**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet a resident medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment that described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #49) reviewed for care plans. The facility failed to ensure Resident #49's Dementia and Hypertension diagnoses and medications were addressed in her comprehensive care plan. This failure could place residents at risk of not receiving appropriate care. The findings included: Record review of Resident #49's face sheet last captured 03/14/2025 reflected Resident #49 was a [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her medical diagnoses included Dementia (group of thinking and social symptoms that interferes with daily functioning) and Essential Hypertension (high blood pressure). Record review of Resident #49's quarterly MDS assessment, dated 02/10/25, revealed a BIMS score of 05 indicating severely impaired cognition. She was totally dependent on staff for all efforts for ADLs including eating, oral hygiene, toileting, showering or bathing self, dressing and personal hygiene. Further review revealed Resident #49 needed extensive assistance with ADL care with two staff assistance and the resident was incontinent of bowel and continent of bladder with indwelling Foley Catheter. Record review of Resident #49's care plan dated 2/10/25 revealed the resident had ADL (activity of daily living) self-care performance deficit related to limited impairment to upper and lower extremities with interventions including resident needed extensive assist with two-person assistance with incontinent care. and totally dependent on staff for all efforts for ADLs including eating, oral hygiene, toileting, showering or bathing self, dressing and personal hygiene . Record review of Resident #49's order summary, dated 3/1/25, revealed Physician Orders which included the following: - Catapres TTS-3 Patch Weekly 0.3 MG/24Hr (Clonidine Hcl) Apply 1 patch trans dermally one time a day every Tuesday for with an order date of 12/26/2024 and a start date of 12/31/2024 - Hydrochlorothiazide oral tablet 25mg, Give 25mg via peg-tube (a tube that is passed through the abdominal wall to the stomach for delivering nutrition or medication) one time a day for HTN with order date 12/26/24. - Lisinopril tablet 20 mg, Give 2 tablet via G-tube one time a day for HTN hold for SBP < 110, HR less than 60. Record review of Resident #49's Comprehensive Care Plan initiated 2/20/2024 revealed there were no focus areas addressing the resident's diagnoses of Dementia and Hypertension and no focus areas which indicated her medications including Catapres hypertension patch, hydrochlorothiazide and Lisinopril. In an interview with LVN-MDS D on 03/13/25 at 2:47 PM, LVN-MDS D said she had been working as the MDS nurse for 3 years, and she completed care plans. MDS D said that Resident #49's Comprehensive Care Plan did not address their diagnoses of HTN and Dementia, and did not address their active orders for hypertension medications, but it should have . LVN MDS-D stated these diagnoses and medications were ordered/documented prior to her Care Plan being completed, so should have been included on her Comprehensive Care Plan. LVN MDS-D stated these diagnoses and medications should automatically trigger a Care Area Assessment (CAA) area and she did not know why they were not triggered or why they were missed. LVN MDS-D stated she was responsible for the quarterly and annual assessments of the Comprehensive Care Plan. LVN MDS-D further stated it was important for these diagnoses and medications to be addressed in the Care Plan, so staff had the information needed to meet the resident's specific care needs. Interview with the DON, on 03/13/2025 at 5:05 p.m. revealed the Comprehensive Care Plans needed to address and include all of the residents' nursing, mental and psychosocial needs, and contain the interventions and services the resident would need to meet these needs. The DON said she would be assessing and in-servicing staff to ensure the resident needs were being met to include completion of assessments and Care Plans. Record review of the facility's policy dated 1/20/2021, titled Comprehensive Care Planning, revealed .The interdisciplinary team will continue to develop the plan in conjunction with the RAI (MDS3.0) and CAAS, completing and conducting comprehensive Care Plan Meeting and Reviews by day 21 after admission. The Care Plan is revised every quarter, significant change of condition, annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process: Procedure: 3. The comprehensive care plan is developed within 21 days of admission .5. The interdisciplinary team will review the healthcare practitioner's notes and orders (e.g., dietary needs, medications, routine treatments) and implement a Comprehensive Care Plan to meet the residents' immediate care needs including but not limited to: a. Initial goals based on an admission include GG section discharge goals. b. Physician orders. i. Specific Care plan on the main reason for admission to the community, i.e.: Dementia

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received care and treatment consistent with professional standards of practice to prevent pressure ulcers for one (Resident #49) of eight residents reviewed for pressure ulcers. 1. The facility failed to ensure Resident #49 was repositioned every two hours as indicated in Resident #49's physician orders on 3/11/2025 at 1:24 p.m. and 3/12/2025 at 11:49 a.m. 2. The facility failed to ensure Resident #49 was repositioned every frequently and as necessary as indicated in Resident #49's care plan. These failures could place residents at risk for worsening pressure ulcers, new pressure ulcers, or infection. Findings included: Record review of Resident #49's face sheet dated 03/12/2025 reflected Resident #49 was a [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her medical diagnoses included compression of brain (commonly occurring as a traumatic brain injury where the brain tissue is acutely or chronically compressed), other speech and language deficits, cognitive communication deficit, Type 2 Diabetes Mellitus ( high glucose in the blood), Post-Traumatic Hydrocephalus (PTH is a condition where there is a buildup of excess fluid in the brain after a traumatic brain injury, potentially causing increased pressure and brain damage), Dementia (group of thinking and social symptoms that interferes with daily functioning), gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach), dysphagia (swallowing difficulties), hemiplegia and hemiparesis (a condition that causes partial or total paralysis of one side of the body), following cerebral infarction affecting left non-dominant side cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain tissue to die due to a lack of oxygen and nutrients), Essential Hypertension (high blood pressure) and neuromuscular dysfunction of bladder with indwelling Foley catheter. Record review of Resident #49's quarterly MDS assessment, dated 02/10/25, revealed a BIMS score of 05 indicating severely impaired cognition. Further review revealed Resident #49 needed extensive assistance with ADL care with one staff assistance. Section GG of Resident #49's MDS indicated Resident #49 was dependent (required assistance and was unable to help with activities) with all ADLs and was unable to roll to the left or right. Section M of Resident #49's MDS assessment indicated Resident #49 was at risk for developing pressure ulcers. Record review of Resident #49's care plan with a revision date of 02/10/2025 revealed Resident #49 had the potential to develop pressure ulcers and interventions included to reposition the resident frequently or more often as needed. Record review of Resident #49's weekly wound evaluation and summary report dated 3/6/2025 revealed Resident #49 had no wound on her sacrum (area at the base of the spine). Record review of Resident #49's skin assessment progress notes dated 3/13/25 reflected open to sacral and coccyx measurement was 5cm (Length) x 0.3cm (width). Record review of Resident #49's physician order dated 3/01/2025 revealed Resident #49 should be repositioned every two hours . In an observation on 3/11/2025 at 9:39 a.m., Resident #49 was observed lying flat on her back with one pillow under her head. No other pillows or wedges (foam wedge used for positioning) were observed in Resident #49's room. Resident #49 was unable to answer questions appropriately. In an observation on 3/11/2025 at 10:46 a.m., Resident #49 was observed lying flat on her back with one pillow under her head. No other pillows or wedges (foam wedge used for positioning) were observed in Resident #49's room. Resident #49 was unable to answer questions appropriately. In an observation on 3/11/2025 at 1:24 p.m., Resident #49 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #49's room. In an observation on 3/11/2025 at 4:45 p.m., Resident #49 was observed lying flat on her back with one pillow under her head. No other pillows or wedges (foam wedge used for positioning) were observed in Resident #49's room. Resident #49 was unable to answer questions appropriately. In an observation on 3/12/2025 at 9:35 a.m., Resident #49 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #49's room. In an observation on 3/12/2025 at 11:49 a.m., Resident #49 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #49's room. In an observation of incontinent and Foley catheter care on 03/12/25 at 1:30 PM with CNA H, Resident #49 was lying in bed on her back. While cleaning in-between Resident #49's buttocks with the wet wipes. Resident #49 was grimacing and said ouch, ouch. CNA H then applied Zinc Oxide 20 % cream, a skin protectant. In an observation on 3/12/2025 at 3:00 p.m., Resident #49 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #49's room. In an interview with C.NA H on 3/12/25 at 3:05PM regarding turning and repositioning Resident #49, CNA H said pressure sores were prevented by rotating or turning the resident every two hours. CNA H stated some residents had extra pillows, and some residents had wedges to use for turning. CNA H stated that if a resident was not turned then sores could develop. Observation on 3/12/25 at 6:23 PM of a skin assessment with Wound Care Nurse revealed Resident #49 was lying on her back in bed. LVN repositioned Resident #49 to her left side and used the wet wipes to clean in-between the buttocks, where the sacral (bone or region at base of spine)and coccyx (tailbone) met, with resident grimacing and hitting the bed. Resident #49 had an open area between sacral and coccyx area about 5cm (length) by 0.2cm (wide) and the Wound Care Nurse was asked to measure the open area. She said the wound doctor does the wound measuring. In an interview with the Wound Care Nurse on 3/12/25 at 6:35 PM, she said she was not aware that Resident #49 had an open area in-between her buttocks and she was going to call the doctor and resident's responsible party to notify them. In an interview on 3/13/2025 at 10:10 a.m., the Wound Care Nurse reported if a resident was bedridden then they were repositioned every one to two hours. The Wound Care Nurse reported they used pillows to help reposition residents, and the nurse was responsible for ensuring residents were repositioned. The Wound Care Nurse stated if residents were not repositioned then it could cause skin breakdown (wounds). The Wound Care Nurse stated Resident #49 was on an air mattress and stated Resident #49 was repositioned every one to two hours . In an interview on 3/13/2025 at 11:55 a.m., the DON reported that dependent (requires assistance) residents should be turned every one and a half to two hours and more frequently if they were in pain. The DON stated pillows or wedges were used for repositioning the residents. The DON reported Resident #49 should still be repositioned every one to two hours. Record review of facility's policy titled, Skin Management Policy, with a revision date of 2/01/2014, revealed If new skin alterations of any type are identified .physician orders are obtained. The patient is reviewed by the interdisciplinary team and a plan of care is initiated. A policy specific to repositioning residents for pressure ulcer prevention was not received at the time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #45) reviewed for incontinent care. The facility failed to ensure CNA O did not place the foley catheter bag on Resident #45's bed during wound care. This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings included: Record review of Resident #45's sheet dated 03/14/25 revealed a [AGE] year-old female was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #45 had diagnoses which included: hypertension (force of blood pushing against artery walls consistently too high pressure), respiratory failure (a serious condition that makes it difficult for a person to breathe without help) and pressure ulcer of right hip (injuries to the skin and the tissue below the skin that are due to pressure on the skin). Record review of Resident #45's Quarterly MDS assessment dated [DATE] revealed Resident had memory problem which indicated severely impaired cognition. Resident #45 was dependent on staff for all ADLs with two staff assistance. Further review revealed the resident was incontinent of bowel and she had an indwelling catheter. Record review of Resident # 45's care plan revised on 04/04/24 revealed Resident #45 had an Indwelling Catheter for dx: neurogenic bladder (lacks bladder control due to brain, spinal cord or nerve problem) and multiple pressure ulcers. Interventions: staff to ensure to position catheter bag and tubing below the level of the bladder and with a privacy bag. Record review of Resident #45's order summary report for March 2025 read in part . urinary catheter 20 FR(measurement for the size of catheter), 30CC . diagnosis: neuromuscular dysfunction of bladder: ordered date 02/27/24 . During an observation on 03/12/25 at 9:45 a.m., Resident #45's wound care treatment was provided by the Wound care nurse and CNA O. CNA O placed Resident #45's foley catheter bag on the bed at the same level of the resident's bladder from 9:45 a.m. to 10:00 a.m. During an interview on 03/12/25 at 10:18 a.m., the Wound care nurse said they typically put the Foley bag on Resident #45's bed so the Foley would not pull out when they turned the resident. The Wound care nurse said since the Foley was on the same level as Resident #45's, bladder and urine would back up, the resident could get an infection. The Wound care nurse said the charge nurse on the floor monitored the aides during rounding. The Wound care nurse said she had in-service and skills check-off training on how to work with a resident with a Foley, and she said she could not recall what was taught during the training. The Wound care nurse said the ADON and DON monitored the nurses during random rounding. During an interview on 03/12/25 at 10:59 a.m., CNA O said she placed Resident #45's Foley bag on the bed because they were about to turn the resident to the right for wound care. CNA O said Resident #45's Foley bag was at the same level as the bladder, and the urine would back up to the resident's bladder. CNA O said she had training on Foley care and was educated to place the Foley bag on the side of the bed, to which the resident would be turned, and hang the Foley bag below the bladder. CNA O said when the urine flows back into Resident #45, it could cause an infection for the resident. She said the charge nurse monitored the aides during rounding. During an interview on 03/12/25 at 1:22 p.m., the DON said Resident #45's foley bag should always be placed below Resident #45's bladder when CNA O turned her or during care so the urine would flow through gravity. The DON said if Resident #45's Foley bag was placed on the bed, which was the same level as the bladder, the urine could flow back and could cause a UTI for Resident #45. She said the Wound care nurse and CNA O had training on Foley care, and the bag should be below the bladder. The DON said the nurse monitors the aides during rounding, and the ADON and DON monitor the nurses during random rounding. Record review of the facility policy indwelling catheter dated 04/20/21 read in part . it is the policy of this community that the resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risk of urinary tract complications . procedure indwelling catheter #6 .secure urinary drainage bag below the level of the bladder .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure based on a resident's comprehensive assessment, a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 3 (Residents # 32, #37 and #49) of 4 residents reviewed for g-tube medication administration . RN A failed to ensure Resident #32's GT (g-tube, a surgically placed device including a tube that leads from the outside of the body to the stomach to provide nutrition or medication) medications and water were administered by gravity, not by pushing the water via Resident #32's g-tube. RN A failed to ensure Resident #49's GT medications and water were administered by gravity, not by pushing the water via Resident #49's g-tube. LVN A did not check Resident #37's feeding bag for dates on 03/14/2025 during her shift. This failure could place residents at risk of abdominal discomfort, tube dislodgement, and tube occlusion (blockage) and possible infection. Findings include: Record review of Resident #32's admission Record dated 03/14/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #32's quarterly MDS Assessment, dated 02/25/25, ref lected his diagnoses included cerebral arteriosclerosis (a narrowing of arteries due to fatty buildup and limits supply of blood to the brain), aphasia (language disorder) following cerebral infarction (stroke), gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach), dysphagia (swallowing difficulties). Resident #32's BIMS score was 00 which indicated severe cognitive impairment. The MDS further reflected Section K - Swallowing/Nutritional Status indicated the resident's nutritional approach was a feeding tube. Record review of Resident #32's care plan, revised date 03/03/25, reflected: Feeding Tube: Resident requires the use of a feeding tube and is at risk for aspirations, weight loss, and dehydration. Goal: Resident will maintain adequate nutritional and hydration status as evidenced by weight being stable, no signs or symptoms of malnutrition, or dehydration through review date. Interventions: Check for tube placement and monitor gastric contents 'residual volume' (amount of liquid drained from a stomach following administration of enteral feed) per facility protocol. Hold tube feedings and notify physician if residual volume is greater than threshold as dictated by the physician. Record review of Resident #32's physician order, dated 03/01/2025, reflected: Enteral Feed Order every shift Check gastric residual volume. Hold feeding and notify physician for residual greater than 150cc. Flush with 30ml of water and reconnect feeding tube. Record review of Resident #32's physician order, dated 03/01/25, reflected: Enteral Feed Order every shift Flush enteral tube with 30ml water pre/post medication administration and 5-10 ml water between each medication. Observation on 03/12/25 at 9:09 AM revealed RN A stood outside Resident #32's door. She was preparing to provide Resident #32's medications. RN A performed hand hygiene and donned a pair of gloves. RN A disconnected Resident #32 from his g-tube feeding and checked the residual with the syringe. RN A proceeded to flush with 30 cc of water with a syringe by pushing down the plunger on the GT , then administered medications and flushed with water by pushing water through the syringe. RN A connected the resident back to the g-tube and turned-on the feeding pump. Record review of Resident #49's face sheet last captured 03/12/2025 Resident #49 was a [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her medical diagnoses included compression of brain (brain tissue that is acutely or chronically compressed commonly due to traumatic brain injury), other speech and language deficits, cognitive communication deficit, Type 2 Diabetes Mellitus (high glucose in the blood), Post-Traumatic Hydrocephalus, (PTH- is a condition where there is a buildup of excess fluid in the brain after a traumatic brain injury, potentially causing increased pressure and brain damage), Dementia (group of thinking and social symptoms that interferes with daily functioning), gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach), dysphagia (swallowing difficulties), hemiplegia and hemiparesis (a condition that causes partial or total paralysis of one side of the body), following cerebral infarction affecting left non-dominant side cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain tissue to die due to a lack of oxygen and nutrients), Essential Hypertension (high blood pressure) and neuromuscular dysfunction of bladder with indwelling Foley catheter. Record review of Resident #49's quarterly MDS assessment, dated 02/10/25, revealed a BIMS score of 05 indicating severely impaired cognition. She was totally dependent on staff for all efforts for ADLs including eating. Record review of Resident #49's physician order, dated 03/01/2025, reflected: Enteral Feed Order every shift Check gastric residual volume. Hold feeding and notify physician for residual greater than 150cc. Flush with 30ml of water and reconnect feeding tube. Observation on 03/12/25 at 9:09 AM revealed RN A stood outside Resident #49's door. She was preparing to provide Resident #49's medications. RN A performed hand hygiene and donned a pair of gloves. RN A disconnected Resident #49 from his g-tube feeding, checked residual with the syringe, then she proceeded to flush with 30 cc of water with a syringe by pushing down GT plunger. Then she administered medications and flushed with water by pushing water through the syringe. RN A connected the resident back to the g-tube and turned-on the feeding pump. Interview on 03/12/25 at 12:05 PM with RN A, revealed she always checked for placement and residual before giving medications. She stated she was pushing down the water with the syringe. She stated she was pushing but not hard. She stated pushing down water instead of using gravity could cause stoma (opening in the abdomen) problems, or cause pressure or bleeding. Interview on 03/13/25 at 5:55 PM with the ADON revealed the expectation when administering medication was nurses should be following the physician order, checking for placement, residual, each medication should be given in separate cups and flush with water in between medications. She stated pushing fluid instead of using gravity could cause discomfort to the resident. Interview on 03/13/25 at 6:07 PM with the DON revealed the expectation when administering medication was nurses should be following the physician order and checking for placement and residual. She stated when administering medication or water it should always be via gravity to prevent aspiration pneumonia. Record review of Resident #37's face sheet reflected she was a [AGE] year-old, she was originally admitted on [DATE] and most recently re-admitted on [DATE]. Her medical diagnoses included cerebral infarction (stroke), Parkinson's Disease (movement disorder of the nervous system that worsens over time), hypertension (high blood pressure) , muscle wasting, cognitive communication deficit, and nontraumatic subarachnoid hemorrhage (bleeding in the brain with symptoms including paralysis and impairments of nerve and brain function). Record review of Resident #37's care plan last updated 1/23/25, reflected Resident #37 required tube feeding related to Dysphagia with interventions including checking for tube placement and gastric contents or residual volume per facility protocol and record and providing local care to the g-tube site as ordered. Record review of Resident #37's Physician Orders, reflected she had orders for Jevity feeding 1.5 at 45 ML/HR for 20 hours and turn off from 8:00am to 12:00pm starting 04/24/24. Record review of Resident #37's MAR/TAR for March 2025, reflected LVN A documented turning off Resident #37's feeding machine on 3/14/25 at 8:00am . Observation of Resident #37 and interview on 03/14/2025 at 11:04am with the ADON, revealed the feeding bag had no label. The ADON said that the bag should have a labelled and have been dated and initialed by the nurse, and she would talk to the nurse about it. She said if nurses don't document something you cannot prove that they did it. In an interview with LVN A on 3/14/2025 at 12:01pm, she said she did not change Resident #37's feeding bag but did turn it off per Physician Orders. She said she did not notice there was no label on the bag, but she should have checked it for a label and created a label if the feeding bag did not have one. She said that labelling the feeding bag is important so nurses could identify what the resident is receiving and if they're getting the right rate. The bag could have been there for days, and no one would know it was an old feeding. A risk to residents would be infection or abdominal issues if the feeding was sour. Record review of Enteral Tube Medication Administration Policy # 9.12, Effective Date 09-2018 with Revision Date 08-2020, reflected the policy read in part: Medications will be administered in a safe and effective manner. The guidelines in this policy detail how to administer medication with an enteral tube. Nursing policies developed by the facility may supersede the procedures outlined in this policy. 