**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission including the minimum healthcare information necessary to properly care for 1 of 3 residents reviewed for new admissions (Resident #267). The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #267. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of an undated face sheet revealed Resident #267 was a [AGE] year-old male admitted [DATE] with the diagnoses of prostate cancer, hypertension (high blood pressure), and PVD (refers to any disease or disorder of the circulatory system outside of the brain and heart). Record review of an admission MDS for Resident #267 was incomplete. Record review of the baseline care plan 10/21/2024 for Resident #267 indicated no baseline care plan was initiated prior to survey intervention. Record review of the MD orders dated October 2024 for Resident #267 indicated he was on oxygen at 2 liters per minute via nasal cannula continuously. MD orders indicated Resident #267 was taking Celexa (antidepressant) for depression/ Record review of the comprehensive care plans 10/21/2024 for Resident #267 indicated no comprehensive care plan was initiated. During an interview on 10/21/2024 at 9:50 a.m., Resident #267 stated he had plans to return home and was unsure why he could not go now. Resident #267 stated he had cancer and wore hearing aids. Resident #267 was unable to answer any further questions. During an interview on 10/21/2024 at 10:20 a.m., the DON stated the floor nurses were to complete the baseline care plan on admission as part of the admission process within 24 hours of admission. The DON reviewed Resident #267's record and stated, Resident #267 had no baseline care plan completed prior to 10/21/2024 at 10:20 a.m. During an interview on 10/22/2024 at 12:45 p.m., the Administrator said she expected the staff members to do their part to complete the baseline care plans. She felt baseline care plans were important information to help the staff care for each resident. The Administrator said it was hard to care for new residents without having an outline of their needs and the baseline care plan gave the staff an outline until the MDS was completed and the comprehensive care plan was created to guide resident care. Record review of the policy dated 11/08/2023 titled Baseline Care Plan, indicated the baseline care plan are developed and implemented within 48 hours of a resident's new admission Baseline care plans are developed by the Registered Nurses and other healthcare team members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to include measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 19 residents reviewed for care plans. (Resident #'s 16). The facility did not follow the physician orders for Resident #16's LCS (low concentrated sweet) diet. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of admission report dated 10/22/24 indicated Resident #16 was admitted on [DATE] was [AGE] years old with diagnoses of diabetes (high blood glucose), stroke and altered mental status. Record review of the physician orders dated October 2024 indicated Resident #16 had a diet order for LCS/NSOT (No salt on tray) Mechanical Soft Texture with Nectar Thick Liquids/Chopped Meats diet with start date of 11/09/2023. The orders did not include a health shake. Record review of a care plan dated 07/21/2024 indicated Resident #16 had diabetes mellitus (Type 2): with interventions including to monitor nutritional intake. Therapeutic or altered consistency diet with interventions including LCS/NSOT (No salt on tray) mechanical soft texture with nectar thick liquids/chopped meats, offer snacks within diet limits and serve diet as ordered and offer subs if less than 75% is eaten, monitor intake. Care plan did not address the health shake. Record review of a progress notes for Resident #16 dated 09/01/24 to 10/21/24 indicated no documentation of physician being notified of the need for a change in the plan of care for regular health shakes or about the resident's refusing meals or diabetic health shakes. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #16 received oral diabetic medications and a therapeutic diet. No behaviors of rejection of care were noted. During an observation on 10/21/24 at 12:38 p.m., Resident #16 refused her lunch meal. LVN E went and got the resident a regular chocolate health shake (nutritional shake high in protein and calories) from the kitchen. Resident #16's tray card indicated her diet was an LCS diet. During an interview on 10/21/24 at 12:40 p.m., LVN E said Resident #16 was on an LCS diet . She said, I gave her the chocolate health shakes today. She said the resident did not like diabetic health shakes, she gives her the regular health shake. She said she should have called the physician to obtain approval for the regular health shakes because of the high sugar. She said when a resident refuses a meal, they would offer a substitute and if substitute was not taken would give a health shake. During an interview on 10/21/24 at 12:42 p.m., the DM said residents on LCS diet would receive diabetic shakes because the regular health shake was high in sugar. During an interview on 10/21/24 at 12:44 p.m., Resident #16 said she would try the diabetic shake. During an interview on 10/23/24 at 9:30 a.m., the Administrator said her expectation was for the nurse to follow physician's orders or to notify the physician of the need to change his plan of care/orders. Record review of the health shakes labels obtained from the website per the internet the regular health shakes contained 19 grams of sugar and the diabetic health shake contained 3 grams of sugar. Record review of the Care Plans, Comprehensive Person - Centered policy dated 2001 indicated A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 4. d. request revisions to the plan of care.g. receives the services and or items included in the plan of care.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained free of accident hazards for 1 of 4 Halls (Hall 200). There was lighter fluid stored closer than 20 feet to the outside of Hall 200. This failure could place the residents at risk of accidents. Finding included: During an observation of the outside of the building on 10/22/24 at 1:50 p.m., a barbeque pit was approximately 10 feet down the sidewalk which had a shelf with 2 bottles of lighter fluid with approximately 4 ounces in each bottle. The bottles were labeled Flammable and Keep out of reach of children. The bottles were approximately 2 feet from the wall of the building (Hall 200). This area was accessible to residents and visitors from Hall 200. During an interview on 10/22/24 at 1:58 p.m., the Maintenance Supervisor said flammable chemicals needed to be at least 20 feet away from the building, to prevent accidents and fires. He said any flammable chemical was to be stored offsite at his office. He said he was responsible for making sure flammable chemicals were 20 feet away from the building. He said he knew to keep flammable chemicals at least 20 feet away from the building. He said he was not sure who left the lighter fluid there. During an interview on 10/22/24 at 2:15 p.m., the Administrator said she wanted chemicals stored correctly or stored off site to prevent accidents. Record review of the policy titled Fire Safety and Prevention indicated All personnel must learn methods of fire prevention and must report condition(s)that could result in a potential fire hazard.Flammable items: . e Store paints, thinners and other flammable liquids away from resident living areas. F. Store flammable liquids in a locked metal cabinet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 resident reviewed for pain management. (Resident #32) The facility failed to ensure Resident #32 had effective pain management by failing to have routine pain medication available. This failure could place residents at risk for increased pain and decreased quality of life. Findings included: Record review of an undated face sheet indicated Resident #32 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), pain(physical suffering or discomfort caused by illness or injury), and rheumatoid arthritis (a chronic inflammatory disorder that can affect more than just your joints. In some people, the condition can damage a wide variety of body systems, including the skin, eyes, lungs, heart, and blood vessels). Record review of Resident #32's admission MDS assessment dated [DATE] indicated she had a BIMS score of 13 and required substantial to maximum assistance for toileting, transfer, and hygiene. The MDS indicated Resident #32 had pain almost constantly and it was rated a 9 on a pain scale of 1-10. Record review of Resident #32's care plan dated 08/21/2024 indicated she had chronic pain related to rheumatoid arthritis. The intervention was to administer hydrocodone-APAP as ordered and to maintain a pain level of 3 or below on a scale of 1-10. Record review of Resident #32's MAR dated October 2024 indicated she received hydrocodone/ APAP 10/325 mg (1) tablet 4 times daily from 10/01/2024 through 10/19/2024. The MAR revealed Resident #32 received the 8 a.m. dose of hydrocodone/APAP 10/325mg (1) tab on 10/20/2024. Resident #32's MAR indicated she missed the 12:00 p.m., 4:00 p.m., and 8:00 p.m. doses of hydrocodone/APAP 10/325mg. Resident #32's MAR indicated she received Morphine Sulfate 20mg/ml 0.75ml twice on 10/20/2024 at 12:00 p.m. and 8:00 p.m. and once the morning of 10/21/2024 at 7:00 a.m. Record review of Resident #32's narcotic count sheet for October 2024 indicated the final last hydrocodone/APAP 10/325mg (1) was administered at 8:00 a.m. on 10/20/2024. The count was zero after the 8:00 a.m. dose was administered on 10/20/2024. During an interview on 10/21/2024 at 8:15 a.m., Resident #32 stated she was in pain and had not slept well because the facility was out of her pain medication. Resident #32 stated she currently had a pain level of 3-4. She stated it was not excruciating but it made it harder to rest. She stated she woke up twice and it took her about 15 minutes each time to get comfortable and go back to sleep. She stated she had not gotten her routine pain medication but one time yesterday (10/21/2024) and the medication nurse this morning (10/21/2024) told her it had not come in yet. She stated she always had pain because of her rheumatoid arthritis, but she could function normally if her pain was between 2-3. She stated her pain had not kept her from eating breakfast, had not kept her from walking with her walker in her room and taking herself to the bathroom. Resident #32 stated she was given morphine sulfate that she had ordered prn while she was out of hydrocodone, and it helped take the edge off. During an interview on 10/21/2024 at 2:00 p.m., LVN B stated Resident #32 was out of hydrocodone/APAP 10/325mg (1) this morning (10/21/2024) when she counted the cart. She stated Resident #32 was not happy this morning when she had to tell her she was still out of her routine hydrocodone. She stated the resident told her the prn morphine was not working to keep her pain under control. Resident #32 stated her pain was a 4. She stated Resident #32 said it was not excruciating pain, just dull and annoying and keeping her from resting. LVN B stated she called the pharmacy at 9:00 a.m. and they stated the courier was in route to the facility with the medication. She stated the courier arrived 15 minutes later and the resident received her morning dose of hydrocodone/APAP 10/325 (1) tablet. LVN B stated had she not been able to get the medication so quickly, the facility had an emergency narcotic box that she could have gotten the medication from. During an interview on 10/22/2024 at 10:00 a.m., LVN A stated she called the MD for Resident #32 on 10/20/2024 around 10:00 a.m. and requested a refill of hydrocodone. She stated the MD sent a refill prescription to the pharmacy at that time. She stated she gave prn morphine per the resident's request at 12:00 p.m. and 8:00 p.m. on 10/20/2024 when she assessed her pain, and she said her pain was a 5. She stated when she reassessed her pain an hour after the morphine at 1:00 p.m. and 9:00 p.m., both times it was a 3. She stated to get into the emergency narcotic box a hard copy of the prescription for the narcotic had been faxed to the pharmacy and the pharmacist gives you a code to retrieve the needed narcotic. She stated there was no way to get a hard copy of the narcotic prescription from the MD on a Sunday evening. During an interview on 10/22/2024 at 2:15 p.m., the DON stated Resident #32's hydrocodone/APAP 10/325mg was missed for 3 doses on 10/20/2024. She stated Resident #32 was given prn morphine while she was without the hydrocodone. She stated the facility had an emergency narcotic kit for times when the resident's need the medication and the facility was without. She stated she asked LVN A why she had not attempted to get a narcotic prescription for Resident #32's hydrocodone to use the emergency narcotic box because she had no way to get