**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview , the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 15 residents reviewed for resident rights. (Resident #31) The facility failed to treat Resident #31 with dignity and respect by CNA F denying his request to have food brought by his family reheated on 02/12/2025. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety. Findings included: Record review of a face sheet dated 04/01/25 indicated Resident #31 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of heart disease, unsteadiness on feet, and generalized weakness. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #31 had a BIMS of 15, which indicated intact cognition. Resident #31 required moderate to maximal assistance for most ADLs. Record review of a care plan dated 03/27/25 indicated Resident #31 had right hemiplegia/hemiparesis (a condition characterized by paralysis on one side of the body) related to a stroke and would maintain optimal status and quality of life within limitations imposed by hemiplegia/hemiparesis. Record review of a Nurse's Note for Resident #31 dated 02/12/25 at 8:00 p.m. indicated, .Res (resident) reports he is upset with CNA staff person due to her declining to heat food brought in by a family member . she made me feel like I didn't need any food. Explained policy of not being able to heat food brought in by family due to infection control, cross contamination and inability to control heat levels of food heated in the microwave. Res voiced understanding but states you know that's BS . The Nurse's Note was signed by RN G. Record review of a Nurse's Note for Resident #31 dated 02/12/25 at 8:30 p.m. indicated, .Res on CL (call light) and CNA went to his aid. She returned to this nurse reporting res had her prepare some snacks for him. She reports res was crying saying he didn't have any supper. This nurse talked with res (resident) and he is calm and having his snacks. Offered crackers or a banana off snack cart and he declines saying he has plenty now . The Nurse's Note was signed by RN G. During an observation and interview on 03/31/25 at 1:55 p.m., Resident #31 said a family member had brought him food from a restaurant. He said the food had been in his refrigerator . There was a refrigerator beside his bed. He said he asked CNA F to reheat the food for him so he could eat it for dinner on 02/12/25. He said she told him it was not their practice to heat up food for residents. He said he had cancelled his supper tray. He said she should have told him that she could not reheat his food before she cancelled his supper for him. He said he was angry and upset that CNA F would not reheat his food for him. He said he skipped supper even though they offered him a sandwich. He said she made him uncomfortable. During an interview on 04/01/25 at 2:12 p.m., CNA F said she went in to Resident 31's room and he asked her to warm up some food that a family member had brought him. She said she carried the food to the kitchen and dietary staff told her they were not allowed to bring it into the kitchen to heat it up due to cross contamination. She said she then went to the nurse and the nurse told her the same thing. She said the nurse also told her she could not heat the food up in the employee breakroom microwave. She said when she went back to tell Resident #31 and he became very upset. She said all she told him was I can only do so much. She said the decision was not up to her. She said he then refused his evening meal tray. She said around 7:15 p.m. she went back in the room to get his roommates bed ready to put him to bed. She said Resident #31 became very upset and began yelling at her. She said he was yelling and hollering. She said again she tried to explain that she had nothing to do with it. That she was not allowed heat up his food. She said she told him to be upset with the nurse and the dietary staff. She said there were no witnesses to the conversation. During an interview on 04/01/25 at 3:18 p.m., RN G said CNA F never came to her and asked her about heating up Resident 31's food. She said staff had been told not to heat up residents' food because they could not regulate the temperature and it was an infection control issue. She said if she were in her home and could not have her food heated up it would make her feel terrible. She said it was Resident 31's right to have his food headed up. She said Resident #31 cried because his food was not heated up for him. During an interview on 04/01/25 at 3:56 p.m., the Social Services Assistant said she met with Resident #31, the DON, and Interim Administrator. She said there were no witnesses to the incident. She said she talked to him about his food not being heated up and he told her it pissed him off. He told her it made him feel like he was fat, and it would not hurt him to miss a meal. He told her that CNA F had not said that to him, but it was how it made him feel. During an interview on 04/02/25 at 9:04 a.m., the Dietary Manager said they did not reheat food that came from outside of the facility. She said this because they cannot prove where it came from or if it is safe or not. She said it would upset her if her food was not reheated but being in the business as long as she had, she would understand the rules and regulations. During an interview on 04/02/25 at 11:07 a.m., the DON said nursing staff could not reheat food for residents. He said food had to be served at a certain temperature and CNAs did not have food preparation training. He said he could not speculate on how not reheating a resident's food could negatively affect a resident. During an interview on 04/02/25 at 11:26 a.m., the Interim Administrator said Resident #31 had requested for CNA F to reheat food his family brought in. She said Dietary staff told CNA F that they could not reheat the food due to cross contamination. She said food brought in by family members was not reheated because they were not able to temp the food and the resident could be burned. She said if the food was old the resident could come in contact with a food borne illness. She said for as much as they were able to do so, she would expect 100% for the resident's preferences to be followed. She said resident preferences not being followed could affect their quality of life and their satisfaction could be negatively affected. Record review of a Foods Brought by Family/Visitors facility policy last revised in 03/2022 indicated, .Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of resident . Record review of a Food and Nutrition Services facility policy last revised in 10/2017 indicated, .Reasonable efforts will be made to accommodate resident choices and preferences . Record review of a Resident Rights facility policy last revised 02/2021 indicated, .Federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the resident's right to .a dignified existence .self-determination .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 3 residents (Residents #7) reviewed for urinary catheters. 1. The facility failed to ensure CNA D performed hand hygiene and changed gloves appropriately during and after providing incontinent care to Resident #7. 2. The facility failed to ensure CNA D performed hand hygiene and changed gloves appropriately prior to providing indwelling urinary catheter care to Resident #7. These failures could place residents at an increased risk for urinary tract infections. Findings included: Record review of Resident #7's face sheet dated 4/01/25 revealed he was [AGE] years old and admitted to the facility on [DATE]. Resident #7 had diagnoses including dementia (forgetfulness), senile degeneration of brain (progressive decline in cognitive abilities, such as memory, thinking, and reasoning), diabetes (high blood sugar, places at higher risk of infection), retention of urine, and chronic kidney disease. Record review of Resident #7's annual MDS assessment dated [DATE] indicated he was unable to complete the BIMS, which indicated he had severe cognitive impairment. Resident #7 was dependent on staff assistance for most ADLs. The MDS indicated Resident #7 had an indwelling catheter (urinary catheter inserted into the bladder to drain urine). The MDS indicated Resident #7 was always incontinent of bowel. Record review of Resident #7's undated Care Plan Report indicated he had an indwelling catheter related to retention of urine with interventions including catheter care daily and PRN; he was at risk for self-care deficit with interventions including toileting-dependent x 2 staff; he had bowel incontinence with interventions including to check resident every two hours and assist with toileting as needed, and provide peri (human private area) care after each incontinent episode. Record review of Resident #7's Order Summary Report dated 4/02/25 revealed an order for foley (urinary) catheter care every shift with an order date of 2/06/25. During an observation on 4/01/25 beginning at 3:30 PM to observe incontinent care and urinary catheter care, observed an Enhanced Barrier Precautions sign and an isolation cart outside the door of Resident #7. CNA D and CNA E both donned (put on) isolation gowns prior to entering Resident #7's room. Upon entering Resident #7's room, CNA D and CNA E washed their hands and donned gloves. CNA D picked up Resident #7's fall mat off of the floor, folded it, and placed against the wall. Then CNA D pulled Resident #7's bed away from the wall and CNA E went between the wall and Resident #7's bed. CNA D without performing hand hygiene or changing gloves, she proceeded to pull Resident #7's bed sheet back toward his feet, unfastened his brief, then assisted CNA E turn Resident #7 onto his right hip toward CNA E by putting one gloved hand on Resident #7's shoulder and the other gloved hand on his hip and pushed him toward CNA E. CNA D then removed Resident #7's soiled brief and proceeded to cleanse feces (bowel movement) from his buttocks using wipes. CNA D then assisted CNA E assist Resident #7 back on to his back by placing one gloved hand on his shoulder and the other gloved hand on his hip and she did not perform hand hygiene or change her gloves after cleaning feces from his buttocks. CNA D, without performing hand hygiene or changing her gloves, then proceeded to use a wipe to cleanse Resident #7's head of his penis, then used a wipe to cleanse down each side of his testicles, then CNA D used another wipe to cleanse down his urinary catheter tubing and repeated twice. CNA D then assisted CNA E to roll Resident #7 over onto his right hip toward CNA E and placed a new brief on him. CNA D then placed her same gloved hands on his hip and shoulder to turn Resident #7 onto his back. CNA D and CNA E then used a draw sheet to pull Resident #7 up in bed. CNA D placed a positioning wedge under Resident #7's left side, then placed his urinary catheter bag back on the side of his bed, then covered Resident #7 with a bed sheet, then moved his bed back against wall, then CNA D used his bed remote to let Resident #7 down to a low position. CNA D did not perform hand hygiene or change her gloves at any point while providing incontinent care, urinary catheter care, positioning, or arranging Resident #7's furniture, except upon entering Resident #7's room and prior to exiting Resident #7's room. During an interview on 4/01/25 at 3:44 PM, CNA E said she had worked at the facility for approximately six years and normally worked on the 6 AM - 2 PM shift. CNA E said staff should perform hand hygiene and change gloves when a resident has had a bowel movement and before placing clean stuff underneath resident. CNA E said CNA D should have changed her gloves after handling the floor fall mat and prior to providing care to the Resident #7. CNA E said CNA D should have changed gloves and washed her hands after cleaning the bowel movement off Resident #7. CNA E said staff could give the resident an infection, such as a UTI (urinary tract infection), if they use the same gloves used to clean bowel movement and whatever bacteria could have been on the floor fall mat. CNA E said CNA D should have washed her hands and changed gloves prior to handling the residents bedding, bed remote, or anything that was not contaminated. CNA E said CNA D could have given Resident #7 any bacteria that could have been on her gloves onto his urinary catheter, clean brief, clothing, bedding, positioning wedge, bed, and bed remote and then the resident could have touched them and even put his hand in his mouth and given him an infection. CNA E said she had received training on performing incontinent care, urinary catheter care, and infection control, and when to perform hand hygiene and when to change gloves. CNA E said it was an infection control issue when CNA D contaminated Resident #7's urinary catheter, his clothing, clean brief, bed, bedding, bed remote, positioning wedge, and urinary catheter bag. During an interview on 4/01/25 at 3:55 PM, CNA D said she had worked at the facility for a little over a year as a CNA and normally worked the 6 AM - 2 PM shift. CNA D said she should have changed her gloves after picking up the floor fall mat and prior to providing care to Resident #7. CNA D said she should have performed used hand sanitizer and changed her gloves after cleaning bowel movement off Resident #7's back half and then flipped him back to do his front half. CNA D said not sanitizing and changing her gloves after cleaning bowel off Resident #8's back half and then performing incontinent/urinary catheter care and then touching multiple things in Resident #7's room was cross contamination and could cause the resident an infection. CNA D said she had been trained on performing hand hygiene, when to change gloves, incontinent care, urinary catheter care, and infection control and prevention. CNA D said she was just nervous. CNA D said it all was an infection control issue. During an interview on 4/01/25 at 4:02 PM, LVN C said staff should wash hands, put gloves on, change gloves when going from dirty to clean, wash hands, change gloves, and then finish dressing or other things. LVN C said it would be cross contamination if staff did not change their gloves from picking something up off the floor, then performing bowel incontinent care, then urinary catheter care, and then proceeding to touch multiple surfaces and bedding in the resident's room. LVN C said the nursing facility residents had a weaker immune system and it placed them at a higher risk of infection. LVN C said it was cross contamination and an infection control issue. During an interview on 4/02/25 at 9:42 AM, RN B said staff should gather their supplies for incontinent care and/or foley catheter care, then wash their hands, and put on gloves. RN B said staff should perform hand hygiene and change their gloves when going from a dirty area to a clean area. RN B said staff should have removed the resident's fall mat and moved his bed prior to beginning resident care and then washed their hands and applied new gloves. RN B said staff should have changed gloves prior to performing front perineal area care and foley catheter care after cleaning bowel movement from the buttocks of the resident. RN B said it was an infection control issue and it was unsanitary by touching everything around the resident without performing hand hygiene or changing gloves. RN B said residents were on Enhanced Barrier Precautions because they were at a higher risk of infection due to having medical implanted devices such as feeding tubes or urinary catheters. RN B said by staff not changing gloves after cleaning bowel movement and then performing urinary catheter care, there was an increased risk of introducing E-coli (Escherichia coli-bacteria found in feces/bowel movement) into the system and placed the resident at a higher risk of infection. During an interview on 4/02/25 at 10:38 AM, the DON said CNA D should have approached the resident with clean gloves and should have changed gloves and sanitized after performing bowel movement incontinent care and after performing incontinent /urinary catheter care, and again before touching anything clean. The DON said the staff had received training on appropriate hand hygiene, changing gloves, incontinent care, urinary catheter care, and infection control. The DON said he could not speculate what the risk to the resident would be from CNA D not performing hand hygiene or changing her gloves appropriately and then touching multiple surfaces in close proximity of Resident #7. The DON said Resident #7 was on Enhanced Barrier Precautions because he had a urinary catheter because that was the way the Enhanced Barrier Precautions guidelines were written. The DON said he could not speculate if Resident #7 was at a higher risk of infection or urinary tract infections from CNA D not changing her gloves or performing hand hygiene appropriately. During an interview on 4/02/25 at 12:17 PM, the ADM said by the CNA not performing hand hygiene or changing her gloves appropriately, it could be an infection control concern. The ADM said by the CNA touching multiple things in the resident's room, it was cross contamination and could place the resident at a higher risk of infections and UTIs (urinary tract infections). The ADM said she would expect staff to follow the facility's policies related to infection control, hand hygiene, incontinent care, and urinary catheter care. Record review of CNA Orientation/Competency check-off form dated completed on 1/09/25 for CNA D indicated she was evaluated by the DON on 1/09/25 on Incontinent Care to include perineum care and foley catheter care and had a check mark in the Passed column . Record review of the facility's policy titled Perineal Care dated revised February 2018 indicated . the purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . steps in the procedure . wash and dry your hands thoroughly . fold the bedspread or blanket toward the foot of the bed . fold the sheet down to the lower part of the body . put on gloves . for a male resident . wash perineal area (private area) starting with the urethra (opening at head of penis) working outward . if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches, gently rinse and dry the area . wash and rinse the rectal area thoroughly . remove gloves and discard . wash and dry hands thoroughly . reposition the bed covers, make the resident comfortable . wash and dry your hands thoroughly . Record review of the facility's policy titled Catheter Care, Urinary dated revised August 2022 indicated . purpose of this procedure was to prevent urinary catheter-associated complications, including urinary tract infections . infection control . use aseptic technique when handling or manipulating the drainage system . Record review of the undated CDC (Centers for Disease Control and Prevention) Indwelling Urinary Catheter Insertion and Maintenance revealed CAUTI (catheter-associated urinary tract infections) were costly and increased morbidity . maintenance catheter care essentials . when an indwelling urinary catheter was indicated, the following interventions should be in place to help prevent infection . use indwelling catheters only when medically necessary . properly secure indwelling catheters to prevent movement and urethral traction . maintain good hygiene at the catheter-urethral interface . maintain unobstructed urine flow . maintain drainage bag below level of bladder at all times . use a catheter securement device to anchor the catheter . perform peri and catheter care per facility policy . assess the patient for any pain or discomfort . inspect for redness, irritation and drainage . once a urinary catheter was inserted, maintaining it according to evidence-based guidelines was crucial to prevent CAUTI . Record review of the facility's policy titled Handwashing/Hand Hygiene dated revised August 2019 indicated . the facility considered hand hygiene the primary means to prevent the spread of infections . all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . wash hands with soap and water for the following situations . when hands are visually soiled . use alcohol-based hand rub or soap and water in the following situations . before and after direct contact with residents . before and after handling an invasive device (urinary catheters, intravenous access sites, etc.) . before moving from a contaminated body site to a clean body site during resident care . after contact with objects in the immediate vicinity of the resident . the use of gloves does not replace hand washing/hand hygiene . integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication storage room (medication storage room [ROOM NUMBER]) reviewed for medication storage. The facility failed to ensure Zinc 50mg was not expired in medication storage room [ROOM NUMBER]. The unopened bottle of Zinc expiration date was 3/2025. The facility failed to ensure Acetaminophen Suppositories 650mg were not expired in the medication storage room [ROOM NUMBER]'s medication refrigerator. The suppositories expiration date was 12/10/24. The facility failed to ensure an opened box of Bisacodyl Suppositories 10mg were not expired in the medication storage room [ROOM NUMBER]'s medication refrigerator. The suppositories expiration date was 2/28/25. These failures could place residents at risk for adverse effects and reduced therapeutic effects of medication and supplies. Findings included: During an observation on 4/1/25, starting at 9:40 a.m., this surveyor reviewed 1 of 1 medication storage rooms and found the following medications with expired expiration dates: *One, unopened bottle of Zinc Tablets 50mg with dated expiration of March 2025. *One package of Acetaminophen Suppositories 650 mg with dated expiration of 12/10/24. *One, opened box of Bisacodyl Suppositories 10mg with dated expiration of 2/28/25. During an interview on 4/2/25 at 11:14 a.m., MA H said there was no designated person responsible for checking expiration dates on medications in the storeroom. She said there was also no set day expiration dates were checked on medications. She said expiration dates were checked before the medication ordering was done. She said the ADON ordered the medications in the storeroom. She said the nurse checked expiration dates on the medications stored in the refrigerator. She said the nurses normally gave the medications stored in the refrigerator. She said expired medications should not be in the storeroom because staff could mistakenly grab an expired medication and give it to a resident. She said if an expired medication was given, the resident would not get the full dose of the medication. During an interview on 4/2/25 at 11:47 a.m., the ADON said, the MAs, LVNs, and RNs were responsible for ensuring expired medications were not in the storeroom. She said they had a MA that kept a pretty good track of expired medications being removed. She said she looked at the expiration dates when ordering more medications. She said the Pharmacy Consultant also performed a monthly sweep for expired medications. She said the nurses were responsible for the medications in the storeroom refrigerator. She said expired medications lost effectiveness and changed their chemical makeup. She said she was ultimately responsible for ensuring expired medications were not stored in the medication storeroom. During an interview on 4/2/25 at 12:00 p.m., RN B said MAs and nurses were responsible for ensuring expired medication were not in the storeroom. She said expiration dates were checked randomly. She said if the medication was close to expiring, the nursing staff circled the expiration date. She said there was no designated person responsible for checking expiration dates on medications in the storeroom. She said there was also no set time expiration dates were checked on medications. She said expired medications should not be stored in the medication room because it could be given to the resident, and it would not work. She said the expired medication would not do its job. During an interview on 4/2/25 at 12:11 p.m., the DON said nursing administration was responsible for ensuring expired medications were not stored in the storeroom. He said MAs and nursing staff were also responsible. He said the pharmacy consultant did a sweep for expired medication once or twice a year. He said expired medication should not be stored in the medication room. He said it increased the risk of a resident being administered an expired medication. He said he could not speculate on how an expired medication affected the resident. During an interview on 4/2/25 at 12:44 p.m., the Administrator, with the Interim Administrator present, said nursing was responsible for ensuring expired medications were not stored in the storeroom. She said she did not know the process of how the facility ensured expired medications were not stored in the storeroom. She said when expired medications were stored, they could potential be given to the residents. She said it could negatively impact the health of the resident if they received an expired medication. She said the DON was ultimately responsible for ensuring expired medications were not stored in the medication storeroom. Record review of a facility's Storage of Medications revised 11/2020 indicated, .all drugs and biologicals in a safe, secure, and orderly manner . nursing staff is responsible for maintaining medication storage and preparation . discontinue, outdated or deteriorated drugs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 3 of 22 residents reviewed for care plans (Resident #8, Resident #29, and Resident #41). 1. The facility failed to develop a comprehensive person-centered care plan for Resident #29's depression and impaired coping with interventions following aggressive behaviors (scratched roommate on face) on 2/21/2025 and calling the police telling them he was being held hostage at gunpoint on 3/18/2025. 2. The facility failed to develop a comprehensive person-centered care plan for Resident #41's for wounds and enhanced barrier precautions (a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs; are bacteria that are resistant to multiple antibiotics and antifungals) implemented. 3.The facility failed to develop a comprehensive person-centered care plan for Resident #8's DNR code status (instruction to not perform life saving measures if a person's heart or breathing stops), diet, anorexia (abnormal loss of the appetite for food), use of a plate guard, mood, anxiety, impaired visual function, and urinary incontinence. These failures could place residents at risk of not having their individualized needs met, and a decline in their quality of care and life. Findings included: 1. Record review of Resident #29's face sheet dated 4/1/2025 indicated Resident #29 was a [AGE] year-old male readmitted to the facility on [DATE]. Resident #29 had diagnoses including unspecified displaced fracture of surgical neck of right humerus (a severe injury where the arm bone (humerus) is broken near the shoulder), fracture of the lower end of right radius (a fracture of the lower end of the right radius (wrist), fracture of unspecified part of neck of right femur (when the ball on top of the femur breaks off at its junction with the neck of the upper thigh bone within the hip joint), Atherosclerotic heart disease of native coronary artery (a buildup of plaque (a waxy, fatty substance) in the arteries), cirrhosis of the liver (is advanced scarring of the liver caused by many diseases and conditions, including hepatitis or alcohol use disorder ) and Major depressive disorder(a mental disorder characterized by a persistent low mood, loss if interest or pleasure in activities). Record review of Resident #29's admission MDS assessment dated [DATE] indicated Resident #29 was usually understood and usually understood others. Resident #29 had a BIMS of 08 which indicated moderate cognitive impairment. Resident # 29 had a diagnosis of Depression and was prescribed antidepressant. Record review of Resident #29's care plan revised on 3/31/2025 indicated Resident #29 had impaired coping with an intervention to monitor the effectiveness of Resident's immediate support system. There was no care plan indicating resident had aggression toward roommate or others, interventions, or effective coping measures to prevent future behaviors. During an interview and observation on 3/31/2025 at 10:39 AM, Resident #29 observed lying in bed with fall mate next to bed. Resident #29 was disheveled in appearance. Resident #29 said he was not eating much because he had a stomachache and he said he was losing weight. Resident said his depression had not been addressed. Resident #29 said he did not want to be here anymore. Resident denied having a plan to harm himself. During an interview on 3/31/2025 at 11:50 AM, the DON was made aware of Resident #29's statement. The DON said he would get the SW and start interventions and a plan for Resident #29's depression. The DON said Resident #29 recently came off isolation and hospice care. During an interview on 3/31/2025 at 12:15 PM, the Social Worker said the resident told her that he has said those things many of times throughout his life and he would not do anything to harm himself. The Social Worker said an outside psychiatric group recently resumed care and the staff are encouraging Resident #29 to participate in activities. During an interview on 3/31/2025 at 1:00 PM, Resident # 29 said he was depressed, not suicidal. The DON came into the room during that time and started conversation with Resident #29. During an interview on 4/1/2025 at 3:35 PM, the Social Worker said Resident #29 should have a Trauma Informed Care assessment, but the Psychiatric group came to the facility while Resident #29 was on Covid restrictions. The Social worker said she had not completed his Trauma Informed care because the facility did not have an official form. The Social worker said she determined if a resident needed a Trauma Informed Care assessment and it was identified if a resident had a diagnosis of depression, other mental illness or behaviors. The Social Worker said she was out when Resident #29 came to the facility. During an interview on 4/1/2025 at 3:50, the Social Worker provided the Trauma Informed Care policy and said she made a referral a couple of weeks ago and the Psychiatric group came in while Resident #29 was on Covid (Coronavirus disease of 2019) restrictions. She said initially Resident #29 was on respite care. The Social Worker said the Psychiatric group would be returning to the facility on 4/4/2025 and she was going to update Resident #29's care plan. During an interview on 4/1/2025 at 4:10 PM, Resident #29's RP said he was a negative person and said he stayed depressed. Resident #29's RP said Resident #29 had multiple losses in his past and past motor vehicle wrecks. Resident #29's RP said the facility was going to resume psychological therapy. 