12. With gloves on, check for proper tube placement in accordance with facility policy. 13. Check gastric content for residual feeding. Return residual volumes to the stomach. Report any residual above 100 ml. 14. If a pump is being used for feedings, turn it off. 15. Remove the plunger from the 60 ml syringe and connect the syringe to the clamped tubing using the appropriate port. 16. Administer each medication separately and flush the tubing between each medication. a. Place 15 ml (or the prescribed amount) of water in the syringe and flush the tubing using gravity flow. b. Pour dissolved/diluted medication in the syringe and unclamp tubing, allowing medication to flow by gravity. c. Flush the tube with 15 ml (or the prescribed amount) of water between each medication. Pinch the tubing below the syringe tip when each volume of liquid clears the syringe to avoid excessive air entering the stomach, as this can cause discomfort or emesis. d. Clamp tubing and detach the syringe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices goals and preferences for 1 of 3 (Resident #49) residents reviewed for pain management. -CNA H failed to stop performing incontinent care while Resident #49 was in pain. -CNA H failed to notify the Wound Care Nurse of Resident #49's pain in a timely manner after incontinent care. These failures could place resident at risk for increased pain causing undue suffering. Findings included: Record review of Resident #49's face sheet, reflected she was a [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her medical diagnoses included compression of brain (brain tissue being acutely or chronically compressed commonly due to a traumatic brain injury), other speech and language deficits, cognitive communication deficit, Type 2 Diabetes Mellitus (high glucose in the blood) Post-Traumatic Hydrocephalus, (PTH- is a condition where there is a buildup of excess fluid in the brain after a traumatic brain injury, potentially causing increased pressure and brain damage), Dementia (group of thinking and social symptoms that interferes with daily functioning), gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach), dysphagia (swallowing difficulties), hemiplegia and hemiparesis (a condition that causes partial or total paralysis of one side of the body), following cerebral infarction affecting left non-dominant side cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain tissue to die due to a lack of oxygen and nutrients), Essential Hypertension (high blood pressure) and neuromuscular dysfunction of bladder with indwelling Foley catheter. Record review of Resident #49's quarterly MDS assessment, dated 02/10/25, revealed a BIMS score of 05 indicating severely impaired cognition. Further review revealed Resident #49 needed extensive assistance with ADL care with one staff assistance. Section GG of Resident #49's MDS indicated Resident #49 was dependent (required assistance and was unable to help with activities) with all ADLs and was unable to roll to the left or right. Section M of Resident #49's MDS assessment indicated Resident #49 was at risk for developing pressure ulcers. Record review of Resident #49's care plan with a revision date of 02/10/2025 revealed Resident #49 had the potential to develop pressure ulcers and interventions included to reposition the resident frequently or more often as needed. Resident #49 was also care-planned for potential pain due to brain injury and stroke, with interventions including assess characteristics of pain, administering pain medications as ordered, discussing with resident regarding factors of pain and what can reduce it, and discuss with physician that for maximum pain to give medications as ordered and as needed. Record review of Resident #49's Physician Orders, she had orders for pain monitoring starting 12/16/2024 and document interventions such as applying heat or cold or re-positioning. Record review of Resident #49's weekly wound evaluation and summary report dated 3/6/2025 revealed Resident #49 had no wound on her sacrum. Record review of Resident #49's MAR dated 3/1/25 through 3/13/25 for monitoring pain every shift (day, evening and night) documented zero every shift, indicating no pain. Record review of Resident #49's skin assessment progress notes dated 3/13/25 reflected an open skin area to the sacral and coccyx bone area measurement was 5cm (Length) x 0.3cm (width). Observation of incontinent and Foley catheter care on 03/12/25 at 1:30 PM with CNA H revealed Resident #49 was lying in bed on her back. CNA H entered Resident #49's room then began cleaning in between Resident #49's buttock with the wet wipes . At the same time CNA H was wiping, Resident #49 was grimacing and said ouch, ouch. CNA H applied Zinc Oxide 20 % cream which was a skin protectant. Resident had an open area between her buttocks measuring about 5 cm. In an interview with CNA H on 3/12/25 at 2:10 PM, she said she had been working with the facility for 1 year and she had an in-services on reporting to her charge nurse when a resident was is in pain. She stated that she failed to notify the Wound Care Nurse of Resident #49's pain in a timely manner. Observation on 3/12/25 at 6:23 PM of a skin assessment with Wound Care Nurse revealed Resident #49 was lying on her back in bed. Resident #49 had a large bowel movement. Wound Care Nurse repositioned Resident #49 to the left side, and used the wet wipes to clean in-between the buttocks, where the sacral and coccyx bones meet. Resident #49 was grimacing and hitting the bed. The Wound Care Nurse did not assess Resident pain level . In an interview with Wound Care Nurse on 3/12/25 at 6:35 PM, she said she was not aware of the open area on Resident #49's buttock and that she was grimacing during incontinent care. The nurse said she did assess Resident #49 afterward, and the resident was still grimacing. When the nurse asked if she was in pain, she said Resident #49 told her she was not in pain but that it burned. The nurse said if someone looks like they're in pain, she will assess and provide pain treatment. If they're in pain during care she said she would stop and ask them. The Wound Care Nurse said she told the doctor about the burning pain, and the resident had a standing order for pain and doctor didn't give anything new. The nurse's expectation for nurses and aides are that they would tell her or nurses on the floor when they find something new. During an interview on 3/12/25 at 6:42 PM the DON said the Wound Care Nurse was supposed to measure the open area and notify the wound doctor and RP of any changes. The DON said she would in-service on notification. In an interview with the DON on 3/13/25 at 12:52 PM she stated CNA H and Wound Care Nurse should have stopped incontinent care when Resident #49 was in pain. The DON stated nurses were instructed to monitor for pain every shift. She stated the negative effects for not monitoring residents' pain would be the pain would be unmanaged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that residents were free of significant medication errors for for 1 of 3 (Resident #49) residents reviewed for pharmacy services. The facility failed to ensure Resident #49 was free of significant medication errors when Resident #49 was reviewed for pain management in that: -CNA H failed to stop performing incontinent care while Resident #49 was in pain. -CNA H failed to notify the Wound Care Nurse of Resident #49's pain in a timely manner after incontinent care. These failures could place resident at risk for increased pain causing undue suffering. Findings included: Record review of Resident #49's face sheet, reflected she was a [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her medical diagnoses included compression of brain (brain tissue being acutely or chronically compressed commonly due to a traumatic brain injury), other speech and language deficits, cognitive communication deficit, Type 2 Diabetes Mellitus (high glucose in the blood) Post-Traumatic Hydrocephalus, (PTH- is a condition where there is a buildup of excess fluid in the brain after a traumatic brain injury, potentially causing increased pressure and brain damage), Dementia (group of thinking and social symptoms that interferes with daily functioning), gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach), dysphagia (swallowing difficulties), hemiplegia and hemiparesis (a condition that causes partial or total paralysis of one side of the body), following cerebral infarction affecting left non-dominant side cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain tissue to die due to a lack of oxygen and nutrients), Essential Hypertension (high blood pressure) and neuromuscular dysfunction of bladder with indwelling Foley catheter. Record review of Resident #49's quarterly MDS assessment, dated 02/10/25, revealed a BIMS score of 05 indicating severely impaired cognition. Further review revealed Resident #49 needed extensive assistance with ADL care with one staff assistance. Section GG of Resident #49's MDS indicated Resident #49 was dependent (required assistance and was unable to help with activities) with all ADLs and was unable to roll to the left or right. Section M of Resident #49's MDS assessment indicated Resident #49 was at risk for developing pressure ulcers. Record review of Resident #49's care plan with a revision date of 02/10/2025 revealed Resident #49 had the potential to develop pressure ulcers and interventions included to reposition the resident frequently or more often as needed. Resident #49 was also care-planned for potential pain due to brain injury and stroke, with interventions including assess characteristics of pain, administering pain medications as ordered, discussing with resident regarding factors of pain and what can reduce it, and discuss with physician that for maximum pain to give medications as ordered and as needed. Record review of Resident #49's Physician Orders, she had orders for pain monitoring starting 12/16/2024 and document interventions such as applying heat or cold or re-positioning. Record review of Resident #49's weekly wound evaluation and summary report dated 3/6/2025 revealed Resident #49 had no wound on her sacrum. Record review of Resident #49's MAR dated 3/1/25 through 3/13/25 for monitoring pain every shift (day, evening and night) documented zero every shift, indicating no pain. Record review of Resident #49's skin assessment progress notes dated 3/13/25 reflected an open skin area to the sacral and coccyx bone area measurement was 5cm (Length) x 0.3cm (width). Observation of incontinent and Foley catheter care on 03/12/25 at 1:30 PM with CNA H revealed Resident #49 was lying in bed on her back. CNA H entered Resident #49's room then began cleaning in between Resident #49's buttock with the wet wipes . At the same time CNA H was wiping, Resident #49 was grimacing and said ouch, ouch. CNA H applied Zinc Oxide 20 % cream which was a skin protectant. Resident had an open area between her buttocks measuring about 5 cm. In an interview with CNA H on 3/12/25 at 2:10PM, she said she has been working with the facility for 1 year and she had in-services on reporting to her charge nurse when a resident is in pain. Observation on 3/12/25 at 6:23 PM of a skin assessment with Wound Care Nurse revealed Resident #49 was lying on her back in bed. Resident #49 had a large bowel movement. Wound Care Nurse repositioned Resident #49 to the left side, and used the wet wipes to clean in-between the buttocks, where the sacral and coccyx bones meet. Resident #49 was grimacing and hitting the bed. The Wound Care Nurse did not assess Resident pain level . In an interview with Wound Care Nurse on 3/12/25 at 6:35 PM, she said she was not aware of the open area on Resident #49's buttock and that she was grimacing during incontinent care. The nurse said she did assess Resident #49 afterward, and the resident was still grimacing. When the nurse asked if she was in pain, she said Resident #49 told her she was not in pain but that it burned. The nurse said if someone looks like they're in pain, she will assess and provide pain treatment. If they're in pain during care she said she would stop and ask them. The Wound Care Nurse said she told the doctor about the burning pain, and the resident had a standing order for pain and doctor didn't give anything new. The nurse's expectation for nurses and aides are that they would tell her or nurses on the floor when they find something new. During an interview on 3/12/25 at 6:42 PM the DON said the Wound Care Nurse was supposed to measure the open area and notify the wound doctor and RP of any changes. The DON said she would in-service on notification. In an interview with the DON on 3/13/25 at 12:52 PM she stated CNA H and Wound Care Nurse should have stopped incontinent care when Resident #49 was in pain. The DON stated nurses were instructed to monitor for pain every shift. She stated the negative effects for not monitoring residents' pain would be the pain would be unmanaged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections including hand hygiene procedures to be followed by staff involved in direct resident contact for 1 (Resident #49) of 6 residents reviewed for infection control. -The facility failed to ensure CNA H utilized proper handwashing, infection control procedures , and completely cleaned Resident #49 when she did not open Resident #49's labia to clean or clean her buttocks and CNA H did not sanitize her hands between changing gloves during indwelling foley and incontinent care. - Wound Care Nurse failed to utilize handwashing, infection control procedure and completely clean Resident #49, during skin assessment, indwelling Foley and incontinent care when she did not open Resident #49's labia to clean and did not use sanitizer before donning gloves before providing incontinent care. These failures could affect residents, who were incontinent or had a catheter, and could place them at risk for urinary tract infections, discomfort, skin breakdown, and a decreased quality of life. Findings included: Record review of Resident #49's face sheet last captured 03/12/2025 reflected Resident #49 was a [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her medical diagnoses included compression of brain (brain tissue is acutely or chronically compressed commonly use to traumatic brain injury), other speech and language deficits, cognitive communication deficit, Type 2 Diabetes Mellitus (high glucose in the blood) Post-Traumatic Hydrocephalus, (PTH- is a condition where there is a buildup of excess fluid in the brain after a traumatic brain injury, potentially causing increased pressure and brain damage), Dementia (group of thinking and social symptoms that interferes with daily functioning), gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach), dysphagia (swallowing difficulties), hemiplegia and hemiparesis (a condition that causes partial or total paralysis of one side of the body), following cerebral infarction affecting left non-dominant side cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain tissue to die due to a lack of oxygen and nutrients), Essential Hypertension (high blood pressure) and neuromuscular dysfunction of bladder with indwelling Foley catheter. Record review of Resident #49's quarterly MDS assessment, dated 02/10/25, revealed a BIMS score of 05 indicating severely impaired cognition. Further review revealed Resident #49 needed extensive assistance with ADL care with one staff assistance and the resident was incontinent of bowel and continent of bladder with indwelling Foley Catheter. She was totally dependent on staff for all efforts for ADLs including eating, oral hygiene, toileting, showering or bathing self, dressing and personal hygiene. Record review of Resident #49's care plan dated 2/10/25 revealed the resident had an ADL self-care performance deficit related to limited impairment to upper and lower extremities. Intervention: resident needed extensive assist with two-person assistance with incontinent care. Record review of Resident #49's order summary, dated 3/1/25, revealed Physician Orders which included the following: secure catheter with leg strap every shift. Record review of Resident #49's MAR dated 3/1/25 through 3/12/25 for secure catheter with leg strap every shift reflected it was initialed as done during day, evening and night shift. Observation of incontinent and Foley catheter care on 03/12/25 at 1:30 PM with CNA H revealed Resident #49 was lying in bed on her back. CNA H entered Resident #49's room without washing her hands. CNA H picked up wet wipes and clean gloves and placed both of those items on Resident # 49's bedside table and began to don her PPE . She pulled the resident's privacy curtain shut, donned clean gloves, and opened Resident #49's brief. The indwelling catheter was not secured with a strap to her leg, and the catheter was seen under her right thigh with 300 ml yellow urine measured. CNA H used wet wipes and cleaned the resident's groin and peri area. There was brownish discharge on the brief with a foul odor. CNA H did not open Resident #49's labia to clean. She then cleaned the indwelling catheter tubing but not starting from the insertion site. She did not clean around the resident's buttocks, outside of wiping in-between Resident #49's buttocks. Then she applied Zinc Oxide 20 % cream, a skin protectant. During incontinent care, CNA H changed gloves 3 times without washing hands or using hand sanitizer . In an interview with C.NA H on 3/12/25 at 2:10PM, she said the nurses always secure the indwelling catheter and she would let the nurse know that it was observed not secured during incontinent care. C.NA H said she did not remember to wash her hands before donning her gloves and during incontinent care. She said she has been working with the facility for 1 year and she had in-services today on indwelling catheters for males and she had not had any in-services for females with catheters. She knew not washing hands during incontinent care could cause cross contamination, and she had in-services for hand washing several weeks ago. Observation on 3/12/25 at 6:23 PM of a skin assessment with Wound Care Nurse revealed Resident #49 was lying on her back in bed. The Wound Care Nurse did not wash her hands. The Wound Care Nurse donned clean gloves, and opened Resident #49's brief with the indwelling catheter not secured under the resident's right thigh. Resident #49 had a large bowel movement. The Wound Care Nurse repositioned Resident #49 to the left side and used the wet wipes to clean in-between the buttocks, where the sacral and coccyx region met on the lower back. The Wound Care Nurse changed gloves 3 times and did not wash hands or use hand sanitizer before donning clean gloves . LVN did not open the labia to clean. In an interview with Wound Care Nurse on 3/12/25 at 6:35 PM, she said she had skills check off and in-services on incontinent care. She said the resident could get an infection and skin breakdown if not cleaned properly. During an interview on 3/12/25 at 6:42 PM the DON said C.NA H should have been separated Resident #49's labia and wiped both sides and the middle. If the aide could not see the rectal area she had to separate and wipe the left and right buttocks. She said there could be a negative outcome for Resident #49, such as UTI and skin breakdown. She said the ADON monitored the aides and ensured they provided care for the residents, while including the DON monitored the nurses, by making random checks. During an interview on 3/14/25 at 10:57am with ADON RN O, she said she trained the aides on how to provide incontinence care, and other aides trained new aides on how to care for the residents. She said Resident #49's labia should have been correctly separated and cleaned on both sides and in the middle and indwelling catheter. RN O said if CNA H did not clean Resident #49 thoroughly, she could have gotten a UTI and rashes. She stated the buttocks should have been separated and wiped from front to back, and the buttocks themselves should have been wiped too . Record review of the facility's policy on perineal care, dated 10/01/21, read in part . to provide cleanliness and comfort to the resident, to prevent infection and skin irritation . steps in procedure . #8b1 . separate labia and wash . #8d . wash the rectal area thoroughly . Record review of the facility's policy on catheters, dated 04/20/21, read in part . it is the policy of this community that resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risk of urinary tract infections . Record review of the facility's policy on Hand Hygiene dated 8/4/2021 read in part, You should always perform hand hygiene before applying and after removing personal protective equipment including gloves, gown and mask, with hand hygiene defined as hand washing using soap and water or the use of an alcohol-based hand rub to destroy harmful pathogens . on the hands.

