**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 4 residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to ensure Resident #1 and Resident #2 were not involved in a resident-to-resident altercation on 04/07/2024. This deficient practice could place residents at risk of physical injury and/or psychosocial harm. The findings were: 1. Record review of Resident #1's face sheet, dated 03/28/2025, revealed a male resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: Nontraumatic Intracerebral Hemorrhage, Intraventricular (A type of stroke where bleeding occurs in the [NAME] tissue and also spills into the ventricles, the fluid filled spaces in the brain), Aphasia, Compression of Brain (A condition where increased pressure within the skull), Cerebral Edema (Swelling of the brain tissue due to an accumulation of fluid), Generalized Anxiety Disorder (A chronic mental health condition characterized by excessive and persistent worry and anxiety that is difficult to control), Bipolar II Disorder (A person experiences a pattern of depressive, not the full-blown manic episodes found in bipolar I disorder), and Cognitive Communication Deficit (Difficulties in communication arising from impairments in cognitive processes like attention, memory, and problem-solving, rather than problems with speech and language itself). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 09, which indicated moderate cognitive impairment. Record review of Resident #1's care plan, initiated 08/02/2023, revealed [Resident #1] has impaired cognitive function/dementia or impaired thought processes related to encephalopathy (A group of conditions that cause brain dysfunction) .has a communication problem related to expressive Aphasia. 2. Record review of Resident #2's face sheet, dated 03/26/2025, revealed a male resident was admitted to the facility on [DATE] and discharged from the facility on 04/07/2024. Resident #2 had diagnoses which included: Cerebrovascular disease affecting left non-dominant side (the right side of the brain has been damaged), Hypertension (When the pressure in your blood vessels is too high), Rhabdomyolysis (A medical condition characterized by the breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream), and Major Depressive Disorder (A mental health condition characterized by persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities, significantly impacting daily functioning). Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #2's care plan, initiated 04/20/2024, revealed Problem: [Resident #2] is potential to be physically aggressive related to Anger, Poor impulse control; per family was in special education and told he has low IQ . he has a behavior problem fixation/fabrication related to low IQ . He is attention seeking and accusatory with fabrications Interventions: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Communication: Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff when agitated. Monitor/document/report PRN any S/S of resident posing danger to self and others. Psychiatry to evaluate and treat as indicated. Psychology to evaluate and treat as indicated. Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #2's clinical record, as of 04/07/2024, revealed an incident note documented by LVN C, dated 04/07/2024, At 1755 (5:55 PM) Dietary Aide came to the nurses desk and reported to charge nurse that when she was in the dining room she saw this resident (Resident #2) hit another resident (Resident #1) causing the resident to bleed from the face. LVN C went to the dining room and noted another resident bleeding from the left eye and asked what happened when this resident stated 'He called me a punk so I hit him in his eye '. LVN C asked this resident to leave the dining room area and return to his room. At 1756 (5:56 PM). LVN C called and reported this incident to the administrator who instructed the charge nurse to call the police. 911 was called immediately and notified of this incident. At 1810, 4 police officers and 2 fire department EMS Techs arrived to the facility and approached both residents. This resident stated to the police officers that he did hit the other resident. The police officers left the building stating that they were completing their investigation by speaking to the other resident. An officer informed the charge nurse that after completing their investigation they have determined that they will arrest this resident and transport him to jail. At 1934, the police came back into the facility and transported this resident (Resident #2) to jail via stretcher and this residents wheelchair was taken along with him . Record review of Resident #1's clinical record, dated 04/07/2024, revealed a nurse assessment was performed immediately following the incident. LVN C went to the dining room and noted resident bleeding from the left eye and asked what happened when this resident stated, 'he hit me in my eye.' LVN C attempted to assess this resident's left eye but resident refused care stating he was okay while holding his shirt up to his eye. LVN C asked this resident to leave the dining room area and return to his room. At 1810 (6:10 PM), 4 police officers and 2 fire department EMS arrived to the facility and this resident told officers that he was ok and that he did not want to file any charges on the other resident. EMS asked this resident if they could look at his eye and this resident refused to allow the EMS workers to look at his eye. This resident remained in his room and continued to deny charge nurse to assess or treat his eye. At 1938 (7:38 PM) LVN C went to this resident's room and asked this resident if he was in pain and this resident denied pain. LVN C asked this resident that since the other resident left the building did he now feel safe and this resident stated 'yes'. Record review of Resident #1's X ray results, dated 04/08/2024, revealed no evidence of facial bone dislocation or fracture. Attempted to interview with Dietary Aide revealed the Dietary Aide was no longer employed at the facility and the phone number was no longer in service. During an interview with the Administrator on 03/27/2025 at 2:18 p.m., she stated she did not witness the altercation between Resident #1 and Resident #2. She stated Resident #2 was not usually physically aggressive but reported he was a trash talker (insulting comments that are made especially to an opponent). She stated this was the first time the residents had a physical altercation. She stated Resident #2 was arrested after the incident and discharged from the facility. She stated the risk of having a physically aggressive resident in the facility was the resident could possibly harm the other residents . During an interview with Resident #1 on 03/28/2025 at 10:43 a.m., revealed he had an altercation with Resident #2 when questioned about specific details regarding the altercation, Resident #1 was unable to answer questions due to Cognitive Communication Deficit. During an interview with Resident #3 on 03/28/2025 at 12:27 p.m., she stated she witnessed the incident with Resident #1 and Resident #2. She stated Resident #2 got in Resident #1's face and hit him. She reported she could not remember if Resident #1 was bleeding or not. She stated staff members (unknown which staff members) intervened and separated the residents. She stated this was the first time she witnessed Resident #2 being physically aggressive with any residents. She stated she did feel safe at the facility. During an interview with LVN C on 03/28/2025 at 1:04 p.m., she stated the dietary aide informed her Resident #1 was cleaning the table in the dining room and Resident #2 hit Resident #1 and Resident #1 sustained a cut under his eye and he was bleeding. She stated she assessed Resident #1 and the physician was contacted and he was supposed to be sent out to the hospital but the resident refused to go to the hospital. She stated she had never observed Resident #2 be physically aggressive with any residents but she reported he did have verbal altercations with residents in the past. Record review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: .b. other residents .

