DATE] at 8:34 a.m., revealed Resident #56 was sitting in her wheelchair next to her bed and eating breakfast. She stated everything was pretty good. She had no complaints. She stated she was not scared in the facility but sometimes people bother her. She stated that the staff help her when she is feeling anxious or scared. She could not give any examples of how they help her. During an interview on [DATE] at 9:48 a.m., the MDSN stated she had worked at the facility in her position about three years and was the long term care MDS nurse. She stated she had been the MDS nurse who had completed the significant change assessment for Resident #56 in February 2022. She stated that she also completed the Discharge Return Anticipated MDS for Resident #56 when she discharged to the acute care behavioral health facility in March. She stated the significant change MDS was because there was an all over functional decline and onset of psychotic behaviors. She stated that they initially thought the behavior change might have been because of her having COVID or for some other medical reason, and she was tested for various infections and conditions, including UTI, for which she was positive. She stated the resident was treated for the UTI, and there were no other issues detected through diagnostic testing. She stated the behaviors then escalated considerably at the beginning of [DATE]. She stated the resident was discharged to an acute behavioral hospital on [DATE], because she had become extremely paranoid, was hallucinating, and thought people were stealing her things and out to get her or hurt her. She stated that Resident #56's cognition is better since she returned to the facility on [DATE] and her ADLs have improved significantly except she is still not able to walk on her own. The MDSN stated that the behaviors are mostly controlled, but Resident #56 is still having some hallucinations. She stated the resident recently said she saw a little boy in her room. The MDSN stated the Discharge Return Anticipated MDS did not include any behaviors, because the behaviors were covered on the significant change assessment. She looked at the significant change assessment and stated that hallucinations and delusions were not marked on that assessment and should have been. She stated that one outcome for the behaviors not being on the MDS was that the behaviors would not be on the care plan, which they needed to be. She stated she thought the behaviors were care planned under the care plan items for depression and psychotropic drugs. She stated she thought the interventions would be the same for hallucinations and delusions. She stated it probably would not have an impact on the Resident #56, because the staff communicated during their morning meetings and on their 24-hour report book. She stated the process for completing care plan was that she completed all the sections and then sent it out to the department heads to review. She stated that she is responsible for oversight and monitoring of the system for care plans. She stated the process was in her head, and she used a notebook to write down any new information about her residents that she learned from the other departments and made sure they went into the care plans. She stated they did interviews and went over nurse's notes, progress notes, and hospital records. She stated she still received training yearly from corporate, but she did not remark about what that training entailed with regard to the process of ensuring MDS assessments are accurate and comprehensive. During an interview on [DATE] at 10:16 a.m., the SW stated Resident #56 was having a lot of mental health issues, but she had been pretty good the past week or so. The SW stated she used the care plan to know what was going on with the residents, and it would be important for behaviors such as hallucinations, delusions, and physical aggression to be care planned. During an interview on [DATE] at 10:23 a.m., ADON A stated that, from her understanding, Resident #56 had started having psychotic behaviors a few months ago. She stated that it was hallucinations and paranoia, and she would latch on to a few people she trusted. ADON A stated she never saw aggressive behaviors, but they may have happened. She stated the MDSN was definitely aware of the behaviors, because they went over those behaviors every morning during their meeting. She stated she assumed that behaviors like that should have gone into the care plan. She stated the care plans confused her when she opened them, so she did not look at them often. She stated she was not aware of whether or not she was supposed to be reading them. She stated she had never had any training about MDS assessments or care plans. 2. Review of a face sheet for Resident #27 reflected a [AGE] year-old male admitted to the facility on [DATE] with a subsequent diagnosis on [DATE] of seborrheic dermatitis. Review of the quarterly MDS for Resident #27 dated [DATE] reflected a BIMS score of 14, indicating little or no cognitive impairment . Review of the care plan for Resident #27 dated [DATE] reflected the following: Resident has been identified at risk for pressure ulcer development or skin breakdown r/t decreased mobility. Resident will have intact skin integrity and preventative measures in place x 90 days. There was no care planning for dermatitis or the behavior of picking at his skin. Review of physician orders for Resident #27 dated [DATE] reflected the following: Bacitracin Ointment 500 UNIT/GM Apply to Affected Area topically every 6 hours as needed for Dermatitis Observation and interview on [DATE] at 11:18 a.m., revealed Resident #27 had scabs and open red spots all over his face, head, and neck. The scabs on his cheeks had the most concentration of open, lightly bleeding areas. Resident #27 stated he had no complaints at all. He stated that he picked at his skin sometimes, but the staff took care of him and the sores he created. During an interview on [DATE] at 1:49 p.m., the DON stated that Resident #27 picked at his skin constantly, and sometimes he picked at one so much it became a more significant problem. She stated it became an infection control problem. She stated the behavior ebbed and flowed, but right now he had a particularly bad spot on his left cheek. She stated that a care plan for the behavior would make sure the staff was aware as far as infection control for the wounds and sores. She stated the behavior should have been care planned. She stated that, around the first of March, Resident #56's behaviors really escalated in a very short period of time. She stated that they treated her for a UTI, it resolved, but the hallucinations and paranoia were still there. The DON stated on the first of [DATE], Resident #56 had visual and audial hallucinations. The DON stated the resident had a traumatic past, and there was a man working in their rehab gym who looked to Resident #56 like her abusive ex-husband. The DON stated that seemed to trigger the behaviors. She stated they had an order for the nurses to document any behaviors, and then they were able to get her into the behavioral hospital very quickly. The DON stated when the resident came back to the facility, she told them and has continued to tell them that she still saw the people she had been hallucinating, but she knew they were not real. The DON stated that Resident #56's hallucinations and delusions were something she would expect to be in the MDS assessment and the care plan. She stated she thought the resident would get the care she needed anyway, though, because the staff relied so heavily on the morning meeting discussions and the 24-hour report. She stated she had no system really in place to look over the MDS and care plans to ensure they are comprehensive and probably needed to create a system. She stated that if the behaviors did not make it into the care plan, it could affect the resident in that she could not get the care she needed. She stated that staff or resident injury could be an outcome to a resident with psychotic behaviors not receiving the treatment he or she needed. The DON stated if no one knew about the hallucinations or aggression, the resident could hurt herself, and there could also be a negative psychological impact. During an interview on [DATE] at 2:35 p.m., the ADM stated that Resident #27 picked at his skin often, and some of it was unconscious. He stated that leaving the behavior unaddressed in the care plan, the resident was subject to an increase in the potential for infection. The ADM stated that Resident #56 has had hallucinations, delusions, and threats of physical aggression. He stated the behaviors were on and off but did persist, and they should have been on the MDS assessments and in the care plan. He stated the MDS nurses explained that Resident #56 might have had interventions in other areas of her care plan that applied to her behaviors, but he had not looked at that, yet. He stated that the MDS nurses had a corporate MDS nurse who supported and trained them, but she had been working at another of their sister facilities that did not have an MDS nurse, so she had not been able to provide as much oversight recently. He stated he was very well versed in the needs of his residents, but he did not have a specific plan related to oversight of the MDS and care planning processes. He stated he did ask a lot of questions and contribute ideas when discussing MDS and care plans in the morning meeting. He stated that, every now and then he fixated on something that might have needed to be care planned and emailed to make sure it was, but it was not systematic. He stated if there was not a care plan for an issue, staff could not help, intervene, or succeed at calming Resident #56 when she is in distress. He stated another potential impact on residents was that they would not get as much monetary reimbursement for a resident's stay if all his or her issues were not marked on the MDS, and that meant that there might not be enough money to run the facility or meet all resident needs. Review of undated facility policy titled Person-Centered Comprehensive Resident Care Planning reflected the following: A comprehensive person centered care plan is developed and implemented for each resident, consistent with the residence rights and will incorporate resident Center goals and wishes about their care, activities, and lifestyle to include measurable short-term and long-term objectives and time frames to meet a Residence medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following the services that are to be furnished to attain and maintain the residence highest practicable physical, mental, and psychosocial well-being; and any services they would otherwise be required under resident rights but are not provided due to the residence exercise of rights, including the right to refuse care and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that was complete and accurately documented for 1 of 13 residents (Resident #26) reviewed for accurate documentation. The facility failed to ensure that wound was accurately documented for a stage III pressure ulcer to Resident #26's left heel. This failure placed residents with pressure ulcers at risk of worsening pressure ulcers, infection and hospitalization. Findings included: Review of face sheet for Resident #26 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of non-pressure ulcer of the left heel and midfoot. Review of admission MDS for Resident #26 dated 4/7/2022 reflected a BIMS score of 13, indicating a mild cognitive impairment . Review of a care plan dated 1/14/2022 for Resident #26 reflected the following: Cleanse stage III pressure ulcer to left heel. Heel ulcer will heal by review date (3/2/2022). Review of physician orders dated 4/5/2022 and with an end date of 4/20/2022 reflected the following: Stage three pressure injury to left heel cleanse pressure injury with an S, pat dry and apply Betadine topically, cover with foam dressing daily until resolved. Ensure proper placement of heel protectors. Review of TAR for Resident #26 reflected that the entries for daily care to his stage III pressure injury ordered 4/5/2022 to 4/21/2022 were blank on 4/6/2022, 4 /7/2022, 4/8/2022, 4/9/2022, 4/12/2022, 4/13/2022, 4/15/2022, 4/16/2022, and 4/21/2022. Review of wound assessments for Resident #26 reflected that the stage III pressure injury was resolved as of 4/21/2022. During an interview on 5/3/2022 at 12:58 p.m., LVN G stated that she hads been the charge nurse for Resident #26 several times during the 6:00 a.m. to 6:00 p.m. shift over the previous month. She stated that, in that role, she has been responsible for performing wound care for Resident #26. She stated he sometimes refused or said to come back later. She stated that it was possible she did not complete the treatments on one or more of the days she worked. She stated that if she did not do the treatment, it was because she thought somebody else would be completing the treatments that night. She stated usually they all tried to do as