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 1 refrigerator reviewed for food safety. The refrigerator located on the 400 hall contained undated and unlabeled perishable food items. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations/Interview on 03/12/2025 at 02:12 p.m. revealed within refrigerator located on hall-400 behind locked code accessed glassed wooden door designated for resident's food brought from the outside contained: 1. Undated bag of plastic containers containing green vegetables and soup. 2. Unlabeled/undated bagged and boxed chicken and other unidentifiable food items. 3. Unlabeled/undated bagged containers of supplement shakes, and protein drinks. 4. Unlabeled/undated clear wrapped cup of sugar. 5. Unlabeled/undated bagged drink container not labeled or dated. 6. Unlabeled/undated bagged oranges not labeled or dated. Assistant Director of Nursing (ADON) A stated that the food in a brown plastic bag with containers of green vegetables and broth like soup labeled with Resident #74's name and not dated belonged to the Resident #47 whose wife had brought and left the food for the resident today. She stated that the wife had the code to the room and was supposed to inform nursing staff that the 2-bagged items with food were being stored so that the nursing staff could label, date, and ensure that the food sat leveled in the refrigerator. ADON A then pulled out a white paper bag sealed with a fast-food restaurant sticker. Inside contained a box with what appeared to be chicken and other unidentifiable food items. The food box was flimsy, worn and not labeled and not dated. ADON A then pulled at a white plastic bag with slight difficulty as the bag was frozen to back of refrigerator wall. Inside the bag contained 2-meal supplement shakes and 8-protein drinks. The bag nor the drinks were labeled or dated. She stated that possibly the nursing staff had stored the shakes/supplemental drinks there for medication pass usage. She stated that the bag being frozen to the back of the refrigerator indicated to her that the drinks had been in there for some time. On the door of the refrigerator ADON was observed removing a white syrofoam cup wrapped in clear plastic wrap resembling sugar, not labeled, or dated. She stated that the nursing staff probably stored the sugar for a resident. She was then observed removing a brown and black drink container not labeled or dated. She stated that the container probably belonged to a nursing staff. The ADON was than observed removing 3-oranges in a clear bag not labeled or dated. The ADON stated that she was unaware who the oranges belonged to. She stated that she would immediately discard the unlabeled and undated items. She stated that the refrigerator was for the storing of resident food items only. She stated that the nursing staff were responsible for monitoring the refrigerator and ensuring foods were leveled to avoid spillage and had not stayed in there too long. During an interview on 03/12/25 at 3:32 p.m., the Administrator said the facility had an area where the family could store food brought from home, and the family should tell the staff whenever the family brought food from home for residents. The Administrator said when the family notified the nurse, the nurse would date the food with the start date, discard date, and resident information. She said if the food was cooked, the facility kept the food for 24 hours. Record review of policy dated effective: 01/2018 and last revised: 03/2021 Section: Nutritional Management Department: Food & Nutrition Services. Policy: Food from Outside Sources. POLICY Residents may have outside sources of food brought in. The community will ensure that proper steps are taken so that the food remains safe. PROCEDURE 1. Community team members will educate residents and/or family members on food brought in from outside the community on: a. Proper Storage i. Cold items stored in resident refrigerator & discarded appropriately based on labeled dates and/or 3 days after opening to prevent food borne illness ii. Dry goods properly sealed to prevent pests & discarded appropriately based on labeled dates . If residents would like the Food & Nutrition Services Team to store their food item, the following conditions must be met: a. Food is unopened b. Resident Name is labeled on food product c. Receive date added d. Open date is added (once opened)

Based on observation, interview, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. The facility failed to ensure staff did not store their personal items on the left second shelf of the walk-in cooler, including:. 1. Jumex mango energy drink can. 2. Red bull watermelon drink can 3. Coffee mate coconut liquid crème 32fl oz 4. A black and white with yellow brown flower lunch bag with 2 bottles of water, and one of the bottled water was open. The facility failed to ensure staff did not store three gray crates on the floor by Dishwasher A. These failures could place residents at risk for cross contamination and air-borne illnesses. Findings include: During an observation on 03/11/25 at 8:21 a.m., the following items were on the left second shelf of the walk-in cooler: a Jumex mango energy drink can, a Red Bull watermelon drink can, a Coffee-mate coconut liquid crème 32fl oz, and a black-and-white with yellow-brown flowers lunch bag with two bottles of water, one of which was open. They were staff personal items stored on the left second shelf of the walk-in cooler. During an interview on 03/12/25 at 8:24 a.m., the DM said the items in the cooler belonged to staff and should not be kept in the walk-ing cooler because it was cross-contamination. The DM said he was responsible for monitoring the staff and ensuring that only the items bought by the facility were stored in the walk-ing cooler. He said the kitchen staff had in-service on infection control and storage. During an observation on 03/11/25 at 8:26 a.m., three gray dish crates were on the floor by the dish washer and the three-compartment sink and the floor was wet. Dish washer A picked up the three crates and placed them on top of the clean stacked crates which were stored off the floor. During an observation and interview on 03/11/25 at 8:28 a.m., the DM said he saw the three crates were on the wet floor between the washing machine, and the three-compartment sink. The DM said the dish crates should not have been placed on the floor because of infection (cross - contamination). He said he monitors the staff throughout the shift. The DM stated if clean plates were placed in the dirty crates, the residents could get sick if the residents ate from the plates. During an interview on 03/11/25 at 8:49 a.m., Dishwasher A said he placed the three crates on the floor, removed them, and placed them on top of the clean crates. Dishwasher A said he should not have put the crates on the floor because of infection control. Dishwasher A said if a resident ate off any plate that came in contact, the resident could become sick because the germs from the crates could be transferred to the plate. Dishwasher A said he had infection control training and in service, and the dietary manager monitors the kitchen staff throughout the shift. During an interview on 03/11/25 at 3:25 p.m., the Administrator said none of the kitchen equipment, including crates, should be placed on the floor. The crates are not supposed to be picked up and placed on a clean surface because of infection control (cross-contamination). The Administrator said the staff should not place their personal belongings in the walk-in cooler because it would cause cross-contamination. Record review of the facility food receiving and storage dated 2001 MED - PASS, Inc. (Revised October 2017) read in part . foods shall be received and stored in a manner that complies with safe food handing practices . policy interpretation and implementation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1of 6 residents (Resident #1) reviewed for cleanliness and sanitization. - The facility failed to ensure Resident #1 had a clean drinking cup. The noncompliance was identified as past noncompliance (PNC) and began on 02/20/2024 and ended on 02/20/2024. The facility corrected the noncompliance before the investigation began. These deficient practices could place residents at risk of living in an unsafe, unclean, and unsanitary environment which could lead to a decreased quality of life. The findings include: Review of Resident #1's Face Sheet, dated 02/20/2025, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] and expired on 02/17/2025. The resident's diagnosed included but were not limited to anemia (blood lacking healthy cells to carry oxygen throughout the body), intestinal obstruction (blockage causing difficult movement of food and waste), moderate protein-calorie malnutrition (low body weight), urinary tract infection (an infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra), and need for assistance with personal care. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment (a federally mandated assessment tool used to evaluate the health of residents in nursing homes) dated 12/10/2024 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated she had moderately impaired cognition. (The BIMS scoring devise identified delirium and needed supports in patients living in skilled nursing facilities and long-term care facilities). Record review of Resident #1 Comprehensive Care Plan capture date on 02/20/2025 reflected that Resident #1 was to have adequate nutrition and fluid intake throughout the review date: Initiated: 06/06/2024 Target Date: 04/13/2025. Record review of Resident #1 Comprehensive Care Plan capture date on 02/20/2025 reflected that Resident #1 was at risk for nutritional impairment related to (r/t) moderate protein calorie malnutrition. Date Initiated: 06/07/2024 Revision on: 06/07/2024. Record review of Resident #1's Progress Notes dated 11/10/2024, reflected no notes taken on or about 11/10/2024 related to the facility addressing residue in the resident's cup. In an observation on 02/20/2025 at 01:19 p.m., Family #1 provided photographs taken on 11/10/2024 at 01:14 p.m., of the cup found at bedside of Resident #1. A clear cup with a blue lid and blue writing on the side appeared in the photograph. Towards the middle bottom to the bottom of the cup appeared to be black discoloration resembling a mold and/or dirt like substance. In an interview on 02/20/2025 at 01:17 p.m. Family #1 stated that Family #2 had visited Resident #1 on 11/10/2024 and found just before 01:14 p.m. that the bottom of resident's clear drinking cup was black with residue that resembled mold. She stated that Family #2 feared that the facility was allowing Resident # 1 to drink from an uncleaned cup. She stated that Family #2 told her that she had alerted facility staff of the dirty cup and that the licensed vocational nurse (LVN) A who introduced herself as the charge nurse spoke to her about the residue in the bottom of Resident #1's cup but could not explain the substance within the cup. She stated that LVN A requested to take the cup and replace with a new cup. She stated that Family #2 refused to turn over the cup but accepted a new cup for the resident. She provided pictures of the discolored cup provided to the resident by the facility showing the time and date the pictures were taken. In an interview on 02/20/2025 at 2:25 p.m., with Director of Nursing (DON) and the Administrator (ADM), reflected that they were not aware of the discoloration at the bottom of Resident #1's cup on 11/10/2024. The DON stated that evening shift was responsible for collecting cups from resident rooms in the evening and replacing them with a new cup. The DON stated she was on vacation the week of 11/06/2024 through 11/19/2024. The ADM stated that her employment with the facility began on 11/18/2024 and she was not made aware of the incident. The DON stated it had been her expectations that the staff were changing out and cleaning resident's drinking cups every evening. She stated that failure to do so would result in resident's drinking from cups that were dirty or residue that could mold. In an interview on 02/21/2025 at 12:15 p.m., LVN A stated she recalled being informed by certified Nursing Aid (CNA) whose name she could not recall and believed no longer worked for the facility alerted her that Family #2 found that Resident #1 had a dirty cup. She stated that she went to Resident #1's room and was told by Family #2 that resident had been drinking from a cup with mold in it. She stated she observed the cup and what appeared to be mold/dirt at the bottom of the cup. She stated she asked Family #2 for the cup, but Family #2 stated she was keeping the cup. She stated that she got Resident #1 a new cup and filled it was ice and water. She stated that Resident #1 made no complaints about the cup. She stated she spoke to the other staff on duty that day and no one recalled seeing the cup with the dark residue. She stated she then reported the incident to ADON. She stated that maybe the residue in Resident #1's cup was from fresh juice. She stated she had staff check all the resident's cups to ensure that they were all free of residue and found that no other residents' cups were like that. She stated it was her expectations that the evening shift made evening rounds and collected and/or checked to see if cups were dirty and needed cleaning. She stated it was the evening shifts responsibility to pick up every cup, replace with a clean cup and then all dirty cups were taken to the dish room for washing. In an interview on 02/24/2025 at 10:57 a.m., Family #2 stated she had gone to visit Resident #1 on 11/10/2024. She stated Resident #1 asked her to pour some lemonade in her drinking cup. She stated she began to pour the lemonade in the cup when she noticed some discoloration at the bottom that appeared to be black mold. She stated she asked Resident #1 had she been drinking from the cup and resident replied that she had. She stated she became extremely upset and went to the nurse's station with the cup to explain that resident had been drinking from a dirty cup. She stated there were 3-staff members sitting at the desk whose names she did not obtain and asked how resident's cup had come to be that way. She stated that none of the staff had an explanation but stated that they would send the resident's nurse to her room to address her concerns. She stated that LVN A came to the resident's room and apologized for the dirty cup. She stated LVN A asked for the cup, but she told her she would be keeping the cup. She stated then LVN A left the room and returned with a new cup filled with fresh ice water. She stated that she had never seen stains in the resident's cup prior or after. She stated that the facility never gave an explanation for the black discoloration in Resident #1's cup. In an interview on 03/12/2025 at 10:37 a.m., CNA A stated that she worked 11/09/2024 from 10:00 p.m. to 6:00 p.m. She stated that she began collecting cups from the room at about 10:30 p.m. She stated that she takes the used cup and replaced it was a clean cup. She stated that she could not recall a time when she missed or skipped picking up Resident #1 cup, neither had resident every refused having her cup changed, nor gave resident a cup that was stained. She stated had she seen stains in a cup, she would have returned the cup to the kitchen. She stated had a resident ever refused having their cup taken, she would go back later and make another attempt to collect the cup. She stated the importance of residents receiving a clean cup daily was to ensure they stay healthy, maintain hygiene and avoid contamination and decease. Facility policy titled Food Receiving and Storage revised date of October 2017 reflected: Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. Facility policy titled Resident Rights revised date of December 2016 reflected: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. Record review of facility in-service dated 11/11/2024 reflected: Hydration Cups, Fresh Ice & Water Pass, Wheelchair Cleaning/Hand Hygiene PPE, Pitcher, and Wheelchair Cleaning. Presenter's ADON A and ADON B. 1. Hydration pitchers are to be collected and swapped with clean cup on 10pm - 6am shift. Take clean cups with fresh ice water with you, swap dirty for clean, take dirty pitchers and place outside of dish room door for cleaning, Every night shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible, and each resident receives adequate supervision to prevent accidents for 5 (Resident #2, #3, #4, #5, #6) of 5 residents reviewed for accidents and supervision. -The facility failed to ensure that the facility's main door alarmed notifying staff when residents with wander guard's exited (Resident #2). -The facility failed to ensure the facility's main entrance wander guard alarmed when residents with wander guard's exited (Resident's #2, #3, #4,#5 and #6). This failure could place residents at risk of injury from accident and hazards. The noncompliance was identified as past noncompliance (PNC) and began on 08/02/2024 and ended on 08/03/2024. The facility corrected the noncompliance before the investigation began. The findings included: Resident #2 Review of Resident #2's Face Sheet, dated 02/20/2025, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident's diagnosis included but were not limited to cerebral infarction (suffered a stroke), hemiplegia and hemiparesis (paralyzed and mild paralyzed) following cerebral infarction affecting right dominant side, hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery (buildup of plaque in the arteries) without angina pectoris (chest pain caused by reduced flood flow), insomnia (difficulty sleeping), visual hallucinations, contracture, right knee, history of falling, limitation of activities due to disability, muscle weakness (generalized), muscle wasting and atrophy (decrease in size and/or wasting away of a body part or tissue), pain in joints of right hand, difficulty in walking, other abnormalities of gait and mobility other specified depressive episodes, unspecified dementia, unspecified severity, with agitation, hearing loss, bilateral, traumatic subdural hemorrhage (blood loss) without loss of consciousness, muscle wasting and atrophy, not elsewhere classified, multiple sites, other lack of coordination, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Record review of Resident #2's Comprehensive Care Plan capture date of 02/21/2025 reflected Focus: Resident is an elopement risk/wanderer and is at risk for possible injury r/t impaired safety awareness and diagnosis of dementia. Actual Event 8.2.24 Date Initiated: 08/02/2024 Revision on: 08/03/2024. Goal: Resident's safety will be maintained throughout the review date. Date Initiated: 08/03/2024 Revision on: 09/25/2024 Target Date: 03/03/2025. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or books. Date Initiated: 08/02/2024. Provide structured activities: Toileting, walking inside and outside, reorientation strategies, including signs, pictures and memory boxes. Date Initiated: 08/02/2024. Wander guard placed for resident's safety, bracelet will alert staff if and when resident attempts to exit doors of facility. Staff to monitor daily. Date Initiated: 08/02/2024. Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected that the resident had a BIMS score of 02 out of 15 which indicated he had severely impaired cognition. Section P - Restraints and Alarms: reflected: E0900. Wandering - Presence and Frequency. Behavior not exhibited. P0200. Alarms: Not used. Record review of Resident #2's Annual MDS assessment dated [DATE] reflected that the resident had a BIMS score of 02 out of 15 which indicated he had severely impaired cognition. Section P - Restraints and Alarms: E0900. Wandering - Presence and Frequency. Behavior not exhibited. P0200. Alarms: E. Wander/elopement alarm. Used less than daily. Record review of Resident #2's Physician Orders dated 08/02/2024 at 07:48 p.m., reflected: Signal device (Wander guard) in place for safety awareness. Record review of Resident #2's Physician Orders dated 08/02/2024 at 07:49 p.m., reflected: Resident Order WANDER GUARD CHECK PLACEMENT EVERY SHIFT. WANDER GUARD CHECK PLACEMENT EVERY SHIFT. Record review of Resident #2's Progress Notes dated 08/02/2024 at 09:58 p.m., reflected: Nurse's Note Text: While making rounds about 07:15 p.m. noted resident was not in common area where he was last seen after dinner. Immediately called code for resident search. MDS Nurse, located resident outside facility at 7:22 p.m., MDS Nurse and writer, LVN B assisted resident back. Assessment completed. Vital signs: Blood Pressure 134/72, Pulse 78, Respiratory Rate: 18, Temperature: 97.6, Oxygen Stats: 97. No signs of distress noted. Resident's payee and nurse practitioner notified, referral for psychiatric (psych) consult, Elopement Risk Assessment completed per protocol. Wander guard place to left ankle. Will continue to monitor. Record review of Resident #2's Progress Notes dated 08/16/2024 at 04:51 p.m., reflected: Social Service Note Text: Quarterly Social Service Assessment for resident who continues to present to be alert and oriented with noted memory problems. He continues to require assistance from staff with activities of daily living (ADL) care which he at times is resistant to, and his daughter is aware of his behavior. He has not demonstrated any major changes in his mood/behavior or psychosocial wellbeing. Resident still spends the majority of the day in his room, periodically coming out and propelling his wheelchair around the facility. He interacts with others of his choice. He still has a roommate of which he appears content with. And his family members visit with him when they can and provide much emotional support while being attentive to his personal needs. Resident remains a full code status which will be honored by all staff persons and reviewed quarterly for any changes needing to be made. He continues to receive psych services with psych services. And he receives ancillary services . There are no plans in place for discharge so he will remain in this facility for long term care placement. Social Worker (SW) will continue to visit one to one and encourage appropriate behavior during care. SW will also monitor for any issues which may arise requiring social service assistances. Record review of Resident #2's Progress Notes dated 11/15/2024 02:31 p.m. Social Service Note Text: Quarterly Social Service Assessment for resident who continues to present to be alert and oriented with noted memory problems during one-to-one visits even with family assistance. He still prefers to spend the majority of the day in his room usually in bed. He does have a roommate who he seems to be satisfied with and he will periodically come out to the television area. He continues to require assistance with ADL care from staff which he accepts on his terms. Resident's family members are aware of his behaviors and visits frequently to encourage acceptance of staff assistance. He is receiving psychotropic medications which are being monitored Psychiatric Services and he is receiving ancillary services as needed or requested. Resident is still a full code status which will be honored by all staff persons and reviewed quarterly for any changes needing to be made. There are no plans in place for discharge from this facility so he will remain here for long term care placement. SW will continue to visit and monitor for any issues which may arise requiring Social Service assistance. Record review of Resident #2's Elopement assessment dated [DATE] at 01:34 p.m., reflected: Reason Quarterly: Reflected that the resident had intermediate confusion, explained by anxiety. Resident did not have a safeguard devise. Record review of Resident #2's Elopement assessment dated [DATE] 10:13 a.m., reflected: Reason: Other. Reflected that the resident had intermediate confusion, explained by depression. Resident did not have a safeguard devise. Intervention: safeguard device placed. SUMMARY/CONCLUSIONS/RECOMMENDATIONS: Wander guard placed, increased monitoring. Record review of Resident #2's Elopement assessment dated [DATE] 10:13 p.m., reflected: Reason: Quarterly. Reflected that the resident had intermediate confusion, explained by dementia. Intervention: safeguard device. Observation and interview attempt on 02/20/2025 at 10:30 a.m., reflected Resident #2 lying in bed under a sheet, bed low to ground. Resident repeated the same word/sound over and over and had not reacted to voice or sound. Interview on 02/20/2025 at 02:25 p.m., with the DON and ADM. DON stated that on 08/02/2025 she would not consider Resident #2 had a full elopement as he had been found immediately in the parking lot by MDS Nurse. She stated that when visitors had exited, Resident #2 followed behind them in his wheelchair out into the parking lot. She stated that MDS Nurse saw him go out the door and she followed after him and brought him back inside. She stated that the resident had a stroke that affected his ability to speak and could not communicate with words his desire to go outside. She stated therefore, he would make hand/arm gestures and grunt which had been his way of voicing he wanted to go outside. She stated that she was aware that the resident enjoyed sunshine. She stated the resident had not had a history of eloping. Interview on 02/20/2025 at 03:09 p.m., MDS Nurse stated on 08/02/2025 around 7:00 p.m. she had seen Resident #2 wheeling out with another resident's family member. She stated she met him and wheeled him back into the facility. She stated that the resident had a speech impairment, and he was not able to explain where he was going. She stated once inside, she handed the resident off to his LVN B which was his nurse. Interview on 02/21/2025 at 12:15 p.m., LVN A, stated that the facility's main door had been malfunctioning in the summer of 2024, she could not recall the exact dates, but that the door had been repaired rather quickly. She stated she was not aware of any elopements. She stated that Resident #2 often hung out around the nurse's station and had been known to venture towards the exit door but had not attempted any elopements that she was aware. Interview on 02/21/2025 at 3:15 p.m., DON stated that on 08/02/2025 Resident #2 had not quite made it to the end of the driveway when MDS Nurse called LVN B telling her that she had located Resident #2. Interview on 02/21/2025 at 03:57 p.m., LVN C stated on 08/02/2024, she was informed by LVN B that Resident #2 was missing. She stated since there was already staffing looking for the resident inside and on around the property that she would began search the neighborhood in her car. She stated that she exited the facility property. She stated she found the resident wheeling himself in his wheelchair out on the street near the Walmart across the street. She stated that the resident was being very aggressive and would not allow her to turn him around or redirect his wheelchair. She stated that she was not the resident's nurse and felt he had not recognized her and why he had been aggressive with her. She stated she called LVN B and informed her where he was located and her, MDS Nurse, and LVN B assisted getting the resident back into the facility. She stated that it was a warm summer day as it was August, but it was not too hot that day and resident was not sweating. She stated at the time she was not aware of any door or alarm malfunctioning's relating to the resident's wander guard. She stated that the resident wore a wander guard, but apparently the door had not recognized his guard when he went out the door. She stated on an unknown date/time she received an in-service provided by the DON on elopements and supervision. She stated that the facility also changed out the resident's wander guard and fixed the door. She stated since that incident, the resident wore two wander guards. She stated the important of supervision and use of wander guards and functioning alarms was to ensure that residents with impairments especially Resident #2 remain safe and secure. Interview on 02/21/2025 at 04:46 p.m., the DON stated that she was not on shift 08/02/2024 when she received a call from MDS Nurse that Resident #2 had eloped to the parking lot and was being aggressive when MDS Nurse tied redirect him back inside the facility. She stated MDS Nurse called LVN B who came to the parking to assist getting resident back into the facility. She stated the resident's skin was tacked, and his wander guard had still been attached. She stated the surveillance video was reviewed and found that the resident had followed other's out of the building approximately 13-minutes from the time resident left the building until he was located. She stated that the facility's main door had ben malfunctioning off and on duration of a month the resident eloped. She stated that the staff were in-serviced on overall elopements, safety and dehydration, and heat related illness. She stated she also gave them a verbal picture of what could have gone wrong had the resident been outside longer. She stated that the resident was not able to communicate clearly. She stated there had been no other incidents of the resident eloping. She stated it was her expectations that the staff supervise residents by always having visual awareness of them, practically after dinner, having someone at the front during the evening with eyes on the door, and being mindful of residents located in the common area. Interview on 02/21/2025 at 03:57 p.m., LVN C stated on 08/02/2024, she was informed by LVN B that Resident #2 was missing. She stated since there was already staffing looking for the resident inside and on around the property that she would began search the neighborhood in her car. She stated that she exited the facility property. She stated she found the resident wheeling himself in his wheelchair out on the street near the Walmart across