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts reviewed for medication storage. The facility failed to ensure medications were properly stored and labled when Resident #4's medications were popped into a pull cup and left unattended. This failure could place residents at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings include: During an observation on 3/27/25 at 9:32am revealed a medication aide cart with a medication cup labeled Resident #4 (name) with at least 7 pills inside. During an interview on 3/27/25 at 9:37am CMA E stated the resident was taking a shower, and she would have to go back to give her medications. During an interview on 3/27/25 at 10:55am LVN A stated you should never leave any open pills on the cart. You never know what could happen to those pills during that time. They should be destroyed, and you start over. During an interview on 3/27/25 at 11:06am LVN B stated you should stand there and wait for the resident to be done. You should never leave them open medications on the cart. Training for CMAs was done with the pharmacist monthly. Medication administration was a part of their training. Monthly. Will do a one to one with medication aide. During an interview on 3/27/24 at 11:11am the administrator stated staff should follow the protocol. They should not be pre popping medications. During an interview on 3/27/24 at 11:11am the regional RN C stated if they knew the resident and medication, they put it in a cup then it should ok. First and last name should be labeled on the cup also timed and dated. If they were destroyed that could be costly to the resident. During an interview on 3/27/24 at 12:55 pm RN D stated medications were to be given on time. Staff should be following the medication rights, right patient, dose, route. Before giving the medication, it should be verified. No premedication popping. If premedication was done, you don't know which medication it was. If there's a blood pressure medication staff need to check before the pressure before giving it. So, based on the vitals it may not allow you to give the medication. This could cause a mix up in medication if staff premedicated and didn't know which one to pull. Record review of the facility provided policy titled, Medication and Preparation Administration revealed the following: Medications should be prepared for only one resident at a time. Facility staff should observe the 6 Rights and verify right resident, right drug, right dose, right route and right time, and right documentation for each medication being administered. Abbreviations: CNA-certified nursing assistant LVN-Licensed vocational nurse RN- registered nurse CMA-certified medication aide

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an effective pest control program so the facility was free of pest and rodents for 2 of 2 residents reviewed for environment. The facility failed to ensure resident rooms were free of gnats. This failure could place residents at risk of infection, skin irritation, allergies, which could result in unsanitary living conditions and decline in health and well-being. Findings include: In an observation with Resident #404, on 03/26/2025 at 9:57am revealed sightings of gnats on the walls, on pictures, lighting above Resident #404 bed, flying around And on a urinal placed on the floor. In an interview with Resident #404 on 03/26/2025 at 9:57 AM, the resident stated the gnats were horrible and there was a substance that was placed by MAINT, but it wasn't catching the gnats. In an interview with HSK on 03/26/2025 at 10:11 AM, revealed the resident room always had gnats. HSK stated they did not know why there were so many gnats in the room but all they did was clean up behind each resident. HSK stated it may be from the trash always overflowing or food that was left out. In an interview with LVN on 03/26/2025 at 10:13 AM, revealed pest control came last week to spray the facility and Resident #404's room. LVN stated when conducting rounds on the morning of, 03/26/2025, he identified gnats in the room, and they were going to have the room cleaned. LVN stated the risk could cause any resident to be uncomfortable with gnats being present in the room/facility. In an observation with Resident #404 on 03/27/2025 at 10:42 AM, revealed gnats in the room, but not as many as the day before. Gnats were observed on the pictures and Resident #404's urinal placed by the bed. In an interview with Resident #404 on 03/27/2025 at 10:43 AM, revealed the gnats seem to come and go, but the gnats were a lot worse than what was being observed. Resident #404 has been at the facility for one month. In an interview with Resident #5 who shared a room with Resident #404 on 03/27/2025 at 10:46 AM, revealed MAINT came to the room and sprayed to try and minimize the gnats. Resident #5 stated there were still gnats in the room, but he did appreciate the facility for trying to take care of the issue. In an interview with MAINT on 03/27/2025 at 12:04 PM, MAINT stated the gnats came from Resident #404 and the urine being spilled on the floors. MAINT stated Resident #404 wanted to be independent and used the urinal and placed it back on the floor. MAINT stated pest control treated the room and the facility once a month. MAINT stated he treated the room as well, once a week to try and prevent the gnats, but they were always present. MAINT stated he used a log to track every time he needed to treat the room or the facility for gnats. In an interview with the ADMN on 03/27/2025 at 2:54 PM, the ADMN stated pest control had been coming to treat the facility and resident rooms. The ADMN stated they were doing the best they could with the gnats, all while trying to encourage the resident to be independent. The ADMN believed Resident #404's urinal waste on the floor and could contribute to the gnats being uncontrolled. Record review of the facility's Pest Control Policy reflected Bed Bugs, Prevent and Managing Infestations of In record review of the facility's maintenance log, on 03/28/2025, listed the issue/concern for a member of maintenance to follow up. On 03/17/2025, 03/19/2025, 03/21/2025, 03/24/2025, 03/25/2025, gnats were noticed and treated by MAINT for rooms [ROOM NUMBERS]. The risk to any resident with gnats could be their dignity and not feeling good about the facility for their care. In record review of the facility's contract with pest control, on 03/28/2025, reflected the pest control company had been active since 07/01/2023. The contract stated pest specifically not covered to include Flying insects (flies, bees, wasps, and gnats) .Service for NON COVERED PESTS may be provided for a fee on a materials plus labor basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 (Resident #290,) of 3 resident reviewed for respiratory care. -The facility administered oxygen to Resident #290 without a physician order. These failures placed residents who received oxygen therapy at risk of respiratory complications. Findings include: Record review of Resident #290's admission face sheet dated 10/19/23 revealed an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted [DATE]. Her diagnoses included diabetes mellitus (metabolic disease involving Hight blood glucose levels), hypertension (blood is pumping with more force than normal through arteries), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activity) and chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problem). Record review of Resident #290's 5-day MDS assessment, dated 12/08/23, revealed the BIMS score was 04, which indicated severely impaired cognition. Further review of the MDS revealed she required oxygen therapy. Record review of Resident #290's physician's order for December 2023 revealed there was no oxygen order until 12/12/23. Record review of Resident #290's hospital discharge order dated 12/04/23 read oxygen at 2L . During an observation and interview on 12/12/23 at 10:05 a.m., Resident #290 was on oxygen, and the concentrator was set to 2.5 L. The NC (nasal canula) was on the floor under the bed. Resident #290 said she could not remember how many liters of oxygen she should be on. Resident #290 said she was having some difficulty breathing at this time. During an observation on 12/12/23 at 10:07 a.m., LVN J said the O2 (oxygen) tubing was on the floor under the bed. During an interview on 12/12/23 at 10:15 a.m., LVN J said the oxygen should be on 2L continuously, and she moved the knob on the concentrator down to 2L. Then, LVN J said she would check Resident #290's physician orders and clarify if the oxygen setting should be on 2L. During an Interview on 12/12/23 at 12:09 p.m., LVN J said Resident #290 came from the hospital on12/04/23 with oxygen, and she was not the nurse who admitted Resident #290 back to the facility. LVN J said she worked with Resident #290 last week, and Resident #290 was on continuous oxygen. LVN J said Resident #290 should have an order for oxygen before administering oxygen. LVN J said she checked Resident #290's oxygen saturation, which fluctuated between 93% and 94 %. LVN J said she did not know how they dropped the ball and did not get an order for the oxygen. LVN J said the DON verified Resident #290 orders when she was admitted to the facility, and she did not realize she did not get an order for the oxygen. LVN J said Resident #290 could go into respiratory distress if Resident #290 was not getting enough oxygen or more than required because she was diagnosed with COPD. During an interview on 12/13/23 at 3:07 p.m., LVN MDS said she independently prepared the MDS and care plan. LVN MDS said she asked the interim DON to review the care plan and make corrections. LVN MDS said Resident #290 was admitted to the facility on [DATE] and she had oxygen on when she was admitted . After a couple of hours, the facility