**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the provider investigation report was turned into the state survey agency (HHSC) within 5 working days of the reported incident for Resident #1 This failure could place residents at risk for abuse and neglect. Findings Included: Record review of Resident #1's face sheet, dated 06/30/25, indicated he was a [AGE] year-old male, initially admitted to the facility on [DATE] and most recently re-admitted on [DATE]. His diagnoses included heart failure (a condition where the heart can't pump enough blood to meet the body's needs), brief psychotic disorder (mental health condition characterized by the sudden onset of psychotic symptoms, such as delusions, hallucinations, or disorganized speech, that last for at least one day but less than one month, with a full return to the person's previous level of functioning), and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly interfere with daily life). Record review of Resident #1's quarterly MDS assessment, dated 04/09/25, indicated he had a BIMS score of 15, which indicated intact cognition. Record review of the facility's provider investigation report for the reported incident for Resident #1, dated 03/15/25, indicated Resident #1 reported that the PASRR representative that took Resident #1 to the store had placed an item on the check out belt and Resident #1 paid for it. The facility notified the local health authority that the representative that he would no longer be allowed in the facility. There were no witnesses to the incident. Ultimately the facility's investigation concluded that the allegation was unconfirmed. The allegation was reported to the state survey agency on 03/11/25. Record review of the TULIP website, accessed on 07/02/25 at 7:58AM, indicated on the page for intake #570206 that a 5-day report or provider investigation report had not been turned into the state survey agency. During an interview on 06/30/25 at 3:00PM, the Area Director of Operations for the facility said they were unable to reach the previous administrator that was responsible for turning in the 5-day report for this intake. She said they were unable to provide proof that the provider investigation report was turned into the state survey agency. On 07/01/25 at 4:25PM, the surveyor attempted to call the phone number that was provided by the facility for the previous administrator. The number was disconnected and no longer in service. Record review of the facility's policy, Abuse/Neglect, last revised 05/09/17, stated: .F. Investigation.3. A report to the appropriate agency will include the following: .The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 24 residents (Resident #1) reviewed for MDS assessment accuracy. The facility incorrectly coded Resident #1's discharge MDS assessment dated [DATE] as return not anticipated instead of return anticipated. This failure could place residents at risk for not receiving care and services to meet their needs.Findings included:Record review of Resident #1's face sheet, reflected Resident #1 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included chronic combined heart failure (the heart has a long-term problem with effectively pumping blood, affecting both its ability to contract and relax). Record review of Resident #1's discharge MDS assessment, dated 04/14/25, reflected discharge assessment-return not anticipated. Record review of an admission progress note dated 04/16/25 completed by RN A reflected Resident #1 was readmitted to the facility from the hospital. During an interview on 07/01/25 at 9:10 a.m., the MDS Coordinator stated she was responsible for Resident #1's discharge MDS assessment. The MDS Coordinator stated if a discharge assessment-return not anticipated was completed that reflected the resident was discharged home or to another facility. After reviewing Resident #1's electronic medical records, the MDS Coordinator stated a discharge assessment-return anticipated should have been completed because the return from the hospital on [DATE]. The MDS Coordinator stated a new admission assessment did not have to be done because the MD assessments schedule continued from Resident #1 last MDS assessment. The MDS Coordinator stated she should have modified the assessment to reflect return anticipated. The MDS Coordinator stated it was important to ensure the correct assessment was completed for accuracy. During a telephone interview on 07/0/25 at 9:59 a.m., the Regional Reimbursement Nurse stated the MDS Coordinator should have completed discharge assessment-return anticipated. The Regional Reimbursement Nurse stated the MDS Coordinator should have notified the support line to let them know that she did an incorrect assessment, and they would have reviewed it and gave her the ok to modify. The Regional Reimbursement Nurse stated a new admission assessment did not have to be completed because the resident was not out for more than 30 days. The Regional Reimbursement Nurse stated it was important to ensure the correct assessment was completed for continuity of care. During an interview on 07/02/25 at 2:14 p.m., the Administrator stated she expected the MDS Coordinator to complete the correct assessment when a resident return from a hospital. The Administrator stated it was important the correct assessment was completed to ensure when the resident returned, they would receive the proper plan of care. During an interview on 07/01/25 at 4:39 p.m., the Regional Compliance Nurse stated there was no policy and procedures regarding MDS assessment accuracy. The Regional Compliance Nurse stated the facility followed the RAI manual. Record review of the Resident Assessment Instrument 3.0 User's Manual, last revised October 2023, reflected. A1900: admission Date. A1900 (admission Date) . if the resident returns after a discharge return not anticipated or after a gap of more than 30 days outside of the facility, a new episode would begin, and a new admission would be required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to coordinate assessments with the PASARR program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 6 residents (Resident #32) reviewed for PASARR. The facility failed to ensure a Form 1012 Mental Illness/Dementia Resident Review was completed for Resident #32 after he was initially admitted to the facility on [DATE] to determine if he required further evaluation due to his mental illnesses. This failure could place residents at risk of not receiving specialized services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being.Findings included: Record review of a face sheet dated 07/02/2025 indicated Resident #32 was initially admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and schizoaffective disorder (mood disorder that can include depression, delusions, hallucinations, disorganized thoughts, speech and behavior). Record review of Resident #32's Comprehensive MDS assessment dated [DATE] indicated he was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS assessment indicated Resident #32 was usually understood by others and usually understood others. The MDS assessment indicated Resident #32 had a BIMS score of 10, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #32 had depression, anxiety disorder, and schizophrenia (for example schizoaffective and schizophreniform disorders). The MDS assessment indicated Resident #32 received antipsychotic, antianxiety, and antidepressant medications. Record review of Resident #32's PASRR Level 1 Screening date of screening 10/22/2024, indicated there was evidence that dementia was the primary diagnosis. The PASRR Level 1 Screening indicated there was no evidence or indicator that Resident #32 had a mental illness. Record review of Resident #32's Order Summary Report dated 07/02/2025 indicated he had the following orders: Depakote (medication used to stabilize mood) 250 mg give 1 tablet by mouth three times a day related to schizoaffective disorder with a start date of 10/24/2024. Fluoxetine (medication used to treat depression) 20 mg 1 capsule one time a day for depression with a start date of 10/24/2024. Fluoxetine 40 mg 1 capsule one time a day for depression with a start date of 10/24/2024. Risperidone (medication used to treat mood disorders) 1 mg give 1 tablet by mouth two times a day for anxiety related to schizoaffective disorder with a start date of 10/24/2024. Record review of Resident #32's care plan last reviewed 05/08/2025 indicated he required medications for depression and schizoaffective disorder to administer medications as ordered and monitor/record occurrence of target behavior symptoms. Record review of Resident #32's electronic health record on 07/02/2025 did not indicate a PASRR Evaluation or Form 1012 had been completed. During an interview on 07/02/2025 at 11:55 AM, the MDS Coordinator said she was responsible for the PASRR Level 1 screenings and coordinating PASRR services. The MDS Coordinator said when a resident had a primary diagnosis of dementia, they were unable to indicate on the PASRR Level 1 Screening that the resident had mental illness. The MDS Coordinator said if the resident had a primary diagnosis of dementia, like Resident #32 did, they did not qualify for PASRR services. During an interview on 07/02/2025 at 12:02 PM, the PASRR Manager said if a resident had a primary diagnosis of dementia, they were unable to put yes on the mental illness option on the PASRR Level 1 Screening. The PASRR Manager said because they could not put yes on the mental illness option on the PASRR Level 1 Screening, the facility should complete a Form 1012. The PASRR Manager said the Form 1012 was the facility's justification to show that the resident had a primary diagnosis of dementia. During an interview on 07/02/2025 at 12:12 PM, the MDS Coordinator said she did not know what Form 1012 was that she had not been provided information regarding it. The MDS Coordinator said it was important to ensure the PASRR process was completed properly so the residents who qualified for services received what they needed. During an interview on 07/02/2025 at 2:14 PM, the Regional Reimbursement Nurse said the MDS Coordinator was responsible for PASRR in the facility. The Regional Reimbursement Nurse said she monitored the MDS Coordinator by reviewing the residents' diagnoses and psychiatric notes for new admissions to ensure the PASRR process was being followed. The Regional Reimbursement Nurse said on the PASRR Level 1 Screening when they indicated the resident had a primary diagnosis of dementia, they were unable to indicate the mental illness. The Regional Reimbursement Nurse said Resident #32 did not require a Form 1012. The Regional Reimbursement Nurse said a Form 1012 was only required when it was not clear a resident's primary diagnosis was dementia. The Regional Reimbursement Nurse said it was important for the PASRR process to be followed so if there was mental illness the residents received the services they required. During an interview on 07/02/2025 at 3:29 PM, the Administrator said the MDS Coordinator was responsible for the PASRR process. The Administrator said she expected for the proper PASRR forms to be completed. The Administrator said this was important for the residents to get the programs that were required. Record review of the facility's policy titled, PASRR Nursing Facility Specialized Services Policy and Procedure, revised 03/06/2019, did not address the PASRR Level 1 or completion of Form 1012. Record review of the instructions for the Texas Health and Human Services Form 1012 Mental Illness/Dementia Resident Review indicated, Form 1012 assists nursing facilities (NF) in determining whether a resident with a negative Preadmission Screening and Resident Review (PASRR) Level I (PL1) Screening form submitted into the Long-Term Care (LTC) Portal, needs further evaluation for Mental Illness (MI). This form is used to determine whether the individual has a primary dementia diagnosis or if the individual has a mental illness diagnosis. This form also serves as the NF's documentation for the individual's medical record as to why further evaluation was or was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 1 of 4 (Resident #44) residents reviewed. The facility failed to care plan Resident #44's oxygen (which is vital for the human body as it is used by cells to produce energy) therapy. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. The findings included: Record review of Resident #44's face sheet, dated 07/02/25, revealed an [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses to include other nonspecific abnormal finding of lung field ( when an abnormality is detected on diagnostic imaging of the lung, but the specific cause or nature of the abnormality is not yet determined), Neuromuscular dysfunction of the bladder(occur when the nerves controlling the bladder are damaged or don't function properly, leading to issues with storage and/or emptying of urine), stroke and diabetes (high blood sugars). Record review of Resident #44's quarterly MDS assessment, dated 04/22/25, indicated Resident #44 usually understood others and was usually understood by others. Resident #44's BIMS score was 08, which indicated her cognition was moderately impaired. The MDS indicated Resident #44 used oxygen. Record review of Resident #44's care plan, revised date of 04/22/25, did not indicate she had an oxygen care plan. Record review of Resident #44 ‘s physician orders dated 01/06/24 indicated to use oxygen at 2-3 liters per minute via nasal canula every shift for hypoxia (lack of oxygen). During an observation on 06/29/25 at 1:00 p.m., Resident #44 had an oxygen sign outside her door. Resident #44 had oxygen in her room, but it was not on. During an observation and attempted interview on 06/30/25 at 8:33 a.m., Resident #44 was in her bed without any oxygen on. Resident #44 did not answer when asked if she wore oxygen. During an observation and interview on 07/02/25 at 9:33 a.m., the MDS Coordinator looked at Resident 44's care plan and said she did not see the care plan for her oxygen. The MDS Coordinator said she and the IDT worked together to do the care plans, but she was responsible for ensuring the care plans were done. She said it was important to care plan the residents' care so they would receive quality care. During an interview on 07/02/25 at 3:20 p.m., the DON said the MDS Coordinator was responsible for completing the care plans. She said each IDT member was responsible for the acute care plans (IE, the treatment nurse updated wounds, dietary manager updated nutrition, etc.). The DON said she was unaware that Resident #44's oxygen-use was not care planned. She said if Resident #44 had a routine order for oxygen, then she should be wearing her oxygen, and it should be care planned. She said the care plan was generated to guide staff and others in the care the resident should receive. During an interview on 07/02/25 at 3:48 p.m., the Administrator said all disciplines should work together to complete a resident's care plan, but the MDS Coordinator was the overseer. She said care plans were generated to provide each resident with proper care based on their needs and diagnosis. Record review of the facility's policy titled, Comprehensive Care planning, dated 03/2018, indicated Policy Statement: the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's right that includes measurable objective and time frame to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following: the services that are to be furnished to obtain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and the right to refuse treatment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her needs, other purposes, and goals, which will address the resident's medical, physical, mental, and psychosocial needs. A comprehensive care plan will be developed within seven days after completion of the comprehensive assessment. The facility will ensure that services are provided, arranged, or delivered by individuals who have the skills, experience, and