**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the state survey agency within five working days of the incident for 5 (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 8 residents reviewed for abuse and neglect. The facility failed to thoroughly investigate 4 separate facility reported incidents involving Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 within five (5) days regarding allegations of abuse or neglect and submit a 3613-A of the findings. This deficient practice could place residents at risk of harm from neglect due to not having a thorough investigation done for facility reported incidents. The findings included. 1. Record review of Resident #2’s face sheet dated 7/10/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included severe protein-calorie malnutrition, lack of coordination, contracture to right and left knee, pain, muscle wasting, muscle weakness, unsteadiness of feet, fracture of the right foot, and need for assistance with personal care. Record review of Resident #2’s most recent quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills, required substantial/maximal assistance with transfers and was always incontinent of bowel and bladder. Record review of Resident #2’s comprehensive care plan with revision date 8/13/24 revealed the resident was impaired with physical functioning related to muscle weakness with interventions that included substantial/maximal assistance with transfers, and partial/moderate assistance with rolling left to right. During an observation and interview on 7/8/25 at 11:01 a.m., Resident #2 stated she reported to a family member about CNA C being rough with her when the CNA tried to reposition her while in bed. Resident #2 stated her family member reported the complaint to the former SW (Social Worker). Resident #2 stated, CNA C “would turn me over, and I would hit the wall.” Resident #2’s bed was placed up against the wall on the right side of the bed and a large piece of padded foam was observed covering the right side of the wall. Resident #2 stated the padded foam was placed on the right of the bed against the wall because CNA C would turn her and her legs, which were contracted and bent at the knee, “would bang her against the wall.” Resident #2 stated the former Administrator had informed her that he had talked to CNA C about the incident, had moved her to another hall, but then CNA C stopped working a short time later. During a telephone interview on 7/9/25 at 1:18 p.m., CNA C stated she had provided care to Resident #2 on several occasions and recalled being suspended because Resident #2 had accused her of hitting the resident’s legs against the wall when repositioning. CNA C stated, Resident #2 never complained to her about it and denied the allegation. During an interview on 7/9/25 at 1:27 p.m., the former SW stated she interviewed Resident #2 regarding the allegation that CNA C had hit her knees against the wall and the former SW then reported the incident to the former Administrator. The former SW stated she recalled doing interviews with other residents regarding abuse/neglect as part of the investigation but then the former Administrator and the former DON took over after that. During an interview on 7/10/25 at 3:47 p.m., the ADON stated the former Administrator at the time made himself in charge of doing the investigation portion that would have been submitted to the State Survey Agency. The ADON stated there was no documentation showing an investigation had been done for the incident involving Resident #2 and CNA C, reported on 1/26/25. 2. Record review of Resident #3’s face sheet, dated 7/9/25, revealed a [AGE] year-old male resident admitted on [DATE] and discharged on 2/17/25 with diagnoses of encounter for surgical aftercare following surgery on the nervous system (his back), partial traumatic amputation of two or more right lesser toes (two toes were surgically removed), type 2 diabetes mellitus with unspecified complications (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood glucose.), intraspinal abscess (collection of pus and infectious material in the spine, often resulting from a bacterial infection) and granuloma (localized area of inflammation that forms around an infection often as a response to the immune system’s attempt to clear the infection), depression, osteomyelitis of vertebra- thoracolumbar region (an infection of the vertebrae in the spine), discitis (inflammation or infection that develops between the intervertebral discs of your spine), spondylosis without myelopathy or radiculopathy (degeneration of the vertebral column), schizophrenia (a chronic mental health condition characterized by symptoms of hallucinations (seeing or hearing things that are not there), delusions (false beliefs), disorganized thinking, and difficulty distinguishing reality from imagination.), and methicillin susceptible staphylococcus aureus infection (a type of bacterial infection caused by staphylococcus aureus). Record review of Resident #3’d discharge MDS assessment, dated 2/17/25, revealed the resident memory was severely impaired for daily decision making. Record review of Resident #3’s admission and baseline care plan/summary, dated 2/13/25, revealed the Resident had an IV PICC to the left arm and had staples on his back from prior surgery. Record review of Resident #3’s comprehensive care plan, dated 7/9/25, revealed he had impaired cognitive function process related to disease process with interventions to monitor/document/report physician changes in cognitive function, specifically changes in: a) decision making ability b) memory, recall and general awareness c) difficulty expressing self d) difficulty understanding others e) level of consciousness f) mental status, and notify the physician with an initiated date of 2/20/25. Record review of Resident #3’s physician orders, dated 7/9/25, revealed an order for Cefazolin sodium injection solution reconstituted 2 grams, use 2 grams intravenously three times a day related to methicillin susceptible staphylococcus aureus infection until 5/2/25 to be given three times a day for 11 weeks. The order had a started date of 2/14/25 and an end date of 5/2/25. Record review of Resident #3’s February MAR, dated 7/9/25, revealed an order for Cefazolin three times a day. The MAR reflected the following administration records: -2/13/25 the 6 p.m.-10 p.m. dose was missed (order not entered until 2/14/25 at 3:15 p.m.) -2/14/25 the 6 a.m.- 10 a.m. dose was missed (order not entered until 2/14/25 at 3:15 p.m.) -2/14/25 the 2 p.m.- 6 p.m. dose was administered (not documented on the MAR but in a late entry nursing note on 2/17/25) -2/14/25 the 6 p.m.-10 p.m. dose was missed (pulled PICC line) -2/15/25 the 6 a.m.- 10 a.m. dose was missed -2/15/25 the 2 p.m.- 6 p.m. dose was administered -2/15/25 the 6 p.m.- 10 p.m. dose was administered -2/16/25 the 6 a.m.- 10 a.m. dose was administered -2/16/25 the 2 p.m.- 6 p.m. dose was administered -2/16/25 the 6 p.m.-10 p.m. dose was missed (pulled PICC line) Record review of nursing progress notes, dated 7/9/25 revealed the following notes: -2/14/25 at 5:30 p.m., written by LVN D, stated “resident is not cooperating staying in his chair or bed. he keeps trying to get up from chair and is rolling around everywhere. CNA tried to adjust him for him to feel comfortable but still is not cooperative” -2/14/25 at 10:38 p.m., written by LVN E, stated “resident pulled his PICC line out earlier, pending new insertion, no IV access at this time”. -2/15/25 at 1:19 p.m., written by LVN B, stated “Picc line placed to Left Upper Arm resident tolerated procedure well no complications or complaints. Pending x-ray results to verify placement to start IV medication.” -2/16/25 at 12:14 p.m., written by RN F, stated “… [Resident #3] continues to be confused and forgetful. Has attempted x1 to remove PICC, was stopped prior to removing bandage, PICC in place, bandage reinforced. He is able to feed himself but continues to try and transfer himself but is unable to stand well even with x2 staff full assist. He removes his clothing, brief and bed sheets/linen repeatedly. No s/s of pain or distress. States . who put me here. Call light within reach, however [Resident #3] does not appear to be able to use it appropriately as indicated by unclipping it and throwing on floor along with everything else. Staff continues to monitor.” -2/16/25 at 7:08 p.m., written by LVN B, stated “Resident continuously found hanging head off the side off the bed and legs/feet bed in lowest position against wall with fall mat in place. Resident pulled blinds completely off window and was trying to eat the pieces he pulled off. Resident cannot use call light or bed remote properly cords found wrapped around his arms.” -2/16/25 at 9:16 p.m., written by LVN B, stated “Notified by cna resident was in bed blood noted on sheets upon assessment midline had been pulled out and resident covered in fresh feces resident noted to be eating feces. ADON notified via text PCP paged. Midline found behind the bed line intact resident arm clean dry no bleeding noted.” -2/16/25 at 9:59 p.m., written by LVN B, stated “resident pulled midline out”. -2/17/25 at 12:58 p.m., written by LVN D, stated “resident threw sweet tea at the window and started to lick it off from it. reoriented resident and offer him a new drink” -2/17/25 at 1:23 p.m., written by LVN D, stated “called hosipital [sic] Atascosa to give report but no answer from the hospital x3” During an interview on 7/10/25 at 1:30 p.m. LVN B stated the couple of times she had worked with Resident #3 he had behaviors of trying to get out of bed, playing with his feces, trying to eat the blinds, and pulling his PICC line. LVN B stated she made the ADON and provider aware of the resident’s status. LVN B stated she was not the nurse who did the admission assessment for Resident #3 and was not aware of what his admission orders were. LVN B stated since then they used an admission check list form to track and communicate new admission orders. During an interview on 7/9/25 at 3:33 p.m. the ADON stated the previous Administrator had reported on 2/14/25 facility failed to notify MD that resident pulled out midline resulting in non-administration of meds. No hold order was obtained; no documentation obtained for monitoring the midline. Resident sent to hospital for assessment to the state. The ADON stated they did not have any investigation reports for this self-report. The ADON stated they had done several in-services over the incident because LVN D never in put the order for the antibiotic on admission. The ADON stated she entered the order herself the on 2/14/25. The ADON stated they also implemented the use of a new check list form since the incident. The ADON stated LVN D no longer worked for the facility and was terminated due to another med error. 3. Record review of Resident #4’s face sheet, dated 7/10/25, revealed a [AGE] year-old male resident admitted on [DATE] and readmitted on [DATE]. with diagnoses of hypo-osmolality and hyponatremia (lower than normal concentrations of solutes leading to low sodium levels in the blood), polydipsia (excessive thirst), and vascular dementia (cognitive impairment resulting from conditions that affect blood flow to the brain) with other behavioral disturbance. Record review of review of Resident #4’s quarterly MDS assessment, dated 6/18/25, revealed he had moderately impaired cognition for daily decision making. Record review of Resident #4’s care plan, revised 4/8/25, stated “I have angry outbursts at times when I don't get the response that I am seeking. I rummage through belongings that are not mine. I layer my clothing and take things that do not belong to me. At times I am observed having auditory and visual hallucinations. Resident to Resident: I pushed another resident and caused skin tears to arm.” Interventions included document behaviors, psych eval and medication review, refer to behavior health as needed, staff to explain care prior to and during process of care, staff to involve family as necessary to assist with behavioral management, and staff to redirect resident to other activities. Record review of Resident #5’s face sheet, dated 7/10/25, revealed an [AGE] year-old made resident admitted on [DATE], readmitted on [DATE], and discharged on 6/5/25 with diagnoses of chronic obstructive pulmonary disease (damage to the lungs leading to swelling and irritation in the airways that restrict airflow), type 2 diabetes (when the body cannot use insulin correctly and sugar builds up in the blood), and vascular dementia with other behavioral disturbances (cognitive impairment resulting from conditions that affect blood flow to the brain). Record review of Resident #5’s significant change MDS assessment, dated 5/6/25, revealed the resident cognition was severely impaired for daily decision making. Record review of Resident #5’s care plan, last revised 6/9/25, revealed the resident had potential for skin related issues related to poor hygiene, decreased mobility, squamous cell carcinoma of skin of scalp and neck (skin cancer), and bullous pemphigoid (rare skin condition that causes large fluid filled blisters), with intervention to provide wound care/ preventative skin care per order, skin checks weekly per facility protocol, document findings, treatment as ordered an x-ray to arm, and wound care consultation to evaluate and treat. Record review on 7/9/25 at 1:55 p.m. revealed an intake was submitted to the state agency reporting Resident #4 shoved Resident #5 on 2/13/25. No provider investigation report was available. During an interview on 7/9/25 at 3:14 p.m. the ADON stated the only documents they had related to this investigation was an in service. The ADON stated the previous Administrator was handling the self-reports. The ADON stated during the altercation Resident #4 pushed Resident #5 with his hands. Resident #5 already had skin tears on his arms that had scabbed over but reopened when he was pushed. The ADON stated the Residents were separated and monitored after. The ADON stated Resident #4 had more health-related issues recently and mostly used a wheelchair to ambulate and was no longer aggressive towards other residents. At the time of the interview Resident #4 was in the hospital for an unrelated health issue. 