that Resident #290 came from, called and said Resident #290 had a critical lab and she was sent to the hospital. LVN MDS said Resident #290 was readmitted on [DATE] with oxygen from the hospital. LVN MDS said the resident had oxygen since she came to the facility and the interim DON verified her medications. LVN MDS said the interim DON should have clarified the oxygen order because it was on her hospital discharged orders. LVN MDS said she added the oxygen to Resident #290's MDS but forgot to care plan the oxygen use. LVN MDS said the interim DON and LVN J admitted Resident #290 and failed to get an oxygen order from the physician. LVN MDS said Resident #290 could have retained carbon dioxide, because she had COPD, which could have caused harm or she could have passed out. During an interview on 12/14/23 at 8:40 a.m., the Interim DON said Resident #290 should not be on oxygen without a physician's order. The interim DON said all the residents on oxygen should have an order from the physician for oxygen before oxygen is administered. The interim DON said the nurse who admitted Resident # 290 should have called Resident #290's physician and verified discharged orders upon admission. The interim DON stated the DON should have verified Resident #290's discharged orders, contacted her physician for any discrepancies, and made corrections the next day. The interim DON said these actions would have prevented Resident #290 from being administered oxygen for at least a week without an order. The interim DON said administering oxygen to Resident #290 could have a negative outcome depending on the oxygen setting. The Interim DON said it could have interfered with CO2 if there was too much oxygen going in since Resident #290 had a diagnosis of COPD. Record review of the facility policy dated 2001 MED - PASS, Inc. (Revised October 2010) read in part, . the purpose of this procedure is to provide guideline for safe oxygen administration . preparation: #1. Verify that there is a physician's order for this procedure . review the physician's order . for oxygen administration . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 1 of 1 medication aide cart and 1 of 1 medication room refrigerator reviewed for medications. -1 of 1 medication aide cart had two discontinued medications. -1 of 1 medication rooms had a water bottle (Ozarka) 700 ml sport cover in the freezer section of the refrigerator. These failures could affect residents, placing them at risk for altered effectiveness of the medication and worsening of the resident's symptoms, requiring medical intervention. The findings include: During an observation on 12/13/23 at 2:35 p.m., revealed the medication aide's cart had two discontinued medications: Clopidogrel 75 mg and Metoprolol [NAME] 25mg were left in the cart. During an interview on 12/13/23 at 2:35 p.m., MA T said the doctor discontinued medications because the resident brought them from home, and it was replaced with the medicines provided by the facility. MA T said the staff should have taken the discontinued medication from the cart and placed it in the box in the medication room. During an observation of the medication room on 12/13/23 at 3:00 p.m., revealed the refrigerator in the medication room had a water bottle (Ozarka) 700 ml sports cover in the freezer section of the fridge. During an interview on 12/13/23 at 3:00 p.m., MA T said the refrigerator should have only the residents and facility medications, no personal food or drinks from the staff to prevent cross-contamination. During an interview on 12/13/23 at 3:18 p.m., LVN R said the refrigerator in the medication room was for medication only, not for any staff personal items, to prevent cross-contamination. During an interview on 12/13/23 at 3:20 p.m., LVN J said the water bottle should not be in the refrigerator because it was used for medications only, and staff personal items are not stored in it because of infection control. During an interview on 12/13/23 at 3:55 p.m., the Interim DON said the nurses should remove the medication the resident came with once the medication from the pharmacy comes in. During an interview on 12/13/ at 3:59 p.m., the Interim DON said staff personal items (water and food) should not be kept in the medication refrigerator in the medication room because of cross-contamination. During interview on 12/14/23 at 3:30 p.m., the Administrator said she could not find the competency skills check off for the nurses and medication aides. Record review of the facility policy on medication storage not dated policy read in part, . facility staff should place open on date to medications label for medications with limited expiration date upon opening . food is not stored with refrigerated medications . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 6 residents (Resident #2), reviewed for the Medication Regimen Review (MRR). -The facility failed to review and act on the pharmacist's Resident #2's to utilize the correct consent form. This failure could place residents at risk from maintaining their highest practicable level of physical, mental, and psychosocial well-being, and could place them at risk for not providing informed consent to a psychotropic medication. The findings include: Record review of Resident #2's admission record dated 12/12/023 revealed a [AGE] year-old woman admitted on [DATE]. The admission record documented her diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), unspecified psychosis (diagnosis assigned to individuals who are experiencing symptoms of schizophrenia or other psychotic symptoms, but do not meet the full diagnostic criteria for schizophrenia or another more specific psychotic disorder), repeated falls, schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), major depressive disorder (mental health disorder having episodes of psychological depression), HIV (virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases), anxiety disorder (group of mental illnesses that cause constant fear and worry), insomnia (trouble falling and/or staying asleep), and convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). Record review of Resident #2's November MAR dated 12/12/2023 revealed a prescription for Aripiprazole (an antipsychotic medication used for treatment of agitation that occurs with certain mental and/or mood disorders) 20mg tablet, one tablet, once daily for schizoaffective disorder. The MAR documented it was given daily at 9:00 AM on 11/1/2023 through 11/30/2023 except 11/4/2023. Per the MAR, the prescription began on 8/29/2023. Record review of Resident #2's December MAR dated 12/12/2023 revealed a prescription for Aripiprazole 20mg tablet, one tablet, once daily for schizoaffective disorder. The MAR documented it was given daily at 9:00 AM on 12/1/2023 through 12/12/20233. Per the MAR, the prescription began on 8/29/2023. Record review of Resident #2's quarterly MDS dated [DATE] with an ARD of 11/13/2023 revealed a BIMS score of 15 indicating no cognitive decline. The MDS documented she required a walker for mobility. Per the MDS, Resident #2 minimal assistance with her ADL's including eating, hygiene, toileting, bathing, dressing, and/or personal hygiene. The MDS revealed Resident #2 was prescribed an antipsychotic. Record review of Resident #2's care plan dated 12/19/2023 revealed she had a focus on her ADL needs with interventions including minimal assistance with locomotion, bed mobility, eating, transfers, and incontinence care. The care plan documented a focus on her behavioral concerns. The care plan included a focus on Resident #2's psychotropic medication use with interventions including monitoring for signs or symptoms of side effects. Record review of Resident #2's September 2023 MRR dated between 9/5/2023 and 9/7/2023 revealed the pharmacist's recommendation to use the consent form number 3713 for Aripiprazole as it was no longer appropriate to use the conventional informed consent form for antipsychotics. Record review of Resident #2's October 2023 MRR dated between 10/1/2023 and 10/3/2023 revealed the pharmacist's recommendation to use the consent form number 3713 for Aripiprazole as it was no longer appropriate to use the conventional informed consent form for antipsychotics. Record review of Resident #2's November 2023 MRR dated between 11/1/2023 and 11/3/2023 revealed the pharmacist's recommendation to use the consent form number 3713 for Aripiprazole as it was no longer appropriate to use the conventional informed consent form for antipsychotics. Interview on 12/12/2023 at 9:23 AM with Resident #2, she said she had lived at the facility for nine years. Resident #2 said she had no concerns with her medical care at the facility. Interview on 12/12/2023 at 11:25 AM with Resident #2, she said she was aware of the medications she took, and she had no concerns with those medications. Interview on 12/13/2023 at 12:19 PM with the Acting DON, he said he had been Acting DON for five total days. The Acting DON said he expected the MRR to be reviewed by the DON monthly after the pharmacist provides the recommendations. The DON said a resident's updated medication consent forms should be obtained by the DON. The DON said Resident #2's Aripiprazole consent should have been updated. The DON said the consent form 3713 detailed the previous attempts and approaches to the underlying mental illness, and without the correct form that would not be available when consent was granted. Interview on 12/14/2023 at 3:47 PM with the Acting DON, he said the facility did not have a specific policy related to MRR's or the DON's responsibility to them. The Acting DON said the facility utilized the consultant pharmacy's policy related to MRR. Telephone interview on 12/14/2023 at 12:57 PM the consultant pharmacist for the facility, she said the facility