2. Record review of Resident #41's face sheet dated 03/31/2025 indicated Resident #41 was an [AGE] year-old male readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (a lung condition caused by damage to the airways and alveoli, usually from smoking or other irritants), Chronic cystitis (infection or inflammation of the urinary bladder or any part of the urinary system cause by a bacteria), Diverticulitis of large intestine without perforation or abscess without bleeding (an inflammation with or without infection of a diverticulum (a pouch-like structure that form in the wall of the large intestine), which causes abdominal pain and can create a collection of pus around the inflamed diverticulum), pressure ulcer of head (an injury to the skin and the tissue below the skin that are due to pressure on the skin for a long time), and abnormal weight loss ( a noticeable drop in your body weight without trying). Record review of Resident #41's comprehensive MDS assessment dated [DATE] indicated Resident #41 understood and was understood by others. Resident #41 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #41 was at risk of developing pressure ulcer/injuries. Record review of Resident #41's care plan initiated on 3/14/2025 indicated Resident #41 had an incomplete care plan and did not indicate he was on enhanced barrier precautions or had any skin concerns. Record review of Resident #41's treatment administration record dated 3/1/2025-3/31/2025 indicated Resident #41 had multiple abrasions documented as follows: o Abrasion to bridge of nose: Resolved 3/17/2025 o Pressure area to left top of ear: Resolved 3/12/2025 o Left lower knee- Resolved 3/3/2025, 3/17/2025 o Abrasion to left lower hip- Resolved 3/17/2025 o Abrasion to lower left lateral leg- ongoing o Left shoulder wound- Resolved 3/12/2025 o Left upper arm wound- Resolved 3/26/2025 o Right shoulder wound- Resolved 3/7/2025 o Right knee wound- Resolved 3/26/2025 o Right lower shin wound- Resolved 3/12/2025 During an interview on 4/2/2025 at 10:22 AM, RN B said the CNAs know what to do for each resident because they have been there for a while. RN B said the care should be on the care plan. RN B said the care plan was completed by the MDS nurse and the nurses complete the assessments and initiate the care plan along with the MDS nurse. RN B said the ADON, DON and the MDS nurse initiate the care plan. She said the nurse staff would also let the staff know if a resident had a foley catheter. She said the initiation of the care plan should be completed within 24 hours. She said if a resident did not have the proper care plan in place, the staff would know how a resident should be transferred, what medications, oxygen and how they eat. She said if a care plan was not initiated a resident could have a fall if improperly transferred, if foley care was not provided and resident could get an infection. RN B said it was the responsibility of everyone to ensure the care plan was being followed. During an interview on 4/2/2025 at 10:53 AM, the MDS nurse said she completes the care plan. She said the DON completes the baseline care plan and each department completes their part, and the baseline goes into the soft file. The MDS nurse said once the care plan goes into the EMR, it pulls over into the new EMR. She said the DON has a cheat sheet with CNA pocket workbook and they keep it at the front. The MDS nurse said she was responsible for ensuring the care plans were put in. The MDS nurse said the facility changed to a new system and she had to put in new care plans on everyone. The MDS nurse said she was adding new care plans to the new EMR when a new resident was admitted and working on the older residents who had been at the facility for a while as she could get to them. The MDS nurse said the facility has morning meetings and she said she tries to get the 24-hour report and updates the care plan. She said the DON ensured the Care plan was in the system and the staff follow the plan of care. The MDS nurse said she had not been adding the EBP to the care plans and said it was a new policy. During an interview on 4/2/2025 at 11:07 AM, the Social Worker said Resident #29 was on respite in October 2024 then discharged and returned on 11/15/2024 for skilled care, then discharged and returned on 1/9/2025. She said upon readmission, Resident #29 was more agitated due to having to return. The Social worker said there was an incident where the resident called the police. She said she knew Resident #29 prior and the RP was concerned about sundowners. The Social Worker said there were other illnesses that could cause delusions and hallucinations. The Social Worker explained Resident #29 had labs in February 2025 to rule out a medical concern before psychological. She said he had slightly elevated ammonia levels but not enough to trigger for hallucinations. She thought he had a urinary tract infection. The Social Worker said she reviewed a trauma informed care policy, and it says it should be performed but was not clear when it should be done, and the regulations were broad. The Social Worker said the facility turn it over the Psychologist. The Social Worker said Resident #29 does things to get RP's attention and had past behaviors of calling RP and cussing them out. The Social Worker said she felt the behaviors were medical and not psychological. The Social Worker said urinary tract infections can cause hallucinations. She said Resident #29 does have depression and was going to get an assessment and it would need to be care planned. During an interview on 4/2/2025 at 12:13 PM, the ADON said she does not complete the care plans. She said the DON completed the initial baseline care plan and the MDS nurse puts in the care plan. The ADON said the MDS nurse should have the care plans updated. She said the plan of care was for the Aides to know what care to provide to the residents. The ADON said she was not involved in the care plans, but she expected the nurses to follow the plan of care. The ADON said she could not speculate what could happen if a care plan was not available. The ADON said enhance barrier precautions should be on the care plan and a container would be outside the resident's door with a sign. She said she could not speculate on what could happen if enhanced barrier precautions were not care planned and followed. During an interview on 4/2/2025 at 12:34 PM, the DON said he completes the baseline care plan within 48 hours, and he talks to the family and offer them a copy of their orders and have them sign it. The DON said the care plan is used to paint a picture of the resident and guides their care. He said the staff should be following the care plan. The DON said he would have to refer the care plan questions to the MDS nurse on when it needs to be completed. The DON said he could not speculate what could happen if a care plan was not completed. The DON said he would have to review enhanced barrier precautions with the infection preventionist. He said the Infection control nurse determined EBP. He said he could not speculate what could happen if staff was not wearing proper personal protective equipment (PPE). During an interview on 4/2/2025 at 12:59 PM, the Interim Administrator said enhanced barrier precautions should be care planned and PPE should have been worn while providing care to Resident #41. The Interim Administrator said if enhanced barrier precautions were not followed or staff was not wearing proper PPE, it could negatively impact the resident quality of life and puts the resident at risk for infection. During an interview on 4/2/2025 at 1:00 PM, the Administrator said the MDS nurse was responsible for ensuring the care plan are in the computer to ensure proper care was delivered. She said it could potentially decrease the quality of care. The Administrator said she would assume the Care Areas populated from the MDS would need to be placed on the care plan. 3. Record review of Resident #8's face sheet dated 3/31/25 revealed she was [AGE] years old and admitted to the facility on [DATE] with an original admission date of 2/09/18. Resident #8 had diagnoses including dementia, anxiety, depression, anorexia, and cataracts (clouding of the normal clear lens of the eye). Record review of Resident #8's annual MDS assessment dated [DATE] indicated she had a BIMS of 3, which indicated she had severe cognitive impairment. The MDS indicated Resident #8 had inattention and disorganized thinking. The MDS indicated Resident #8's vision was severely impaired. The MDS indicated Resident #8 was always incontinent of bowel and bladder. The MDS indicated Resident #8 had diagnoses of anxiety disorder, depression, and anorexia. Record review of Resident #8's Order Summary Report dated 4/02/25 reflected an order for a regular diet with soft finger foods with an order and start date of 9/30/24; an order for a DNR Code Status with an order date of 9/30/24; and an order of may use plate guard on plate at mealtimes with an order date of 2/12/25. Record review of Resident #8's undated Care Plan Report reflected the resident had a mood problem, impaired visual function, and bladder incontinence, but there were no interventions for those focus areas. The Care Plan Report reflected there were no focus areas or interventions related to her DNR code status, diet, anorexia, or use of a plate guard. During an observation on 3/31/25 beginning at 12:48 PM, Resident #8 was sitting in her wheelchair at a dining table. Resident #8 was served her meal on a plate with a plate guard and staff told her what foods and where each food was located on the plate. Resident #8 attempted to feed herself and staff sat at the table beside her to assist and give verbal cues during the meal service as needed. During an interview on 4/02/25 at 10:01 AM, the MDS Coordinator said she was still learning the new software since the new company took over the facility in October 2024. The MDS Coordinator said she was responsible for completing the Comprehensive Care Plans. The MDS Coordinator said the purpose of the Comprehensive Care Plan was to show areas including medications, ADL assistance, diagnoses, preferences, Code Status, oxygen, diet, pressure ulcer risks, and fall risks. The MDS Coordinator said if there was a problem care area on the Comprehensive Care Plan then there should be goals and interventions to manage the problem care area. The MDS Coordinator said she would correct Resident #8's Comprehensive Care Plan and did not know how she missed it. The MDS Coordinator said they had to create brand new care plans for each resident when they switched software systems beginning in October 2024 when the new company took over the facility and she could have missed those care areas then. During an interview on 4/02/25 at 10:38 AM, the DON said the MDS Coordinator and himself were responsible for ensuring the Comprehensive Care Plans were complete and included all the care areas pertinent to the resident. The DON said the purpose of the Comprehensive Care Plan was to paint a picture of the resident and to guide the care of the resident. The DON said care areas such as oxygen, diet, vision impairment, DNR code status, ADL assistance, diagnoses, and medications were care areas that should be included in the Comprehensive Care Plan. The DON said each care should include goals and interventions the Comprehensive Care Plan. The DON said he could not speculate what the risk to the resident would be if the Comprehensive Care Plan did not include all the pertinent care areas for the resident. During an interview on 4/02/25 at 12:17 PM with both the ADM and the Interim ADM, the ADM said the purpose of the Comprehensive Care Plan was to have a clear picture of how the team was to care for the resident, so the resident had the best optimum outcomes. The ADM said general quality of care could be impacted if the resident did not have a complete Comprehensive Care Plan with pertinent care areas specific to the resident and could result in a decreased quality of life. The Interim ADM said all areas of care for each resident needed to be addressed in the Comprehensive Care Plan. Record review of a facility's Care Plans, Comprehensive Person-Centered revised March 2022 indicated .A comprehensive, person-centered care plan that includes measurable objectives and timetables .The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develop and implements a comprehensive .The comprehensive, person-centered care plan is developed within 7 days of the completion of the required MDS assessment (Admission, Annual, or Significant change in status), and no more than 21 days after admission .The care plan interventions are derived from a thorough analysis of the information gathered .Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate .including the right to .participate in the planning process, identify individuals or roles to be included, request meetings, request revisions to the care plan, participate in establishing the expected goals and outcomes of care, and participate in determining the type, amount, frequency and duration of care .Services provided for or arranged by the facility and outlines in the comprehensive care plan are: provided by a qualified person, culturally competent and trauma informed .Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making . When possible, interventions address the underlying source (s) of the problem area (s), not just symptoms triggers . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . Record review of a facility's Care Plans, Comprehensive Person-Centered revised March 2022 indicated .A comprehensive, person-centered care plan that includes measurable objectives and timetables .The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develop and implements a comprehensive .The comprehensive, person-centered care plan is developed within 7 days of the completion of the required MDS assessment (Admission, Annual, or Significant change in status), and no more than 21 days after admission .The care plan interventions are derived from a thorough analysis of the information gathered .Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate .including the right to .participate in the planning process, identify individuals or roles to be included, request meetings, request revisions to the care plan, participate in establishing the expected goals and outcomes of care, and participate in determining the type, amount, frequency and duration of care .Services provided for or arranged by the facility and outlines in the comprehensive care plan are: provided by a qualified person, culturally competent and trauma informed .Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making . When possible, interventions address the underlying source (s) of the problem area (s), not just symptoms triggers . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 10 of 10 residents in a confidential group meeting (Anonymous Resident (AR)1-Anonymous Resident (AR) 10), and 1 of 1 meal (Lunch meal) reviewed for food and nutrition services. The facility failed to ensure on 4/1/25, AR 1through AR 10 were not served hard, burnt dinner rolls at the noon lunch meal. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: During an interview and observation, of a confidential resident group meeting on 4/1/25 at 2:30 p.m., AR1-AR 10 were in attendance and wished to remain anonymous. All residents in the confidential meeting said they attended regularly. Anonymous Resident 1 said the facility served burnt rolls today (4/1/25). Anonymous Resident 1 presented a roll wrapped in a paper towel. The roll was dark brown on top and black on the bottom. The roll presented by AR 1 was hard. All residents in the confidential meeting said they had been served burnt bread today and at other mealtimes. The residents said they did not eat the burnt bread or only ate the top portion of the roll. During an interview on 4/2/25 at 10:48 a.m., the Dietary Manager said the rolls served yesterday (4/1/25) were burnt. She said she noticed the rolls were burnt before they were served. She said she did not instruct [NAME] K to discard the rolls and serve something else. She said bread products for the resident's meals had been burnt and served before. She said the oven cooked unevenly. She said no residents, until today, had complained about breads being served burnt. She said it was important not to serve burnt food because it affected the appearance and flavor. She said she was responsible for ensuring food was not served burnt to the residents. She said she should be doing that by inspecting the meals before they were served to the residents. During an interview on 4/2/25 at 11:24 a.m., CNA D said yesterday (4/1/25) a lot of the resident's rolls were burnt. She said none of the residents she served asked for something else. She said on 4/1/25, most of the residents ate the top portion of the roll. She said occasionally the resident's bread has been burnt in the past. She said most of the time, the residents just ate the top portion of the bread. She said serving the residents burnt bread could upset the residents. She said the residents could have been looking forward to eating a nice, soft roll but then were served a burnt one. During an interview on 4/2/25 at 12:00 p.m., CNA J said she noticed the burnt rolls served on 4/1/25. She said several of the residents did not eat the burnt rolls. She said sometimes the resident's bread was served burnt. She said no alternated bread option was offered to the residents on 4/1/25. She said burnt food affected the appearance and flavor. She said the rolls served yesterday were like little rocks! During an interview on 4/2/25 at 12:11 p.m., the DON said he did not know burnt rolls were served on 4/1/25. He said he expected the dietary staff to follow the guidance of the Dietary Manager in what should or should not be served. He said he could not speculate how the burnt rolls affected the residents. He said burnt food was not palatable. He said the Dietary Manager was responsible to ensure palatable food was served. During an interview on 4/2/25 at 12;44 p.m., the Administrator, with the Interim Administrator present said the dietary team and Dietary Manager were responsible for serving palatable and appetizing meals. She said she expected the dietary team to not serve burnt rolls and to substitute something more palatable. She said serving residents burnt food decreased their quality of life. She said the Dietary Manger was overall responsible for ensuring the dietary team served palatable food to the resident. Record review of a facility's Food and Nutrition Services policy revised 10/2017 indicated, .each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs .food and nutrition service staff will inspect food trays .the food appears palatable and attractive .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 for 2 of 15 residents (Residents #7 and Resident #41) reviewed for infection control practices. 1. The facility failed to ensure CNA D performed hand hygiene and changed gloves appropriately prior to, during, and after providing incontinent care/indwelling urinary catheter care to Resident #7. 2. The facility failed to ensure CNA D did not contaminate Resident #7's clothing, clean brief, bed, bedding, bed remote, positioning wedge, and urinary catheter bag after CNA D had performed bowel incontinent care and incontinent/urinary catheter care. 3. The facility failed to ensure Resident #41 had signage to identify the resident was on Enhance Barrier Precaution (EBP) and the use of personal protective equipment (PPE ) due to open wounds on 4/02/25. 4. The facility failed to ensure Treatment Nurse followed the Enhanced Barrier Precautions (EBP) (interventions to prevent spread of infection in high-risk residents) policy of wearing a gown during Resident #41's wound to left lateral ankle and right mid back wound care to on 4/2/25. These failures could place residents at risk for cross contamination, at an increased risk of infection, and the spread of infection. Findings included: 1. Record review of Resident #7's face sheet dated 4/01/25 revealed he was [AGE] years old and admitted to the facility on [DATE]. Resident #7 had diagnoses including dementia (forgetfulness), senile degeneration of brain (progressive decline in cognitive abilities, such as memory, thinking, and reasoning), diabetes (high blood sugar, places at higher risk of infection), retention of urine, and chronic kidney disease. Record review of Resident #7's annual MDS assessment dated [DATE] indicated he was unable to complete the BIMS, which indicated he had severe cognitive impairment. Resident #7 was dependent on staff assistance for most ADLs. The MDS indicated Resident #7 had an indwelling catheter (urinary catheter inserted into the bladder to drain urine). The MDS indicated Resident #7 was always incontinent of bowel. Record review of Resident #7's undated Care Plan Report indicated he had an indwelling catheter related to retention of urine with interventions including catheter care daily and PRN; he was at risk for self-care deficit with interventions including toileting-dependent x 2 staff; he had bowel incontinence with interventions including to check resident every two hours and assist with toileting as needed, and provide peri (human private area) care after each incontinent episode. Record review of Resident #7's Order Summary Report dated 4/02/25 revealed an order for foley (urinary) catheter care every shift with an order date of 2/06/25. During an observation on 4/01/25 beginning at 3:30 PM of incontinent care and urinary catheter care, surveyor observed an Enhanced Barrier Precautions sign and an isolation cart outside the door of Resident #7. CNA D and CNA E both donned (put on) isolation gowns prior to entering Resident #7's room. Upon entering Resident #7's room, CNA D and CNA E washed their hands and donned gloves. CNA D picked up Resident #7's fall mat off of the floor, folded it, and placed against the wall. Then CNA D pulled Resident #7's bed away from the wall and CNA E went between the wall and Resident #7's bed. CNA D without performing hand hygiene or changing gloves, she proceeded to pull Resident #7's bed sheet back toward his feet, unfastened his brief, then assisted CNA E turn Resident #7 onto his right hip toward CNA E by putting one gloved hand on Resident #7's shoulder and the other gloved hand on his hip and pushed him toward CNA E. CNA D then removed Resident #7's soiled brief and proceeded to cleanse feces (bowel movement) from his buttocks using wipes. CNA D then assisted CNA E assist Resident #7 back on to his back by placing one gloved hand on his shoulder and the other gloved hand on his hip and she did not perform hand hygiene or change her gloves after cleaning feces from his buttocks. CNA D, without performing hand hygiene or changing her gloves, then proceeded to use a wipe to cleanse Resident #7's head of his penis, then used a wipe to cleanse down each side of his testicles, then CNA D used another wipe to cleanse down his urinary catheter tubing and repeated twice. CNA D then assisted CNA E to roll Resident #7 over onto his right hip toward CNA E and placed a new brief on him. CNA D then placed her same gloved hands on his hip and shoulder to turn Resident #7 onto his back. CNA D and CNA E then used a draw sheet to pull Resident #7 up in bed. CNA D placed a positioning wedge under Resident #7's left side, then placed his urinary catheter bag back on the side of his bed, then covered Resident #7 with a bed sheet, then moved his bed back against wall, then CNA D used his bed remote to let Resident #7 down to a low position. CNA D did not perform hand hygiene or change her gloves at any point while providing incontinent care, urinary catheter care, positioning, or arranging Resident #7's furniture, except upon entering Resident #7's room and prior to exiting Resident #7's room. During an interview on 4/01/25 at 3:44 PM, CNA E said she had worked at the facility for approximately six years and normally worked on the 6 AM - 2 PM shift. CNA E said staff should perform hand hygiene and change gloves when a resident has had a bowel movement and before placing clean stuff underneath resident. CNA E said CNA D should have changed her gloves after handling the floor fall mat and prior to providing care to the Resident #7. CNA E said CNA D should have changed gloves and washed her hands after cleaning the bowel movement off Resident #7. CNA E said staff could give the resident an infection, such as a UTI (urinary tract infection), if they use the same gloves used to clean bowel movement and whatever bacteria could have been on the floor fall mat. CNA E said CNA D should have washed her hands and changed gloves prior to handling the residents bedding, bed remote, or anything that was not contaminated. CNA E said CNA D could have given Resident #7 any bacteria that could have been on her gloves onto his urinary catheter, clean brief, clothing, bedding, positioning wedge, bed, and bed remote and then the resident could have touched them and even put his hand in his mouth and given him an infection. CNA E said she had received training on performing incontinent care, urinary catheter care, and infection control, and when to perform hand hygiene and when to change gloves. CNA E said it was an infection control issue when CNA D contaminated Resident #7's urinary catheter, his clothing, clean brief, bed, bedding, bed remote, positioning wedge, and urinary catheter bag. During an interview on 4/01/25 at 3:55 PM, CNA D said she had worked at the facility for a little over a year as a CNA and normally worked the 6 AM - 2 PM shift. CNA D said she should have changed her gloves after picking up the floor fall mat and prior to providing care to Resident #7. CNA D said she should have performed used hand sanitizer and changed her gloves after cleaning bowel movement off Resident #7's back half and then flipped him back to do his front half. CNA D said not sanitizing and changing her gloves after cleaning bowel off Resident #8's back half and then performing incontinent/urinary catheter care and then touching multiple things in Resident #7's room was cross contamination and could cause the resident an infection. CNA D said she had been trained on performing hand hygiene, when to change gloves, incontinent care, urinary catheter care, and infection control and prevention. CNA D said she was just nervous. CNA D said it all was an infection control issue. During an interview on 4/01/25 at 4:02 PM, LVN C said staff should wash hands, put gloves on, change gloves when going from dirty to clean, wash hands, change gloves, and then finish dressing or other things. LVN C said it would be cross contamination if staff did not change their gloves from picking something up off the floor, then performing bowel incontinent care, then urinary catheter care, and then proceeding to touch multiple surfaces and bedding in the resident's room. LVN C said the nursing facility residents had a weaker immune system and it placed them at a higher risk of infection. LVN C said it was cross contamination and an infection control issue. During an interview on 4/02/25 at 9:42 AM, RN B said staff should gather their supplies for incontinent care and/or foley catheter care, then wash their hands, and put on gloves. RN B said staff should perform hand hygiene and change their gloves when going from a dirty area to a clean area. RN B said staff should have removed the resident's fall mat and moved his bed prior to beginning resident care and then washed their hands and applied new gloves. RN B said staff should have changed gloves prior to performing front perineal area care and foley catheter care after cleaning bowel movement from the buttocks of the resident. RN B said it was an infection control issue and it was unsanitary by touching everything around the resident without performing hand hygiene or changing gloves. RN B said residents were on Enhanced Barrier Precautions because they were at a higher risk of infection due to having medical implanted devices such as feeding tubes or urinary catheters. RN B said by staff not changing gloves after cleaning bowel movement and then performing urinary catheter care, there was an increased risk of introducing E-coli (Escherichia coli-bacteria found in feces/bowel movement) into the system and placed the resident at a higher risk of infection. During an interview on 4/02/25 at 10:38 AM, the DON said CNA D should have approached the resident with clean gloves and should have changed gloves and sanitized after performing bowel movement incontinent care and after performing incontinent /urinary catheter care, and again before touching anything clean. The DON said the staff had received training on appropriate hand hygiene, changing gloves, incontinent care, urinary catheter care, and infection control. The DON said he could not speculate what the risk to the resident would be from CNA D not performing hand hygiene or changing her gloves appropriately and then touching multiple surfaces in close proximity of Resident #7. The DON said Resident #7 was on Enhanced Barrier Precautions because he had a urinary catheter because that was the way the Enhanced Barrier Precautions guidelines were written. The DON said he could not speculate if Resident #7 was at a higher risk of infection or urinary tract infections from CNA D not changing her gloves or performing hand hygiene appropriately. During an interview on 4/02/25 at 12:17 PM, the ADM said by the CNA not performing hand hygiene or changing her gloves appropriately, it could be an infection control concern. The ADM said by the CNA touching multiple things in the resident's room, it was cross contamination and could place the resident at a higher risk of infections and UTIs (urinary tract infections). The ADM said she would expect staff to follow the facility's policies related to infection control, hand hygiene, incontinent care, and urinary catheter care. Record review of CNA Orientation/Competency check-off form dated completed on 1/09/25 for CNA D indicated she was evaluated by the DON on 1/09/25 on Incontinent Care to include perineum care and foley catheter care and had a check mark in the Passed column . 