the street. She stated that the resident was being very aggressive and would not allow her to turn him around or redirect his wheelchair. She stated that she was not the resident's nurse and felt he had not recognized her and why he had been aggressive with her. She stated she called LVN B and informed her where he was located and her, MDS Nurse, and LVN B assisted getting the resident back into the facility. She stated that it was a warm summer day as it was August, but it was not too hot that day and resident was not sweating. She stated at the time she was not aware of any door or alarm malfunctioning's relating to the resident's wander guard. She stated that the resident wore a wander guard, but apparently the door had not recognized his guard when he went out the door. She stated on an unknown date/time she received an in-service provided by the DON on elopements and supervision. She stated that the facility also changed out the resident's wander guard and fixed the door. She stated since that incident, the resident wore two wander guards. She stated the important of supervision and use of wander guards and functioning alarms was to ensure that residents with impairments especially Resident #2 remain safe and secure. Interview on 02/21/2025 at 04:46 p.m., the DON stated that she was not on schedule she received a call from MDS Nurse who was in the parking lot with Resident #2 who was being aggressive with her and not allow her to redirect him back inside. She stated she told MDS Nurse to call LVN B who was the resident's nurse and familiar with the resident. She stated that MDS Nurse told her, I am trying to call her (LVN B) right now, but he is being very aggressive, he won't let me touch him, he is trying to fight me. She stated that MDS Nurse stated that the resident was refusing to allow her to touch him and was being aggressive. She stated she advice the MDS Nurse to call LVN B who had been someone he had been familiar with. She stated that the resident allowed LVN B to assist him back inside and gave him a cup of coffee as she performed her assessment of him. She stated resident was assessed find his skin in tacked, and his wander guard was still attached. She stated she later looked back and the surveillance video and found that the resident had followed another resident's family out the building. She stated it had been approximately 13-minutes from the time resident left the building until he was located. She stated during that time frame it was a duration of a month or so that the main facility door had been malfunctioning. Maintenance would check it and it would work fine and then other times, the alarm would go off for no reason. She stated after a few complaints, it was noted that the door needed to be fixed and the resident received a new wander guard that was attached to his ancle. She stated that the staff were in-serviced on overall elopements, safety and dehydration, and heat related illness. She stated she also gave them a verbal picture of what could have gone wrong had the resident been outside longer. She stated that the resident was not able to communicate clearly. She stated that she was aware that the resident enjoyed going outside for fresh air and she would take him and use time to sit outside and cut his nails. She stated there had been no other incidents of the resident eloping. She stated it was her expectations that the staff supervise residents by always having visual awareness of them, practically after dinner, having someone at the front during the evening with eyes on the door, and being mindful of residents located in the common area. Interview on 02/24/2025 at 11:40 a.m., LVN B stated on 08/02/2024, she was called by a staff member who which she could not recall regrading Resident #2 missing. She stated they began looking for the resident in other rooms on the hall he resided on. She stated then she received a call from MDS Nurse who stated she saw him in the parking lot. She stated that she went out to get the resident, checked his vital signs which were within range and placed in to bed. She stated that the resident had on a wander guard, was not sure what happened that he was able to get out the door without their knowledge. She stated she called DON, there resident's family and physician, and charted notes on the incident. She stated that the resident was not overheated nor sweating when she found him in the parking lot. She stated it was important for residents to be supervised and to ensure their safety and keep them from harm's way. She stated failure could result in injury In an interview on 03/06/2025 at 5:37 PM the Maintenance Director stated he checked the wander guard system daily. The wander guard system had a malfunction around August 2024, but he was not sure how long it had not worked properly. During that time the door only had one keypad. The automatic latch was not working properly so the door would not close, or the alarm sometimes would not sound if a resident went by the door. If the door was already open and a resident was leaving the alarm would not sound off. The system was replaced. This system has two keypads one for the door and one for the wander guard system. Staff notify him if there are any issues with the door. In an interview on 03/06/2025 at 5:51 PM CNA D stated staff knows residents are an elopement risk if they have a wander guard on, they can check the kiosk on the wall for their care plan, or the nurse will let the aides know. If a resident is missing staff report this to the nurse and try to search for the resident inside and outside the facility. If the wander guard system is broken, then staff notify the Nurse and Maintenance Director. Staff must monitor door until its back working. In an interview on 03/06/2025 at 5:55 PM CNA E if a resident is missing, they search for the resident throughout the facility. Residents that are an elopement risk have wander guard bracelets. Staff can look on kiosk and see the resident's care plan. Staff will take residents to the door in the morning to determine if the wander guard system is working. She has worked at the facility for 8 years and knows residents behaviors and if they are exit seeking. If the system was not working properly, they notify the Maintenance Director. In interview on 03/06/2025 at 5:59 PM CNA G stated she knows residents that are an elopement risk because they have a wander guard bracelet. Staff can the care plans of the resident. When residents go missing staff perform a search. Staff report any issues to the Maintenance Director. Residents that go to the door are redirected. The door is monitored if it is not working, and residents are redirected when they go toward the door. In an interview on 03/06/2025 at 6:04 PM RN F stated when a resident was missing, she notified the Administrator and DON. The staff check the facility and surrounding areas. She stated if the wander guard system was down the nurses notified the DON, Administrator, and Maintenance Director to get instructions. She stated she completed the elopement risk assessments on residents and monitored their behaviors. The physician were notified, and orders were written for wander guard bracelets. She stated that staff could tell if a resident maybe exit seeking if they constantly went by doors and look out windows. In an interview on 03/06/2025 at 6:09 PM, LVN H stated residents who were an elopement risk had elopement risk assessment and wander guard bracelet. The Maintenance Director tested the wander guard system. If the system was down staff would monitor the door and may put a staff to just monitor the door. He stated he would let the DON know the system was down. In an interview on 03/06/2025 at 6:12 PM ADON A stated the front door malfunctioned in the past, but it was fixed. Staff were unable to keep the door locked. The door would not lock, the alarm would not sound, or the alarm would go off when no one was near the door. When the wander guard system was down the facility had staff monitor the door. In an interview on 03/06/2025 at 6:17 PM LVN B stated when the wander guard system was down, the facility normally had someone in the front of the building watching the door. Resident #3 Review of Resident #3's Face Sheet, dated 02/20/2025, reflected the resident was a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident's diagnosis included but were not limited to other sequelae of cerebral infarction (stroke), metabolic encephalopathy (confusion, memory loss and loss of consciousness), essential (primary) hypertension, cerebral infarction, vascular dementia (impaired blood flow causing memory loss and confusion), severity, without behavioral disturbance, psychotic disturbance (mental disorder), mood disturbance, and anxiety. Review of Resident #3's Quarterly MDS dated [DATE] BIMS of 14 reflected resident had cognition. score of 14 out of 15 which indicated he had intake cognition. Review of Resident #3's Comprehensive Care Plan captured date of 02/21/2025 reflected: FOCUS: Resident had impaired cognitive, unction or impaired thought processes at times r/t Dementia. Date Initiated: 07/22/2021 Revision on: 08/22/2022. GOAL: Resident will be able to communicate basic needs on a daily basis through the review. Date Initiated: 07/22/2021 Revision on: 02/20/2025 Target Date: 05/19/2025 date. INTERVENTIONS: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/22/2022. Ask yes/no questions in order to determine the resident's needs. Date Initiated: 07/22/2021. Cue, reorient and supervise as needed. Date Initiated: 07/22/2021 Monitor/document/report as needed any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty RN expressing self, difficulty understanding others, level of consciousness, mental status. Date Initiated: 08/22/2022. Present just one thought, idea, question or command at a time. Resident #4 Review of Resident #4's Face Sheet, dated 02/20/2025, reflected the resident was a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident's diagnosis included but were not limited to hypertension, Alzheimer's disease with early onset, insomnia, major depressive disorder, generalized anxiety disorder, cognitive communication other lack of coordination, and unspecified lack of coordination. Review of Resident #4's Quarterly MDS dated [DATE] reflected resident had a BIMS of 03 reflected resident severely cognition impairment. Review of Resident #4's Comprehensive Care Plan captured date of 02/21/2025 reflected: FOCUS: Resident was at risk for increased falls with Alzheimer's Disease and was a wanderer. Date Initiated: 06/14/2023 Revision on: 06/14/2023. FOCUS: Resident elopement risk/wanderer and at risk for possible injury with impaired safety awareness and diagnosis of dementia. Resident wearing a wander guard for safety. On 05/24/2024 resident with behavior of trying to get out of facility by wandering, had exit seeking behavior, wander guard in place. Date Initiated: 06/14/2023 Revision on: 06/10/2024. FOCUS: at risk for increased falls with Alzheimer's Disease, resident was a wanderer. Date Initiated: 06/14/2023 Revision on: 06/14/2023 Review of Resident #4's Progress Notes Dated 08/07/2024 at 09:05 p.m. reflected: Social Service Note Text: Quarterly Social Service Assessment for Resident #4 who continued to exhibit memory problems related to her Alzheimer's Disease. She continued to be up and dressed daily assisted by staff persons walking around the facility freely. She interacts with others of her choice, oftentimes, offering to help residents by pushing their wheelchairs for them. She continued to receive psychotropic medications which are being monitored by Psychological Services. Resident #4 continues to require redirection when trying to leave the facility to go pick up her grandchildren. Her family members continue to visit regularly to provide emotional support while being attentive to her personal needs. There are no plans for discharge from this facility so she will remain for long term care placement. SW will continue to visit one to one and allow open expression of feelings while monitoring for any issues which may arise requiring Social Service assistance. Observation/Interview on 02/20/2025 at 10:10 a.m., Resident #4 laying on her made bed fully dressed. Resident with or without others. Resident was not able to answer any more questions. Interview on 02/20/2025 at 2:25 p.m., DON stated that Resident #4 had attempted elopement in the past and had been wearing a wander guard. She stated that the resident's sister comes to the facility often to braid her hair resident can been seen looking for her sister thereafter. She stated that ADON had to bring resident back into the facility after an elopement and attempt. She stated at that time it had been determined the resident had taken off her wander guard. She stated the resident refused to put it back on so the sister came up to the facility the next day to address the resident who then allowed them to place it back on. She stated that they called in the elopement to Health and Human Service and it had been investigation unsubstantiated. Resident #5 Review of Resident #5's Face Sheet, dated 02/20/2025, reflected the resident was an [AGE] year-old male who initially admitted to the facility 09/03/2023 and readmitted on [DATE]. Resident's diagnosis included but were not limited to malignant neoplasm of unspecified part of unspecified bronchus or lung, encephalopathy, insomnia, restlessness and agitation, essential (primary) hypertension, brief psychotic disorder, benign prostatic hyperplasia without lower urinary tract symptoms, presence of cardiac pacemaker, shortness of breath, other lack of coordination, cognitive communication deficit, and other lack of coordination. Review of Resident #5's Annual MDS assessment dated of 08/18/2024 reflected resident had a BIMS score of 03 indicating the resident had severe impaired cognition. Section P - Restraints and Alarms. P0200. Alarms: E. Wander/elopement alarm. Used less than daily. Review of Resident #5's Quarterly MDS assessment dated [DATE] resident had a BIMS score of 02 indicating he had severe impaired cognition. Section P - Restraints and Alarms. P0200. Alarms: E. Wander/elopement alarm. Used less than daily. Review of Resident #5's Care Plan capture date of 02/21/2025 at 10:06 a.m., reflected that resident was an elopement risk/wanderer and at risk for possible injury with impaired safety awareness and diagnosis of dementia. At higher risk with weekend pass with family, and continuous removal of wander guard device. Date Initiated: 10/24/2023 Revision on: 05/25/2024. GOAL: Will be maintained throughout the review date. Date Initiated: 10/24/2023 Revision on: 06/11/2024 Target Date: 03/22/2025. INTERVENTION: Assess for fall risk. Date Initiated: 10/24/2023 Revision on: 10/24/2023. Distract Resident #3 from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. Date Initiated: 10/24/2023 Revision on: 10/24/2023. Provide structured activities: Toileting, walking inside and outside, reorientation strategies, including signs, pictures and memory boxes. Date Initiated: 10/24/2023 Revision on: 10/24/2023. Wander guard placed for resident's safety; bracelet will alert staff when resident attempts to exit doors of facility. Staff to monitor daily. Date Initiated: 10/24/202. Revision on: 10/24/2023. Wander guard device disguised and attached onto rollator. Educated family on importance of keeping wander guard in place. Date Initiated: 03/14/2024. Review of Resident #5's Elopement assessment dated [DATE] at 01:47 p.m. The resident was Is the resident cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficit or disoriented all the time)? Yes. If yes, explain (no explanation provided). Intervention: Personal safety alarm devices. SUMMARY/CONCLUSIONS/RECOMMENDATIONS: Same as above. Review of Resident #5's Order dated 01/24/2024 at 02:37 p.m., reflected: Order Summary: Wander guard check for placement Description: Wander guard check for placement. every shift. Resident #6 Interview on 02/20/2025 at 02:25 p.m., DON stated that Resident #6 had not been exiting seeking in a long time but could not provide any specific dates/times. She stated that the resident had previously fought to go outside until she was taken out. Observation/interview on 02/20/2025 at 10:21 a.m., Resident #3 stated that Resident #2, #4, #5 and #6 who were all elopement risks with wander guards. He stated in August of 2024, the facility's main entrance door failed to alarm when residents with wander guards went out the door. He stated on 07/16/2024, during the day, Resident #6 left through the back door and the alarm went off. He stated he looked for staff to help and could not find anyone. He stated he opened the door using a shoe to propped open the door went out to assisted Resident #6 back into the facility. He stated at that time a staff whose name he could not recall, helped bring Resident #6 back into the facility. He stated on 08/02/2024, around 05:00 p.m., Resident #2 left the facility through the front door. He stated that the alarm did not go off because the resident did not have on the device that alerts staff when a resident leaves (wander guard). He stated that Resident #2 used his right leg to scoot in his wheelchair about half a mile down the road. He started a passerby whose name or description he could not provide, reported to the facility that Resident #2 was seen. He stated that LVN C left the facility in her vehicle and found the Resident. He stated that the resident was gone about 2-hours. He stated that it was 100 degrees outside on 08/02/2024 when staff found the resident. He stated while having a mock fire drill, Resident #5 walked past all of the staff and out of the front door unnoticed. He stated the alarm did not go off because he was not wearing his wander guard. He stated another (unknown) resident altered staff and redirected the resident [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews a facility must coordinate assessments with the pre-admission screening and resident review (PASRR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes, Incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 5 of 5 (Resident #1, #2, #3, #4, #5.) resident with PASRR recommendations in that: Resident #1 NFSS for therapy services was not submitted timely. Resident #2 NFSS for therapy services was not submitted timely. Resident #3 NFSS for therapy services was not submitted timely. Resident #4 NFSS for therapy services was not submitted timely. Resident #5 NFSS for therapy services was not submitted timely. The Failures could affect residents who require PASRR services and could result in residents not receiving the PASSR recommended specialized services. The findings included: Record review of Resident #1's admission record dated 4/10/2024 revealed the resident was admitted on [DATE], re-admitted on [DATE] with diagnoses of Dementia, moderate intellectual disabilities (condition that affects general mental abilities and adaptive functioning), muscle wasting (both legs), dysphagia (difficulty in swallowing food or liquid), unsteadiness on feet. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1's BIMS was 3 which indicated severely cognitively impaired. Record review of Resident #1's Care plan dated 4/10/2024 revealed Resident #1 had a positive PASRR status on 3/31/2023 related to an intellectual disability/MR (mental retardation) after The LIDDA finished their investigation into my diagnoses. Interventions: Habilitative OT/ST and customized wheelchair has been approved for 6 months at a time. 7/17/2023 Resident #1's Guardian agreed to continue OT/St services for another 6 months. Record review of Resident #1's P1 (PASARR 1) dated 3/31/2023 revealed Resident #1 had an intellectual disability, indicated as yes. Record review of Evaluation revealed a response of Yes for Intellectual Disability, Developmental Disability. Record review of Resident #1's PASSR Comprehensive Service Plan (PCSP) dated 1/10/2024 revealed Resident #1 was recommended OT, PT, and ST. Record review of complaint intake #491508 dated 3/20/2024 revealed Resident #1 has not received a Medicaid service as a result of the following: 1. Nursing Facility did not submit PASRR NF Specialized Service Assessments within HHS's required timeframe - 1/30/2024. Resident #2 Record review of Resident #2's admission record dated 4/10/2024 was admitted on [DATE], re-admitted on [DATE] with diagnoses of severe intellectual disabilities (condition that affects general mental abilities and adaptive functioning) and cerebral palsy (neurological disorder that affects movement and muscle tone). Record review of Resident #2's annual MDS dated [DATE] revealed Resident #2's BIMS was 0 which indicated severely cognitively impaired. Record review of Resident #2's Care plan dated 4/10/2024 revealed Resident #2 had a positive PASRR status on 3/22/2023 related to cerebral palsy and intellectual disabilities. Interventions: .getting up in wheel chaire once facility receives his specialized wheelchair . Record review of Resident #2's P1 (PASRR 1) dated 2/27/2023 revealed Resident #2 had an intellectual disability, indicated as yes. Record review of Evaluation revealed a response of Yes for Intellectual Disability, Developmental Disability. Record review of Resident #2's PASSR Comprehensive Service Plan (PCSP) dated 2/06/2024 revealed Resident #2 was recommended OT, PT, and ST. Meeting was held on 2/06/2024. Record review of complaint intake #491508 dated 3/20/2024 revealed Resident #2 has not received a Customized Manual Wheelchair assessment to assist with safe positioning and mobility after a 2/6/2024 PASRR update meeting. Nursing Facility did not submit the NF Specialized Customized Manual Wheelchair assessment within the required timeframe. Resident #3 Record review of Resident #3's admission record dated 4/11/2024 was admitted on [DATE], re-admitted on [DATE] with abnormalities of gait and mobility, cognitive communication deficit, psychosis not due to a substance, schizoaffective disorder-bipolar type (serious mental illness characterized by extreme mood swings). Record review of Resident #3's annual MDS dated [DATE] revealed Resident #3's BIMS was 12 which indicated moderately cognitively impaired. Record review of Resident #3's Care plan dated 4/10/2024 revealed Resident #3 had a positive PASRR status on 9/30/2022 related to intellectual disabilities/mental illness for schizophrenia/MDD. Interventions: OT specialized services approved for 6 months at a time on 1/25/2023. Evaluate for habilitative services and or durable medical equipment to maintain current level of function. ST specialized services approved for 6 months at a time on 4/27/2023. Record review of Resident #3's P1 (PASARR 1) dated 9/13/2022 revealed Resident #3 had an intellectual disability/developmental disability and mental illness, indicated as yes. Record review of Resident #3's PASSR Comprehensive Service Plan (PCSP) dated 2/6/2024 revealed Resident #3 was recommended OT, ST, and DME. Meeting was held on 2/06/2024. Record review of complaint intake #491508 dated 3/20/2024 revealed Resident #3 has not received NF Specialized PT and OT assessments in support of maintaining strength and ADL's after the SPT agreed to needed services at a 2/06/2024 PASRR update meeting. NF did not submit NF Specialized therapy assessments within the required timeframe. Resident #4 Record review of Resident #4's admission record dated 4/11/2024 was admitted on [DATE], re-admitted on [DATE] with diagnosis of legal blindness, Parkinson's disease (chronic and progressive movement disorder), muscle wasting, and difficulty walking. Record review of Resident #4's quarterly MDS dated [DATE] revealed Resident #4's BIMS was 14 which indicated cognitively intact. Record review of Resident #4's Care plan dated 4/10/2024 revealed Resident #4 had a positive PASRR status on 5/19/2021 related to developmental disability - legal blindness. Interventions: .evaluate for habilitative services and or durable medical equipment to maintain current level of function. Record review of Resident #4's P1 (PASRR 1) dated 9/15/2023 revealed Resident #4 had a developmental disability indicated yes. Record review of Resident #4's PASSR Comprehensive Service Plan (PCSP) dated 9/15/2022 revealed Resident #4 was recommended return to the community. Record review of complaint intake #491508 dated 3/20/2024 revealed Resident #4 has not received NF Specialized PT, OT, and a Customized Manual Wheelchair assessments in support of maintaining strength, ADL's, and mobility after the SPT agreed to needed services at a 1/10/2024 PASRR update meeting. NF did not submit NF Specialized therapy assessments within the required timeframe following the meeting. Resident #5 Record review of Resident #5's admission record dated 4/11/2024 was admitted on [DATE] with diagnosis of quadriplegic cerebral palsy (severe form of cerebral palsy that affects all four limbs, the trunk, and the face), muscle weakness, and difficulty walking. Record review of Resident #5's quarterly MDS dated [DATE] revealed Resident #5's BIMS was 14 which indicated cognitively intact. Record review of Resident #5's Care plan dated 4/11/2024 revealed Resident #5 had a positive PASRR status on 3/10/2021 related to spastic quadriplegia cerebral palsy. Interventions: 6/15/2023 .agreed to continue habilitation coordination, specialized habilitative PT services. Record review of Resident #5's P1 (PASRR 1) dated 9/15/2023 revealed Resident #5 had a developmental disability indicated yes. Record review of Resident #5's PASSR Comprehensive Service Plan (PCSP) dated 2/06/2024 revealed Resident #5 was recommended OT, PT, DME. Meeting was held on 2/6/2024. Record review of complaint intake #491508 dated 3/20/2024 revealed Resident #5 has not received NF Specialized PT, OT, and ST assessments to assist with receiving therapy authorization approval in support of maintaining strength and ADL's after SPT agreed to needed services at a 2/2/2024 PASRR update meeting. The NFSS was not submitted within the required timeframe. Interview on 4/10/2024 at 11:25 AM with the MDS Reg. Coord. said the Rehab. Director was responsible for submitting the NFSS forms. MDS Reg. Coord. said the previous Rehab. Dir. resigned in February 2024. She said there was not a replacement until the middle of March. MDS Reg. Coord. said in January she tried to help but there was a delay in doctor signatures which in turn delayed the NFSS submissions. She said by not submitting the NFSS form it would delay approval of specialized services. MDS Reg. Coord. said delay in services could affect residents maintaining their current strength or abilities. MDS Reg. Coord. said the NFSS forms were not submitted in 1/2024 and 2/2024 to PASRR. Interview on 4/11/2024 at 8:45 AM with Resident #1 was attempted in the hospital. Resident #1 did not answer if he had OT, PT or ST after questions were asked. Interview on 4/11/2024 at 11:15AM, Resident #5 said she had not been to therapy in months and started yesterday. Interview on 4/11/2024 at 11:35 AM, Interim Rehab. Dir. said the facility had staff changes in the rehabilitation therapy department. She said she took over the Rehabilitation Director duties temporarily until a new director was hired. The Interim Rehab. Dir. said the previous Rehab. Director was responsible for submitting the NFSS forms. The Interim Rehab. Dir. said the NFSS forms for specialized services were not submitted after the PASRR meetings held in January and February of 2024. She said the facility did not have a full time Rehab. Dir. and the facility failed to submit the NFSS to the LIDDA. She said services for PASRR residents would have been delayed because the NFSS was not submitted. She said she reviewed the therapy notes for Resident's #1, #2, #3, #4, and #5 and the note's revealed evaluations were completed, but there was no therapy (OT, PT, ST, or DME) sessions completed. She said the services were not started because the NFSS form was not submitted to PASRR (for Residents #1, #2, #3, #4,#5) after the IDT meetings and the process (assessment, submission of NFSS to start services) had to be started over again. Interview on 4/11/2024 at 12:00 PM with Resident #2 was attempted. Resident #2 did not respond to questions asked related to OT, PT, ST. Interview on 4/11/2024 at 12:10 PM, Resident #3 said she wanted to go to therapy to exercise. She said she did not remember if she attended therapy. Interview on 4/11/2024 at 12:30 PM, Resident #4 said he had not been to therapy in over a month and a half. He said he wanted to be in therapy to help with mobility and help as much as he could with his Parkinson's diagnosis. Interview on 4/11/2024 at 1:39 PM, the ADM said the Rehab. Dir. was responsible for submitting the NFSS forms for PASRR services. ADM said the previous Rehab. Dir. resigned three months ago and there was a lapse in a facility staff completing the NFSS forms and submitting them. ADM said the risk would be a delay in specialized services. ADM said the delay in services could affect the residents ability to obtain or maintain skills. NFSS submissions for 1/2024-3/2024 for Residents #1, #2, #3, #4, #5 were requested on 4/11/2023 from Administrator and Interim Rehab. Dir. and were not received before exit. Record review of facility policy Resident Assessment - PASRR dated 11/2023, revealed the following in part: The purpose of this policy is to ensure PASRRs are being obtained and completed timely and accurately. 6. Follow Texas PASSR Policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status. Record review of Texas Health and Human Services policy Companion Guide for completing the authorization request for PASRR Nursing Facility Specialized Services (NFSS) dated November 2023 revealed the following part: The NF submitters must submit the authorization request for a service through the NFSS form no more than 30 days after the date the assessment for the service was completed by the therapist.