4. Record review of Resident #6’s face sheet, dated 7/10/25, revealed an [AGE] year-old made resident admitted on [DATE], readmitted on [DATE], with diagnoses of major depressive disorder single episode, legal blindness, anxiety disorder, post-traumatic stress disorder, attention and concentration deficit, and unspecified mood [affective] disorder. Record review of Resident #6’s Annual MDS assessment, dated 6/15/25, revealed the resident cognition was severely impaired for daily decision making. Record review of Resident #6’s care plan, last revised 4/8/25, revealed the “I get nervous and anxious at times. I repeatedly state help me even after staff have attempted to reassure me that I am okay. When asked what is wrong, I typically respond I don't know. I report symptoms of depression (feeling down, little pleasure in doing things, poor concentration, poor appetite, difficulty sleeping, feeling bad about myself) and sometimes relate them to experiences from my past.” Interventions included call resident by name, if upset redirect the conversation or task, offer things that are soothing, and avoid things that make the resident more anxious. Record review on 7/9/25 at 1:55 p.m. revealed an intake was submitted to the state agency reporting Resident #6 reported a staff member struck him in the face with an open hand on 1/31/25. Resident refused to provide a name of the staff member. No provider investigation report was available. During an interview on 7/10/25 at 7:21 p.m. Resident #6 stated something happened about 6 months ago but he did not want to talk about it. Resident #6 stated he felt safe at the facility. Resident #6 then stopped answering question and pursed his lips. During an interview on 7/9/25 at 3:12 p.m. the ADON stated they did not have any investigation reports related to the incident with Resident #6. The ADON stated she did recall they had done resident safe interviews but could not locate them. The ADON stated the resident reported this incident to his behavior health therapist. The ADON stated the resident is blind and provided a physical description of the alleged perpetrator but there was not staff that fit the description. The ADON stated they had the resident listen to staff who worked the day voices, and he denied it was any of those staff members. The ADON stated a full body assessment was done, and the resident had no marks. During a follow up interview on 7/10/25 at 6:09 p.m., the ADON stated she had contacted the former Administrator and was told he left all the facility investigation reports in the current Administrator’s office. The ADON stated the current Administrator was looking for the reports in the office but could not find them and were not made available to the survey team at the time of exit. The ADON was unfamiliar with official reporting requirements to the state. Record review of the facility document titled, Abuse Prevention Program, dated 2022 revealed in part, “…Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to…verbal, mental, sexual or physical abuse…As part of the resident abuse prevention, the administration will…Protect our residents from abuse by anyone including…staff, other residents, or any other individual…Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents…Implement measures to address factors that may lead to abusive situations…Identify and asses all possible incidents of abuse…Investigate and report any allegations of abuse within timeframes as required by federal requirements…”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #3) of 3 residents reviewed for pharmacy services. The facility failed to ensure staff timely acquired and administered Resident #3's cefazolin (antibiotic used to treat and prevent bacterial infections. It is administered intravenously) per physician orders on 2/13/25 and 2/14/25. The failure could place residents at risk for exacerbation of health conditions, worsening of conditions, and physical/emotional discomfort. Findings included:Record review of Resident #3's face sheet, dated 7/9/25, revealed a [AGE] year-old male resident admitted on [DATE] and discharged on 2/17/25 with diagnoses of encounter for surgical aftercare following surgery on the nervous system (his back), partial traumatic amputation of two or more right lesser toes (two toes were surgically removed), type 2 diabetes mellitus with unspecified complications (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood glucose.), intraspinal abscess (collection of pus and infectious material in the spine, often resulting from a bacterial infection) and granuloma (localized area of inflammation that forms around an infection often as a response to the immune system's attempt to clear the infection), depression, osteomyelitis of vertebra- thoracolumbar region (an infection of the vertebrae in the spine), discitis (inflammation or infection that develops between the intervertebral discs of your spine), spondylosis without myelopathy or radiculopathy (degeneration of the vertebral column), schizophrenia (a chronic mental health condition characterized by symptoms of hallucinations (seeing or hearing things that are not there), delusions (false beliefs), disorganized thinking, and difficulty distinguishing reality from imagination.), and methicillin susceptible staphylococcus aureus infection (a type of bacterial infection caused by staphylococcus aureus). Record review of Resident #3'd discharge MDS assessment, dated 2/17/25, revealed the resident memory was severely impaired for daily decision making. Record review of Resident #3's admission and baseline care plan/summary, dated 2/13/25, revealed the Resident had an IV PICC to the left arm and had staples on his back from prior surgery. Record review of Resident #3's comprehensive care plan, dated 7/9/25, revealed he had impaired cognitive function process related to disease process with interventions to monitor/document/report physician changes in cognitive function, specifically changes in: a) decision making ability b) memory, recall and general awareness c) difficulty expressing self d) difficulty understanding others e) level of consciousness f) mental status, and notify the physician with an initiated date of 2/20/25. Record review of Resident #3's physician orders, dated 7/9/25, revealed an order for Cefazolin sodium injection solution reconstituted 2 grams, use 2 grams intravenously three times a day related to methicillin susceptible staphylococcus aureus infection until 5/2/25 to be given three times a day for 11 weeks. The order had a started date of 2/14/25 and an end date of 5/2/25. Record review of Resident #3's February MAR, dated 7/9/25, revealed an order for Cefazolin three times a day between 6 a.m.-10 a.m., 2 p.m.-6p.m., and 6p.m.-10 p.m. The MAR reflected the following administration records: -2/13/25 the 6 p.m.-10 p.m. dose was missed (order not entered until 2/14/25 at 3:15 p.m.)-2/14/25 the 6 a.m.- 10 a.m. dose was missed (order not entered until 2/14/25 at 3:15 p.m.) Record review of Resident #3's hospital #1's discharge paperwork, dated 2/12/25, reveled he needs to be on IV antibiotics 12 weeks followed by long-term oral antibiotics . Record review of Resident #3's hospital #2 admission record, dated 2/17/25, did not reveal much information and only stated AMS altered mental status under the stated complaint. Record review of Resident #3' hospital #3 admission record, dated 2/17/25, stated [Resident #3] . a significant past medical history of: Diabetes mellitus type 2, hypertension, hyperlipidemia, iron deficiency anemia, schizophrenia, infectious disease with osteomyelitis on the right foot toes. Patient who presents as a transferred from the outlying [Hospital 1] for higher level of care due to complaints of altered mental status and worsening of back pain, no history on note and patient is encephalopathy (broad term for any disease or disorder that affects the brain's function or structure. It can result from various causes including infections, toxins, metabolic issues, or lack f oxygen) unable to provide any history.At the initial evaluation the patient appears: confused, hypoxic (inadequate levels of oxygen in the tissues and cells of the body), somnolent (sleepy or drowsy). recommendation will be observation admission for medical management and evaluation.Hx Obtained From Prior medical records. During an interview on 7/10/25 at 1:30 p.m. LVN B stated the couple of times she had worked with Resident #3 he had behaviors of trying to get out of bed, playing with his feces, trying to eat the blinds, and pulling his PICC line. LVN B stated she made the ADON and provider aware of the resident's status. LVN B stated she was not the nurse who did the admission assessment for Resident #3 and was not aware of what his admission orders were. LVN B stated since then they used an admission check list form to track and communicate new admission orders. During an interview on 7/10/25 at 4:20 p.m. The ADON stated LVN D had not put the antibiotic order in when she admitted the resident on 2/13/25 because she needed clarification of the order and was not sure how to administer it. The ADON stated LVN D should have reported to the oncoming nurse LVN B that the order was not put in, but LVN D did not report this to LVN B at shift change. The ADON stated she entered the order herself the on 2/14/25. The ADON stated they also implemented the use of a new check list form since the incident. The ADON stated they had done several in-services over the incident because LVN D never input the order for the antibiotic on admission. The ADON stated LVN D no longer worked for the facility and was terminated due to another med error. The ADON stated the Resident was sent to the hospital on 2/17/25 for altered mental status. During an interview on 7/10/25 at 2:26 p.m. The MD stated he recalled Resident #3 pulled out his PICC line a few times and became more altered. The MD stated he was not able to remember if he was the physician on call that was contacted when the resident pulled out his PICC line and was having behaviors. The MD stated although Resident #3 may have missed a few doses of his antibiotic, that antibiotic had a good half-life (the time it takes a for the concentration of the drug in the bloodstream to decrease by half). The MD stated the resident also had a history of psychiatric disease and was admitted with the infection. The MD stated he did not think missing a few doses of the antibiotic would have contributed to his AMS. The MD stated he could not recall if he was notified of the initial missed doses and only knew of the doses of antibiotics that were missed from the resident pulling his PICC line. During an interview on 7/10/25 at 5:04 p.m. a pharmacist stated the facility ordered the 2 mg IV push of cefazolin on 2/14/25 at 2:41 p.m. and was delivered to the facility just after midnight on 2/15/25. The Pharmacist stated interrupted antibiotic therapy is not a good thing, but you would need to see labs or signs and symptoms to know if the infection had worsened. Record review of the facility's policy titled admission of a Resident, dated 5/16/25, stated Policy: The admission process is intended to obtain all possible information regarding the resident or the development of the comprehensive care plan, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician. Policy explanation and compliance guidelines.b. Once the resident/family had selected the facility, pre-admission information should be gathered. Preadmission information may include, but is not limited to.i. physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 6 residents (Residents #1 and Resident #3) reviewed for medical records. 