2. Record review of Resident #41's face sheet dated 3/31/2025 indicated Resident #41 was an [AGE] year-old male readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (a lung condition caused by damage to the airways and alveoli, usually from smoking or other irritants), Chronic cystitis (infection or inflammation of the urinary bladder or any part of the urinary system cause by a bacteria), Diverticulitis of large intestine without perforation or abscess without bleeding (an inflammation with or without infection of a diverticulum (a pouch-like structure that form in the wall of the large intestine), which causes abdominal pain and can create a collection of pus around the inflamed diverticulum), pressure ulcer of head (an injury to the skin and the tissue below the skin that are due to pressure on the skin for a long time), and abnormal weight loss ( a noticeable drop in your body weight without trying). Record review of Resident #41's comprehensive MDS assessment dated [DATE] indicated Resident #41 understood and was understood by others. Resident #41 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #41 was at risk of developing pressure ulcer/injuries. Record review of Resident #41's care plan initiated on 3/14/2025 indicated Resident #41 had an incomplete care plan and did not indicate he was on enhanced barrier precautions or had any skin concerns. Record review of Resident #41's skin assessment completed on 4/1/2025 indicated Resident #41 had a new sebaceous cyst that opened measuring 0.5 cm x 0.4 cm x 0 with no drainage and wound bed appearance was white. During an observation and interview on 3/31/2025 at 10:18 AM, Resident #41 was sitting up in his wheelchair with observed bruising to bilateral upper arms, and a bandage on his left lower leg. Resident #41 said he had sores all over him and an area on his back that was giving him problems. Resident #41 said the nurse had been keeping his wounds covered. Resident #41 did not have signage and/or PPE outside his door. During an observation on 4/2/2025 at 9:35 AM, Resident #41 did not have signage to identify the resident was on EBP and/or PPE outside his door. The Treatment Nurse performed wound care to Resident #41's left lateral ankle and right mid back without gown. The Treatment Nurse said the wound on Resident #41's back did have some drainage and redness was observed on the peri-wound (skin surrounding the wound). During an interview on 4/2/2025 at 10:10 AM, CNA A said personal protective equipment would be worn while providing care to residents with catheters, wounds, and peg tubes. CNA A said the plan of care would be on the computer and a container would be set up outside a resident's door indicating a resident was on enhanced barrier precautions. CNA A said the enhanced barrier precautions would be documented on the care plan. She said the facility had PPE which included gowns, gloves, and mask. CNA A said the nurse was responsible for ensuring proper PPE was worn. CNA A said the staff could cross-contaminate or get an infection from the resident if PPE was not worn. She said the staff had been in-serviced on EBP precautions. During an interview on 4/2/2025 at 10:22 AM, RN B said the staff had been in-serviced on enhanced barrier precautions. She said anyone providing direct care should wear the proper PPE. RN B said the Infectious Disease nurse was responsible for ensuring PPE was worn. RN B said the care plan indicates what care would be provided to a resident. She said not wearing proper PPE with a resident with wounds could cause infection if not worn properly. During an interview on 4/2/2025 at 11:55 AM, the Treatment Nurse said the Centers for Disease Control (CDC) says PPE should be worn for chronic wounds and Resident #41's has small abrasions when he came into the facility. The Treatment Nurse said she did not place Resident #41 on enhanced barrier precautions because it was not a chronic wound and it was not required with small wounds. She said he was on precautions when he first came to the facility and after he completed an antibiotic, he got much better. The Treatment nurse said the Centers for Disease Control (CDC) leaves things unclear. The Treatment nurse said she had gone over enhanced barrier precautions with the aides on how to properly wear PPE. The Treatment Nurse said enhanced barrier precautions should be worn with Resident's with foley catheters, tracheostomies (a surgical procedure that involves creating an opening through the neck into the trachea (windpipe) to facilitate breathing) , gastrostomy (a medical devices that delivers liquid nutrition directly to the stomach or small intestine through a flexible tube), and wounds. The Treatment nurse said the enhanced barrier precautions were not required for wounds that only required a bandage. During an interview on 4/2/2025 at 12:10 PM, the ADON said enhanced barrier precautions are for residents who have foley catheters, peg tubes and wounds. The ADON said personal protective equipment (PPE) should be worn while providing care for residents with foley catheters, peg tubes and wounds. She said the facility had PPE for staff and she just ordered 400 more gowns. The ADON said if a resident was on enhanced barrier precautions, it should be on the resident's care plan, have a container outside the resident door and a sign on the door. She said she could not speculate what could happen if proper PPE was not worn. During an interview on 4/2/2025 at 12:34 PM, the DON said he would have to review with the Infection Preventionist. He said he did not want to speculate on what could happen if PPE was not worn during care. During an interview on 4/2/2025 at 12:59 PM, the Interim Administrator said the treatment nurse should have worn PPE while providing care to Resident #41. The Interim Administrator said enhanced barrier precautions would be care planned if on precautions and signage should be placed on the door. The Interim Administrator said the facility had in-serviced the staff on enhanced barrier precautions. The Interim Administrator said if a resident was not placed on proper enhanced barrier precautions and the staff was not wearing proper personal protective equipment (PPE), it could place a resident at risk for infection and negatively impact their quality of life. Record review of the facility's policy titled Infection Prevention and Control Program dated revised October 2018 indicated . an infection prevention and control program was established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . important facets of infection prevention include . educating staff and ensuring that they adhere to proper techniques and procedures . implementing appropriate isolation precautions when necessary . following established general and disease specific guidelines such as those of the Centers for Disease Control (CDC) . Record review of the facility's policy titled Perineal Care dated revised February 2018 indicated . the purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . steps in the procedure . wash and dry your hands thoroughly . fold the bedspread or blanket toward the foot of the bed . fold the sheet down to the lower part of the body . put on gloves . for a male resident . wash perineal area (private area) starting with the urethra (opening at head of penis) working outward . if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches, gently rinse and dry the area . wash and rinse the rectal area thoroughly . remove gloves and discard . wash and dry hands thoroughly . reposition the bed covers, make the resident comfortable . wash and dry your hands thoroughly . Record review of the facility's policy titled Handwashing/Hand Hygiene dated revised August 2019 indicated . the facility considered hand hygiene the primary means to prevent the spread of infections . all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . wash hands with soap and water for the following situations . when hands are visually soiled . use alcohol-based hand rub or soap and water in the following situations . before and after direct contact with residents . before and after handling an invasive device (urinary catheters, intravenous access sites, etc.) . before moving from a contaminated body site to a clean body site during resident care . after contact with objects in the immediate vicinity of the resident . the use of gloves does not replace hand washing/hand hygiene . integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . Record review of Centers for Medicare and Medicaid Services (CMS ) guideline titled Center for Clinical Standards and Quality/Quality, Safety & Oversight Group dated 3/20/2025 indicated . Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use . used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities . indicated for residents with any of the following: . infection or colonization . wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO . Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage . Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies (a surgical procedure that involves creating an opening through the neck into the trachea (windpipe) to facilitate breathing).Facilities should ensure protective personal equipment (PPE) and alcohol-based hand rub are readily accessible to staff. Protective personal equipment PPE for enhanced barrier precautions (EBP) were only necessary when performing high-contact care activities and may not need to be donned prior to entering a resident's room .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure residents were free from abuse for 4 of 42 residents (Resident #1, #2, #4, and #5) reviewed for resident abuse. The facility did not ensure Resident (Resident #1, #2, #4, and #5) were free from abuse. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. The findings included: 1. Record Review of Resident #1's face sheet dated 1/28/25 at 1:43 p.m., indicated Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of COPD-chronic obstructive pulmonary disease with (acute) exacerbation (chronic inflammatory lung disease that causes obstructed airflow from the lungs), atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow), osteoarthritis (degeneration of joint cartilage and the underlying bone), and GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining). Record Review of Resident #1's MDS assessment dated [DATE] indicated, Resident #1 sometimes understood others and sometimes made herself understood. The MDS assessment indicated Resident #1 had a BIMS score of 11, which indicated Resident #1 was moderately impaired. The MDS assessment indicated Resident #1 had no behaviors of hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. The MDS assessment indicated verbal behavior directed towards others occurred 1 to 3 days (threatening others, screaming at others, cursing at others). The MDS assessment indicated Resident #1's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. Record Review of Resident #1's care plan, dated on 12/11/24, indicated Resident #1 had impaired physical mobility. The care plan interventions included, encourage use of prescribed assistive devices; evaluate skin for areas of blanching or redness; determine level of needed assistance based on ADLs / IADLs evaluation; and Educate Resident / Representative on safety precautions. Record Review of Resident #2's face sheet dated 1/28/25 at 1:47 p.m., indicated Resident #2 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance (loss of memory, language, problem solving, and other thinking abilities that were severe enough to interfere with daily life), kidney disease unspecified (a progressive decline in kidney function over time), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), and essential hypertension (high blood pressure). Record Review of Resident #2's MDS assessment dated [DATE] indicated, Resident #2 understood others and made herself understood. The MDS assessment indicated Resident #2 had a BIMS score of 6, which indicated Resident #2 had a severe impairment. The MDS assessment indicated Resident #2 had no behaviors of hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. The MDS assessment indicated Resident #2's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. Record Review of Resident #2's care plan, dated on 8/14/24, indicated Resident #2 had behavior symptoms. The care plan indicated, Resident #2 had potential for problems related to behaviors: verbal aggression, physical aggression, socially inappropriate behavior, low frustration tolerance, and cursing at staff/other residents. The care plan interventions included approach in a slow calm manner, explain to resident why behaviors were not appropriate, allow resident time to express self, listen closely to reasons for resident actions, record frequency of inappropriate behaviors, administer medication per order, record and report any cognitive changes, notify physician of any physical or cognitive changes, meet physical needs of resident, and remove resident from public area when behavior was unacceptable. Record review of an All Staff Inservice Training for Employees: Resident-To-Resident Altercations, dated 12/16/24, revealed in-service training, which was signed by all employees, on resident-to-resident altercations, behavior awareness, prevention of resident-to-resident abuse, and abuse and neglect policy. Record Review of the intake investigation worksheet dated 8/14/24 at 6:30 p.m. indicated, Narrative of The Incident: Residents #1 and Resident #2 engaged one another in the smoke area over an ash tray. Each resident claims the other slapped them. Staff member laundry aid C was present in smoke area and states both residents slapped one another. Neither resident has any visible marks or injury from altercation. Both residents tell me they are fine mentally, emotionally, and physically. Actions and Notifications: Staff separated the two residents immediately. Notified Admin, DON, physician, and family. Administrator directed Charge Nurse to keep the two separated the rest of the night. Notified ombudsman. Started in service. Record Review of grievance log reviewed on 1/27/25 at 10:01 a.m. Record Review of abuse and neglect policy reviewed on 1/27/25 at 10:26 a.m. Record Review of in-services reviewed on 1/27/25 10:31 a.m. During an interview on1/28/25 at 9:34 a.m., Laundry aid C stated Resident #2 got the ash tray off the table to put her cigarette ashes in and then Resident #1 said to Resident #2 Why did you take that ash tray, how did you know I was done using it. Laundry aid C stated Resident #2 replied and said, Did you pay for it. Laundry aid C stated next Resident #1 said she would come and take the ash tray back. Laundry aid C stated next Resident #2 said, If you do take my ash tray, I will slap you. Laundry aid C stated next Resident #1 tried to take the ash tray from Resident #2. Laundry aid C stated that's when Resident #2 slapped Resident #1 across her head. Laundry aid C stated she was not sure if the slap from Resident #2 went across Resident #1 left or right side of head. Laundry aid C stated she believed the slap from Resident #2 to Resident #1 was made on Resident #1's right side of her head. Laundry aid C stated Resident #1 then slapped Resident #2 back across her hand. Laundry aid C stated she was not sure if the slap from Resident #1 to Resident #2 was made to her left or right hand. Laundry aid C stated Resident #1 started the incident. Laundry aid C stated neither resident occurred any injuries. Laundry aid C stated it was not a hard slap from neither resident. Laundry aid C stated the two residents slapped each other and that was it. Laundry aid C stated, I got a nurse to come help me separate the two residents. Laundry aid C stated she could not remember if any in-services were completed following this incident. Laundry aid C stated this incident occurred around 6 in the evening. Laundry aid C stated she was outside with the residents on the smoking patio when this incident occurred. Laundry aid C stated she reported this incident to LVN D on the night shift. During an interview on 1/28/25 at 10:07a.m., the Administrator stated Resident #2 passed last year on the 21st of August 2024. During an interview on 1/28/25 at 10:12 a.m., Resident #3 stated Resident #2 took the ash tray that Resident #1 was using. Resident #3 stated, It made Resident #1 mad. Resident #3 stated Resident #1 tried to take back the ash tray and that's when Resident #2 hit her. Resident #3 stated next the nursing broke up the fight between the two residents. Resident #3 stated, Resident #1 tried to hit Resident #2 back. Resident #3 stated Resident #2 had grabbed arm to keep her from hitting her back. Resident #3 stated this incident happened so long ago and she was doing her best at remembering this incident. Resident #3 stated, Resident#1 had some bruising on her arm from where Resident #2 grabbed her arm. Resident #3 stated this incident happened on the smoke patio outside. During an interview on 1/28/25 at 10:17 a.m., Resident #1 stated she did not remember the incident. Resident #1 stated, This incident happened so long ago I'm afraid I don't remember. During an interview on 1/28/25 at 10:57 a.m., the Administrator stated he had been employed for 2 years. The Administrator stated the two residents, (Resident #2) and (Resident #1), were roommates for a good year prior to this altercation. The Administrator stated both residents, (Resident #2) and (Resident #1), had strong personalities and were very funny. The Administrator stated eventually they got on each other's nerves when they were out in the smoke area. The Administrator stated usually there was about 3 or 4 ash trays out on the smoke patio. The Administrator stated Resident #2 got one of the ash trays. The Administrator stated Resident #1 did not like that she got the ash tray. The Administrator stated both residents were fussing at each other. The Administrator stated, Resident #1 rolled over and kicked the ash tray then Resident #2 slapped Resident #1. The Administrator stated the staff member interceded and got them apart. The Administrator stated, When Resident #2 slapped Resident #1 that her glasses came off her face. The Administrator stated, Resident #1 had bruising on her arm from when Resident #2 grabbed her arm. The Administrator stated there were no injuries from either resident. The Administrator stated staff separated the residents. The Administrator stated, Resident #2 was put on 15m check to make sure the resident was not re-engaging with Resident #1. The Administrator stated after this incident the residents were not put back in the same room. The Administrator stated, Resident #2 wanted to apologize but Resident #1 did not want her apology. The Administrator stated this resident-to-resident altercation was discussed in QAPI meeting. The Administrator stated the police were not called. The Administrator stated the residents did not want him to call the police. The Administrator stated this was a mutual engagement from both residents. The Administrator stated an in-service on resident-to-resident altercations, awareness and prevention, abuse, and neglect policy was completed following this incident. The Administrator stated the families and physician were notified after this incident. The Administrator stated the interventions that were put in place after the resident-to-resident altercation was Resident #2 was placed on 15m checks for 24 hours and 30m checks thereafter or until he told staff to stop the checks, training was completed, and a referral to for behavior. The Administrator stated the resident-to-resident altercation was discussed in QAPI. The Administrator stated the DON, the ADON, the infection preventionist, the business office manager, social services, the housekeeping supervisor, the diet supervisor, maintenance, CNA, and himself attended QAPI meetings. The Administrator stated the medical director was not able to go to the all the meetings, but he sat down with the medical director and talked about what was discussed in QAPI. The Administrator stated QAPI was completed every month usually the 3rd week of the month. 2. Record Review of Resident #4's face sheet dated 1/28/25 at 1:50 p.m., indicated Resident #4 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining), hemiplegia (part of the brain controlling movement is damaged) affecting right dominant side), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), and essential hypertension (high blood pressure). Record Review of Resident #4's MDS assessment dated [DATE] indicated, Resident #4 usually understood others and usually made herself understood. The MDS assessment indicated Resident #4 had a BIMS score of 7, which indicated Resident #4 had a severe impairment. The MDS assessment indicated Resident #4 had no behaviors of hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. The MDS assessment indicated Resident #4's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. Record Review of Resident #4's care plan, dated on 1/27/25, indicated Resident #4 was at Risk for Harm: Self Directed or Other-Directed due having history of fighting with another resident. The care plan goal indicated; Resident #4 will be free of physically aggressive behaviors. The care plan interventions included administer medications as prescribed, to evaluate and treat as indicated, if resident poses a potential threat to injure self or others notify provider, if wandering or pacing, initiate visual supervision during acute episode, monitor for signs / symptoms of agitation, and utilize calming touch. Record Review of Resident #5's face sheet dated 1/28/25 at 1:47 p.m., indicated Resident #5 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (brain chemical imbalance in the blood), hypokalemia (deficiency of potassium in the bloodstream), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), and essential hypertension (high blood pressure). Record Review of Resident #5's MDS assessment dated [DATE] indicated, Resident #5 understood others and made himself understood. The MDS assessment indicated Resident #5 had a BIMS score of 6, which indicated Resident #5 had a severe impairment. The MDS assessment indicated Resident #5 had no behaviors of hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. The MDS assessment indicated Resident #5's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. Record Review of Resident #5's care plan, dated on 1/27/25, indicated Resident #5 was at risk for harm: other-directed due to having altercation in the past. The care plan goal indicated; Resident #5 will be free of non-aggressive behaviors. The care plan interventions included administer medications as prescribed, to evaluate and treat as indicated, monitor for cognitive, emotional, or environmental factors that may contribute to violent behaviors, monitor for signs / symptoms of agitation, and provide verbal feedback to resident regarding behavior. Record Review of grievance log reviewed on 1/27/25 at 10:01 a.m. Record Review of abuse and neglect policy reviewed on 1/27/25 at 10:26 a.m. Record Review of in-services reviewed on 1/27/25 10:31 a.m. Record Review of intake investigation worksheet dated 12/6/24 at 4:00 p.m. indicated, Narrative of The Incident: Staff member reports observing Resident #4 approach and slap Resident #5. Staff member states Resident #5 was accusing his roommate Resident #4 of taking his pants immediately before this incident. Altercation was witnessed by CNA B and CNA A. Head to toe assessment shows no injuries, bruising, scratches, related to this incident. Actions and Notifications: Separated residents. Roommates moved to separate rooms. Resident #4 placed on 15-minute checks. Staff directed to keep residents separated. Notified DON, Administrator, Physician, families, and Ombudsman. During observation on 1/27/25 at 3:30 p.m., Resident to Resident interactions were observed in the lounge area of the facility and no issues was observed. During observation on 1/28/25 at 11:00 a.m., Resident to Staff interaction were observed on the smoke patio outside and no issues was observed. During observation on 1/28/25 at 11:00 a.m., Resident to Resident interactions were observed on the smoke patio outside and no issues was observed. During a phone interview on 1/27/25 at 2:32 p.m., CNA A stated she witnessed Resident #4 slap Resident #5 in the face. CNA A stated the residents was separated after the slap to the face in the dining room. CNA A stated after the residents were separated that the two residents were screaming at each other from across room in the dining room. CNA A stated Resident #5 was taken to a separate area to calm down. CNA A stated neither resident had injuries. CNA A stated she reported this incident to the Administrator. During an attempted phone interview on 1/27/25 on 2:36 p.m., CNA B was unavailable to be reached by phone. Record Review of a written statement undated signed by the CNA B indicated, I (CNA B) was coming out of room [ROOM NUMBER] when I was stopped by Resident #5. He asked me did I steal a pair of his pants out of the closet his back was facing the nurses station and my face is facing towards the nurses as Resident #5 and I are talking Resident #4 rolls towards Resident #5 and I and was aggressive, Resident #4 calls Resident #5 a bitch and I stand in between the Resident #5 back is still facing towards Resident #4 as I'm standing between Resident #4 and Resident #5 I push Resident #4 back towards the nurses station he rolls back up takes his left hand and goes across Resident #5 face I separated them CNA A 6/2 shift got the RN E and she took over from there this happened between 3:30 and 4:00 p.m. During an interview on 1/27/25 at 2:55 p.m., Resident #5 stated he did not remember being hit by Resident #4. Resident #5 stated he could not recall what the altercation was about. Resident #5 stated staff was nice to him. Resident #5 stated he did feel safe in the facility but wanted to go home with his. During an interview on 1/27/25 at 2:50 p.m., Resident #4 stated he could not recall the incident. Resident #4 stated he did feel safe. Resident #4 stated staff were nice to him. During an interview on 1/28/25 at 10:47 a.m., the Administrator stated he had been the administrator for 2 years. The Administrator stated the two residents, (Resident #4) and (Resident #5), were roommates. The Administrator stated the aid was trying to help Resident #4 change clothes because he had spilled something on his clothing. The Administrator stated Resident #5 accused the aide of putting his pants on Resident #4. The Administrator stated Resident #4 rolled to Resident #5 and hit him along the face or head area. The Administrator stated there was no injuries or bruising on either resident. The Administrator stated the aide was not sure if Resident #5 made contact to Resident #4's face. The Administrator stated each resident resided on different halls now. The Administrator stated in-services were completed on Behaviors and being aware of behaviors before they escalate to something else. The Administrator stated, I just did an in-service on trying to look for ways to prevent things that frustrated with the residents that leads to altercations. The Administrator stated the police were not notified about this incident. The Administrator stated he asked the resident if they wanted him to call the police and each resident replied that they were fine and not to call the police. The Administrator stated neither resident went to the hospital following this incident. The Administrator stated the family, and the physician were notified about this incident. The Administrator stated the resident-to-resident altercation was discussed in QAPI. The Administrator stated the DON, the ADON, the infection preventionist, the business office manager, social services, the housekeeping supervisor, the diet supervisor, maintenance, CNA, and himself attended QAPI meetings. The Administrator stated the medical director was not able to go to the all the meetings, but he sat down with the medical director and talked about what was discussed in QAPI. The Administrator stated QAPI was completed every month usually the 3rd week of the month. The Administrator stated the interventions that were put in place after the resident-to-resident altercation was Resident #4 was placed on 15m checks for 24 hours and 30m checks thereafter or until he told staff them to stop the checks, training was completed and referral to deer oaks clinic for behavior. Record Review of the facility's abuse and neglect policy dated 2/1/23 indicated, (g) Physical Abuse - includes hitting, slapping, pinching, kicking, or controlling behavior through corporal punishment. (8) All completed Abuse, Neglect, and Misappropriation investigations will be reported to and reviewed by the QAPI committee. The QAPI committee will review and analyze trends and patterns to seek out improved performance opportunities and find ways to prevent future issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 5 residents reviewed for assessments. (Resident #1) The facility failed to ensure Resident #1's MDS assessment did not improperly code Cilostazol (in a class of medications called platelet-aggregation inhibitors (antiplatelet medications)) as an anticoagulant instead of an antiplatelet. This failure could place residents at risk of not having individual needs met. Findings included: Record review of Resident #1's face sheet printed 03/20/24 indicated Resident #1 was a [AGE] year-old, male and was admitted on [DATE] with diagnosis including peripheral vascular disease (is a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), acute embolism (a blood clot or a foreign body enters the bloodstream and obstructs blood flow) and thrombosis (a blood clot forms in blood vessels and partially or completely blocks blood flow) of unspecified deep vein of right lower extremity, and non-pressure chronic ulcer of right calf with fat layer exposed (is defined as a defect in the skin below the level of knee persisting for more than six weeks and shows no tendency to heal after three or more months). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated Resident #1 had clear speech, adequate hearing, and adequate vision. The MDS indicated Resident #1 had a BIMS score of 10 which indicated moderate cognitive impairment. The MDS indicated Resident #1 was independent for toilet hygiene and dressing, setup or clean-up assistance for oral and personal hygiene and eating. The MDS indicated Resident #1 had taken an anticoagulant during the last 7 days of the assessment period. Record review of Resident #1's care plan dated 05/28/19, edited 04/20/23 indicated Resident #1 took Plavix and Eliquis for embolism, he was at risk for bruising easily. Intervention included administer medication per MD orders. Record review of Resident #1's consolidated physician orders dated 01/01/24-01/31/24 indicated an order for Cilostazol, 50 mg, 1 tablet, oral, Diagnosis: acute embolism and thrombosis of unspecified deep vein of right lower extremities, twice a day. Start date 11/03/23- open ended. The consolidated physician orders did not indicate a current order for Plavix or Eliquis. Record review of Resident #1's MAR dated 01/01/24-01/31/24 indicated Cilostazol, 50 mg, 1 tablet, oral, twice a day, Diagnosis: acute embolism and thrombosis of unspecified deep vein of right lower extremities. Start date 11/03/23- open ended. During an interview on 03/20/23 at 10:45 a.m., the MDS Coordinator said she was responsible for MDSs. She said Resident #1 was on a blood thinner and it was antiplatelet. She said she must have marked the wrong button when she did Resident #1's MDS. She said she did not have someone to monitor the MDS she submitted. She said she had a consultation she contacted for questions or guidance. She said she reviewed the list of MDS triggered problems monthly, orders, and other parts of the chart to complete the MDS. She said the MDS needed to be accurate because it affected the facility's funding. She said the MDS reflected the care the resident received, individualized resident status, what area or problem the resident needed care provided for them. During an interview on 03/20/24 at 1:43 p.m., the DON said the MDS Coordinator was responsible for completion of MDSs, and he signed the MDS to signify it was completed correctly. He said he expected the MDS coordinator to complete the MDS accurately to the best of her knowledge. He said the MDS coordinator had a consultation to monitor her but did not know if the consultation did audits. He said the MDS should be correct to reflect the resident's status and it is a payment source for the facility. He said an incorrect MDS should not negatively affect the resident because the resident would still get the care they needed. During an interview on 03/20/23 at 2:33 p.m., the ADM said the MDS coordinator was responsible for the accuracy of resident's MDSs. He said a consultation did a percentage of audits, quarterly. He said MDS needed to be accurate because any assessment needed to be correct to provide proper care. The ADM said the facility did not have a policy on accuracy of assessment but followed the RAI guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 1 of 3 residents (Resident #2) reviewed for resident assessments. The facility failed to review Resident #2's PASRR level 1 assessment for accuracy. Resident #2 was diagnosed with Bipolar, and the mental health question was answered no. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record review of Resident #2's face sheet printed 03/18/24 indicated Resident #2 was a [AGE] year-old, male and admitted on [DATE] with diagnosis including other bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) without behavioral disturbance , and other recurrent depressive disorders (involves a depressed mood or loss of pleasure or interest in activities for long periods of time). Record review of Resident #2's MDS assessment dated [DATE] indicated Resident #2 was usually understood by other and usually understood others. The MDS indicated Resident #2 had a BIMS score of 10 which indicated moderate cognitive impairment. The MDS indicated Resident #2 had inattention and disorganized thinking that fluctuated. The MDS indicated Resident #2 required partial/moderate assistance for oral, personal, and toilet hygiene, shower/bathe self and lower body dressing. The MDS indicated Resident #2 had an active diagnosis of bipolar disorder and depression. Record review of Resident #2's care plan dated 03/10/23 indicated Resident #2 was at risk for social isolation/loneliness related to little interest/pleasure in doing things at times. Interventions included assess for verbal/nonverbal indicators of social isolation/loneliness. Record review of Resident #2's PASRR Level 1 Screening dated 01/18/23 indicated .Mental illness .Is there evidence or an indicator this is an individual that has a Mental Illness .No . During an interview on 03/20/24 at 10:45 a.m., the MDS Coordinator said she was responsible for PASRRs. She said she input the referring entity's referral paperwork in the system. She said she was aware Resident #2 had a bipolar disorder diagnosis but since he had dementia, she did not think he was PASRR positive. She said when PASRRs were not correct, residents risked not receiving outside services, therapy, outpatient and inhouse mental health therapy, specialized wheelchairs, and trainings. She said the facility had initiated audits, after Resident #2's PASRR was brought to their attention, with the IDT for resident with new and current residents with diagnosis of mental illness to ensure PASRR screenings were completed correctly. During an interview on 03/20/24 at 1:43 p.m., the DON said he only knew the MDS coordinator was responsible for PASRRs with some assistance by social services. He said he was not knowledgeable enough on the process to answer other questions. During an interview on 03/20/24 at 2:33 p.m., the ADM said the MDS coordinator submitted PASRRs, and he reviewed them before accepting new residents. He said the referring entity was responsible for the PASRR that came with the residents on admission. He said there was no process to ensure the referring entity referrals was accurate until Resident #2's PASRR incident. He said now the facility had a process in place to review the referral before it was submitted in the portal. He said when PASRRs were not completed accurately, resident did not receive PASRR services. The ADM said the facility did not create a PASRR policy until 03/20/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 13 residents (Residents #1 and Resident #11) reviewed for care plans. 1. The facility failed to revise and update Resident #1's comprehensive care plan for the type of blood thinner, Cilostazol (is in a class of medications called platelet-aggregation inhibitors (antiplatelet medications)), he was prescribed instead of Plavix (is an antiplatelet drug you can take to prevent blood clots) and Eliquis (is a blood thinner medicine that reduces blood clotting.). 