knowledge to do a particular task or activity. Residents' preferences and goals may change throughout their stay, so the facility should have ongoing discussions to ensure that changes are reflected in the comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #51) of 1 resident reviewed for enteral nutrition. The facility failed to follow physician orders for Resident #51's enteral feeding tube to be administered at 53 ml/hr. This failure could place residents who had gastrostomy tube at risk for fluid overload.Findings included: Record review of Resident #51's face sheet, dated 07/01/25, reflected Resident #51 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included severe protein-calorie malnutrition. Record review of Resident #51's quarterly MDS assessment, dated 04/15/25, reflected Resident #51 made herself understood, and usually understood others. Resident #51's BIMS score was 13, which reflected her cognition was intact. Resident #51 had a feeding tube that she received 51% total calories through the feeding tube. Record review of Resident #51's comprehensive care plan revised on 12/31/24 reflected Resident #51 required a feeding tube for nutrition. The care plan interventions included: check for tube placement and gastric contents/residual volume per facility protocol and record. Record review of Resident #51's physician order summary report, dated 07/01/25 reflected an active physician order for enteral feeding at bedtime start continuous: Isosource 1.5 calorie (formula): rate 53 ml/hr with a start date 02/06/25. Record review of a progress note dated 06/30/25 completed by LVN K reflected Resident #51 had significant residual (something that remains or was left behind after a process, treatment, or event has occurred) noted. Nurse Practitioner notified, new order hold feeding for 2 hrs. and recheck residual. During an observation on 06/29/25 at 1:42 p.m., Resident #51 was lying in bed. The feeding tube machine reflected, Isosource 1.5 calorie at a continuous rate of 55 ml/hr. During an observation and interview on 06/30/25 at 09:29 AM, LVN K checked Resident #51's room to administer her routine morning medications via her peg tube. LVN K stopped the feeding pump, checked for peg tube placement and residual. Resident #51 had 60 mL of residual. After LVN K administered Resident #51's medication she said she was not restarting the feeding because Resident #51 had quite a bit of residual and had to notify the physician. During an observation on 06/30/25 at 2:50 p.m., Resident #51 was lying in bed. The feeding tube machine reflected, Isosource 1.5 calorie at a continuous rate of 55 ml/hr. During an observation and interview on 06/30/25 at 2:52 p.m., after reviewing Resident #51's electronic medical records, LVN K stated Resident #51 tube feeding formula rate should be 53 ml/hr. LVN K observed the rate with the state surveyor at 55 ml/hr. LVN K stated the charge nurses were responsible for verifying each order, every shift, every time the resident's feeding was administered. LVN K stated receiving 55 ml/hr instead of 53 ml/hr of feeding formula would result in overload. During an interview on 07/02/25 at 10:09 a.m., the DON stated she expected the nurses to follow the physician order. The DON stated her and the ADONs were responsible for monitoring accuracy by daily champion rounds and random checks throughout the day. The DON stated, It was missed. The DON stated it was important for the resident to receive the correct rate for their safety. During an interview on 07/02/25 at 2:14 p.m., the Administrator stated she expected the nurses to ensure the correct rate was set per the physician order. The Administrator stated the DON/ADONs were responsible for monitoring. The Administrator stated it was important for the resident to receive the correct rate to prevent overload. Record review of the undated facility's policy titled Enteral Nutrition reflected. We will provide nutritionally complete enteral or parenteral feedings as ordered by the physician for the nourishment of residents who are unable to eat by mouth. 1. The Nursing Services Department is responsible for all feeding equipment and the administration of tube feedings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 3 residents (Resident #48) reviewed for respiratory care. The facility failed to ensure Resident #48's CPAP (a device that keeps breathing airways open while sleeping) mask was stored properly. This failure could place residents requiring respiratory care at risk for shortness of breath, respiratory distress, or complications.Findings included: Record review of a face sheet dated 07/02/2025 indicated Resident #48 was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed air flow in the lungs). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #48 understood others and was understood by others. The MDS assessment indicated Resident #48 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #48 was dependent on staff for eating, oral hygiene, dressing, and required partial/moderate assistance with personal hygiene and eating. The MDS assessment did not address the use of a CPAP. Record review of Resident #48's Order Summary Report dated 07/02/2025 indicated she had an order for may use CPAP at bedtime with a start date of 05/29/2025. Record review of Resident #48's care plan last reviewed 05/28/2025 indicated she required the use of a CPAP, and she would use the device as ordered. During an observation and interview on 06/29/2025 at 12:44 PM, Resident #48's CPAP mask was on top of a bubble gum container that was on top of her nightstand, and it was not in a bag, it was exposed. Resident #48 said the staff usually kept it that way and did not store it in a bag. Resident #48 said the staff had to assist her with putting it on and taking it off because she was unable to do it on her own. Resident #48 said she could not reach her CPAP mask due to her limited mobility. During an interview on 07/02/2025 at 2:46 PM, ADON B said the CPAP masks should be placed in a bag when not in use. ADON B said she conducted rounds daily in the mornings to ensure they were stored properly. ADON B said the night nurses were responsible for ensuring the CPAP masks were stored in a bag. ADON B said it was important for the CPAP masks to be stored in a bag when not in use for them to be kept sanitary. During an interview on 07/02/2025 at 2:59 PM, the DON said the CPAP masks should be stored in a bag when not in use. The DON said ultimately, she was responsible for ensuring they were stored properly. The DON said they conducted champion rounds during the week and the RN supervisor on the weekend ensured the masks and cannulas were stored in a bag. The DON said the CPAP mask not being stored properly could result in it not being clean and could cause an infection. During an interview on 07/02/2025 at 3:24 PM, the Administrator said the CPAP masks should be stored in a bag when not in use. The Administrator said the nurses were responsible for ensuring this occurred. The Administrator said it was important for them to be stored in a bag for infections reasons and to keep them clean. During an interview on 07/02/2025 at 3:39 PM, RN A said the CPAP masks should be stored in a bag when not in use. RN A said she did not know why Resident #48's CPAP mask was not stored in a bag. RN A said she tried to check in the mornings when she went into the residents' rooms to ensure the CPAP masks and nasal cannulas were stored properly. RN A said it was important for the CPAP masks to be stored in a bag to protect them from dust and germs. Record review of the facility's policy titled, Oxygen Administration, revised March 21, 2023, did not address the storage of CPAP masks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, 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 1 of 5 residents (Resident #6) reviewed for pharmacy services. The facility failed to ensure ADON H administered Resident #6's Magdelay (magnesium chloride, combination medication used as a supplement for minerals lacking in diet) as ordered on 06/30/25. This failure could place the residents at risk of not receiving the intended therapeutic benefits of prescribed medications.Findings included: Record review of Resident #6's face sheet dated 07/01/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included dementia (memory loss), essential hypertension (high blood pressure), muscle weakness, and osteoporosis (disease that weakens the bones and increases the risk of fractures). Record review of Resident #6's quarterly MDS assessment dated [DATE], indicated she was understood and understood others. Resident #6 had a BIMS score of 14, which indicated her cognition was intact. Record review of Resident #6's comprehensive care plan revised 01/16/24, indicated she had impaired cognitive function/dementia or impaired thought processes. The care plan interventions indicated to administer medications as ordered. Record review of Resident #6's order summary report dated 07/01/25, indicated she had an order for MagDelay 64mg give one tablet one time a day for supplement with an order started date of 06/01/25. During an observation on 06/30/25 at 08:45 AM, ADON H prepared Resident #6's routine morning medications. ADON H obtained one tablet of sloMg and placed it in the medicine cup. The bottle of sloMg indicated it contained the following ingredients: magnesium 143mg, calcium 238mg, and chloride 416mg. ADON H then administered Resident #6 her medications. Resident #6 took all medications including the sloMg tablet. Record review of Resident #6's medication administration record dated 06/01/25-06/30/25, indicated she had received one tablet of Magdelay 64mg on 06/30/25 in the morning and had been administered by ADON H. Record review of the website on 07/01/25, https://hargravesotc.com/products/magdelay-64-mg-delayed-release-60-tablets-by-major?variant=32392354562131, indicated the active ingredients for Magdelay included: calcium 212mg, magnesium 128mg, and chloride 375mg. During an interview on 07/01/25 at 2:32 PM, ADON H reviewed the bottle of sloMg she administered and said it was not the correct dosage, and she should have not administered the medication to Resident #6 until she had clarified the order with the physician. ADON H said she had given the medication because it had handwritten on the top of the bottle magnesium delay. She said she had only administered one tablet although the bottle had indicated a dose was 2 tablets because she assumed she had calculated the magnesium correctly and obviously she did not. She said she was responsible for ensuring the medications were being administered as ordered. ADON H said not administering the correct medication was a medication error and Resident #6 was at risk for receiving more than the prescribed dose which could cause cardiac related adverse reactions. During an interview on 07/01/25 at 3:16 PM, the DON said she expected medications to be administered as ordered. The DON said the nurse was responsible for clarifying the order with the physician. The DON said not giving the correct dose of medication was a medication error and the resident could have ill effects depending on their diagnoses. During an interview on 07/01/25 at 3:19 PM, the Administrator said she expected medications to be administered following the medication rights. She said ADON H should have had called the physician to get clarification if the medication could be administered. She said failure to administer medications as ordered could cause the resident not to get the therapeutic level of the ordered supplement. Record review of the facility's undated policy Medication Administration and General Guidelines indicated. Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized themselves with the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 24 residents (Resident #20) reviewed for medications at their bedside. The facility did not ensure Resident #20's Ayr Nasal Solution (nasal spray), and biotene dry mouth moisturizing spray were not left on his bedside table. This failure could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications.Findings included: Record review of Resident #20's face sheet, dated 07/01/25, reflected Resident #20 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included diastolic (congestive) heart failure (occurs when the heart's lower left chamber becomes stiff and cannot relax and fill with blood properly between beats). Record review of Resident #20's quarterly MDS, dated [DATE], reflected Resident #20 sometimes made himself understood and usually understood others. Resident #20's BIMS score was 14, which reflected his cognition was intact. Record review of Resident #20's comprehensive care plan revised on 11/11/24 reflected discharge from the facility was not feasible as evidenced by resident unable to safely self-medicate and required 24 hr. nursing care. The care plan interventions included respect resident's right to view nursing facility as his home. Record review of Resident #20's order summary report dated 06/01/25 reflected an active physician order for Ayr Nasal Solution: 2 sprays in both nostrils every 4 hours as needed for nasal irritation with a start date 06/29/25. Record review of Resident #20's order summary report dated 06/01/25 reflected an active physician order for biotene dry mouth moisturizing spray: 1 spray by mouth every 4 hours as needed for dry mouth with a start date 06/29/25. During an observation and attempted interview on 06/29/25 at 1:58 p.m., A bottle of Ayr Nasal Solution (nasal spray) and biotene dry mouth moisturizing Spray were observed on Resident#20's bedside table. Resident #20 had a communication problem related to unclear speech. During an observation and interview on 06/29/25 at 2:00 p.m., the DON was coming out of the room next door to Resident #20 when the state surveyor asked her if anyone on the hall was able to self-medicate. The DON stated there was no one in the building able to self-medicate. The state surveyor asked the DON if the nasal spray and the mouth moisturizing spray should be on Resident #20's bedside table. The DON removed the medication from the table and told Resident #20 the medication should be stored in the nurse's cart. During an interview on 06/29/25 at 2:03 p.m., ADON H stated Resident #20 had not been evaluated for self-administration of medications. ADON H stated if a resident was able to self-administer, he/she must be assessed for competence. ADON H stated once the resident was safe to self-medicate an order must be obtained. ADON H stated she did not see the medication on his bedside table when she went into his room. ADON H stated, he has so much stuff on that table. ADON H stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 07/02/25 at 10:09 a.m., the DON stated she expected that if Resident #20 was able to self-administer that the resident be assessed, obtain an order for the resident to self-administer and store the medications on the nurse's cart. The DON stated all staff should be ensuring medications were not left at bedside. The DON stated she was responsible for monitoring medications at bedside by daily champion rounds. The DON stated she was not aware if a round was made that morning prior to surveyor intervention. The DON stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 07/02/25 at 2:14 p.m., the Administrator stated medications should be locked/secured in the nurse's cart and administered by the nurse or MA. The Administrator stated the DON was responsible for monitoring and overseeing medication storage by daily rounds. The Administrator stated it was important to ensure medications were not left at bedside for resident safety. Record review of the undated facility's policy titled Medication Storage in the Facility reflected. 2. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents were provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs for 1 of 2 residents (Resident #19) reviewed for dietary needs and preferences. The facility failed to ensure Resident #19 received small, frequent meals as recommended by her physician. This failure placed residents at risk for altered nutritional status and decreased quality of life. Findings included: Record review of Resident #19's face sheet dated 07/02/2025 indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type 2 diabetes mellitus with other circulatory complications (insulin resistance leading to high blood sugars resulting in complications with circulation), gastro-esophageal reflux disease without esophagitis (a long-term condition in which acid from the stomach comes up into the esophagus without inflammation of the esophagus), and irritable bowel syndrome (condition that affects the digestive system and can cause abdominal pain, cramping, bloating, gas, constipation, and diarrhea). Record review of Resident #19's Quarterly MDS assessment dated [DATE] indicated she understood others and was understood by others. The MDS assessment indicated Resident #19 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #19 was independent for eating. The MDS assessment did not indicate Resident #19 required a therapeutic diet. Record review of Resident #19's Order Summary Report dated 07/01/2025 indicated she had an order for a regular diet with regular texture and consistency with a start date of 11/19/2024. Record review of Resident #19's care plan last reviewed 04/14/2025 indicated she had a potential nutritional problem related to diabetes mellitus to provide and serve diet as ordered. Record review of Resident #19's Physician's Orders in her After Visit Summary from the gastroenterology lab (specialized area where procedures and tests related to the digestive system are performed) dated 05/29/2025 indicated, gastroparesis (condition where the stomach empties its contents too slowly) with solid food in stomach likely diabetic gastroparesis (condition in people with diabetes that causes delayed emptying of the stomach). should be on small frequent meals 4-5 times daily. Record review of Resident #19's electronic health record indicated the last Dietary Profile completed was on 04/16/2025, and it did not address Resident #19's requirement of small frequent meals. The Dietary Profile was signed completed by the Dietary Manager on 04/16/2025. During an interview on 06/29/2025 at 2:30 PM, Resident #19 said she had diabetic gastroparesis and was told by the doctor she was supposed to have little meals. Resident #19 said she was supposed to eat every 2 hours, and the facility could not accommodate that for her. Resident #19 said she did the best she could to eat small meals by saving food from the meals she was served to eat throughout the day. Resident #19 said she talked to the kitchen manager, and they flat out say they cannot do it. Resident #19 said the kitchen manager told her everybody received the same diet. During an interview on 07/01/2025 at 4:47 PM, the Dietary Manager said if a resident required a special diet the nursing staff notified dietary, and they tried to accommodate the diet. The Dietary Manager said a diet order should be completed and given to the kitchen. The Dietary Manager said she tried to visit the residents monthly and completed dietary profiles to get the residents' dietary preferences. The Dietary Manager said she was not aware Resident #19 required small, frequent meals, and she was not provided a diet order. The Dietary Manager said she tried to visit with Resident #19 every couple of weeks, and Resident #19 had not informed her she wanted small, frequent meals. The Dietary Manager said it was important to accommodate the residents' dietary needs and preferences for their dignity and because they should have as much control as possible over their meals. During an interview on 07/02/2025 at 2:49 PM, ADON B said Resident #19 had gastroparesis, and was instructed to eat small meals. ADON B said when a resident went to the doctor the nurses should review the orders upon the residents return to the facility. ADON B said she thought she may have been the charge nurse the day Resident #19 returned with the order for the small meals, but she did not remember. ADON B said she did not complete a dietary communication sheet, and it should have been completed. ADON B said she did not put an order in because she guessed in her mind she did not because Resident #19 controlled her meals. ADON B said if the residents' dietary needs and preferences were not followed it could cause adverse reactions and have a bad outcome. During an interview on 07/02/2025 at 3:02 PM, the DON said the nurses were responsible for reviewing the physician's orders when the residents returned from a doctor's appointment. The DON said the ADONs and herself reviewed the orders after the nurses did. The DON said she was aware Resident #19 required small, frequent meals. The DON said she had communicated it to the Dietary Manager in one of the morning meetings. The DON said if there was a diet order change a communication form should be completed and given to dietary. The DON said since she communicated it to the Dietary Manager in the morning meeting, she did not complete a communication form. The DON said if Resident #19's dietary needs were not followed as recommended by the physician she could end up having to go back to the doctor. During an interview on 07/02/2025 at 3:25 PM, the Administrator said if Resident #19 required frequent meals they should be able to provide her snacks or they could store food for her, and she could get it or request it later. The Administrator said when they received information from the physician it should be communicated from the DON/ADON to dietary. The Administrator said if the residents' dietary needs and preferences were not followed, they would not get the proper meals they needed. Record review of the facility's policy titled, Menu Approval and Honoring Resident Special Requests, And Food Brought to the Facility From Unapproved Sources from the Dietary Services Policy & Procedure Manual 2012, indicated, .Every attempt will be made to honor resident food preferences. If a resident wishes to eat at non-traditional times or outside of scheduled meal service times, the resident preferences will be honored as much as possible. The facility plan for meeting these requests will be documented in the resident's written care plan. If a resident has requested in advance to eat at non-traditional times, the foods served on the menu can be stored and reheated at the appropriate time, or shelf-stable/refrigerated foods that can be prepared without access to the facility kitchen can be kept on hand for these requests.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility did not ensure:1. The ham was discarded after the use by date of 06/26/25.2. The potatoes were labeled and dated. These failures could place residents at risk for foodborne illness.Findings included: During the initial tour observation of the kitchen on 06/29/25 beginning at 11:20 AM, the following was revealed in the fridge: Ham had a use by date of 06/26/25. Potatoes were found in a container with no label or date. During an interview on 07/01/25 at 2:54 PM, the Dietary Manager said the ham was unfortunately 1 day out of date. She said the potatoes had just been pulled from the freezer, were labeled, and dated but the label had gotten soggy from the ice. She said a new label should have been placed. The Dietary Manager said the ham should have been pulled on the day it expired and thrown away. She said the fridges were checked daily for expired food and she was unsure how it was missed. The Dietary Manager said the cooks and herself were responsible for ensuring the food was labeled correctly, and expired food was removed. She said failure to remove the expired food items could cause the residents to get sick. During an interview on 07/01/25 at 2:58 PM, Dietary [NAME] M said he checked the fridges daily for expired food. He said the potatoes should have been labeled and dated when they were prepared, and the ham should have been removed the day it expired. Dietary [NAME] M said failure to remove the expired food or not labeling/dating correctly could place a resident at risk for receiving expired food and cause them to get sick. He said the kitchen staff was responsible for ensuring the food was labeled/dated correctly and expired food was removed. During an interview on 07/01/25 at 3:19 PM, the Administrator said she expected all food items to be labeled and dated accordingly and discarded upon the expiration date. The Administrator said the Dietary Manager was responsible for overseeing it was being completed. She said depending on the food itself expired food could case GI discomfort and upset for the residents if used. Record review of the facility's policy Food Storage and Supplies dated 2012 indicated. All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.Perishable items that are refrigerated are dated once opened and used within 7 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #44) reviewed for infection control. The facility failed to ensure CNA N performed hand hygiene while providing incontinent care for Resident #44 on 06/29/25. This failure could place any resident at the facility at risk for cross-contamination and the spread of infection.Finding included: Record review of Resident #44's face sheet, dated 07/02/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include Neuromuscular dysfunction of the bladder (occurs when the nerves controlling the bladder are damaged or don't function properly, leading to issues with storage and/or emptying of urine), stroke and diabetes (high blood sugars). Record review of Resident #44's quarterly MDS assessment, dated 04/22/25, indicated Resident #44 usually understood and was usually understood by others. Resident #44's BIMS score was 08, which indicated her cognition was moderately impaired. The MDS indicated Resident #44 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS did not indicate she was frequently incontinent of bladder. Record review of Resident #44's comprehensive care plan, revised on 07/27/23, indicated that Resident #44 had an ADL Self Care Performance Deficit. The care plan interventions were for 2 staff to provide toileting. During an observation on 06/29/25 at 1:00 p.m., CNA N provided incontinent care of bowel and bladder for Resident #44. She wiped her front area and then her backside without changing her gloves or performing hand hygiene. She then grabbed a clean brief, applied barrier cream, changed her linen, and then applied her gown, while using the same dirty gloves. CNA N then removed her gloves, gathered her equipment, left the room, and then washed her hands. During an interview on 06/29/25 at 3:02 p.m., CNA N said she did not realize she did not perform hand hygiene or change her gloves after wiping Resident #44, then touching the clean brief, linen, and her gown with dirty gloves. She said she knew that without hand hygiene or removing dirty gloves, she could cause cross-contamination and infection. During an interview on 07/02/25 at 3:20 p.m., the DON said she expected the CNAs to perform incontinent care correctly. She said she expected staff to change their gloves between dirty to clean and use hand hygiene between glove changes. The DON said they went over incontinence care and hand washing at least annually. She said she oversaw the infection control process. She said staff should change gloves and practice hand hygiene to prevent infection and cross-contamination. During an interview on 07/02/25 at 3:48 p.m., the Administrator said she expected all staff to use proper hand hygiene techniques between dirty and clean areas with all care. The Administrator said the DON was responsible for ensuring staff were trained on incontinent care and infection control. She said improper hand hygiene could place residents at risk for cross-contamination. Record review of the facility's policy titled Hand Hygiene, undated, indicated, You may use alcohol-based hand cleaner or soap and water for the following: when hands are visibly soiled, after contact with a residents mucous membrane and body fluids or excretions, after handling soiled or used linens, before and after assisting a resident with personal care, and before and after assisting a resident with toileting. Record review of the facility's policy titled Infection Control, revised 03/23, indicated, The facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by acceptable professional practice.

Based on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response for 3 of 3 confidential resident council meetings reviewed (04/18/25, 05/13/25, and 06/10/25) for grievances. The facility failed to ensure there was documentation of the facility's efforts to resolve concerns collected at the resident council meetings on 04/18/25, 05/13/25, and 06/10/25. This failure could place residents at risk of not having their concerns and grievances followed through, and a diminished quality of life. Findings included: Record review of the Resident Advisory Council Minutes for 04/18/25 indicated the call lights were not being answered timely and were worse over the weekend, the residents were not receiving scheduled showers, and they had no towels for bathing, and the residents' beds were not being made timely, and they did not have clean sheets. Record review of the Resident Advisory Council Minutes for 05/13/25 indicated the call lights were not being answered timely, the residents were not always receiving scheduled showers, and the residents' beds were not being made timely. Record review of the Resident Advisory Council Minutes for 06/10/25 indicated the call lights were not being answered timely, the residents were not always receiving scheduled showers, and the residents' beds were not being made timely. Record review of the grievances from April 2025 to June 2025 revealed they did not indicate grievances to address the resident councils' concerns. During a confidential group interview with 9 residents on 06/30/25 starting at 10:08 a.m., the resident group said the facility was shorthanded, people were not getting showers, people's beds were not being made on shower days, people were not getting changed promptly, and call lights were not answered timely. The resident group said that every meeting, they discussed the call lights not being answered timely. The resident group said they had invited some of the department heads, including the DON, to the meetings, and they were aware of the call lights not being answered in a timely manner, showers not being given, and beds not being changed timely. The resident group said they were told they would look into it, or we would investigate it. The resident group said they did not get back with them on a resolution and had not given them an explanation as to why the call lights were not being answered timely as that was their greatest concern. During an interview on 07/01/25 at 5:39 p.m., the Activities Director said, after the resident council meeting, she made three copies of the results of the meeting with the residents' concerns and gave one to the DON, one to the Administrator, and one for the resident council meeting book. The Activities Director said every month, the residents complained about the call lights not being answered, and the Administrator and DON had been told about it. She said she was not aware of what to do about the resident concerns since it had been voiced so many times in the resident council meeting, so she invited the DON to the resident council meeting. She said the residents told the DON about the call lights, showers, and beds not being made in the resident council on 06/10/25. The Activities Director said the DON said she would handle it. The Activities Director said she did not know how to file a grievance. The Activities Director said it was important for the residents' concerns/complaints to be addressed so they felt safe and were taken care of. During an interview on 07/01/25 at 5:38 p.m., the Social Worker said he was responsible for the grievances. The Social Worker said he