does not currently have a DON. The Pharmacist said the facility had multiple consent for psychotropic medication forms completed but they may not be uploaded. The Pharmacist said Resident #2's correct consent form could be at the facility and not uploaded to the EMR. The Pharmacist said if the facility could not produce the consent it would be a concern because certain medications require appropriate consents to ensure the resident or their representative were able to give informed consent to the medication. Interview on 12/14/2023 at 4:28 PM with the Admin, she said she expected that the MRR was reviewed, and the resident's physician was contacted to determine if the recommendations would be put in place. The Admin said she expected the facility's nurses to follow-up and a obtain the correct consent for psychotropic medications. Record review of the undated consultant pharmacy's policy related to MRR revealed the pharmacist would conduct an MRR for each resident at the facility monthly. The policy documented the purpose of the MRR was to ensure the resident's were receiving the correct medication therapy. The policy read in part .All findings and recommendations made during the MRR are reported to the director of nursing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7 % based on 2 errors out of 27 opportunities, which involved 1 of 11 residents (Resident #31) reviewed for medication errors. - MA B was going to administer Metoprolol and Lisinopril (used to treat high blood pressure) and not follow the blood pressure parameters according to the physician's orders for Resident #31. This failure could place residents at risk for increased negative side effects and a decline in health. Findings include: Record review of Resident #31's Face Sheet dated 12/14/23 revealed, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hypertension (condition in which the blood vessels have persistently raised pressure), major depressive disorder (medial illness that negatively affect how you feel, the way you think and how you act), and chronic obstructive pulmonary disease ( group of disease that cause airflow blockage and breathing related problem). Record review of Resident #31's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 10, which indicated the resident had moderately impaired cognition . Record review of Resident #31's Care Plan initialed 10/13/21 revealed, resident had cardiac disease related to CAD and HTN. Interventions: administer medication per physician orders. Record review of Resident #31's order summary report for December 2023 revealed a start date for Lisinopril 20 mg 1 tab po qd was started on 09/02/23, and the parameter read hold if SBP below 110. Metoprolol Tartrate 50 mg 1 tab po qd hold for SBP less than 110, DBP less 60, and HR less 60. Record review of Resident #31's MAR for December 2023 did not reveal any area to document the vital signs. During medication pass observation on 12/13/23 at 8:35 a.m., MA B was about to administer Lisinopril 20 mg and Metoprolol Tartrate 50 mg to Resident #31 without checking the residents blood pressure. The state surveyor stopped the medication aide before administration. During an interview on 12/13/23 at 8:38 a.m., M A B said she did not check Resident #31's blood pressure because when she started working in the facility three months ago, she told the nurse who was on duty, there was no area in MAR for documenting Resident #31's blood pressure and heart rate. MA B said the nurse told her not to take Resident #31's blood pressure because Resident #31 was on blood pressure medication for maintenance. MA B said the nurse no longer works for the facility. During an interview on 12/13/23 at 8:41 a.m., the Interim DON said MA B should check Resident #31's blood pressure before she administered blood pressure medication and documented it on the MAR. The interim DON said if the blood pressure medication had a perimeter, there should be an area in the MAR for documentation. During an observation on 12/13/23 at 8:49 a.m., MA B checked Resident #31's blood pressure on her right wrist, and Resident #31's blood pressure was 102/50with a pulse of 87. During an observation on 12/13/23 at 8:51 a.m., MA B rechecked Resident #31's blood pressure with an electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure was 144/93, and her pulse was 69. During an observation on 12/13/23 at 8:55 a.m., LVN J checked Resident#31's blood pressure with an electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure was 97/71, and pulse was 63. During an observation on 12/13/23 at 9:00 a.m., LVN J checked Resident #31's blood pressure with an electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure was 109/55 and pulse was 63. During an interview on 12/13/23 at 9:02 a.m., LVN J said Resident #31's blood pressure medication would be held because the blood pressure was below the parameter. LVN J said if MA B had given the blood pressure medications to Resident#31, it would have caused Resident #3's blood pressure to drop more, which could have made the resident dizzy or even fall. LVN J said she was not aware MA B was not checking Resident #31's blood pressure before she gave blood pressure medication, and she did not tell MA B not to check Resident #31's vitals. LVN J said she monitored MA B during medication administration when she made random rounds, and the DON monitored the nurses when she made random rounds. During an interview on 12/13/23 at 9:08 a.m., MA B said she would have given the medication without checking Resident #31's blood pressure if the state surveyor had not intervened. MA B said Resident #31's blood pressure could have dropped very low if she had given the blood pressure medications because it was already below the parameter. MA B said Resident #31 could have had a negative outcome. MA B said the floor nurse does monitor the medication aides during medication administration. She said she had a skills check-off, and it included checking the resident's blood pressure before administering blood pressure medication. During an interview on 12/14/23 at 9:04 a.m., the Interim DON said Resident #31's blood pressure was low, and if MA B administered BP medications to Resident #31, it could drop the BP even lower. The interim DON said the negative outcome for Resident #31 could be dizziness and weakness. The interim DON said if Resident #31's blood pressure medication had a parameter, then MA B should have checked blood pressure before administering medication. During interview on 12/14/23 at 3:30 p.m., the Administrator said she could not find the competency skills check off for the nurses and medication aides. Record review of the undated facility policy on medication administration read in part . facility staff should observe the six medication rights . right documentation for each resident . a triple check of these 5 rights is recommended . if there is any other reason to question . or directions, the physician's orders are checked . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from any significant medication errors for 1 of 11 residents (Residents #31) reviewed for significant medication errors. - MA B failed to administer medications as ordered by the physician to Resident # 31. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and negative outcomes. Findings include: Record review of Resident #31's Face Sheet dated 12/14/23 revealed, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hypertension (condition in which the blood vessels have persistently raised pressure), major depressive disorder (medial illness that negatively affect how you feel, the way you think and how you act), and chronic obstructive pulmonary disease (group of disease that cause airflow blockage and breathing related problem). Record review of Resident #31's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 10, which indicated the resident had moderately impaired cognition. Record review of Resident #31's Care Plan initialed 10/13/21 revealed, resident had cardiac disease related to CAD and HTN. Interventions: administer medication per physician orders. Record review of Resident #31's order summary report for December 2023 revealed a start date for Lisinopril 20 mg 1 tab po qd was started on 09/02/23, and the parameter read hold if SBP below 110. Metoprolol Tartrate 50 mg 1 tab po qd hold for SBP less than 110, DBP less 60, and HR less 60. Record review of Resident #31's MAR for December 2023 did not reveal any area to document the vital signs. During medication pass observation on 12/13/23 at 8:35 a.m., MA B was about to administer Lisinopril 20 mg and Metoprolol Tartrate 50 mg to Resident #31 without checking the residents blood pressure. The state surveyor stopped the medication aide before administration. During an interview on 12/13/23 at 8:38 a.m., M A B said she did not check Resident #31's blood pressure because when she started working in the facility three months ago, she told the nurse who was on duty, there was no area in MAR for documenting Resident #31's blood pressure and heart rate. MA B said the nurse told her not to take Resident #31's blood pressure because Resident #31 was on blood pressure medication for maintenance. MA B said the nurse no longer works for the facility. During an interview on 12/13/23 at 8:41 a.m., the Interim DON said MA B should check Resident #31's blood pressure before she administered blood pressure medication and documented it on the MAR. The interim DON said if the blood pressure medication had a perimeter, there should be an area in the MAR for documentation. During an observation on 12/13/23 at 8:49 a.m., MA B checked Resident #31's blood pressure on her right wrist, and Resident #31's blood pressure was 102/50with a pulse of 87. During an observation on 12/13/23 at 8:51 a.m., MA B