2. The facility failed to revise and update Resident #11's comprehensive care plan for his diet, fluid restriction, and increase protein need for dialysis. These deficient practices could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: 1. Record review of Resident #1's face sheet printed 03/20/24 indicated Resident #1 was a [AGE] year-old, male and was admitted on [DATE] with diagnosis including peripheral vascular disease (is a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), acute embolism (a blood clot or a foreign body enters the bloodstream and obstructs blood flow) and thrombosis (a blood clot forms in blood vessels and partially or completely blocks blood flow) of unspecified deep vein of right lower extremity, and non-pressure chronic ulcer of right calf with fat layer exposed (is defined as a defect in the skin below the level of knee persisting for more than six weeks and shows no tendency to heal after three or more months). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated Resident #1 had clear speech, adequate hearing, and adequate vision. The MDS indicated Resident #1 had a BIMS score of 10 which indicated moderate cognitive impairment. The MDS indicated Resident #1 was independent for toilet hygiene and dressing, setup or clean-up assistance for oral and personal hygiene and eating. The MDS indicated Resident #1 had taken an anticoagulant during the last 7 days of the assessment period. Record review of Resident #1 care plan dated 05/28/19, edited 04/20/23, indicated Resident #1 took Plavix and Eliquis for embolism, and he was at risk for bruising easily. An intervention included administer medication per MD orders. The care plan did not indicate use of Cilostazol. Record review of Resident #1's consolidated physician orders dated 01/01/24-01/31/24 indicated an order for Cilostazol, 50 mg, 1 tablet, oral, Diagnosis: acute embolism and thrombosis of unspecified deep vein of right lower extremities, twice a day. Start date 11/03/23- open ended. The consolidated physician orders did not indicate a current order for Plavix or Eliquis. 2. Record review of Resident #11's face sheet printed 03/18/24 indicated Resident #11 was a [AGE] year-old, male and admitted on [DATE] with diagnoses including end stage renal disease (is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), cerebral infarction (stroke), acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), hypotension of hemodialysis (occurs because a large volume of blood water and solutes are removed over a short period of time), and arteriovenous fistula (is an irregular connection between an artery and a vein). Record review of Resident #11's quarterly MDS assessment dated [DATE] indicated Resident #11 had clear speech, minimal difficult hearing, and impaired vision with corrective lenses. The MDS indicated Resident #11 was usually understood and understood others. The MDS indicated Resident #11 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #11 required partial/moderate assistance for shower/bathe self, dressing, and putting on footwear, supervision for toileting and personal hygiene, and setup for oral hygiene. The MDS indicated Resident #11 was on a mechanically altered diet and dialysis. Record review of Resident #11's care plan dated 03/15/22, edited 01/05/23, indicated Resident #11 had experienced weight loss related to being on dialysis on Monday, Wednesday, and Friday. Intervention included renal diet. The care plan did not indicate mechanical soft diet with chopped meats, double protein portions with each meal, and increase protein intake by 15 grams a day with extra protein portions or supplements. Record review of Resident #11's consolidated physician's orders dated 03/01/24-03/20/24 indicated orders for the following: *Mechanical soft diet with chopped meats, double protein portions with each meal, start date 03/25/23, no end date. *Increase protein intake by 15 grams a day with extra protein portions or supplement, start date 01/19/24, no end date. *Liberal fluid restriction 1200 milliliters a day, start date 02/24/23, no end date. Record review of Resident #11's care plan dated 03/15/22, edited 01/05/23, indicated Resident #11 had dialysis related to renal failure. Intervention included assist resident in preparing for transport to dialysis. The care plan did not indicate liberal fluid restriction of 1200 milliliters a day. During an interview on 03/20/24 at 10:45 a.m., the MDS Coordinator said social services, the DON, and herself worked on care plans. She said the care plans were reviewed and revised during care plan meetings with the IDT. She said during the quarterly care plan meetings, new orders over the last 3 months were reviewed and reflected on the care plan. She said it was herself and social services' responsibility to make sure care plans were current. She said she did not make sure changes were made to resident's care plans after care plan meetings. She said Resident #11's diet order should have been updated and fluid restriction added to his care plan. She said Resident #1's blood thinner medication should have been updated to his current care plan. She said the care plan needed to be updated or revised because they reflected the individual needs of the residents. During an interview on 03/20/24 at 1:33 p.m., the social service representative said she took notes during the care plan meetings. She said meetings were done quarterly. She said she reviewed the care plan with issues regarding behaviors. She said if she was not directly told to update a problem on a care plan during the meeting, it could get missed. During an interview on 03/20/24 at 1:43 p.m., the DON said the MDS coordinator was responsible for updating care plans. He said care plans were revised with the IDT quarterly, as needed, and at care plan meetings. He said the care plans should be revised to accurately reflect the resident and it guided the resident's care. He said the MDS coordinator should be monitoring if care plans are revised and updated. He said the facility had a consultant that assisted the MDS coordinator, but he did not know her involvement in care plans. He said he could not speculate how not having an updated or revised care plan affected the resident. During an interview on 03/20/24 at 2:33 p.m., the ADM said care plans were generated after quarterly assessment CAAS from the MDS and out of cycle done by the IDT. He said physician orders were reviewed during IDT meetings for updates. He said Resident #11's diet order should have reflected what his current physician order stated. He said monitoring of care plan revision happened during IDT meetings. Record review of a facility's Care Area Assessment policy revised 05/2011 indicated .care area assessment will be used .to develop individualized care plans .link between assessment and care planning .review the triggered CAAs .history taking, physical assessments, gathering of relevant information .sequencing of clinically significant events .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents reviewed for infection control during wound care. (Resident #1) The facility failed to ensure WCN practiced infection control measures by using hand gel or washing hands after the removal of gloves. This failure could place residents at risk for cross-contamination and at an increased risk of infection. Findings included: Record review of Resident #1's face sheet printed 03/20/24 indicated Resident #1 was a [AGE] year-old, male and was admitted on [DATE] with diagnosis including peripheral vascular disease (is a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), acute embolism (a blood clot or a foreign body enters the bloodstream and obstructs blood flow) and thrombosis (a blood clot forms in blood vessels and partially or completely blocks blood flow) of unspecified deep vein of right lower extremity, and non-pressure chronic ulcer of right calf with fat layer exposed (is defined as a defect in the skin below the level of knee persisting for more than six weeks and shows no tendency to heal after three or more months). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated Resident #1 had clear speech, adequate hearing, and adequate vision. The MDS indicated Resident #1 had a BIMS score of 10 which indicated moderate cognitive impairment. The MDS indicated Resident #1 was independent for toilet hygiene and dressing, setup or clean-up assistance for oral and personal hygiene and eating. The MDS indicated Resident #1 had one venous and arterial ulcers present. The MDS indicated Resident #1 received application of nonsurgical dressings other than to feet and ointments/medications. Record review of Resident #1's care plan dated 03/18/21, edited 02/15/24 indicated Resident #1 had chronic venous ulcer wound to right lower medial leg. An intervention included complete ordered treatment daily. During an observation and interview on 03/19/24 at 11:30 a.m., the WCN performed a wound care dressing change on Resident #1. The WCN placed wound care supplies on the bedside cart on top of wax paper. The WCN washed her hands then placed gloves on her hands. The WCN placed a pad on Resident #1's bed and Resident #1 placed his leg on the pad. The WCN grabbed a pair of scissors and proceeded to cut the outer layer dressing off. She removed the outer layer dressing then removed her gloves and placed new ones on without using hand gel or washing her hands. The WCN then removed moderately saturated inner dressing from Resident #1's leg. The WCN removed her gloves then placed new gloves on without hand gel or washing her hands. The WCN removed the old pad from underneath Resident #1 then placed a new pad down. The WCN cleaned the wound bed with gauze and ordered solution. The WCN removed her gloves, went to Resident #1's bedroom door where the treatment cart was to get more gloves and gauze without hand gel or washing her hands. The WCN returned to bedside with gloves already on. Unable to determine if the WCN use hand gel before putting on new gloves because of Resident #1's bedroom door blocking view. The WCN resumed cleaning Resident #1's wound bed. The WCN said I should be washing my hands or using gel after I take my gloves off! During an interview on 03/20/24 at 10:10 a.m., the WCN said she could not fully remember step by step how she did Resident #1's dressing change for yesterday (03/19/24). She said she normally washed her hands, sanitized the scissors, placed a pad on the resident's bed, place sheets of wax paper down and set up table with supplies, pulled the resident's curtain, cut the bandage, cleaned the scissors, changed gloves, cleaned site with ordered solution, let the solution dry, placed moisture barrier around site, changed gloves, placed absorbent pads over the site, wrapped the leg in kerlix and Coban tape, then disposed of dressing in biohazard room. She said she washed her hands twice during the dressing change. She said she washed before she started the wound care and after cleaning the gloves in Resident #1's sink. She said she had hand gel on her treatment cart, but it was not in the room with her during the dressing change. She said she did recall saying she should have been washing her hands or using hand gel before putting on new gloves. She said not doing that placed resident at risk for infections. She said resident could get an infection and get sick or septic. She said the resident then could require hospitalization or death. During an interview on 03/20/24 at 1:43 p.m., the DON said it depended on the circumstances if hand gel or hand washing was needed after glove removal. He said Resident #1's dressing change was a clean procedure not a sterile procedure. He said hand washing or gel needed to be used after glove removal for soiled gloves or sterile procedures. He said when the WCN removed Resident #1's inner soiled dressing, she should have washed her hands after she removed her gloves. He said washing hands or using hand gel after glove removal was important to prevent the spread of contaminates. Record review of a facility's Wound Care policy revised 10/2010 indicated .put on exam glove .loosen tape and remove dressing .pull glove over dressing and discard .wash and dry your hands thoroughly .put on gloves . Record review of a facility's Work Practices policy revised 08/2008 indicated .employee shall wash their hands as soon as possible after removing contaminated gloves or other personal protective equipment and after contact with blood or other potentially infectious materials .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 5 of 13 residents (Resident #31, Resident #18, Resident #38, Resident #33, and Resident #30) reviewed for resident rights. 1. The facility failed to ensure Resident #31 had a dignified existence by allowing her to use the working bathroom commode in her room. 2.The facility failed to ask Resident #18 to remove a food item from her plate prior to reaching into her plate during her lunch meal. 3.The facility failed to provide Resident #38 with a knife to cut his meat during meals. 4.The facility failed to provide Resident #33 with a requested knife to his cut meat during the lunch meals on 03/18/2024 and 03/19/2024. 5. The facility failed to ensure CNA G sat in a chair and remained at eye level with Resident #30 while assisting her with her lunch on 03/18/2024. These failures could place residents at risk of humiliation, diminished quality of life, loss of dignity and loss of self-worth. Findings included: 1. Record review of Resident #31's face sheet dated 3/19/24 indicated Resident #31 was [AGE] year-old and admitted to the facility on [DATE] with diagnoses including acute pulmonary edema (swelling of the lungs), pneumonia (infection of the lungs), urinary tract infection, hypertension (high blood pressure), cognitive communication deficit, weakness, history of falls, heart failure, major depressive disorder (persistent sadness), and anxiety (nervousness). Record review of Resident #31's annual MDS assessment dated [DATE] indicated Resident #31 was understood and understood others. The MDS indicated Resident #31 had a BIMS score of 15 which indicated she was cognitively intact. Resident #31 had fluctuating inattention and disorganized thinking. Resident #31 did not have behavioral symptoms. Resident #31 used a walker and a wheelchair for mobility. Resident #31 was independent with toilet transfers and required partial assistance with toilet hygiene. The MDS indicated Resident #31 was occasionally incontinent of bowel and bladder. Record review of Resident #31's care plan with a revision date of 3/04/24 indicated Resident #31 had a problem area of compulsively putting wipes and toilet tissue in commode in bathroom after multiple education and notes put by toilet to not put objects in toilet, resident continued to do, so object had even been denied, but was found to have wipes in her wheelchair where she had taken them off the nurse aide cart, which had caused several plumbing issues and bedside commode was placed in the resident's room. Resident #31 had consults due to gastric (stomach) system issues as evidenced by anal fixation and pain. Resident #31 had infatuation with anal area. During an observation and interview on 03/18/24 at 10:11 AM, Resident #31 was sitting on the side of her bed with her breakfast tray on her bedside table in front of her. Resident #31 said her breakfast was good and she had eaten most of it. Resident #31 had a bedside commode against the wall at the end of her bed. Resident #31's room had a strong smell of bowel movement. Resident #31 said she had to use a bedside commode because her bathroom commode had not worked since January 2024. Resident #31 said she wished they would fix her commode, because she did not like using the bedside commode. There was a Sorry Out of Order sign on the outside of bathroom door. There was a sign behind the bathroom commode to not put toilet paper or wipes in toilet. During an observation and interview on 03/19/24 at 8:25 AM, Resident #31 was sitting on the side of her bed with breakfast tray on her bedside table. Resident #31 said she didn't like having to use the bedside commode and wished they would get the bathroom fixed. Resident #31 said it was embarrassing to use the bedside commode and it did not feel private, even with a curtain. During an observation and interview on 03/20/24 at 12:48 PM, Resident #31 said she asked the DON about getting the commode fixed because she did not like using the bedside commode and he told her he would look into it. Resident #31 said they were trying to blame her for stopping the commode up, but she said she put the toilet paper and wipes in the trash can, so it wasn't her. Resident #31 said using the bedside commode made her feel uncomfortable due to anyone could walk into her room. Resident #31 said they put the curtain up, but it just did not provide the privacy that a door does in a bathroom. Resident #31 said they just really needed to fix her commode. During an interview on 3/19/24 at 3:28 PM, the Maintenance Supervisor said they have had to call out the plumbers couple times due to Resident #31 was flushing wipes down the commode and it backed up the entire building septic system. The Maintenance Supervisor said the bathroom toilet in Resident #31's room did work, but they have a sign on the door that it was out of order. The Maintenance Supervisor said Resident #31's bathroom room toilet was fixed approximately a month ago. The Maintenance Supervisor said they have not had an issue with the septic system since they put the bedside commode in Resident #31's room. The Maintenance Supervisor said they were monitoring the situation and there had not been any other issues with the septic system. The Maintenance Supervisor said he did not know what the fix was due to it caused issues with the whole facility's septic system being backed up and residents not being able to flush their toilets. The Maintenance Supervisor said they did not have a specific timeframe to monitor the situation. The Maintenance Supervisor said he knew Resident #31 asked about when her commode would be fixed because the staff told him she asked about it regularly. The Maintenance Supervisor said it was not the ideal situation with an able-bodied person not being able to use their toilet in their room. During an interview on 3/19/24 at 3:44 PM, CNA A said she had worked at the facility since June 2023 and normally worked the evening and night shifts. CNA A said the kept a plastic bag in Resident #31's bedside commode. CNA A said she would carry Resident #31's bucket of the bedside commode, bag and cover it then transport it to the shower room down the hall and would empty the Resident #31's bedside commode contents in the commode in the shower room. CNA A said she had not heard Resident #31 complain about using the bedside commode. CNA A said if it was her, she would want to go to the bathroom commode with a door. CNA A said she thought they were trying to limit Resident #31's toilet paper, but she was not sure what other interventions they have tried other than bedside commode. During an interview on 3/20/24 at 01:08 PM, CNA B said she had worked at the facility for approximately 2 years and normally worked the day shift on Resident #31's hall. CNA B said the plumbing had been messed up and Resident 31 had a bedside commode placed in her room. CNA B said she kept a plastic bag in the bedside commode bucket. CNA B said she usually emptied the bedside commode by getting the air out of the plastic bag and tying it up, removed it from the room and then put it in her big trash barrel. CNA B said she did not know if Resident #31's toilet worked, but there was an out of order sign on her bathroom door. CNA B said all the toilets were stopped up at the same time on Resident #31's hall. CNA B said Resident 31 used a lot of toilet paper and sometimes puts it in the trash and sometimes put it in the bedside commode. CNA B said Resident #31 was able to transfer herself and did everything on her own. CNA B said Resident #31 asked for her potty to be fixed almost daily. CNA B said if circumstances warranted the use of a bedside commode, she would be good to use a bedside commode, but if there was a working commode in her room, she would expect to be able to use it. CNA B said Resident #31 did not have a comfortable homelike environment because she had to use a bedside commode and not use the bathroom commode. CNA B said she did not know how it affected Resident #31, but Resident #31 had told her that she did not like having to use the bedside commode. During an interview on 3/20/24 at 1:37 PM, RN C said she had worked at the facility since 2018 and normally worked the day shift. RN C said they started using the bedside commode in Resident #31's room when the toilets stopped up. RN C said she did not remember how long ago that was and she had not tried to flush Resident #31's toilet to see if it worked. RN C said she believed the bedside commode was a short-term situation. RN C said the maintenance director and the ADM were responsible for monitoring the toilet situation. RN C said a homelike environment should be whatever Resident #31 preferred as her homelike environment. RN C said Resident #31 had not mentioned anything to her about her toilet situation. RN C said it would be a dignity issue if someone came in Resident #31's room and saw her using the bedside. During an interview on 3/20/24 at 2:29 PM, the DON said he did not think it had been that long since Resident #31 started using the bedside commode due to toilet issues. The DON said he was unaware of the plan related to how long Resident #31 would have the bedside commode. The DON said the ADM would make the final determination when/if the bedside commode would be removed from Resident #31's room and when she would be allowed to use the bathroom commode in her room. The DON said he was unaware if Resident #31's bathroom toilet was working, but to the best of his knowledge it was working. The DON said Resident #31 had not asked him to fix her toilet. The DON said he could not speculate on how Resident #31 felt using a bedside commode. The DON said people use bedside commodes all over the world as a useable tool. The DON said he could not speculate as to what would be reasonable to accommodate her. During an interview on 3/20/24 at 2:55 PM, the ADM said his plan was to get occupational therapy to work with Resident #31 to not use so much toilet paper. The ADM said Resident #31 had a compulsive personality. The ADM said Resident #31 had an anal fixation and would use an abundance of toilet paper and wipes and would flush down the commode and it would stop up the septic system. The ADM said there was one week he had to call the plumber out three times. The ADM said Resident #31's rights were infringing on the rights of others in the facility. The ADM said they have tried multiple interventions with Resident #31. The ADM said they have done education, signs, redirection, and even got Resident #31 bidet commode training with occupational therapy about six months ago. The ADM said Resident #31 was the only resident with a bidet commode in the facility. The ADM said they tried removing wipes from Resident #31's room, but she was found to have taken wipes off the aides' cart. The ADM said he had spoken to occupational therapy about doing some training with Resident #31, but he had not had a chance to see where they were at with it. The ADM said there were situations where a bedside commode was warranted, and he felt he had taken every step he could take with Resident #31 and the next step was to have occupational therapy work with her. 2. Record review of Resident #18's face sheet dated 3/18/24 indicated Resident #18 was a [AGE] year-old and admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke-damage to brain tissue due to a loss of oxygen to the area), left hemiplegia/hemiparesis (paralysis/weakness to one side of body), major depressive disorder (persistent sadness), dysphagia (difficulty swallowing), memory deficit, and altered mental status. Record review of Resident #18's admission MDS assessment dated [DATE] indicated Resident #18 was usually understood and usually understood others. The MDS indicated Resident #18 had a BIMS score of 8 which indicated she had moderate cognitive impairment. Resident #18 had fluctuating inattention and disorganized thinking. Resident #18 did not have behavioral symptoms. Resident #18 required setup or clean-up assistance with eating. Record review of Resident #18's undated care plan indicated Resident #18 had a problem area related to taking antidepressant medications (used to treat depression) and antianxiety medications (used to treat anxiety). During an observation on 3/18/24 at PM, the DON took a napkin and reached onto Resident #18's lunch plate and removed an egg roll and said, You can't have that. During an interview on 3/18/24 at 2:23 PM, Resident #18 said during lunch today (3/18/24), she was served an egg roll on her meal plate. Resident #18 said because she was on a mechanical soft diet, the DON took the egg roll away from her. Resident #18 said he gave her an extra ice cream for it. Resident #18 said the DON got a napkin and took the egg roll off her plate and did not say anything just that she could not have it. Resident #18 said she felt like a bulldog getting their steak taken away. Resident #18 said her meal plate was sitting in front of her and everyone else at the table. Resident #18 said she would have been fine if the DON had asked her first before putting his hand into her plate and just saying you cannot have that as he was doing it. Resident #18 said they seemed to treat her like a little kid and not explain things. During an interview on 3/20/24 at 01:08 PM, CNA B said if she saw a resident was served something that was not part of their ordered diet, she would explain to the resident the item was not on their ticket and it did not fit into their ordered diet. CNA B said you should explain the situation to the resident before reaching into their plate, because she would not want someone putting their hands into her plate. During an interview on 3/20/24 at 1:37 PM, RN C said she assisted in the dining room during mealtimes. RN C said she usually stood at the kitchen door where the meal trays were handed out and would check the tickets versus what was placed on the residents' trays. RN C said she would have the dietary staff to fix or remove a wrong item before it was delivered to the resident. RN C said if an item was mistakenly placed on a resident's meal plate and delivered to the resident, she would go to the resident and explain what was going on prior to removing the item from the resident's plate. RN C said you cannot grab anyone's food off their plate without first letting them know why. RN C said it would never be appropriate to take something off a resident's plate without explaining the reason why first. RN C said, imagine if someone stole your food off your plate. RN C said the resident could be upset and not know why staff took their food and not know staff were just trying to protect them from choking. During an interview on 3/20/24 at 2:29 PM, the DON said he would explain the reason to a resident if he had to take food items from the resident's plate. The DON said he explained to Resident #18 the egg roll was not part of her mechanical soft diet prior to removing her egg roll from her plate. The DON said he offered Resident #18 ice cream and she said she would like some ice cream. The DON said he brought Resident #18 ice cream and replaced the egg roll with bread, which was the substitute for the egg roll and the DON said she was satisfied at the table. The DON said he did not just yank the egg roll from Resident #18 and throw it away. The DON said he offered her ice cream and gave her the substitution of bread. The DON said Resident #18 had an adequate nutritious meal. The DON said he could not speculate of how it made Resident #18 feel, but she was satisfied at the lunch table. During an interview on 3/20/24 at 2:55 PM, the ADM said he would expect staff to explain to the resident why something was being removed from the meal plate prior to reaching into the resident's meal plate. The ADM said he was sure it would be upsetting for the resident to have a food item removed from their plate by a staff member and not be explained to of why the item was being removed. 3. Record review of Resident #38's face sheet dated 3/20/24 indicated Resident #38 was 81-years-old and admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain (mental deterioration associated with old age), severe protein-calorie malnutrition (inadequate intake of protein-calorie foods), altered mental status, cognitive communication deficit, nutritional anemia (results from deficiency in either iron, vitamin B-12, or folic acid), adult failure to thrive, and abnormal weight loss. Record review of Resident #38's MDS assessment dated [DATE] indicated Resident #38 had a BIMS score of 6 which indicated he had severe cognitive impairment. Resident #38 had fluctuating inattention and disorganized thinking. Resident #38 was independent with eating. Record review of Resident #38's undated care plan indicated Resident #38 preferred activities that identified with his prior lifestyle. Resident #38 had a problem area of nutritional status with unintended weight loss and potential for malnutrition. During an observation on 3/18/24 at 12:42 PM, Resident #38 was sitting at the dining table with 2 other male residents. Resident #31 was served a baked chicken breast and struggled for several minutes to try to cut the chicken breast with his fork. Resident #38 then hollered at CNA G to Go get me a knife! How the hell am I supposed to cut this with a fork? I'm sick of this shit. Resident #38 did not receive a knife, but eventually was able to pull the chicken breast apart with his fork and hands and consumed the chicken breast. During an observation on 3/19/2024 at 12:40 PM, Resident #38 was given plastic eating utensils and stated, what am I supposed to do with plastic utensils, when he received his lunch tray. Resident #38 stated I can't cut meat with plastic. I guess I'm going to have to write my congressman to get a real knife in this place. During an interview on 3/20/24 at 01:08 PM, CNA B said she had not had any residents ask her for a knife at mealtimes. CNA B said she usually asked the resident if she could help cut the resident's meat for them when she delivered the resident's meal tray. During an interview on 3/20/24 at 1:37 PM, RN C said she assisted in the dining room during mealtimes. RN C said she had not had residents ask her for a knife, but she would ask the residents if they needed help cutting their meat when she delivered their meals. RN C said there was usually staff in the dining area who could assist the residents with any needs. RN C said the staff had worked at the facility long enough to know what the residents' wanted. During an interview on 3/20/24 at 2:55 PM, the ADM said he assisted in the dining room during mealtimes when he could, and he had not heard residents ask for a knife to cut their meats. The ADM said he offered to help cut the residents meat if needed. 