much as they could on their shifts and then in the 24-hour report book, they let the oncoming charge nurses know what still needed to be done. She stated the only systems for communication were the 24-hour book and verbal report. She stated they wrote down big changes in the 24-hour report. She stated the ADONs had talked to them and said the ADONs were going to try to help with wound care, but she did not see that had happened. She stated the facility's wound care nurse had been working nights for weeks because of the staffing issues the entire industry was having. She stated if a resident did not receive get wound treatment, he or she could get infection and lose a foot or something like that. She stated she loved doing wound treatments and did not know what happened on the days she worked that would prevent the treatment from being done. During a telephone interview on 5/3/2022 at 1:17 p.m., LVN H stated she worked on the 200 hall and was responsible for Resident #26's wound care. She stated there were a couple days when Resident #26 refused and a couple where someone else was supposed to have done the wound care that the care might have been missed. She stated she could not speak any more at that time. During a telephone interview on 5/3/2022 at 1:30 p.m., LVN I stated she picked up overtime shifts and sometimes switched with the nurse who worked the 200 hall, so she had worked there a few times. She stated she did not remember doing any wound care for Resident #26. She stated he sometimes got in a very aggressive mood when the nurses went in his room, and he started cursing them out immediately. She stated that, if he was aggressive or cursing and told them to leave, there was a place to click in the TAR for resident refused. She stated they should be able to click on their click offs and hit patient refused. She stated she was certain she had never performed wound care for Resident #26. She did not know why she had not done the wound care, but she speculated it was because someone else had already taken care of it on the days she worked on the hall. She stated she could not say for sure if she just forgot to perform the wound care. She stated they had been getting reminders from their DON about performing wound care on all the residents, because their wound care nurse had been working night shifts. During an interview on 5/3/2022 at 1:37 p.m., the DON stated that the facility was desperately short on PRN on-call nurses, and they had a solid, dedicated on-call team of five, one of whom was the treatment nurse. She stated the treatment nurse agreed to go to night shift, and the ADONs were told to work to keep up with wound care treatments. She stated the charge nurses should have been performing the wound care treatments unless the ADONs came and told them they would cover the treatments that day. She stated she was also helping with wound care on certain occasions. She stated that her guess regarding the blanks spots in Resident #26's TAR meant that some of those days he probably got wound care that the nurse failed to document, some he refused, and some he did not get at all. She stated the outcome to the resident could be as bad as death, osteomyelitis, or amputation. She stated she had probably not done in-servicing on wound care with her staff in the last six months. During an interview on 5/3/2022 at 2:53 p.m., the ADM stated that wound care was entirely overseen by the DON. He stated they did talk during morning meeting about any refusals or changes, and they heard the things they needed to take care of. He stated he is not aware of any full-blown system to ensure the wound care always got done. He stated the outcome of residents not receiving treatments could escalate very quickly to losing a limb or causing all the way to death. Review of undated policy titled Skin Integrity/Pressure Ulcers' reflected the following: The facility will provide care, consistent with professional standards of practice and based on each residence comprehensive assessment, to ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless pressure ulcers are unavoidable due to the predictable patterns of the residence clinical condition or the resident or his/her Representatives refusal of care and treatment to prevent pressure ulcers. Resident assessment protocols are APs are used to assess casual causal factors of decline or potential for improvement of pressure ulcers. Aggressive and appropriate preventative measures and care are provided to address a residence as factors. Based on each residence comprehensive assessment, appropriate treatment and services, consistent with professional standards of practice, are provided to prevent the formation of pressure ulcers. Residence having pressure ulcers receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to use appropriate alternatives prior to installing a side or bed rails, assess the resident for risk of entrapment, review the risk and benefits, and obtain informed consent prior to installation for 20 of 32 residents (Residents #4, #13, #15, #24, #34, #37, #38, #39, #41, #49, #51, #54, #57, #58, #77, #80, #99, #110, #119, and #126) reviewed for bedrails. The facility failed to assess and get signed consents for Residents #4, #13, #15, #24, #34, #37, #38, #39, #41, #49, #51, #54, #57, #58, #77, #80, #99, #110, #119, and #126 prior to installing bed rails. This deficient practice could affect residents who utilized bed rails by placing them at risk for unintended entrapment of the head, neck, or limbs, restraints, and injuries. The findings include: Record review of Resident #4's clinical face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of urinary tract infection. Record review of Resident #4's quarterly MDS dated [DATE] revealed no BIMS summary score. Record review of Resident #4's physician orders dated 2/11/2022 revealed the order, Safety Devices-Side Rails= May have half or quarter rails up while in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #4's care plan revealed a focus area initiated on 12/09/2021 that states, At risk for injury/immobility due to need for quarter or half side rails to assist with turning and repositioning. Record review of Resident #4's consents revealed no informed consent on file for the use of bedrails. Record review of Resident #4's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation. Observation on 5/1/2022 at 3:05 p.m., revealed Resident #4 was asleep in her bed with ¼ inch metal side rails up on both sides of the head of the bed. Record review