Based on observation and interview the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Food and Nutrition Services in that -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings included: Observation on 01-23-24 at 9:10 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster ¾ full of garbage and food refuse and the door was wide open. In an interview on 01-23-23 at 9:20 am, with the Food Service Manager, he stated that the dumpster doors always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. He also stated that he will in service dietary staff that the dumpster door is to be always closed for proper sanitation and residents' safety. Requested a copy of policy and procedure for Waste Disposal/Dumpster of the facility. Facility did not provide the requested copy before exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent decrease in range of motion for 1 of 12 residents (Resident #49) reviewed range of motion. -The facility failed to ensure Resident #49, with contractures to both hands, was wearing a hand splint device on both hands as care planned and ordered by the physician. - This failure could place resident at risk for further contractures of the hands and fingers, pain, and a decrease in quality of life. Findings: Record review of Resident #49's face sheet dated 11/01/2023 revealed a [AGE] year-old female admitted to the facility originally on 10/07/2020 and again on 05/09/2023 with the following diagnoses that included: subarachnoid hemorrhage (blood vessel that bursts in the brain) , sickle cell disorder with cerebral vascular involvement, cerebral infarction (disrupted blood flow to the brain), narcolepsy ( sleep disorder causing daytime drowsiness) , contracture of hand (fixed tightening of a body part that prevents movement), aphasia (language disorder that effects a person's ability to communicate), pain in unspecified fingers, cognitive deficit, dysphagia (difficulty swallowing), diabetes mellitus, and gastrostomy (opening into the stomach surgically for the introduction of food/nutrition). Record review of Resident #49's quarterly MDS assessment dated [DATE] revealed that the resident's BIMS score was 3 indicating that the resident's cognition was severely impaired. Further review revealed that resident upper and lower extremities were impaired. Record review of Resident #49's Care Plan dated 07/14/2022 revealed that resident was being care planned for musculoskeletal status r/t contracture of bilateral hands with interventions included the following: -Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness. -Provide and apply bilateral UE Splints Record review of Resident #49's Physician Orders revealed the following orders: -Dated 03/08/2021 for bilateral splints UE to be worn at least 5 days a week or as tolerated. -Dated 06/06/2023 Tylenol give 650mg via peg tube (surgically inserted feeding tube) q 12 hours for joint pain contractures, do not exceed 3gm q 24 hr. Record review of Resident #49's MAR for the month of January 2024 revealed that the facility was administering the resident's Tylenol as ordered by the physician. Record review of Resident #49's Occupational Therapy Discharge summary dated [DATE] revealed in part: .Patient will safely wear a hand roll on and finger separators on right fingers, right hand, left hand and left fingers for up to 8 hours . Observation on 01/23/24 at 10:05AM revealed Resident #49 was resting in bed with a touchpad call light within reach. Resident #49 had side rails to upper bed. Resident was receiving continuous gastrostomy feedings Jevity at 1.5 at 45ml/hr hung on 1/23/24 at 5:00AM. Further observation was made of resident with both hands with contractures and no splint device to prevent further contractures. Observation on 01/23/24 at 3:00PM revealed Resident #49's hands with no device in her hands for contractures. Resident was resting quietly and did not appear to be in discomfort. Observation on 01/24/24 at 8:20AM, 9:45AM, 10:25AM, 12:20PM, and 5:00PM of Resident #49 revealed she was resting quietly in bed with head of bed elevated. Resident with no devices in hands. Observation 01/25/24 at 9:10AM and 12:00PM of Resident #49 revealed with no hand splints being worn. Interview on 01/25/2024 at 9:10AM, LVN Z said she was Resident #49's nurse. LVN Z said she had not worked at the facility in a long time. LVN Z said she was not sure if resident had an order for any type of splint device for her hand and finger contractures. LVN Z said she saw that resident had contractures to both of her hands and fingers. LVN Z said it was important to place something in Resident #49's hands to prevent resident hands from becoming more contracted. Interview on 01/25/24 at 9:28AM, the Director of Rehab said the last time Resident #49 was on OT services was 11/01/2023. The Director of Rehab said she started working at the facility in December of 2023. The Director of Rehab said she was not sure if Resident #49 had orders for hand contractures. The Director of Rehab said residents with hand contractures wore a hand splint device to prevent pain and neuromuscular dysfunction. The Director of Rehab said if a resident with contractures was not receiving treatment for the contracture, they could regress. The Director of Rehab said she was in the process of assessing all residents on Rehab Therapy. The Director of Rehab said the Physical Therapy staff were all new staff. Interview on 01/25/2024 at 10:35AM, the DON said before she was hired as the facility's DON, the facility did not have a restorative program. The DON said she addressed a restorative program with the Administrator who was supposed to be checking into the matter. The DON said when the facility had a restorative program, CNA R was the restorative aide. The DON said CNA R was supposed to continue to make sure that the residents that had contractures were wearing their splints or contracture devices. The DON was asked for the facility policy on quality of care/restorative care. The DON said the facility did not have a policy on Quality of Care, but submitted a policy on restorative services. Interview on 01/25/2024 at 10:55AM, CNA R said she was the facility's restorative aide when the facility had the restorative program. CNA R said although the facility no longer had a restorative program, she was doing the best she could to ensure that the residents with contractures were wearing their contracture devices to help with range of motion. CNA R said she guessed she missed checking for Resident #49. Interview on 01/25/2024 at 11:00AM, the Administrator said the NF had not had a restorative program since she had been working at the facility for the past several years. Interview on 01/25/2024 at 12:20PM, CNA O said she worked at the facility PRN on the morning and evening shift. CNA O said she was Resident #49's CNA. CNA O said she could only speak for herself and did not recall ever being in-serviced on contractures or how to care for residents who had contractures. CNA O said she just knew to clean the palms of a resident hands who had hand contractures to ensure their hands were clean. Observation on 01/25/2024 at 12:25PM of the palms of Resident #49's hands revealed they were clean with her skin intact, resident was not wearing a hand splint. Observation on 01/25/2024 at 12:45PM of Resident #49's family member revealed the family member standing at Resident #49's bedside rearranging resident linen on bed. Interview on 01/25/2024 at 12:45PM with the family member of Resident #49 revealed she was not against the facility providing some type of hand splint to the resident's hands and fingers to prevent further contractures. The family member said she was trying to get the previous PT that used to work at the facility to help her with getting splints for Resident #49's hands and fingers to help keep resident hands and fingers extended as much as possible. The family member said PT never got resident the splints for her upper extremities. The family member said she was continuing to look for some type of device for resident contractures to her hands and fingers. Record review of the facility policy on Restorative Nursing Services revised July 2017 revealed in part: .Residents will receive restorative nursing care as needed to help promote optimal safety and independence .Restorative goals and objectives are individualized and resident-centered, and are outline in the president's plan of care .Restorative goals may include, but are not limited to supporting and assisting the resident in: adjusting or adapting to changing abilities; developing, maintaining his/her dignity, independence and self-esteem; and participating in the development and implementing of his/her plan of care .

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 in 1 of 1 kitchen reviewed for food procurement in that The facility failed to prevent the following. 1. A Plastic Container of Shredded Cheese dated 1/15/24. 2. A Plastic Container of Mozzarella Cheese dated 1/02/24. 3. A Plastic Container of Chili dated 1/02/24. The scoop was left in the flour bin in the storeroom. These failures could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 01/23/24 at 8:30 AM revealed that leftover foods were not discarded prior to the use by date. Observation of the facility's food storeroom on 01/23/24 at 8:40 AM revealed that a scoop was left in the flour bin. Interview with the Food Service Manager on 01/23/24 at 8:45 AM he stated that the leftover food stored in the refrigerator should have been used or discarded prior to use by date. He stated that he will in-service dietary staff on policy and procedure for leftover food and scoops storage. Record review of facility's policy and procedure for food storage dated 9/20/23 revealed that food products are discarded before the use by date. The facility failed to follow the policy for food storage including leftover opened containers of potentially hazardous food or leftovers are dated or used with in 7 days in the refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 6 Residents (Resident #78) reviewed for administration. -The facility failed to completely and accurately document Resident #78's use of splint/braces on his care plan; These failures could place residents at risk of having incomplete and inaccurate records. Findings include: Record review of Resident #78's clinical record revealed he was a [AGE] year-old male who was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to include: cerebral palsy (disorder effecting movement and ability to maintain balance), depressive episodes, severe intellectual disabilities, pulmonary fibrosis (scarring of the lungs cause difficulty to breath), end stage renal disease (kidney failure), encounter for palliative care (medical care focused on pain relief and comfort), and protein-calorie malnutrition (underweight). Record review of Resident #78's quarterly review MDS (Minimum Data Set) assessment dated [DATE] revealed that his BIMS (Brief Interview for Mental Status) was not scored. The resident's cognitive skills for daily decision making was scored as 3 which indicated his cognition was severely impaired. Record review of Resident #78's Care plan dated 3/5/18 revealed: Focus area cerebral palsy affected the ability for Resident #78 to speak or ambulate and receive medication daily for increased movements. Goal: Resident #78 to be able to function at the fullest potential possible as outlined by the treatment team throughout the next review date. Interventions: Maintain good body alignment to prevent contractures. Use braces and splints as ordered. Record review of Resident #78's orders revealed no orders for braces and splints. An observation on 01/23/2024 at 09:53 AM revealed Resident #78 laying in fetal position on his left side with his arms bent to his chest, and his hands and feet were contracted. No braces or splints on resident's hands, legs or feet. Resident appeared to be asleep and nonresponsive. An observation on 01/24/2024 at 11:10 am revealed Resident #78 laying in fetal position on right side. Resident appeared to be awake but nonresponsive. Resident's arms bent to chest and hands contracted. No braces or splints observed on resident's hands. An observation on 01/25/2024 at 09:49 am revealed Resident #78 laying in fetal position on left side. Resident appeared to be awake but nonresponsive. Resident's arms bent to chest and hands contracted. No braces or splints observed on resident's hands. In an interview on 01/25/24 at 12:42 pm, the Rehabilitation Director (RD) stated that she was over occupational therapy (OT) and physical therapy (PT). She stated she assigned admissions, baseline and quarterly evaluations for residents receiving part A Medicare services. She stated at the time, the evaluation would determine if a resident with contractures was capsular (highly treatable) or fixed (untreatable) and whether the resident would benefit from positioning and splints or braces. She stated if a resident required services, she would request authorized by their physician. She stated a resident with a fixed contracture would not benefit from a splint or brace, rather it would cause more damage and more than likely pain. She stated that she was not familiar with Resident #78. She stated that she was unaware of how many residents with contractures were on census. She stated that the facility does offer in facility restorative services. She stated that they outsource restorative services with a telehealth agency. In an interview on 01/25/24 at 02:00 pm, the RD stated that she did not know the true number but believes there are a total of 11 residents with contractures. In an interview on 01/25/24 at 02:14 pm, the Certified Occupational Therapy Aid (COTA) stated she was hired in October of 2023. She stated she performed the physical joint mobility (moved resident's limbs) during telehealth evaluations as directed by the physiatrist. She stated she was not aware of how many residents had contractures. She stated she was given her assignments by the RD and was the only COTA on staff. She stated she only had 3-residents on her caseload. She stated she was not familiar with Resident #78, his contractures, and had not evaluated him. In an interview on 01/25/24 at 02:23 pm, the DON stated she started working in the facility in June 2022. She stated that MDS B took the role of MDS on 12/06/2023 and MDS A started training around thanksgiving and acquired the role in December 2023. She stated she was unaware of the total residents with contractures. She stated evaluations were scheduled by MDS A and performed quarterly by MDS A and the RD every Friday. In an interview on 01/25/24 at 03:07 pm, the MDS A stated that she had been the MDS and trained since 11/03/2023 under MDS B. She stated that the corporate registered nurse (RN) had begun providing guidance to her when MDS B was terminated 01/03/2024. She stated MDS A and therapy services had meetings every Friday to discuss assessment needs such as residents who were coming off or on therapy, who had a change in condition, or who were up for quarterly review. She stated that Resident #78 had not come up on her caseload and she had not completed his quarterly MDS or care plan since she had been hired. In an interview on 01/25/2024 at 04:46 pm, the DON stated that she had not been made aware that Resident #78's care plan reflected use braces and splints as ordered. She stated that resident had not had an order since he had been admitted for braces/splints. She stated that if he was to have had braces/splints an order should have been received and reflected on his care plan. She stated if there was not an order, braces/splints should not have been reflected on his care Plan. She stated it would have been MDS B's responsibility to complete his care plan accurately, but MDS B was terminated on 01/03/2023. She stated that the responsibility would now fall to MDS A who took over when MDS B had been terminated. In an interview on 01/26/2024 at 10:42 am, the DON stated she had spoken to Hospice Nurse (HN) who conformed Resident #78 had no previous order for braces, splints, or therapy. She stated she would update his care plan and also submit authorization and referral for a therapy evaluation. In an interview on 01/26/2024 at 12:37 pm, the NP stated that she has been over Resident #78's care since admission and resident had never had an order for any braces or splints. In an interview on 01/26/2024 at 12:43 pm, the HN stated that Resident #78 had been under his care since 03/29/2023 and had a recent (Individual Development Plan) meeting (exact date not given). He stated since providing the resident care, there had not been an order, discussion, or care plan for resident to have had splints or braces. In an interview on 01/26/24 at 12:55 pm, the Administrator stated that Resident #78 had never had an order for splints or braces. She stated that the DON and MDS B were responsible for the resident's care plan. She stated that MDS B may have opened up the wrong care plan when updating Resident #78's care plan. She stated, at some point, his care plan was initiated and/or updated by too many individuals who were unaware what the last individual had or had not done. She stated that the adverse effects of an inaccurate care plan could result in misdiagnosis and missed care for residents. She stated the MDS A was new, and the RN had been assisting with MDS and care plan suggestions and updates. She stated that the resident's care plan would be corrected. She stated the DON and herself were responsible for care plan and MDS in-services. In an interview on 01/26/2024 at 01:28 pm, the RN stated that that she was not familiar with Resident #78 diagnoses or care plan. She stated that she had been assisting MDS A since MDS B had been terminated. She stated that the all department heads were responsible for ensuring that the care plans were accurate. She stated that inaccurate care plans would result in resident care plans not being followed correctly and resident's not receiving accurate care. Requested a copy of policy and procedures related to clinical records. The facility did not provide the requested copy before exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for 1 of 4 residents (Resident #1) reviewed for ADLs. -The facility failed to provide showers to Resident #1 in compliance with her shower schedule and as she requested. This deficient practice could place residents at risk of a decline in their sense of well-being, level of satisfaction with life, and at risk for skin breakdown. Findings include: Record review of Resident #1's, undated, face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms), hypertension (A condition in which the force of the blood against the artery walls is too high) and depression (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #1's Comprehensive MDS, dated [DATE], revealed a BIMS score was 15 out of 15, which indicated the resident was cognitively intact. Resident #1 required limited assistance from one person assist from staff with bed mobility, dressing, toilet use and personal hygiene. Record review of Resident #1's Care plan initiated on 12/20/22 revealed the following: Focus: I, (Resident#1) have an ADL self-care performance deficit r/t schizoaffective/bipolar disorder. Goal: I, (Resident#1) will maintain current level of function in ADL's through the review date. Interventions: Bathing/showering: I, (Resident#1) require extensive assist by 1 staff with bathing/showing three times weekly and as necessary. Record review of Resident#1's nurses notes for the month of June 2023 revealed there was no documentation of the resident's refusal for showers/bad bath. Record review of Resident#1's ADLs Task for the month of June 2023 revealed CNA Z's initialed with time stamp 13:59 (1: 59 pm) for Monday (6/19/23) and Wednesday (6/21/23) under ADL-Bathing (MWF 6-2). In a telephone interview on 06/22/23 at 3:23 p.m., the complainant said Resident #1 had not been offered a shower during the week of June 19, 2023. Resident #1's assigned shower days were Monday, Wednesday, and Friday. In an interview on 06/23/23 at 10:05 a.m., Resident #1 said she loved taking her showers. She said her shower days were Monday's, Wednesday's, and Friday's. She said this week she had not received a shower. She said Monday (6/19/23) no one offered her a shower. She said on Wednesday (6/21/23) CNA Z came early in the morning around 7:00 am and asked if she wanted to take a shower. Resident #1 said she did not feel good so she asked CNA Z if she could take a shower later in the afternoon. CNA Z agreed. Resident#1 said she pressed her call light sometime after lunch requesting a shower. CNA Z told her she was in the middle of something and could not give a shower at that time. Resident #1 said she waited but CNA Z never came back. She said, Today is my shower day. I felt dirty and requested CNA this morning to give me a shower. I got my shower and i feel much better now. In a telephone interview on 06/23/23 at 11:10 a.m., with CNA Z, she said she worked with Resident#1 on Monday (06/19/23) and Wednesday (6/21/23) of this week. She said the resident got her shower on Monday (06/19/23). On Wednesday (6/21/23) around 7:00 am she went to ask Resident#1 if she would like to take a shower the resident refused saying that she was not feeling well. She said she notified a male nurse that was on duty that day of the resident's refusal. She said toward the end of her shift Resident#1 said she wanted to shower but it was time for CNA Z to go home. CNA Z said she forgot to notify the oncoming shift CNA of the resident's shower request. In an interview on 6/23/23 at 11:49 a.m., with LVN AA, he said he worked with Resident#1 on Wednesday (06/21/23). He said he did not recall CNA Z telling him of Resident #1 refused a shower. He said the process was if the resident refused to shower the nurse would talk to the resident to inquire the reason for refusal. Ask if a resident wanted to take a shower later in the day, or on a different shift. If the resident continued to refuse then educate the resident on the importance of showering, and then document in the nurses note. Record review and interview on 6/23/23 at 1:04 p.m., the Surveyor reviewed Resident #1's bathing tasks and the nurses notes with the DON. The DON said she did not see any specific note for the refusal of the shower for Resident #1 on Monday (06/19/23) and Wednesday (6/21/23) of this week. She said Resident #1 was an easy shower, you just have to monitor her. The DON said on the ADLs documentation CNA Z documented at 1359 (1:59 pm) on Monday (06/19/23) and Wednesday (6/21/23) which was the time she sat down to do her charting towards the end of her shift. She said the CNA should be charting after every resident before going to the next resident. She said her expectations were that the aides showered the residents according to their shower schedules and as needed. She said if a resident refused a shower, the aides should notify the nurse. A negative outcome of not receiving showers regularly could be foul hygiene, fungal infections, not assessing skin, and unidentified wounds. She said the nurses were responsible for ensuring residents were getting showers on their assigned days. At this time a policy on ADLs was requested. The DON said the facility did not have a policy on ADLs. Record review of facility's Charting and Documentation policy (Revised July 2017) revealed read in part: .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F623 Based on interview, and record review, the facility failed to notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing, failed to record the reasons for the transfer or discharge in the resident's medical record, resident discharged [DATE] and failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 1 resident reviewed for discharge. 1. The facility failed to notify Resident #1's representative (POA) of the discharge and reasons for the discharge in writing. The resident was discharged [DATE]. 2. The facility failed to record the reasons for the discharge in Resident #1's medical record. 3. The facility failed to notify the Ombudsman of Resident #1's discharge. These deficient practices could place all residents at risk for disruption in the continuum of care which could result in health complications. Findings included: Record review of Resident #1's face sheet not dated revealed an [AGE] year-old female who was re-admitted on [DATE] with a diagnosis of unspecified Dementia (Memory loss and Confusion), Unspecified Severity with other Behavioral Disturbance, Mood Disorder (Emotional Distortion) Due to Unknown Physiological Condition, Psychosis (Disconnection from Reality), Depressive (Sadness) Episodes. Record review of Resident #1's Discharge MDS dated [DATE], read: Section A, Code 11, Discharge assessment-return anticipated. The BIMS section C0500. BIMS Summary Score was left blank. Resident #1 required limited assistance with one person assist for bed mobility, transfers, locomotion on and off unit, dressing, and toilet use. Resident #1 required supervision with set up for eating and extensive assistance with one person assist for personal hygiene. Record review of Resident #1's Care Plan initiated on 1/15/19 and revised on 4/21/22 read . Focus: Resident #1 has a Deficit r/t Dementia, CVA, general weakness. Goal: Resident #1 will maintain current level of function in ADL's through the next review date. Interventions: Resident #1 requires Supervision and cueing X 1 staff with bathing/showering three times weekly and PRN; BED MOBILITY: Resident #1 requires Supervision and cueing X 1 staff with turning and repositioning; requires Supervision and cueing X 1 staff for dressing; requires Supervision and cueing X 1 staff for toileting/incontinent care and transfers. Record review of Resident #1's Transfer Form not dated revealed Resident #1 was discharged from the facility to the local Behavioral Health Hospital. In an interview on 4/13/2023 at 9:00 am, Resident #1's family member said Resident #1 had been at the facility for four years. Family member said Resident #1's behavioral issues could not be controlled so every 90 days she would end up in psychiatric care. The family member said the facility never issued warning notices but in October of last year they were notified about a process for a thirty-day eviction notice. She said they never received the eviction notice they discussed in October. She said that in January 2023, there was an incident where Resident #1 stabbed a volunteer with a pencil, so the facility called the family two days after, and said the facility was sending Resident #1 for psychiatric evaluation and treatment. She said Resident #1 called POA to come to get her. She said she was under the impression that Resident #1 would be returning to the facility post psychiatric care. She said the POA got a text from the administrator noting Resident #1 was discharged to a personal care home. She said the facility called her the next morning 1/4/2023 and asked them to come and get Resident #1's personal property and personal funds. She said the resident was now at another nursing home facility. Record review revealed no documentation of notification of resident discharge from facility to POA in Resident #1's medical record. Record review revealed no documentation of the reasons for the discharge in Resident #1's medical record. Record review revealed no documentation of notification of resident discharge to Ombudsman from facility in Resident #1's medical record. In an interview on 4/13/2023 at 9:49 am with the Administrator she said Resident #1 had become a danger to residents and staff when she attacked the housekeeper and injured her neck on 1/2/2023. She said she had a conversation with the family to notify them that Resident #1 could not stay at the facility. She said the family was agreeable. She said contact with the resident's POA was made to discuss an incident that occurred which forced the facility to send Resident #1 to the local psychiatric facility on 1/3/2023 for evaluation and psychiatric treatment. She said she gave the resident a ride to the personal care home herself because there were transportation issues, and she did not want her sitting there waiting. She said Resident #1's family member knew about this, and he was looking at places as well. In an interview on 4/13/2023 at 12:15 pm with the Administrator she said the facility did not have discharge papers and a discharge summary for Resident #1. She said she could not explain why said documents were not in Resident #1's clinical record. In an interview on 4/13/2023 at 3:00 pm with the Administrator she said the facility was supposed to notify the family by mail in writing and call family when discharging a resident. She said the purpose was to ensure the necessary continuum of care for discharged residents. She said if the family was not notified in writing, there could be a lapse in continuum of care. In an interview on 4/13/2023 at 3:15 pm with the DON she said the importance of discharge notification was to ensure residents who were discharged were equipped with the necessary tools to continue their care without interruptions. She said it was important to document the reasons for discharge and the location of where the resident/s were being discharged to. Record review of facility's discharge policy titled, Transfer or Discharge Notice, dated 2016, read in part . The resident and/or representative will be notified in writing of the following information: The reason for the transfer or discharge; The effective date of the transfer or discharge; The location to which the resident is being transferred or discharged ; A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. In determining the transfer location for a resident, the decision to transfer to a particular location will be determined by the needs, choices, and bests interests of that resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F661 Based on record review and interview the facility failed to provide a discharge summary that included the required elements for 1 (Resident #1) of 1 resident reviewed for discharge summaries. 