4.Record review of an undated face sheet revealed Resident #33 was a [AGE] year-old male, admitted to the facility on [DATE] with the diagnoses of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), depression ( mood disorder that causes a persistent feeling of sadness and loss of interest ), and diabetes type II ( condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of the quarterly MDS assessment dated [DATE] revealed Resident #33 had a BIMS of 10 which indicated a moderate cognitive impairment. The MDS also indicated Resident #33 required set up/cleanup for eating assistance. Record review of a care plan dated 01/03/2024 revealed Resident #33 had a care plan titled 'Nutritional Status'. The goal for Resident #33 was to gain 1 pound per week to reach his ideal body weight. The care plan intervention revealed to decrease distractions during meals. During an observation and interview of meal service on 03/18/2024 at 12:25 p.m., Resident #33 received a baked chicken breast as the protein for lunch. Resident #33 received a fork and a spoon to eat with and no knife. Resident #33 stated he could not eat the chicken breast because he had no knife and was not going to gnaw it off the bone like a dog. Resident #33 gave his piece of chicken to another resident. He stated he did not want the food to go to waste. During an observation and interview on 03/19/2024 at 12:30 p.m., it was noted Resident #33 received plastic utensils to eat with. Resident #33 said what in the hell am I supposed to do with plastic silverware. Resident #33 said he was sick of not getting the utensils he needed to eat his meal. He stated he never got a knife to cut his meat and no one helped him cut it up. During an interview on 03/18/2024 at 1:45 p.m. CNA G said the kitchen did not pass out knives routinely and it was up to the staff to cut the meat up for the residents. She was not sure how the meat for Residents # 38 and #33 got missed being cut up when their trays were served. CNA G stated if Resident # 38 and Resident #33 were given a knife they could have easily cut up their own meat with no problems. During an interview on 03/19/2024 at 2:00 p.m., the Dietary Manager stated the kitchen never passed out knives with the meal trays. She stated the facility had butter knives, but she stated the residents never asked for a knife that she was aware of. The Dietary Manager stated she could understand how having a knife would make it easier to cut meat. 5.Record review of an undated face sheet revealed Resident # 30 was an 83- year-old female, admitted to the facility on [DATE] with the diagnoses of diabetes type II (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and anxiety. Record review of a quarterly MDS assessment dated [DATE] revealed Resident #30 had a BIMS of 99, which indicated Resident #30 was unable to complete the interview . The MDS revealed Resident #30 required supervision/ touch assistance with eating. Record review of a care plan dated 07/25/2023, titled 'Nutritional Status', revealed Resident #30 had a goal of gaining or maintain weight over the next 90 days. One of the interventions for this care plan was to observe Resident #30 while eating to monitor for problems. During an observation on 03/18/2024 at 12:40 p.m., Resident #30 was fed by CNA G. CNA G was standing over Resident #30 while feeding her the last half of the lunch meal. During an interview on 03/18/2024 at 1:45 p.m., CNA G said she knew she was supposed to sit down while assisting a resident to eat. CNA G said she knew it was for the resident's dignity that she was supposed to sit and be on eye level with her while assisting. CNA G said not sitting while feeding Resident #30 could have made her feel embarrassed or rushed. During an interview on 03/20/2024 at 1:00 p.m., the ADON stated the CNAs were supposed to sit beside the residents that they assisted feeding and talk with them to help the resident feel comfortable while eating. The ADON stated standing could make the resident feel rushed and uncomfortable. During an interview on 03/20/2024 at 2:00 p.m., the ADM stated it was his expectation for any staff trained to assist in feeding the residents, that they all be seated when assisting. The ADM stated this was for resident's comfort and dignity. Review of an undated policy titled Resident Rights revealed that all residents have the right to a dignified existence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment 4 of 15 residents reviewed for environment. (Resident #1, Resident #41, Resident #29, and Resident #31) 1.The facility failed to ensure Resident #1, Resident #29, and Resident #41's bedroom ceiling tiles did not have brown water stains. 2.The facility failed to ensure Resident #31 was allowed to use the working commode in her room. These failures could place residents at risk of an unsafe, unsanitary, uncomfortable environment, embarrassment due to room not appearing homelike, and a decrease in quality of life and self-worth. Findings included: 1. Record review of Resident #1's face sheet printed [DATE] indicated Resident #1 was a [AGE] year-old, male and was admitted on [DATE] with diagnosis including moderate intellectual disabilities (is a term used when there are limits to a person's ability to learn at an expected level and function in daily life), history of acute respiratory disease (occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs), and non-pressure chronic ulcer of right calf with fat layer exposed (is defined as a defect in the skin below the level of knee persisting for more than six weeks and shows no tendency to heal after three or more months). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated Resident #1 had clear speech, adequate hearing, and adequate vision. The MDS indicated Resident #1 had a BIMS score of 10 which indicated moderate cognitive impairment. During an interview and observation on [DATE] at 10:16 a.m., Resident #1 was sitting on the side of his bed. Above Resident #1's bed, in the corner of the room were three ceiling tiles with brown water mark stains noted. Underneath the brown water mark stains were two buckets sitting on a shelf. In the corner of Resident #1's room near the closet, one ceiling tile with a brown stain and a container underneath it. Resident #1 said the ceiling used to leak but had not leaked in a couple months after the facility fixed the roof. He said sometimes his room had a mildew smell. He said he did not know why the facility had not changed the tiles since the leak was supposed to be fixed. 2. Record review of Resident #41's face sheet printed [DATE] indicate Resident #41 was a [AGE] year-old, male and admitted on [DATE] with diagnosis including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and history of shortness of breath. Record review of Resident #41's quarterly MDS assessment dated [DATE]indicated Resident #41 was usually understood and usually understood others. The MDS indicated Resident #41 had clear speech, minimal difficulty hearing, and impaired vision with no corrective lenses. The MDS indicated Resident #41 was unable to complete the BIMS assessment due to being rarely/never understood. The MDS indicated Resident #41 had short-and-long term memory recall problem and severely impaired cognitive skills for daily decision making. During an observation on [DATE] at 10:45 a.m., in Resident #41's room in the corner, near his window were three slightly bowing ceiling tile with brown water stains. Two ceiling tiles above the head of his bed were water stained also. During an interview on [DATE] at 10:20 a.m., the maintenance supervisor said he had been employed at the facility since the end of [DATE]. He said the water-stained ceiling tiles in Resident #1 and Resident 41's room were there when he started in [DATE]. He said the roof was damaged by some storms but was fixed in [DATE]. He said he did not know why the water-stained ceilings were not changed after the roof was fixed. He said he meant to change the ceiling tiles since he started but had not gotten to it. He said he did not know why buckets were underneath the water-stained ceilings. He said he did not place the buckets there. He said the water-stained tiles and bucket were not a homelike environment and was tacky. He said the water buckets were also hazardous. He said if the ceiling tiles were wet, they could potentially collapse. During an interview on [DATE] at 1:43 p.m., the DON said he did not know about the water-stained ceiling tiles in Resident #1 and Resident #41's rooms. He said he expected staff members to put maintenance issues in the maintenance log. He said he expected the maintenance supervisor to fix the issues in timely manner. He said he could not speculate how the water-stained ceiling tiles made the residents feel. He said he could not speculate what risks the water-stained ceiling tiles posed to the residents. During an interview on [DATE] at 2:33 p.m., the ADM said the maintenance director was responsible for the upkeep of the facility. He said staff members had a logbook to place maintenance issues in. He said maintenance issue had priority level decided on by him and the maintenance director. He said he was not aware of Resident #1 and Resident #41's water-stained ceiling tiles in their rooms. He said he imagined the water-stained ceiling tiles in the resident's rooms was unpleasant to look at. 3. Record review of a face sheet dated [DATE] revealed Resident #29 was an [AGE] year-old male, admitted to the facility on [DATE] with the diagnoses of cerebral infarction (damage to tissue in the brain due to lack of oxygen in the area), portal vein thrombosis (a narrowing or blocking of the portal vein by a blood blot), and depression (feelings of sadness, emptiness, and hopelessness). Record review of Resident #29's annual MDS dated [DATE] revealed Resident #29 had a BIMS of 13, which indicated intact cognition. The MDS also indicated Resident #29 was independent for ADL such as mobility and toileting. Record review of a care plan dated [DATE], titled 'Psychological Well Being', indicated Resident #29 had a potential for adjustment to the nursing facility and the intervention was listed to encourage Resident #29 to express his feelings and concerns. Record review of the maintenance log dated [DATE] showed no work order for Resident #29's ceiling tiles. During an observation on [DATE] at 9:45 a.m., the ceiling to the left of the door when entering the room of Resident #29 was noted to have an 18-to-20-inch semicircular brown water stain. During an observation on [DATE] at 2:15 p.m., the stain remained to the ceiling tiles in Resident #29's room. The brown stain was approximately 18-to-20 inches at the widest point. During an interview on [DATE] at 9:47 a.m., Resident #29 stated the water stain on the ceiling had been there for a few months and the ceiling would leak if a hard rain came through. Resident #29 stated it was just a few days prior the ceiling had leaked. Resident #29 stated the leaking ceiling and dirty tile made his anxiety worse because it made him worry about black mold. Resident #29 stated he reported the tiles to the maintenance man several weeks prior, but no one had replaced them. During an interview on [DATE] at 1:20 p.m., the Maintenance Director stated he was aware there were a few rooms that had ceiling tiles that needed to be replaced. He stated he just replaced most of the tiles less than 6 weeks ago. He stated he replaced the ceiling tiles in Resident #29's room around that time. The Maintenance Director stated he did not always make a formal request document or log everything he did. He stated sometimes an issue was reported to him and he just took care of it then. During an interview on [DATE] at 1:30 p.m., the DON stated he could not speculate on how ceiling tiles showing water leakage could impact a resident. During an interview on [DATE] at 2:00 p.m., the Administrator stated it was important for physical health, as well as mental health to have clean and well-kept rooms, including no stained ceiling tiles in the resident's rooms. The Administrator stated he could not speculate on what ill outcomes could occur from a stained ceiling. 4. Record review of Resident #31's face sheet dated [DATE] indicated Resident #31 was [AGE] year-old and admitted to the facility on [DATE] with diagnoses including acute pulmonary edema (swelling of the lungs), pneumonia (infection of the lungs), urinary tract infection, hypertension (high blood pressure), cognitive communication deficit, weakness, history of falls, heart failure, major depressive disorder (persistent sadness), and anxiety (nervousness). Record review of Resident #31's annual MDS assessment dated [DATE] indicated Resident #31 was understood and understood others. The MDS indicated Resident #31 had a BIMS score of 15 which indicated she was cognitively intact. Resident #31 had fluctuating inattention and disorganized thinking. Resident #31 did not have behavioral symptoms. Resident #31 used a walker and a wheelchair for mobility. Resident #31 was independent with toilet transfers and required partial assistance with toilet hygiene. The MDS indicated Resident #31 was occasionally incontinent of bowel and bladder. Record review of Resident #31's care plan with a revision date of [DATE] indicated Resident #31 had a problem area of compulsively putting wipes and toilet tissue in commode in bathroom after multiple education and notes put by toilet to not put object in toilet, resident continued to do, so object had even been denied, but was found to have wipes in her wheelchair where she had taken them off the nurse aide cart, which had caused several plumbing issues and bedside commode was placed in the resident's room. Resident #31 had consults due to gastric (stomach) system issues as evidenced by anal fixation and pain. Resident #31 had infatuation with anal area. During an observation and interview on [DATE] at 10:11 AM, Resident #31 was sitting on the side of her bed with her breakfast tray on her bedside table in front of her. Resident #31 said her breakfast was good and she had eaten most of it. Resident #31 had a bedside commode against the wall at the end of her bed. Resident #31's room had a strong smell of bowel movement. Resident #31 said she had to use a bedside commode because her bathroom commode had not worked since [DATE]. Resident #31 said she wished they would fix her commode, because she did not like using the bedside commode. There was a Sorry Out of Order sign on the outside of bathroom door. There was a sign behind the bathroom commode to not put toilet paper or wipes in toilet. During an observation and interview on [DATE] at 8:25 AM, Resident #31 was sitting on the side of her bed with breakfast tray on her bedside table. Resident #31 said she did not like having to use the bedside commode and wished they would get the bathroom fixed. Resident #31 said it was embarrassing to use the bedside commode and it did not feel private, even with a curtain. During an observation and interview on [DATE] at 12:48 PM, Resident #31 said she asked the DON about getting the commode fixed because she did not like using the bedside commode and he told her he would look into it. Resident #31 said they were trying to blame her for stopping the commode up, but she said she put the toilet paper and wipes in the trash can, so it wasn''t her. Resident #31 said using the bedside commode made her feel uncomfortable due to anyone could walk into her room. Resident #31 said they put the curtain up, but it just did not provide the privacy that a door does in a bathroom. Resident #31 said they just really need to fix her commode. During an interview on [DATE] at 3:28 PM, the Maintenance Director said they have had to call out the plumbers couple times due to Resident #31 was flushing wipes down the commode and it backed up the entire building septic system. The Maintenance Director said the bathroom toilet in Resident #31's room did work, but they have a sign on the door that it was out of order. The Maintenance Supervisor said Resident #31's bathroom room toilet was fixed approximately a month ago. The Maintenance Director said they have not had an issue with the septic system since they put the bedside commode in Resident #31's room. The Maintenance Director said they were monitoring the situation and there had not been any other issues with the septic system. The Maintenance Director said he did not know what the fix was due to it caused issues with the whole facility's septic system being backed up and residents not being able to flush their toilets. The Maintenance Director said they did not have a specific timeframe to monitor the situation. The Maintenance Director said he knew Resident #31 asked about when her commode would be fixed because the staff told him she asked about it regularly. The Maintenance Director said it was not the ideal situation with an able-bodied person not being able to use their bathroom toilet in their room. During an interview on [DATE] at 3:44 PM, CNA A said she had worked at the facility since [DATE] and normally worked the evening and night shifts. CNA A said the kept a plastic bag in Resident #31's bedside commode. CNA A said she would carry Resident #31's bucket of the bedside commode, bag and cover it then transport it to the shower room down the hall and would empty the Resident #31's bedside commode contents in the commode in the shower room. CNA A said she had not heard Resident #31 complain about using the bedside commode. CNA A said if it was her, she would want to go to the bathroom commode with a door. CNA A said she thought they were trying to limit Resident #31's toilet paper, but she was not sure what other interventions they have tried other than the bedside commode. During an interview on [DATE] at 01:08 PM, CNA B said she had worked at the facility for approximately 2 years and normally worked the day shift on Resident #31's hall. CNA B said the plumbing had been messed up and Resident #31 had a bedside commode placed in her room. CNA B said she kept a plastic bag in the bedside commode bucket. CNA B said she usually emptied the bedside commode by getting the air out of the plastic bag and tying it up, removed it from the room and then put it in her big trash barrel. CNA B said she did not know if Resident #31's toilet worked, but there was an out of order sign on her bathroom door. CNA B said all the toilets were stopped up at the same time on Resident #31's hall. CNA B said Resident 31 used a lot of toilet paper and sometimes puts it in the trash and sometimes put it in the bedside commode. CNA B said Resident #31 was able to transfer herself and did everything on her own. CNA B said Resident #31 asked for her potty to be fixed almost daily. CNA B said if circumstances warranted the use of a bedside commode, she would be good to use a bedside commode, but if there was a working commode in her room, she would expect to be able to use it. CNA B said Resident #31 did not have a comfortable homelike environment because she had to use a bedside commode and not use the bathroom commode. CNA B said she did not know how it affected Resident #31, but Resident #31 had told her that she did not like having to use the bedside commode. During an interview on [DATE] at 1:37 PM, RN C said she had worked at the facility since 2018 and normally worked the day shift. RN C said they started using the bedside commode in Resident #31's room when the toilets stopped up. RN C said she did not remember how long ago that was and she had not tried the Resident #31's toilet to see if it worked. RN C said she believed the bedside commode was a short-term situation. RN C said the maintenance director and the ADM were responsible for monitoring the toilet situation. RN C said a homelike environment should be whatever Resident #31 preferred as her homelike environment. RN C said Resident #31 had not mentioned anything to her about her toilet situation. During an interview on [DATE] at 2:29 PM, the DON said he did not think it had been that long since Resident #31 started using the bedside commode due to toilet issues. The DON said he was unaware of the plan related to how long Resident #31 would have the bedside commode. The DON said the ADM would make the final determination when/if the bedside commode would be removed from Resident #31's room and when she would be allowed to use the bathroom commode in her room. The DON said he was unaware if Resident #31's bathroom toilet was working, but to the best of his knowledge it was working. The DON said Resident #31 had not asked him to fix her toilet. The DON said he could not speculate on how Resident #31 felt using a bedside commode. The DON said people use bedside commodes all over the world as a useable tool. The DON said he could not speculate as to what would be reasonable to accommodate her. During an interview on [DATE] at 2:55 PM, the ADM said his plan was to get occupational therapy to work with Resident #31 to not use so much toilet paper. The ADM said Resident #31 had a compulsive personality. The ADM said Resident #31 had an anal fixation and would use an abundance of toilet paper and wipes and would flush down the commode and it would stop up the septic system. The ADM said there was one week he had to call the plumber out three times. The ADM said Resident #31's rights were infringing on the rights of others in the facility. The ADM said they have tried multiple interventions with Resident #31. The ADM said they have done education, signs, redirection, and even got Resident #31 bidet commode training with occupational therapy about six months ago. The ADM said Resident #31 was the only resident with a bidet commode in the facility. The ADM said they tried removing wipes from Resident #31's room, but she was found to have taken wipes off the aides' cart. The ADM said he had spoken to occupational therapy about doing some training with Resident #31, but he had not had a chance to see where they were at with it. The ADM said there were situations where a bedside commode was warranted, and he felt he had taken every step he could take with Resident #31 and the next step was to have occupational therapy work with her. On [DATE] at 11:00 AM, a policy on Safe, Comfortable Home like environment was requested and the ADM said they did not have a policy related to Safe, Comfortable, Home-like environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 1 resident reviewed for dialysis services. (Resident #11) The facility failed to document vital signs and an assessment of the access site after Resident #11 returned from dialysis. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #11's face sheet printed 03/18/24 indicated Resident #11 was a [AGE] year-old, male and admitted on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), cerebral infarction (stroke), acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), hypotension of hemodialysis (occurs because a large volume of blood water and solutes are removed over a short period of time), and arteriovenous fistula (is an irregular connection between an artery and a vein). Record review of Resident #11's quarterly MDS assessment dated [DATE] indicated Resident #11 had clear speech, minimal difficult hearing, and impaired vision with corrective lenses. The MDS indicated Resident #11 was usually understood and understood others. The MDS indicated Resident #11 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #11 required partial/moderate assistance for shower/bathe self, dressing, and putting on footwear, supervision for toileting and personal hygiene, and setup for oral hygiene. The MDS indicated Resident #11 was on dialysis. Record review of Resident #11's care plan dated 03/15/22, edited 01/05/23, indicated Resident #11 had dialysis related to renal failure. Interventions included assist resident in preparing for transport to dialysis, listen for bruit (a sound heard over an artery or vascular channel, reflecting turbulence of flow) over shunt site every shift, monitor access site every shift, and palpate shunt for thrill (An abnormal vibration that is felt on the skin overlying a loud cardiac murmur or an arteriovenous fistula) site every shift. Record review of an undated, blank facility's dialysis communication form indicated .day of dialysis (pre dialysis) .Resp .Temp .examine shunt site .Dialysis .BP .Pulse .Resp .Temp . The facility's dialysis communication form did not indicate post dialysis vital signs and assessment of access site. Record review of Resident #11's dialysis communication form dated 03/18/24, 03/15/24, 03/13/24, 03/11/24, 03/09/24, 02/23/24, 02/26/24, and 02/23/24 did not indicate post dialysis vital signs and assessment of access site. Record review of Resident #11's progress notes dated 12/05/23-03/18/24 did not reveal post dialysis assessment documentation. Record review of Resident #11's vital report dated 03/04/24-03/18/24 indicated blood pressure and pulse at the beginning of each shift. During an interview on 03/18/24 at 2:30 p.m., Resident #11 said he went to dialysis three times a week. He said when he returned from dialysis, nursing staff did not check his blood pressure or pulse. During an interview on 03/20/24 at 1:18 p.m., RN C said the nurse was responsible for filling out the dialysis form when the resident went to dialysis. She said before dialysis, the nurse checked the resident's vital signs and thrill and bruit of the shunt. She said when the resident returned from dialysis, a bandage was over the site and left on for a couple hours before its removed. She said the nurse normally documented post dialysis vital signs in the vital signs section or progress notes. She said it was important to do a post dialysis assessment to make sure there was no abnormal bleeding, monitor vital signs, and make sure the resident tolerated dialysis. She said if a post dialysis assessment was not done, bleeding could be missed, fistula malfunction could occur, or miss the resident having problems. She said the facility did not have a guideline to specify where to document the post dialysis assessment done at the facility. During an interview on 03/20/24 at 1:43 p.m., the DON said the facility used a dialysis communication form to document vital signs and thrill and bruit. He said the nursing staff should review the documentation from the dialysis center when the resident returned. He said he did not know if nursing staff had to check vital signs after the resident returned from dialysis. He said he had to review the dialysis form and policy. He said the post dialysis assessment was important to ensure the patient was stable. He said he could not speculate how not obtaining the post dialysis assessment affected the resident. He said if staff documented post dialysis assessments, a progress note, or vital signs section would be adequate. Record review of https://www.mayoclinic.org/tests-procedures/hemodialysis/about/pac-20384824 dated 08/05/23 and accessed on 04/04/24 indicated .hemodialysis treatment can be efficient at replacing some lost kidney function, you may experience some of the related conditions .low blood pressure .muscle cramps .sleep problems .anemia .high/low potassium levels .access site complications .it's extremely important to take care of your access site to reduce the possibility of infection and other complications . Record review of the facility's Outpatient Dialysis Service Agreement effective date 02/06/23 which indicated .whereas, the provision of hemodialysis services to ESRD Residents deemed appropriate for such care is consistent with ESRD Residents' rights, community standards of care, public policy, and the efficient and economic delivery of care . Record review of a facility's End-Stage Renal Disease, Care of a Resident with policy dated 09/10 indicated .residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring) for 4 (Resident # 2, Resident # 11, Resident # 16, and Resident # 41) of 13 residents whose medications were reviewed in that: 1.The facility failed to ensure Resident #2 had behavior monitoring for his prescribed Zoloft (is an antidepressant used to treat major depression). 2.The facility failed to ensure Resident #11 had behavior monitoring for his prescribed Lexapro (is an antidepressant used to treat depression). 3.The facility failed to ensure Resident #16 had behavior monitoring for his prescribed Ativan (is used to treat anxiety), Buspirone (is used to treat anxiety disorders) and Lexapro (is an antidepressant used to treat depression). 4.The facility failed to ensure Resident #41 had behavior monitoring for his prescribed Depakote (is used to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder), and to prevent migraine headaches) and Sertraline (is an antidepressant used to treat major depression). This deficient practice could place residents at risk of not receiving the intended therapeutic benefits of their psychotropic medications. Findings included: 1. Record review of Resident #2's face sheet printed 03/18/24 indicated Resident #2 was a [AGE] year-old, male and admitted on [DATE] with diagnosis including other bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) without behavioral disturbance, and other recurrent depressive disorders (a depressed mood or loss of pleasure or interest in activities for long periods of time). Record review of Resident #2's MDS assessment dated [DATE] indicated Resident #2 usually understood and usually understood others. The MDS indicated Resident #2 had a BIMS score of 10 which indicated moderate cognitive impairment. The MDS indicated Resident #2 had inattention and disorganized thinking that fluctuated. The MDS indicated Resident #2 required partial/moderate assistance for oral, personal, and toilet hygiene, shower/bathe self and lower body dressing. The MDS indicated Resident #2 had an active diagnosis of bipolar disorder and depression. The MDS indicated Resident #2 had received an antidepressant during the 7 days assessment period. Record review of Resident #2's care plan dated 02/08/23 indicated Resident #2 was at risk for adverse consequence related to receiving Zoloft for diagnosis of depressive disorder. Intervention included monitor resident's behavior and response to medication. Record review of Resident #2's consolidated physician order dated 03/01/24-03/20/24 indicated an order for Zoloft (Sertraline), 100 mg, 1 tablet, oral, DX: other recurrent depressive disorders, at bedtime, start date 01/24/23, no end date. No order for behavior monitoring noted. Record review of Resident #2's Side Effects/Behavior Administration history dated 03/01/24-03/20/24 indicated Anti-depressant Medication Use, observe resident closely for significant side effects, every shift, start date 09/26/23, no end date. No administration record for behavior monitoring noted. 2. Record review of Resident #11's face sheet printed 03/18/24 indicated Resident #11 was a [AGE] year-old, male and admitted on [DATE] with diagnosis including other history of recurrent depressive disorders. Record review of Resident #11's quarterly MDS assessment dated [DATE] indicated Resident #11 had clear speech, minimal difficult hearing, and impaired vision with corrective lenses. The MDS indicated Resident #11 was usually understood and understood others. The MDS indicated Resident #11 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #11 required partial/moderate assistance for shower/bathe self, dressing, and putting on footwear, supervision for toileting and personal hygiene, and setup for oral hygiene. The MDS indicated Resident #11 had received an antidepressant during the 7 days assessment period. Record review of Resident #11's care plan dated 03/15/22, edited 01/05/23 indicated Resident #11 was at risk for adverse consequences related to receiving Lexapro 10mg an antidepressant for depression. Intervention included monitor resident's behavior and response to medication. Record review of Resident #11's consolidated physician order dated 03/01/24-03/20/24 indicated an order for Lexapro, 10mg, 1 tablet, oral, DX: other recurrent depressive disorders, once a day. Start date 05/22/23, no end date. No order for behavior monitoring noted. Record review of Resident #11's Side Effects/Behavior Administration history dated 03/01/24-03/20/24 indicated Anti-depressant Medication Use, observe resident closely for significant side effects, twice a day, start date 07/25/23, no end date. No administration record for behavior monitoring noted. 3. Record review of Resident #16's face sheet printed 03/18/24 indicated Resident #16 was a [AGE] year-old, male and admitted on [DATE] and 04/20/22 with diagnoses including depression (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act), alcohol abuse with alcohol-induced anxiety disorder, generalized anxiety disorder (a constant state of worry, fear, and dread), and other recurrent depressive disorders (depression). Record review of Resident #16's quarterly MDS assessment dated [DATE] indicated Resident #16 was understood and understood others. The MDS indicated Resident #16 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #16 required supervision for shower/bathe self and personal hygiene, setup for oral hygiene, independent for toileting hygiene, dressing, and putting on footwear. The MDS indicated Resident #16 an antidepressant and antianxiety during the 7 days assessment period. Record review of Resident #16's care plan dated 09/27/28, edited 02/08/23 indicated Resident #16 received antidepressant medication related to major depressive and disorder and insomnia. Intervention included monitor resident's behavior and response to medication. Record review of Resident #16's care plan dated 11/23/20, edited 02/08/23 indicated Resident #16 received antianxiety medication related to anxiety, Lorazepam. Intervention included monitor resident's mood and response to medication. Record review of Resident #16's consolidated physician order dated 03/01/24-03/2024 indicated an order for: *Lorazepam, 0.5mg, 1 tab, oral, twice a day, DX: Generalized anxiety disorder. Start date 04/14/23, no end date. *Lexapro, 10mg, 1 tablet, oral, DX: Depression, once a day. Start date 05/11/23, no end date. *Buspirone, 5mg, 1 tablet, oral, DX: Generalized anxiety disorder, twice a day. Start date 10/25/23, no end date. No order for behavior monitoring noted. Record review of Resident #11's Side Effects/Behavior Administration history dated 03/01/24-03/20/24 indicated: * Anti-depressant Medication Use, observe resident closely for significant side effects, every shift, start date 02/06/23, no end date. *Anti-anxiety Medication Use, observe resident closely for significant side effects, twice a day, start date 07/25/23, no end date. *Target Behavior: (Angry). At the end of each shift mark frequency, intervention, and effectiveness, twice a day, start date 05/23/22, no end date. No administration record for behavior monitoring noted. 