rechecked Resident #31's blood pressure with an electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure was 144/93, and her pulse was 69. During an observation on 12/13/23 at 8:55 a.m., LVN J checked Resident#31's blood pressure with an electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure was 97/71, and pulse was 63. During an observation on 12/13/23 at 9:00 a.m., LVN J checked Resident #31's blood pressure with an electronic wrist blood pressure machine on Resident #31's left wrist, and Resident #31's blood pressure was 109/55 and pulse was 63. During an interview on 12/13/23 at 9:02 a.m., LVN J said Resident #31's blood pressure medication would be held because the blood pressure was below the parameter. LVN J said if MA B had given the blood pressure medications to Resident#31, it would have caused Resident #3's blood pressure to drop more, which could have made the resident dizzy or even fall. LVN J said she was not aware MA B was not checking Resident #31's blood pressure before she gave blood pressure medication, and she did not tell MA B not to check Resident #31's vitals. LVN J said she monitored MA B during medication administration when she made random rounds, and the DON monitored the nurses when she made random rounds. During an interview on 12/13/23 at 9:08 a.m., MA B said she would have given the medication without checking Resident #31's blood pressure if the state surveyor had not intervened. MA B said Resident #31's blood pressure could have dropped very low if she had given the blood pressure medications because it was already below the parameter. MA B said Resident #31 could have had a negative outcome. MA B said the floor nurse does monitor the medication aides during medication administration. She said she had a skills check-off, and it included checking the resident's blood pressure before administering blood pressure medication. During an interview on 12/14/23 at 9:04 a.m., the Interim DON said Resident #31's blood pressure was low, and if MA B administered BP medications to Resident #31, it could drop the BP even lower. The interim DON said the negative outcome for Resident #31 could be dizziness and weakness. The interim DON said if Resident #31's blood pressure medication had a parameter, then MA B should have checked blood pressure before administering medication. The interim DON stated the incident with Resident #31 could have the potential for significant medication error because MA B would have administered the blood pressure medications to Resident #31 without checking her blood pressure, which was already low if the surveyor had not intervened. During interview on 12/14/23 at 3:30 p.m., the Administrator said she could not find the competency skills check off for the nurses and medication aides. Record review of the undated facility policy on medication administration read in part . facility staff should observe the six medication rights . right documentation for each resident . a triple check of these 5 rights is recommended . if there is any other reason to question . or directions, the physician's orders are checked . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, comfortable, and homelike environment for one of twelve residents (Resident #2) reviewed for a safe, clean, and homelike environment. -The facility failed to ensure Resident #2 had a working light in her room above her sink. -The facility failed to ensure the residents who smoked cigarettes had a safe, comfortable seating area available as the bench in the smoking area was broken. These failures could place the residents at risk of injury from the visible nails on the bench in the smoking area and could place the residents at risk of decreased quality of like due to the lack of a well-maintained environment. Findings include: Record review of Resident #2's admission record dated 12/12/023 revealed a [AGE] year-old woman admitted on [DATE]. The admission record documented her diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), unspecified psychosis (diagnosis assigned to individuals who are experiencing symptoms of schizophrenia or other psychotic symptoms, but do not meet the full diagnostic criteria for schizophrenia or another more specific psychotic disorder), repeated falls, schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), major depressive disorder (mental health disorder having episodes of psychological depression), HIV (virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases), anxiety disorder (group of mental illnesses that cause constant fear and worry), insomnia (trouble falling and/or staying asleep), and convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). Record review of Resident #2's quarterly MDS dated [DATE] with an ARD of 11/13/2023 revealed a BIMS score of 15 indicating no cognitive decline. The MDS documented she required a walker for mobility. Per the MDS, Resident #2 minimal assistance with her ADL's including eating, hygiene, toileting, bathing, dressing, and/or personal hygiene. The MDS revealed she had adequate vision abilities with the use of corrective lenses. The MDS documented Resident #2 received PT services. Record review of Resident #2's care plan dated 12/19/2023 revealed she had a focus on her ADL needs with interventions including minimal assistance with locomotion, bed mobility, eating, transfers, and incontinence care. The care plan documented a focus on her behavioral concerns. There was no documented focus on her vision needs. Interview on 12/12/2023 at 9:23 AM with Resident #2, she said she had lived at the facility for nine years. Resident #2 said the light above her sink was not working. Observation on 12/12/2023 at 9:23 AM of Resident #2's call light and bedroom, the light over the sink in Resident #2's room would not turn on whether the switch was in the on or off position. Interview on 12/12/2023 at 11:25 AM with Resident #2, she said she had spoken to staff about the broken light in her room but no one from the facility had repaired it yet. Resident #2 said she could not recall who she had spoken to or how long the light had been broken. Observation on 12/13/2023 at 8:29 AM revealed the bench in the smoking area was in disrepair. The back of the bench had become partially dislodged from the base and nails were visible. A nurse and a resident were both sitting on the bench. Interview on 12/13/2023 at 12:19 PM with the Acting DON, he said he had never been informed of the malfunctioning light in Resident #2's room. The Acting DON said if he had been informed, he would have ensured it was repaired. The Acting DON said his expectations were that as soon as staff were informed that a resident's room was not homelike, the staff or an outside technician should repair the concern. Interview on 12/14/2023 at 3:47 PM with the Admin, she said the facility had no specific policy related to facility maintenance and/or repair. The Admin said the facility utilized an electronic repair request system in which repairs were requested and completed. Interview on 12/14/2023 at 4:28 PM with the Admin, she said no one had ever informed her that the bench in the smoking area was broken. The Admin said no one had ever informed her the light in Resident #2's room was not working. The Admin said the facility staff should have been aware of the light and the bench. The Admin said issues such as the bench and Resident #2's light would have been entered into the electronic repair system to ensure repair. The Admin said she had removed the bench completely and had replaced it with two chairs. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication aide cart, 1 of 1 medication room refrigerator, and 1 of 1 nurse's carts reviewed for medications. -1 of 1 medication aide cart had two opened undated eye drops and two discontinued medications. -1 of 1 medication rooms had a water bottle(Ozarka) 700ml sport cover in the freezer section of the refrigerator. -1 of 1 nurse's medication cart had opened and undated medications. These failures could affect residents, placing them at risk for altered effectiveness of the medication and worsening of the resident's symptoms, requiring medical intervention. The findings include: During an observation on 12/13/23 at 2:20 p.m., it revealed the medication aide cart had two eye drop containers that were opened and not dated: Latanoprost sol 0.005% and Combigan sol 0.2/0.5%. During an interview on 12/13/23 at 2:20 p.m., MA B said she was not the person who opened the eye drops. MA B said when a medication aide opened an eye drop container, she should date the container with the opened date to prevent staff from administering the drops to residents past the expiration date. MA B said if any staff administered the medication past the open date, the drug might not be effective, and the resident would not get the desired outcome. MA B said she did not know how long the eye drops should be used after opening them. During an observation on 12/13/23 at 2:35 p.m., revealed the medication aide's cart had two discontinued medications: Clopidogrel 75 mg and Metoprolol [NAME] 25mg were left in the cart. During an interview on 12/13/23 at 2:35 p.m., MA T said the doctor discontinued medications because the resident brought them from home, and it was replaced with the medicines provided by the facility. MA T said the staff should have taken the discontinued medication from the cart and placed it in the box in the medication room. During an observation of the medication room on 12/13/23 at 3:00 p.m., revealed the refrigerator in the medication room had a water bottle (Ozarka) 700ml sports cover in the freezer section of the fridge. During an interview on 12/13/23 at 3:00 p.m., MA T said the refrigerator should have only the residents and facility medications, no personal food or drinks from the