1. The facility failed to provide Resident #1's POA with a discharge summary for Resident #1 that included recapitulation of the resident's diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; final summary of the resident's status; Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter); post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which would assist the resident to adjust to his or her new living environment. Findings included: Record review of Resident #1's face sheet not dated revealed an [AGE] year-old female who was re-admitted on [DATE] with a diagnosis of unspecified Dementia (Memory loss and Confusion), Unspecified Severity with other Behavioral Disturbance, Mood Disorder (Emotional Distortion) Due to Unknown Physiological Condition, Psychosis Disconnection from Reality), Depressive (Sadness) Episodes. Record review of Resident #1's Discharge MDS dated [DATE], read: Section A, Code 11, Discharge assessment-return anticipated. The BIMS section C0500. BIMS Summary Score was left blank. Resident #1 required limited assistance with one person assist for bed mobility, transfers, locomotion on and off unit, dressing, and toilet use. Resident #1 required supervision with set up for eating and extensive assistance with one person assist for personal hygiene. Record review of Resident #1's Care Plan initiated on 1/15/19 and revised on 4/21/22 read . Focus: Resident #1 has a Deficit r/t Dementia, CVA, general weakness. Goal: Resident #1 will maintain current level of function in ADL's through the next review date. Interventions: Resident #1 requires Supervision and cueing X 1 staff with bathing/showering three times weekly and PRN; Bed Mobility: Resident #1 requires Supervision and cueing X 1 staff with turning and repositioning; requires Supervision and cueing X 1 staff for dressing; requires Supervision and cueing X 1 staff for toileting/incontinent care and transfers. Record review of Resident #1's Transfer Form not dated revealed Resident #1 was discharged from the facility to the local Behavioral Health Hospital. Record review revealed no discharge summary documentation in Resident #1's clinical record. In an interview on 4/13/2023 at 12:15 pm with the Administrator she said the facility did not have discharge papers and a discharge summary for Resident #1. She said she could not explain why said documents were not in Resident #1's clinical record. In an interview on 4/13/2023 at 3:20 pm with the Administrator, she said the discharge summary showed where a resident was being discharged to, medications reconciliation, and to ensure the Interdisciplinary Team were all on the same page. She said if the facility did not provide a discharge summary to residents, family members or resident representatives, the resident could have a lag in their continuum of care. Policy for discharge summary was requested on 4/13/23 at 1:30 pm; and 3:30 pm from the DON and Administrator; the facility did not provide the discharge summary prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for clinical records. -The facility failed to ensure staff documented wound care treatments on Resident #1's MAR/TAR. This failure could affect residents that received wound care and place them at risk of inaccurate or incomplete clinical records. Findings include: Record review of the admission sheet for Resident #1 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), type 2 diabetes mellitus without complication (A chronic condition that affects the way the body processes blood sugar (glucose) and gastro-esophageal reflux disease without esophagitis (A digestive disease in which stomach acid or bile irritates the food pipe lining). Record review of Resident #1's Comprehensive MDS, dated [DATE], revealed the BIMS score was blank. Staff assessment for mental status was conducted resident was unable to complete interview. Resident#1 has short term memory problem, long term memory problem, and cognitive skills for daily decision making is severely impaired never/rarely made decision. Further review of the MDS revealed he required total dependence from one-person physical assist for personal hygiene, toilet and transfer. Resident was always incontinent of bowel and bladder. Record review of Resident #1's Care plan initiated 06/01/22 and revised on 12/29/2022 revealed the following: Focus: Resdent#1 had stage 2 pressure injury to Sacrum r/t shearing and Hx of ulcers and Immobility. Goal: My Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Record review of Resident #1's physician order dated 12/18/2022 revealed an order for sacral: clean with NS/wound cleanser, apply CaAlg, and cover with dry dressing one time a day for wound. The order was discontinued on 12/26/22. Record review of Resident #1's MAR/TAR for the month of December 2022 for sacral wound had blanks on the TAR indicating the treatment did not occur on 12/18/22, 12/20/22, 12/21/22, 12/23/22, 12/24/22 and 12/26/22. Record review of Resident #1's physician order dated 12/27/2022 revealed an order for sacral: clean with NS/wound cleanser, pat dry, apply collagen and CaAlg, and cover with dry dressing one time a day for wound. Record review of Resident #1's MAR/TAR for the month of December 2022 for sacral wound had blanks on the TAR indicating the treatment did not occur on 12/30/22 and 12/31/22. Record review of Resident #1's physician order dated 12/01/22 revealed an order for Rt foot 2nd toe amputation clean NS/wound cleanser, pat dry, apply CaAlg, and cover with dry dressing one time a day for surgical wound right foot/2nd toe. The order was discontinued on 12/12/22. Record review of Resident #1's MAR/TAR for the month of December 2022 for Rt foot 2nd toe had blanks on the TAR indicating the treatment did not occur on 12/02/22, 12/05/22, 12/07/22, 12/10/22, 12/11/22 and 2/12/22. Record review of Resident #1's physician order dated 12/13/22 revealed an order for Rt foot 2nd toe amputation clean NS/wound cleanser, pat dry, apply CaAlg, and cover with dry dressing one time a day for surgical wound right foot/2nd toe. Record review of Resident #1's MAR/TAR for the month of December 2022 for Rt foot 2nd toe had blanks on the TAR indicating the treatment did not occur on 12/13/22, 12/14/22, 12/15/22, 12/17/22, 12/18/22, 12/20/22, 12/21/22, 12/33/22, 12/24/22 and 12/26/22. Record review of Resident #1's nurses note for the month of December 2022 revealed there was no documentation of Resident #1's treatments not being done, notification to the MD or a Nurse Practitioner of treatment not being done, or of Resident #1's refusing treatment. There was no documentation indicating why the scheduled treatment was withheld or not administered as ordered. In an interview and record review on 01/03/23 at 12:01p.m., Surveyor A reviewed Resident #1's TAR/MAR, physician order and nurses notes with the DON. The DON confirmed the Treatment Nurse, and the floor nurses did not document on the TAR/MAR after performing the treatments in December 2022. She said there should not be any open/blank spaces in the MAR/TAR and that if it was not documented it means it was not completed. The DON said, there was no explanation for the holes in the MAR. The DON said she went over MAR/TAR once a week. Record review of facility's Charting and Documentation policy (Revised July 2017) read in part: .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation. 2. The following information is to be documented in the resident medical record: c. Treatments or services performed; 7. Documentation of procedures and treatments will include care-specific details; including: the date and time the procedure slash treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment date and/ or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedures/treatment; e. Whether the resident refused to procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out the activities of daily living received the necessary services to maintain grooming and personal hygiene care for two (Resident #49, and Resident #48) of four residents reviewed for ADL care. 1. The facility failed to ensure Resident # 49 was provided timely personal grooming (shaving). 2. The facility failed to ensure Resident #48 was provided showers as scheduled. These failures could place residents, who required ADL care, at risk of not receiving personal care and services and residents felt unkempt. Findings include: Record review of Resident #49's face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were, dementia (impaired ability to remember things or make decisions that interferes with doing everyday activities), hypertension (persistently raised blood pressure), heart failure (heart does not pump enough blood for the body), and schizoaffective disorder (mental illness that affect thoughts, mood, and behavior). Record review of Resident #49's quarterly MDS assessment, dated 08/16/22, revealed the resident was severely cognitively impaired for daily decision-making skills. Further review revealed Resident #49 needed extensive assistance with ADL care with one staff assistance and the resident was frequently incontinent of bowel and bladder. Record review of Resident #49's undated care plan revealed the resident had ADL (activity of daily living) self-care performance deficit related to dementia. Intervention: resident needed extensive assist with one person assistance with personal hygiene. Record review of Resident # 49's documentation survey report for November 2022 did not reveal Resident #49 refused to be shaved. During an observation and interview on 11/29/22 at 10:15 a.m., Resident # 49 said she had to ask for a shower; sometimes she got her shower, and other times she does not . She said she could not remember the last time the staff shaved. Resident# 49 said she does not want facial hair because she is a woman. Resident #49 had curled white and gray hair on her chin, and she said she did nor refused showers or being shaved. An observation and interview 11/30/22 at 8:25 a.m. revealed Resident # 49 still had facial hair on her chin , and she said none of the staff had offered to shave her. During an observation and interview on 11/30/22 at 8:59 a.m., WCN A said she saw the black and gray facial hair on Resident #49's chin. She stated the resident should be showered at least three times a week and shaved during the shower and as needed. She said RCPs document on PCC (point click care), and there was a section for shaving. WCN A said Resident # 49 wanted the facial hair shaved. However, she said if the resident did not wish to have facial hair, she could feel unkempt. During an interview on 11/30/22 at 9:04 a.m., RCP AA said Resident #49's shower days were Tuesday, Thursday, and Saturday morning. She said she was unsure if there was a spot for shaving on the POC (point of care) to document if a resident refused to shave. RCP AA said she would tell the nurse if the resident declined to shower to shave, and the charge nurse would monitor the RCPs to ensure they provided ADL (activity of daily living) for residents. She said she had skills check-off on daily living activities, including showering and shaving residents. RCP AA said she saw Resident #49 when she made rounds that morning; RCP AA stated she did not see the facial hair on her chin until then when it was pointed out. She said the resident had black and gray hair on her chain. She said facial hair were shaved whenever you see it. She said if the resident did not want the facial hair, it would make the resident feel unkempt. During an interview on 11/30/22 at 9:15 a.m., LVN B said he was the charge nurse for Resident #49 and had seen the resident that morning, but did not observe the facial hair on her chin. He stated the residents were shaved on shower days and as needed. LVN B said he still needed to get to her to ask if she wanted her facial hair shaved. He stated the nurse monitored the RCPs, but he had not checked up on RCP AA that day and ensured she provided personal hygiene for Resident #49 that morning. Then he said her shower was the following day and she would be shaved then. He said if Resident # 49 did not want the facial hair on her chin, it would affect her dignity and self-image. During an interview on 11/30/22 at 2:55 p.m., the DON said she saw Resident # 49 but did not notice the facial hair on her chain. The DON said Resident #49 refused care, and she was unsure if it was care planned. She said shaving was done whenever it was seen, and there was no scheduled time; it was done as needed. She said it could have be a dignity issue and mental distress for Resident # 49 if she did not want the facial hair. During an interview on 12/01/22 at 3:05 p.m., the DON said she could not find RCP AA's skills checks on ADL because she completed them during floor orientation and she did not know where human resources kept them because the company had removed human resources from facilites. Record review of Resident #48's face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were, cerebrovascular disease (loss of blood flow to part of the brain, which damages brain tissue.), hypertension (persistently raised blood pressure), heart failure (heart does not pump enough blood for the body) and hemiplegia (caused by brain injury that results in a varying degree of weakness or stiffness on one side of the body). Record review of Resident #48's quarterly MDS assessment, dated 10/24/22, revealed a BIMS of 15 indicating intact cognition. Further review revealed Resident #48 needed extensive assistance with showers with one staff. Record review of Resident #48's undated care plan revealed the resident had an ADL self - care deficit related to left hemiplegia. Intervention: resident needed extensive assist with one person assistance with showers three times weekly and PRN (as needed). Record review of Resident # 48's documentation survey report for November 2022 revealed Resident #48 was not showered on 11/02/22, 11/28/22 and 11/30/22 . Record review of Resident # 48's documentation survey for November 2022 revealed Resident #48's shower days were, Monday, Wednesdays, and Fridays on 2 :0 p.m. to 10:00 p.m. shift. During an interview on 11/30/22 at 2:15 p.m., Resident #48 said he had about three showers in the past three weeks. He stated the staff kept saying he refused to shower, but all he said was he wanted his shower later. He stated when Resident #48 asked for his shower later, the aide would say he refused, and they would not shower him. Resident # 48 said it made him feel the aides did not care about his needs, and he felt unkempt. During an interview on 11/30/22 at 3:27 p.m., the DON said Resident #48 refused showers and sometimes said he would take his shower later. Then she stated he would ask for his shower about 15 minutes before the RCP got off, and the oncoming shift had their assigned residents to shower. She said, sometimes, the staff would accommodate him. She said if Resident #48 did not get his bath as scheduled, it would affect his dignity and cause skin break issues. During an interview on 11/30/22 at 4:46 p.m., RCP BB said Resident # 48 showers were Tuesdays, Thursdays, and Saturdays. She stated the resident liked to take his shower after dinner. She said the resident did not refuse to take his shower, but he had a particular time he would like to shower. During an interview on 11/30/22 at 5:24 p.m., RN B said Resident # 48 did not refuse to shower.; She stated most of the time, he was the one asking who would shower him. She stated the resident might have skin breakdown, infection, and may have a body odor if Resident #48 was not showered as scheduled. During an interview on 12/01/22 at 9:00 a.m., the DON stated that the facility does not have any ADL, shower, or shaving policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent received appropriate treatment and services to prevent urinary tract infections for 2 of 4 residents (Resident #21 and Resident #16) reviewed for catheter and incontinent care in that: 1. The facility failed to ensure LVN A followed proper infection control procedure during Resident #21's Foley care. 2. The facility failed to ensure WCN A placed Resident # 21's Foley bag below the bladder during turning and repositioning in bed. 3. The facility failed to ensure RCP AA utilized proper handwashing, infection control procedures, and completely cleaned Resident #16, during incontinent care. These failures could affect residents, who were incontinent or had a catheter, and place them at risk for urinary tract infections, discomfort, skin breakdown, and a decreased quality of life. Findings include: Record review of Resident #21's face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were, neuromuscular dysfunction of bladder (lacks bladder control), major depressive disorder (feeling of sadness and loss of interest), neurogenic bowel (loss of normal bowel due to a nerve problem), generalized anxiety (excessive worry and feeling of fear), and hypotension (low blood pressure). Record review of Resident #21's annual MDS assessment, dated 09/16/22, revealed a BIMS score of 14 indicating intact cognition. Further review revealed Resident #21 needed total assistance with ADL care with one to two staff and the resident was incontinent of bowel and had a supra pubic catheter. Record review of Resident #21's undated care plan revealed the resident had ADL (activity of daily living) self-care performance deficit related to quadriplegia. Intervention: resident needed total assist with one person assistance with personal hygiene. It also revealed the resident had a suprapubic catheter related to neurogenic bladder and was at risk for increased urinary tract infections. Interventions: Monitor/record/ report to MD (medical doctor) for signs and symptoms of UTI, pain, burning, blood tinted urine, cloudiness, and no output. Record review of Resident #21's order summary report for November 2022, read: flush suprapubic catheter with 60 CCs of normal saline every shift, for a flush ordered date 07/19/20. During an observation on 11/29/22 at 9:10 a.m., LVN A walked into the room and placed a syringe wrapped in four brown paper towels on top of Resident #21 refrigerator, and walked out of the room. She returned to the room with a black basket, took the wrapped-up syringe, placed it on the basket, and sat it on the bedside table. LVN A washed her hands, dried her hand with a paper towel, and used another dry paper towel to turn off the water tap. She placed the dry paper towel with the ones she had dried her hands and continued to dry her hands until she came out of the restroom and disposed of them into the trash can in the resident's room. While donning gloves, one of the gloves was torn, and she took a glove from her uniform pocket and donned it. Then she took the basket and placed it on the resident bed, removed the brown paper towels, and placed it between the resident legs. She disconnected the tubing from the Foley bag from the French Foley catheter and inserted the 60 CC syringe filled with water (normal saline). While she pushed the fluid into the French catheter, the liquid splashed out on Resident #21's face (eyes, mouth, and nose) and shirt. LVN A took the brown paper towel from the bed, which she used as a barrier, and wiped the resident's face. Resident #21 told LVN A not to use the paper towel to clean his face because it had already been between his legs. LVN A said it was just water and the paper was clean. She did not check to see if the water used for the flush returned from the Foley. During an interview on 11/29/22 at 2:03 p.m., LVN A said she placed the 60 CC syringe on top of the refrigerator, which was on top of the nightstand, and the paper towel and tip of the syringe were touching Resident # 21's lotion and orange juice bottle. LVN A said she placed the syringe in a basket with the contaminated paper from the nightstand. She used the same paper towel as a barrier when pushing the water into the Foley. The water splashed while she irrigated (cleaned) the Foley, and some of the water splashed on the resident's face and clothes. She wiped the resident face with the paper towel she placed on the refrigerator and used it as a barrier. LVN A said she had to use a glove from her uniform pocket, and she should not have used it because it had her germs, and she could have transferred her germs to the resident. LVN A said she should have cleaned the bedside table, placed a barrier, set her supply for irrigation for the Foley to prevent contaminating the syringe, and checked to see if the irrigation had cleared the sediments and if the Foley was draining appropriately. LVN A said she should not have used the paper towel she used as a barrier to clean Resident # 21 face because she could have transferred germs from the bed and the Foley to his face, which could have gone to her respiratory system. LVN A said no trash can in the restroom was why she mistakenly dried her hands again with the used paper towel and contaminated her hands. She said she had in service on infection control and skills check-off. During an interview on 11/30/22 at 11:01 a.m.; the DON said LVN A should had cleaned the bedside table, placed a barrier, set up an irrigation supply, then provided care to Resident # 21 with the flush amount as ordered. The DON said it was an infection control issue because the paper towel and syringe had been contaminated because they touched the personal items on top of the resident's refrigerator. The DON said LVN A should not have used the paper and cleaned the resident's face because it was contaminated from being placed on the bed as a barrier during foley irrigation. LVN A could have transferred the germs from the peri area to the resident's face. She said the staff should not carry gloves in their uniform pocket or use them to attend to residents. She stated LVN A should have checked and ensured the water used to flush the foley, returned and the sediment and the foley were draining appropriately. During an observation on 11/29/22 at 10:15 a.m., WCN A assisted in turning and repositioning Resident #21 when she placed Resident #21's foley bag on the bed. The urine was observed back flowing in the tube. WCN A said the urine in the tube was back flowing into Resident #21's bladder because it was on the bed. WCN A placed the catheter bag on the bed for 5 minutes. When WCN A lowered the foley bag, she said now the urine was returning to the foley bag. During an interview on 11/30/08/22 at 8:15 a.m., WCN A said she placed Resident #21's Foley bag on the bed for a while, but did not know how long it was at the bladder level. She said she thought the foley bag should be placed on the bed; while turning the resident. WCN A stated the foley bag had 700 CC (centimeter) of urine when she put it on the bed. She said she saw the backflow of the urine on the tube, and it was flowing back into his bladder, which could cause infection for the resident. She said the Foley bag should always be below the bladder to prevent backflow and help drain the urine through gravity. In addition, she stated the aides During an interview on 11/30/22 at 11:16 a.m., the DON said Resident #21's foley bag should be below the bladder level, so the urine will not backflow into the resident bladder to prevent infection. She said Resident #21 wants the bag on top of the bed while he is being turned and repositioned . The DON said she educated the resident, but she did not document or care plan it, and it was her fault. She stated the Foley bag should have been emptied before WCN A placed on the bed. Record review of Resident #16's face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were, Alzheimer's disease (loss of memory, confusion, and difficulty in thinking), major depressive disorder (feeling of sadness and loss of interest), generalized anxiety (excessive worry and feeling of fear), and anoxic brain damage (brain is starved of oxygen). Record review of Resident #16's quarterly MDS assessment, dated 08/23/22, revealed a BIMS score of 03 indicating severely impaired cognition. Further review revealed Resident #16 needed extensive assistance with ADL care with one staff assistance and the resident was incontinent of bowel and bladder. Record review of Resident #16's undated care plan revealed the resident had ADL (activity of daily living) self-care performance deficit related to limited impairment to upper extremity. Intervention: resident needed extensive assist with one person assistance with incontinent care. An observation on 11/29/22 at 10:45 a.m. revealed RCP AA washed her hands, dried her hands, used a dry towel, and turned off the water faucet. Then she placed the dry towel with the wet towel and continued to dry her hand until she entered Resident #16 room, and she disposed of the paper towel in the trash can by the door. She donned her gloves, wiped Resident #16's peri area, and went back into the wipe packet four times during the procedure with the same gloved hand she was cleaning the resident with. RCP AA did not separate the resident's labia or buttocks and wiped the rectum or both sides of the buttocks during incontinent care. She changed her gloves once but did not wash or sanitize her hands before she donned another pair of gloves. During an interview on 11/29/22 at 1:47 p.m., RCP AA said she washed her hand and dried her hand with a paper towel, and turned off the water faucet, but she continued to use the wet and dry paper towel. She stated she turned off the water faucet to dry her hands again and trashed it in the trash can in the resident's room. RCP AA said she contaminated her hands and donned her gloves without washing or sanitizing her hands. She said she should have pulled wipes from the container before starting care for Resident #16, and