received the minutes from the resident council, but never really looked at them as far as a grievance. He said he was not aware he needed to fill out the grievance forms from the resident council minutes. He said the Activity Director was supposed to fill out the grievance form and give it to him, and then he would put it into their computer software system. He said they would discuss any grievance in the morning meeting, come up with a resolution (by talking to the resident or investigating the situation), and mark the grievance as completed. The Social Worker said it was important for grievances to be filed so they could be documented and to ensure they were managed appropriately, so it would not happen again. During an interview on 07/02/25 at 10:50 a.m., NA P said the residents complained about their call lights not being answered promptly or not receiving their assigned showers. She said they had a challenging time answering lights and giving showers due to the staffing shortage. She said management was aware of the call lights and showers concerns. During an interview on 07/02/25 at 3:20 p.m., the DON said the Social Worker was responsible for the grievances. She said the Activity Director had given her the resident council minutes, but she had not read thoroughly through them. She said she had been invited to the resident council meeting this month (June 2025) but did not remember anything specific from the meeting about call lights, showers, or beds not being made. She said she had never filled out a grievance form since starting as the DON. She said any concerns voiced at the resident council meeting should have been filed as a grievance. During an interview on 07/02/25 at 3:48 p.m., the Administrator said the Social Worker was responsible for the grievances. She said grievances were talked about in the morning meetings and given to each department head responsible for investigating. She said that after the department head investigated and reached a solution, they resolved the grievance. She said she received the resident council minutes after each meeting from the Activity Director but had not thoroughly reviewed them all. She said she was not aware that a grievance had not been filed from the resident council meetings by the Social Worker. She said if she received a grievance, she would input it into their software system. She said, but she was guilty of sometimes doing verbal communication with issues that were brought to her. She said she now realized the importance of ensuring a grievance had been filed and documented to prove the issues had been investigated and resolved. The Administrator said the resident councils' concerns not being addressed could affect their care, and she expected the residents' needs to be responded to promptly, and if the staff were not answering the call lights, they would not be aware of the residents' needs. Record review of the facility's policy titled, Grievance, revised 11/02/16, indicated, The resident has the right to voice grievances to the facility or other agency that hears grievances without discrimination or reprisal and without fear of discrimination. Such grievances include those with respect to care and treatment which have been furnished or have not been furnished, concerns regarding their long-term care facility stay. The resident has the right to, and the facility must make prompt efforts by the facility to resolve grievance the resident may have. #2 The grievance officer of this facility is the administrator or their designee, the grievance official will oversee the grievance process, receive and track grievances to their conclusion, lead any necessary investigations by the facility, maintain the confidentiality of all information associated with the grievance, issue written grievance decision to the resident, and coordinate with state and federal agency as necessary. #8 Maintain evidence demonstrating the results of all grievances for no less than three years from the issue of the grievance decision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 3 of 24 residents (Resident #53, Resident #40 and Resident #29) reviewed for ADL care. 1. The facility failed to ensure Resident #53 was showered or offered a shower as scheduled for June 2025. 2. The facility did not ensure Resident #40 received her shower as scheduled for June 2025. 3. The facility failed to provide Resident #29's showers as scheduled for June 2025. These failures could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity. Findings included: 1. Record review of Resident #53's face sheet, dated 01/29/25, indicated a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses which included Atrial fibrillation, also known as AFib (a heart condition characterized by an irregular and often rapid heartbeat), Dementia (a general term for the loss of thinking, remembering, and reasoning abilities), and Gastroesophageal Reflux Disease, also known as GERD (is a digestive disorder where stomach acid flows back into the esophagus, causing symptoms like heartburn and regurgitation). Record review of Resident #53's quarterly MDS assessment, dated 05/01/25, indicated Resident #53 understood others and was understood by others. Her BIMS score was a 12, which indicated her cognition was moderately impaired. The MDS indicated she required limited assistance for bathing, bed mobility, dressing, and transferring. Record review of the care plan dated 07/24/24 indicated Resident #53 had an ADL self-care performance deficit requiring assistance with bathing. Resident #53 also refused showers at times, revised 06/11/25. The interventions were for staff to assist with bathing, negotiate a time for ADLs, so that the resident participates in the decision-making process. Return at the agreed-upon time, and if the resident resists with ADLs, reassure and return 5-10 minutes later, and try again. Record review of Resident #53’s Documentation Survey Report dated 06/01/25-06/30/25, indicated Resident #53 was to be bathed on the 10 am-6 pm shift, but it did not indicate what days. It appears the days marked for Resident #53 showers were on Monday, Wednesday, and Friday. It showed Resident #53 was bathed on 06/09/25 and 06/11/25 and refused a shower on 06/06/25, 06/16/25, and 06/25/25. During an interview on 07/02/25 at 10:24 p.m., Resident #53 said she was not getting her showers 3 times a week. She said she was lucky to get a shower 1 time a week. She said when she did get a shower, she had to ask several times before she received it. She said she did receive her shower yesterday (07/01/25) after asking several times. During an interview on 07/02/25 at 10:50 a.m., MA O said Resident #53 received her shower late yesterday (07/01/25). She said Resident #53 had to ask the aides several times before they gave it to her. She said she thought Resident #53 was to receive night showers. During an interview on 07/25/25 at 11:00 a.m., NA P said residents did complain about not receiving their baths. She said they were not always able to give the residents showers because of time and all the duties they had to complete. She said she reported to the oncoming shift if a shower was not given. She said they were mostly behind on giving showers because the night aides were not giving their showers. She said she reported to the ADONs and the DON (unknown times) about them not being able to complete their showers, but nothing had changed. 2. Record review of Resident #40’s face sheet, dated 07/01/25, reflected Resident #40 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypercapnia (abnormal high levels of carbon dioxide in the blood). Record review of Resident #40’s quarterly MDS, dated [DATE], reflected Resident #40 made herself understood, and understood others. Resident #40’s BIMS score was 15, which reflected her cognition was intact. Resident #40 required partial/moderate assistance with showering and supervision or touching assistance with toileting, upper/lower body dressing, and putting on/taking off footwear. Resident #20 did not have behaviors or refused care. Record review of Resident #40’s comprehensive care plan revised 02/08/24, reflected Resident #40 had an ADL self-care performance deficit. The care plan interventions included assist with personal hygiene as required: hair, shaving, oral care as needed, and bathing required staff x1 for assistance. Record review of Resident #40’s documentation survey report for the month of June 2025, reflected Resident #40 was scheduled to receive a shower/bed bath on Monday, Wednesday, and Friday between 6:00 AM-2:00 PM. The report reflected Resident #40 did not received a shower/bed bath on 06/02/25, 06/23/25, 06/27/25 and 06/30/25. During an interview on 06/29/25 at 1:26 p.m., Resident #40 was in her bed. Resident #40 stated she had only been receiving her shower once a week and would like to receive them at least 3 times a week. Resident #40 stated, “I feel nasty and dirty” when she did not receive a shower regularly. 3. Record review of Resident #29’s face sheet dated 07/02/2025 indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Parkinson’s disease with dyskinesia (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves causes unintended or uncontrollable movements with involuntary muscle movements) and atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow without chest pain). Record review of Resident #29’s Comprehensive MDS assessment dated [DATE] indicated he was understood by others and understood others. The MDS assessment indicated Resident #29 had a BIMS score of 9, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #29 required substantial/maximal assistance with showering/bathing and lower body dressing, and partial/moderate assistance with toileting hygiene, upper body dressing, and personal hygiene. Record review of Resident #29’s care plan last reviewed 04/14/2025 indicated he had an ADL self-care performance deficit to assist him with personal hygiene as required, and he required the assistance of one staff member for bathing. Record review of Resident #29’s Documentation Survey Report for June 2025 indicated he received one bath in the month of June 2025 on 06/17/2025. Record review of Resident #29’s shower sheets for the month of June 2025 indicated he was scheduled to receive showers Tuesday, Thursday, and Friday from 2 PM to 10 PM. The shower sheets indicated he received a shower on 06/22/2025. During an observation and interview on 06/29/2025 at 2:18 PM, Resident #29 said he was not receiving his showers like he wanted. Resident #29 said, “They may give me one on Monday and the next one is Thursday.” Resident #29 said he thought his last shower was Thursday (06/26/2025) or Friday (06/27/2025), but he had no idea of the time, so he was not sure. Resident #29 said he told the staff he needed a bath, and they told him they would get to it, but they did not. Resident #29 said it was normal for them to tell him that. Resident #29 was wearing a white t-shirt with multiple brown stains down the front of it. During an observation and interview on 06/30/2025 at 3:56 PM, Resident #29 had a white t-shirt with multiple brown stains down the front of it. Resident #29 said he thought they had put on a clean shirt on him last night, but he was not sure. Resident #29 said he had not received a shower yet. During an interview on 06/30/2025 at 10:34 PM, LVN E said she worked the night shift from 6 PM-6 AM. LVN E said she thought all the showers were completed prior to the start of her shift since there were more staff available. LVN E said she had not observed any showers being given on her shift. During an interview on 07/01/2025 at 2:23 PM, CNA D said the CNAs turned in the shower sheets to her and she placed them in a file, and then put them in the ADONs’ office. CNA D said the showers were completed on the 6 AM-6 PM shift that there were no showers completed on the 6 PM-6 AM shift. CNA D said she had told the ADONs and the DON that the residents had been missing showers because they were unable to complete all the showers. CNA D said if they were unable to complete a shower/bath during the day shift they left a note for the night shift for them to complete it. CNA D said the residents complained to her that they were not receiving their showers as scheduled. CNA D said if the residents did not receive their showers, it could affect their dignity, and the residents needed to be cleaned. During an interview on 07/01/2025 at 2:49 PM, CNA F said they had missed showers a few times. CNA F said she did not give Resident #29’s showers because he was scheduled to receive his shower on the night shift. CNA F said if the residents did not receive their showers, they could feel neglected and dirty. During an interview on 07/01/2025 at 3:11 PM, ADON H said she had only been the ADON for about a week. ADON H said the staff had not reported to her that they were not able to give all the showers as scheduled. ADON H said the CNAs were supposed to complete shower sheets. ADON H said if the residents did not receive their showers as scheduled, they could have skin breakdown, get infections and odor. ADON H said the residents needed their showers so they could have a general feeling of well-being. During an interview on 07/01/2025 at 3:15 PM, ADON B said she had been the ADON for about a month. ADON B said the staff had not reported to her they were not able to complete all the showers. ADON B said CNA D collected the shower sheets, and the nurses were supposed to review the shower sheets to ensure the residents wee receiving their baths. ADON B said if the residents did not receive their showers, it could affect their skin and self-esteem. During an interview on 07/01/2025 at 3:41 PM, CNA C said she worked the 6 PM-6 AM shift. CNA C said she did not give showers on her shift because she did not have time. CNA C said when she started her shift they had to help with dinner and pick-up trays, then do her rounds, and by the time she finished her rounds it was too late. CNA C said as far as she knew there were showers scheduled but she did not have the time to get to them. CNA C said if the residents did not receive their showers it could result in odors and infections. During an interview on 07/01/2025 at 4:06 PM, LVN G said she worked the 6 PM-6 AM shift. LVN G said the night CNAs were supposed to be giving showers, but by the time they finished dinner and got all the patients changed it was too late to give showers. LVN G said one CNA and two nurses for the building was not enough to provide care for the residents. LVN G said they were supposed to have 3 CNAs at night, but they had a lot of people call in. LVN G said she had talked to CNA D, who scheduled the showers, and told her the CNAs were not able to complete the showers at night. LVN G said the ADONs and DON were aware the residents were not receiving their showers as scheduled. LVN G said she had not been able to find a way to fix the missed showers. LVN G said the residents not getting their baths was neglect. During an interview on 07/02/2025 at 3:05 PM, the DON said the showers were documented on the bathing sheets and the electronic health record. The DON said the CNAs were supposed to turn in the shower sheets to the ADONs for them to review. The DON said the staff had not reported to her that they were unable to complete the showers as scheduled. The DON said if the residents did not receive their showers, it could affect the residents’ personal hygiene. The DON said it was important for the residents to receive their showers to keep them from being sent out to the hospital and to the doctor. During an interview on 07/02/2025 at 3:27 PM, the Administrator said the residents should be placed on the shower schedule, and they should be getting their showers as scheduled. The Administrator said if the resident requested, they could also have a shower in between their scheduled days. The Administrator said nursing was responsible for ensuring the showers were completed. The Administrator said the residents not receiving their showers as scheduled could affect their hygiene. Record review of the facility’s undated policy titled, “Bath, Tub/Shower”, from the Nursing Policy & Procedure manual indicated, “Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation…The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level…The resident will receive assistance with bathing according to their resident centered plan of care…”.