1. The facility failed to ensure Resident 1's use of a wander guard (electronic monitoring device) was accurately documented on the TAR (Treatment Administration Record). 2. The facility failed to ensure the ADON documented the administration of Resident #3's cefazolin (antibiotic used to treat and prevent bacterial infections. It is administered intravenously.) at the time of administration on the MAR. This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records.The findings included: 1.Record review of Resident #1’s face sheet dated 7/8/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included senile degeneration of brain (age-related deterioration of brain tissue and function), schizoaffective disorder (chronic mental health condition characterized by a combination of hallucinations or delusions and mood), need for assistance with personal care and Alzheimer’s disease (a progressive brain disorder that gradually destroys memory, thinking skills, and the ability to carry out simple tasks). Record review of Resident #1’s most recent comprehensive MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills, required substantial/maximal assistance with transfers, utilized a wheelchair and utilized a wander/elopement alarm. Record review of Resident #1’s comprehensive care plan with revision date 7/8/25 revealed the resident had wandering behaviors and had been seen near exit doors but had a wander guard in place. Review of Resident #1’s comprehensive care plan revealed the resident was at risk for injury related to wandering behavior with interventions that included the use of the wander guard, and when the resident was observed wandering to re-direct to another activity. Record review of Resident #1’s Order Summary Report dated 7/9/25 revealed the following: - Signaling Device: Change electronic monitoring device according to manufacturer's recommendations and as needed if noted non-functional, every shift with order date 6/24/25 and no end date. - Signaling Device: Check electronic monitoring device via testing machine every day, every shift, with order date 4/29/25 and no end date. - Signaling Device: Visually check electronic monitoring device every shift for Elopement risk, with order date 4/29/25 and no end date. - Skin monitoring - Monitor skin at the site of Wander guard device and surrounding area for any redness, bruising, swelling, circulation issues, and/or any breakdown. Report. If Observed Skin Integrity Changes, Notify ADON/DON, Provider, and Change Placement of Wander guard every shift, with order date 6/20/25 and no end date. Record review of Resident #1’s TAR for July 2025 revealed the following: - LVN A documented the resident was visually checked during the 7:00 p.m. to 7:00 a.m. shift on 7/9/25 and documented the resident was wearing the electronic monitoring device on the right upper extremity. - LVN B documented the resident was visually checked during the 7:00 a.m. shift to 7:00 p.m. shift on 7/10/25 and documented the resident was wearing the electronic monitoring device on the right upper extremity. During an observation and interview on 7/9/25 at 8:27 a.m., Resident #1 would not acknowledge or confirm he had used a wander guard. Resident #1 was not observed wearing a wander guard on his person and the wander guard was not seen on the wheelchair he was sitting on. During an observation and interview on 7/10/25 at 10:27 a.m., LVN B stated Resident #1 was not wearing the wander guard because the resident had “ripped it off.” LVN B stated she knew Resident #1 was not wearing the wander guard since last night, 7/9/25 because the night shift nurse, LVN A had given the wander guard to her at shift change. LVN B stated she had marked on Resident #1’s TAR that the resident was seen wearing the wander guard, but stated, “I wasn’t really paying attention, I’ll go back and fix it.” LVN B stated, because she had documented Resident #1 was visually seen wearing the wander guard but was not, was considered false documentation and could have resulted in the resident eloping and nobody knowing about it because he was not wearing the wander guard. An attempt at a telephone interview on 7/10/25 at 10:51 a.m. with LVN A was unsuccessful. During an interview on 7/10/25 at 4:17 p.m., the DON stated, Resident #1 was considered an elopement risk and had to wear a wander guard. The DON stated LVN B should not have documented Resident #1 was wearing the wander guard because it was false documentation. The DON stated since she had only been employed by the facility for less than a month, she had implemented an in-service for the wander guard system due to inconsistencies. The DON stated, in the event the wander guard was not in place, the facility was supposed to be putting the resident on 15-minute checks until the wander guard was replaced. The DON stated, if the nurse documented the resident had the wander guard on when he didn’t, the resident could elope, and nobody would know about it and the resident could get hurt. 2. Record review of Resident #3’s face sheet, dated 7/9/25, revealed a [AGE] year-old male resident admitted on [DATE] and discharged on 2/17/25 with diagnoses of encounter for surgical aftercare following surgery on the nervous system (his back), partial traumatic amputation of two or more right lesser toes (two toes were surgically removed), type 2 diabetes mellitus with unspecified complications (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood glucose.), intraspinal abscess (collection of pus and infectious material in the spine, often resulting from a bacterial infection) and granuloma (localized area of inflammation that forms around an infection often as a response to the immune system’s attempt to clear the infection), depression, osteomyelitis of vertebra- thoracolumbar region (an infection of the vertebrae in the spine), discitis (inflammation or infection that develops between the intervertebral discs of your spine), spondylosis without myelopathy or radiculopathy (degeneration of the vertebral column), schizophrenia (a chronic mental health condition characterized by symptoms of hallucinations (seeing or hearing things that are not there), delusions (false beliefs), disorganized thinking, and difficulty distinguishing reality from imagination.), and methicillin susceptible staphylococcus aureus infection (a type of bacterial infection caused by staphylococcus aureus). Record review of Resident #3’d discharge MDS assessment, dated 2/17/25, revealed the resident memory was severely impaired for daily decision making. Record review of Resident #3’s admission and baseline care plan/summary, dated 2/13/25, revealed the Resident had an IV PICC to the left arm and had staples on his back from prior surgery. Record review of Resident #3’s comprehensive care plan, dated 7/9/25, revealed he had impaired cognitive function process related to disease process with interventions to monitor/document/report physician changes in cognitive function, specifically changes in: a) decision making ability b) memory, recall and general awareness c) difficulty expressing self d) difficulty understanding others e) level of consciousness f) mental status, and notify the physician with an initiated date of 2/20/25. Record review of Resident #3’s physician orders, dated 7/9/25, revealed an order for Cefazolin sodium injection solution reconstituted 2 grams, use 2 grams intravenously three times a day related to methicillin susceptible staphylococcus aureus infection until 5/2/25 to be given three times a day for 11 weeks. The order had a started date of 2/14/25 and an end date of 5/2/25. Record review of Resident #3’s February MAR, dated 7/9/25, revealed an order for Cefazolin three times a day. The MAR reflected there was no documentation for the administrator of the medication on 2/14/25 for the 2:00 p.m.- 6:00 p.m. dose. Record review of nursing progress notes, dated 7/9/25 revealed a note written by the ADON on 2/17/25 at 6:18 p.m. for 2/14/25 at 3:16 p.m. which stated “cefazolin 2g given over 5 min slow push in L brachial via midline, flushed with 10 mlns [sic] slow push”. During an interview on 7/10/25 at 1:30 p.m. LVN B stated she was not the nurse who did the admission assessment for Resident #3 and was not aware of what his admission orders were. LVN B stated since then the facility implemented the use of an admission check list form to track and communicate new admission orders. During an interview on 7/9/25 at 3:33 p.m. the ADON stated she entered the order herself the on 2/14/25. The ADON stated she discovered on 2/14/25 that LVN D had not input the order for the resident’s IV antibiotic. The ADON stated LVN D told her she had questions about the order and the administration of the medication. The ADON stated she put the order in and ordered the antibiotic from the pharmacy. The ADON stated she then went to the automated medication dispensing system, pulled the medication from their back up supply, and administered it. The ADON stated she forgot to document the medication had been at administered on 2/14/25 at 3:16 p.m. The ADON stated she documented it on 2/17/25 at 6:18 p.m. in a nursing note. The ADON stated she should have documented on the MAR at the time she administered the medication as proof she gave it. The ADON stated if you do not document at the time of administration the resident could receive a 2nd dose from another nurse who was not aware the resident already received the medication. Record review of the facility’s policy titled “Resident Alarms”, dated 6/10/25, stated “it is the policy of this facility to utilize resident alarms in limited circumstances, in accordance with resident needs, goals, and preferences, so the resident would be able to attain his or her highest practical level of physical, mental, and psychosocial well-being… policy explanation and compliance guidelines: 1. The use of alarms does not eliminate the need for adequate supervision of the resident. Types of alarms include…e. Wander/ elopement alarms- includes devices such as bracelets, pins/ buttons worn on the resident’s clothing, sensors in the shoes, or building/unit exit sensors worn/attached to residents that alert the staff when residents nears or exits an area or the building. This includes devices that are attached to the residence assisted devices…6. Monitoring and modification…b. when alarms are utilized, additional monitoring shall be provided, including but not limited to: i. Verifying alarms are used in accordance with the resident’s care plan. ii. Verifying alarms are working properly at least once per shift, per facility protocol…” Record review of the facility’s policy titled “Medication Administration”, dated 5/7/25, stated “…Policy Explanation and Compliance Guidelines…11. Review MAR to identify medication to be administered. 