the prescription to fax to the pharmacy to be able to get the hydrocodone out of the emergency kit. During an interview on 10/23/2024 at 12:20 p.m., the ADM stated she was made aware of the 3 missed doses of the hydrocodone/APAP 10/325mg on 10/21/2024 by the DON. She stated she expected the resident's medication to be ordered in a timely manner to ensure they were not without any medication. She stated Resident #32 was given morphine in the time she was without hydrocodone and had not complained of pain to the nursing staff. Review of a facility policy dated 2001 indicated the general guidelines for pain management were defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 10 residents reviewed for medications. (Resident #32) The facility failed to ensure: Resident #32 missed 3 doses of hydrocodone 10/325mg (12:00 p.m., 4:00 p.m., and 8:00 p.m. doses) on 10/20/2024. These failures could cause increased pain and decreased quality of life Resident #32 Findings included: Record review of an undated face sheet indicated Resident #32 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), pain(physical suffering or discomfort caused by illness or injury), and rheumatoid arthritis (a chronic inflammatory disorder that can affect more than just your joints. In some people, the condition can damage a wide variety of body systems, including the skin, eyes, lungs, heart, and blood vessels). Record review of Resident #32's admission MDS assessment dated [DATE] indicated she had a BIMS of 13 and required substantial to maximum assistance for toileting, transfer, and hygiene. The MDS indicated Resident #32 had pain almost constantly and it was rated a 9 on a pain scale of 1-10. Record review of Resident #32's care plan dated 08/21/2024 indicated she had chronic pain related to rheumatoid arthritis. The intervention was to administer hydrocodone-APAP as ordered. Record review of Resident #32's MAR dated October 2024 indicated she received hydrocodone/ APAP 10/325 mg (1) tablet 4 times daily from 10/01/2024 through 10/19/2024. The MAR revealed Resident #32 received the 8 a.m. dose of hydrocodone/APAP 10/325mg (1) tab on 10/20/2024. Resident #32's MAR indicated she missed the 12:00 p.m., 4:00 p.m., and 8:00 p.m. doses of hydrocodone/APAP 10/325mg. Record review of Resident #32's narcotic count sheet for October 2024 indicated the final last hydrocodone/APAP 10/325mg (1) was administered at 8:00 a.m. on 10/20/2024. The count was zero after the 8:00 a.m. dose was administered on 10/20/2024. During an interview on 10/21/2024 at 8:15 a.m., Resident #32 stated she was in pain and had not slept well because the facility was out of her pain medication. Resident #32 stated she currently had a pain level of 4-5. She stated it was excruciating but it made it hard to rest. She stated she had not gotten her routine pain medication but one time yesterday and the medication nurse this morning (10/21/2024) told her it had not come in yet. She stated she always had pain because of her rheumatoid arthritis, but she could function normally if her pain was between 2-3. She stated her pain had not kept her from eating breakfast, had not kept her for walking with her walker in her room and taking herself to the bathroom. During an interview on 10/21/2024 at 2:00 p.m., LVN B stated Resident #32 was out of hydrocodone/APAP 10/325mg (1) this morning (10/21/2024) when she counted the cart. She stated Resident #32 was not happy this morning when she had to tell her she was still out of her routine hydrocodone. She stated the resident told her the prn morphine was not working to keep her pain under control. Resident #32 stated her pain was a 4. She stated Resident #32 said it was not excruciating pain, just dull and annoying and keeping her from resting. LVN B stated she called the pharmacy at 9:00 a.m. and they stated the courier was in route to the facility with the medication. She stated the courier arrived 15 minutes later and the resident received her morning dose of hydrocodone/APAP 10/325 (1) tablet. LVN B stated had she not been able to get the medication so quickly, the facility had an emergency narcotic box that she could have gotten the medication from. During an interview on 10/22/2024 at 10:00 a.m., LVN A stated she called the MD for Resident #32 on 10/20/2024 around 10:00 a.m. and requested a refill of hydrocodone. She stated the MD sent a refill prescription to the pharmacy at that time. She stated she gave prn morphine per the resident's request at 12:00 p.m. and 8:00 p.m. on 10/20/2024 when she assessed her pain, and she said her pain was a 5. She stated when she reassessed her pain an hour after the morphine at 1:00 p.m. and 9:00 p.m., both times it was a 3. She stated in order to get into the emergency narcotic box a hard copy of the prescription for the narcotic had been faxed to the pharmacy and the pharmacist gives you a code to retrieve the needed narcotic. She stated there was no way to get a hard copy of the narcotic prescription from the MD on a Sunday evening. During an interview on 10/22/2024 at 2:15 p.m., the DON stated Resident #32's hydrocodone/APAP 10/325mg was missed for 3 doses on 10/20/2024. She stated Resident #32 was given prn morphine while she was without the hydrocodone. She stated the facility had an emergency narcotic kit for times when the resident's need the medication and the facility is without. She stated she asked LVN A why she had not attempted to get a narcotic prescription for Resident #32's hydrocodone to use the emergency narcotic box because she had no way to get the prescription to fax to the pharmacy to be able to get the hydrocodone out of the emergency kit. During an interview on 10/23/2024 at 12:20 p.m., the ADM stated she was made aware of the 3 missed doses of the hydrocodone/APAP 10/325mg on 10/21/2024 by the DON. She stated she expected the resident's medication to be ordered in a timely manner to ensure they were not without any medication. She stated Resident #32 was given morphine in the time she was without hydrocodone and had not complained of pain to the nursing staff. Record review of policy dated April 2019 was documented Administering Medications, Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a clean and comfortable environment for 1 of 1 secured unit reviewed for environmental concerns. The facility failed to ensure that floors were clean and devoid of dirt and debris in the secured unit. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. The findings included: During observations on 10/21/24 from 8:45 a.m. to 9:25 a.m. in the secured unit indicated the following: *The hall floor was dusty and had bits of debris. There was a thick buildup of grime 3 inches wide along the edges of the hallway and sitting area. *The dining room floor / activity room was dirty with debris and spilled beverages. There was a medication patch stuck in the middle of the floor covered with dirt. The patch was deteriorated, unable to read the label on the patch. The edges of the activity/dining room had a buildup of grime. *Resident room [ROOM NUMBER] had wheelchair tracks with dirt all over the floor beside the bed and the perimeter of the room had buildup of grime. *Resident room [ROOM NUMBER] had trash behind the night side table and was covered with heavy dust layer. The door into the room had dirt, grime and a dead spider behind the door. During an interview on 10/22/24 at 1:00 p.m., Housekeeper C said she had been trained and was aware to sweep and mop all halls and resident rooms. She said the secure unit was cleaned by 2 housekeepers each day. During an interview on 10/22/24 at 1:30 p.m., Housekeeper D said she had been trained in cleaning resident rooms, halls and common areas on hire. She said there were 4 housekeepers for the building each day. During an interview on 10/22/24 at 2:30 p.m., the Administrator said her expectations were for the halls and resident's rooms to be cleaned each day. During an interview on 10/23/24 at 12:30 p.m., the Housekeeping Supervisor said his expectation was for the secure unit to be clean and free of buildup of grime. He said the housekeepers were to sweep and mop all rooms and halls each day. He said he was responsible for ensuring the facility was clean. He said the floors were not clean in the secure unit. He said each room and hall should be kept clean. He said the floors on the secure unit needed to be cleaned better. Record review of the facility's Operations Policies and Procedures manual that was dated 2001, section Homelike Environment, indicated Residents are provide a safe, clean, comfortable and homelike environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 3 of 19 residents reviewed for accuracy of assessments. (Resident #s 21, 23 and 27) The facility did not accurately complete the MDS assessment to indicate Resident #21 did not have a restraint. The facility did not accurately complete the MDS assessment to indicate Resident #23 did not have a restraint. The facility did not accurately complete the MDS assessment to indicate Resident #27 did not have a restraint. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of a face sheet dated 10/21/24 indicated Resident #21 was a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia (group of thinking and social symptoms that interfere with daily function) and glaucoma (a group of eye conditions that can cause blindness). Record review of the physician's orders dated 10/21/24 indicated Resident #21 was prescribed Geri-chair (large, padded chair that provides support and comfort for people with limited mobility) for poor trunk control every shift with a start date of 06/03/24. Record review of Resident #21's October 2024 MAR indicated Geri-chair for out of bed every shift with documentation he was in the Geri-chair every shift with a start date of 06/03/24. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #21 had a BIMS score of 3 indicating moderately impaired cognition and was totally dependent on staff to transfer resident from chair to bed or chair to chair. The assessment indicated Resident #21 had a physical restraint used in chair or out of bed as other used daily during the last 7 days. Record review of Resident #21's care plans initiated 06/11/24 indicated Resident #21 required the use of enablers related to the inability to safely transfer self, poor positioning, high risk for falls, poor cognition, and poor redirection with interventions including Geri-chair for out of bed stimulation. During an observation on 10/21/24 at 11:00 a.m., Resident #21 was lying in a Geri-chair in the television room. He was non-interviewable and appeared comfortable with no signs of distress. During an interview on 10/21/24 at 1:30 p.m., the MDS Nurse said Geri-chairs were restraints because residents could not put the foot of it down themselves. She said she was taught by a previous MDS nurse who had told her Geri-chairs were always restraints. During a phone interview on 10/23/24 at 8:00 a.m., the NP said Geri-chairs were not considered restraints regarding Resident #21. She said she did not know why the facility would think they were because Resident #21 had never attempted to get out of the Geri-chair. During a joint interview on 10/23/24 at 8:49 a.m., LVN A and LVN F said Resident #21 had never made any attempt to get out of the Geri-chair. They said they did not consider it a restraint. 2. Record review of a face sheet dated 10/21/24 indicated Resident #23 was a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia (group of thinking and social symptoms that interfere with daily function) and cerebral vascular accident (stroke). Record review of the physician's orders dated 10/21/24 indicated Resident #23 was prescribed Geri-chair (large, padded chair that provides support and comfort for people with limited mobility) for poor trunk control every shift with a start date of 08/30/23. Record review of Resident #23's October 2024 MAR indicated Geri-chair for out of bed every shift with documentation he was in the Geri-chair every shift with a start date of 08/30/23. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #23 had a BIMS score of 99 indicating severely impaired cognition and was total dependent on staff to transfer resident from chair to bed or chair to chair. The assessment indicated Resident #23 had a physical restraint used in chair or out of bed as other used daily during the last 7 days. Record review of Resident #23's care plans initiated 06/06/24 indicated Resident #23 required the use of enablers related to the inability to safely transfer self, poor positioning, high risk for falls, poor cognition, and poor redirection with interventions including Geri-chair for out of bed stimulation. During an observation on 10/22/24 at 10:00 a.m., Resident #23 was lying in a Geri-chair in the television room. He was non-interviewable and appeared comfortable. During an interview on 10/21/24 at 1:30 p.m., the MDS Nurse said Geri-chairs were restraints because residents could not put the foot of it down themselves. She said she was taught by a previous MDS nurse who had told her Geri-chairs were always restraints. During a phone interview on 10/23/24 at 8:00 a.m., the NP said Geri-chairs were not considered restraints regarding Resident #23. She said she did not know why the facility would think they were because Resident #23 had never attempted to get out of the Geri-chair. During a joint interview on 10/23/24 at 8:49 a.m., LVN A and LVN F said Resident #23 had never made any attempt to get out of the Geri-chair. They said they did not consider it a restraint. 