staff to prevent cross-contamination. During an interview on 12/13/23 at 3:18 p.m., LVN R said the refrigerator in the medication room was for medication only, not for any staff personal items, to prevent cross-contamination. During an interview on 12/13/23 at 3:20 p.m., LVN J said the water bottle should not be in the refrigerator because it was used for medications only, and staff personal items are not stored in it because of infection control. During an observation of the nurse's medication cart on 12/13/23 at 3:30 p.m., revealed the following medications were open and not dated: 2 Insulin lispro injection 100unit, BREO Ellipta 200/25 mcg, Levalbuterol inhalation solution USP 25 vials in a foil packet, and 4 of the vials was not inside the foil packet. During an interview on 12/13/23 at 3:32 p.m., LVN R said all open insulins and breathing treatments should be dated to prevent administering a medication that had passed the opened expiration date. LVN R said if the medication was administered to the resident after the medication had passed the expiration date, the medication would not provide the expected outcome. LVN R said it could have a negative effect on the resident. LVN R said the breathing treatments should be stored in the foil package to protect the medication from light. She said she had skills check offs, and medication administration and storage were part of the check-offs. LVN R said it was the nurse's responsibility to date medicines when opened and remove medication without a date from the medication cart. LVN R said The DON monitored the nurses when she did random cart checks. During an interview on 12/13/23 at 3:55 p.m., the Interim DON said the nurses should remove the medication the resident came with once the medication from the pharmacy comes in. The Interim DON said the eye drop container should be labeled with the opened date because once eye drop medicine was opened, it had an expiration date. During an interview on 12/13/ at 3:59 p.m., the Interim DON said staff personal items (water and food) should not be kept in the medication refrigerator in the medication room because of cross-contamination. During an interview on 12/13/23 at 4:01 p.m., the Interim said the insulin pen, BREO inhaler, and eye drops should be labeled with the open date so the staff would only use them up to the expiration date to prevent any adverse outcome. During interview on 12/14/23 at 3:30 p.m., the Administrator said she could not find the competency skills check off for the nurses and medication aides. Record review of the facility policy on medication storage not dated policy read in part, . facility staff should place open on date to medications label for medications with limited expiration date upon opening . food is not stored with refrigerated medications . .

Based on interview and record review, the facility failed to use the service of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 36 of 92 days (09/11/2023, 09/12/2023, 09/13/2023, 09/14/2023, 09/15/2023, 09/17/2023, 09/18/2023, 09/19/2023, 09/20/2023, 09/21/2023, 09/22/2023, 09/23/2023, 09/25/2023, 09/26/2023, 09/27/2023, 09/28/2023, 09/29/2023, 09/30/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/05/2023, 10/06/2023, 10/07/2023, 10/08/2023, 10/09/2023, 10/10/2023, 10/11/2023, 10/12/2023, 10/13/2023, 11/02/2023, 12/05/2023, 12/06/2023, 12/07/2023, 12/08/2023, and 12/11/2023) reviewed during a look back period from 09/11/2023 to 12/11/2023. -The facility failed to have RN coverage in the facility for eight consecutive hours on 09/11/2023, 09/12/2023, 09/13/2023, 09/14/2023, 09/15/2023, 09/17/2023, 09/18/2023, 09/19/2023, 09/20/2023, 09/21/2023, 09/22/2023, 09/23/2023, 09/25/2023, 09/26/2023, 09/27/2023, 09/28/2023, 09/29/2023, 09/30/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/05/2023, 10/06/2023, 10/07/2023, 10/08/2023, 10/09/2023, 10/10/2023, 10/11/2023, 10/12/2023, 10/13/2023, 11/02/2023, 12/05/2023, 12/06/2023, 12/07/2023, 12/08/2023, and 12/11/2023. This failure could affect the residents by placing them at risk for not having their nursing and medical needs met and receiving improper care. Findings include: Review of the facility's Timecard Detail sheets dated 12/13/2023 reflected there was not eight consecutive hours of coverage by an RN on the following days/dates: Monday 09/11/2023 Tuesday 09/12/2023 Wednesday 09/13/2023 Thursday 09/14/2023 Friday 09/15/2023 Sunday 09/17/2023 Monday 09/18/2023 Tuesday 09/19/2023 Wednesday 09/20/2023 Thursday 09/21/2023 Friday 09/22/2023 Saturday 09/23/2023 Monday 09/25/2023 Tuesday 09/26/2023 Wednesday 09/27/2023 Thursday 09/28/2023 Friday 09/29/2023 Saturday 09/30/2023 Monday 10/02/2023 Tuesday 10/03/2023 Wednesday 10/04/2023 Thursday 10/05/2023 Friday 10/06/2023 Saturday 10/07/2023 Sunday 10/08/2023 Monday 10/09/2023 Tuesday 10/10/2023 Wednesday 10/11/2023 Thursday 10/12/2023 Friday 10/13/2023 Thursday 11/02/2023 Tuesday 12/05/2023 Wednesday 12/06/2023 Thursday 12/07/2023 Friday 12/08/2023 Monday 12/11/2023 Interview with the Admin on 12/14/23 at 10:00 AM revealed she began her position at the facility on 09/26/2023. She said she was aware the facility did not have RN coverage for several days after starting her position. The Admin said she understood the facility is required to have an RN in the facility every day for eight consecutive hours a day and seven days a week. She said the RN coverage currently is being covered by the Regional Director of Clinical Services and he will be at the facility every day until the facility has a DON on board. She said she has one potential candidate for the DON position going through a third interview next week. She said she has run an ad for a PRN RN position as a backup, so she does not have to deal with the stress of RN coverage in the future. The Admin said not having RN coverage as required affects residents because an RN has more knowledge, and they are able to double check and sign off on things an RN can only sign off on. She also said if she has an RN onsite, she does not have to reach out to someone else to get things done. The Admin said she does not have a policy for RN coverage. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (CR #1) reviewed for comprehensive assessments. - The facility failed to ensure CR #1's comprehensive care plan reflected medication (Provera) and interventions. This failure could place residents at risk of not receiving the care and treatment listed in the care plan and could lead to a diminished quality of care. Findings include: Record review of the admission sheet for CR#1 revealed a [AGE] year old male admitted to the facility on [DATE], re-admitted on [DATE] and discharged on 11/22/2022 with diagnoses which included paraphilia (a condition characterized by abnormal sexual desires, typically involving extreme or dangerous activities), unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), delirium due to known physiological condition and other sexual dysfunction not due to a substance or known physiological condition ( a serious change in mental abilities). Record review of CR#1's Discharge MDS, dated [DATE], revealed his staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. He was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making was severely impaired never/rarely made decision. Further review of MDS revealed he required supervision from staff with transfers, dressing and toilet use. Record review of CR#1's physician order dated 9/21/22 revealed an order for Provera tablet 10 mg (medroxyprogesterone) Acetate) Give 1 tablet by mouth one time a day related to other sexual dysfunction not due to a substance or known physiological condition. Record review of CR#1's nurses notes written by LVN A on 9/21/2022 at 1:25pm read in part: .staff reports that this resident is verbalizing sexual things to them at this time. resident continues to show sexual behaviors by being verbally aggressive as to telling staff members sexual things he wants to do to them. charge nurse notified md of these behaviors. new order received for Provera 10mg po qd. order was transcribed into system at this time. RP called, message left and still waiting for call back to facility at this time . Record review of CR#1's nurses notes written by LVN B on 9/25/2022 at 6:55pm read in part: '' .Resident alert and stable, started to say verbally inappropriate words to staff by saying sexual things that he would like to do. Writer redirected resident and informed resident that it's inappropriate, Resident redirected without difficulty . Record review of CR#1's nurses notes written by LVN A on 11/22/2022 at 1:32pm read in part: .resident awake and alert with no s/s of distress noted walking around the facility. activity director reports that during an activity this resident approached another resident asking if she would be his girlfriend. activity director states that the other resident raised her hand up to let this resident know to get out of her face due to this resident being deaf but this resident continued to ask the other resident to be his girlfriend and continued by telling her to come to his room. the activity director stated that she intervened and asked this resident to leave the resident alone and return to his room. this resident then left the dining room at this time . Record review of CR#1's nurses notes written by previous DON on 11/22/2022 at 4:50pm read in part: .Resident RP called explained discharge to pysch facility per MD resident in facility sexually aggressive w/resident making statements of aggressive sexual nature Resident also chased HR down hallway yelling sexual statements Resident at nurses station scream for DICK [NAME] medication resident re-directed multiple times refusing to stop behavior . In an interview on 01/02/23 at 9:51 a.m. with CNA AA, she said