4. Record review of Resident #41's face sheet printed 03/20/23 indicate Resident #41 was a [AGE] year-old, male and admitted on [DATE] with diagnosis including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia, moderate, with anxiety (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), 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 #41's quarterly MDS assessment dated [DATE]indicated Resident #41 was usually understood and usually understood others. The MDS indicated Resident #41 had clear speech, minimal difficulty hearing, and impaired vision with no corrective lenses. The MDS indicated Resident #41 was unable to complete the BIMS assessment due to being rarely/never understood. The MDS indicated Resident #41 had short-and-long term memory recall problem and severely impaired cognitive skills for daily decision making. The MDS indicated Resident #41 an antidepressant and antianxiety during the 7 days assessment period. Record review of Resident #41's care plan dated 11/15/23 indicated Resident #41 received antidepressant medication. Intervention included monitor resident's mood and response to medication. Record review of Resident #41's consolidated physician order dated 03/01/24-03/2024 indicated order for the following: *Depakote Sprinkle capsules, 125mg, 1 tablet, oral, DX: Dementia in other diseases classified elsewhere, severe, with other behavioral disturbance, twice a day. Start date 11/02/23, no end date. *Sertraline, 25mg, ½ tablet, oral, DX: Depression, unspecified, once a day. Start date 02/28/24, no end date. No order for behavior monitoring noted. Record review of Resident #41's Side Effects/Behavior Administration history dated 03/01/24-03/20/24 indicated: * Anti-depressant Medication Use, observe resident closely for significant side effects, every shift, start date 11/03/23, no end date. *Anti-anxiety Medication Use, observe resident closely for significant side effects, every shift, start date 11/03/23, no end date. *Anticonvulsant Medication Use, observe resident closely for significant side effects, every shift, start date 11/03/23, no end date. *Target Behavior: Increase anxiety, restlessness, panic attacks, At the end of each shift mark frequency, intervention, and effectiveness, every shift, start date 11/03/22, no end date. No administration record for behavior monitoring noted. During an interview on 03/20/24 at 12:50 p.m., the ADON said she had been employed at the facility since July 2023. She said target behavior was to monitor the behaviors the resident received the medication for. She said only antipsychotic and antianxiety medications needed behavior monitoring. She said she believed the state only required those two drug classes. She said all psychotropic medication needed side effect monitoring. She said resident did not need orders for behavior monitoring for it to be done. She said using nursing judgement let you know to look for behaviors on all residents. She said she did not feel like the behavior monitoring done by nurses needed to always be documented because you always did not see what the previous nurse charted. She said if a nurse wanted to document behaviors, a progress note, report between nurse, and the 24-hour report was sufficient. During an interview on 03/20/24 at 1:18 p.m., RN C said she had been employed at the facility since 2018. She said the behavior monitoring was under the side effects area. She said behaviors were increased agitation, confusion, or sleepiness. She said behavior monitoring should include intensity, intervention, and effectiveness of intervention. She said behavior monitoring was important to know if the medication was not working and if it needed to be changed. She said if behavior monitoring was not done, residents could hurt themselves or other residents, fall, elope, and wander. During an interview on 03/20/24 at 1:43 p.m., the DON said behavior monitoring was in the side effects/behaviors administration. He said behavior monitoring was to monitor if the resident had behaviors related to what the medication was prescribed to treat. He said behavior monitoring was not the side effects of taking the medication. He said he thought the side effects area had a frequency and intervention section for behavior monitoring. During a phone interview on 03/20/24 at 3:10 p.m., the pharmacy consultant said the facility was not required to do behavior monitoring on antidepressants or anticonvulsants. She said this was per the State. At that time, a request was made to the pharmacy consultant to email the DON the information from the State stating behavior monitoring was not required for certain drug classifications. No information received before or after exit. Record review of an undated facility's Medical Utilization and Prescribing policy indicated .the physician and staff will adjust existing medication based on their efficacy and the continued presence of relevant conditions and risk .monitoring .the staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to ensure that the medication and dosage are still relevant and are not causing undesired complications .this may be reviewed in care plan or other routine assessments .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for one of four nurse medication carts (Hall 100 nurse medication cart). 1. The facility failed to ensure LVN D did not leave 2 Insulin pens on top of nursing cart unsupervised. 2. The facility failed to ensure LVN D's medication cart was not left unlocked and supervised. These deficient practices placed residents at risk of drug diversion and having access to medications not prescribed for them which could result in injury and hospitalization. The findings include: Observation on 03/19/2024 at 12:00 PM revealed the nurse in charge of the cart, LVN D left 2 insulin pens on top of nursing cart unsupervised and parked in the hall in front of room [ROOM NUMBER], while going into resident room to check resident's blood glucose. Observation on 03/19/2024 at 12:06 PM after LVN D checked resident blood glucose she grabbed the 2 insulin pens and left the cart unlocked with the keys in the cart unsupervised. On 03/20/2024 at 12:45 PM attempted to call LVN D, no answer and left message for a returned call. 03/20/2024 at 3:07 PM attempted to call LVN D, no answer and left message for a returned call. During an interview on 03/20/24 12:55 PM CMA F stated in the nurse cart there were several taken as needed medications, Nebulizer treatments, inhalers, diabetic medications and insulins. CMA F said she honestly did not know everything that was kept in the nursing cart. CMA F said the first thing should be done prior to walking away from medication carts was to make sure the cart was locked, and the screen was closed, before the cart was left. CMA F said it was important to keep the nursing cart locked because anyone can get into the cart. CMA F said residents could get things they did not need and the facility would be in trouble. During an interview on 03/20/2024 at 1:10 PM RN C said the facility had a lot of stuff on the nursing cart like as needed medications for every resident, Nitroglycerin, Diabetic testing strips, insulins, breathing treatments, bandages and stir strips on the nursing cart. RN C said the first thing should have been done before walking away from the nursing cart was to make sure everything was cleaned off the top of the cart, wipe down items had been used from the cart, make sure the cart was locked and log off the computer. RN C said the cart should be locked, because it had items on the cart the facility did not want random people, other staff or residents to get ahold to. When RN C was asked what could happen if a resident got into the cart RN C replied, It will not happen, because the carts should be locked at all times. RN C said as needed medications and insulins could make resident's blood sugar drop. RN C said residents could get into the inhalers; anything could happen. During an interview on 03/20/24 at 1:17 PM LVN E said the nursing cart had breathing treatments, Insulins, alcohol swabs, creams, purple top wipes, as needed medications and Narcotics box of medications. LVN E said before walking away from the nursing cart the drawers should be closed and locked. LVN E said it was important to keep the nursing cart locked, because of the Narcotics (a drug that relieves pain and induces drowsiness, stupor, or insensibility). LVN E said no one should have access to the nurse cart, except for the nurse. LVN E said if a resident got ahold to some of the medications on the nurse cart it could be very dangerous. LVN E said most of the items on the cart could be a hazard and danger to an unsupervised resident. During an interview on 03/20/24 at 1:36 PM the DON said there were medications on the Nursing cart. The DON said the first thing should be done was to follow the standards set for the storage of medications. When asked why it was important to keep the nursing cart locked, the DON responded, I do not speculate. After the question was rephrased, the DON still replied I do not speculate. When asked what could happen if a resident got into the nursing cart, the DON replied, I do not speculate. After the question was rephrased, the DON still replied I do not speculate. During an interview on 03/20/24 at 1:56 PM the Administrator said there were medications on the nurse cart, but he was not sure exactly what all would be on the cart. The Administrator said the first thing before walking away from the nurse cart was lock it. The Administrator said the reason the cart should be locked was because it should have limited access. When asked what could happen to a resident if got into the nurse cart the Administrator said the facility would have a problem. The Administrator said, he could not speculate on that. Record review of the facility policy titled Medication Storage revised on 07/14/2017 read in part: Policy statement Medications must only be accessible to authorized staff and locked when not under the direct observation of authorized staff. The medication cart should always be locked unless it is in direct view of the Nurse or medication aide. No medications should be left unattended: on medication carts. Controlled medications must be stored in a manner to limit access and to facilitate reconciliation in accordance with the facility policies.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure the ceiling was in good repair in the kitchen. This failure could place residents at risk of foodborne illness and food contamination. Findings included: During initial tour observations in the kitchen on 3/18/24 beginning at 9:08 AM, there was brown staining to approximately six ceiling tiles above to area of the tea maker machine, juice machine, and the food processor (used to make puree and chopped foods). One of the ceiling tiles had a rounded dropped appearance and had loose ceiling tile particles hanging from it directly above the tea maker where there were two uncovered tea filter holders sitting on top of the tea maker and the food processor was beside the tea maker. There was an approximate 1-inch gap in the ceiling tile around half of the fire sprinkler head located above the juice machine. One ceiling tile located directly in front of the tea maker, juice machine and the food processor had a rounded dropped appearance with an approximate 3/4 to 1-inch crack/separation in the ceiling tile on both sides of the air vent, and the air vent was dropped approximately ¾ of an inch from the ceiling. During an observation on 3/19/24 beginning at 11:26 AM, the DM used the food processor located beside the tea machine and below the damaged ceiling tiles to puree (thick liquid suspension made from cooked food) pork loin, green beans, and black-eyed peas. During an interview on 3/19/24 at 3:11 PM, the DM said the ceiling tiles in the kitchen above the area of the food processor, tea, and juice machines, had been like that since around the first of year or a little before. The DM said the maintenance supervisor had been trying to fix it from leaking. The DM said the maintenance supervisor had put tar on the roof trying to fix the leak. The DM said the area in the kitchen would leak if they had a hard rain, but it did not leak when it rained last month. The DM said it made her a little nervous working in the area where the ceiling tile damage was due to the electrical wiring and ducts. The DM said there could be cross-contamination from the particles hanging from the ceiling tile and/or open areas in the ceiling tiles, but they made sure they washed things down before they used the tea machine, tea filter containers, juice machine, or food processor and kept it as clean as possible. During an interview on 03/19/24 at 3:28 PM, the Maintenance Supervisor said the damaged ceiling tiles in the kitchen had been that way since before he started at the facility in June 2023. The Maintenance Supervisor said he had been on the roof of the building and in the attic trying to patch things and it still leaked when it rained heavy. The Maintenance Supervisor said he did replace the damaged ceiling tiles in the kitchen around the beginning of March, but after the last big rain it was back like it was again. The Maintenance Supervisor said he did not have the repairs documented in his log. The Maintenance Supervisor said he had the ceiling tiles to repair the ceiling in the kitchen, but he had not been able to fix them yet because he would need to schedule the repair when the kitchen was not in use. The Maintenance Supervisor said he had reported the issue to the ADM. The Maintenance Supervisor said the damaged ceiling tiles in the kitchen did not look nice and attic dust and/or insulation could potentially get into the drinks or food with the juicing and tea machines and the food processor being located in the same area. During an interview on 3/20/24 at 2:55 PM, the ADM said he had seen the damaged kitchen tiles and they had been dealing with a leak. The ADM said they had repaired it and sometimes it would leak and sometimes it did not leak. The ADM said he was waiting on a repair quote from a roofing company. The ADM said it seemed like it would be a sanitation issue with the cracks in the ceiling tiles and particles hanging from the ceiling. Record review of the facility's policy titled Food Safety and Sanitation Plan dated revised on 11/28/2017 indicated . it was the policy of the facility to follow an effective, proactive food safety program that was based on preventing food safety hazards before they occurred . residents risk serious complications from foodborne illness as a result of their compromised health status . sanitary conditions must be present in health care food service settings to promote safe food handling .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 1 of 5 residents reviewed for- residents rights. (Resident #5) The facility failed to ensure Resident #5 was provided privacy when she used a bedside commode in her room. This failure placed residents at risk for diminished quality of life, loss of dignity and decrease in comfort. Findings include: Record review of Resident #5's face sheet dated 03/05/24 indicated Resident #5 was a [AGE] year-old female and admitted on [DATE] with diagnoses including screening for malignant neoplasm of colon (is a cancer, or malignant tumor, of the large intestine, which may affect the colon or rectum), need for assistance with personal care, chronic superficial gastritis with bleeding (a persistent, but low grade, inflammation and damage to the stomach lining), noninfective gastroenteritis and colitis (a disorder characterized by inflammation of the colon), and constipation. Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated Resident #5 was understood and understood others. The MDS assessment indicated Resident # 5 had a brief interview for mental status score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident # 5 required limited assistance with activities of daily living. Resident #5 had partial assistance with toilet hygiene, supervised with personal hygiene and independent with toilet transfer. Record review of Resident #5's care plan dated 12/20/2023 indicated Resident #5 has a risk for constipation related to medication usage, low level of physical activity, pain in bottom area (history of hemorrhoidectomy (is a surgical procedure to remove hemorrhoids. Hemorrhoids are enlarged blood vessels in your anus that can sometimes cause uncomfortable symptoms, like anal pain and bleeding)). Intervention included monitored for signs and symptoms of constipation such as lethargy, decreased bowel sounds, abdominal distention, tenderness, change in level of consciousness. Record review of Resident #5's care plan dated 02/09/23 indicated Resident #5 had an infatuation her with anal area. Intervention included education on the need to leave area alone to allow area to not be irritated. Record review of Resident #5's care plan dated 03/04/24 indicated Resident #5 compulsively put multiple wipes and toilet tissue in commode in bathroom which has caused several plumbing issues. Bedside commode placed in room. Intervention included maintain dignity while bedside commode in room. During an observation and interview on 03/04/24 at 10:04 a.m., Resident #5 said her bathroom had not worked since January 2024. She said the facility had given her a bedside commode to use instead. She said she did not have privacy and it made her uncomfortable when she used the bedside commode. She said when people entered her room when she was on the bedside commode, they could see her. She said it would make her very happy if the facility fixed her bathroom toilet. Resident #5's bedside commode was in her room against the bathroom door. No privacy curtain noted in room or by bedside commode. There was a sign on the bathroom door that said, Sorry Out of Order. During an interview on 03/05/24 at 12:31 p.m., CNA A said had been a couple weeks since Resident #5's bathroom toilet had been out of order. She said it would have made her feel uncomfortable if she had to use a bedside commode with no privacy curtain. CNA A said housekeeping were responsible for residents' privacy curtain. During interview on 03/04/2024 at 1:29 PM, the Maintenance Man said the facility had some plumbing issues. The Maintenance man said staff took Resident #5 to shower room to use bathroom but Resident #5 took too long in the restroom and tied up the shower room from the other residents. The Maintenance Man said the lines were clogged. The Maintenance Man said the plumbers came out to the facility twice in one week and said the toilet was clogged due to wipes flushed. The Maintenance Man said he does not have the exact date when the plumber came. During interview and observation on 03/04/2024 at 2:43 PM the Maintenance Man said Resident #5 toilet worked. The Maintenance said the plumber came out a couple weeks ago and fixed toilet. The Maintenance Man flushed the toilet and verified proper function. The Maintenance Man said the suction with the toilet was not the best. During interview on 03/05/2024 at 9:39 AM LVN A said Maintenance were responsible for privacy curtains. LVN A said she did not know Resident #5 had a bedside commode in her room. During interview on 03/05/2024 at 9:55 AM LVN B said she was aware Resident #5 had a bedside commode and Housekeeping was responsible privacy curtains. LVN B said she did not know why Resident #5 did not have privacy curtains. LVN B said she would not feel comfortable if people could walk in and see her on the pot. During observation on 03/05/2024 at 10:03 AM Resident #5 Bedside commode was in her room against the bathroom door. No privacy curtain noted in room or by bedside commode. There was a sign on bathroom door said, Sorry Out of Order. Resident #5 bedside commode had a brown substance on bedside commode and had a foul odor. During interview on 03/05/2024 at 10:05 AM CNA B said when she walked in Resident #5 could see her if she was on her bedside commode and she do not any privacy. CNA B said it would make her feel uncomfortable if she had to use a bedside commode with no privacy. During interview on 03/05/2024 at 10:10 AM LVN C said Resident #5 bathroom had not been used, due to plumbing issues. CNA C said Resident #5 had never complained to her about her bathroom not available. CNA C said Resident #5 stopped up the toilet with wipes when she used the bathroom. CNA C said she would be embarrassed if she had no privacy when she used the bathroom. During interview on 03/05/2024 at 10:30 AM the DON said he was aware Resident #5 has a bedside commode. DON said the facility has had plumbing issues with wipes. DON said Resident #5 had a fixation with her anal area. DON said Resident #5 had been advised not flush wipes down the toilet. DON said Resident #5 door to her room would secure her privacy and staff should knock prior to entrance. DON said Resident # 5 had not complained about privacy or use of bedside commode to him. During interview on 03/05/2024 at 10:53 AM the Administrator said he was aware Resident #5 had a bedside commode. The Administrator said Resident # 5 had a documented history of putting things in the toilet. The Administrator said he had used signs to discourage Resident #5 for wipes placed in toilet. The Administrator said the facility had plumbers out two or three times a week, due to wipes placed in the toilet. The Administrator said Resident #5 did not have a roommate since she had her bedside commode. The Administrator said he knew Resident #5 would not be happy if someone just walked in while she used the bathroom. The Administrator said Resident #5 had not complained about the bedside commode to him. Record review of the facility's Rights of Nursing Facility Residents Policy revealed, .By law every Texas nursing facility resident has the right to be treated with dignity, respect, courtesy and consideration without regard to race, religion, national origin, sex, disability, marital status or source of payment .to privacy during visits and telephone calls and while attending to personal needs, unless providing would infringe on rights of others .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 13 residents (Resident #6, Resident #27) reviewed for reasonable accommodations. The facility failed to ensure Resident #6 had access to a call light. The facility failed to ensure Resident #27's call light was within reach. These failures could place residents at risk for unmet needs, injuries, and decreased quality of life. Findings included: 1. Record review of a face sheet dated 02/08/23 indicated Resident #6 was [AGE] years old and was initially admitted on [DATE] with diagnoses including need for assistance with personal care, chronic pain, and history of falling. Record review of a care plan dated 01/05/23 indicated Resident #6 had potential for decline in ADL function related to terminal illness, decline in health. There was a goal for Resident #6's needs to be met by staff. There was an intervention to encourage the resident to call for assistance. To leave the call bell within reach while in bed or chair and to answer the call bell promptly. Record review of the MDS dated [DATE] indicated Resident #6 was understood and understood others. The MDS indicated a BIMS score of 5 indicating severe cognitive impairment. The MDS indicated Resident #6 required supervision to extensive assistance with ADLs. Record review of a Maintenance Request Log dated 01/25/23 - 02/08/23 kept near the nurse's station did not indicate any request for repair of Resident #6's call light. During an observation on 02/06/23 at 9:59 a.m., Resident #6 was asleep in bed. There was no call light near the resident. At the call light outlet there was a call light leading to the roommate's bed. The other call light outlet had a plastic plug inserted with no cord. During an observation on 02/06/23 at 10:29 a.m., Resident #6 was provided incontinent care. There was no call light from the call light outlet to Resident #6's bed. Only one call light noted in room, and it was attached to the roommate's bed. During an observation on 02/06/23 at 1:42 p.m., there was no call light leading to Resident #6's bed. At the call light outlet there was a call light leading to the roommate's bed. The other call light outlet had a plastic plug inserted with no cord. During an observation 02/07/23 at 8:00 a.m., Resident #6 was asleep in bed. There was no call light near the resident. At the call light outlet there was a call light leading to the roommate's bed. The other call light outlet had a plastic plug inserted with no cord. During an observation on 02/07/23 at 9:10 a.m., Resident #6 was asleep in bed. There was no call light near the resident. At the call light outlet there was a call light leading to the roommate's bed. The other call light outlet had a plastic plug inserted with no cord. During an observation 02/07/23 at 10:34 a.m., Resident #6 was asleep in bed. There was no call light near the resident. At the call light outlet there was a call light leading to the roommate's bed. The other call light outlet had a plastic plug inserted with no cord. During an interview on 02/08/23 at 8:40 a.m., Resident #6 said she did not know how long she was without a call light. She said she could not remember if she needed assistance when she did not have one. She said without a call light she would have to yell for assistance. I can get pretty loud. During an interview on 02/08/23 at 8:55 a.m., CNA E said Resident #6 was not without a call light for very long. She said the call light had kept going off by itself. She said she verbally reported the call light not working on the morning of 2/7/23 to maintenance and the call light was replaced. She said she did know that Resident #6 did not have a call light on 2/6/2023. She said she did not report it to maintenance because it just slipped her mind. During an interview on 02/08/23 at 9:11 a.m., the Maintenance Supervisor said he normally found out about maintenance issues from the maintenance logbook that was kept near the nurse's station. He said maintenance was told by a CNA on 2/7/2023 that Resident #6's call light was not working. He said he was not sure how long there had not been a call light. He said he did weekly rounds on Wednesdays to check each call light. He said he last did rounds on 2/1/2023 and there were no issues with the call light. He said there has been a huge amount of move ins and it may have fell through the cracks. During an interview on 02/08/23 at 9:37 a.m., Maintenance Assistant said he was told by an aide on 2/7/23 that the call light for Resident #6 was shorted out. He said he put in a new call light immediately. During an interview on 02/08/23 at 10:44 a.m., the DON said any staff should report a malfunctioning call light immediately so it could be replaced. He said if a CNA found a call light not working appropriately it should have been reported immediately to a nurse and a new call light should be placed in the room. He said a resident without a functioning call light might not have their needs met. 2. Record review of the face sheet dated 02/06/23 revealed Resident #27 was [AGE] year-old male and admitted on [DATE] with diagnoses including focal (confined to one area of the brain) traumatic brain injury (damage to the brain) with loss of unconsciousness and nondisplaced comminuted fracture (one in which the bone cracks or breaks but retains its proper alignment) of shaft of right fibula (is a small bone that runs along the outside of the lower leg). Record review of the quarterly MDS dated [DATE] revealed Resident #27 was understood and understood others. The MDS revealed Resident #27 had a BIMS of 06 which indicated severe cognitive impairment. The MDS revealed Resident #27 was independent for bed mobility, transfer, dressing, toilet use, and bathing but needed supervision for personal hygiene. Record review of the care plan dated 12/28/22 revealed Resident #27 had a history and was at risk for increased falls and injury as evidence by actual fall. Interventions included fall 1/10/23, Resident #27 encouraged to use assistive rollator when going to restroom, evaluate the need for further intervention for increased falls, fall 12/28/22, fall star program initiated. Record review of the care plan dated 07/20/21, edited 01/10/23 revealed Resident #27 has potential for decline in ADL function related to history of traumatic brain injury and progressive decline in cognition. Intervention dated 04/13/22 included encourage to call for assistance. Leave call bell within reach while in bed or chair. Answer promptly. During an observation and interview on 02/06/23 at 10:24 a.m., Resident #27 was lying in his bed watching television. Resident #27 had an orthopedic boot/brace on his right leg. Resident #27's call light was on the other side of his bed, on the floor not within reach. Resident #27 said he did not know where his call light was and did not help getting out of the bed. He said he did not use the call light often but would use it if it was available. He said if fell and the call light was not within reach, he would have to holler for help, and someone would eventually show up to help him. During an observation on 02/07/23 at 9:10 a.m., Resident #27 was lying in his bed watching television. Resident #27 had an orthopedic boot/brace on his right leg. Resident #27's call light was on the other side of his bed, on the floor not within reach. During an observation on 02/08/23 at 9:10 a.m., Resident #27 was lying in his bed watching television. Resident #27 had an orthopedic boot/brace on his right leg. Resident #27's call light was on the other side of his bed, on the floor not within reach. During an interview on 02/08/23 at 11:29 a.m., CNA A said she had worked at the facility for 3 years. She said she was the aide assigned to Resident #27's hall. She said Resident #27 did not use the call light because he was independent, but he would use it if he really needed something. She said he did have two falls recently and broke his right leg the last fall. She said she mainly monitored the hall by making rounds but knew call lights needed to be always in reach to prevent falls. During an interview on 02/08/23 at 11:46 a.m., the ADON said Resident #27 was on the fallen star program which a yellow star was placed by his name on the door letting staff know he had fallen within the last 4 weeks. She said she did not know if Resident #27 used his call light for assistance. The ADON said his call light should be within reach when he was in the bed or chair to encourage him to call for assistance. She said it was the CNAs responsibility to ensure call lights were within reach when they made rounds. The ADON said call lights needed to be in reach so residents could get assistance and prevent falls or injuries. During an interview on 02/08/23 at 2:16 p.m., the DON said Resident #27 was on the fall prevention program due to recent falls with an injury. He said Resident #27 was independent with his ADLs so did not know how much he used the call light. The DON said the call light should at least be in the bed not behind it. The DON said it was aides and nurses' responsibility to ensure call lights were within reach. He said a lot of things could happen if a resident call light was not within reach, so he did not want to speculate. During an interview on 02/08/23 at 11:17 a.m., the Administrator said he would expect all residents to have working call light. He said CNAs should report malfunctioning call lights without delay before it has time to slip their mind. He said a resident not having a call light could interfere with them getting assistance with something they want or need. Review of a facility Answering the Call Light policy dated 10/2010 indicated, .The purpose of this procedure is to respond to the resident's requests and needs .be sure that the call light is plugged in at all times .when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .report all defective call lights to the nurse supervisor promptly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 13 residents reviewed for assessments. (Resident #27) The facility failed ensure Resident #27 was not improperly coded for limb restraints and chair alarms on the MDS. This failure could place residents at risk of not having individual needs met. Findings included: 1. Record review of the face sheet dated 02/06/23 revealed Resident #27 was [AGE] year-old male and admitted on [DATE] with diagnoses including focal (confined to one area of the brain) traumatic brain injury (damage to the brain) with loss of unconsciousness and nondisplaced comminuted fracture (one in which the bone cracks or breaks but retains its proper alignment) of shaft of right fibula (is a small bone that runs along the outside of the lower leg). Record review of the quarterly MDS dated [DATE] revealed Resident #27 was understood and understood others. The MDS revealed Resident #27 had a BIMS of 06 which indicated severe cognitive impairment. The MDS revealed Resident #27 was independent for bed mobility, transfer, dressing, toilet use, and bathing but needed supervision for personal hygiene. The MDS revealed Resident #27 used limb restraint less than daily in the bed and chair alarm less than daily. During an interview on 02/06/23 at 10:24 a.m., Resident #27 said he never had a restraint used on his body or a device in his wheelchair that alarmed when he got up. During an interview on 02/08/23 at 1:23 p.m., the MDS coordinator said she incorrectly coded Resident #27 for restraints and alarms. She said the facility did not use either for residents. The MDS coordinator said it was her responsibility to ensure MDSs were accurate. She said the inaccurate MDS made discrepancy on the resident's chart and did not provide an accurate assessment of Resident #27. During an interview on 02/08/23 at 2:16 p.m., the DON said he expected the MDSs to be accurate and reflect the resident's status. He said the MDS coordinator was responsible for MDS input and accuracy. The DON said he did not know Resident #27 had been incorrectly coded for restraints and alarms. He said himself and the corporate MDS coordinator were responsible for overseeing the MDS coordinator input and accuracy. During an interview on 02/08/23 at 2:51 p.m., the Administrator said he expected residents to have accurate assessments or MDSs. Record review of an undated facility Certifying Accuracy of the Resident Assessment policy revealed .all personnel who complete any portion of the resident assessment (MDS) must sign and certify the accuracy of that portion of the assessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the baseline care plan included the instructions for resident care needed to provide effective and person-centered care was provided to the resident and/or their representative for 3 of 12 residents reviewed for new admissions (Resident #139, #140, and #5). The facility did not provide Residents #139, #140, and #5 and/or their representative with a summary of the baseline care plan. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of the admission Face Sheet dated 02/08/2023, for Resident #139 revealed an [AGE] year-old male. Resident #139 was admitted to the facility on [DATE]. His diagnoses included cerebral infarction (stroke), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), and heart failure (occurs when the heart muscle doesn't pump blood as well as it should). Record review of the admission MDS dated [DATE] documented a BIMS score of 12, which indicated moderate memory impairment. Resident #139 required extensive assistance x 2 staff assistance for bed mobility, transfer, and toileting. Resident #139 required limited assistance x1 staff assistance for eating. Record review of the 01/08/2023 to 02/08/2023 Active Physician Orders revealed Resident #139 received Eliquis 2.5 mg twice daily (blood thinner), Lexapro 20 mg once daily (antidepressant), Lantus 15 units at bedtime (insulin), and was on Hospice. Resident #139 had an order to cleanse deep tissue injury (DTI) to right buttock with normal saline, pat dry and apply a hydrocolloid dressing every other day. Resident #139 had an order to cleanse deep tissue injury to left buttock with normal saline, pat dry and apply a hydrocolloid dressing every other day. The orders revealed Resident #139 had an order for supplemental oxygen at 2-4 liters via nasal cannula and an order of do not resuscitate. Record review of Resident #139's paper and online chart for the Baseline Care Plan revealed a baseline care plan with no completion date and no date reviewed with resident or representative listed. During an interview on 02/08/2023 at 9:30 a.m., Resident #139 stated no care plan meeting or review of a base line care plan had been done with him since admission. Resident #139 stated it was important to him to have his family involved in his care decisions. During an interview on 02/08/2023 at 10:00 a.m., the family member of Resident #139 stated no care plan meeting or review of care had been done with the family since admission. The family member of Resident #139 stated a care plan meeting would be beneficial to the resident to ensure all aspects of his medical condition were being addressed. 2. Record review of the admission Face Sheet dated 02/08/2023, for Resident #140 revealed a [AGE] year-old male. Resident #140 was admitted to the facility on [DATE]. His diagnoses included acute cerebrovascular accident (stroke), atrial fibrillation (irregular heartbeat), and dysphagia (difficulty swallowing). Record review of the admission MDS dated [DATE] documented a BIMS score of 03, which indicated severe memory impairment. Resident #140 required extensive assistance x 2 staff assistance for bed mobility and toileting. Resident #140 required dependent assistance for transfer x 2 staff and was independent for eating. Record review of the 01/08/2023 to 02/08/2023 Active Physician Orders revealed Resident #140 received amiodarone 200mg once daily (regulate heartrate), aspirin 81mg once daily (blood thinner), Eliquis 5mg twice daily (blood thinner), lacosamide 100mg once daily (antiseizure medication), losartan 25 mg once daily (hypertension), metoprolol 25 mg twice daily (regulate heartrate), and spironolactone (fluid pill). Resident #140 had an order for left lateral foot arterial wound to be cleansed with normal saline, barrier cream to be applied around wound, iodosorb gel to wound bed, absorbent pad, and change every other day. Resident #140 had an order for a low concentrated sweet, mechanical soft diet. Record review of Resident #140's paper and online chart for the Baseline Care Plan revealed a baseline care plan with no completion date and no date reviewed with resident or representative listed. During an interview on 02/08/2023 at 10:00 a.m., the family of Resident #140 stated no one contacted them about a care plan meeting and Resident #140 was admitted in the middle of January. Resident #140's family stated it was important to them and the resident to all be part of his care. Resident #140's family was unaware of the type of wound Resident #140 had and what was being used. 3. Record review of the admission Face Sheet dated 02/08/2023, for Resident #5 revealed an [AGE] year-old female. Resident #5 was admitted to the facility on [DATE]. Her diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), diabetes mellitus type 2 (impairment in the way the body regulates and uses sugar (glucose) as a fuel), and chronic kidney disease (gradual loss of kidney function). Record review of the admission MDS dated [DATE] a BIMS score of 13, which indicated intact cognition. Resident #5 required extensive assistance x 2 staff assistance for bed mobility. Resident # 5 was dependent x 2 staff assistance for transfer and toileting. Resident #5 required supervision assistance x1 staff assistance for eating. Record review of the 01/08/2023 to 02/08/2023 Active Physician Orders revealed Resident #5 received aspirin 81mg once daily (blood thinner), hydrocodone 10/325mg as needed for pain, metoprolol 25mg once daily (regulate heartrate), midodrine 25mg as needed for low blood pressure, Neurontin 1250mg once daily (nerve pain), Plavix 75 mg once daily (antiplatelet), and Renvela 3200mg three times daily with meals (controls phosphorus levels in people with chronic kidney disease). Resident #5 had a diet order of renal low potassium with low phosphorus foods, and double meat portions. Resident #5 had an order for dialysis three times per week. Record review of Resident #5's paper and online chart for the baseline care plan revealed a baseline care plan with no completion date and no date reviewed with resident or representative listed. During an interview on 02/07/2023 at 11:30 a.m., Resident #5 stated no care plan meeting or review of a base line care plan had been done with her since admission. Resident #5 stated it was important to her to have her family involved in his care decisions. During an interview on 02/08/2023 at 10:15 a.m., the family member of Resident #5 stated no care plan meeting or review of care had been done with the family since admission. The family member of Resident #5 stated having input into Resident #5's care was very important to the family. During an interview on 02/08/2023 at 11:58 a.m., the MDS Coordinator stated the DON was responsible for completing the baseline care plan. The MDS Coordinator stated the process for baseline care plan completion was the DON filled out the medical information and he passed it to the other departments. When all departments were done with the baseline care plan, the DON gave it back to the MDS Coordinator to file in the soft file and use as reference for the comprehensive care plan. The MDS Coordinator stated the family was not contacted during the process. The MDS Coordinator stated she was not aware a copy of the baseline care plan needed to be given to the family or the resident. The MDS Coordinator stated including the family in the base line care plan process could affect continuity of care. During an interview on 02/08/2023 at 12:00 p.m., the DON stated he completed the nursing portion of the baseline care plan when a new resident admitted . The DON stated he then passed the baseline care plan to the other departments like dietary, social services and activities. The DON stated he expected the completed baseline care plan to be back to him within one to two days and for the most part the baseline care plans were completed within 48 hours. The DON stated it was the responsibility of the MDS nurse to coordinate with the family and discuss the plan of care and set up care plan meetings. The DON stated he was not sure if the family or resident was getting a copy of the baseline care plan. The DON stated he was ultimately responsible for ensuring the base line care plan process was followed in the facility. During an interview on 02/08/2023 at 3:00 p.m., the Administrator stated he expected the policy for baseline care plans to be followed. The Administrator stated not involving the family or resident in the baseline care plan process could result in a disruption in continuity of care. Record review of the undated facility Care Plans Baseline Policy revealed The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: initial goals of the resident, a summary of resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, and any updated information based on the details of the comprehensive care plan, as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to review and revise by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment for 1 resident (Resident #15) of 13 residents reviewed for comprehensive person-centered care plans in that: Resident #15's care plan was not revised after his anti-anxiety medication was discontinued and no longer was coded on his MDS. This failure could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in a decline in physical well-being and care needs not being addressed. Findings included: Record review of the face sheet dated 02/08/23 revealed Resident #15 was [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), generalized anxiety disorder and adult failure to thrive (is a decline seen in older adults). Record review of the significant change in status MDS dated [DATE] revealed Resident #15 was usually understood and usually understood others. The MDS revealed Resident #15 was unable to complete the BIMS due to being rarely/never understood. The MDS revealed Resident #15 required extensive assistance for ADLs. The MDS revealed Resident #15 did not have an active diagnosis of anxiety disorder. The MDS revealed Resident #15 did not receive an antianxiety medication during the last 7 days of the assessment. Record review on the care plan dated 01/13/23 revealed Resident #15 received antianxiety medication related to anxiety. During an interview on 02/08/23 at 1:23 p.m., the MDS coordinator said she should have revised the care plan to reflect Resident #15 was no longer receiving antianxiety. She said she must have forgotten to revise the care plan. She said the Resident #15's MDS reflected the change which should have prompted her the do the same for the care plan. She said it was important to have an accurate care plan so residents were monitored for the correct signs/symptoms and labs, and it was a change of condition to monitor for tolerance. During an interview on 02/08/23 at 2:16 p.m., the DON said he expected the MDS coordinator to update and revise the care plan with scheduled MDSs and changes. He said he was responsible for ensuring the care plans and MDS were revised and updated. He said it was important for the care plan to be revised to reflection the resident accurate status. Record review of a facility Care Conference policy dated 07/17/14 revealed .the DON will lead the care plan meeting .review recent changes in medications and physician's orders .review the nursing care plan, reading each problem statement .discuss with the care plan team if addition or changes need to be made to the resident's care plan .care plan do not need to be completely rewritten with each assessment .they can be edited each time . compare the care plan to the MDS and make sure everything matches .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 3 of 13 residents reviewed for accidents. (Residents #11, #8, and #21) The facility failed to ensure CNA A and CNA E performed a safe mechanical lift transfer for Resident #11. The facility did not complete quarterly safe smoking assessments for Residents #8 and #21. These failures could place residents at risk of injury from accident and hazards. Findings included: 1. Record review of the face sheet dated 02/07/23 revealed Resident #11 was [AGE] years old and admitted on [DATE] with diagnoses including paraplegia (paralysis of the legs and lower body caused by spinal injury or disease), need for assistance with personal care, and weakness. Record review of the quarterly MDS dated [DATE] revealed Resident #11 was understood and understood others. The MDS revealed Resident #11 had adequate hearing, clear speech, and adequate hearing. The MDS revealed Resident #11 had a BIMS of 14 which indicated intact cognition. The MDS indicated Resident #11 required extensive assistance with all ADLs. Record review of the care plan dated 02/06/23 revealed Resident #11 had a potential for decline in ADL function related to paraplegia. The care plan indicated Resident #11 was total care for transfers. Record review of an In-Service Training Report titled Transfers, Pocket Worksheets, and Care Plans dated 1/24/23 indicated, .Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents . The In-Service was signed by CNA A and CNA E. During an observation on 02/06/23 at 11:09 a.m., CNA A and CNA E used a mechanical lift to transfer Resident #11 from the wheelchair to the resident's bed. After lifting Resident #11 from the wheelchair CNA A moved the legs of the base of the lift from a wide position to a narrow position. CNA E then moved the lift across the room approximately 6 feet to the bed with the legs in the narrow position. The resident was then lowered into the bed. During an interview on 02/07/23 at 10:40 a.m., CNA E said after lifting Resident #11 from the wheelchair on 2/6/2023 the legs on the base were narrowed before moving the resident across the room to the bed. She said the legs should have been left in the wide position. She said the legs were supposed to be kept in the wide position to prevent the mechanical lift from tipping over while moving the resident. During an interview on 02/07/23 at 11:30 a.m., CNA A said she was the CNA that narrowed the legs on the base of the mechanical lift during the transfer of Resident #11. She said the reason she narrowed the legs was because she did not feel there was enough room to maneuver the lift to the bed. She said she had received trainings in the past and she did know she was supposed to the leave the legs of base in a wide position. She said when the legs were narrowed, it could cause the lift to tip over. 2. Record review of the face sheet dated 02/08/23 revealed Resident #8 was [AGE] year-old male and admitted on [DATE]. His diagnoses included acute respiratory failure with hypoxia (is a condition in which your lungs have a hard time loading your blood with oxygen), chronic obstructive pulmonary disease (lung diseases that block airflow and make it difficult to breathe), lack of coordination, weakness, and nicotine dependence, other tobacco product, with withdrawal (occurs when you need nicotine and can't stop using it). Record review of the quarterly MDS dated [DATE] revealed Resident #8 was understood and understood others. The MDS revealed Resident #8 had adequate hearing, clear speech, and adequate hearing. The MDS revealed Resident #8 had a BIMS of 13 which indicated intact cognition and required supervision for dressing, toilet use, personal hygiene, and extensive assistance for bathing. The MDS revealed Resident #8 required oxygen therapy while a resident. Record review of the care plan dated 04/10/20 revealed Resident #8 was a current smoker and had a history of 25 years for smoking. Interventions included instruct on smoking risks and hazards. Promote smoking cessation. Instruct on facility's smoking protocol: location, times, cigarette disposal and safety concerns. Observe skin and clothes for signs of cigarette burns. Record review of an admission smoking assessment dated [DATE] revealed Resident #8's smoking risk score of 5 which indicated safe smoker (score of 0-9). No quarterly smoking assessment performed after Resident #8's admission assessment. During an observation and interview on 02/06/23 at 11:11 a.m., Resident #8 was lying in his bed with an oxygen nasal cannula on his face. A pack of cigarettes and lighter was on the bedside table and another pack on top of the oxygen concentrator. Resident #8 said he could keep his smoking material in the room, and he did not take his oxygen outside with him to smoke because it was dangerous. During an observation and interview on 02/07/23 at 3:00 p.m., Resident #8 was sitting in his wheelchair beside his bed with an oxygen nasal cannula on his face. A pack of cigarettes and lighter was on the bedside table, another pack of cigarettes on top of the oxygen concentrator, and open carton of cigarettes on the empty bed next to him. Resident #8 said he did not know he was supposed to have a smoking assessment done every 3 months. During an observation on 02/07/23 at 3:15 p.m., Resident #8 self-propelled himself in his wheelchair to the smoking area without oxygen. 3. Record review of the face sheet dated 02/07/23 revealed Resident #21 was [AGE] years old and admitted on [DATE] with diagnoses including diabetes, lack of coordination, and kidney failure. Record review of the quarterly MDS dated [DATE] revealed Resident #21 was understood and usually understood others. The MDS revealed Resident #21 had adequate hearing, clear speech, and adequate hearing. The MDS revealed Resident #21 had a BIMS of 12 which indicated moderate cognitive impairment. The MDS indicated Resident #21 required supervision to extensive assistance with ADLs. Record review of the care plan dated 01/05/23 revealed Resident #21 was an independent smoker who does not require supervision while smoking. The care plan indicated Resident #21 would follow smoking policy. There were interventions to allow resident to keep cigarettes and lighter and to review smoking assessments quarterly and as needed. Record review of an admission smoking Risk assessment dated [DATE] indicated Resident #21 had a smoking risk score of 2 which indicated the resident was a safe smoker. There were no other Smoking Risk assessments in Resident #21's electronic medical record or Resident #21's chart. During an observation on 02/06/23 at 1:50 p.m., Resident #21 was outside smoking in the designated smoking area unsupervised. No staff or other residents were present in the smoking area. During an interview on 02/07/23 at 2:22 p.m., the Social Worker Liaison said she normally completed safe smoking assessments annually. She said she began working at the facility after Resident #21 was admitted to the facility. She said nothing had triggered her to complete a safe smoking assessment for Resident #21. She said she had taken the residents who smoke outside at times and if she saw anything concerning, she would complete a safe smoking assessment then. She said Resident #21 smoked safely so she had not seen a reason to do another safe smoking assessment. She said since she started working at the facility in October 2022, she had completed smoking assessments for all new admits and if a current resident had shown a decline. During an observation and interview on 02/07/23 at 3:30 p.m. Resident #21 said she just came in from smoking. She said she took herself out to smoke and she kept all of her smoking material and lighter with her. She said she went out to smoke by herself 4 and 5 times a day. She said she was allowed to smoke unsupervised. She said she kept her smoking material in her bra. She pulled a pack of cigarettes and lighter out of her bra. During an interview on 02/08/23 at 8:55 a.m., CNA E said Resident #21 always took herself out to smoke and kept her smoking material with her. During an interview on 02/08/23 at 10:44 a.m., the DON said staff should follow the facility policy when performing a mechanical lift. He said he just held an in-service on mechanical lift transfers. He said if policy said the base should be kept wide then it should be kept wide. He said he could not say what could happen if the base was not kept wide. He said he could not speculate what could happen. He said the social worker completed all of the safe smoking assessments. He said he would have expected for the smoking policy to have been followed. He said he could not speculate what could happen if safe smoking assessments were not completed per policy. During an interview on 02/08/23 at 11:17 a.m., the Administrator said he would have expected safe smoking assessments to have been completed quarterly per policy. He said completing a safe smoking assessment should be triggered by the quarterly MDS. He said the social worker liaison was new to her position and had a lot to learn. He said if a resident had a change in condition and they were no longer a safe smoker there could be negative outcome such as burns in clothes and other negative outcomes. He said he would have expected CNAs to follow the rules and trainings concerning mechanical lift transfers. He said anytime there was a body weight on the lift, the base should be in the wide position. He said the base not being in the wide position could lead to a fall. Review of a facility Transfers, and Lifts policy dated 07/14/17 indicated, .lock wheels of bed and lift before using, widen base of lift to transfer . Review of an undated facility Smoking Policy indicated, .Smoking assessments will be conducted on admission and updated quarterly. Those residents deemed safe to smoke independently may manage their own lighters/matches and tobacco products, and smoke independently. Those residents deemed unsafe to smoke independently will be taken to smoke at the specified times. Smoking times will be limited to 15 minutes for unsafe smokers .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status when there was a nutritional problem for 1 of 13 residents (Resident #27) reviewed for nutritional problems. The facility failed to serve Resident #27 double portion with all meals prescribed by the MD. This failure could place residents at risk for poor intake, weight loss, and unmet nutritional needs. Findings included: Record review of the face sheet dated 02/06/23 revealed Resident #27 was a [AGE] year-old male admitted on [DATE]. His diagnoses included focal (confined to one area of the brain) traumatic brain injury (damage to the brain) with loss of unconsciousness and nondisplaced comminuted fracture (one in which the bone cracks or breaks but retains its proper alignment) of shaft of right fibula (is a small bone that runs along the outside of the lower leg). Record review of Resident #27's consolidated physician order dated 10/28/22 revealed an order for double portion with each meal plus health shake with each meal. Record review of the quarterly MDS dated [DATE] revealed Resident #27 was understood and understood others. The MDS revealed Resident #27 had a BIMS of 06 which indicated severe cognitive impairment. The MDS revealed Resident #27 was independent for bed mobility, transfer, dressing, toilet use, and bathing but needed supervision for personal hygiene. Record review of the care plan problem dated 1/10/23 revealed nutritional status: Resident #27 is at risk for nutritional problems related to depression, traumatic brain injury, and adjusting to facility. Interventions included monitor weights per facility protocol, provide diet per orders, and provide verbal cues as needed to complete meals. Record review of Resident #27's meal ticket dated 02/08/23 revealed Breakfast-Regular, Large Portion at Lunch ONLY, Lunch- Regular, Large Portion at Lunch ONLY, and Dinner- Regular, Large Portion at Lunch ONLY. Record review of Resident #27's weights dated 05/01/22-02/07/23 revealed 12/07/22 181.2 lbs., 01/04/23 176.6 lbs., 02/01/23 181 lbs. Record review of the nutritional recommendation for Resident #27 dated 12/31/22 revealed Resident #27: continue plan of care (on appetite stimulant, double portion, health shake with each meal) During an observation on 02/07/23 at 12:10 p.m., Resident #27 portion size was not double on his meal tray. During an observation on 02/08/23 at 12:25 p.m., Resident #27 was eating lunch in the dining room. Resident #27's portion size was not double. Resident #27's meal ticket stated, large portion for lunch only. During an interview on 02/08/23 at 11:29 a.m., CNA A said she thought Resident #27 was supposed to have double meat for all meals and could not recall seeing a health shake. She said the nurses verified the meal tickets were correct and CNAs documented the meal intake. During an interview on 02/08/23 at 11:46 a.m., the ADON said Resident #27 had double portions with all meals and health shakes added in October. She said Resident #27 had weight loss but not significant loss, so this intervention was attempted. The ADON said Resident #27 refused the double portion and did not see a difference in his weight. She said an appetite stimulant was added on 11/1/22 but the diet order was not modified or discontinued. The ADON said the dietary supervisor received a communicate note to inform her of diet orders and changes. She said the nurses should be looking at the meal ticket to ensure the resident received the right diet ordered. During an interview on 02/08/23 at 1:16 p.m., the dietary supervisor said Resident #27 was on a regular diet with health shakes. She said she was notified of diet orders with communication slips from the nursing staff. The dietary supervisor said she thought Resident #27 requested only large portions at lunch. She said normally if a resident request something not ordered, she asked the nurses to ask for order or modify current order. She said she did not know if anyone notified nursing staff Resident #27 only wanted large portion at lunch. During an interview on 02/08/23 at 2:00 p.m., LVN D said she did not know Resident #27's diet order had changed to double portion for all meals in October 2022. She said because she did not know about the order change, she would not question his meal ticket with a different order. She said when nursing staff received a diet order, a communicate slip was written and given to the dietary supervisor. LVN D said if a resident requested a diet order different then what was ordered then the doctor would have to be called. During an interview on 02/08/22 at 2:16 p.m., the DON said the diet order was printed out then given to the dietary supervisor. He said then the nurse documents the order on the 24-hour report to communicate to all nursing staff the change. The DON said the nurses should always be checking meal tickets at meal service to ensure physician orders were being followed. He said he would not speculate the risk to the resident, but physician orders were not being followed. The DON said it was the nursing staff and dietary supervisor responsibility to ensure diet orders were being followed. During an interview on 02/08/23 at 2:51 p.m., the ADM said he expected physician's orders to be followed by nursing staff and dietary supervisor. Record review of a facility Care Conference policy dated 07/17/14 revealed .review recent changes in medications and physician's orders .make sure issues .and weight loss are discussed and that effective interventions are implemented and documented .