3. Record review of a face sheet dated 10/21/24 indicated Resident #27 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (group of thinking and social symptoms that interfere with daily function), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). Record review of the physician's orders dated 10/21/24 indicated Resident #27 was prescribed Geri-chair for out of bed stimulation every shift with a start date of 06/19/23. Record review of Resident #27's October 2024 MAR indicated Geri-chair for out of bed stimulation every shift with documentation she was in the Geri chair every shift with a start date of 06/19/24. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #27 had a BIMS score of 8 indicating moderately impaired cognition and was total dependent on staff to transfer resident from chair to bed or chair to chair. The assessment indicated Resident #27 a physical restraint used in chair or out of bed as other used daily during the last 7 days. Record review of Resident #27's care plans initiated 06/06/24 indicated Resident #27 required the use of enablers related to the inability to safely transfer self, poor positioning, high risk for falls and poor cognition with interventions including Geri-chair for out of bed stimulation. During an observation and interview on 10/21/24 at 02:04 p.m., Resident #27 was lying in Geri-chair near the nurse's station. She said she was treated well, the staff provided needed care and her chair was comfortable. During an interview on 10/22/24 at 3:33 p.m., the MDS Nurse said she was responsible for all MDSs in the facility and her back up was the Regional RN. She said she was educated on completion of MDS, frequently watched Webinar trainings, and could call her Regional RN for any questions. She said Resident #'s 21, 23, and 27 were captured on their MDSs as restrained but after surveyor intervention and consultation with her Regional RN they were incorrect. She said she was confused about documentation of Geri-chairs related to the RAI but received confirmation from the Regional RN. The MDS nurse said the risk to residents captured as restrained that were not restrained was an inaccurate reporting of the resident. During an interview on 10/23/24 at 8:35 a.m., LVN A said she was providing care for Resident #27 today. She said Resident #27 did not try to get out of the Geri chair. She said it was an enabler not a restraint. During an interview on 10/23/24 at 8:40 a.m., the Regional RN said the MDS nurse was responsible for all MDSs in the facility and was educated on completion and accuracy of MDSs. The Regional RN said she was the back up and signed all the MDSs for completion and checked for accuracy. She said Resident #'s 21, 23 and 27's MDSs captured for restraints related to Geri chairs were overlooked and should not have been captured as restraints. The Regional RN said the risk of an MDS marked as restraints and resident did not have restraints was an inaccuracy of an MDS. During an interview on 10/23/24 at 09:02 a.m., the DON said the MDS Nurse was responsible for all MDSs in the facility and the Regional RN was her back up to double check MDSs and signed the completed MDSs. She said the MDS nurse was educated on completion and accuracy of MDSs. The DON said Geri chairs were not used as restraints they were enablers in this facility. She said the MDS nurse misunderstood and thought since the residents could move their arms all Geri chairs were restraints but after a consult with the Regional RN, she modified Resident #21, 23 and 27's MDSs to indicate no restraints. The DON said her expectation was all MDS to be completed accurately. During an interview on 10/23/2024 at 10:00 a.m., the Administrator said the MDS nurse was responsible for all MDS in the facility and the Regional RN was her back up. She said the MDS nurse was educated on completion and accuracy of MDSs. The Administrator said her expectation was all MDS completed accurately. She said the risk of a resident captured on the MDS having a restraint that did not have a restraint was an inaccurate picture of the resident. Record review of a facility policy dated November 2019, titled, Certifying Accuracy of the Resident Assessment indicated, . Any person completing a portion of the Minimum Data Set/ MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 indicated, . P0100: Physical Restraints Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restrict freedom of movement or normal access to one's body Coding: 1. Not used 2. Used less than daily 2. Used daily . Used in chair or Out of Bed . D. Other . For resident who have no ability to transfer independently, the geriatric chair does not meet the definition of a restraint and should not be coded at P0100 G - Chair Prevents Rising.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to use the services of a registered nurse for 8 at least consecutive hours 7 days a week (140 days) and have a DON licensed in her state of residency (since [DATE]) reviewed for sufficient staffing. The facility failed to ensure they had a full time DON licensed in Texas and failed to ensure there was an RN for 8 consecutive hours 7 days a week. These failures could place residents at risk of lack of nursing oversight and a higher level of care. Findings included: Record review of the personnel file from 09/01/23 through 10/23/24 indicated the DON had a valid Florida license for RN and assume the DON position on 09/01/23. She had an active LVN license in Texas. Her driver's license indicated a Texas address. Record review of a list of no RN coverage based off time sheets provided by the facility from 09/01/23 through 10/23/24 indicated there was no RN coverage for the following months: September 2023 for 9 days; October 2023 for 14 days; November 2023 for 10 days; December 2023 for 11 days; January 2024 for 13 days; February 2024 for 12 days; March 2024 for 13 days; April 2024 for 13 days; May 2024 for 11 days; June 2024 for 12 days; July 2024 for 14 days; August 2024 for 13 days; September 2024 for 12 days; October 2024 for 8 days. During an interview on 10/23/24 at 10:30 a.m., the staff member of the BON said the nurse should have applied for a Texas licensed. She said there had been some schools in Florida involved in fraud. She said if this nurse had gone to the school involved in fraud this would need to be reported. She said the BON would investigate this matter after it was reported to determine if license was a case of fraud. Record review of the BON website on 10/23/24 at 10:45 a.m., indicated the RN license was required to be in the state of the nurse's residency. During an interview on 10/23/24 at 11:44 a.m., DON said she had gone to school and tested in Texas and had a Florida RN license. She said she resided in both states and during her time in college and there was on a waiver because of COVID. She said during the training, the college had her to travel more frequently to Florida during her training. She denied notifying the BON for assistance or for application for Texas license and said some of her classmates had trouble getting a Texas license. She said she was going to check into it but never did. She denied having any knowledge of any wrongdoing on her part. She said she went to Florida once a month for her classes for almost 2 years. She said the name of her school was College AA. She said she had transcripts and her license at home. Record Review obtained on 10/23/24 from the internet site of the Texas BON indicated College AA was on the top of the list of the schools that were involved in fraud during the operation nightingale. During an interview on 10/23/24 at 12:00 p.m., the Administrator said she was not aware the college that the DON went to was involved in fraud and was unaware that nurses had to be licensed in the state they live in. She said they had checked the nursysnurses website to verify licensure status prior to her being the DON. She said the system indicated a Florida license was active and multi state so she could work in Texas because Texas was compact state and so was Florida. She said she and HR were responsible for checking backgrounds prior to hire. She said if RN license was not good, they did not have RN coverage 8 hour a day. During an interview on 10/23/24 at 12:45 p.m., DON said she did not try to obtain her license illegally/fraudulently and she earned her license and would investigate this matter with the Texas board of Nursing. The list of days without RN coverage provided by Administrator was attached to this survey. Record review of the undated Job Description - Director of Nursing indicated . He/She must be a graduate of an accredited school of nursing currently registered with the state agency for nursing licensure and hold a valid licensed in the state he/she is employed. Must have and maintain a License according to the Board of Nursing Examiners.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain bathing were provided for 1 of 16 residents reviewed for ADLs (Residents # 60). The facility did not provide scheduled showers, grooming and nail care for Resident #60. The failure could place residents at risk of not receiving services/care and decreased quality of life. Findings Include: Record review of a face sheet dated 08/28/2023 indicated Resident #60 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), diabetes mellitus type II ( a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel.), and hyperlipidemia (an excess of lipids or fats in your blood). Record review of the MDS dated [DATE] indicated Resident # 60 understood others and made herself understood. The MDS indicated Resident #60 was moderately cognitively impaired with a BIMS score of 12. The MDS indicated Resident #60 did not reject evaluation or care. The MDS indicated the resident required extensive assistance with transferring, dressing, and personal hygiene. Record review of the comprehensive care plan dated 08/24/2023 for Resident #60 indicated no refusal or rejection of care. The care plan did not address her bathing needs. Record review of the Completed ADL Report for August 2023 indicated Resident #60 received a bath on 08/03/2023, 08/22/2023, and 08/26/2023. Record review of an undated Shower Schedule indicated Resident #60 was listed as a Tuesday, Thursday, and Saturday bath. During an observation on 08/28/2023 at 10:00 a.m., revealed Resident # 60 was observed to have 20-30 thick ½ inch gray whiskers to her chin. Resident #60 was noted to have a thick brown substance under her fingernails. During an interview on 08/28/2023 at 10:00 a.m., Resident #60 said she had not had a bath since the previous Tuesday (08/22/2023), 6 days ago. Resident #60 said it was embarrassing to her to have chin hair. Resident #27 said the aides were supposed to shave her when she got a bath, but it had been nearly a week. Resident #60 said her whiskers grew back fast. Resident #60 said she also had to get the nurse to trim her pubic hair because she did not get a bath enough to keep the odor in her pubic area and the hair collected dried feces and odor. Resident #60 stated she was too picky about the way she wanted to be bathed and when she asked the CNAs to bathe her they would say they would come back and never did. During an interview on 08/29/2023 at 2:35 p.m., CNA H said Resident #60 was picky about how she liked her bath and Resident #60 would tell the aides exactly where to put the towels and wash clothes and how to wash her peri area. CNA H said she was unsure why Resident #60 had missed baths in August. CNA H said Resident #60 would ask to wait for a CNA working another hall to have free time to come and assist her (Resident #60) with her bath. During an interview on 08/30/2023 at 2:10 p.m., LVN A said Resident #60 was scheduled to get a bath on Tuesday, Thursday, and Saturday. LVN A stated it was the responsibility of the CNA bathing her to make sure her whiskers and nails were taken care of. LVN A said Resident #60 only liked one CNA to give her a bath and that was why she only got 3 in August. LVN A said that the CNA often worked another hall. LVN A said the CNA could have given Resident #60 a bath even when working another hall. LVN A said Resident #60 would not refuse baths but Resident #60 would say she preferred to wait for the other CNA to assist her, when she had free time. LVN A said the CNA often did not have free time to come assist Resident #60. During an interview on 08/30/2023 at 2:30 p.m., the DON said the CNAs performed showers on the residents, but any of the nursing staff could and should perform showers when needed. The DON said she expected the CNAs to provide bathes to the residents three days per week at minimum. The DON said she was aware Resident #60 was particular about who gave her a bath, but the facility could make accommodations to make sure Resident #60 got her bath. The DON said each resident was to get 12-15 baths per month depending on the schedule and it was unacceptable that Resident #60 only got 3. The DON said not getting a bath could lead to feeling bad about oneself and depression. During an interview on 08/30/2023 at 2:40 p.m., the Administrator stated it was the job of the nursing department to ensure all residents were bathed and personal hygiene was maintained. The Administrator stated she was unaware Resident #27 had missed 2-3 baths per week for the month of August. The Administrator said not having a regular bath could lead to skin issues and psychological issues. The ADL policy was requested on 08/30/2023 at 10:15 a.m. and was not received prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain routine dental services to meet the need of each resident for 1 of 23 residents reviewed for dental services. (Resident #48) The facility failed to provide routine and follow up dental services for Resident #48, who had missing and decayed teeth, and recent tooth infection/abscess. This failure could place the residents at risk for not receiving care and services to prevent further decline, dental pain, and infections. Findings included: Record review of face sheet dated 8/29/2023 indicated Resident #48, admitted to the facility on [DATE] and was an [AGE] year old with diagnoses including disturbances in tooth eruption, cellulitis (serious skin infection) and abscess of mouth, diabetes, and Parkinson's disease. Record review of physicians' orders dated 9/27/2021 indicated the resident may have dental care PRN. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #48 was alert, oriented and had a BIMs of 15 indicating cognitively intact. The assessment indicated the resident had a cavity or broken natural teeth. She required supervision assistance in perform most activities of daily living. Record review of the care plans dated 08/02/2023 indicated Resident #48 had a tooth infection with interventions of monitoring vital signs, assess level of consciousness, and administer antibiotic of Penicillin as ordered. There were no dental service care plan interventions listed prior to this 8/2/2023 start date. During observation and interview on 08/28/2023 at 2:30 p.m., revealed Resident #48 had missing teeth to the top and bottom jaw and multiple decayed teeth with black areas to both jaws. The resident said she was seen by the facility dentist since she was admitted to the facility. She said when the dentist visited 2/9/2023 & 4/4/2023, they told her she needed dentures, but it still had not happened. She said she had to go to a local dentist for emergency dental care 8/1/2023 because her mouth and teeth were hurting, and her teeth got infected/abscessed. She said the local dentist told her to come back for a follow up visit after completing the 7-day antibiotics treatment, and they would evaluate her for dentures, but that appointment was not scheduled. She said the facility said they would forward the emergency dental visit information to the facility dentist and when he came to facility, he could assess the resident and follow up. Resident #48 said I still have not seen the facility dentist for the follow up, and they all know I need dental care. The resident denied dental pain. During an interview and record review on 08/29/2023 at 10:02 a.m., the SW said Resident #48 was placed on the schedule to see the facility dentist for July & August 2023, but the contracted dental company cancelled the visit, and the company was no longer in business. She said the facility has now contracted with a new dental company and they were to begin visiting the facility mid-September 2023. The SW said Resident #48 was seen by the facility dentist on 2/9/2023 and 4/4/2023. The SW provided a document from a contract dental company dated 2/9/2023 with Resident #48 listed as a resident seen and services rendered: 11-14, 22-27, f/f and a document from the contract dental company dated 4/4/2023 with Resident #48 listed as a resident seen and services rendered: Cop, x-ray, F/C. The SW unable to transcribe the meaning of services rendered on documents and reports the contract dental service was no longer in business and was unable to verify services rendered. The SW said the facility's contracted dentist did not document in a resident's medical records, but the dentist provided a list of residents seen and services rendered which was kept in the SW's office. The document from the contract dental company has a disclosure stating to enhance communications they presented the list of residents seen today in the facility. The dental provider had already made the appropriate documentation in the patient's chart. The SW said Resident #48 had an emergency dental visit on 8/1/2023 with a local dentist. The SW said Resident #48 was on the list to be seen by the new contract dental company at the next scheduled visit mid-September 2023. During an observation and interview on 08/30/2023 at 10:24 a.m., LVN A, acknowledged that Resident #48 had missing teeth and decayed teeth. LVN A said residents who needed dental service/care were reported to the SW and they were scheduled to see the contracted dentist who came to the facility. She said if it were an emergent/urgent dental concern, they would send a resident to the local dentist office for care. She said Resident #48 has not complained to her about tooth pain or needing dental services. She said the possible negative outcome of not seeing the dentist could be fragments of teeth falling out, pain, further decay, and weight loss. During an interview on 8/30/2023 at 12:55 p.m., the local dental office staff said their office provided emergency care to Resident #48 on 8/1/2023 for tooth and mouth pain. The office staff reported when a patient comes in for tooth pain/infection, standardly the patient was prescribed an antibiotic, pain medications, a proposed treatment plan, and a scheduled time to return to the office for a follow up visit. The local dental office staff said the facility staff did not schedule the follow up appointment for Resident #48 at the time of the initiate emergent/urgent visit on 8/1/2023. During an interview on 08/30/2023 at 3:14 p.m., the DON and the Administrator said their expectations were for the residents to receive dental services as needed. The DON said the nurses should be assessing the residents routinely to ensure their needs were taken care of. They both acknowledge that Resident #48 should be seen by dentist to follow up after recent tooth infection/ abscess. The Administrator said residents should be seen by dental services at least quarterly; however, after reviewing the facility's dental policy, she said the policy indicated residents would be seen monthly. The Administrator and the DON both acknowledged the possible negative outcome of not receiving dental services/care could be tooth/mouth infection, pain and/or poor nutrition/weight loss. Record review of facility policy titled Dental Services and last revised December 2016 indicated in part, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Policy Interpretation and Implementation, 1. Routine and 24-hour emergency dental services are provided to our residents through: a. A contract agreement with a licensed dentist that comes to the facility monthly; b. Referral to resident's personal dentist; c. referral to community dentists; or d. referral to other care organization that provided dental services. 11. All dental services provided are recorded in the resident's medical record. A copy of the resident's dental record is provided to any facility to which the resident is transferred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 8 resident personal refrigerators reviewed for food safety (Resident #60). The facility failed to ensure the refrigerator for Resident #60 did not contain expired orange juice. This failure could place resident at risk for food borne illnesses. Findings include: Record review of a face sheet dated 08/28/2023 indicated Resident #60 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoseis including dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), diabetes mellitus type II ( a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel.), and hyperlipidemia (an excess of lipids or fats in your blood). Record review of the MDS dated [DATE] indicated Resident #60 understood others and made herself understood. The MDS indicated Resident #60 was moderately cognitively impaired with a BIMS score of 07. The MDS indicated Resident #60 did not reject evaluation or care. The MDS indicated Resident #60 required set up and supervision for eating. Record review of a care plan for Resident #60 dated 08/24//2023 revealed Resident #60 required supervision setup by staff participation to eat. During an observation and interview on 08/28/2023 at 09:50 a.m., Resident #60 said she got food and drinks from her personal refrigerator herself when she wanted. Her personal refrigerator had an unopened 240 ml bottle container of orange juice with the expiration date of 10/15/2022. When asked if staff checked her refrigerator, she said the staff cleaned and took care of the refrigerator for her. Resident #60 said the people she raised (non-biological children) brought her food and drinks when they visited. Resident #60 said she was unsure how long the orange juice had been in the refrigerator. During an interview and observation on 08/29/2023 at 2:10 p.m. CNA H said housekeeping was responsible for cleaning out the resident refrigerators and making sure there is no expired food. CNA H said she does not think there is a facility policy for personal refrigerators. CNA H removed the expired orange juice from Resident #60's personal refrigerator. During an interview on 08/29/2023 at 2:20 p.m., the Housekeeping Supervisor said housekeeping had always been responsible for cleaning the personal refrigerators. She said she was not sure how Resident #60's refrigerator was missed. She said personal refrigerators are to be cleaned daily when the resident's room is cleaned. She said there was no formal paperwork to show that the task of checking the fridge was completed. During an interview on 08/30/2023 at 2:40 p.m., the Administrator said it was the policy of the facility for the housekeepers to keep the refrigerators cleaned out daily. She said they checked the temperature every day when they cleaned the rooms and checked for expired foods. Record Review 08/30/2023 at 08:50 a.m., of policy titled Foods Brought by Family/Visitors indicated, the nursing staff will discard perishable foods on or before the use by date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to be free from any physical restraints imposed for purposes of convenience and not required to treat medical symptoms for 4 of 21 residents reviewed for restraint use (Resident #56, Resident #12, Resident #23, and Resident #27). The facility failed to ensure Resident #56 was free from physical restraints in the form of a merry walker/merry chair (a wheeled walker with a seat used for use by individuals with balance or walking disabilities) and a bed alarm (devices that contain sensors that trigger an alarm or warning light when they detect a change in pressure). The facility failed to ensure Resident #12, Resident #23, and Resident #27 were free from physical restraints in the form of bed alarms and tab chair alarms (alarms with a pull-string that attaches magnetically to the alarm with a garment clip to the resident). This failure could place residents at risk for a decreased quality of life, a decline in physical functioning and injury. Findings included: 1. Record review of a face sheet dated 08/30/23 revealed Resident #56 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses including reduced mobility, unsteadiness on feet, and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). Record review of the most recent MDS dated [DATE] indicated Resident #56 was rarely to never understood and rarely to never understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) interview was not conducted due to Resident #56 being rarely to never understood. The MDS indicated daily use of Restraints in chair/out of bed: other and Bed Alarm. Record review of a care plan last revised on 06/14/23 indicated Resident #56 required the use of enablers related to high risk for falls, poor cognition, and poor redirection. There were interventions for bed alarms at all times and may have merry walker. Record review of the physician's orders for Resident #56 indicated an order with a start date of 05/05/23 for May have a merry chair. There was no stop date for the order. There was an order with