of Resident #13's clinical face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of repeated falls, muscle weakness, fracture of upper end of right humerus, and dementia. Record review of Resident #13's quarterly MDS dated [DATE] listed her with a BIMS of 11 indicating a mild cognitive impairment. Record review of Resident #13's physician orders reflected no orders for the use of side rails. Record review of Resident #13's Care Plan revealed a focus area initiated on 8/2/2021 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #13's consents reflected no bed rail consents. Record review of Resident #13's assessments reflected no assessment for entrapment related to side rails. Observation and interview on 5/1/2022 at 8:34 a.m., revealed Resident #13's bed had metal quarter rails at the head of the bed. Resident #13was sitting on the side of her bed, she stated she did not use her side rails and had never been injured or trapped by them. Record review of Resident #15's clinical face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of fracture of left femur, chronic kidney disease, muscle weakness, senile degeneration of the brain. Record review of Resident #15's quarterly MDS dated [DATE] listed him with a BIMS of 3, indicating severe cognitive impairment. Record review of Resident #15's physician orders dated 1/13/2022 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #15's Care Plan revealed a focus area initiated on 12/7/2019 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #15's Assessments revealed no risk assessment completed prior to instillation. Record review of Resident #15's Consents revealed no informed consent on file for the use of bedrails. During an observation on 5/1/2022 at 1:35 p.m., Resident #15 was asleep in his bed with ¼ inch metal side rails up on both sides of the head of the bed. Record review of Resident #34's clinical face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of type 2 diabetes, low blood pressure, acute kidney failure, epilepsy, morbid obesity, depression, muscle weakness, heart disease, cognitive communication deficit. Record review of Resident #34's quarterly MDS dated [DATE] listed her with a BIMS of 4, indicating severe cognitive impairment. Record review of Resident #34's physician orders dated 6/14/2021 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #34's Care Plan revealed a focus area initiated on 12/7/2019 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #34's consents revealed a Bed Rail Consent signed on 9/18/2019. Record review of assessments revealed there was not a risk assessment obtained prior to instillation of the bed rails. During an observation on 5/1/2022 at 8:45 a.m., Resident #34 was asleep in her bed with ¼ inch metal side rails up on both sides of the head of the bed. Record review of Resident #37's clinical face sheet revealed a [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction, encephalopathy, lack of coordination, abnormal posture, chronic kidney disease, acquired absence of right leg above knee, and acquired absence of left leg above knee. During an interview on 5/3/2022 at 12:27 p.m., Resident #37 stated that he has no problem with the rails, they can put them down or up, it does not matter. Record review of Resident #37's quarterly MDS dated [DATE] revealed a BIMS of 15, indicating an intact cognitive response. Record review of Resident #37's physician orders dated 7/19/2021 revealed an order for, Safety Devices- Side Rails= May have half side rails up while in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #37's care plan revealed a focus area initiated 3/7/2019 that states, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #37's consents revealed a Bed Rail Plan and Informed Consent dated 9/18/2019. Record review of Resident #37's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation. Observation on 5/1/2022 at 3:02 p.m., revealed Resident #37 was laying on his bed awake with ¼ inch metal side rails up on both sides of the head of the bed. Record review of Resident #38's clinical face sheet revealed a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses of Huntington's disease, reduced mobility, lack of coordination, auditory hallucinations, Parkinson's disease, psychotic disorder, mood disorders, history of falling, MDD, anxiety, unspecified convulsions, and cognitive communication deficit. Record review of Resident #38's annual MDS dated [DATE] revealed a BIMS of 04, indicating a severe cognitive impact. Record review of Resident #38's physician orders dated 10/21/2020 revealed an order for, Safety Devices- Side Rails= May have half side rails up while in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #38's care plan revealed a focus area initiated on 9/17/19 that states, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #38's consents revealed a Bed Rail Plan and Informed Consent dated 9/18/2019. Record review of Resident #38's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation. Observation on 5/1/2022 at 3:03 p.m., revealed Resident #38 was asleep in her bed with ¼ inch metal side rails up on both sides of the head of the bed. Record review of Resident #39's clinical face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia, epilepsy, depression, morbid obesity, chronic pain, high blood pressure. Record review of Resident #39's quarterly MDS dated [DATE] listed her with a BIMS of 14, indicating she is cognitively intact. Record review of Resident #39's physician orders dated 12/9/2020 revealed an order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #39's Care Plan revealed no mention of the bed rails. Record review of Resident #39's consents revealed a Bed Rail Consent signed on 9/18/2019. There is not a risk assessment obtained prior to instillation of the bed rails. During an observation and interview on 5/1/2022 at 1:32 p.m., Resident #39 was lying in her bed awake with ¼ inch metal side rails up on both sides of the head of the bed. Resident #39 stated she liked having the rails up on the bed, stated that they help keep her in the bed and that she utilizes them to assist her to lift herself up in the bed. She denies any injuries from the rails. Record review of Resident #41's face sheet revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses of MDD, acute kidney failure, muscle weakness, lack of coordination, cognitive communication deficit, and history of falling. Record review of Resident #41's quarterly MDS dated [DATE] revealed a vision of 4, indicating severely impaired, and a