CR#1 showed sexual behaviors by being verbally aggressive as to telling staff members sexual things he wanted to do to them. She said she started working in this facility in April 2022 on the memory care unit. She said she had witnessed CR#1 had sexual behaviors while in the memory care unit and continued when moved of MCU. She said interventions were to re-direct and he was put of medication. In a telephone interview on 01/02/23 at 11:32a.m., with CR#1's doctor, he said due to CR#1's sexually aggressive behavior inventions were placed to move him out of the secure unit, be in a room closer to nurses station and started him on medication. In a telephone interview on 01/02/23 at 12:05 p.m., with CR#1's RP, she said CR#1's care plan did not address the medications he was taking to control the desire and there were no interventions to address his behaviors. She said LVN A told her that the resident was having on going sexually behaviors, but those behaviors were not addressed in the care plan. In a telephone interview on 01/02/23 at 12:29 p.m., with LVA A, she said CR#1 had explicit sexual behaviors. She said CR#1 was on medication Provera. She said CR#1 was going to be discharged to a psych facility because of his sexually aggressiveness with another female resident. She said RP refused to send resident to psych facility and decided to discharge him home. Record review of CR #1's care plan initiated 11/24/2021 and revised on 12/05/2022 revealed no documentation of care plans addressing medication (Provera) and interventions for behaviors. The Care plan was revised 12 days after CR#1 was discharged from the facility by the previous DON on 12/05/2022. Attempted telephone interview on 01/02/23 at 12:20p.m., with previous DON was unsuccessful. In an interview on 01/02/23 at 1:32 p.m., with the LVN/MDS nurse, she said she updated the care plan quarterly and upon significant change of condition. She said she updated the care areas that triggered on the MDS. She said she worked on the floor and was aware of CR#1 sexually behaviors towards staff and the medications. She said she notified the previous DON so she would update the care plan. LVN/MDS nurse said she was an LVN and only RNs could create the care plan. She said it was important to update the care plan because nurses followed the care plan. Record review and interview on 1/2/23 at 1:42 p.m. the DON and, this Surveyor reviewed CR#1's physician orders, nurses notes and care plan with the DON. The DON said an RN had to initiate the care plan, but LVN/MDS nurse was responsible for updating the comprehensive care plan. She said CR#1 problem existed as he was having on going behaviors. The DON said CR#1 had psychiatric assessment on 05/02/2022 for violent behavior. Another episode in September 2022 and then in November 2022. She said CR#1 was placed on new medication (Provera). She said the care plan should have been updated to include new medication and new interventions for the behaviors. She said it was important to update the care plan because it was the plan that told how the facility would care for him. Record review of the facility's Care Plan, Comprehensive Person-Centered Policy (Revised March 2022) read in part: .Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; e. reflects currently recognized standards or practice for problem areas and conditions. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure professional standards of quality were met for 1 of 6 residents reviewed for professional standards. The facility failed to follow the dietitian's order for weekly weights x4 for Resident #1 These failures placed residents in the facility at risk for not receiving care according to professional standards. Findings Included: Record review of Resident #29 admission face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included legal blindness, hyperlipidemia; a condition where blood has too many fats, constipation, muscle spasm, glaucoma, and arthritis. Record review of Resident #29 care plan revealed Resident #29 required a regular diet for nutritional support and potential weight loss regular diet, regular texture, regular consistency. Resident #29 wishes will be respected, and resident will be provided favorite/comfort foods. Record review of Physician Order Summary revision date 8/17/2022 revealed regular diet, regular texture, and regular consistency. Record review of quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating that she was moderately impaired for cognition for decision making. For eating, toilet use, she required supervision with limited assistance. For dressing, personal hygiene, she required limited supervision. For Swallowing and Nutrition Status she was coded as having no swallowing issues. Her weight was 180 lbs and she was checked as having weight loss which was not on a physician prescribed weight loss regimen. She was not receiving mechanically altered and therapeutic diet. Record review of Dietician's notes/recommendation dated 9/6/2022 read in part . Current weight 166.9 lbs, height 61, BMI 31.5. Noted loss of -7.2%/30 days, -7.8%/90 days, -1%/180 days. Resident's diet: regular, regular, regular, meal intake: 76-100% per staff. Resident ate meals in room and is able to eat independently with tray set up. Preferences had been obtained. Note scale recalibrated last month likely contributed to weight variance. Staff report no visual weight loss. Estimated needs: 1839-1912kcal, protein: 76-91g, (1-1.2g/kg), and fluid: 2276-2655ml (30-35ml/kg) po intake may not be adequate to meet needs. Dietician's recommended offer more encouragement of meals and fluids and honor resident's food preferences. Weekly weights x 30days to get baseline. Record review of DON's progress notes dated 9/6/2022 Weight change note: resident with weight loss no significant changes. New Order for weekly weights x4. Record review of Resident #29 electronic weight records revealed weight dated 7/5/2022 as 182.1 lbs, weight dated 8/4/2022 as 179.8 lbs, and weight dated 9/1/2022 as 166.9 lbs. There were no records of any weekly weights taken. During an interview on 9/29/22 at 12:02 pm, DON stated whenever there was a professional recommendation, the facility's process was to run the recommendations by the physician via a communication form, if the physician agreed with the recommendations, then it will be implemented. She stated the time frame for implementing an order is 48-72 hours. She stated Resident #29 had some recent weight changes, but it was not believed that the resident had a weight loss. She stated the resident did not have any indications of weight loss, and there was no concern about the resident's diet. She stated it was believed that the facility scale was inaccurate, due to the scale being moved from the Memory Care Unit sometime in August 2022 due to ongoing renovations, and the scale needed recalibration. She stated the Dietician recommended a weekly weight x4 for Resident #29 to establish a new baseline weight for the resident. She stated she was responsible for coordinating resident weights at the facility. She admitted that Resident #29 weights had not been taken and recorded weekly since the Dietician's recommendation. She stated it was probably due to no internet connectivity, and the recent ongoing renovation within the facility. She stated the Dietician's recommendation on weekly weights x 4 did not require the physician's approval. She stated there was no risk associated with the failure to follow the Dietician's recommendation of weekly weights x4, because Resident #29 ate well, and it was believed that the scale needed recalibration due to moving it recently. During an interview on 9/29/22 at 12:18 pm, Resident #29 stated her weights were taken once monthly, around the first of the month, she stated the next weight will be taken probably around the weekend (October 1, 2022). She stated she used to be an overweight person, but she lost weight and then gained it back. She stated she wanted to loss more weight because she had arthritis and she had a lot of weight on her back. During an interview on 9/29/22 at 01:20 pm, the Dietician stated whenever she gave a recommendation, her expectation was for the facility to get a physician's approval and then implement it within 72 hours. She stated the recommendation for Resident #29 weekly weight x4 was at the physician's discretion to agree or not. She stated the weekly weight was recommended because she was aware that the facility scale was recalibrated, and there was a need to get a new baseline weight for Resident #29. However, there was no concern about the resident's diet. She also stated the weekly weight was dependent on if the resident agreed to allow staff to take her weight. She stated the negative outcome associated with the facility not following her recommendation included, Resident #29 was at risk of further weight loss, and a decline in independence. During an attempted interview on 9/29/2022 at 1:40 pm, the Physician was telephoned but there was no response. A voice message was left with a call back number. The Physician did not callback before exit. Record review of progress notes from 9/6/22 through 9/29/22 revealed there was no documentation of weight refusals. Record review of scale calibration invoice from PTOT service dated 8/1/22 and due date 8/16/22, quarterly scale calibration was the service provided. Record review of facility undated policy titled: Implementation of recommendations policy number: 06.005 read in part . Policy: Recommendations submitted by the nutrition professional, or Nutrition and Dietetics Technician Registered (NDTR), as assigned will be implemented as soon as possible, but no later than 72 hours after submission in order to ensure the best nutritional care possible for the residents of the facility.