that would have prevented her from going into the wipe container with her dirty gloved hand. RCP AA said she was trying to hurry, and she did not separate Resident #16's labia and clean it three times, and she also did not open the buttock cheeks and wipe it or the buttocks. She said there was no reason why she should not clean Resident #16 properly. She said she had skills check off and in-services on incontinent care. She said the resident could got an infection and skin breakdown if not cleaned properly. RCP AA said the nurses monitored the aides to ensure they provided ADL care. During an interview on 11/30/22 at 8:32 a.m., LVN A said the nurses trained the aides on how to provide incontinence care, and other aides trained new aides on how to care for the residents. She said Resident #16's labia should have been correctly separated and cleaned on both sides and in the middle. LVN A said if RCP AA did not clean Resident #16 thoroughly, she could have gotten a UTI and rashes. She stated the buttocks should have been separated and wiped from front to back, and the buttocks themselves should have been wiped too. During an interview on 11/30/22 at 11:42 a.m., the DON said RCP AA should have been separated Resident #16's labia and wiped both sides and the middle. If the aide could not see the rectum, she had to separate and wipe the left and right buttocks. She said there could be a negative outcome for Resident #16, such as UTI and skin breakdown. She said the charge nurse monitored the aides and ensured they provided care for the residents, while the nurse managers, including the DON monitored the nurses , by making random checks. In an interview on 11/01/22 at 9:30 a.m., ADON AAA said RCP AA should have pulled her wipes so as not to use her dirty gloved hand and take wipes from the container. RCP AA should have prevented contaminating the wipe container when she used her dirty glove and pulled wipes from the container during incontinent care for Resident #16. She said when she changed the dirty gloves, she should have washed or sanitized her hand before donning a clean glove. She stated the labia and buttocks were separated to ensure the resident was completely cleaned. She said there should have been a trash can in the restroom to prevent the staff from cross-contamination after they washed their hands. Record review of RCP AA's competency assessment revealed she had perineal care check off dated 09/8/22. Record review of LVN A competency assessment revealed she had suprapubic catheter care skill check off dated 05/16/22 but there was no section on how to flush the foley. Record review of WCN A competency assessment revealed she had no skill check off on suprapubic catheter care. Record review of the facility's policy on perineal care, dated 10/01/21, read in part . to provide cleanliness and comfort to the resident, to prevent infection and skin irritation . steeps in procedure . #8b1 . separate labia and wash . #8d . wash the rectal area thoroughly . Record review of the facility's policy on catheters, dated 04/20/21, read in part . it is the policy of this community that resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risk of urinary tract infections . Record review of the facility's skills check of suprapubic catheter, dated 2018, MED -PASS, Inc (Revised October 2010) read in part . general guidelines . #4 . the urinary drainage bag must be held or position lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff were able to demonstrate competency in skills and techniques 1 of 2 RCPs and 2 of 2 LVN (RCP AA G, LVN A and WCN A )observed for care, in that: 1. The facility failed to ensure LVN A followed proper infection control procedure during Resident #21's foley care. 2. The facility to ensure WCN A placed Resident # 21's foley bag below the bladder during turning and repositioning in bed. 3. The facility failed to ensure RCP AA followed proper hand hygiene technique, and separated the labia and buttocks during Resident # 16's incontinent care. These failure could affect residents who were incontinent and place them at risk for urinary tract infections, discomfort, skin breakdown, and a decreased quality of life. Findings include: Record review of Resident #21's face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were, neuromuscular dysfunction of bladder (lacks bladder control), major depressive disorder (feeling of sadness and loss of interest), neurogenic bowel (loss of normal bowel due to a nerve problem), generalized anxiety (excessive worry and feeling of fear), and hypotension (low blood pressure). Record review of Resident #21's annual MDS assessment, dated 09/16/22, revealed a BIMS score of 14 indicating intact cognition. Further review revealed Resident #21 needed total assistance with ADL care with one to two staff and the resident was incontinent of bowel and had a supra pubic catheter. Record review of Resident #21's undated care plan revealed the resident had ADL (activity of daily living) self-care performance deficit related to quadriplegia. Intervention: resident needed total assist with one person assistance with personal hygiene. It also revealed the resident had a suprapubic catheter related to neurogenic bladder and was at risk for increased urinary tract infections. Interventions: Monitor/record/ report to MD (medical doctor) for signs and symptoms of UTI, pain, burning, blood tinted urine, cloudiness, and no output. Record review of Resident #21's order summary report for November 2022, read: flush suprapubic catheter with 60 CCs of normal saline every shift, for a flush ordered date 07/19/20. During an observation on 11/29/22 at 9:10 a.m., LVN A walked into the room and placed a syringe wrapped in four brown paper towels on top of Resident #21 refrigerator, and walked out of the room. She returned to the room with a black basket, took the wrapped-up syringe, placed it on the basket, and sat it on the bedside table. LVN A washed her hands, dried her hand with a paper towel, and used another dry paper towel to turn off the water tap. She placed the dry paper towel with the ones she had dried her hands and continued to dry her hands until she came out of the restroom and disposed of them into the trash can in the resident's room. While donning gloves, one of the gloves was torn, and she took a glove from her uniform pocket and donned it. Then she took the basket and placed it on the resident bed, removed the brown paper towels, and placed it between the resident legs. She disconnected the tubing from the Foley bag from the French Foley catheter and inserted the 60 CC syringe filled with water (normal saline). While she pushed the fluid into the French catheter, the liquid splashed out on Resident #21's face (eyes, mouth, and nose) and shirt. LVN A took the brown paper towel from the bed, which she used as a barrier, and wiped the resident's face. Resident #21 told LVN A not to use the paper towel to clean his face because it had already been between his legs. LVN A said it was just water and the paper was clean. She did not check to see if the water used for the flush returned from the Foley. During an interview on 11/29/22 at 2:03 p.m., LVN A said she placed the 60 CC syringe on top of the refrigerator, which was on top of the nightstand, and the paper towel and tip of the syringe were touching Resident # 21's lotion and orange juice bottle. LVN A said she placed the syringe in a basket with the contaminated paper from the nightstand. She used the same paper towel as a barrier when pushing the water into the Foley. The water splashed while she irrigated (cleaned) the Foley, and some of the water splashed on the resident's face and clothes. She wiped the resident face with the paper towel she placed on the refrigerator and used it as a barrier. LVN A said she had to use a glove from her uniform pocket, and she should not have used it because it had her germs, and she could have transferred her germs to the resident. LVN A said she should have cleaned the bedside table, placed a barrier, set her supply for irrigation for the Foley to prevent contaminating the syringe, and checked to see if the irrigation had cleared the sediments and if the Foley was draining appropriately. LVN A said she should not have used the paper towel she used as a barrier to clean Resident # 21 face because she could have transferred germs from the bed and the Foley to his face, which could have gone to her respiratory system. LVN A said no trash can in the restroom was why she mistakenly dried her hands again with the used paper towel and contaminated her hands. She said she had in service on infection control and skills check-off. During an interview on 11/30/22 at 11:01 a.m.; the DON said LVN A should had cleaned the bedside table, placed a barrier, set up an irrigation supply, then provided care to Resident #21 with the flush amount as ordered. The DON said it was an infection control issue because the paper towel and syringe had been contaminated because they touched the personal items on top of the resident's refrigerator. The DON said LVN A should not have used the paper and cleaned the resident's face because it was contaminated from being placed on the bed as a barrier during foley irrigation. LVN A could have transferred the germs from the peri area to the resident's face. She said the staff should not carry gloves in their uniform pocket or use them to attend to residents. She stated LVN A should have checked and ensured the water used to flush the foley, returned and the sediment and the foley were draining appropriately. During an observation on 11/29/22 at 10:15 a.m., WCN A assisted in turning and repositioning Resident #21 when she placed Resident #21's foley bag on the bed. The urine was observed back flowing in the tube. WCN A said the urine in the tube was back flowing into Resident #21's bladder because it was on the bed. WCN A placed the catheter bag on the bed for 5 minutes. When WCN A lowered the foley bag, she said now the urine was returning to the foley bag. During an interview on 11/30/08/22 at 8:15 a.m., WCN A said she placed Resident #21's Foley bag on the bed for a while, but did not know how long it was at the bladder level. She said she thought the foley bag should be placed on the bed; while turning the resident. WCN A stated the foley bag had 700 CC (centimeter) of urine when she put it on the bed. She said she saw the backflow of the urine on the tube, and it was flowing back into his bladder, which could cause infection for the resident. She said the Foley bag should always be below the bladder to prevent backflow and help drain the urine through gravity. In addition, she stated the aides During an interview on 11/30/22 at 11:16 a.m., the DON said Resident #21's foley bag should be below the bladder level, so the urine will not backflow into the resident bladder to prevent infection. She said Resident #21 wants the bag on top of the bed while he is being turned and repositioned . The DON said she educated the resident, but she did not document or care plan it, and it was her fault. She stated the Foley bag should have been emptied before WCN A placed on the bed. Record review of Resident #16's face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were, Alzheimer's disease (loss of memory, confusion, and difficulty in thinking), major depressive disorder (feeling of sadness and loss of interest), generalized anxiety (excessive worry and feeling of fear), and anoxic brain damage (brain is starved of oxygen). Record review of Resident #16's quarterly MDS assessment, dated 08/23/22, revealed a BIMS score of 03 indicating severely impaired cognition. Further review revealed Resident #16 needed extensive assistance with ADL care with one staff assistance and the resident was incontinent of bowel and bladder. Record review of Resident #16's undated care plan revealed the resident had ADL (activity of daily living) self-care performance deficit related to limited impairment to upper extremity. Intervention: resident needed extensive assist with one person assistance with incontinent care. An observation on 11/29/22 at 10:45 a.m. revealed RCP AA washed her hands, dried her hands, used a dry towel, and turned off the water faucet. Then she placed the dry towel with the wet towel and continued to dry her hand until she entered Resident #16 room, and she disposed of the paper towel in the trash can by the door. She donned her gloves, wiped Resident #16's peri area, and went back into the wipe packet four times during the procedure with the same gloved hand she was cleaning the resident with. RCP AA did not separate the resident's labia or buttocks and wiped the rectum or both sides of the buttocks during incontinent care. She changed her gloves once but did not wash or sanitize her hands before she donned another pair of gloves. During an interview on 11/29/22 at 1:47 p.m., RCP AA said she washed her hand and dried her hand with a paper towel, and turned off the water faucet, but she continued to use the wet and dry paper towel. She stated she turned off the water faucet to dry her hands again and trashed it in the trash can in the resident's room. RCP AA said she contaminated her hands and donned her gloves without washing or sanitizing her hands. She said she should have pulled wipes from the container before starting care for Resident #16, and that would have prevented her from going into the wipe container with her dirty gloved hand. RCP AA said she was trying to hurry, and she did not separate Resident #16's labia and clean it three times, and she also did not open the buttock cheeks and wipe it or the buttocks. She said there was no reason why she should not clean Resident #16 properly. She said she had skills check off and in-services on incontinent care. She said the resident could got an infection and skin breakdown if not cleaned properly. RCP AA said the nurses monitored the aides to ensure they provided ADL care. During an interview on 11/30/22 at 8:32 a.m., LVN A said the nurses trained the aides on how to provide incontinence care, and other aides trained new aides on how to care for the residents. She said Resident #16's labia should have been correctly separated and cleaned on both sides and in the middle. LVN A said if RCP AA did not clean Resident #16 thoroughly, she could have gotten a UTI and rashes. She stated the buttocks should have been separated and wiped from front to back, and the buttocks themselves should have been wiped too. During an interview on 11/30/22 at 11:42 a.m., the DON said RCP AA should have been separated Resident #16's labia and wiped both sides and the middle. If the aide could not see the rectum, she had to separate and wipe the left and right buttocks. She said there could be a negative outcome for Resident #16, such as UTI and skin breakdown. She said the charge nurse monitored the aides and ensured they provided care for the residents, while the nurse managers, including the DON monitored the nurses , by making random checks. In an interview on 12/01/22 at 9:30 a.m., ADON AAA said RCP AA should have pulled her wipes so as not to use her dirty gloved hand and take wipes from the container. RCP AA should have prevented contaminating the wipe container when she used her dirty glove and pulled wipes from the container during incontinent care for Resident #16. She said when she changed the dirty gloves, she should have washed or sanitized her hand before donning a clean glove. She stated the labia and buttocks were separated to ensure the resident was completely cleaned. She said there should have been a trash can in the restroom to prevent the staff from cross-contamination after they washed their hands. Record review of RCP AA's competency assessment revealed she had perineal care check off dated 09/8/22. Record review of LVN A competency assessment revealed she had suprapubic catheter care skill check off dated 05/16/22 but there was no section on how to flush the foley. Record review of WCN A competency assessment revealed she had no skill check off on suprapubic catheter care. Record review of facility policy on competency of nursing staff dated 2001 MED - PASS, Inc. (Revised October 2017) read in part . all nursing staff must meet the specific competency requirements of their respective licensure ana certification requirements . Record review of facility policy on perineal care dated 10/01/21 read in part . to provide cleanliness and comfort to the resident, to prevent infection and skin irritation . steeps in procedure . #8b1 . separate labia and wash . #8d . wash the rectal area thoroughly . Record review of the facility policy on catheters dated 04/20/21 read in part . it is the policy of this community that resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risk of urinary tract infections . Record review of the facility skills cheek of suprapubic catheter dated 2018 MED -PASS, Inc(Revised October 2010) read in part . general guidelines . #4 . the urinary drainage bag must be held or position lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of two (Resident #181 and #33) of five residents reviewed for medication administration. -The facility failed to ensure Resident #181 and Resident #33 received medications as ordered by the physician. This failure could place residents at risk of medicinal adverse effects, decreased health status and being hospitalized . Findings include: Resident # 181 Record review of the admission sheet (undated) for Resident # 181 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included unspecified asthma, syncope and collapse and hypertension. Record review of Resident #181's baseline care plan, dated 11/23/22, read in part: .3. Health Conditions: 1a. oxygen therapy-while a resident. Record review of Resident#181's physician order, dated 11/25/22, revealed an order for Pulmicort suspension 1 mg/2ml (Budesonide) 2 ml inhale orally via nebulizer two times a day for asthma AE for 10-15 minutes each dose. Record review of Resident#181's MAR for the month of November 2022 revealed Pulmicort suspension 1 mg/2ml (Budesonide) 2 ml inhale orally via nebulizer two times a day for asthma AE for 10-15 minutes each dose. Documented '9' 9=other/ see progress notes on 11/29/22 at 9:00am and 5:00pm. In an interview on 11/29/22 at 9:51a.m., with Resident#181, she said she was new to the facility. She said she received breathing treatments throughout the day, but did not remember the name of the medication or the times treatments were given. In an interview on 11/29/22 at 11:45a.m. with RN B, she said Resident#181 did not receive her Budesonide breathing treatment that morning at 9:00 am. RN B said she was out of Budesonide in her cart and in the e-kit. She said she called the pharmacy and the pharmacy said they would send it out that day to be available for the evening dose. She said she did not notify the NP/MD of the missed dose because the pharmacy said they would send it that evening. She said, personally we need to have 5 to 7 days of meds on hand. So, we don't run out of meds. I don't work on this hall. She said if the med was not available, the nurse needed to call the doctor and call the pharmacy for follow up on the status of med. In an interview on 11/30/22 at 2:54p.m. with RN A she said Resident #181 did not receive her Budesonide breathing treatment yesterday (11/29/22) at 5pm because it was 'on order'. She said the 6-2 pm shift nurse told her, during shift report on 11/29/22, that she called the pharmacy and the pharmacy said it would be delivered by evening. She said, I did not call the doctor/NP that the resident missed her breathing treatment because the pharmacy told the 6-2 pm nurse that the medication was coming. She said the facility's protocol was to have 4 days of medications on hand. She said the risk for not getting breathing treatments as ordered was resident could have respiratory issues. Record review of the admission sheet (undated) for Resident # 33 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness (generalized), contracture, right hand and contracture of muscle, right hand. Record Review of Resident #33's comprehensive MDS assessment, dated 10/07/2022, revealed the BIMS score was 11 out of 15 indicating moderately impaired cognitive skills. Further review of the MDS revealed that she required extensive assistance from staff for dressing, toilet-use, personal hygiene, and supervision with eating. Resident was always incontinent of bowel and bladder. Record Review of care plan, dated 6/22/22 and revised on 6/23/22, revealed the following: Focus: (Resident #33) has the potential for pain r/t R Hemiplegia[x] R Hand and R Foot Contractures Stroke. Goal: (Resident #33) will maintain current ADLs and pain/discomfort will be relieved with interventions through the review date. Interventions: Administer pain medications as ordered. Discuss with physician that for maximum pain relief pain medication are best given around the clock, with prns for breakthrough pain. Monitor for potential side effects of pain medication. Discuss with resident factors that precipitate pain and what may reduce it. Record review of Resident#181's physician order, dated 11/12/22, revealed an order for Pregabalin Capsule 100 MG. Give 1 capsule by mouth every 12 hours for Nerve Pain. Record review of Resident#181's physician order, dated 11/30/22, revealed an order for Salonpas Pain Relief Patch Patch (Menthol-Methyl Salicylate). Apply to hips topically at bedtime for pain and remove per schedule. Record review of Resident#33's MAR, for November 2022, revealed an order for Pregabalin Capsule 100 MG Give 1 capsule by mouth every 12 hours for Nerve Pain. Documented '9' 9=other/ see progress notes on 11/27/22. Record review of Resident#33's MAR for the month of November 2022 revealed an order for Salonpas Pain Relieving Patch (Lidocaine) Apply to both hips topically at bedtime for Pain and remove per schedule. Documented '9' 9=other/ see progress notes on 11/23/22, 11/24/22, 11/25/22, 11/26/22, 11/27/22, 11/28/22 and 11/29/22. Record review of Resident #33's nurses notes dated 11/23/2022 at 7:58pm written by MA ZZ read in part: .Did not give . Record review of Resident #33's nurses notes dated 11/24/2022 at 7:49pm written by MA ZZ read in part: Salonpas pain relieving patch apply to both hips topically at bedtime for pain and remove per schedule on order . Record review of Resident #33's nurses notes dated 11/25/2022 8:28am written by MA LL read in part: . Salonpas pain relieving patch apply to both hips topically at bedtime for pain and remove per schedule not acceptable . Record review of Resident #33's nurses notes dated 11/25/2022 8:44pm written by MA ZZ read in part: .Did not give . Record review of Resident #33's nurses notes dated 11/26/2022 9:17am written by MA LL read in part: .Salonpas Pain Relieving Patch Apply to both hips topically at bedtime for Pain and remove per schedule not acceptable . Record review of Resident #33's nurses notes dated 11/27/2022 9:22am written by MA LL read in part: .Salonpas Pain Relieving Patch Apply to both hips topically at bedtime for Pain and remove per schedule not on . Record review of Resident #33's nurses notes dated 11/27/2022 8:37pm written by MA ZZ read in part: .Waiting on supply . Record review of Resident #33's nurses notes dated 11/28/2022 11:46am written by MA GG read in part: .Pregabalin Capsule 100 MG Give 1 capsule by mouth every 12 hours for Nerve Pain medication not given. awaiting pharmacy delivery . Record review of Resident #33's nurses notes dated 11/28/2022 11:49 written by MA GG read in part: .Salonpas Pain Relieving Patch Apply to both hips topically at bedtime for Pain and remove per schedule . Record review of Resident #33's nurses notes dated 11/29/2022 8:18pm written by MA ZZ read in part: . Did not give . Record review of Resident #33's nurses notes dated 11/30/2022 8:50am written by MA LL read in part: .Salonpas Pain Relieving Patch Apply to both hips topically at bedtime for Pain and remove per schedule Not acceptable . Record review and interview on 12/01/22 at 12:35p.m., with Resident # 33, she said her hip and buttocks hurt a lot. She said, I am supposed to get a pain patch daily but nurses don't usually put it on. In an interview and record review on 11/30/22 at 2:08 p.m. with MA LL, she said Resident #33 had an order for salonpas pain patch applied to both hips at bedtime for pain and removed in the morning. She said she documented 'not acceptable' because there was no patch on the resident to remove. She said she would ask the resident and the resident told her that the night nurse did not apply the patch on her. She said the facility's policy was to have 9 to 10 days of meds on hands before re-ordering so the resident would not go without their meds. In an interview and record review on 11/30/22 at 3:03p.m. with MA ZZ, she said Resident#33 had an order for a pain patch but it was not always available for her to apply. She said she would check for the pain patch in the med room and if it was not available, she would notify the nurse. So, the evening nurse would let the oncoming night nurse during the shift report. She stated the night shift nurse would let the morning shift nurse know to tell the Unit Manager the patch was not available and needed to be re-ordered. In an interview and record review on 12/01/22 at 9:54a.m. with ADON AAA, she said if a resident's med was not available, the nurse needed to call the doctor and let them know the ordered medication was not available, so the doctor would order a different med or dose that was available in the e-kit. She said 5 days of meds should be on hand. She said the pharmacy did not let them re-order before that. She said she was aware Resident#33 missed one day of not having her pain patch because the resident had an order for Salonpas Pain Relieving Patch (Lidocaine) and the facility had Salonpas Pain Relief Patch Patch (Menthol-Methyl Salicylate), so she called the NP on 11/30/22 and received an order for resident to have the patch that was available. In an interview and record review on 12/01/22 at 12:20p.m. with the DON, she said if the resident missed a dose, or the medication was not available on hand, the doctor needed to be notified immediately. The nurse should have called the pharmacy to get the status of the drug. She said nurses should have 7 days worth of meds on hand and to let her or the Administrator know as they both have access to preauthorization. She said the Salonpas patch was available in house. The DON stated ADON could go to the Walmart across the street as it was readily available. When asked how were staff monitored to ensure they were ordering meds appropriately and when needed DON/ADONs were responsible for monitoring and training staff on the process of ordering medication, she said she expected nurses to check the e-kit, and if the med was not available, the nurse was supposed to call the doctor to let them know which meds were not available or on hand. This Surveyor reviewed Resident #33's consolidated orders, MAR and the nurses notes with the DON. The DON said nurses' notes should have read when the nurse notified the doctor and if any new orders were given. Attempts to contact the pharmacy to find the status of the medication. Record review of facility's Pharmacy Services Overview policy (revised April 2007) read in part: .Policy statement: The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed pharmacist. 3. The facility shall contract with a licensed pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consisted with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility and Medical Director to: f. Help the facility assure the medications are requested, received, and administered in timely manner as ordered by authorized prescribers .