12. Compare medication source…with MAR to verify resident name, medication name, form, dose, route, and time .17. Administer medication as ordered in accordance with manufacturer specifications…20. Sign MAR after administered. For those medications requiring vital signs, record vital signs onto the MAR…”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 2 of 9 residents (Resident #1 and #2) reviewed for documentation. Resident #1's and Resident #2's electronic medical record did not contain complete and accurate documentation that CNA A (night shift) and CNA B (day shift) recorded in the March 2025 POC (records system) that both residents were given peri-care on 3/17/25 (night) and 3/18/25 (day). This failure could result in residents' records not accurately documenting interventions, monitoring, and information provided to the charge nurse or DON involving shift documentation of peri-care given to residents. The findings included: Record review of Resident #1's face sheet, dated 3/24/25, reflected resident was a female age [AGE] admitted on [DATE] with diagnoses that included: schizoid affective (a mental health condition that includes symptoms both schizophrenia and mood disorders), gerd (a chronic disease that occurs when stomach acid or bile flows into the food pipe and irritates the lining), and epilepsy (a seizure disorder). The RP was listed as a family member. Record review of Resident #1's quarterly MDS dated [DATE] reflected that the resident's BIMS score was 3 (severely impaired in cognition). Section GG reflected the resident required extensive assistance for toileting by one staff member because the resident was incontinent of bowel and bladder (section H). Record review of Resident #1's skin assessment dated [DATE] reflected that resident had excess moisture to abdominal folds. Record review of Resident #1's CP, undated, reflected in toileting the resident required substantial/maximal assistance. Record review of Resident #1's Nurse Notes dated from 3/17/25 to 3/18/25 did not reflect that the resident refused incontinent care. Record review of Resident #1's POC for peri-care dated March 2025 reflected peri-care given every shift and documented; except on 3/17/25 (night shift) and 3/18/25 (day shift) not documented by CNA A and CNA B. Observation and interview on 3/21/25 at 4:40 PM, Resident #1 was sitting in a W/C (wheelchair) in the hall, verbally vocal. There were no injuries, skin tears or bruises present. The resident's mental state was one of verbal aggression. The resident was alert and oriented to person only. Resident #1 stated, .I can reach my call light .they take too long to respond .left wet sometimes .no skin breakdown or skin [concerns]. During an interview on 3/24/25 at 11:24 AM, RN C stated: the Resident #1's refusal of care could explain the redness to the abdominal folds on the last skin assessment (3/17/25). RN C stated, no evidence existed that staff (CNA A and CNA B) refused to provide the resident with peri-care. However, RN stated that documentation was not present on 3/17/25 (night shift: 7:00 PM to 7:00 AM) and 3/18/25 (day shift (7:00 AM-7:00 PM) that resident refused peri-care or that peri-care was given. RN C stated that documentation needed to exist to back-up that refusal was made by the resident; or that peri-care was not necessary. RN C stated that documentation was necessary for continuity of care between shifts. During telephone interview on 3/24/25 at 11:30 AM, CNA A stated that she forgot to document on 3/18/25 that peri-care was given to both Resident #1 and Resident #2 because she was too involved with other residents. CNA A stated documentation was important in POC so as to show that services were given to the residents. During telephone interview on 3/24/25 at 2:05 PM, CNA B (night shift 7:00 AM to 7:00 PM) stated peri-care was given to both Resident #1 and Resident #2, but documentation was not done because she was involved in getting residents ready for the breakfast meal. CNA B stated documentation was required to show that services were given. During an interview on 3/24/25 at 1:40 PM, the ADON stated CNAs were required to document peri-care to serve as evidence that the service was given. Also, the ADON stated documentation was needed as a means of communications between shifts and evidence of continuity of care. The ADON stated that she could not provide an explanation for the lack of documentation for Resident #1 and Resident #2 on 3/17/25 and 3/18/25. Record review of Resident #2' face sheet, dated 3/24/25, reflected resident was a male age [AGE] re-admitted on [DATE] with diagnoses that included: cerebral palsy (a group of disorders that affect movement, muscle tone and coordination due to damage to the developing brain), post-polio (a condition that causes gradual muscle weakness and muscle atrophy), and dementia (memory loss). The RP was listed as a family member. Record review or Resident #2's quarterly MDS dated [DATE], reflected the resident's BIMS score was 5 (severely impaired in cognition). In the area of toileting the resident required substantial/maximum assistance by one nursing staff. Record review of Resident #2's CP, undated, in the ADL section for toileting reflected substantial/maximum assistance. Record review of Resident #2's skin assessment dated [DATE] reflected, pinkness on the left ankle. Record Review of Resident #2's POC for March 2025 reflected: no documentation for 3/17/25 (night) and 3/18/25 (morning) involving peri-care. Observation and interview on 3/21/25 at 4:48 PM, Resident #2 was sitting on a W/C being prepared for the dinner meal. Resident was impaired to upper and lower extremities. The resident had difficulty in speech. There were no injuries, skin tears or bruises present. Mental status was one of happiness. The resident was alert and oriented to person only. The Resident stated, .call light works .yes, they come [to provide peri-care] .yes, [not left soiled]. Record review of facility's policy titled Charting and Documentation, dated revised July 2017, read: All services provided to the resident .shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to offer a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 1 (Resident #6) of 1 residents reviewed for diets. The facility failed to provide Resident #6 with large protein portions as ordered by his physician. This failure could affect all residents on therapeutic diets by placing them at increased risk for significant weight loss and malnutrition. Findings include: Record review of Resident #6's face sheet, dated 10/03/2024, revealed resident was a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #6's order summary dated 10/03/2024 revealed Resident #6 was ordered large protein portions at all meals starting 09/06/2024. Record review of Resident #6's Nutritional Assessment, dated 09/04/2024, revealed Resident #6 was under his IBW (ideal body weight). Section 8 Summary stated, Change diet to Regular with large protein portions at meals. Observation of Resident #6 on 10/01/2024 at 12:14 PM revealed resident was eating his lunch. Resident #6 received a slice of meatloaf, potatoes and peas. Resident #6 did not have a large portion of protein. Observation of lunch service in the kitchen on 10/03/2024 at 12:03 PM revealed Dietary Manager making Resident #6 a sandwich for lunch. Dietary Manager made a turkey sandwich using two slices of turkey, lettuce and tomato. Observation of Resident #6 on 10/03/2024 at 12:38 PM revealed resident was eating his sandwich. Resident #6 did not have large portion of protein on his sandwich. Interview with Dietary Manager on 10/03/2024 at 12:14 pm revealed she was unaware that Resident #6's diet changed. Dietary Manager stated the nurses are responsible to inform the kitchen staff when a resident's diet changes and then she updated the resident's dietary card. Dietary Manager stated if residents did not receive the therapeutic diets as ordered it could put them at risk for losing weight. Interview with Resident #6 on 10/03/2024 at 12:38 PM revealed resident had not received large protein portions at meals since being in the facility. Resident #6 stated he likes the food and tends to eat as much as he could at mealtimes. Interview with DON on 10/04/2024 at 2:05 PM revealed nursing staff update diet orders in the residents' medical records and communicate changes to the kitchen staff. DON was unable to say why Resident #6 had not received large protein portions. DON stated if a resident does not get the prescribed therapeutic diet they would be at risk for further weight loss or malnutrition. Record review of facility policy titled Interdepartmental Notification of Diet (Including Changes and Reports) dated October 2017, revealed 1. When a new resident is admitted , or a diet has been changed, the nurse supervisor shall ensure that the food and nutrition services department receives a written notice of the diet order. 2. The food and nutrition services department will be notified verbally if the diet change or report occurs one hour or less before a scheduled meal, or if circumstances indicate that the written procedures will not be adequate to ensure service at the next meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (the Treatment Cart) reviewed for medication storage, in that; The facility failed to ensure the Treatment Cart was locked when it was left unattended in the common area in front of the nurses' station, and then again left unlocked and unattended in the 200-hallway opposite of room [ROOM NUMBER]. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings were: In an observation on 10/03/2024 at 10:46 AM, the Treatment Cart was left unlocked and unattended in the common area in front of the nurse's station. The cart contained scissors, prescription and over the counter medications related to skin and wound care. There were staff, residents, and visitors in the immediate vicinity. In an interview on 10/03/2024 at 10:47 AM, RN A stated the Treatment Cart was her responsibility. RN A stated the Treatment Cart should not be left unlocked when not in use. RN A stated she had been trained not to leave it unlocked when not attended. RN A stated that the Treatment Cart had been unlocked and unattended just while I stepped into the DON's office to pick up some print outs. RN A stated she was unsure off the top of her head if any of the items in the Treatment Cart could cause harm if used inappropriately. RN A stated that she believed some risk of harm was always possible. In an observation on 10/03/2024 at 10:52 AM, the Treatment Cart was left unlocked and unattended in the 200-hallway opposite of room [ROOM NUMBER]. The cart contained scissors, prescription and over the counter medications related to skin and wound care. There were staff, residents, and visitors in the immediate vicinity. Specifically, an unidentified resident could be seen pacing in the hallway near where the Treatment cart was parked during the provision of resident care. The drawers were facing out in to the 200-hallway. In an interview on 10/03/2024 at 11:22 AM, RN A stated that she could not believe she had left the Treatment Cart unlocked again. RN A stated that she had only been working at the facility for about a week and had not ever been through a SA survey and was very nervous. RN A stated she had mistakenly left the Treatment Cart unlocked when she stepped into room [ROOM NUMBER] to begin a procedure that was being observed by a SA surveyor. In an interview on 10/03/2024 at 1:50 PM, the DON stated that she had her eyes on the cart through the window when it was at the nurses' station, when RN A was in her office at the printer. The DON stated she did not believe the Treatment Cart should be considered unattended when it was left unlocked at the nurses' station because she could see it from where she sat in the DON office. The DON conceded that she did not intervene before the drawers on the Medication Cart were opened and assessed by this SA surveyor. The DON inquired if the cart drawers opened into the room when the Medication Cart was observed for a second time unlocked and unattended in the 200-hallway opposite of room [ROOM NUMBER]. The DON stated that if the drawers were facing into a resident's room while the nurse was working in that room, that would be acceptable. [This SA surveyor explained that the drawers were accessible and facing out in the 200-hallway in the above observation.] Record review of the facility policy entitled Medication Labeling and Storage, revised February 2023, reflected under the heading Medication Storage 4.) Compartments .including carts . are locked when not in use .are not left unattended if open or otherwise potentially available to others. Record review of the undated facility policy entitled Administering Medications, reflected in step 17.) .During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Review of Lippincott procedures entitled Medication Delivery Acceptance: Long Term Care, reviewed 5/19/2024, accessed from https://procedures.lww.com/lnp/view.do?pId=4420028&hits=care,long,term&a=false&ad=false&q=long%20term%20care, accessed on 10/04/2024, reflected under the heading Implementation, subheading Ordering and Receiving Regular Medications, Place the delivered medication in a locked cart, cabinet, or room as designated by your facility. Review of Lippincott procedures entitled Oral drug Administration, reviewed 5/19/2024, accessed from https://procedures.lww.com/lnp/view.do?pId=4420477, accessed on 10/04/2024, reflected, under the heading Reducing Medication Risk in an Older Adult, Store medications in a secure, dry location, away from sunlight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #12) with wounds observed for infection control, in that: The facility failed to ensure hand hygiene was initiated between glove changes