BIMS of 03, indicating severe cognitive impact. Record review of Resident #41's physician orders dated 12/8/2020 revealed an order for, Safety Devices- Side Rails= May have half side rails up while in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #41's care plan revealed a focus area initiated on 9/14/2020 that states, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #41's consents revealed no informed consent on file for the use of bedrails. Record review of Resident #41's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation. Observation on 5/3/2022 at 12:03 p.m. revealed Resident #41 was not in her room, further observation reveals ¼ inch metal side rails up on both sides of the head of the bed. Record review of Resident #49's clinical face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of muscle weakness, cognitive communication deficit, difficulty swallowing, age-related physical debility. Record review of Resident #49's significant change MDS dated [DATE] listed him with a BIMS of 2, indicating severe cognitive impairment. Record review of Resident #49's physician orders dated 12/7/2020 revealed an order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #49's Care Plan revealed a focus area initiated on 12/7/2019 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #49's consents and assessments did not reveal a consent for the Bed Rails and no risk assessment obtained prior to instillation. During an observation on 5/2/2022 at 8:45 a.m. revealed Resident #49 was asleep in his bed with ¼ inch metal side rails up on both sides of the head of the bed. Record review of Resident #51's clinical face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of paraplegia, high blood pressure, bipolar disorder, depression, multiple sclerosis, obesity. Record review of Resident #51's quarterly assessment dated [DATE] listed him with a BIMS of 14 indicating he is cognitively intact. Record review of Resident #51's physician orders dated 12/15/2020 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #51's Care Plan revealed a focus area initiated on 9/23/2019 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #51's consents revealed a Bed Rail Consent signed on 9/18/2019. There is not a risk assessment obtained prior to instillation of the bed rails. During an observation and interview on 5/1/2022 at 2:06 p.m., Resident #51 was sitting up in his bed with ¼ inch metal side rails up on both sides of the head of the bed. Resident #51 stated he has lived at the facility for almost 6 years and likes the rails on his bed and has not obtained any injury on the rails. Record review of Resident #54's clinical face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of heart failure, high blood pressure, end-stage renal disease, diabetes, liver disease, dementia, bipolar disease. Record review of Resident #54's quarterly assessment dated [DATE] listed him with a BIMS of 14 indicating he is cognitively intact. Record review of Resident #54's physician orders dated 10/28/2021 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #54's Care Plan revealed a focus area initiated on 11/1/2021 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #54's consents and assessments did not reveal a consent for the Bed Rails and no risk assessment obtained prior to instillation. During an observation and interview on 5/1/2022 at 3:19 p.m., Resident #54 is sitting up in his bed with ¼ inch metal side rails up on both sides of the head of the bed. Resident #54 stated that he uses the rails to help position himself in the bed and denies that he has obtained any injury from the rails. Record review of Resident #56's clinical face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified intellectual disabilities, affective disorder, bipolar disorder, convulsions, obstructive sleep apnea history of falling. Record review of Resident #56's significant change MDS dated [DATE] listed her with a BIMS of 3 indicating a severe cognitive impairment. Record review of Resident #56's physician orders dated 4/1/2022 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #56's Care Plan revealed a focus area initiated on 11/15/2021 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #56's consents reflected no bed rail consents. Record review of Resident #56's assessments reflected no assessment for entrapment related to side rails. Observation and interview on 5/1/2022 at 8:34 a.m. revealed that Resident #56's bed had plastic quarter rails at the head of the bed. Resident #56 stated she used her side rails (but could not say exactly how) and has never been injured by or trapped by them. Record review of Resident #57's face sheet revealed a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses of lack of coordination, abnormal posture, repeated falls, muscle weakness, MDD, and dementia. Record review of Resident #57's quarterly MDS dated [DATE] revealed no BIMS summary score. Record review of Resident #57's physician orders dated 6/29/2021 revealed an order for, Safety Devices- Side Rails= May have half side rails up while in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #57's care plan revealed a focus area initiated on 3/19/2020 that states, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #57's consents revealed a Bed Rail Plan and Informed Consent dated 9/17/2019. Record review of Resident #57's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation. Observation on 5/3/2022 at 12:13 p.m. revealed Resident #57 was not in her room, further observation reveals ¼ inch metal side rails up on both sides of the head of the bed. Record review of Resident #77's clinical face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, unsteadiness on feet, muscle weakness, lack of coordination, cerebral infarction, seizures, anxiety disorder, displaced fracture of left humerus neck and shaft of left clavicle. Record review of Resident #77's 5-Day MDS dated [DATE] listed her with a BIMS of 9, indicating a moderate cognitive impairment. Record review of Resident #77's physician orders dated 2/21/2022 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #77's Care Plan revealed a focus area initiated on 3/10/2022 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #77's consents reflected no bed rail consents. Record review of Resident #77's assessments reflected no assessment for entrapment related to side rails. Observation and interview on 5/1/2022 at 8:34 a.m., revealed that Resident #77's bed had plastic quarter rails at the head of the bed. Resident #77, who was