a start date of 05/05/23 for Bed alarms at all times. There was no stop date for the order. Record review of a Pre-restraining Evaluation dated 08/10/23 indicated Resident #56 was not alert and oriented. The evaluation indicated a history of falls and loss of balance. During an observation on 08/28/23 at 10:44 a.m., revealed Resident #56 was resting in bed. There was an alarm hanging on the side of the bed. There was a sensory pad attached to the alarm. The sensory pad was between the sheet and absorbent under-pad . During an observation and interview on 08/28/23 at 11:15 a.m., revealed Resident #56 was sitting up in the common area. Resident #56 was sitting inside a merry walker. The resident was sitting on the seat of the merry walker surrounded by 4 sides of the walker. There was a strap from the seat, wrapped around the bar across the front of the walker several times. The strap was positioned between the resident's legs. The strap was closed with a plastic clasp. The bar had a spring bolt holding it in the closed position. The resident was confused and did not answer questions appropriately. During an observation on 08/28/23 at 12:06 p.m., revealed Resident #56 was in the dining room in a merry walker. Lunch was being served to Resident #56 on a bedside table placed just above the merry walker. During an observation on 08/29/23 at 9:28 a.m., revealed Resident #56 was sitting up in the common area. Resident #56 was sitting inside a merry walker. The resident was sitting on the seat of the merry walker surrounded by 4 sides of the walker. There was a strap from the seat, wrapped around the bar across the front of the walker several times. The strap was positioned between the resident's legs. The strap was closed with a plastic clasp. The bar had a spring bolt holding it in the closed position. When the resident was asked if she could remove the strap and open the bar to the merry walker, she only laughed. Resident #56 never attempted to follow commands. The residents in the common area were being observed by Medication Aide G. During an interview on 08/29/23 at 9:32 a.m., Medication Aide G said Resident #56 was able to stand and walk around in the merry walker. She said Resident #56 was not capable of opening up the bar on the merry walker. She said the resident had falls before the merry chair was used. She said staff had been using the merry chair approximately 6 months for Resident #56. During an observation on 08/30/23 at 9:48 a.m., revealed Resident #56 was sitting in a merry walker in the common area. During an observation and interview 08/30/23 at 9:55 a.m., revealed Resident 56's bed was made. There was an alarm hanging on the side of the bed. There was a sensory pad attached to the alarm. The sensory pad was between the sheet and absorbent under-pad. Medication Aide G said staff always used a bed alarm on Resident #56's bed. 2. Record review of a face sheet dated 08/30/23 revealed Resident #12 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain (a decrease in cognitive abilities or mental decline), generalized muscle weakness, and kidney disease. Record review of the most recent MDS dated [DATE] indicated Resident #12 was usually understood and usually understood others. The MDS indicated a BIMS of 2 indicating Resident #12 was severely cognitively impaired. The MDS indicated daily use of a Chair Alarm. The MDS did not indicate a bed alarm. Record review of a care plan last revised on 08/09/23 indicated Resident #12 required the use of enablers related to the inability to safely transfer, poor positioning, high risk of falls, poor cognition, and poor redirection. There were interventions for a chair alarm . The care plan did not indicate a bed alarm. Record review of the physician's orders for Resident #12 indicated an order with a start date of 05/04/23 for Chair alarm to chair while OOB. There was no stop date for the order. There was not an order for a bed alarm. Record review of a Pre-restraining Evaluation dated 07/18/23 indicated Resident #12 was alert and oriented. The evaluation indicated a history of falls and loss of balance. During an observation and interview on 08/30/23 at 10:00 a.m., Resident #12's bed was made. There was an alarm hanging on the side of the bed. There was a sensory pad attached to the alarm. The sensory pad was between the sheet and the mattress. Medication Aide G said staff always used a bed alarm on Resident #12's bed. During an observation and interview on 08/30/23 at 10:21 a.m., revealed Resident #12 was sitting in a wheelchair participating in an activity. There was a tab alarm hanging on the chair with a clip attached to the resident's shirt. The resident did not answer questions. The resident was confused and said, I don't know who brought me in here. 3. Record review of a face sheet dated 08/30/23 revealed Resident #23 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses including dementia (a general decline in cognitive abilities), anxiety disorder, and stroke. Record review of the most recent MDS dated [DATE] indicated Resident #23 was understood and understood others. The MDS indicated a BIMS of 2 indicating Resident #23 was severely cognitively impaired. The MDS indicated daily use of a Chair Alarm and a bed alarm. Record review of a care plan last revised on 08/09/23 indicated Resident #12 required the use of enablers related to the inability to safely transfer, poor positioning, high risk of falls, poor cognition, and poor redirection. There were interventions for a chair alarm and a bed alarm. Record review of the physician's orders for Resident #23 indicated an order with a start date of 05/05/23 for a bed alarm on at all times. There was no stop date for this order. There was an order with a start date of 05/05/2023 for May have chair alarm on at all times. There was no stop date for this order. Record review of a Pre-restraining Evaluation dated 07/12/23 indicated Resident #23 was alert and oriented. The evaluation indicated a history of falls and loss of balance. During an observation on 08/28/23 at 10:24 a.m., revealed Resident #23 was sitting in a wheelchair in the common area. There was a tab alarm attached to the back of the wheelchair and clipped to the back of her shirt. During an observation and interview on 08/30/23 at 9:50 a.m., revealed Medication Aide G was observing the residents in the locked unit common area. She said there were two residents that used the chair alarms on the locked unit. She said the residents that used the chair alarms were Residents #12 and Resident #23. She said Residents #56, Resident #12, and Resident #23 had bed alarms. She said the merry walker, the bed alarms, and the chair alarms were all used as a fall prevention for each resident. During an observation and interview on 08/30/23 at 9:58 a.m., revealed Resident #12's bed was made. There was an alarm hanging on the side of the bed. There was a sensory pad attached to the alarm. The sensory pad was between the sheet and the mattress. Medication Aide G said staff always used a bed alarm on Resident #12's bed. 4. During a record review the resident face sheet dated 08/30/2023 indicated Resident #27 was a 91- year- old male, admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), depression (a group of conditions associated with the elevation or lowering of a person's mood), and anxiety (a feeling of fear, dread, and uneasiness). During the record review, the MDS assessment dated [DATE] indicated Resident #27 had a BIMS of 03, which indicated severe cognitive impairment. The MDS indicated the required extensive assistance with 2 staff members for bed mobility, and transfer. The MDS indicated Resident #27 was totally dependent for sitting in a chair to standing. The MDS indicated Resident #27 had no falls since admit or entry. The MDS indicated daily use of a restraint in chair on out of bed, daily use of bed alarms, and chair alarms. During the record review the care plan for Resident #27 revealed it did not indicate the use of restraints, bed alarms or chair alarms During the record review of the consolidated physician orders for Resident #27 dated August 2023 did not indicate the use of restraints, bed alarms or chair alarms During the record review the quarterly physical restraint evaluation dated 07/04/223 indicated Resident #27 used a Geri chair (a chair used for those with mobility issues and can also be used for bedridden patients who have difficulty sitting upright in a conventional wheelchair) for poor trunk control, a bed alarm, and a chair alarm to prevent falls. During an observation on 08/28/23 at 9:20 a.m., revealed Resident #27 was noted to be reclined in Geri chair sitting in the dining room while activity was being conducted. Resident #27 was noted to have a clip alarm pinned to the back of his sweatshirt while in the Geri chair. During an observation on 08/28/23 at 2:50 p.m., revealed Resident #27 was noted to be in bed with a bed alarm on under the incontinent pad on the mattress, bed lowered to the floor and a mattress on the floor beside the bed as a fall mat. During an observation on 08/29/23 at 10:00 a.m., revealed Resident #27 was noted to be up in Geri chair in a reclined position with a clip alarm pinned to the back of his shirt. During an interview on 08/30/23 at 12:48 p.m., LVN E said he was the nurse for hall 1 and the left side of hall 3. LVN E said he was not aware of any residents with restraints. LVN E said he knew of 5 residents that had alarms. LVN E said Resident #27 had a chair alarm and a bed alarm. He said the Resident #27 was bad about getting up and trying to get out of bed himself. LVN E said Resident #27 had not moved nearly as much for the last 6 months since getting the alarms. LVN E said he provided care to Resident #56 on the locked unit. He said he made observations on the locked unit every 1 - 2 hours. He said those observations were not charted. He said restraint evaluations were completed quarterly. He said he did not consider the merry walker a restraint. He said he considered wrist constraints a restraint. He said he thought Resident #56's family pushed for her to use the merry walker because she was having falls. He said Resident #56 could crawl out of the merry walker but could not open the merry walker. He said she was able to crawl out by getting a leg over the strap and slipping under the walker. During an interview on 08/30/23 at 1:02 p.m., LVN A said there were residents with bed alarms. She said she had 5 or 6 total with alarms. She said some were on beds and some on chairs. She said all the residents with alarms were a fall risk and that was why the alarms were used. She said some had falls and they were trying to prevent falls. She said some residents were getting out of the bed. She said Resident #56, she used to walk in the merry walker. She said it kept her from falling. She said the merry walker was a restraint. She said a restraint could keep the resident from ambulating and doing certain things. She said Resident #56 could not open the bar of the merry walker by herself. She said nursing staff did document on poor trunk control for Geri chairs. She said nursing staff did not chart specific observations on restraints. During an interview on 08/30/23 at 1:14 p.m., the MDS Coordinator said a restraint was anything that limited a resident's movement such as getting out of bed or walking. She said the Geri chair and alarms were restraints for Resident #27 . She said both were used daily. She said Resident #56's merry walker and bed alarm were coded as restraints. She said Resident #56 had falls in the past and she thought that was why she was in the merry walker. She said the nurses completed the restraint assessments. She said she would consider an alarm a restraint . She said Resident #23's alarms were being used for fall prevention. She said Resident #12 had an alarm. She said the alarm was used for fall prevention. During an interview on 08/30/23 on 1:28 p.m., the DON said a restraint was anything that would prevent a resident from moving around and physically be mobile. She said there were no residents in the facility with physical restraints. She said they only put residents in Geri chairs with poor trunk control. She said Resident #56 was very mobile in her merry walker. She said she had the merry walker awhile and she had been able to get out of it. She said the merry walker was because she was having a lot of falls. She said she thought she had the merry walker over a year or two. She said personal alarms were not considered restraints. She said they did not keep anyone from getting up. She said it just alerted the staff and they were only placed after the resident had had several falls. She said she was not familiar with the regulation concerning restraints. During an interview on 08/30/23 at 1:44 p.m., the Administrator said she did not feel there were any restraints in the building. She said a restraint was something that prevented a resident from doing something they would normally do independently. She did not consider the merry walker a restraint. She said when Resident #56 was first admitted she had back-to-back falls. With the merry chair she was able to walk. She felt it was more helpful for her to prevent major injuries from falls. She said she did not know if she could walk without the merry chair. She said she did not know if she could lift herself out of the merry chair. She said she did not feel chair alarms and bed alarms were restraints. She said they were not the first go to intervention and was the last intervention as a fall prevention. Review of a Use of Restraints facility policy dated April 2017 indicated, .Use of Restraints .Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls . Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached to the resident's body that the individual cannot remove easily, which restricts freedom of movement .If the resident cannot remove a device in the same manner in which staff applied it given the resident's physical condition .and this restricts his/her typical ability to change position or place, that device is considered a restraint .Examples of devices that are/or may be considered physical restraints include .Geri-chairs .orders for restraints will not be enforced for longer than twelve (12) hours, unless the resident's condition requires continued treatment . Record review of an Abuse, Grievances, and Restraints facility in-service dated 03/07/23 indicated, .Use of Restraints .Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls . Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached to the resident's body that the individual cannot remove easily, which restricts freedom of movement .If the resident cannot remove a device in the same manner in which staff applied it given the resident's physical condition .and this restricts his/her typical ability to change position or place, that device is considered a restraint .orders for restraints will not be enforced for longer than twelve (12) hours, unless the resident's condition requires continued treatment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of one resident (Resident #22) reviewed for dialysis services. The facility failed to develop a process to communicate with the dialysis facility, where Resident #22 received hemodialysis services. 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 #22's face sheet, dated 08/30/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included severe intellectual disabilities (term used when there are limits to a person's ability to learn at an expected level and function in daily life), anxiety disorder (persistent and excessive worry that interferes with daily activities), and chronic kidney disease, stage 5 (a disease that has progressed to a stage where the kidneys have lost nearly all their ability to do their job effectively). Record review of Resident #22's annual MDS assessment, dated 07/25/23, indicated he had a BIMS score of 99 which indicated the resident was unable to complete the brief interview for mental status. He did not exhibit behaviors of wandering or rejection of care. He required supervision assist for bed mobility, transfers, walking in room and corridor, locomotion on and off unit, eating, and toileting. He required limited assistance for dressing, and personal hygiene. The assessment indicated he received dialysis as a resident at the facility. Record review of Resident #22's physician's orders, active as of 08/30/23, indicated he had these orders: *Dialysis every Tuesday, Thursday, Saturday at [dialysis facility] at 10:40 AM. The start date was 5/22/23. *Remove pressure dressing at bedtime on dialysis days. The start date was 5/9/23. *check for bruit (a sound heard through a stethoscope) and thrill (a vibration caused by blood flowing through a dialysis access site) every shift. The start date was 5/18/23. Record review of Resident #22's care plan, dated 08/30/23, indicated a care plan for renal disease: requires dialysis. The goal was to resolve without complications. Interventions included provide and coordinate transportation to the dialysis center, monitor shunt for patency (bruit and thrill), and remove pressure dressing at bedtime on dialysis days, dialysis on Tuesday's, Thursday's, Saturday's. During an interview on 08/30/23 at 07:50 AM, LVN E said he was the nurse assigned to Resident #22 on 08/30/23. He said he does not send any sort of communication sheet to dialysis when Resident #22 goes to dialysis. He said he did not call dialysis or receive any communication about how the dialysis session went. He said they do not receive a sheet after dialysis with any information. He said the dialysis center does not reach out to the facility after dialysis to communicate any information. During an interview on 08/30/23 at 8:00 AM, LVN A said she was not assigned to Resident #22 on 08/30/23. She said she did not take care of him often, but she thought there was a dialysis communication sheet when they used paper charts, and she thought they communicated with the dialysis center electronically through the electronic medical record. During an interview on 08/30/23 at 08:10 AM, the DON said they did not typically communicate with the dialysis company. She said they received calls from the dialysis company if there was a complication, but otherwise there was not typically any communication. She said they did not receive or request communication about vital signs, weights, or how the dialysis session went. During an interview on 08/30/23 at 08:17 AM, the DON said they did not use anything to communicate with the dialysis company each visit. She said they did an in-service with both nurses on shift on 08/30/23 and they will now print out a dialysis communication sheet to send with Resident #22 when he goes to dialysis. During an interview on 08/30/23 at 09:54 AM, the dialysis center clinic manager said she was the clinic manager for the dialysis center that Resident #22 attended for dialysis sessions. She said the facility never sent a communication form for them to fill out. She said if he had complications during a session they call the facility, but otherwise they had no communication with the facility. During an interview on 08/30/23 at 12:49 PM, the ADON said she expected the nurses to call and discuss with the kidney center about Resident #22's dialysis sessions. She expected the nurses to obtain information that included any complications, vital signs, whether there were issues with his shunt access, and any change in condition. She said the risk to the resident was that the facility would not know if the kidney center had trouble accessing his shunt, or if his vital signs were out of normal limits. She said if they did not know those things it would put the resident at risk of harm. During an interview on 08/30/23 at 12:51 PM, the DON said she expected the nurses to communicate with the dialysis center via telephone. She expected the nurses to communicate any pain, abnormal vital signs, and any complications. She said the resident could suffer sickness or possible harm since they did not facilitate communication with the dialysis center During an interview on 08/30/23 at 12:53 PM, the Administrator said she expected the nurses to follow the policy and communicate with the dialysis center. She said the resident could suffer harm, or critical labs. She said now they would change and communicate with a sheet of paper to be filled out by the dialysis center. She said if they did not get the sheet of paper back from the kidney center then the nurse would call the kidney center to get the information. Record review of the facility's policy, care of a resident with end-stage renal disease, revised September 2010, stated: .Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care . .4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: . .b. how information will be exchanged between facilities; Record review of the facility's dialysis contract, effective 12/20/19, stated: .This Agreement is made by and between [facility owner] (hereinafter referred to as the Owner) and [dialysis center owner] (hereinafter referred to as the Company). Effective upon the date of last signature . .3. Interchange of information. The Long-Term Care Facility shall provide for the interchange of information useful or necessary for the care of the ESRD Residents. Including a contact person at the Long-Term Care Facility whose responsibilities include assisting with the coordination of Renal Dialysis Services for ESRD residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their established smoking policy for 3 or 24 (Residents #37, #58, and #14) residents reviewed for smoking. The facility failed to ensure Residents #37, #58 and #14 did not have smoking supplies at their bedside and in their possession . This failure could place residents at risk for injury, harm, and impairment or death. Findings included: 1. Record review of Resident #37's face sheet dated 2/19/23 revealed he was an [AGE] year-old male, who was admitted to the facility on [DATE] with the diagnoses of Conduct Disorder (a group of behavioral and emotional problems characterized by a disregard for others), Muscle Weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy), and Cerebral Infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it.) Record review of Resident #37's quarterly MDS dated [DATE] indicated he had a BIMS of 15, which indicated he was cognitively intact. Resident #37 normally used a wheelchair as a mobility device. Resident #37 required a one person assist with transfer, bed mobility, and personal hygiene. Record review of Resident #37's care plan dated 7/1/23 revealed the resident may not keep cigarettes/tobacco products or lighters/matches on their person or in their possession, be informed of facility smoking policies, be assessed as a safe smoker. Record review of Resident #37's safe smoking evaluation, dated 6/26/23, indicated he was safe to smoke unsupervised. The evaluation further indicated he was able to independently follow smoking policies, and that he return the smoking material to the appropriate storage. During an observation and interview on 8/28/23 at 10:45 a.m., Resident # 37 stated that he had cigarettes and a lighter in his shirt pocket. He stated that he smoked by himself and with other residents outside in the smoking section. He said that he keeps his cigarettes and lighter and didn't give it to the nurse's station when he was finished smoking. He stated that he smoked when he wanted to and kept his cigarettes in his dresser drawer. The Surveyor observed cigarettes in Resident #37's shirt pocket. During an observation and interview on 8/29/23 at 2:56 p.m., revealed Resident #37 was in room lying in bed. He stated that his cigarettes were in his dresser drawer. The Surveyor asked if he could look in Resident #37's drawer which he stated, Yes. The Surveyor observed cigarettes and a lighter in Resident #37's dresser drawer. During an interview on 8/30/23 at 9:42 a.m., CNA F stated that Resident #37 does smoke. She stated that she believes that Resident #37 he goes out every hour to smokes once an hour each dayeach day. She stated that residents are supposed to leave smoking supplies at the nurse's station. She stated that residents are not allowed to keep cigarettes or lighters on their person. She stated that usually residents are supposed to ask the staff at the nurse's station to get their smoking supplies. 2. Record review of Resident #58's face sheet, dated 08/29/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included multiple sclerosis (a potentially disabling disease of the brain and spinal cord), cerebral infarction (the pathologic process that results in an area of necrotic [dead] tissue in the brain), anxiety disorder (persistent and excessive worry that interferes with daily activities), and aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension). Record review of Resident #58's annual MDS, dated [DATE], indicated she had a BIMS score of 8, which indicated moderately impaired cognition. She did not exhibit behaviors of rejection of care or wandering. She required supervision assist for bed mobility, transfers, locomotion on and off unit, dressing, eating, toileting, and personal hygiene. She normally used a wheelchair as a mobility device. Record review of Resident #58's care plan, dated 08/29/23, indicated a care plan for safe smoker. The start date was 06/12/23. The goal was resident will have no injury from smoking through next review date. Interventions included: *resident will be informed of the facility smoking policy *resident will sign smoking agreement with facility *resident may not keep cigarettes/tobacco products or lighters/matches on their person or in their possession *assess resident to ensure they are following facility's safe smoke guidelines *resident will smoke in supervised approved smoking area only Record review of Resident #58's safe smoking evaluation, dated 08/28/23, indicated she was safe to smoke unsupervised. The evaluation further indicated she was able to independently able to follow smoking policies, and that she returns the smoking material to appropriate storage. During an observation and interview on 08/28/23 at 10:37AM, Resident #58 was lying in bed in her room. She was unable to speak but nodded yes when theis surveyor asked if she was a smoker. She showed theis surveyor her pack of cigarettes and it had cigarettes and a lighter inside. During an observation on 08/29/23 at 09:54 AM, Resident #58 was lying in her bed in her room. There was a pack of cigarettes and a lighter at her bedside. During an observation on 08/29/23 at 02:53 PM, Resident #58 was lying underneath a blanket in her bed in her room. She had her cigarettes and a lighter on her bedside table. During an observation on 08/30/23 at 09:37 AM, Resident #58 had cigarettes and a lighter on her bedside table. She was lying in bed under her blanket. 