during wound care for Resident #12 on 10/03/2024. This deficient practice could affect residents who required wound care by contributing to the bacteria load and/or cross contamination in the wound resulting in delayed healing. Findings included: Record review of admission Record printed 10/03/2024, reflected Resident #12 was a [AGE] year-old female originally admitted on [DATE]. Record review of Diagnosis Report, printed 10/03/2024, reflected Gastrostomy Status was the admitting diagnosis for Resident #12. Other active diagnoses included Stage 4 pressure injury [full thickness tissue loss with exposed underlying tissue (such as bone, tendon, or muscle], slough or eschar [collection of dry, dead tissue within a wound] may be present, and often includes undermining and tunneling] of right buttock with an onset of 11/20/2023. Record review of Progress Note dated 11/28/2023 at 5:00 AM, reflected that Resident #12 had returned from hospitalization with new, stage 4 pressure injury to right buttock and had a wound vacuum in place upon arrival to the facility. Record review of the quarterly MDS assessment, dated 9/26/2024, reflected Resident #12 had a BIMS summary score of 11, indicative of moderate cognitive impairment. Under section M - Skin Conditions, Resident #12 was coded as having a pressure injury, considered unhealed, and at stage 4. Record review of the Care Plan reflected Resident #12 had a focus area of pressure injury with a revision date of 08/07/2024; with the following associated interventions: follow facility policies/protocols for the prevention/treatment of skin breakdown, initiated 12/13/2020. Record review of Order Details, printed 10/03/2024 at 12:19 PM, reflected Resident #12 had physician orders to perform wound care 4 times per day and as needed to stage 4 pressure injury to right buttock with an order date of 9/27/2024. Record review of Weekly Wound Review dated 9/27/2024 reflected Resident #12 had a pressure injury on the right buttock measuring 0.5 centimeters length by 0.4 centimeters width and a depth of 0.3 centimeters, considered a stage 4, with undermining 0.5 centimeters on the 12 to 6 o'clock directional. In an observation and interview on 10/03/24 at 10:47 AM, RN A performed wound care on Resident # 12 with CNA B present to assist in positioning. RN A failed to sanitize hands after removing gloves prior to donning clean gloves. RN A stated she did not realize she did not use an alcohol-based hand sanitizer prior to donning clean gloves for the next step in the wound care procedure. RN A stated that she should have used an alcohol-based hand sanitizer after discarding her gloves. RN A stopped the process to go wash her hands at the sink in the resident's restroom and obtain additional supplies needed for the continuation of the wound care procedure. RN A stated she was nervous due to being a new employee at the facility, and her experience was in the acute care setting not in long term care. RN A stated that she had been trained both in nursing school, and at this facility that hands must be either washed or use hand sanitizer after removing gloves. RN A then used an alcohol-based hand sanitizer before donning clean gloves to resume the wound care procedure. Record review of undated Handwashing/Hand Hygiene Policy, reflected under the implementation section in step 7.) Use an alcohol-based hand rub .After removing gloves. Under the applying and removing gloves section, the final step included: Perform hand hygiene. Review of CDC Clean Hands web page, dated 02/27/2024, entitled Clinical Safety: Hand Hygiene for Healthcare Workers, accessed from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, accessed on 10/07/2024, reflected, under the subheading Know when to clean your hands, immediately after glove removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 residents (Resident #5) reviewed for infection control, in that: While providing incontinent care for Resident #5 CNA A did not wash or sanitize her hands between change of gloves, before touching the resident's briefs and after cleaning the resident's buttocks' area. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: Record review of Resident #5's face sheet, dated 01/05/2024, revealed a [AGE] year old female resident with an admission date of 09/19/2023, with diagnoses which included: Encephalopathy (disorder or disease of the brain), History of urinary tract infection (an infection in any part of the urinary system), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Alcohol abuse (unhealthy drinking behavior). Record review of Resident #5's Quarterly MDS, dated [DATE] revealed Resident #5 had a BIMS score of 5, indicating severe cognitive impairment. Resident #5 was coded as always incontinent of bowel and bladder. Record review of Resident #5's Optional State assessment MDS revealed Resident #5 needed extensive assistance with her activities of daily living. Review of Resident #5's care plan, dated 09/19/2023, revealed a problem of FUNCTIONING DEFICIT- I have physical functioning deficit related to: Dx: Encephalopathy/, with an intervention of Toileting assistance of one. Observation on 01/05/2024 at 9:19 a.m. revealed while providing incontinent care for Resident #5, CNA A cleaned Resident #5's buttocks, changed her gloves, then placed a clean brief on the resident. CNA A did not wash or sanitize her hands, between change of gloves, before touching the clean briefs and fastening the briefs to the resident. During an interview with CNA A on 01/05/2024 at 9:25 a.m., CNA A verbally confirmed she did not wash or sanitize her hands, between change of gloves, before touching the clean brief and fastening the brief to the resident. CNA A confirmed she should have wash or sanitize her hands prior to placing the new brief on Resident #5. She confirmed the staff received infection control training regularly. During an interview with the ADON on 01/05/2024 at 9:46 a.m., the ADON confirmed the CNA should have washed or sanitize her hands, between change of gloves and, prior to placing the clean brief under the resident to prevent risk of cross contamination and prevent infection for the resident. She confirmed the staff received infection control training frequently and their skills were checked yearly. The ADON revealed she was doing spot checks weekly to check the skills of the staff. Review of CNA A's CNA proficiency audit , dated 09/27/2023 revealed CNA A met proficiency for incontinent care. Review of facility's policy, titled Perineal care, dated February 2018, revealed 8.m. Wash hands rinse rectal area [ .], n, dry area [ .], 9. Discard disposable items into designated containers., 10. remove gloves and discard into designated containers, 11. wash and dry your hands thoroughly. Review of Guidelines for Hand Hygiene in Healthcare Settings Published 2002 [PDF - 496 KB]; 29-30.Indications for, and limitations of, glove use. · Hand contamination may occur as a result of small, undetected holes in examination gloves (321,361) · Contamination may occur during glove removal (50) · Wearing gloves does not replace the need for hand hygiene (58) · Failure to remove gloves after caring for a patient may lead to transmission of microorganisms from one patient to another (373).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 1 of 16 residents (Resident #14) reviewed for resident rights, in that: Residents #14 was told they could not lay down at the living area table to sleep and was told to go sleep in her room. This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth. The findings included: Record review of Resident #14's face sheet, dated 09/08/2023, reflected a [AGE] year-old female most recently admitted to the facility on [DATE] with a primary diagnosis of schizoaffective disorder, unspecified(A mental health condition including schizophrenia and mood disorder symptoms.) Record review of Resident #14's quarterly MDS, dated [DATE], revealed the BIMS to be incomplete, however question C1000 - Cognitive Skills for Daily Decision Making was marked as 2 - Moderately Impaired, Decisions poor, cues/supervision required. Record review of Resident #14's comprehensive person-centered care plan, dated 08/10/2023 as last care plan review completed, reflected a goal area of MOOD - I have a mood problem [refer to] schizoaffective disorder, mood disorder, [Major Depressive Disorder], and anxiety disorder. The associated intervention reflected Observe/record/report to [medical director] [as needed] acute episode feelings or sadness . change in sleep patterns. Record review of the PIR dated 08/14/2023 reflected Resident #14 and #10 were observed to be the targets of foul language and hand gestures by LVN C as witnessed by CNA D, CNA E, and CNA F. The PIR further reflected that LVN C was suspended during the investigation with psychosocial assessments completed of Residents #14 and #10, with the final conclusion to be Unfounded due to inconsistencies found with dates and times. Record review of LVN C's letter following the allegation dated 08/14/2023 reflected Regarding allegations made against me: That I used foul language towards my resident's I would never outloud curse at any of my residents. Totally inappropriate and unprofessional. I'm not perfect! I can't say a word or 2 might have slipped before but never towards residents. I had told a certain someone he didn't have to sit at door watching. That she will be back later today. In-turn he flipped me off. I then went to nurse's station and behind the counter I just flipped my wrist to inform CN of on goings. Interview on 09/05/2023 at 2:09 PM, the ADM reported the incident on 08/14/2023 and described the incident as the morning of 08/14/2023 was observed by CNA's D, E, and F to tell Resident #14 to sleep in her bedroom and not at the common area table. The ADM stated the investigation did not result in a finding due to the [CNA's] telling me [ADM] different days and times or have the same details. Attempted interview on 09/05/2023 at 11:29 AM and again on 09/06/2023 at 9:31 AM with Resident #14 having refused to answer questions. Attempted phone interview on 09/08/2023 at 6:38 PM with CNA E without answer to the phone call. Interview on 09/08/2023 at 6:40 PM, CNA D stated she recalled LVN C telling Resident #14 to go to sleep in her room after sitting in the living area. CNA D stated she reported to the ADM having seen LVN C instructing Resident #14 to sleep in her room. Interview on 09/08/2023 at 6:56 PM, LVN C stated she worked the overnight shift from 11:00 PM to 7:00 AM but would sometimes work double shifts and saw Resident #14 tended to sleep at the living area tables during her shift. LVN C stated Resident #14 will salivate on the table and LVN C will have to clean the tables 6-7 times during her shift. LVN C stated having to clean the tables several times throughout her shift was an inconvenience to her and thus told Resident #14 to sleep in her room instead. LVN C stated she corresponded with the ADM about Resident #14 sleeping on the living area tables outside of her bed and was told by the ADM to let her sleep where she would like as it was her right to do so. LVN C continued to state that residents who were non-compliant [with their care plans] need to be on DNR's. LVN C stated during her shift, positioning residents out of their rooms was important to her as I prefer the residents to stay in the same place as that was easier. Interview on 09/08/2023 at 7:31 PM, the ADM stated LVN C did not describe the incident previously as she did to the survey team. The ADM stated the depiction of the allegations by LVN C to the survey team was concerning and intended to suspend LVN C to complete an additional investigation. The ADM stated as the abuse coordinator, her intent was to protect the residents and not allow Resident #14 to be told where she can sleep. The ADM stated her expectation was that residents were able to exercise their rights regardless of whether it inconvenienced the staff. Interview on 09/08/2023 at 8:06 PM, CNA F stated she used to work the 7:00 AM - 3:00 PM shift from February 2023 until August of 2023. CNA F stated during a morning shift taking over after a weekend overnight shift, she observed LVN C tell Resident #14 to sleep in her room and then moved Resident #14's wheelchair to her room without asking Resident #14. CNA F stated during instance, she also observed LVN C to use profanity openly at the nurse's station without a subject. CNA F stated she reported these allegations to the previous DON which was followed by an investigation taking place by the ADM where LVN C was suspended for a single day during the investigation. CNA F stated she did not remember being a part of a in-service related to the incident or abuse and neglect. Record review of the facility policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revision date April 2021 reflected in part, .