lying in bed, stated she used her side rails to pull herself up and has never been injured by or trapped by them. Record review of Resident #58's clinical face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of repeated falls, unsteadiness on feet, stiffness of right and left shoulders, poly osteoarthritis, dementia, lack of coordination, abnormalities of gate and mobility, muscle weakness, and cervicalgia. Record review of Resident #58's quarterly MDS dated [DATE] listed him with a BIMS of 11 indicating a mild cognitive impairment. Record review of Resident #58's physician orders reflected no orders for the use of side rails. Record review of Resident #58's Care Plan revealed a focus area initiated on 3/23/2020 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #58's consents revealed a Bed Rail Consent signed on 6/6/2019. Record review of Resident #58's assessments reflected no assessment for entrapment related to side rails. Observation and interview on 5/1/2022 at 8:41 a.m., revealed Resident #58's bed had metal quarter rails at the head of the bed. Resident #58, who was lying in bed, stated he used his side rails to reposition himself and has never been injured by or trapped by them. Record review of Resident #80's clinical face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cerebrovascular disease, cerebral infarction, aphasia, dysphagia, and mild cognitive impairment. Record review of Resident #80's 5-Day MDS dated [DATE] listed him with a BIMS of 4 indicating a severe cognitive impairment. Record review of Resident #80's physician orders dated 1/6/2022 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #80's Care Plan revealed a focus area initiated on 1/6/2022 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #80's consents reflected no bed rail consents. Record review of Resident #80's assessments reflected no assessment for entrapment related to side rails. Observation on 5/1/2022 at 8:34 a.m., revealed that Resident #80's bed had plastic quarter rails at the head of the bed. Resident #80 did not respond when addressed. Record review of Resident #99's clinical face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of bone infection, unsteadiness on feet, liver cancer, heart disease, type 2 diabetes, high blood pressure, chronic pain. Record review of Resident #99's significant change MDS dated [DATE] listed him with a BIMS of 14 indicating he is cognitively intact. Record review of Resident #99's physician orders dated 4/27/2022 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #99's Care Plan revealed a focus area initiated on 9/26/2019 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #99's consents revealed a Bed Rail Consent signed on 9/18/2019. There is not a risk assessment obtained prior to instillation of the bed rails. During an observation and interview on 5/3/2022 at 1:00 p.m., Resident #99 was lying in bed with ¼ inch plastic bed rails up on both sides of the head of the bed. Resident #99 stated that he does not like the rails on his bed and is not sure why they have them there. He denies ever injuring himself on the rails. Record review of Resident #110's clinical face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of difficulty swallowing, high blood pressure, muscle weakness, chronic kidney disease, cognitive communication deficit. During an observation on 5/1/2022 at 9:00 a.m., Resident #110 was asleep in bed with ¼ inch metal side rails up on both sides of the head of the bed. Record review of Resident #110's quarterly MDS dated [DATE] listed her with a BIMS of 6, indicating she is severely cognitively impaired. Record review of Resident #110's physician orders dated 12/11/2020 revealed the order: Safety Devices-Side Rails= May have half or quarter rails up when in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #110's Care Plan revealed a focus area initiated on 9/17/2019 that revealed, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #110's consents revealed a Bed Rail Consent signed on 9/18/2019. There is not a risk assessment obtained prior to instillation of the bed rails. Record review of Resident #119's face sheet revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses of orthopedic aftercare, fracture right femur, transient paralysis, MDD, anxiety, spinal stenosis, osteoporosis, cognitive communication deficit, unspecific fracture of sacrum, complication of internal orthopedic prosthetic devices, repeated falls, atrophy, disorder of bone, and lack of coordination. Record review of Resident #119's quarterly MDS dated [DATE] revealed a BIMS of 08, indicating a moderate cognitive impairment. Record review of Resident #119's physician orders dated 4/13/2022 revealed an order for, Safety Devices- Side Rails= May have half side rails up while in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #119's care plan revealed a focus area initiated on 5/15/2020 that states, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #119's consents revealed no informed consent on file for the use of bedrails. Record review of Resident #119's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation. Observation on 5/3/2022 at 12:38 p.m., revealed Resident #119 with ¼ inch metal side rails up on both sides of the head of her bed. Record review of Resident #126's face sheet revealed a [AGE] year-old-male admitted on [DATE] with a diagnoses of muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, and history of falling. During an interview on 5/3/2022 at 12:21 p.m., Resident #126 stated that he does not recall being tangled in his rails to cause any accidents. He stated that the rails no not bother him as he, does not usually use them for any support. Record review of Resident #126's quarterly MDS dated [DATE] revealed a BIMS of 11, indicating a moderate cognitive impairment. Record review of Resident #126's physician orders dated 7/8/2021 revealed an order for, Safety Devices- Side Rails= May have half side rails up while in bed to enable resident to turn and reposition him/herself as desired. Record review of Resident #126's care plan revealed a focus area initiated on 7/8/2021 that states, At risk for injury/immobility due to need for half side rails to assist with turning and repositioning. Record review of Resident #126's consents revealed no informed consent on file for the use of bedrails. Record review of Resident #126's assessments revealed that there was no assessment completed for the risk of entrapment from bed rails prior to installation. Observation on 5/3/2022 at 