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 12 resident reviewed for respiratory care. (Resident #14) The facility failed to properly store Resident #14's nasal cannula when not in use. This failure could place residents at risk for respiratory infections. Findings included: Record review of the face sheet dated 02/08/23 revealed Resident #14 was a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), history of acute respiratory disease (a serious and widespread infection of the bloodstream), emphysema (a lung condition that causes shortness of breath), and chronic obstructive pulmonary disease (A group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #14's consolidated physician orders dated 02/08/23 revealed oxygen at 3 liters per minute via nasal cannula, twice a day (08/17/20) and oxygen at 2 liters per minute via nasal cannula at hour of sleep as needed, oxygen saturation less than 90%, or shortness of breath (01/18/23). Record review of the quarterly MDS dated [DATE] revealed Resident #14 was understood and understood others. The MDS revealed Resident #14 had adequate hearing, clear speech, and impaired vision with corrective lenses. The MDS revealed Resident #14 had a BIMS of 15 which indicated intact cognition and independent for ADLs. The MDS revealed Resident #14 had oxygen therapy while a resident. Record review of the care plan problem dated 04/05/18 revealed Resident #14 had diagnosis of COPD/emphysema and had a potential risk for complications. Resident #14 wears oxygen at night while sleeping and during day wears it as needed. Resident #14 will remove and replace oxygen per self. Interventions change oxygen tubing/clean filter per protocol or scheduled on Sunday and maintain oxygen flow per nasal cannula per MD orders. During an observation and interview on 02/06/23 at 10:39 a.m., Resident #14 was sitting in his recliner watching television. Resident #14 said he wore he oxygen when he needed. The nasal cannula was noted to be in his recliner, underneath his bottom not in a bag. During an observation on 02/07/23 at 9:13 a.m., Resident #14 was sitting in his recliner watching television. The nasal cannula was noted to be in his recliner, underneath his bottom not in a bag. During an observation on 02/07/23 at 11:43 a.m., Resident #14 was sitting in his recliner watching television. The nasal cannula was wrapped around the flowmeter (an equipment used to control oxygen flow delivery in patients undergoing oxygen therapy) attached to the oxygen concentrator (take air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe), not in a bag. During an interview on 02/08/23 at 10:49 a.m., Resident #14 was sitting in his recliner watching television. The nasal cannula was noted to be in his recliner, underneath his bottom not in a bag. Resident #14 said he would use a bag to store his nasal cannula when he was not using it. Resident #14 said he could not recall anyone offering him a bag to store his nasal cannula when not in use. During an interview on 02/08/23 at 11:29 a.m., CNA A said she had been employed at the facility for 3 years. She said was the aide assigned to Resident #14. CNA A said Resident #14 normally only wore his nasal cannula when he was in bed. CNA A said Resident #14 was independent for ADLs and removed/replaced his nasal cannula. She said she had not noticed the nasal cannula stored in bag when not in use. CNA A said Resident #14's nasal cannula should probably not be in his recliner uncovered because the recliner may not clean. During an interview on 02/08/23 at 1:48 p.m., the ADON said Resident #14's nasal cannula should be stored in a bag. She said the nasal cannula not being stored in a bag and Resident #14 sitting on it was an infection control risk and potential damage the tubing. She said respiratory equipment stored unsanitary could lead to respiratory infection which may require antibiotics, increased oxygen need, or hospitalization. The ADON said it was nursing staff responsibility to ensure respiratory equipment was store in a sanitary manner. During an interview on 02/08/23 at 2:00 p.m., LVN D said Resident #14 used his oxygen as needed. She said Resident #14's nasal cannula should be stored in a plastic bag for infection control. LVN D said it was the nursing staff responsibility to ensure correct storage of Resident #14's nasal cannula. She said Resident #14 was at risk for respiratory infection. During an interview on 02/08/23 at 2:16 p.m., the DON said Resident #14's nasal cannula should be stored in a bag when not in use to minimize contamination. The DON said he did not want to speculate on the risk of using contaminated respiratory equipment. He said it was the nursing staff responsibility to ensure respiratory equipment was store in a sanitary manner. The DON said he was responsible for overseeing the nursing staff in ensuring proper storage of respiratory equipment. During an interview on 02/08/23 at 2:51 p.m., the ADM said he could not comment on nursing equipment. Record review of a facility Cleaning, and Disinfection of Resident-Care Items and Equipment policy dated 07/14 revealed .semi-critical items consist of items that may come in contact with mucous membranes on non-intact skin (e.g. respiratory equipment) .critical and semi-critical items will be sterilized/disinfected .stored appropriately until use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 2 of 13 residents (Resident #10 and Resident #27) reviewed for a homelike environment. The facility failed to ensure Resident #10 and Resident #27's room door stayed closed when latched. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: 1. Record review of the face sheet dated 02/08/23 revealed Resident #10 was [AGE] year-old male admitted on [DATE] with diagnoses including need for assistance with personal care, generalized anxiety (is a feeling of fear, dread, and uneasiness), and insomnia (persistent problems falling and staying asleep). Record review of the quarterly MDS dated [DATE] revealed Resident #10 was understood and understood others. The MDS revealed Resident #10 had a BIMS of 15 which indicated intact cognition and only required supervision for bed mobility. 2. Record review of the face sheet dated 02/06/23 revealed Resident #27 was [AGE] year-old male and admitted on [DATE] with diagnoses including focal (confined to one area of the brain) traumatic brain injury (damage to the brain) with loss of unconsciousness and nondisplaced comminuted fracture (one in which the bone cracks or breaks but retains its proper alignment) of shaft of right fibula (is a small bone that runs along the outside of the lower leg). Record review of the quarterly MDS dated [DATE] revealed Resident #27 was understood and understood others. The MDS revealed Resident #27 had a BIMS of 06 which indicated severe cognitive impairment. The MDS revealed Resident #27 was independent for bed mobility, transfer, dressing, toilet use, and bathing but needed supervision for personal hygiene. During an observation and interview on 02/06/23 at 10:24 a.m., Resident #27 was lying in bed watching television. This surveyor went to shut the door to conduct interview and the door would not stay latched. Resident #27 said the door had been broken for a while but could not remember how long. He said it did not bother him unless other resident's televisions got too loud. During an interview on 02/06/23 at 11:33 a.m., Resident #10, roommate to Resident #27 said his door did not latch. He said it had been broken at least 6 months. He said maintenance was aware of the issue. Resident #10 said it bothered him that he could not completely shut his room door. During an interview on 02/08/23 at 11:29 a.m., CNA A said Resident #10 and Resident #27's room door did not stay latched when closed. She said she had verbally notified the maintenance assistance of the broken door about 4 months ago. She said the facility did have a maintenance logbook and the facility preferred staff placed issues in the book. She said the door had been broke at least 4 months. CNA A said she could not recall Resident #10 complaining about the door being broken. She said neither Resident #10 and Resident #27 required assistance with incontinent care, but Resident #27 was particular about his privacy when he dressed himself. During an interview on 02/08/23 at 1:45 p.m., the maintenance supervisor said Resident #10 and #27's room door was kicked in and broken by the police. The maintenance supervisor said he could not recall the timeframe of the incident. He said he fixed the door and handle but has not been able to fix the striker plate (is a metal plate that is affixed to the doorjamb and has a hole (or holes) that accommodate the lock bolt) that hold the handle in place. The maintenance supervisor said the business office manager was going to look online to find the part because it was hard to find parts in the area. During an interview on 02/08/23 at 2:16 p.m., the DON said he was not aware of how Resident #10 and #27's door gotten broken or that it was broken. He said the facility was working on getting it fixed. During an interview on 02/08/23 at 2:51 p.m., the ADM said the maintenance supervisor had been working on a backlog of work orders. He said the maintenance supervisor was prioritizing worker orders by working on safety issues first. He said the residents deserved a functioning door to provide privacy and the facility was working on getting it fixed. Record review of the maintenance log dated 06/22-02/23 did not reveal work order for Resident #10 and #27's striker plate needing repair. Record review of a facility Maintenance service policy dated 12/00 revealed .maintenance service shall be provided to all areas of the building, grounds, and equipment .the maintenance department is responsible for maintaining the building .in a safe and operable manner .maintain the building in good repair and free from hazards .the maintenance director is responsible for developing and maintaining service to assure that the buildings .are maintained in a safe and operable manner

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 5 of 12 residents (Resident #19, Resident #29, Resident #27, Resident # 32, and Resident #15) reviewed for comprehensive person-centered care plans. The facility failed to implement fall care plan interventions for Resident #19. The facility failed to care plan Resident #29's use of psychotropic medications. The facility failed to care plan Resident #15's admission to hospice. The facility failed to implement care plan intervention on call bell within reach for Resident #27. The facility failed to develop a care plan problem to address Resident #32's hearing loss and use of communication/writing board. These failures could place residents at risk of not having their individualized needs met, falls and a decline in their quality of care and life. Findings included: 1. Record review of a face sheet dated 02/08/2022 revealed Resident #19 was an [AGE] year-old female and admitted on [DATE]. Her diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), repeated falls, lack of coordination, and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Record review of the annual MDS dated [DATE] revealed Resident #19 was understood and understood others. The MDS revealed Resident #19 had a BIMS score of 14 which indicated no cognitive impairment. The MDS revealed Resident #19 required limited assistance x 1 staff member for bed mobility, extensive assistance x 1 staff member for transfer and toileting, and supervision x 1 staff member for eating. Record review of the Morse Fall Scale dated 01/06/2023 revealed a score of 80 for Resident #19, which indicated a high fall risk. Record review of the care plan for Resident #19, with a revision date of 01/23/2023 by the DON revealed a care plan titled Falls. The care plan problem revealed Resident #19 had a history of falls and was at risk for increased falls and injury. The care plan interventions listed for this problem included: encourage use of call light, bed in lowest position, falling star program, and fall mat at bedside. During an observation on 02/06/2023 at 9:45 a.m., Resident #19 was in bed with no fall mat at bedside and bed not in lowest position. Resident #19 had a falling star symbol located on the outside of her door. During an observation on 02/06/2023 at 11:45 a.m., Resident #19 was in bed with no fall mat at bedside and bed not in lowest position. Resident #19 had visitor at bedside. During an observation on 02/07/2023 at 10:45 a.m., Resident #19 was in bed with no fall mat at bedside and bed not in lowest position. During an observation on 02/07/2023 at 4:45 p.m., Resident #19 was in bed with no fall mat at bedside and bed not in lowest position. During an observation on 02/08/2023 at 9:45a.m., Resident #19 was in bed with no fall mat at bedside and bed not in lowest position. No fall mat was in the room. During an interview on 02/07/2023 at 10:45 a.m., Resident #19 stated she had not had a fall mat in several months. Resident #19 stated she thought they needed it for someone else. Resident #19 stated the CNAs never lowered her bed to the floor. During an interview on 02/07/2023 at 10:45 a.m., CNA A stated she was unaware Resident #19 was supposed to have a fall mat. CNA A stated all residents in the bed should be left in lowest position to decrease distance to the floor if a fall occurred. CNA A stated a falling star symbol is put outside the doors of all residents that are high fall risks and these people need a fall mat and the bed in the lowest position. During an interview on 02/08/2023 at 10:45 a.m., the DON stated he was unaware Resident #19 did not have a fall mat at her bedside. The DON stated it was the floor nurse's responsibility to ensure all beds were in the lowest position when a resident was left in bed. The DON stated it was his responsibility to ensure the charge nurses were doing their jobs. The DON stated he could not speculate on what injuries could occur from a fall from the bed not in the lowest position with no fall mat beside the bed. 2. Record review of the face sheet dated 02/08/2023 revealed Resident #29 was a [AGE] year-old male admitted on [DATE] with diagnoses of left below the knee amputation, hypertension (high blood pressure), and depression. Record review of the quarterly MDS dated [DATE] revealed Resident #29 was understood and usually understood others. The MDS revealed Resident #29 had a BIMS score of 09 which indicated moderate cognitive impairment. The MDS revealed Resident #29 was independent for bed mobility and eating and required only supervision for transfer and toileting. The MDS revealed the daily use of antidepressants. Record review of the comprehensive care plan for Resident #29, revised 05/18/2022 by the MDS Coordinator revealed no care plan for psychotropic medication usage. During an interview on 02/08/2023 at 10:00 a.m. the MDS Coordinator stated the process for creating comprehensive care plans started with doing the MDS and care planning anything that triggered in the Care Area Assessment (CAA) area. The MDS Coordinator stated it was important to care plan these areas because the areas required the most monitoring and intervention to ensure good quality of care and life for each resident. The MDS Coordinator was not aware of why Resident #29 was not care planned for psychotropic medication usage for the 2 antidepressants taken daily. The MDS Coordinator stated it was her responsibility to make sure all psychotropic medications were care planned. The MDS Coordinator stated it was an oversight. During an interview on 02/08/2023 at 11:00 a.m., the DON stated it was important to care plan each triggered area on the MDS and was unaware Resident #29 did not have a care plan for the use of his Celexa and Remeron. The DON stated he could not speculate on what outcomes would develop from not care planning triggered MDS items. The DON stated it was the responsibility of the MDS Coordinator to ensure all psychotropic medications were care planned. 3. Record review of the face sheet dated 02/08/23 revealed Resident #15 was [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), adult failure to thrive (is a decline seen in older adults), and moderate protein-calorie malnutrition (is the state of inadequate intake of food). Record review of Resident #15's consolidated physician order dated 12/07/22 revealed an order to admit to a hospice company under a medical doctor for terminal diagnosis of Alzheimer's disease. Record review of the significant change in status MDS dated [DATE] revealed Resident #15 was usually understood and usually understood others. The MDS revealed Resident #15 was unable to complete the BIMS due to being rarely/never understood. The MDS revealed Resident #15 required extensive assistance for ADLs. The MDS revealed Resident #15 had hospice care while a resident. Record review of Resident #15's care plan dated 01/13/23 did not reveal a care plan problem for hospice care. 4. Record review of the face sheet dated 02/06/23 revealed Resident #27 was [AGE] year-old male admitted on [DATE]. His diagnoses included focal (confined to one area of the brain) traumatic brain injury (damage to the brain) with loss of unconsciousness and nondisplaced comminuted fracture (one in which the bone cracks or breaks but retains its proper alignment) of shaft of right fibula (is a small bone that runs along the outside of the lower leg). Record review of the quarterly MDS dated [DATE] revealed Resident #27 was understood and understood others. The MDS revealed Resident #27 had a BIMS of 06 which indicated severe cognitive impairment. The MDS revealed Resident #27 was independent for bed mobility, transfer, dressing, toilet use, and bathing but needed supervision for personal hygiene. Record review of the care plan dated 07/20/21, edited 01/10/23 revealed Resident #27 has potential for decline in ADL function related to history of traumatic brain injury and progressive decline in cognition. Intervention dated 04/13/22 included encourage to call for assistance. Leave call bell within reach while in bed or chair. Answer promptly. During an observation and interview on 02/06/23 at 10:24 a.m., Resident #27 was lying in his bed watching television. Resident #27 had an orthopedic boot/brace on his right leg. Resident #27's call light was on the other side of his bed, on the floor not within reach. Resident #27 said he did not know where his call light was and did not help getting out of the bed. He said he did not use the call light often but would use it if it was available. He said if fell and the call light was not within reach, he would have to holler for help, and someone would eventually show up to help him. During an observation on 02/07/23 at 9:10 a.m., Resident #27 was lying in his bed watching television. Resident #27 had an orthopedic boot/brace on his right leg. Resident #27's call light was on the other side of his bed, on the floor not within reach. During an observation on 02/08/23 at 9:10 a.m., Resident #27 was lying in his bed watching television. Resident #27 had an orthopedic boot/brace on his right leg. Resident #27's call light was on the other side of his bed, on the floor not within reach. During an interview on 02/08/23 at 11:29 a.m., CNA A said she had worked at the facility for 3 years. She said she was the aide assigned to Resident #27's hall. She said Resident #27 did not use the call light because he was independent, but he would use it if he really needed something. She said he did have two falls recently and broke his right leg the last fall. She said she mainly monitored the hall by making rounds but knew call lights needed to be always in reach to prevent falls. During an interview on 02/08/23 at 11:46 a.m., the ADON said Resident #27 was on the fallen star program which a yellow star was placed by his name on the door letting staff know he had fallen within the last 4 weeks. She said she did not know if Resident #27 used his call light for assistance. The ADON said his call light should be within reach when he was in the bed or chair to encourage him to call for assistance. She said it was the CNAs responsibilities to ensure call lights were within reach when they made rounds. The ADON said call lights needed to be in reach so residents could get assistance and prevent falls or injuries. During an interview on 02/08/23 at 2:16 p.m., the DON said Resident #27 was on the fall prevention program due to recent falls with an injury. He said Resident #27 was independent with his ADLs so did not know how much he used the call light. The DON said the call light should at least be in the bed not behind it. The DON said it was aides and nurses' responsibility to ensure call lights were within reach. He said a lot of things could happen if a resident call light was not within reach, so he did not want to speculate. 5. Record review of the face sheet dated 02/08/23 revealed Resident #32 was [AGE] year-old male admitted on [DATE]. His diagnoses included impacted cerumen, left ear (is an accumulation of cerumen that causes symptoms, such as hearing loss, fullness, otorrhea, tinnitus, dizziness, or other symptoms, and/or prevents a required assessment of the ear canal, tympanic membrane, or audiovestibular system) and hemiplegia (a severe or complete loss of strength) and hemiparesis (a relatively mild loss of strength) following cerebral infarction (stroke) affecting right dominant side. Record review of Resident #32's consolidated physician order dated 01/23/23 revealed Carbamide peroxide 6/5% solution, 5 drops, left ear, twice a day. Record review of Resident #32's consolidated physician order dated 01/31/23 revealed follow up appointment with an otolaryngologist (is a doctor that specializes in treating conditions that affect the ears, nose, and throat, as well as head and neck) on 01/31/23 at 1:15 p.m. Record review of the admission MDS dated [DATE] revealed Resident #32 was understood and understood others. The MDS revealed Resident #32 had minimal difficulty hearing without hearing aide. The MDS revealed Resident #32 had a BIMS of 06 which indicated severe cognitive impairment and required extensive assistance for bed mobility, transfer, dressing, and personal hygiene and total dependence for toilet use and bathing. Record review of Resident #32's care plan dated 11/07/22 did not a reveal a care problem for hearing deficits with use of writing board. Record review of a progress note for Resident #32 written by the activity director on 11/14/22 revealed .he is hard of hearing, so speak a little louder and very clear for him to understand . Record review of a progress note for Resident #32 written by the ADON on 01/05/23 revealed .report from hearing company sent to Ear, Nose, and Throat doctor for further evaluation and treatment .Resident #32 has an appointment in office January 17th at 10am . Record review of a progress note for Resident #32 written by LVN F on 01/17/23 revealed .Resident has started wanting staff to write on paper any questions because he is hard of hearing . During an observation and interview on 02/06/23 at 11:07 a.m., Resident #32 was sitting up in bed watching television. Resident #32 did not hear knock on door. Resident #32 noticed surveyor only when in line of vision. The surveyor started to speak but Resident #32 lifted a writing board with a pen. Resident #32 said he was hard of hearing and preferred using the board. During an interview on 02/08/23 at 10:56 a.m., Resident #32 responded to questions written on the writing board. He said when he admitted to the facility, he had hearing issues. Resident #32 said after he got COVID-19 (1/13/23) his hearing got worse. Resident #32 said he started asking staff to write questions of paper and pen then a staff member brought him the writing board. During an interview on 02/08/23 at 3:00 p.m., the MDS coordinator said she was responsible for updating residents care plan with new care problems. She said she did know Resident #32 was hard of hearing and was seeing a doctor for treatment. The MDS coordinator said she did not know he preferred communicating with staff using a writing board. She said she collected her information to implement or update care plan from the progress notes and orders. She said she missed the progress note mentioning his wishes to use writing tablet. She said it would be an important problem to care plan because aides can access the care plan and it would inform them on his communication needs. She said his needs could not get met or wishes not honored due to his care plan not being developed for hearing loss. The MDS coordinator said when Resident #15's significant change MDS was done for hospice admission, she should have developed a care plan problem. She said it was a change of condition and all staff needed to be on the same page. Record review of a policy named Care Conferences dated 07/14/2017 revealed, Make sure issues related to falls, restraints, skin breakdown, psychotropic medications, pain management, and weight loss are discussed, and effective interventions are implemented and documented. Compare the care plan to the MDS and make sure everything matches.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 4 of 5 residents reviewed antibiotic use. (Resident #7, Resident #26, Resident #85, Resident #86) The facility failed to add a diagnosis to support antimicrobial use for prescribed antibiotics for Resident #7, Resident 26, Resident #85, and Resident #86. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: Record review of an undated facility Antimicrobial Stewardship Policy and Procedure revealed the facility will establish a multidisciplinary stewardship program that defines and provides for optimal antimicrobial use .the consultant pharmacist should review antimicrobial orders during interim and monthly medication regimen review to ensure proper ordering .will develop, endorse and adopt established guidelines for use by facility staff for appropriate identification and assessment of infections and treatment guidelines . 1. Record review of a face sheet dated 02/08/23 revealed Resident #7 was an 80- year -old male admitted on [DATE]. His diagnoses included elevated white blood cell count (may be high because your body is fighting an infection), chronic obstructive pulmonary disease (A group of lung diseases that block airflow and make it difficult to breathe), and acute respiratory disease (a serious and widespread infection of the bloodstream). Record review of the Resident #7's MDS dated [DATE] did not reveal active diagnosis of infection or use of antibiotics. Record review of Resident #7's care plan dated 01/05/23 did not reveal care problem addressing use of antibiotics. Record review of Resident #7's physician order dated 12/30/22 revealed Rifampin capsule 300mg 1 capsule BID x 10 days. No diagnosis noted on order. Record review of the antimicrobial stewardship recommendation created between 01/01/23-01/09/23 written by the Pharmacist revealed for Resident #7 . Please consider adding a diagnosis to the computer to support antimicrobial use to the active order for: Rifampin 300mg BID x10 days. 2. Record review of the face sheet dated 02/08/23 revealed Resident #26 was an 89 -year-old male admitted on [DATE] with diagnoses including pneumonia (is an infection that inflames the air sacs in one or both lungs) and infection following a procedure. Record review of the significant change in status MDS dated [DATE] revealed Resident #26 was usually understood and understood others. The MDS revealed Resident #26 had a BIMS of 13 which indicated intact cognition. The MDS revealed Resident #26 had an active diagnosis of pneumonia and received antibiotic in the last 3 days of the assessment period. Record review of Resident #26's care plan dated 02/08/23 did not reveal care problem addressing use of antibiotics. Record review of Resident #26's physician order dated 12/12/22 revealed Amoxicillin-Potassium Clavulanate tablet; 875-125mg; 1 tablet twice a day. No diagnosis noted on the order. Record review of the antimicrobial stewardship recommendation created between 12/1/22-12/14/22 written by the Pharmacist revealed for Resident #26 . Please consider adding a diagnosis to the computer to support antimicrobial use to the active order for: Augmentin 875mg BID x 7 days. 3. Record review of the face sheet dated 02/08/23 revealed Resident #85 was a [AGE] year-old female admitted on [DATE] with diagnosis including urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra). Record review of the quarterly MDS dated [DATE] revealed Resident #85 was understood and understood others. The MDS revealed Resident #85 had a BIMS of 02 which indicated severe cognitive impairment. The MDS revealed Resident #85 had urinary tract infection in the last 30 days. The MDS revealed Resident #85 had 0 days of antibiotics during the assessment period. Record review of Resident #85 care plan dated 07/27/22 revealed history of infection as evidence by actual infection. Intervention included administer antibiotic as prescribed. Record review of Resident #85's physician order dated 12/08/22 revealed Clindamycin capsule; 300mg; 1 capsule oral; three times a day x 7 days. No diagnosis noted on the order. Record review of Resident #85's physician order dated 12/22/22 revealed Bactrim tablet; 800-160mg; 1 tablet; twice a day. No diagnosis noted on the order. Record review of the antimicrobial stewardship recommendation created between 12/1/22-12/14/22 written by the Pharmacist revealed for Resident #85 . Please consider adding a diagnosis to the computer to support antimicrobial use to the active order for: Clindamycin 300mg TID x 7 days. 4. Record review of the face sheet dated 02/08/23 revealed Resident #86 was an [AGE] year-old female admitted on [DATE] with diagnosis including urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra). Record review of the admission MDS dated [DATE] revealed Resident #86 was sometimes understood and sometimes understood others. The MDS revealed Resident #86 was unable to complete the BIMS due to being rarely/never understood. The MDS revealed Resident #86 had short-and-long term memory loss. The MDS revealed Resident #86 had a urinary tract infection within the last 30 days and received antibiotic in the last 4 days of the assessment period. Record review of Resident #86's care plan dated 02/17/22 revealed resident has a urinary tract infection. Intervention administer antibiotic as ordered. Record review of Resident #86's physician order dated 03/13/22 revealed Cipro tablet; 250mg; 1 tablet; twice a day. No diagnosis noted on the order. Record review of the antimicrobial stewardship recommendation created between 03/01/22-03/13/22 written by the Pharmacist revealed for Resident #86 . Please consider adding a diagnosis to the computer to support antimicrobial use to the active order for: Cipro 250mg BID x 7 days. During an interview on 02/08/23 at 10:20 a.m., the DON said he was the Infection Control Preventionist for the facility. He said the antibiotic stewardship program met monthly. The DON said the ADON was responsible for reviewing and completing pharmacy recommendation. The DON said diagnosis for the use of the antibiotic should be on the order. The DON said the ADON was responsible for verifying orders which included diagnosis. The DON said he should be overseeing the process. He said it was important to have an appropriate diagnosis for antimicrobial use to ensure medications were giving for the right reason. The DON said he did not want to speculate on the risk of not having a diagnosis for antimicrobial usage. During an interview on 02/08/23 at 11:46 a.m., the ADON said she was responsible for pharmacy recommendations. She said the pharmacy recommendations were sent monthly by the pharmacist. The ADON said she printed the recommendations then faxed and delivered recommendation requiring MD approval. She said she completed the recommendations for nurses. The ADON said she was responsible for ensuring orders had an appropriate diagnosis and did not know why Residents #7, #26, #85, and #86 were not done. She said the original copy was in the antibiotic stewardship program binder and she signed the pharmacy recommendations when completed so if it was not signed, she had not added the diagnoses. The ADON said she ran a report of physician orders, but the report only looked at the end dates and correctly inputted. The ADON said she would have to start running a more involved report to monitor diagnoses of orders. She said it was important to have appropriate diagnosis for antibiotics to ensure medication was susceptible to the infection, make sure medication appropriate for diagnosis, watch for correct symptoms/reactions, and verify pharmacy accuracy. Record review of the CDC's Core Elements of Antibiotic Stewardship for Nursing Homes accessed on 02/12/23 at https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-b-508.pdf .other important data elements can be useful for tracking antibiotic use at the facility level .these data elements help identify the reason for inappropriate antibiotic prescribing .indication .tracking antibiotic use by the reason for treatment .

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure that all staff members wore hairnets appropriately. This failure could place residents at risk of food contamination. Findings included: During an observation on 02/07/2023 at 11:45 a.m., Transportation aide #B entered the kitchen to deliver a package with no hair net on during meal service. During an observation on 02/07/2023 at 11:48 a.m., a sign on each entrance door to the kitchen stated kitchen personnel only. During an observation and interview on 02/07/2022 at 11:51 a.m., Business Office Worker # C walked into the kitchen and asked for foam plates and plastic forks to eat her personal lunch with no hair net on. Business Office Worker #C did not leave the kitchen when she was told by the Dietary Manager that the state was in the kitchen watching meal service. Business Office Worker #C stated she thought employees could come into the kitchen with no hair net on as long as they were not standing directly in front of the food. The Dietary Manager informed Business Office Worker #C, she was required to have a hair net on if she entered the kitchen. During an interview on 02/08/2023 at 10:00 a.m., the Dietary Manager said hair nets were required to enter the kitchen no matter if food was being served or not because food was always being prepared. She said residents could be negatively affected by hair contaminating food and the residents might not want to eat the food. During an interview on 02/08/2023 at 11:00a.m., the DON stated he was shocked people came into the kitchen at all because the Dietary Manager was known to run people out of the kitchen that did not belong there. During an interview on 02/08/2023 at 2:16 p.m., the Administrator said anyone in the kitchen should be wearing a hair net and the hair net should be covering all their hair. He said wearing a hair net inappropriately could cause hair to get into the food and cause contamination of the food item. Review of a facility Employee Hygiene and Sanitary Practices policy dated 2021 revealed, hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.