Based on observation, interviews, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one (Medication Cart #1) of two medication carts observed for storage of medications. The facility failed to ensure the Medication Cart #1 was secured when unattended. This deficient practice could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: Observation on 09/28/2022 at 7:16 AM revealed Medication Cart #1 observed unlocked and no person near cart in the 100 hall nursing station area. Interviewed and observation with LVN A on 09/28/2022 at 7:17AM, when LVN A was notified Medication Cart #1 was unlocked, she pressed the lock. She stated the medication cart should be locked when not attended, so people cannot get in it (she didn't continue). Observation on 09/29/2022 at 10:00 AM of Medication Cart #1 inventory revealed the following: Medication Cart #1 Left side: Drawer #1: Resident over the counter minerals/ supplement, 81 mg aspirin, cardiac meds, straws, cups, Mucinex Drawer#2: Resident locked narcotic box. Drawer#3: Resident medicated lotion, gauze, band aids, masks. Drawer #4: Resident non medicated lotion, tuberculosis syringes, blood pressure machine, diabetic machine. Medication Cart #1 Right side: Drawer #1: Diabetic testing supplies. Drawer #2: Liquid medications, exam gloves, sanitizer, tongue depressor. Drawer #3: Liquid medications, insulin auto shield. Drawer #4: Miscellaneous medication supplies, wound care supplies, pharmacy scanner, narcotic drug book. Interviewed Director of Nursing (DON) on 09/28/2022 at 8:35 AM, she stated all medication carts were to be locked when left unattended and the staff must take the key. The risk of the medication cart not being locked was anyone can get into the cart and take something out they should not have. Plan of correction was to in-service and re-educate the staff. Interviewed Administrator on 9/29/22 at 11:40 am regarding policy and procedure regarding locked medication carts. She reported the med cart should be locked by pushing the lock button in when not attended and the keys are held by the person assigned to that cart for the day. The reason the cart should be locked was to keep medications secure, prevent drug diversion, resident safety, prevent resident illness, injury or death. She reported education regarding locking medication carts is given in orientation, as needed and annually. Record review of the facility's policy, 2017 Omnicare. Page 1 of 4; 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles read in part .Policy Statement: 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Caraday of Houston Based on observation, interview, and record review, the facility failed to ensure staff had the appropriate competencies and skills for 2 (DC- A and DC- B) of 6 dietary staff reviewed for Dietary support personnel. 1. The facility failed to ensure that DC- A and DC- B were working with within the active date of their food handler's certification. This failure could place residents who consumed food prepared from the kitchen at risk of food-borne illness. Findings included: During an observation of the kitchen on 9/27/22 at 11:36am, 3 Food Manager's Certifications were on display. Each certification was currently active and up to date. During an interview with the DM on 9/27/22 at 11:36am, she stated that out of 6 dietary staff members, 3 were up to date with their certifications, 1 staff member was a new hire, and DC-A and DC- B were currently working on their certification. She stated that they use to do the classes in person, but because of Covid, the in-person classes stopped, and they are now only offered online. During an interview with DC-B on 9/27/22 at 11:45am, she stated that had worked at the facility for about 9-10 years. On 9/28/22, at 9:15am, an interview was attempted with DC-B, but she was not at work. The DM stated that she would be off for the next 3 days. During an interview with DC-A on 9/28/22 at 9:39am, it was revealed that DC-A was currently working on her Food Manager's Course, and she did not have a reason as to why she did not have it completed sooner. When asked when it expired, she stated that it was believed to have been some time last year. During an interview with the HR on 9/28/22 at 11:45am, she stated that during the hiring process, she is responsible for ensuring all future employees undergo a background check, certification/licensure check, electronic medical record review, and a vaccination status check. For 3 of the dietary staff, a certification was provided. When asked about DC-B, she stated that she has her certification, but she would have to pull it up through their online portal because she did not have a printed copy. In a follow up interview with HR on 9/28/22 at 12:04pm, she stated that dietary aides do not have to acquire a certificate in a certain amount of time after hire and DC-A did not need to have a certificate because she is not a cook. Record Review of the facility roster reviewed on 9/28/22 revealed that DC-A is titled at the facility as a dietary cook. On 9/28/22 at 2:45pm, the policy on dietary certifications for dietary staff was requested from the administrator. The facility was not able to provide a policy on this subject because they did not have one for their facility. Record review of the requested Personnel Files form completed by the facility on 9/29/22 displayed that the licensure number and expiration date for DC-A was not available. For DC-B, a licensure number was provided, but the expiration date was not available. Record review of the facility's dietary certifications on 9/29/22 revealed that DC- A Food Manager's Certification had expired on 3/07/2021 and DC-B's Food Manager's Certification had expired on 5/13/22. During an interview with the admin on 9/29/22 at 12:17pm, it was stated that the DM thought that the staff were able to work under her license but was now aware that all staff is required to complete their Food Manager's Certification within 30 days of hire. Record review of the Texas Administration Code, Title 25, Part 1, Chapter 228 subchapter B updated August 8, 2021, indicates: . Certified Food Protection Manager and Food Handler Requirements. (d) . All food employees, except for the certified food protection manager, shall successfully complete an accredited food handler training course, within 30 days of employment. (e) The food establishment shall maintain on premises a certificate of completion of the food handler training course for each food employee.