3. Record review of Resident #14's face sheet, dated 08/29/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), anxiety disorder (persistent and excessive worry that interferes with daily activities), type 1 diabetes mellitus (a lifelong disease in which there is a high level of sugar in the blood), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a serious mental disorder in which people interpret reality abnormally), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Record review of Resident #14's quarterly MDS, dated [DATE], indicated he had a BIMS score of 9, which indicated moderate cognitive impairment. He did not exhibit behaviors of rejection of care or wandering. He required supervision assist with bed mobility, transfers, locomotion on and off unit, dressing, eating, toileting, and personal hygiene. He normally used a wheelchair as a mobility device. Record review of Resident #14's care plan, dated 08/29/23, indicated a care plan for safe smoker. The start date was 06/12/23. The goal was resident will have no injury from smoking through next review date. Interventions included: *resident will be informed of the facility smoking policy *resident will sign smoking agreement with facility *resident may not keep cigarettes/tobacco products or lighters/matches on their person or in their possession *assess resident to ensure they are following facility's safe smoke guidelines *resident will smoke in supervised approved smoking area only Record review of Resident #14's safe smoking evaluation, dated 07/10/23, indicated he was safe to smoke unsupervised. The evaluation further indicated he was able to independently able to follow smoking policies, and that he returns the smoking material to appropriate storage. During an observation on 08/29/23 at 09:53 AM, Resident #14 was self-ambulating with his wheelchair near the nurse's station. He had an unlit cigarette in his mouth. During an observation on 08/29/23 at 09:56 AM, Resident #14 had a pack of cigarettes on his bedside table in his room . During an interview on 08/30/23 at 09:38 AM, CNA D said she was taking care of Residents #58 and #14 on 08/30/23. She said residents should not have smoking materials at the bedside. She said the smoking materials were supposed to be locked up at the nurse's station. She said sometimes Resident #58's family member would sneaks cigarettes in and give them to her without notifying the staff. During an interview on 08/30/23 at 09:40 AM, LVN E said he was taking care of Residents #58 and #14 on 08/30/23. He said residents should not have cigarettes or a lighter at the bedside. He said the supplies should have been locked up at the nurse's station. He said Resident #58's family member probably brought them to her without telling staff. He said the risk to the residents could be they could start a fire. During an interview on 8/30/23 at 12:57 p.m., the DON stated that residents are supposed to take cigarettes from the nurse's station and leave their lighters at the nurse's station when they are finished e done smoking. She stated that if residents arewere allowed to keep their cigarettes and lighters, they might smoke in their rooms or harm themselves. She stated that the residents could also be placed at risk for causing a fire. She stated that the facility was not following company policy by allowing residents to have lighters and cigarettes in their bedroom. During an interview on 8/30/23 at 12:57 PM the Administrator stated that facility policy is that residents are not allowed to keep cigarettes and lighters in their rooms. She stated that residents are supposed to leave their cigarettes and lighters at the nurse's station when they are done smoking. She stated that residents could be placed at risk by keeping a lighter in their rooms by starting a fire. Record review of an undated facility policy entitled Smoking Policy revealed that, The resident is not allowed to keep matches, cigarettes, lighters, or other smoking paraphernalia in the room. These are kept at the nurse's station.

Based on record review and interview the facility failed to ensure the arbitration agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements. The facility did not ensure the arbitration agreement contained the required elements: *Failed to provide the right to rescind in 30 calendar days of signing This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included: Record review of undated admission Agreement included: .29. ARBITRATION Pursuant to the Federal Arbitration Act, any action, dispute, claim or controversy of any kind (.e.g., whether in agreement or in tort, statutory or common law, legal equitable, or otherwise) now existing or hereafter arising between the parties in any way arising out of, pertaining to or in connection with the provision of health care services, any agreement between the parties, the provision of any good or services by the Health Care Center or other transactions, agreements or agreements of any kind whatsoever, any past present or future incidents, omissions, acts, errors, practices or occurrence causing injury to either party whereby the other party or its agents, employees or representative may be liable, in whole or in part or any other aspect of the past, present, or future relationships between the parties shall be resolved by binding arbitration administered by the National Arbitration Forum . Record review of an undated Dispute Resolution Plan did not indicate the resident or the resident's representative had the right to rescind the agreement within 30 calendar days of signing the agreement. During an interview on 08/30/23 at 1:44 p.m., the Administrator said there were no residents active in the arbitration process. She said arbitration agreements were signed when the admission packet was completed. She said the Dispute Resolution Plan was part of the admission packet. She said she verbally explained the agreement to the resident or the resident's representative and that they had a choice to sign or not. She said no residents had asked to rescind the agreement in 30 days. She said she had not been in the position to have to select a neutral venue and there was no process for that. She said she had gotten the agreement from another facility and did not know it did not reflect the right to rescind within 30 days. She said residents could refuse to sign and would still be admitted to the facility. An email was sent to the Administrator of the facility on 08/31/23 at 12:32 p.m. requesting a policy concerning Arbitration Agreements. No response was received.

Based on record review and interview the facility failed to ensure the Arbitration Agreement included the provision of a neutral arbitrator and a convenient venue for 1 of 1 facility reviewed for Arbitration Agreements . The facility failed to ensure the provision of a neutral arbitrator. The facility failed to ensure the Arbitration Agreement contained a section indicating the provision of a convenient venue. These failures could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included: Record review of undated admission Agreement included: .29. ARBITRATION Pursuant to the Federal Arbitration Act, any action, dispute, claim or controversy of any kind (.e.g., whether in agreement or in tort, statutory or common law, legal equitable, or otherwise) now existing or hereafter arising between the parties in any way arising out of, pertaining to or in connection with the provision of health care services, any agreement between the parties, the provision of any good or services by the Health Care Center or other transactions, agreements or agreements of any kind whatsoever, any past present or future incidents, omissions, acts, errors, practices or occurrence causing injury to either party whereby the other party or its agents, employees or representative may be liable, in whole or in part or any other aspect of the past, present, or future relationships between the parties shall be resolved by binding arbitration administered by the National Arbitration Forum . Record review of an undated Dispute Resolution Plan did not indicate the provision of a neutral arbitrator and a section indicating the provision of a convenient venue . During an interview on 08/30/23 at 1:44 p.m., the Administrator said there were no residents active in the arbitration process. She said arbitration agreements were signed when the admission packet was completed. She said the Dispute Resolution Plan was part of the admission packet. She said she verbally explained the agreement to the resident or the resident's representative and that they have a choice to sign or not. She said no residents had asked to rescind the agreement in 30 days. She said she had not been in the position to have to select a neutral venue and there was no process for that. She said residents could refuse to sign and would still be admitted to the facility. An email was sent to the Administrator of the facility on 08/31/23 at 12:32 p.m. requesting a policy concerning Arbitration Agreements. No response was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a discharge resident assessment within the required time frame for 1 of 16 residents (Resident #1) reviewed for MDS (Minimum Data Set) completion. The facility failed to complete a required discharge assessment for Resident #1 within 14 days after Resident #1 discharged from the facility. This failure placed the residents at risk of not getting continuity of care, if their clinical and discharge assessment information was not current and accurate in the MDS (RAI) database. Findings included: Record Review of Resident #1's Face Sheet dated 6/27/2022 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses that included: acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar levels to be abnormally high), high blood pressure and depression. Record review of the last MDS completed for Resident #1, a discharge from therapy MDS dated [DATE] revealed Resident #1 needed extensive assistance for ADLs and was discharged off skilled services on 1/9/22. There was no evidence of a discharge MDS assessment. Record review of a Discharge Summary form dated 2/9/22, signed by the physician indicated Resident #1 was discharged from the facility on 1/26/22 to another nursing facility. During an interview on 6/27/22 at 2:30 p.m., the MDS nurse said she was responsible for completing the Medicaid MDS assessments and the DON was responsible for the Medicare MDS assessments. She said the DON was her back up to double check MDS assessments for accuracy and completeness. The MDS nurse said the DON trained her on MDS completion and accuracy. She said her most recent update on training was about 3 to 6 months ago. She said Resident #1 should have had a discharge assessment when he left the facility, but it was just missed. During an interview on 6/27/22 at 2:35 p.m., the DON, said she did the Medicare MDS assessments and the MDS nurse did the Medicaid MDS assessments. The DON said she did the discharge off therapy assessment and just missed completing a discharge assessment when Resident #1 discharged to another facility on 1/26/22. The DON said she was responsible for completing the discharge assessment. The DON said she completed the HHSC (Texas Health and Human Services Commission) MDS training about a year ago online. She said she keeps updated on changes on the HHSC web site and receives MDS update emails. The DON said the risk to Resident #1 of missing the discharge assessment was continuity of care for Resident #1, because it would look like he was still in their facility when he was not. During an interview on 6/28/22 at 8:30 a.m., the Administrator said her expectation was for all MDS to be completed timely and correctly. She said the MDS nurse was responsible for completing all Medicaid assessments including Resident #1's discharge assessment. The Administrator said the discharge assessment was just missed. She said the DON was responsible for completing all the Medicare MDS assessments. She said the DON was responsible for being the MDS nurse's back up. The Administrator said the MDS nurse and DON received education on MDS accuracy and completion. She said the DON completed a course from CMS and stays updated with the changes and educated the MDS nurse and updates her on changes. She said they can look on the web site, Simple LTC to find a list a missing discharge assessment. Record review of a policy revised November 2019 titled, Resident Assessments indicated, . 