12:21 p.m., revealed Resident #126's ¼ inch metal side rails up on both sides of the head of her bed. During an interview on 5/3/2022 at 1:42 p.m., DON stated that there are no entrapment assessments completed at the facility although she states based on corporate perspective, everyone is at a risk for entrapment, although she does state that not all residents have the same risks of entrapment, residents have specific needs and levels of care and for dangers. She does confirm that all residents should be individually assessed for entrapment. In the past they have had separate consents for bedrails, but now they are included in the admission packets. States that bedrail checks related to installation and maintenance are completed by [NAME] Branch. She states there are not any annual assessments completed for resident risk of entrapment, if there were related assessment to that perspective Therapy would make that type of suggestions for any gradual reduction of use or continued use. She states that nursing and therapy work together provide the best equipment to meet resident needs. She states that if the resident request to remove the bedrails, facility will follow steps to have them removed. During an interview on 5/3/2022 at 2:10 p.m., MAINT stated that checks on bedrails are done at a Quarterly schedule. He states they are checked for spacing and dimensions of the rails, if they are securely fastened, securely locked, connected, and tightened to bed. He does not recall any significant issues in the installment or any wear and tear on bedrails. Stated some risks for not assuring proper installation and maintenance on rails that it can cause entrapment, rails may be unsafe or loose, the resident may fall out the bed or be more at risks for falls. During an interview on 5/3/2022 at 2:31 p.m., ADM stated there are no resident centered assessments for entrapment completed. He states that there is no standard monitoring for standing orders for bed rail use. He adds that nursing considers that all residents are at a risk high for entrapment, so they do not have anyone monitoring it, he considers it like a standing order for the use of bedrails for falls. He states that therapy makes recommendation for bedrail use. States there is not difference in the metal or plastic bedrails, they are standard supplies that are given. He stated risks associated for not having resident assessed for entrapment routinely are, serious injuries to minor injuries. Resident can get stuck on rails, can get his or her arm or any items stuck and can also result in death in some cases. Record review of Bed Inspection Policy and Procedure updated 10/2002 revealed that, The Maintenance Supervisor will do a quarterly bed inspection of all bed frames, mattress, and bed rails, if any, to identify areas of possible entrapment. And that, A risk assessment has been completed for the person, and a determination made that bed rails are required for safety. Record review of the Nursing Facility admission and Financial Agreement, Rev-Mar-2022, revealed that, This facility utilizes bed rails in certain situations upon Resident/Resident Representative consent. The benefits of bed rails include increased independence on mobility, better positioning in bed and increased sense of security. The inherent risks include the potential for injury resulting from, among other, entrapment or impingement which in the most extreme cases could result in fatality. Further record review Nursing Facility admission and Financial Agreement-section Nursing admission/readmission Assessment V-2.0, Area O reveals Identified risk areas/intervention implemented.

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 one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure: - All food items in the kitchen were labeled and dated and discarded prior to the manufacturer's expiration date. - Raw animal foods were stored away from ready-to-eat food. - DA D's personal lunch box was stored in a refrigerator separate from resident food. -CK E failed to measure the temperature of three items on the steam table prior to serving lunch. -CK E, DA C, and DW F failed to wash their hands using proper technique. This failure placed residents at risk of food-borne illness. Findings include: 1. During observations of the kitchen on 5/01/2022 from 7:35 am-8:23 am, the following was noted: At 7:35 a.m., reach in refrigerator contained three trays of portioned out drinks, covered, with no label or date. At 7:36 a.m., reach in refrigerator contained four jugs of unidentified liquid without a label or date. At 7:40 a.m., walk in refrigerator contained two gallons of milk with best by dates of 4/28/22. At 7:45 a.m., reach in refrigerator contained three trays of portioned out drinks which then had a paper towel label on each with black writing that read 5/1. At 7:50 a.m., walk in refrigerator contained a container of tomato soup labeled 4/26/22. At 8:08 a.m., walk in refrigerator contained containers of creole mustard and pimento cheese, in manufacturers' packaging, opened and without an opened date or received date. At 8:22 a.m., dry room storage contained bags of an unidentified substance in an unlabeled and undated plastic container in the dry storage room. CK E stated the substance was coffee. She stated it was delivered at the same time as the tea and pointed to a box of tea labeled with a delivery date. An observation and interview on 5/01/2022 at 8:23 a.m. revealed ten loaves of bread in the dry storage room without a label or date. CK E stated usually the DM dates the bread with a label gun and their procedure for labeling bread was to label it when it was delivered. In an interview on 5/01/2022 at 7:38 a.m., CK E stated the portioned-out drinks were from breakfast and the liquid in the jugs was tea . CK E stated the drinks and tea should be labeled. In an interview on 5/01/2022 at 7:55 a.m., CK E stated the expired milk should not be in the walk-in refrigerator. She stated the jugs of tea in the reach in refrigerator should be labeled and dated. She stated leftover food items only need to be labeled with a preparation date because they knew when to throw things away. She stated the facility's policy on discarding leftovers was three days with day one being the preparation date. In an interview on 5/01/2022 at 8:00 a.m., when asked if the tomato soup was expired, CK E stated yeah, I'm taking it and proceeded to discard it. In an interview on 5/01/2022 at 8:16 a.m., CK E stated the mustard and pimento cheese should have an opened date. She stated all condiments should be labeled with the delivery date. In an interview on 5/02/2022 at 3:39 p.m., the DM stated foods did not have to be labeled when they were opened if there was an expiration date printed on the product. She stated she would write an opened date on products because she's used to it but stated it was not required. A record review of the facility's undated policy on labeling reflected all leftovers were to be discarded after three days. A record review of the facility's undated policy on food storage reflected all food packages were to be labeled upon delivery with a received date. A record review of the USDA's 2017 Food Code reflected refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section. 