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior for 2 of 16 residents (#19 and #24) reviewed for housekeeping and maintenance services in that: 1. Resident #19's had flies in his room. 2. Resident #24's floor, bed, and in room ac unit had debris. Flies were present in the room. An empty dignity bag was hanging from the bed touching the floor with debris around it for 3 days. These failures could place residents at risk of living with unclean, uncomfortable, un-homelike rooms and a diminished quality of life. The findings were: 1. Record review of Resident #24's facesheet, dated 09/07/23, revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. He had diagnoses which included unspecified protein-calorie malnutrition, chronic obstructive pulmonary disease, and type 2 diabetes mellitus with unspecified complications. Record review or Resident #24's quarterly MDS assessment 06/25/23 revealed a BIMS score of 9 which indicated moderate cognitive impairment. Record review of Resident #24's care plan, dated 9/7/2023, revealed behavior symptoms I prefer to use chewing tobacco while in bed. I use bottles to spit it into but frequently miss and drop some on my bed and floor. I also prefer to keep old chewed up gum in a bottle on my bedside table. During observation and interview on 09/05/23 beginning at 11:23 a.m. revealed Resident #24 resided in the 400 hallway and was laying in his bed. The resident's bed and clothes had an unknown dark debris all over, brown stains, and food crumbs. The Resident stated the crumbs and dirt on his bed did not bother him. Flies were in the room and landed on the Residents face during the interview. The room had an ac unit with different color debris caked on the vent area. The Resident stated he used the ac unit sometimes. An empty catheter dignity bag was hanging from the bed and touching the floor with debris all around it. During an observation and interview on 09/07/23 beginning at 9:58 a.m. a empty catheter bag was hanging from Resident #24's bed, touching the floor, with dirt all over the floor. A piece of baseboard had fallen off the wall and way laying on the floor. The Residents bed was with yellow and red stains. The Resident stated his bed felt dirty and nasty, but he was comfortable. The resident stated they changed his sheet last Tuesday when he had a shower. During an interview on 09/07/23 at 9:52 a.m. CNA D stated Resident #24's bed was dirty with tobacco. CNA D brushed the debris off the resident's bed with her hands. CNA D stated staff had a program they can use to report issues with the residents' room, and they can call for housekeeping if the room was dirty. CNA D stated in the past she reported issues with the resident's door, bed, and blinds. During an interview on 09/07/23 at 10:22 a.m. LVN C stated the dignity bag should not be there. LVN C removed the bag. LVN C kicked the debris around on the floor with her foot and stated it was dirt and crumbs. LVN C stated the floor looked like it needed to be swept. 2. During an observation and interview on 09/05/23 beginning at 3:13 p.m. Resident #19 was in his room on the 400 hallway. Flies were observed flying around the resident's room. The Resident stated there are many flies in the building and they bothered him. The Resident stated staff cleaned his floors once a week. During an interview on 09/07/23 at 1:34 p.m. housekeeping supervisor stated they had some staff out and he was helping clean the rooms. The housekeeping supervisor stated the resident rooms get swept and mopped once a day. The housekeeping supervisor stated some residents required more attention throughout the day. The housekeeping supervisor stated he forgot to clean Resident #24's room that morning but had gone back and cleaned it. The housekeeping supervisor stated the workload was manageable and they did not need extra help. The housekeeping supervisor stated other staff was assigned to the room the previous two days and it looked like they were not paying attention to the bottom of the beds and cleaned around the dignity bag on the floor. The housekeeping supervisor stated maintenance was responsible for cleaning the ac unit in the room and the resident was throwing his tobacco all over the room and into the ac unit. The housekeeping supervisor stated Resident #24 needed extra attention every 3 hours or so because he threw snuff on the floor. The housekeeping supervisor stated he went in to discard the extra bottles on the resident's bedside table, but the resident declined for them to be removed. The housekeeping supervisor stated the resident preferred to keep items on his bedside table but Resident #24 did not bother staff when cleaning the room. During an interview on 09/08/23 at 5:26 p.m. the ADON stated they have a program to report issues in the residents' rooms and staff can also alert the charge nurse. The ADON stated the rooms are cleaned daily and they have a schedule for deep cleaning rooms. The ADON stated if the residents' room was messy, it should be cleaned daily. During an interview on 09/08/23 at 5:56 p.m. the clinical nurse stated it was everyone's responsibility to keep residents' rooms clean. She stated Resident #24 preferred to keep the items on his bedside table and the resident room being dirty could be uncomfortable for him. During an interview on 09/08/23 at 6:15 p.m. the Administrator stated staff cleaned the floors in resident rooms daily. The Administrator stated Resident #24 preferred to leave his cups on his bedside table. She stated staff should have noticed the dignity bag and dirt on the floor in the three days it was there. She stated while the resident did not want staff to touch items on his bedside table, she has never known him to be resistant to staff cleaning the rest of his room. The Administrator stated the housekeeping supervisor was not usually on the floor cleaning the resident's rooms and was normally in charge of the laundry room. She stated she would get with the supervisor to see if they needed more help, complete an in service on cleaning, a demonstration, and audits. She stated the housekeeping supervisor performed the audits, did his own audits, and if there was a resident room that they identified as filthy they should go back more than daily. Record review of the facility's policy titled Homelike Environment, dated 02/21, stated Policy statement: Residents are provided with a safe, clean, comfortable and home like environment and encouraged to use their personal belongings to the extent possible. Policy interpretation and Implementation: 1. staff provides person centered care that emphasizes the residents comfort, independent and personal needs and preferences. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. clean, sanitary and orderly environment .

**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 is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #24) reviewed for incontinence/perineal care, in that: CNA D did not clean the urethral meatus or glans when providing peri care and catheter care to resident #24 and failed to sanitize her hands in between glove changes. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #24's face sheet, dated 09/07/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia without lower urinary tract symptoms (non-cancerous condition in men in which the prostate gland was enlarged causing blockage of urine flow out of the bladder), neuromuscular dysfunction of bladder (injury or disorder of the brain, spinal cord, or nerves. The condition can lead to voiding difficulties, such as urinating too often or at the wrong time, or being unable to completely empty the bladder), and type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy). Record review of Resident #24's most recent admission MDS assessment, dated 6/25/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and was always incontinent of bowel and had an indwelling catheter. Record review of Resident #24's comprehensive care plan, review date 7/7/23 revealed the resident had bowel and bladder incontinence related to prostate enlargement and loss of control with interventions that included to check the resident as required for incontinence and to wash, rinse and dry perineum. Observation on 8/24/23 at 10:07 a.m., during incontinence/perineal care, CNA D cleaned Resident #24's perineum area and scrotum. CNA D did not cleanse around the meatus (opening of the male urethra that's located at the very tip of the penis) or the glans (tip or head of penis). CNA D then grabbed a new wipe cleaned the catheter tubing from the insertion site outwards. CNA D removed her gloves and put on new gloves with no hand hygiene and continued peri care cleaning the resident's buttocks area. During an interview on 09/07/23 at 10:03 a.m. CNA D was asked by this surveyor when she should be performing hand hygiene. CNA D stated she changes her gloves every time they are dirty and performs hand hygiene every time, she touches a Resident with her hands. CNA D stated she normally keeps hand sanitizer in her pocket but forgot it that morning. CNA D stated she did not clean her hands between glove changes. CNA D stated she did clean Resident #24's penis. During an interview on 09/08/23 at 6:02 p.m. the Clinical Nurse stated staff was expected to sanitize their hands between glove changes to prevent infections. Record review of the Facility's document titled Catheter Care, Urinary, dated 08/2022, stated Purpose: The purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections .14. For a male resident: a. use a washcloth with warm water and soap to cleanse around the meatus. B. cleanse the glands using circular strokes from the meatus outward. C. Change the position of the washcloth or white with each cleansing stroke. D. with a clean washcloth or white rinse using the above technique. E. return foreskin into normal position.

Based on observation, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1 of 5 aides (CNA D) reviewed for demonstration of skills and techniques necessary for residents' needs, in that: The facility failed to ensure nurse aide competency assessments for CNA D, reviewed, were completed, documented, and checked off. These failures could place residents at risk for not receiving the appropriate care and services to maintain their health and safety. The findings included: 1. Observation on 8/24/23 at 10:07 a.m., during incontinence/perineal care, CNA D cleaned Resident #24's perineum area and scrotum. CNA D did not cleanse around the meatus (opening of the male urethra that's located at the very tip of the penis) or the glans (tip or head of penis). CNA D then grabbed a new wipe cleaned the catheter tubing from the insertion site outwards. CNA D removed her gloves and put on new gloves with no hand hygiene and continued peri care cleaning the resident's buttocks area. During an interview on 09/07/23 at 10:03 a.m. CNA D was asked by this surveyor when she should be performing hand hygiene. CNA D stated she changes her gloves every time they are dirty and performs hand hygiene every time, she touches a Resident with her hands. CNA D stated she normally keeps hand sanitizer in her pocket but forgot it that morning. CNA D stated she did not clean her hands between glove changes. CNA D stated she did clean Resident #24's penis. During an interview on 09/08/23 at 6:02 p.m. the Clinical Nurse stated staff was expected to sanitize their hands between glove changes to prevent infections. Record review of facility's document titled Employee Orientation checklist, General dated 12/09, revealed CNA D was hired on 05/31/23, Orientation began on 05/31/23-06/03/23. The document further revealed CNA D was checked off on 05/31, 06/01, and 06/04/23 for the following subjects: abuse recording ethnic background screening investigations, the confidentiality of residence information, departmental policies, disaster preparedness, dress code, employee health program, evacuation procedures, explanation of fire alarm systems, fire safety, hazards communication program, hepatitis B vaccination, infection control, introduction to department directors, job description, lifting/ moving residents, meal and break periods, personal policies, reporting accidents/ incidents, resident abuse, resident rights, safety program, smoking regulations, standards passions, training classes healthcare Academy, tour of facility, QAPI, work hours, coffee, aids/HIV. Record review of CNA D's staff records revealed CNA D had no documentation for nurse aide skills check off during orientation on 05/31/23-06/03/23. During an interview on 09/08/23 at 6:55 p.m. the Clinical Nurse stated they did not have any documentation that showed CNA D had been trained and checked off on catheter or peri care skills. The Clinical nurse stated the ADON and DON are responsible for ensuring staff was trained on nurse aide skills during orientation. She stated they had no documentation for training or in services for CNA D related to hand hygiene, catheter care, or peri care. She stated CNA B was one staff who did train CNA D upon hire. During an interview on 09/08/23 at 7:13 p.m. CNA B stated she did train CNA D when she started. CNA B stated she trained her one day and two other days it was two other CNAs. CNA B stated the areas she trained CNA D on were patient privacy, peri care on a female resident, and partial bed bath. CNA B stated she did not train her on catheter care. CNA B stated she just verbally told CNA D what to and in the 8 years she had worked at the facility she had never seen a form for skills check off. CNA B stated it was hard to train a more tenured CNA and she felt CNA D listened to about half of what she trained her on. A facility policy regarding staff trainings was requested and not provided prior to exit.