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements: . (5) Discharge Assessment - Conducted when a resident is discharged from the facility. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 updated October 2019 indicated, .OBRA-Required Tracking Records and Assessments are Federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. They include: . o Discharge (return not anticipated or return anticipated). discharge assessment - return not anticipated . MDS completion date is no later than discharge date +14 calendar days. and must be submitted 14 days after the MDS completion date . During the exit meeting on 6/28/22 at 2:45 p.m., the Administrator was given the opportunity to provide additional information related to discharge MDS's. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessments accurately reflected the resident's status for 1 of 16 residents reviewed for accuracy of assessments. (Resident #58) The facility did not ensure Resident #58's most recent comprehensive assessment captured the resident was not taking an anticoagulant (medication to help prevent blood clots). These failures could place the residents at risk for not receiving the appropriate care and services. Findings included: Record review of a physician order dated 3/29/22 indicated Resident #58 was to receive Lovenox (an anticoagulant medication) 30mg subcutaneously (under the skin) one time. Record review of Medication Administration Record (MAR) dated March 2022 indicated Resident #58 received Lovenox 30mg subcutaneously on 3/29/22 at 9:00 a.m. for diagnosis of right hip fracture. Record review of physician orders dated June 2022 indicated Resident #58, re-admitted [DATE], was [AGE] years old with a diagnosis of fracture of head and neck of right femur (right hip fracture). There were no anticoagulant medications ordered. Record review of a MAR dated June 2022 indicated Resident #58 was not receiving an anticoagulant. Record review of Significant Change Minimum Data Set (MDS) dated [DATE] indicated Resident #58 had received anticoagulant medication 1 of the last 7 days. Record review of a care plan last updated 6/10/22 did not indicate Resident #58 had received an anticoagulant. During an interview on 6/27/22 at 2:45 p.m., the MDS Nurse said she had made an error by documenting anticoagulant given 1 day out of 7 to Resident #58 on the MDS dated [DATE]. MDS Nurse said the only time Resident #58 received an anticoagulant was in March 2022 after surgery to repair her fractured right hip. She said she would submit a correction. She said she had been the MDS Nurse for about a year and was trained on completing MDS by the DON. She said possible negative outcome to and incorrect MDS could be resident received the wrong treatment and facility could receive the wrong payment. She said it could also interrupt continuity of care. During an interview on 6/28/22 at 8:47 a.m., the administrator said her expection was that MDS would be completed accurately. She said the MDS Nurse was responsible for completing all Medicaid MDS including Resident #58. She said anticoagulant was included on MDS by mistake. She said possible negative outcome for incorrect coding of MDS could be wrong payment. During an interview on 6/28/22 at 11:15 a.m., the DON said she had trained the MDS. She said she had received her MDS training for MDS online through HHSC approximately one year ago. DON said she keeps updated on MDS changes through HHSC and CMS websites and email. She said Resident #58 had only received an anticoagulant in March 2022 and should not have been included on the latest MDS. She said possible negative outcome to MDS being coded wrong could be wrong payment. Record review of facility policy Certifying Accuracy of Resident Assessment revised November 2019 indicated .3. The information captured on the assessment reflects the status of the resident during the observation look-back period for that assessment. During the exit meeting on 6/28/22 at 2:45 p.m., the administrator was given the opportunity to provide additional information related to MDS. No additional information was provided.

Based on observation, interview, and record review, the facility failed to maintain mechanical and electrical equipment in safe operating condition for 1 of 1 kitchen. Two of the six burners on the gas stove in the kitchen did not light when turned on. This failure could place residents and staff at risk of breathing in gas fumes and food borne illness. Findings included During an observation and interview on 6/26/22 at 9:00 a.m., [NAME] D turned on the burners of the gas stove and said the 2 back burners (middle and back right) of the 6 burners did not light . She said she will report this to the Maintenance Supervisor. She said she was unsure when the burners stopped working properly. [NAME] D said she had been trained on hire to report to the Maintenance Supervisor when equipment was broken or not working properly. During an interview on 6/28/22 at 8:59 a.m., The Administrator said the Maintenance Supervisor checked the burners and she thought they were fixed on Monday morning (6/27/22). She said her expectation was for the equipment to be in good working order. She said the DM oversees the kitchen and maintenance oversees the equipment. During an interview on 6/28/22 at 11:25 a.m., the Maintenance Supervisor said he tried to fix the burners on Monday morning (6/27/22), after the dietary reported it. He said he had not been notified of the burners not working properly until surveyor had asked the kitchen about the burners. He said he thought he had fixed one burner, but then said he needed a part for the pilot light that works those 2 back burners. He said the part was ordered. He said anytime something was not working properly, the staff were trained on hire to fill out work orders or call him. He said if the burners do not light it could let gas leak. Review of the policy dated December 2009 and titled Maintenance Service indicated Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 4 shower rooms (hall 400 shower room) reviewed for environment in that: The facility failed to ensure the hall 400 shower room was safe. Missing floor tiles resulted in the floor being uneven which could lead to an accident especially when the floor is wet after using the shower. This failure could place residents at risk of living in an unsafe environment and a diminished quality of life. Findings included: During an observation on 6/26/22 at 9:30 a.m., of the Hall 400 shower room the front shower stall was missing seventeen floor tiles in the front of the shower, where the shower tiles meet the shower floor. The back shower stall was missing ten floor tiles in the front of the shower, where the shower tiles meet the shower floor. Both areas of missing floor tiles were in the path of getting in and getting out of the shower. During an observation and interview on 6/27/22 at 1:45 p.m., of the Hall 400 shower room with CNA B, she said she was unsure when the shower floor tiles were first missing. CNA B said she transferred from night shift to the day shift last month and had not noticed the tiles were missing before. During an observation and interview on 6/27/22 at 2:05 p.m., of the Hall 400 shower room with CNA C, she said she noticed the shower room floor tiles were missing in front of both of the shower stalls. CNA C said she was unsure when the shower floor tiles were first missing. CNA C said the shower floor tiles were both already missing when she started working at the facility six months ago. CNA C said it was hard to get the residents in and out of the shower due to the missing floor tiles. CNA C said she had not reported the missing shower floor tiles, but she was pretty sure they knew about it because it had been that way a while. During an observation and interview on 6/27/22 at 2:15 p.m., of the Hall 400 shower room with Housekeeper A who works on the 400 hall. Housekeeper A said she had not noticed the shower floor tiles were missing before. During an observation and interview on 6/27/22 at 2:30 p.m., of the Hall 400 shower room with the Maintenance Supervisor, he said he was aware of missing floor tiles in front of both showers, but could not remember when he was first aware of the missing floor tiles. The Maintenance Supervisor said he had a similar issue on hall 100 in the shower room that he had already repaired. The Maintenance Supervisor said he could not remember when he repaired the floor tiles in the hall 100 shower room. The Maintenance Supervisor said when the shower chair rolls into the shower it breaks the floor tiles in front of the shower. The Maintenance Supervisor said he had not had time to repair the floor tiles in the Hall 400 shower room because he was busy with the rest of the building. The Maintenance Supervisor said he was responsible for the whole building. The Maintenance Supervisor said he was not sure how long the floor tiles had been missing. During an interview on 6/28/22 at 9:45 a.m., the Maintenance Supervisor said he received the work order request for the missing floor tiles in the Hall 400 shower on 6/27/22. The Maintenance Supervisor said he did not have a work order request before 6/27/22 and could not remember getting a maintenance request before then either. During an interview on 6/28/22 at 10:00 a.m., the DON said she was notified on 6/27/22 of the missing floor tiles in the Hall 400 shower room. The DON said the missing tiles needed to be replaced. The DON said the missing floor tiles in the shower room could be a hazard and cause a safety concern for residents and staff. During an interview on 6/28/22 at 11:30 a.m., the Administrator said the missing floor tiles in the shower room needed to be replaced. The Administrator said all staff were responsible for completing maintenance work order request forms and the Maintenance Supervisor was responsible for making the repairs. The Administrator said she expected for staff to complete maintenance work order request forms and for the Maintenance Supervisor to complete the repairs. The Administrator said the missing floor tiles in the shower room could be a hazard and cause a safety concern for residents and staff. Review of the Agency P&P revised 12/2009 Titled Maintenance Service read in part, . 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. b. Maintaining the building in good repair and free from hazards. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for one of one kitchen reviewed food service safety, in that: There were unlabeled, undated containers of food items stored in the refrigerator and 2 food items were past the use by date. These failures could place residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: During an observation on 6/26/22 at 8:45 a.m., the first refrigerator of 2 contained the following items: A plastic clear zip-locked gallon size bag contained pancakes and was not labeled or dated. A plastic clear zip-locked gallon size bag contained 2 slices of uncooked bacon and 2 uncooked sausage patties, and the bag was not labeled or dated. A plastic clear zip-locked gallon size bag contained 15 slices of ham and was not marked with an open date. A 2-pound container of pimento cheese with an open date of 2/9/22 and use by date of 5/20/22. A quart container with heavy cream had an opening date of 6/1/22 and use by date of 6/7/22. During an interview on 6/26/22 at 8:50 a.m., [NAME] D said she had been trained to date and label all food items when placing them in the refrigerator or when opening food. She said the dietary staff was responsible for checking the refrigerators every shift to ensure all the food was labeled labels and dated. She said if the residents were to eat food that was old, it could make the residents sick, or the food might not taste good. During an interview 6/27/22 at 8:00 a.m., the DM (Dietary Manager) said the dietary staff had been trained and retrained about labeling and dating items in refrigerator. She said she comes in on Mondays and cleans the refrigerators out of any food items not labeled or dated properly and dispose of all items not dated or labeled. She was responsible for overseeing the kitchen and dietary staff. The DM said every Monday morning she checks the refrigerators. She said the items the surveyor had found on Sunday (6/26/22) should had been disposed of, or dated and labeled. Review of a policy dated July 2014 titled Food Receiving and Storage indicated Policy Statement Foods shall be received and stored in a manner that complies with safe pfoor handling practices. 8. All foods stored in the refrigerator will be covered, labeled, and dated (use by date).