2. An observation on 5/01/2022 at 7:40 a.m., revealed four gallons of milk stored on the bottom shelf of the walk-in refrigerator directly adjacent to raw ground beef. In an interview on 5/01/2022 at 8:10 a.m., CK E stated meat had always been thawed on the bottom shelf next to the milk. A record review of the facility's policy on food storage dated 00/00/00 reflected raw meat was to be stored away from ready-to-eat foods. A record review of the USDA's 2017 Food Code reflected Cross-contamination must be prevented by properly storing ready-to-eat food away from raw animal foods and soiled equipment and utensils. 3. An observation on 5/01/2022 at 7:40 a.m., revealed a lunch box labeled DA D stored on the bottom shelf of the walk-in refrigerator. In an interview on 5/01/2022 at 8:10 a.m., CK E stated she thought it was okay to have personal lunch boxes in the walk-in refrigerator if they were placed on the bottom shelf. In an interview on 5/01/2022 at 8:15 a.m., DA D stated DM told her it was okay to keep her lunch in the walk-in refrigerator. A record review of the facility's undated policy on food storage reflected employee lunches were to be stored in a refrigerator separate from where resident food was stored. 4. An observation on 5/01/2022 at 11:32 a.m., revealed CK E measured and recorded the temperatures of the following items on the steam table prior to serving lunch: pork, carrots, and rice. In an interview on 5/01/2022 at 11:33 a.m., CK E stated she was finished measuring food temperatures. When asked if cooks usually measured the temperatures of the alternate menu food items and pureed food items, she stated yes, do you want me to do that? An observation on 5/01/2022 at 11:34 a.m., revealed CK E measured the temperatures of mashed potatoes, green beans, and turkey with gravy. An observation on 5/01/2022 at 11:36 a.m. revealed CK E did not measure the temperatures of pureed pork, pureed carrots, and pureed rice on the steam table. An observation revealed she proceeded to serve lunch without measuring the temperatures of these items. A record review of the facility's policy on measuring food temperatures reflected cooks were required to measure the temperature of all food items on the steam table prior to serving. 5. An observation on 5/01/2022 at 8:14 a.m., revealed CK E handled dirty dishes, ran the dish machine, and pulled a rack of clean dishes from the other end of the dish machine without washing her hands in between. In an interview on 5/01/2022 at 8:16 a.m., CK E stated they always had two staff members present when washing dishes, one on one side to handle dirty dishes and another on the opposite side to handle clean dishes. An observation on 5/02/2022 at 11:10 a.m., revealed CK E washed her hands for five seconds. An observation on 5/02/2022 at 11:16 a.m., revealed CK E removed a clean food processer from the dish machine, washed her hands for three seconds, and proceeded to puree rice. An observation on 5/02/2022 at 11:22 a.m., revealed CK E washed her hands for five seconds. An observation on 5/02/2022 at 11:32 a.m., revealed CK E washed her hands for eight seconds. An observation on 5/02/2022 at 11:38 a.m., revealed CK E washed her hands for three seconds. An observation on 5/022022 at 11:39 a.m. revealed DA C washed her hands for three seconds. An observation on 5/02/2022 at 11:53 a.m., revealed DW F washed his hands for ten seconds. A record review of the facility's undated policy on handwashing reflected all employees were required to wash hands between tasks for at least 20 seconds. A record review of the USDA's 2017 Food Code reflected the following: All aspects of proper handwashing are important in reducing microbial transients on the hands. However, friction and water have been found to play the most important role. This is why the amount of time spent scrubbing the hands is critical in proper handwashing. Research has shown a minimum 10-15 second scrub is necessary to remove transient pathogens from the hands and when an antimicrobial soap is used, a minimum of 15 seconds is required. In an interview on 5/03/2022 at 2:03 p.m., the DON stated she did not know what the facility's policies were on food storage, food safety, and sanitation. She stated I would have to look it up. I know things have to be dated. When asked how these processes are monitored to ensure compliance, she stated she would have to get with DM, she has a log. She stated if foods were not in date, they should be thrown out. When asked what a negative outcome might be if these policies were not followed, she stated GI issues and stomach bugs. In an interview on 5/03/2022 at 2:26 p.m., ADM stated the facility's policies on food storage, food safety, and sanitation included labeling food items when they came in and dating items when they are received and opened. He stated expired items should be thrown away on the day they expire or earlier. He stated, meats should be at the bottom so they can't drip down on other things and hands should be washed frequently and before starting a new task. He stated he was not sure how long hands needed to be washed. When asked how these processes are monitored to ensure compliance, he stated DM followed up on those policies. He stated if she were not there when a truck was delivered, she needed to follow up on it when she came back. When asked what a negative consequence of failing to ensure those policies were followed might include, he stated someone is bound to get sick. A lot of people could get real sick really quick, especially in here. ADM stated failing to wash hands long enough could lead to the contamination of other items. He stated individuals in charge of monitoring compliance of the kitchen included himself, a corporate dietitian, and a compliance officer.