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 2 of 5 staff (CNA D and CMA E) reviewed for infection control, in that: 1. CNA D did not sanitize her hands between glove changes. 2. CMA E touched the curtains and put on her gloves which contaminated her hands prior to administering eye drops to Resident #13. These deficient practices could place residents who receive wound care or catheter care at-risk for infections. The findings included: Observation on 09/07/23 at 09:52 a.m., during incontinence/perineal care and catheter CNA D removed her gloves and put on new gloves with no hand hygiene and continued peri care. During an interview on 09/07/23 at 10:03 a.m. CNA D was asked by this surveyor when she should be performing hand hygiene. CNA D stated she changes her gloves every time they are dirty and performs hand hygiene every time, she touched a Resident with her hands. CNA D stated she normally keeps hand sanitizer in her pocket but forgot it that morning. CNA D stated she did not clean her hands between glove changes. During an interview on 09/08/23 at 6:02 p.m. the Clinical nurse stated staff was expected to sanitize their hands between glove changes. 2. During an observation on 09/06/23 at 4:05 p.m. CMA E planned to administer eye drops to Resident #13. CMA E washed her hands in the resident's bathroom, walked over to the resident's bedside, pulled the curtain closed, and put on gloves with no hand hygiene after touching the curtain. CMA E then administered the eye drops. During an interview on 09/06/23 at 4:22 p.m. CMA E stated she did not notice she touched the curtain after washing her hands. CMA E stated she contaminated her hands after she touched the curtain. Record review of the facility's policy titled Administering Medications, dated 04/2019, stated Policy statement: medications are administered in a safe and timely manner, as prescribed .25. Staff falls established facility infection control procedures (e.g., hand washing, a septic technique, gloves, isolation precautions, etc) for the administration of medications, as applicable. Record review of the facility's policy titled Handwashing/Hand Hygiene, dated 08/2019, stated Policy statement: this facility considers pan hygiene the primary needs to prevent the spread of infections. Policy Interpretation and Implementation .7. Use an alcohol based hand rub containing at least 62% alcohol; Or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .m. After removing gloves .Procedure . Applying and Removing Gloves 1. Perform hand hygiene before applying nonsterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. 3. When removing gloves .5. perform hand hygiene.

Based on observation, interview, and record review the facility failed to ensure their medication error rate was not 5 percent or greater and had a medication error rate of 71.88% percent with 3 medications administration opportunities observed with 23 errors for 4 of 6 residents (Residents #12, Resident #13, Resident #32, and Resident #42) and 2 of 3 staff (LVN C and CMA E) reviewed for medication administration, in that: 1. LVN C did not administer the full dose of Resident #12's gabapentin and simethicone medications when she left residue in a medication up during a PEG tube medication administration. 2. CMA E did not administer Resident #13's sucralfate 2 hours after all other medications. 3. CMA E administered 9 of Resident #32's medications 2 hours after the order time. 4. CMA E administered 10 of Resident #42's medications 2 hours after the order time. These deficient practices could place residents at risk of not receiving therapeutic effects from their medications as intended by the prescribing physician order. The findings include: 1. Record review of Resident #12's orders, dated 09/07/23, revealed a physician order for, enteral feed may mix each medication with 5-10 ml of water for administration every shift for medication administration, order date 09/07/23, start date 09/07/23, and no end date. Record review of Resident #12's orders, dated 09/07/23, revealed a physician order for, Gabapentin Capsule 400 MG Give 1 capsule via PEG-Tube four times a day for Pain, order date 08/17/22, start date 08/18/22, and no end date. Record review of Resident #12's orders, dated 09/07/23, revealed a physician order for, Simethicone 80 MG Give 1 tablet via PEG-Tube three times a day for Bloating, order date 05/12/22, start date 05/12/22, and no end date. An observation on 09/07/23 at 12:56 p.m. LVN C dispensed (1) 400 mg capsule of gabapentin and (1) 80 mg tablet of simethicone. LVN C opened the capsule and mixed it with approximately 15 mLs of water and crushed the tablet and mixed it with approximately 15 mLs of water in a separate medication cup. LVN C then administered both medications via PEG tube to Resident #12. A visible amount of the mixture of water and medication were left in both medication cups. During an interview on 09/07/23 at 12:56 p.m. LVN C stated the medications did not dissolve all the way. LVN C stated she usually adds warm water to the medications and would let them sit for 5 minutes to dissolve them better. 2. Record review of Resident #13's orders, dated 09/08/23, revealed a physician order for 1 GM Sucralfate Give 1 tablet by mouth two times a day for Epigastric pain Give 2 hours after rest of meds./ per pharmacy rec, with an order date of 07/01/22, a start date of 07/01/22, and no end date. An observation on 09/06/23 at 4:05 p.m. CMA E dispensed (1) 1 mg tablet of sucralfate at the same time as other medications ordered that afternoon for the resident. During an interview on 09/08/23 at 4:39 p.m. CMA E stated she had no idea what it meant on the order to give it two hours after the other medications, and she had never noticed the order said to give it two hours after the other medications. 3. Record review of Resident #32's orders, dated 09/08/23, revealed a physician order for Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet by mouth one time a day for Heart Health, with an order date of 08/11/23, a start date of 08/12/23, no end date. Record review of Resident #32's orders, dated 09/08/23, revealed a physician order for Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for pain/fever Not to exceed more than 3 grams in 24 hour period. give 2 tabs to equal 650mg, with an order date of 08/11/23, a start date of 08/11/23, no end date. Record review of Resident #32's orders, dated 09/08/23, revealed a physician order for Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for Hypertension Hold for SBP<100, HR<60, with an order date of 08/11/23, a start date of 08/11/23, no end date. Record review of Resident #32's orders, dated 09/08/23, revealed a physician order for Amlodipine Besylate Tablet 2.5 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold if systolic below 110 OR DBP IS THAN 60. May DC medication if systolic is below 110 for 3 consecutive days., with an order date of 08/16/23, a start date of 08/17/23, no end date. Record review of Resident #32's orders, dated 09/08/23, revealed a physician order for Tablet 75 MG (Clopidogrel Bisulfate) Give 1 tablet by mouth one time a day for Blood Thinner, with an order date of 08/11/23, a start date of 08/12/23, no end date. Record review of Resident #32's orders, dated 09/08/23, revealed a physician order for Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day for Blood Thinner, with an order date of 08/11/23, a start date of 08/12/23, no end date. Record review of Resident #32's orders, dated 09/08/23, revealed a physician order for Losartan Potassium Oral Tablet 25 MG (Losartan Potassium) Give 1 tablet by mouth one time a day for Blood Pressure Hold for SBP<100 and pulse < 60., with an order date of 08/17/23, a start date of 08/18/23, no end date. Record review of Resident #32's orders, dated 09/08/23, revealed a physician order for Gabapentin Oral Capsule (Gabapentin) Give 100 mg by mouth three times a day related to CEREBRAL INFARCTION, UNSPECIFIED, with an order date of 08/11/23, a start date of 08/11/23, no end date. Record review of Resident #32's orders, dated 09/08/23, revealed a physician order for Docusate Sodium Capsule 100 MG Give 1 capsule by mouth one time a day for constipation, with an order date of 08/31/23, a start date of 09/01/23, no end date. Record review of Resident #32's orders, dated 09/08/23, revealed a physician order for Cyanocobalamin Tablet 1000 MCG Give 1 tablet by mouth one time a day for Supplement, with an order date of 08/17/23, a start date of 08/18/23, no end date. During an observation on 09/08/23 at 10:35 a.m. CMA E administered medication for Resident #32. The electronic medication administration record showed all medication in red indicating they were past due. The medication times showed as due at 8 a.m. or 9 a.m. 4. Record review of Resident #42's orders, dated 09/08/23, revealed a physician order for Potassium Chloride Microencapsulated Crystals ER Give 20 mEq by mouth two times a day for Supplement take with food &4-8oz of water do not crush, with an order date of 08/15/23, a start date of 08/16/23, no end date. Record review of Resident #42's orders, dated 09/08/23, revealed a physician order for Calcium Carbonate Oral Tablet (Calcium Carbonate) Give 500 mg by mouth one time a day for Bones, with an order date of 07/21/23, a start date of 07/22/23, no end date. Record review of Resident #42's orders, dated 09/08/23, revealed a physician order for Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 1 tablet by mouth three times a day for Parkinsons, with an order date of 07/21/23, a start date of 07/21/23, no end date. Record review of Resident #42's orders, dated 09/08/23, revealed a physician order for Carvedilol Oral Tablet 25 MG (Carvedilol) Give 1 tablet by mouth two times a day for Blood pressure Hold for SBP<100, HR<60, with an order date of 07/28/23, a start date of 07/29/23, no end date. Record review of Resident #42's orders, dated 09/08/23, revealed a physician order for Apixaban Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day for Afib MONITOR FOR BLEEDING, with an order date of 07/28/23, a start date of 07/29/23, no end date. Record review of Resident #42's orders, dated 09/08/23, revealed a physician order for Losartan Potassium Oral Tablet 100 MG (Losartan Potassium) Give 1 tablet by mouth one time a day for High blood pressure Hold for SBP<100 and pulse <60., with an order date of 08/17/23, a start date of 08/18/23, no end date. Record review of Resident #42's orders, dated 09/08/23, revealed a physician order for Rasagiline Mesylate Oral Tablet 1 MG (Rasagiline Mesylate) Give 1 tablet by mouth one time a day related to PARKINSON'S DISEASE, with an order date of 07/28/23, a start date of 07/29/23, no end date. Record review of Resident #42's orders, dated 09/08/23, revealed a physician order for Docusate Sodium Oral Tablet (Docusate Sodium) Give 100 mg by mouth two times a day for Stool Softner, with an order date of 07/21/23, a start date of 07/22/23, no end date. Record review of Resident #42's orders, dated 09/08/23, revealed a physician order for Acetaminophen Tablet 500 MG Give 1 tablet by mouth three times a day for Pain, with an order date of 08/10/23, a start date of 08/10/23, no end date. Record review of Resident #42's orders, dated 09/08/23, revealed a physician