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access for 2 of 5 residents (Resident #59 and Resident # 63) reviewed for medications in that: The facility failed to ensure Resident #59 and Resident# 63 did not have medication in their room. This failure could affect all residents and place them at risk for medication diversion, being administered the wrong medication, injury, and hospitalization. Findings include: Record review of the admission sheet (undated) for Resident #59 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included unspecified dementia, unspecified severity with other behavioral disturbance, obsessive-compulsive disorder, and cognitive communication deficit. Record review of Resident #59's quarterly MDS assessment, dated 10/25/2022, revealed a BIMS of 08 out of 15 indicating moderately impaired cognition. He required limited assistance from staff for dressing, toilet-use, personal hygiene. He required supervision with transfers and bed mobility. Resident #59 was always continent of bowel and bladder. Record review of Resident #59's care plan, dated 12/20/2021 and revised on 6/10/2022, revealed the following care plan: Focus: (Resident #59) had impaired cognitive function, impaired decision-making abilities, was not always understood or able to understand verbal and non-verbal expression. DX: dementia. Goal: (Resident #59) will be able to communicate basic needs on a daily basis through the review date 01/19/2023 Interventions: COMMUNICATION: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Cue, reorient and supervise as needed. Present just one thought, idea, question or command at a time. Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. Resident #59 was not care planned for having meds at bedside. During an observation and attempted interview on 11/29/22 at 8:32 a.m. of Resident #59, in his room, revealed a bottle of Vitamin C sitting on top of the bedside table, a bottle of aspirin sitting on the resident's bed, and two bottles of multivitamins sitting in a clear bin near resident's bed. Resident #59 mumbled for 5 minutes, while being interviewed, and did not respond appropriately to the questions asked about OTC meds at bedside. Record review of Resident #59's physician's order revealed Resident #59 was not prescribed the above-mentioned medication. There were no orders for self-administration. During an observation and interview on 11/29/22 at 11:39a.m. with RN B, she said residents were not supposed to have any medications at bedside because they could react with any other medications given to them per their orders. She said she did not know how the medications got in his room. RN B said the resident did not have orders for it. RN B took the medication and told Resident #59, If you need these medications, we have it at the facility, but I need to get an order for it. I am going to have to take it with me. She said we needed to verify any allergy or adverse effect of the medication before giving it to the resident. She said the doctor had to approve it first. Resident #59 became upset and grabbed the OTCs out of RN B's hand. RN B left the medication with the resident at bedside. In a later interview and record review on 11/29/22 at 12:05p.m. with RN B. This Surveyor reviewed Resident #59's physician orders with the Surveyor. RN B said the resident did not have an order for OTC meds. She said, management is aware [of] resident having OTC [meds] in his room. Whenever he goes to dining room, we go to his room and take the meds out or else he fights us if we touch his meds. Record review of the admission sheet (undated) for Resident #63 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included senile degeneration of brain, cognitive communication deficit, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #63's quarterly MDS assessment, dated 11/18/2022, revealed a BIMS of 07 out of 15 indicating moderately impaired cognition. She required total dependence from staff for dressing, toilet-use, personal hygiene, transfers and bed mobility. Record review of Resident #63's care plan initiated 10/15/21 and revised on 6/24/22 revealed the following: Focus: (Resident#63) had impaired cognitive function and problems with communication related to language barrier and dementia. Goal: (Resident#63) will be able to communicate basic needs on a daily basis through the review date. Interventions: Communicate with the resident/family/caregivers regarding residents capabilities and needs. Cue, reorient and supervise as needed. Resident was not care planned for having meds at bedside. During an observation and attempted interview on 11/29/22 at 8:41 a.m., of Resident #63 in her room revealed a bottle of l-lysine 1000mg, bottle of cranberry caps, and 2 bottles of tums sitting on top of the side table. Resident #63 mumbled for 5 minutes while being interviewed and did not respond appropriately to the questions asked about OTC meds at bedside. Record review of Resident #63's physician's order revealed Resident #59 was not prescribed the above-mentioned medications. There were no orders for self- administration. During an observation and interview on 11/29/22 at 11:46 a.m. with RN B, she said residents were not supposed to have any medications at their bedside. RN B said, there is nobody in that room. I just transferred this resident to the hospital. Her family member must have brought it. At that time, RN B took the OTC meds out of the resident's room and placed them in her med cart. She said, I was not aware residents had meds in their room. She said nurses needed to call the doctor and get an order because we don't know what residents were taking. We could be giving them that medicine as well and resident can overdose. In an interview on 11/30/22 at 2:31p.m., the DON said residents were not allowed to have medication in their rooms. She said if a resident was deemed safe to self-administer medication, they would also need a doctor's order. She said Resident #59 and #63 were not deemed safe to have medications in their room. The DON said, Resident#59 constantly does that. I have spoken to his family on several occasions, and they get very aggressive. It's a cultural thing. Family feels he needs certain meds, but the doctor hasn't prescribed. It's mostly herd, supplement OTC. She said but he was not supposed to have OTC at his bedside. She said department heads made focused rounds and were responsible for checking the rooms for medications. She said risk for leaving OTC at bedside was not safe med administration, might not be right dose, have adverse effect, OTC meds could interact with prescribed meds, overdose and wanders can get hold of meds. She said she was not aware of Resident #63 having meds at bedside. Record review of facility's Storage of Medications policy (Revised April 2007) read in part: .Policy statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for 3 of 4 Residents(Resident #21, Resident #16 and Resident 10) reviewed for infection control. 1. The facility failed to ensure LVN A provided proper infection control procedures during foley care for Resident #21. 2. The facility failed to ensure WCN A provided proper hand washing and infection control procedure during wound care assessment and repositioning for Resident #21. 3. The facility failed to ensure RCP AA provided proper handwashing and infection control procedure during incontinent care for Resident #16. 4. The facility failed to ensure RCP AA provided proper use of PPE after providing a shower for Resident #10. These deficient practices could affect residents and place them at risk for infection, and cross contamination. Findings include: Record review of Resident #21's face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were, neuromuscular dysfunction of bladder (lacks bladder control), major depressive disorder (feeling of sadness and loss of interest), neurogenic bowel (loss of normal bowel due to a nerve problem), generalized anxiety (excessive worry and feeling of fear), and hypotension (low blood pressure). Record review of Resident #21's annual MDS assessment, dated 09/16/22, revealed a BIMS score of 14 indicating intact cognition. Further review revealed Resident #21 needed total assistance with ADL care with one to two staff and the resident was incontinent of bowel and had a supra pubic catheter. Record review of Resident #21's undated care plan revealed the resident had ADL (activity of daily living) self-care performance deficit related to quadriplegia. Intervention: resident needed total assist with one person assistance with personal hygiene. It also revealed the resident had a suprapubic catheter related to neurogenic bladder and was at risk for increased urinary tract infections. Interventions: Monitor/record/ report to MD (medical doctor) for signs and symptoms of UTI, pain, burning, blood tinted urine, cloudiness, and no output. Record review of Resident #21's order summary report for November 2022, read: flush suprapubic catheter with 60 CCs of normal saline every shift, for a flush ordered date 07/19/20. During an observation on 11/29/22 at 9:10 a.m., LVN A walked into the room and placed a syringe wrapped in four brown paper towels on top of Resident #21 refrigerator, and walked out of the room. She returned to the room with a black basket, took the wrapped-up syringe, placed it on the basket, and sat it on the bedside table. LVN A washed her hands, dried her hand with a paper towel, and used another dry paper towel to turn off the water tap. She placed the dry paper towel with the ones she had dried her hands and continued to dry her hands until she came out of the restroom and disposed of them into the trash can in the resident's room. While donning gloves, one of the gloves was torn, and she took a glove from her uniform pocket and donned it. Then she took the basket and placed it on the resident bed, removed the brown paper towels, and placed it between the resident legs. She disconnected the tubing from the Foley bag from the French Foley catheter and inserted the 60 CC syringe filled with water (normal saline). While she pushed the fluid into the French catheter, the liquid splashed out on Resident #21's face (eyes, mouth, and nose) and shirt. LVN A took the brown paper towel from the bed, which she used as a barrier, and wiped the resident's face. Resident #21 told LVN A not to use the paper towel to clean his face because it had already been between his legs. LVN A said it was just water and the paper was clean. She did not check to see if the water used for the flush returned from the Foley. During an interview on 11/29/22 at 2:03 p.m., LVN A said she placed the 60 CC syringe on top of the refrigerator, which was on top of the nightstand, and the paper towel and tip of the syringe were touching Resident # 21's lotion and orange juice bottle. LVN A said she placed the syringe in a basket with the contaminated paper from the nightstand. She used the same paper towel as a barrier when pushing the water into the Foley. The water splashed while she irrigated (cleaned) the Foley, and some of the water splashed on the resident's face and clothes. She wiped the resident face with the paper towel she placed on the refrigerator and used it as a barrier. LVN A said she had to use a glove from her uniform pocket, and she should not have used it because it had her germs, and she could have transferred her germs to the resident. LVN A said she should have cleaned the bedside table, placed a barrier, set her supply for irrigation for the Foley to prevent contaminating the syringe, and checked to see if the irrigation had cleared the sediments and if the Foley was draining appropriately. LVN A said she should not have used the paper towel she used as a barrier to clean Resident # 21 face because she could have transferred germs from the bed and the Foley to his face, which could have gone to her respiratory system. LVN A said no trash can in the restroom was why she mistakenly dried her hands again with the used paper towel and contaminated her hands. She said she had in service on infection control and skills check-off. During an interview on 11/30/22 at 11:01 a.m.; the DON said LVN A should have cleaned the bedside table, placed a barrier, set up an irrigation supply, then provided care to Resident #21 with the flush amount as ordered. The DON said it was an infection control issue because the paper towel and syringe had been contaminated because they touched the personal items on top of the resident's refrigerator. The DON said LVN A should not have used the paper and cleaned the resident's face because it was contaminated from being placed on the bed as a barrier during foley irrigation. LVN A could have transferred the germs from the peri area to the resident's face. She said the staff should not carry gloves in their uniform pocket or use them to attend to residents. She stated LVN A should have checked and ensured the water used to flush the foley, returned and the sediment and the foley were draining appropriately. During an observation on 11/29/22 at 10:15 a.m., WCN A assisted in turning and repositioning Resident #21 when she placed Resident #21's foley bag on the bed. The urine was observed back flowing in the tube. WCN A said the urine in the tube was back flowing into Resident #21's bladder because it was on the bed. WCN A placed the catheter bag on the bed for 5 minutes. When WCN A lowered the foley bag, she said now the urine was returning to the foley bag. During an interview on 11/30/08/22 at 8:15 a.m., WCN A said she placed Resident #21's Foley bag on the bed for a while, but did not know how long it was at the bladder level. She said she thought the foley bag should be placed on the bed; while turning the resident. WCN A stated the foley bag had 700 CC (centimeter) of urine when she put it on the bed. She said she saw the backflow of the urine on the tube, and it was flowing back into his bladder, which could cause infection for the resident. She said the Foley bag should always be below the bladder to prevent backflow and help drain the urine through gravity. In addition, she stated the aides During an interview on 11/30/22 at 11:16 a.m., the DON said Resident #21's foley bag should be below the bladder level, so the urine will not backflow into the resident bladder to prevent infection. She said Resident #21 wants the bag on top of the bed while he is being turned and repositioned . The DON said she educated the resident, but she did not document or care plan it, and it was her fault. She stated the Foley bag should have been emptied before WCN A placed on the bed. Record review of Resident #16's face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were, Alzheimer's disease (loss of memory, confusion, and difficulty in thinking), major depressive disorder (feeling of sadness and loss of interest), generalized anxiety (excessive worry and feeling of fear), and anoxic brain damage (brain is starved of oxygen). Record review of Resident #16's quarterly MDS assessment, dated 08/23/22, revealed a BIMS score of 03 indicating severely impaired cognition. Further review revealed Resident #16 needed extensive assistance with ADL care with one staff assistance and the resident was incontinent of bowel and bladder. Record review of Resident #16's undated care plan revealed the resident had ADL (activity of daily living) self-care performance deficit related to limited impairment to upper extremity. Intervention: resident needed extensive assist with one person assistance with incontinent care. An observation on 11/29/22 at 10:45 a.m. revealed RCP AA washed her hands, dried her hands, used a dry towel, and turned off the water faucet. Then she placed the dry towel with the wet towel and continued to dry her hand until she entered Resident #16 room, and she disposed of the paper towel in the trash can by the door. She donned her gloves, wiped Resident #16's peri area, and went back into the wipe packet four times during the procedure with the same gloved hand she was cleaning the resident with. RCP AA did not separate the resident's labia or buttocks and wiped the rectum or both sides of the buttocks during incontinent care. She changed her gloves once but did not wash or sanitize her hands before she donned another pair of gloves. During an interview on 11/29/22 at 1:47 p.m., RCP AA said she washed her hand and dried her hand with a paper towel, and turned off the water faucet, but she continued to use the wet and dry paper towel. She stated she turned off the water faucet to dry her hands again and trashed it in the trash can in the resident's room. RCP AA said she contaminated her hands and donned her gloves without washing or sanitizing her hands. She said she should have pulled wipes from the container before starting care for Resident #16, and that would have prevented her from going into the wipe container with her dirty gloved hand. RCP AA said she was trying to hurry, and she did not separate Resident #16's labia and clean it three times, and she also did not open the buttock cheeks and wipe it or the buttocks. She said there was no reason why she should not clean Resident #16 properly. She said she had skills check off and in-services on incontinent care. She said the resident could got an infection and skin breakdown if not cleaned properly. RCP AA said the nurses monitored the aides to ensure they provided ADL care. During an interview on 11/30/22 at 8:32 a.m., LVN A said the nurses trained the aides on how to provide incontinence care, and other aides trained new aides on how to care for the residents. She said Resident #16's labia should have been correctly separated and cleaned on both sides and in the middle. LVN A said if RCP AA did not clean Resident #16 thoroughly, she could have gotten a UTI and rashes. She stated the buttocks should have been separated and wiped from front to back, and the buttocks themselves should have been wiped too. During an interview on 11/30/22 at 11:42 a.m., the DON said RCP AA should have been separated Resident #16's labia and wiped both sides and the middle. If the aide could not see the rectum, she had to separate and wipe the left and right buttocks. She said there could be a negative outcome for Resident #16, such as UTI and skin breakdown. She said the charge nurse monitored the aides and ensured they provided care for the residents, while the nurse managers, including the DON monitored the nurses , by making random checks. In an interview on 11/01/22 at 9:30 a.m., ADON AAA said RCP AA should have pulled her wipes so as not to use her dirty gloved hand and take wipes from the container. RCP AA should have prevented contaminating the wipe container when she used her dirty glove and pulled wipes from the container during incontinent care for Resident #16. She said when she changed the dirty gloves, she should have washed or sanitized her hand before donning a clean glove. She stated the labia and buttocks were separated to ensure the resident was completely cleaned. She said there should have been a trash can in the restroom to prevent the staff from cross-contamination after they washed their hands. Record review of Resident #10's Face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were, morbid obesity (abnormal fat accumulation that present a risk to health), hypertension (persistently raised pressure), diabetes mellitus (when the body does not make enough insulin or do not use it the way it should), chronic obstructive pulmonary disease (makes breathing difficult), and schizoaffective disorder (mental illness that affect thoughts, mood, and behavior). Record review of Resident #10's quarterly MDS assessment, dated 11/11/22, revealed a BIMS score of 15 indicating intact cognition. Further review revealed Resident #10 needed extensive assistance with shower/bath with one staff and the resident was continent of bowel and bladder. Record review of Resident #10's undated care plan revealed the resident had ADL (activity of daily living) self-care performance deficit related to sick sinus and COPD. Intervention: resident needed extensive assistance with one person with bathing/shower. An observation on 12/01 22 at 9:15 a.m. revealed RCP AA propelled Resident #10 out of the shower room on 100 hall and closed the door behind her. She pushed the resident two doors down from the shower room with gloves on her hands. During an interview on 12/01/22 at 9:20 a.m., RCP AA said she forgot to take off the gloves she wore when she gave Resident #10 a shower and dressed her up in the shower room. RCP AA said she was supposed to have taken the gloves off and washed her hands after she showered and dressed up the resident. She said gloves should have not been worn in the hallway whether it was clean or dirty, because of the spreading of germs. During an interview on 12/01/22 at 9:30 a.m., ADON AAA said RCP AA should have taken off her gloves and washed her hand in the shower before she took Resident # 10 out of the shower room. She was not supposed to walk out of the shower room because of infection control issues. She touched the door handle of the shower room and was walking in the hallway while pushing Resident# 10 wheelchair with the used gloved. Record review of LVN A skills - check off dated 5/16/22 revealed she was checked off on isolation and PPE and it included hand washing. Record review of RCP AA skills - check off dated 5/16/22 revealed she was checked off on hand hygiene. Record review of RCP AA's competency assessment revealed she had perineal care check off dated 09/8/22. Record review of LVN A competency assessment revealed she had suprapubic catheter care skill check off dated 05/16/22 but there was no section on how to flush the foley. Record review of WCN A competency assessment revealed she had no skill check off on suprapubic catheter care. Record review of the facility's policy on infection control dated 2001 MED - PASS, Inc. Revised October 2018) read in part . the facility's infection control policies and practice are intended to facilitate maintain . to help prevent and manage transmission of disease and infection . Record review of the facility policy on hand hygiene dated 8/4/21 red in part .hand hygiene is used to prevent the spread of pathogens . procedure .#9 dry your hands thoroughly with a clean disposable towel. Drop the towel in a trashcan without touching the container. Then use a clean, dry disposable towel to turn off the faucet Record review of facility policy on perineal care dated 10/01/21 read in part . to provide cleanliness and comfort to the resident, to prevent infection and skin irritation . steeps in procedure . #8b1 . separate labia and wash . #8d . wash the rectal area thoroughly . Record review of the facility policy on catheters dated 04/20/21 read in part . it is the policy of this community that resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risk of urinary tract infections . Record review of the facility skills cheek of suprapubic catheter dated 2018 MED -PASS, Inc(Revised October 2010) read in part . general guidelines . #4 . the urinary drainage bag must be held or position lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .

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 68 of 77 residents receiving meals other than via Gastrostomy tubes. -Opened packages in the walk-in freezer were not labelled or dated. -Food holding temperatures were not within safe parameters. -Food service staff were not able to state what safe reheating temperatures were. The deficient practice placed residents at risk for food-borne illness. Findings include: Observation on 11/29/2022 at 8:19 a.m. revealed the facility kitchen had a walk-in freezer. Observation inside the freezer revealed one blue plastic bag on a shelf. The bag was not labelled or dated. The contents were not visible. It was on top of an unopened box of Italian vegetable blend. Continued observation revealed a plastic bag that contained hashbrowns. The bag was not labelled or dated. Continued observation revealed a second plastic bag that contained a plastic tray half-filled with unknown contents. Observation on 11/29/2022 at 8:27 a.m. revealed an unopened 16 ounce block of margarine on a shelf in the dry pantry. There was an opened bag of dry spaghetti on one of the shelves. There was no date on the spaghetti wrapper. Observation and interview on 11/29/2022 at 8:45 a.m. with [NAME] A revealed she acknowledged the unlabeled items in the freezer. She said the bag with the unknown contents contained dinner rolls from the previous day. She placed them into an opened box of dinner rolls without dating the bag. She gathered the blue bag and the bag of hashbrowns and exited the freezer. Observation and interview on 11/29/2022 at 8:50 a.m. revealed [NAME] A picked up the margarine from the shelf in the pantry. She said it was still cold, and handed it to Kitchen Staff B. Kitchen Staff B placed it in the walk-in refrigerator. Interview on 11/29/2022 at 11:00 a.m. with the Dietary Manager revealed he said when foods were opened and placed back in the freezer or refrigerator they should be sealed, labelled, and dated. Observation and interview on 11/29/2022 at 11:05 a.m. with the Dietary Manager revealed the blue plastic bag and the opened bag of hashbrowns were in the freezer, dated 11/29/2022. The opened bag of dinner rolls was in the box, but was not labelled or dated. The Dietary Manager said if the opened bag was placed back in the same box, it did not need to be dated. Observation on 11/29/2022 at 11:10 a.m. revealed two stainless steel containers on the surface of the stove. One contained baked chicken pieces. One contained mixed vegetables. The gas burners under the containers were not on. Observation and interview on 11/29/2022 at 12:35 p.m. revealed [NAME] A retrieved the container of baked chicken from the stove. As she was placing it on the steam table, the surveyor asked her to check the temperature. [NAME] A then said she needed to warm the chicken up. She placed the container in the oven. Observation on 11/29/2022 at 12:41 p.m. revealed [NAME] A checked the temperature of the container of vegetables on the stove. The thermometer reflected 136 degrees F. She used a towel she had been using to wipe counter surfaces on to pick up a container of vegetables from the steam table. Observation revealed the surface of the dirty towel contacted the remaining vegetables. [NAME] A began to pour the vegetables into the container of vegetables on the stove. The surveyor asked her to stop and informed her the towel had become in contact with the contents. When asked if that was safe, [NAME] A said 'no' and placed the container to the side. She then placed the full container from the stove into the oven. Observation on 11/29/2022 at 12:45 p.m. revealed [NAME] A retrieved the baked chicken from the oven. The temperature was 119 degrees F. Interview on 11/29/2022 at 12:51 p.m. with the Dietary Manager revealed he said the re-heated foods needed to reach a temperature of 135 degrees F. The surveyor asked him to check with their policy. Interview on 11/29/2022 at 1:02 p.m. with the Dietary Manager revealed he said the foods needed to be re-heated to 165 degrees F. Observation on 11/29/2022 at 1:26 p.m. revealed the re-heated baked chicken and vegetables were at 165 degrees F. Record review of the facility policy Food Receiving and Storage (revised October 2017) revealed Foods shall be received and stored in a manner that complies with safe food handling practices. The policy also reflected .8. All foods stored in the refrigerator or freezer will be covered, labeled and dated [use by date]. Record review of the facility policy Food Preparation and Service (revised October 2017) revealed the 'danger zone' for food temperatures was between 41 degrees F and 135 degrees F, due to the rapid growth of pathogenic microorganisms that cause foodborne illness. The policy reflected .6. Previously cooked food must be reheated to 165 degrees F for at least 15 seconds. Record review of the CMS Form 672 dated 11/29/2022 revealed that of the 77 residents at the facility, 9 were receiving tube feedings.