order for Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk)) Give 17 mg by mouth one time a day for Constipation, with an order date of 07/21/23, a start date of 07/22/23, no end date. During an observation on 09/08/23 at 10:13 a.m. CMA E administered medication for Resident #42. The electronic medication administration record showed all medication in red indicating they were past due. The medication times showed as due at 8 a.m. or 9 a.m. During an interview on 09/08/23 at 4:39 p.m. CMA E stated policy allowed for medications to be administered an hour before or an hour after the time they were due. CMA E stated the medications she administered to Resident #32 and Resident #42 were showing up in red on the EMAR because they were over the 1 hour allotted and they showed late. CMA E stated she was responsible for administering medications to the whole building. CMA E stated she had other residents that were in therapy and had to administer their medications when they got out of therapy. CMA E stated she administered the medications late because she ran behind from waiting for the other residents. CMA E stated she could have alerted nursing staff if she was behind to asked for help but did not. CMA E stated nursing staff chose the administration time and many of the staff was new and did not know the time frames she needed to allow her to pass all medications within the time frames stated on the EMAR. CMA E stated the previous DON planned to fix this issue for her. CMA E stated she never notified a doctor that she administered the medications late and only alerts nursing staff if a resident refused a medication. CMA E stated it was a medication error if the medication was alerted late to a resident. During an interview on 09/08/23 at 5:12 p.m. the ADON stated they would normally alert a provider if a medication was not administered. The ADON stated she was only informed about residue from a gas pill being left in the medication cup for Resident #12. The ADON stated the gas was hard to dissolve and the resident may just have more gas if it was not completely administered. The ADON stated she was not aware of the gabapentin also having residue left over in a medication cup and if the resident received it for pain, she could have more pain. The ADON stated medications are usually due an hour before and an hour after the ordered time. The ADON stated they recently did some reorganization of residents in rooms and had been working on fixing the medication administration times so it would be easier on the medication aides. During an interview on 09/08/23 at 5:50 p.m. the Clinical Nurse quoted the medication policy If a drug is withheld, refused, or given at a time other than scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose., When asked what the expectations are for staff administering medications on time. The Clinical Nurse stated they changed all the medication orders to block times now. The Clinical Nurse stated the nursing staff established the order times and physicians normally ordered the medication in the morning, so they were able to adjust the order times as needed. The Clinical Nurse stated they also followed the recommended pharmaceutical administration times as needed. Record review of the facility's policy titled Administering Medications, dated 04/2019, Policy statement: medications are administered in a safe and timely manner, as prescribed .4. Medications are administered in accordance with the prescriber orders, including any required time frames. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medications b. Preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her plan of care .7. Medications are administered within (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals orders) .20. For residents not in their rooms or otherwise unavailable to receive medications on the path, the MAR maybe flagged. After completing medication task, the nurse will return to the missed resident to administer the medications. 21. If a drug is withheld, refused, or given at a time other than scheduled time, the individual administering the medication shall initial encircle the MAR space provided for that drug and dose. Record review of the facility's policy titled Administering Medications through an Enteral Tube, dated 11/2018, stated Purpose: the purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .3 .d. Follow USP <795> (compound non sterile preparations) procedures for crushing, diluting and/ or mixing prior to administration .9. Dilute medication: b. dilute crushed (powdered) medication with at least 30ML water (or prescribed amount).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity and cared for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, for one of one resident reviewed for privacy bag. (Resident #41 ) Resident #41's foley catheter drainage bag did not have a privacy bag, leaving the urine in the bag visually exposed. This failure could place residents at risk of feeling uncomfortable and disrespected and could decrease residents' self-esteem and/or quality of life. Findings were: Record review of Resident # 41's Face sheet dated documented a [AGE] year-old male, initially admitted on [DATE] with the diagnoses of benign prostatic hyperplasia: is a condition in men in which the prostate gland is enlarged and not cancerous not allowing urine to empty from the bladder, type 2 diabetes mellitus with unspecified complications: a chronic condition that affects the way the body processes blood sugar and, neuromuscular dysfunction of bladder- lack of bladder control due to the brain, spinal cord, or nerve problems.(start date : 3/21/22) Record review of Resident # 41's MDS, dated [DATE], revealed a Brief Interview of Mental Status score of 11 which indicating the resident was moderately impaired cognitively. Record review of Resident # 41's Care plan dated 7/13/22 documented that R #41 required a foley catheter related to benign prostatic hyperplasia per MD orders. Record review of Resident # 41's Physician's orders dated 07/26/22 revealed Foley Catheter 16 -18 French 5 cc - 10 cc, may change PRN every evening shift starting on the 21st. Dx: neuromuscular dysfunction of bladder, (start date:3/21/22) During an observation of Resident #41 on 7/26/22 at 9:50 AM revealed his foley catheter drainage bag was hanging on the right side of the bed with yellow urine noted. The urinary drainage bag was able to be viewed from outside of the room while in the hall. In an interview with LVN A on 07/26/22 at 10:25 AM revealed he was the charge nurse for R #41. He revealed there should be a privacy screen or bag over the foley catheter urinary drainage bag for privacy. He revealed there was usually a privacy bag on the drainage bag that the facility used but he was unsure why R #41's urinary drainage bag didn't have one. He revealed it was important to have something covering the urinary drainage bag for the privacy and dignity of the resident but did not know where the dignity bags were located at this time. In an interview with the DON on 7/26/22 at 11:50 AM, she revealed there should be a privacy bag on the urinary drainage bag of Resident # 41 to maintain his privacy and dignity. The DON stated she in-serviced nursing staff on providing dignity bags for foley catheter urinary drainage bags. She revealed it was important to provide privacy for the urinary bag as a part of dignity purposes. During an interview on 7/26/2022 at 12:10 PM, the DON stated, the facility currently had no policy regarding dignity bags used to cover foley drainage bags.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs and for 1 of 43 residents (Resident #3) reviewed for call lights. The facility failed to have a call light within reach for Resident #3. This failure could place residents at risk for a delay in care and services, increased falls, excessive wait times, pain, and a decreased quality of life. Findings included: Record review of Resident #3's facesheet, dated 07/28/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder bipolar type (a mental health condition where people experience hallucinations or delusions as well as symptoms of a mood disorder), chronic obstructive pulmonary disease: (a group of diseases that cause airflow blockage and breathing-related problems), and muscle weakness generalized. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS score of 7 which indicated severe cognitive impairment. Further review revealed the resident required extensive assistance from two or more staff members to perform activities of daily living. Record review of Resident #3's care plan, revised 11/20/2021, revealed, [Resident #3] is High risk for falls r/t [related to] decreased mobility .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Observation on 07/26/2022 at 9:15 a.m. revealed Resident #3's call light cord was wrapped around the mechanical unit secured to the wall and was not within the resident's reach. During an interview with Resident #3 on 07/26/2022 at 9:15 a.m., Resident #3 confirmed he was unable to reach his call light and stated he was in pain and needed assistance from staff to transfer to a more comfortable position in his bed. On 7/26/2022 @ 09:15 Am , LVN A confirmed the residents did not have their call lights with in reach and stated this is his last week of employment and he did not have time to make rounds on all his patients when he received report from the previous nurse . During an interview with Medication Aide B on 07/26/2022 at 9:18 a.m., Medication Aide B confirmed Resident #3's call light was not within his reach. During an interview with the DON on 7/26/22 at 10:30 AM, she stated it was her expectation that all nurses do walking rounds and check on patients during a shift-to-shift report plus anticipate the needs of residents. She stated that all staff have received in-service education and confirmed that when call lights are out of reach, residents are at risk of a delay in care and services, increased falls, excessive wait times, pain, and a decreased quality of life. Record review of the Routine Resident Care Policies and Procedures dated December 2021 which revealed that call lights should be placed within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #41) reviewed for indwelling catheters. The facility failed to ensure Resident #41's indwelling catheter was attached to prevent pulling or tugging to the urethra. These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections. Findings included: Record review of Resident #41's face sheet, undated, revealed a [AGE] year-old male, admitted to the facility on [DATE] with the diagnoses of benign prostatic hyperplasia: which is a condition in men in which the prostate gland is enlarged and not cancerous not allowing urine to empty from the bladder, type 2 diabetes mellitus with unspecified complications: A chronic condition that affects the way the body processes blood sugar and, neuromuscular dysfunction of bladder: lack of bladder control due to the brain, spinal cord, or nerve problems. Record review of Resident #41's MDS, dated [DATE], revealed a BIMS score of 11 (moderately impaired). Record review of Resident#41's care plan initiated on 07/13/2022 revealed interventions: Anchor catheter to prevent tension. Observation on 7/26/22 at 10:20 AM, revealed Resident #41's indwelling catheter anchor was not in place. In an interview on 7/26/22 at 10:30 a.m., LVN A stated the nurses were responsible to put a foley stat lock anchor on the resident as sometimes the resident can lay on it, it can get coiled, or it can get pulled. The stat lock for the Foley catheter should be on to stabilize the foley and prevent tugging, if the balloon comes out it would be painful for the resident. He stated the CNAs were expected to tell nurses when a new stat lock was needed. He stated she had not gotten a chance to see Resident#41 this morning. He said he was in the middle of meds pass and had not made it to the patient's room yet. LVN A stated he did not know where to find a foley catheter anchor. In an interview with the ADON on 7/26/22 at 1:55 PM, she said all staff had been educated on where to find catheter anchors in the central supply closet. In an interview on 7/26/22 at 2:00 p.m., the DON stated residents who had indwelling urinary catheters needed to have a leg strap or securing device so the catheter tubing was not pulled which could cause irritation to the urethra. The DON stated the nurse was responsible for ensuring the urinary catheter tubing was secured to the resident's leg. Record review of Urinary Drainage bag policy dated December 2021 revealed, catheter is to be securely placed.