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 5 of 24 residents (Residents #1, #10, #29, #48, and #53) and 1 of 1 lunch meal reviewed for palatability. The facility did not provide palatable food served at an appetizing temperature or taste to residents who complained the food was cold and not seasoned. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings include: Record review of Resident #53's grievance dated 05/08/25, indicated Resident #53 had stated .food was ‘always ice cold'. Record review of the Resident Council Minutes dated 06/10/25 indicated . hall food cold, coffee cold. During an interview on 06/29/25 at 12:36 PM, Resident #1 stated he ate in his room and the food was served lukewarm and needed to be seasoned more. During an interview on 06/29/2025 at 12:44 PM, Resident #48 said the food was cold. During an interview on 06/29/2025 at 1:25 PM, Resident #10 said the food was not good, most of the time it was not seasoned, the meat was too hard, and sometimes the food was cold. During an interview on 06/29/2025 at 2:28 PM, Resident #29 said sometimes the food was cold, but then sometimes the food was too hot to eat. During an observation and interview on 06/30/25 at 1:07 PM, a lunch tray was sampled by the Dietary Manager, the Area Director of Operations and 5 surveyors. The sample tray consisted of meatloaf, red potato wedges, brussels au gratin, roll, and strawberry banana cake. The meatloaf was not sampled as the meat had red tinged areas. The Area Director of Operations said she could see the redness in the meat. She said overall the meal was good. The surveyors observed the redness of the meat, and the potato wedges were lukewarm. During an interview on 07/01/25 at 2:54 PM, the Dietary Manager said there was nothing wrong with the test tray meal. She said the meat loaf was made from ground beef and ground beef was safe to eat at any color if the temperature was correct. She said the potatoes were fine as well and that the Area Director of Operations had agreed there was nothing wrong with the meal. She said she had not received any complaints of cold food. She said residents had even voiced to her that they were happy she was in the kitchen because the food was tasting so much better. During an interview on 07/01/25 at 3:19 PM, the Administrator said if the residents did not like what was being served then they would most likely not eat. She said an alternate meal would have been offered. She said she had received one food complaint that she was aware of for cold food. During an interview on 07/01/25 at 3:25 PM, the Area Director of Operations said she thought the test tray was okay and was aware of the concerns of the surveyors regarding the red meat. She said the ground meat could be served if the temperature was correct, and it had been because the temperature was 197 degrees Fahrenheit. She said there were no concerns from the residents regarding the meal. She said she had not received any food complaints when she had visited the facility. The Area Director of Operations said she visited the facility twice a month and obtained a test tray each time with no issues noted with the meals. Record review of the facility's policy Menu Approval and Honoring Resident Special Requests, and Food Brought to the Facility from Unapproved Sources dated 2012, indicated . 4. Every attempt will be made to honor resident food preferences. The policy did not address the facility providing food that was palatable, attractive, and at a safe and appetizing temperature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement written policies that prohibit and prevent abuse, neglect, misappropriation of resident property, and exploitation for 1 of 69 (Resident #1) residents reviewed for abuse and neglect. The facility failed to implement the abuse and neglect policy and procedure regarding reporting misappropriation of property for Resident #1. This failure could place the residents at increased risk for abuse and neglect. The findings included: Record Review of the abuse and neglect policy dated 3/29/18 indicated Abuse is the willful infliction of injury, unreasonable confinement, intimidation. Or punishment resulting physical harm. pain or mental anguish. Abuse also includes the deprivation by an individual. including a caretaker, of goods or services that are necessary to attain or maintain physical. mental. and psychosocial well-being. Instances of abuse of all residents. irrespective of any mental or physical condition. cause physical harm, pain or mental anguish. It includes verbal abuse. sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse. means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Adverse event. An adverse event is an untoward. undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. (9) Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. (3) Facility employees must report all allegation of: abuse, neglect, exploitation, mistreatment, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter I 9-1 7 dated 7 / l 0/1 9. (a.) If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours. (b) If the allegation does not involve abuse or serious bodily injury. The report must be made within 24 hours of the allegation. Record review of Resident #1's face sheet dated 3/11/25 at 6:19 p.m., indicated Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining), acute chronic systolic (congestive) heart failure (heart is unable to pump enough force to push enough blood into circulation), osteoarthritis (degeneration of joint cartilage and the underlying bone), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to) and essential hypertension (high blood pressure). Record review of Resident #1's MDS assessment dated [DATE] indicated, Resident #1 understood others and made himself understood. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated Resident #1 was cognitively intact. The MDS assessment indicated Resident #1's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. Record review of Resident #1's care plan, dated on 1/3/19, indicated Resident #1 had an ADL Self Care Performance Deficit. The care plan goal included, the resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. The care plan interventions included Bed Mobility: supervision as needed, Eating: supervision as needed, resident chooses to grow his hair out, resident chooses to have a beard and mustache, toileting: supervision as needed and walking: provide supervision as needed. Record review of the intake worksheet dated 3/7/24 at unknown time indicted, On 03/07/25, facility LVN A reported she overheard Resident #1 stating that the community support advocate IDD and independent trainer who was employed with IDD office, Community Support Advocate B allegedly purchased a candy bar for himself with Resident #1's purchases. Community Support Advocate B assisted with shopping and offered to take Resident #1 shopping. The date and location of the incident is unknown. The desired outcome is to report the situation that occurred. Record Review of Resident Bank Statement dated 3/12/25 at 1:33 p.m., indicated Resident #1 was advanced $60.00 in cash on 2/18/25. The Bank statement indicated Resident #1 was advanced $60.00 in cash on 12/11/24. Record Review of leave of absence form revised dated 9/14/2016 indicated Resident#1 last checked out of the facility on 12/17/24 at 8:37 a.m. and returned on 12/17/24 at 9:15 a.m. During a phone interview on 3/11/25 at 3:23 p.m., Confidential complainant stated an allegation had been made towards one of the workers at outside of the facility where she worked at independent living skills office. Confidential complainant stated it was overheard and she was not sure if this incident even occurred that her employee Community Support Advocate B had purchased a candy bar with Resident #1's money. Confidential complainant stated her coworkers name was Community Support Advocate B who was suspected of taking money from the resident to buy candy from the vending machine Confidential complainant stated the Community Support Advocate B informed her that he did not purchase a candy bar with the resident's money. Confidential complainant stated she wanted to make sure the resident was not being taken advantage of. During a phone interview on 3/11/25 at 4:38 p.m., Community Support Advocate B stated he never used the resident's money to purchase a fountain drink. Community Support Advocate B stated he did not use the resident's money to purchase a candy bar from the vending machine. Community Support Advocate B stated he came to see the resident every Wednesday morning. Community Support Advocate B stated he had never told the resident that he had authority over him. Community Support Advocate B stated he just makes sure the resident was safe when he leaves the building and when he comes back to the facility. During an interview on 3/11/25 at 3:45 p.m., Resident #1 stated the Community Support Advocate B always buys his drinks with Resident#1's money. Resident #1 stated Community Support Advocate B buys coca cola fountain drinks with Resident #'1's money. Resident #1 stated the Community Support Advocate B always asked the resident how much money he had and was his money in his account. Resident #1 stated when Community Support Advocate B would take him to the store that he would tell him, Don't go that way, come this way. Resident #1 stated he did not like Community Support Advocate B telling him not to go certain places in the store. Resident #1 stated he went shopping every week with Community Support Advocate B. Resident #1 stated he did not like shopping every week. Resident #1 stated Community Support Advocate B always asked him, How much money you got, and I got authority over you. Resident #1 stated he did not like Community Support Advocate B stating that he had authority over him. Resident #1 stated he did not know anything about Community Support Advocate B buying candy from the vending machine using his money. During an interview on 3/11/25 at 4:29 p.m., LVN A stated she did not overhear Resident #1 say anything regarding Resident #'1s money being spent on the community Support Advocate B from the vending machines. LVN A stated in the morning meeting someone had told her, Hey, off the cuff I overheard that the PASRR guy had used the resident #1's money to purchase a candy bar. LVN A stated that, Resident #1 thought that Community Support Advocate B had put a candy bar up there for him to pay for it one time when they were out at the store. LVN A stated that this information was said to her at the morning meeting on Friday 3/7/25. LVN A stated she did not remember who brought it up in the morning meeting. LVN A stated all of the department heads attended the morning meetings. LVN A stated the rumor on the Community Support Advocate B using the resident's money for a candy bar at the vending machine should have been reported to the Administrator, but she figured everyone heard the discussion at the morning meeting. LVN A stated she notified IDD office. LVN A stated she reported to IDD office because Community Support Advocate B was not one of the facility's employees. LVN A stated Community Support Advocate B sees Resident #1 once a week. LVN A stated she was not sure if they went to the store every week. During an interview on 3/12/25 at 9:01 a.m., LVN A stated the Administrator oversaw her. LVN A stated she was the MDS Coordinator. LVN A stated the abuse coordinator was the Administrator. LVN A stated she did not know when the exact time frame of when Community Support Advocate B was supposed to have used the resident's money for the candy bar. LVN A stated she last completed abuse and neglect in-services yesterday 3/11/25. LVN A stated, It would be important to report ANE (Abuse, Neglect, exploitation) to prevent and to protect the residents against any forms of abuse and exploitation; be a voice for them when they cannot be a voice for themselves. During an interview on 3/12/25 at 9:17 a.m., with the Administrator, she stated she had been the Administrator since the middle of December 2025. The Administrator stated she oversaw the MDS Coordinator. The Administrator stated she was the abuse coordinator. The Administrator stated she last provided in-services on abuse and neglect yesterday 3/11/25. The Administrator stated she did not remember overhearing about misappropriation of property for Resident #1. The Administrator stated she was responsible for reporting ANE to State. The Administrator stated this incident should have been reported to State and investigated. The Administrator stated the reason why it was not investigated and reported was because she was not made aware of the incident by LVN A. The Administrator stated the State guideline and the facility's policy for reporting ANE was 24 hours. The Administrator stated this incident occurred at a local store. The Administrator stated the resident stated it was a little package of donuts that the resident reported to her of what Resident #1 spent with his money. The Administrator stated she did not know how often Resident #1, and Community Support Advocate B went to the store. The Administrator stated it was important to investigate, report and follow facility's policy on ANE to protect the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 69 (Resident #1) residents reviewed for abuse and neglect. The facility failed to report to the state agency within 24 hours of being notified of misappropriation of property for Resident #1. This failure to report could place the residents at risk for abuse. The findings included: Record Review of the abuse and neglect policy dated 3/29/18 indicated Abuse is the willful infliction of injury, unreasonable confinement, intimidation. Or punishment resulting physical harm. pain or mental anguish. Abuse also includes the deprivation by an individual. including a caretaker, of goods or services that are necessary to attain or maintain physical. mental. and psychosocial well-being. Instances of abuse of all residents. irrespective of any mental or physical condition. cause physical harm, pain or mental anguish. It includes verbal abuse. sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse. means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Adverse event. An adverse event is an untoward. undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. (9) Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. (3) Facility employees must report all allegation of: abuse, neglect, exploitation, mistreatment, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter I 9-1 7 dated 7 / l 0/1 9. (a.) If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours. (b) If the allegation does not involve abuse or serious bodily injury. The report must be made within 24 hours of the allegation. Record review of Resident #1's face sheet dated 3/11/25 at 6:19 p.m., indicated Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining), acute chronic systolic (congestive) heart failure (heart is unable to pump enough force to push enough blood into circulation), osteoarthritis (degeneration of joint cartilage and the underlying bone), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to) and essential hypertension (high blood pressure). Record review of Resident #1's MDS assessment dated [DATE] indicated, Resident #1 understood others and made himself understood. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated Resident #1 was cognitively intact. The MDS assessment indicated Resident #1's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. Record review of Resident #1's care plan, dated on 1/3/19, indicated Resident #1 had an ADL Self Care Performance Deficit. The care plan goal included, the resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. The care plan interventions included Bed Mobility: supervision as needed, Eating: supervision as needed, resident chooses to grow his hair out, resident chooses to have a beard and mustache, toileting: supervision as needed and walking: provide supervision as needed. Record review of the intake worksheet dated 3/7/24 at unknown time indicted, On 03/07/25, facility LVN A reported she overheard Resident #1 stating that the community support advocate IDD and independent trainer who was employed with IDD office, Community Support Advocate B allegedly purchased a candy bar for himself with Resident #1's purchases. Community Support Advocate B assisted with shopping and offered to take Resident #1 shopping. The date and location of the incident is unknown. The desired outcome is to report the situation that occurred. Record Review of Resident Bank Statement dated 3/12/25 at 1:33 p.m., indicated Resident #1 was advanced $60.00 in cash on 2/18/25. The Bank statement indicated Resident #1 was advanced $60.00 in cash on 12/11/24. Record Review of leave of absence form revised dated 9/14/2016 indicated Resident#1 last checked out of the facility on 12/17/24 at 8:37 a.m. and returned on 12/17/24 at 9:15 a.m. During a phone interview on 3/11/25 at 3:23 p.m., Confidential complainant stated an allegation had been made towards one of the workers at outside of the facility where she worked at independent living skills office. Confidential complainant stated it was overheard and she was not sure if this incident even occurred that her employee Community Support Advocate B had purchased a candy bar with Resident #1's money. Confidential complainant stated her coworkers name was Community Support Advocate B who was suspected of taking money from the resident to buy candy from the vending machine Confidential complainant stated the Community Support Advocate B informed her that he did not purchase a candy bar with the resident's money. Confidential complainant stated she wanted to make sure the resident was not being taken advantage of. During a phone interview on 3/11/25 at 4:38 p.m., Community Support Advocate B stated he never used the resident's money to purchase a fountain drink. Community Support Advocate B stated he did not use the resident's money to purchase a candy bar from the vending machine. Community Support Advocate B stated he came to see the resident every Wednesday morning. Community Support Advocate B stated he had never told the resident that he had authority over him. Community Support Advocate B stated he just makes sure the resident was safe when he leaves the building and when he comes back to the facility. During an interview on 3/11/25 at 3:45 p.m., Resident #1 stated the Community Support Advocate B always buys his drinks with Resident#1's money. Resident #1 stated Community Support Advocate B buys coca cola fountain drinks with Resident #'1's money. Resident #1 stated the Community Support Advocate B always asked the resident how much money he had and was his money in his account. Resident #1 stated when Community Support Advocate B would take him to the store that he would tell him, Don't go that way, come this way. Resident #1 stated he did not like Community Support Advocate B telling him not to go certain places in the store. Resident #1 stated he went shopping every week with Community Support Advocate B. Resident #1 stated he did not like shopping every week. Resident #1 stated Community Support Advocate B always asked him, How much money you got, and I got authority over you. Resident #1 stated he did not like Community Support Advocate B stating that he had authority over him. Resident #1 stated he did not know anything about Community Support Advocate B buying candy from the vending machine using his money. During an interview on 3/11/25 at 4:29 p.m., LVN A stated she did not overhear Resident #1 say anything regarding Resident #'1s money being spent on the community Support Advocate B from the vending machines. LVN A stated in the morning meeting someone had told her, Hey, off the cuff I overheard that the PASRR guy had used the resident #1's money to purchase a candy bar. LVN A stated that, Resident #1 thought that Community Support Advocate B had put a candy bar up there for him to pay for it one time when they were out at the store. LVN A stated that this information was said to her at the morning meeting on Friday 3/7/25. LVN A stated she did not remember who brought it up in the morning meeting. LVN A stated all of the department heads attended the morning meetings. LVN A stated the rumor on the Community Support Advocate B using the resident's money for a candy bar at the vending machine should have been reported to the Administrator, but she figured everyone heard the discussion at the morning meeting. LVN A stated she notified IDD office. LVN A stated she reported to IDD office because Community Support Advocate B was not one of the facility's employees. LVN A stated Community Support Advocate B sees Resident #1 once a week. LVN A stated she was not sure if they went to the store every week. During an interview on 3/12/25 at 9:01 a.m., LVN A stated the Administrator oversaw her. LVN A stated she was the MDS Coordinator. LVN A stated the abuse coordinator was the Administrator. LVN A stated she did not know when the exact time frame of when Community Support Advocate B was supposed to have used the resident's money for the candy bar. LVN A stated she last completed abuse and neglect in-services yesterday 3/11/25. LVN A stated, It would be important to report ANE (Abuse, Neglect, exploitation) to prevent and to protect the residents against any forms of abuse and exploitation; be a voice for them when they cannot be a voice for themselves. During an interview on 3/12/25 at 9:17 a.m., with the Administrator, she stated she had been the Administrator since the middle of December 2025. The Administrator stated she oversaw the MDS Coordinator. The Administrator stated she was the abuse coordinator. The Administrator stated she last provided in-services on abuse and neglect yesterday 3/11/25. The Administrator stated she did not remember overhearing about misappropriation of property for Resident #1. The Administrator stated she was responsible for reporting ANE to State. The Administrator stated this incident should have been reported to State and investigated. The Administrator stated the reason why it was not investigated and reported was because she was not made aware of the incident by LVN A. The Administrator stated the State guideline and the facility's policy for reporting ANE was 24 hours. The Administrator stated this incident occurred at a local store. The Administrator stated the resident stated it was a little package of donuts that the resident reported to her of what Resident #1 spent with his money. The Administrator stated she did not know how often Resident #1, and Community Support Advocate B went to the store. The Administrator stated it was important to investigate, report and follow facility's policy on ANE to protect the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure in response to allegations of abuse, neglect, or mistreatment, have evidence that all alleged violations were thoroughly investigated to prevent further potential abuse, neglect, or mistreatment while the investigation was in progress. And report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1of 69 (Resident #1) residents reviewed for Abuse and Neglect. The facility's Administrator failed to ensure on Resident #1's misappropriation of property was thoroughly investigated. This failure could place residents at risk for ANE. Findings included: Record Review of the abuse and neglect policy dated 3/29/18 indicated Abuse is the willful infliction of injury, unreasonable confinement, intimidation. Or punishment resulting physical harm. pain or mental anguish. Abuse also includes the deprivation by an individual. including a caretaker, of goods or services that are necessary to attain or maintain physical. mental. and psychosocial well-being. Instances of abuse of all residents. irrespective of any mental or physical condition. cause physical harm, pain or mental anguish. It includes verbal abuse. sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse. means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Adverse event. An adverse event is an untoward. undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. (9) Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. (3) Facility employees must report all allegation of: abuse, neglect, exploitation, mistreatment, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter I 9-1 7 dated 7 / l 0/1 9. (a.) If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours. (b) If the allegation does not involve abuse or serious bodily injury. The report must be made within 24 hours of the allegation. Record review of Resident #1's face sheet dated 3/11/25 at 6:19 p.m., indicated Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining), acute chronic systolic (congestive) heart failure (heart is unable to pump enough force to push enough blood into circulation), osteoarthritis (degeneration of joint cartilage and the underlying bone), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to) and essential hypertension (high blood pressure). Record review of Resident #1's MDS assessment dated [DATE] indicated, Resident #1 understood others and made himself understood. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated Resident #1 was cognitively intact. The MDS assessment indicated Resident #1's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. Record review of Resident #1's care plan, dated on 1/3/19, indicated Resident #1 had an ADL Self Care Performance Deficit. The care plan goal included, the resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. The care plan interventions included Bed Mobility: supervision as needed, Eating: supervision as needed, resident chooses to grow his hair out, resident chooses to have a beard and mustache, toileting: supervision as needed and walking: provide supervision as needed. Record review of the intake worksheet dated 3/7/24 at unknown time indicted, On 03/07/25, facility LVN A reported she overheard Resident #1 stating that the community support advocate IDD and independent trainer who was employed with IDD office, Community Support Advocate B allegedly purchased a candy bar for himself with Resident #1's purchases. Community Support Advocate B assisted with shopping and offered to take Resident #1 shopping. The date and location of the incident is unknown. The desired outcome is to report the situation that occurred. Record Review of Resident Bank Statement dated 3/12/25 at 1:33 p.m., indicated Resident #1 was advanced $60.00 in cash on 2/18/25. The Bank statement indicated Resident #1 was advanced $60.00 in cash on 12/11/24. Record Review of leave of absence form revised dated 9/14/2016 indicated Resident#1 last checked out of the facility on 12/17/24 at 8:37 a.m. and returned on 12/17/24 at 9:15 a.m. During a phone interview on 3/11/25 at 3:23 p.m., Confidential complainant stated an allegation had been made towards one of the workers at outside of the facility where she worked at independent living skills office. Confidential complainant stated it was overheard and she was not sure if this incident even occurred that her employee Community Support Advocate B had purchased a candy bar with Resident #1's money. Confidential complainant stated her coworkers name was Community Support Advocate B who was suspected of taking money from the resident to buy candy from the vending machine Confidential complainant stated the Community Support Advocate B informed her that he did not purchase a candy bar with the resident's money. Confidential complainant stated she wanted to make sure the resident was not being taken advantage of. During a phone interview on 3/11/25 at 4:38 p.m., Community Support Advocate B stated he never used the resident's money to purchase a fountain drink. Community Support Advocate B stated he did not use the resident's money to purchase a candy bar from the vending machine. Community Support Advocate B stated he came to see the resident every Wednesday morning. Community Support Advocate B stated he had never told the resident that he had authority over him. Community Support Advocate B stated he just makes sure the resident was safe when he leaves the building and when he comes back to the facility. During an interview on 3/11/25 at 3:45 p.m., Resident #1 stated the Community Support Advocate B always buys his drinks with Resident#1's money. Resident #1 stated Community Support Advocate B buys coca cola fountain drinks with Resident #'1's money. Resident #1 stated the Community Support Advocate B always asked the resident how much money he had and was his money in his account. Resident #1 stated when Community Support Advocate B would take him to the store that he would tell him, Don't go that way, come this way. Resident #1 stated he did not like Community Support Advocate B telling him not to go certain places in the store. Resident #1 stated he went shopping every week with Community Support Advocate B. Resident #1 stated he did not like shopping every week. Resident #1 stated Community Support Advocate B always asked him, How much money you got, and I got authority over you. Resident #1 stated he did not like Community Support Advocate B stating that he had authority over him. Resident #1 stated he did not know anything about Community Support Advocate B buying candy from the vending machine using his money. During an interview on 3/11/25 at 4:29 p.m., LVN A stated she did not overhear Resident #1 say anything regarding Resident #'1s money being spent on the community Support Advocate B from the vending machines. LVN A stated in the morning meeting someone had told her, Hey, off the cuff I overheard that the PASRR guy had used the resident #1's money to purchase a candy bar. LVN A stated that, Resident #1 thought that Community Support Advocate B had put a candy bar up there for him to pay for it one time when they were out at the store. LVN A stated that this information was said to her at the morning meeting on Friday 3/7/25. LVN A stated she did not remember who brought it up in the morning meeting. LVN A stated all of the department heads attended the morning meetings. LVN A stated the rumor on the Community Support Advocate B using the resident's money for a candy bar at the vending machine should have been reported to the Administrator, but she figured everyone heard the discussion at the morning meeting. LVN A stated she notified IDD office. LVN A stated she reported to IDD office because Community Support Advocate B was not one of the facility's employees. LVN A stated Community Support Advocate B sees Resident #1 once a week. LVN A stated she was not sure if they went to the store every week. During an interview on 3/12/25 at 9:01 a.m., LVN A stated the Administrator oversaw her. LVN A stated she was the MDS Coordinator. LVN A stated the abuse coordinator was the Administrator. LVN A stated she did not know when the exact time frame of when Community Support Advocate B was supposed to have used the resident's money for the candy bar. LVN A stated she last completed abuse and neglect in-services yesterday 3/11/25. LVN A stated, It would be important to report ANE (Abuse, Neglect, exploitation) to prevent and to protect the residents against any forms of abuse and exploitation; be a voice for them when they cannot be a voice for themselves. During an interview on 3/12/25 at 9:17 a.m., with the Administrator, she stated she had been the Administrator since the middle of December 2025. The Administrator stated she oversaw the MDS Coordinator. The Administrator stated she was the abuse coordinator. The Administrator stated she last provided in-services on abuse and neglect yesterday 3/11/25. The Administrator stated she did not remember overhearing about misappropriation of property for Resident #1. The Administrator stated she was responsible for reporting ANE to State. The Administrator stated this incident should have been reported to State and investigated. The Administrator stated the reason why it was not investigated and reported was because she was not made aware of the incident by LVN A. The Administrator stated the State guideline and the facility's policy for reporting ANE was 24 hours. The Administrator stated this incident occurred at a local store. The Administrator stated the resident stated it was a little package of donuts that the resident reported to her of what Resident #1 spent with his money. The Administrator stated she did not know how often Resident #1, and Community Support Advocate B went to the store. The Administrator stated it was important to investigate, report and follow facility's policy on ANE to protect the residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents had the right to a safe, clean, comfortable, and homelike environment for 1 of 6 resident rooms (room [ROOM NUMBER]) reviewed for the homelike environment. The facility failed to ensure Resident #4's room was without urine odor during the surveyors observation 04/28/24 through 05/02/24. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept and clean environment. Findings included: 1.Record review of Resident #4's face sheet dated 05/02/24, indicated a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses including seizures, Pseudobulbar affect {PBA} (a condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), high blood pressure, and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). Record review of Resident #4's quarterly MDS assessment dated [DATE], indicated she rarely understood and was sometimes understood by others. Resident #4's had short and long-term memory deficits. The MDS indicated Resident #4 required total assistance with toileting, dressing, bathing, and extensive assistance with personal hygiene, transfers, eating, and bed mobility. The MDS indicated she was always incontinent of bowel and bladder. Record review of Resident #4's comprehensive care plan dated 03/25/21, indicated she had bowel and bladder incontinence. The interventions were for staff to provide incontinence care, check her for incontinent episodes every 2 hours, and assist as needed. During an observation on 04/28/24 at 12:20 p.m., Resident #4 was in her bed with no clothes on. The room smelled of urine and bowel with bowel feces observed on the resident. During an observation on 04/29/24 at 10:35 a.m., Resident #4 was in her bed with a brief and a blanket. The room smelled of urine. During an observation and interview on 04/29/24 at 5:24 p.m., the treatment nurse walked into Resident #4's room and said it smelled like urine. She said Resident #4 often removed her briefs and urinated on the mattress. During an observation and interview on 04/29/24 at 5:25 p.m., Housekeeper U said Resident #4's room does smell like bowel and urine at times. She said she was using the chemicals they had to clean each room. She said they clean the mattress and fall mats daily. She said she would not like her house to smell of urine. During an interview on 04/29/24 at 5:28 p.m., Resident #47, roommate of Resident #4 said the room does smell like urine at times. She said she and her roommate were incontinent of urine and they could not help it. She said she did not say anything to anyone about the urine smell because she said it could have been her. During an observation and interview on 04/30/24 at 4:57 p.m., The Administrator said he went to Resident #4's room and smelled urine in her room. He said he looked for the source and found soiled clothes in her closet. He said the resident had the wrong type of hamper in her room. He said he would call the family and have them bring the correct type of hamper. He said if a visitor smelled urine odor in the facility, they would assume we did not give diligent care. He said he expected all rooms to be free of urine odor. Record review of the facility policy of Resident Rights, dated 11/08/16, revealed, Safe environment: the resident has a right to a clean, safe, comfortable and home-like environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 22 residents (Resident #219) reviewed for abuse and neglect. The facility failed to ensure CNA G and SNA H provided incontinent care every two hours as required for Resident #219 on 04/30/24, which resulted in a strong urine odor and wet, brown stains to her sheets and mattress. This failure could result in pressure injuries, infections, psychosocial harm, and a decreased quality of life. Findings included: Record review of a face sheet dated 05/02/24 indicated Resident #219 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with behaviors). Record review of Resident #219's care plan date initiated 04/30/24 indicated she had an ADL self-care performance deficit and required the assistance of 1 staff for bathing, bed mobility and dressing and required assistance with personal hygiene. Resident #219's care plan indicated she had a potential for pressure ulcer development to provide incontinent care after each episode and apply moisture barrier. Record review of Resident #219's electronic health record on 05/02/24 indicated the MDS assessment had not been completed yet. During an observation and interview on 04/30/24 starting at 5:20 PM, a strong urine odor was noted in Resident #219's room. Resident #219 said she had not been changed but was unable to provide a timeframe. Resident #219 said she was not feeling good. CNA G and SNA H to turned Resident #219 to make an observation of her buttocks. CNA G asked if she could do it after passing the dinner trays because it was time for dinner. Instructed CNA G to have the nurse come to the room, due to the strong urine odor in the room. LVN F came into the room and turned Resident #219 onto her side. Upon turning her Resident #219 had a dark brown stain extending up her buttocks with the edges darker brown then the center. LVN F agreed the urine odor was very strong. LVN F left the room and had the nurse aides return and provide incontinent care. CNA G and SNA H turned Resident #219 and brown stain extended down to the mattress. The blue mattress was darker where Resident #219's buttocks were with stain-like areas extending out. CNA G said she did not feel the mattress was wet with urine. SNA H said she was not sure if it was wet or not. The mattress was felt and noted to be wet in the center, and the stain-like areas that extended out were dry. During an interview on 04/30/24 at 5:47 PM, CNA G said she had changed Resident #219 after lunch around 12:30 PM. CNA G said Resident #219 was a heavy wetter and she should be changed more frequently. CNA G said she was supposed to round on the residents and check them every 2 hours. CNA G said she had not checked on Resident #219 as frequently as she should because she had other duties to perform, and she got sidetracked. CNA G said it was important to provide incontinent care to the residents frequently so they did not have skin breakdown, and because they could get an infection. During an interview on 04/30/24 at 5:54 PM, SNA H said CNA G and herself were caring for Resident #219, and they were providing care for the residents on the hall together. SNA H said the last time they changed Resident #219 was before breakfast. SNA H said they were going to get Resident #219 out of bed at lunchtime, but she did not want to get out of bed. SNA H said they had not attempted to provide incontinent care. SNA H said they were supposed to check on the residents every hour at least. SNA H said it was important to provide incontinent care to prevent infections. During an interview on 04/30/24 at 6:05 PM, LVN F said the nurse was responsible for ensuring the nurse aides provided prompt incontinent care. LVN F said it appeared as Resident #219 had not been changed all day. LVN F said the nurse aides should be checking on the residents at least every 2 hours. LVN F said not providing incontinent care promptly could cause bed sores and infections. During an interview on 05/02/24 starting at 6:28 PM, the DON said in the past the residents had complained about not getting changed promptly, and she had in serviced the CNAs. The DON said the nurse aides should be checking on the residents at least every 2 hours. The DON said not providing prompt incontinent care could result in pressure injuries and infection. The DON said the charge nurses and herself were responsible for ensuring the nurse aides provided prompt incontinent care. The DON said she monitored the nurse aides by checking the tasks in the electronic health record to see if the nurse aides has provided incontinent care. The DON said the nurse aides not changing Resident #219 could be considered neglect. During an interview on 05/02/24 starting at 7:37 PM, the Administrator said the incident with Resident #219 not being changed was confirmed. The Administrator said Resident #219 was wet and had not been changed, and it could be considered neglect. The Administrator said he was still trying to pin down the exact timeframe for her not being changed. The Administrator said the nurse aides should be checking on the residents every 2 hours and more frequently for those that were heavy wetters. The Administrator said not changing the residents frequently could result in skin breakdown, they could be affected psychologically for laying in urine. The Administrator said the charge nurses should be monitoring the nurse aides and providing immediate oversight. Record review of the facility's policy revised 03/29/18, titled, Abuse/Neglect, indicated, The resident has the right to be free from abuse, neglect, misappropriation, of resident property, and exploitation as defined in this subpart . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm pain, mental anguish, or emotional distress .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit neglect and abuse for 1 of 22 residents (Resident #11 and Resident #219) reviewed for abuse and 1 of 21 staff (LVN K) reviewed for abuse training. The facility failed to ensure the Social Worker followed the facility's policy when he did not immediately report Resident #11's allegation of verbal abuse by Resident #219 to the Administrator on 04/28/24. The facility failed to follow its policy when LVN K did not complete abuse training upon hire on 03/05/24. These failures could place residents at risk of abuse, neglect, and decreased quality of life. Findings included: 1. Record review of a face sheet dated 05/02/24 indicated Resident #11 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system) and anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #11 was usually understood by others and understood others. The MDS assessment indicated Resident #11 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment did not indicate physical or verbal behavioral symptoms directed towards others. Record review of Resident #11's care plan with last review completed on 03/29/2024 indicated she had a hard time coping with a roommate that the social worker and staff would monitor if the resident was unable to cope with her roommate, and the social worker would try to fine another roommate for the resident. During an interview on 04/28/24 at 4:00 PM, Resident #11 said her roommate (Resident #219) had cussed her out the other night and today had threatened to kill her with a gun she had. Resident #11 said she had not reported to staff that Resident #219 had cussed at her the other night, but today she had gotten the nerve to let the Social Worker know about her roommate threatening to kill her because she was scared of her. Resident #11 said she was not sure if her roommate, Resident #219, could get out of her chair on her own, but what if her roommate could and she did something to her. 2. Record review of a face sheet dated 05/02/24 indicated Resident #219 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with behaviors). Record review of Resident #219's care plan date initiated 04/30/24 indicated she had impaired cognitive function/dementia or impaired thought processes. Record review of Resident #219's electronic health record on 05/02/24 indicated the MDS assessment had not been completed yet. During an interview on 04/28/24 at 4:15 PM, the Social Worker said Resident #11 had told him her roommate, Resident #219, had accused her of stealing her purse and was mean to her. The Social Worker said Resident #11 was kind of crying about it when she told him. The Social Worker said Resident #11 had brought up to him that Resident #219 said she was going to kill her. The Social Worker said he believed Resident #219 was not capable of yelling or cursing at Resident #11, and she could not do anything to Resident #11. The Social Worker said Resident #11 had told him about 1-2 hours ago and she was crying. The Social Worker said he had not reported the incident to anyone. The Social Worker said since he believed Resident #219 could not hurt Resident #11, he was going to wait until the morning meeting the next day to bring up what Resident #11 had reported to him to see if they could change rooms or what could be done. During an interview on 04/28/24 at 4:27 PM, the Administrator said nothing had been reported to him regarding any incidents with Resident #11 and Resident #219. Surveyor intervention required and reported Resident #11's allegations regarding Resident #219. The Administrator said he was not aware of the situation, and the Social Worker should have reported the incident to him immediately. The Administrator said any threats or resident to resident altercations should be reported to him immediately. During an interview on 05/01/24 at 9:14 AM, Resident #219 said she had not threatened to kill anyone, and she had never yelled at anyone else or cussed at them. During an interview on 05/01/24 at 3:52 PM, the Social Worker said he had only been employed at the facility for 3 months, and he was still learning about long-term care facilities. The Social Worker said Resident #219 threatening Resident #11 could be considered verbal abuse and he should have reported it to the abuse coordinator. The Social Worker said initially when Resident #11 reported Resident #219's threat he did not think it was abuse, and he thought it was more of a grievance. The Social Worker said he had received training on abuse, but he was still learning. The Social Worker said it was important for abuse to be reported so the residents could feel safe. 3. Record review of the undated Recruiter Payroll Form indicated LVN K was hired on 03/05/24. Record review of LVN K's trainings dated 05/02/24 indicated, new hire orientation abuse prevention was completed on 03/25/24, which indicated it was completed 20 days late. During an interview on 05/02/24 at 5:56 PM, the Human Resource Coordinator said LVN K was hired back on 03/05/24. The Human Resource Coordinator said the abuse training should be completed within 3-5 days of hire. The Human Resource Coordinator said LVN K's was completed about 20 days after hire, and it should have been completed before. The Human Resource Coordinator said she was responsible for ensuring the abuse training was completed upon hire, and she did not know why LVN K's abuse training was not completed upon hire. The Human Resource Coordinator said it was important for the abuse training to be completed upon hire, so the staff knew the protocols and what to do if abuse was suspected. During an interview on 05/02/24 at 8:55 PM, the Administrator said the Human Resource Coordinator was responsible for ensuring the abuse training was completed upon hire. The Administrator said he expected for the staff to complete the abuse training on hire. The Administrator said it was important for the new staff to complete the abuse training on hire, so they knew who to report abuse to and what the types of abuse were. Record review of the facility's policy revised 03/29/18, titled, Abuse/Neglect, indicated, The resident has the right to be free from abuse, neglect, misappropriation, of resident property, and exploitation as defined in this subpart . Verbal Abuse: any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability . Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident . The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. 1. New employee orientation will consist of educational resources to identify abuse, neglect, exploitation, and misappropriation of resident property .2. The facility will maintain documentation of all educational in-services . When a suspected abused, neglected, exploited, mistreated, or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist and/or designee will be called. 3. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator . Record review of the Facility Assessment date completed/updated 04/11/24 indicated, Education/In-services Resident Abuse should be completed immediately upon hire for all staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 22 residents (Resident #11 and Resident #219) reviewed for abuse and neglect reporting. The facility failed to ensure the Social Worker reported Resident #11's allegation of verbal abuse by Resident #219 immediately to the Administrator on 04/28/24. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of a face sheet dated 05/02/24 indicated Resident #11 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system) and anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #11 was usually understood by others and understood others. The MDS assessment indicated Resident #11 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment did not indicate physical or verbal behavioral symptoms directed towards others. Record review of Resident #11's care plan with last review completed on 03/29/2024 indicated she had a hard time coping with a roommate that the Social Worker and staff would monitor if the resident was unable to cope with her roommate, and the social worker would try to fine another roommate for the resident. During an interview on 04/28/24 at 4:00 PM, Resident #11 said her roommate (Resident #219) had cussed her out the other night (Resident #11 was unable to provide an exact date) and today had threatened to kill her with a gun she had. Resident #11 said she had not reported to staff that Resident #219 had cussed at her the other night, but today she had gotten the nerve to let the Social Worker know about her roommate threatening to kill her because she was scared of her. Resident #11 said she was not sure if her roommate, Resident #219, could get out of her chair on her own, but what if she could and she did something to her. 2. Record review of a face sheet dated 05/02/24 indicated Resident #219 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with behaviors). Record review of Resident #219's care plan date initiated 04/30/24 indicated she had impaired cognitive function/dementia or impaired thought processes. Record review of Resident #219's electronic health record on 05/02/24 indicated the MDS assessment had not been completed yet. During an interview on 04/28/24 at 4:15 PM, the Social Worker said Resident #11 had told him her roommate, Resident #219, had accused her of stealing her purse and was mean to her. The Social Worker said Resident #11 was kind of crying about it when she told him. The Social Worker said Resident #11 had brought up to him that Resident #219 said she was going to kill her. The Social Worker said he believed Resident #219 was not capable of yelling or cursing at Resident #11, and she could not do anything to Resident #11. The Social Worker said Resident #11 had told him about 1-2 hours ago and she was crying. The Social Worker said he had not reported the incident to anyone. The Social Worker said since he believed Resident #219 could not hurt Resident #11, he was going to wait until the morning meeting the next day to bring up what Resident #11 had reported to him to see if they could change rooms or what could be done. During an interview on 04/28/24 at 4:27 PM, Surveyor asked the Administrator if the Social Worker had reported any incidents regarding Resident #11 and Resident #219. The Administrator said nothing had been reported to him. Surveyor reported Resident #11's allegations regarding Resident #219. The Administrator said he was not aware of the situation, and the Social Worker should have reported the incident to him immediately. The Administrator said any threats or resident to resident altercations should be reported to him immediately. During an interview on 05/01/24 at 9:14 AM, Resident #219 said she had not threatened to kill anyone, and she had never yelled at anyone else or cussed at them. During an interview on 05/01/24 at 3:52 PM, the Social Worker said he had only been employed at the facility for 3 months, and he was still learning about long-term care facilities. The Social Worker said Resident #219 threatening Resident #11 could be considered verbal abuse and he should have reported it to the abuse coordinator. The Social Worker said initially when Resident #11 reported Resident #219's threat he did not think it was abuse, and he thought it was more of a grievance. The Social Worker said he had received training on abuse, but he was still learning. The Social Worker said it was important for abuse to be reported so the residents could feel safe. Record review of the facility's policy revised 03/29/18, titled, Abuse/Neglect, indicated, The resident has the right to be free from abuse, neglect, misappropriation, of resident property, and exploitation as defined in this subpart . Verbal Abuse: any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability . Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident . When a suspected abused, neglected, exploited, mistreated, or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist and/or designee will be called .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review , the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 4 (Resident #54) residents reviewed for comprehensive person-centered care plans. The facility failed to care plan Resident #54's interventions, diagnoses, and medication use of Trazodone (an antidepressant medication used to help with her sleep). This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1.Record review of Resident #54's face sheet, dated 05/02/24, indicated Resident #54 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included insomnia, high blood pressure, Dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), stroke, and diabetes. Record review of Resident #54's quarterly MDS assessment, dated 02/27/24, indicated Resident #54 sometimes understood and sometimes understood by others . Resident #54's BIMS score was 00, which indicated her cognition was severely impaired . Resident #54 required extensive assistance with toileting, limited assistance with personal hygiene, transfer, dressing, bed mobility, and set-up with eating. The MDS indicated she used antidepressant medications. Record review of Resident #54's physician orders dated 11/22/23, indicated Trazodone HCI Oral Tablet 150 MG, Give 1 tablet by mouth 1 time a day for insomnia/mood. Record review of Resident #54's comprehensive care plan dated 12/04/23 did not indicate any plan of care or interventions for the medication use of Trazadone. During an observation and interview on 05/02/24 at 4:00 p.m., the MDS nurse said she was responsible for the comprehensive care plans, but all the department heads did their acute care plans. The MDS nurse and the surveyor looked at Resident #54's care plan together and she said she did not see her use of Trazadone on the care plan. The MDS nurse said the diagnoses and interventions should have been listed on Resident #54's care plan. She said the omissions were an oversight. She said care plans were done to address concerns and for continuity of care so that the residents could have the best possible outcome for their care. During an interview on 05/02/24 at 6:51 p.m., the DON said the MDS nurse was responsible for completing the care plans. She said she was the overseer. The DON said she was not aware that Resident 54's medication use of Trazadone was not care planned. She said care plans reflected residents' care and needs and should have been complete and accurate to ensure the residents received the care they needed. During an interview on 05/02/24 at 7:54 p.m., the Administrator said all disciplinaries should work together to complete a resident's care plan. He said the DON was the overseer. He said Resident #54 should have had intervention, diagnoses, and medication indicated on their care plan. He said care plans were generated to provide each resident with the best care. Record review of Resident #54's comprehensive care plan, dated 05/02/24 (after the state surveyor intervention) indicated: Resident #54 was on antidepressant medication of Trazadone related to insomnia. The interventions were for staff to administer antidepressant medication as ordered by the physician and monitor for side effects and effectiveness. Record review of the facility Policy titled, Comprehensive Care Planning, indicated, the facility will develop and implement A comprehensive person-centered care plan for each resident comma consistent with the resident rights that includes measurable objectives and time frames to meet a residence medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals and address the resident's medical, physical, mental, and psychosocial needs. A comprehensive care plan will be developed within seven days after completion of the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 22 residents (Resident #219) reviewed for incontinence. 1. The facility failed to ensure Resident #219 was provided prompt and proper incontinent care. 2. The facility failed to ensure CNA C properly cleaned the peri area, changed gloves, and used hand hygiene before going from dirty to clean while providing incontinent care to Resident #54. These failures could place residents at risk for urinary tract infections, skin breakdown, and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 05/02/24 indicated Resident #219 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with behaviors). Record review of Resident #219's care plan date initiated 04/30/24 indicated she had an ADL self-care performance deficit and required the assistance of 1 staff for bathing, bed mobility and dressing and required assistance with personal hygiene. Resident #219's care plan indicated she had a potential for pressure ulcer development to provide incontinent care after each episode and apply moisture barrier. Record review of Resident #219's electronic health record on 05/02/24 indicated the MDS assessment had not been completed yet. During an observation and interview on 04/30/24 starting at 5:20 PM, a strong urine odor was noted in Resident #219's room. Resident #219 said she had not been changed but was unable to provide a timeframe. CNA G and SNA H provided incontinent care. CNA G and SNA H donned gloves. CNA G wiped Resident #219's front peri area, tucked the dirty brief and they turned Resident #219 on her side. Resident #219 had a dark brown stain extending up her buttocks with the edges darker brown then the center. The brown stain extended down to the mattress. The blue mattress was darker where Resident #219's buttocks were with stain-like areas extending out. CNA G said she did not feel the mattress was wet with urine. SNA H said she was not sure if it was wet or not. Surveyor touched the mattress, and it was wet in the center, and the stain-like areas extending out were dry. SNA H wiped Resident #219's buttock because she also had a bowel movement. SNA H used the same wipe to clean Resident #219's buttocks multiple times. SNA H did not use a clean area of the wipe for each stroke. SNA H continued to wipe Resident #219's buttocks and peri area wiping with the same wipe multiple times. SNA H and CNA G proceeded to apply the clean brief and clean sheets. SNA H and CNA G did not change gloves. They used their dirty gloves to apply the clean brief and sheets. SNA H and CNA G had the clean sheet and dirty sheet and brief touching each other while tucking it under Resident #219. SNA H and CNA G turned Resident #219 to the opposite side and removed the dirty linens and dirty brief and disposed of it. SNA H and CNA G repositioned Resident #219 in bed and covered her up using the same dirty gloves. During an interview on 04/30/24 at 5:47 PM, CNA G said she had changed Resident #219 after lunch around 12:30 PM. CNA G said Resident #219 was a heavy wetter and she should be changed more frequently. CNA G said she was supposed to round on the residents and check them every 2 hours. CNA G said she had not checked on Resident #219 as frequently as she should because she had other duties to perform, and she got sidetracked. CNA G said she was supposed to change gloves a lot, but she had only taken one pair of gloves with her to provide incontinent care to Resident #219. CNA G said she should change gloves and perform hand hygiene when going from dirty to clean. CNA G said when wiping the residents, the same wipe should not be used multiple times. CNA G said it was important to provide incontinent care to the residents frequently so they did not have skin breakdown, and because they could get an infection. During an interview on 04/30/24 at 5:54 PM, SNA H said CNA G and herself were caring for Resident #219, and they were providing care for the residents on the hall together. SNA H said the last time they changed Resident #219 was before breakfast. SNA H said they were going to get Resident #219 out of bed at lunchtime, but she did not want to get out of bed. SNA H said they had not attempted to provide incontinent care. SNA H said they were supposed to check on the residents every hour at least. SNA H said when wiping the residents, she should only wipe once and discard the wipe. SNA H said the same wipe should not be used to wipe multiple times. SNA H said gloves should be changed after she cleaned the front area and before she touched the back area. SNA H said she did not wipe correctly and change gloves as she should because she was nervous. SNA H said it was important to provide prompt and proper incontinent care to prevent infections. During an interview on 04/30/24 at 6:05 PM, LVN F said the nurse was responsible for ensuring the nurse aides provided prompt and proper incontinent care. LVN F said it appeared as Resident #219 had not been changed all day. LVN F said the nurse aides should be checking on the residents at least every 2 hours. LVN F said when providing incontinent care gloves should be changed when moving from dirty to clean. LVN F said the same wipe should not be used to wipe multiple times because this could cause urinary tract infections. LVN F said not providing incontinent care promptly could cause bed sores and infections. During an interview on 05/02/24 starting at 6:28 PM, the DON said in the past the residents had complained about not getting changed promptly, and she had in serviced the CNAs. The DON said the nurse aides should be checking on the residents at least every 2 hours. The DON said when providing incontinent care gloves should be changed after cleaning the residents and before putting anything new on. The DON said the nurse aides should not use the same wipe to wipe multiple times that a clean area or new wipe should be used. The DON said the charge nurses and herself were responsible for ensuring the nurse aides provided prompt incontinent care. The DON said she provided oversight on proper incontinent care by randomly going in with the nurse aides to provide incontinent care. The DON said she had not noticed any issues with incontinent care. The DON said it was important to provide prompt and proper incontinent care for infection control. During an interview on 05/02/24 starting at 7:37 PM, the Administrator said the nurse aides should be checking on the residents every 2 hours and more frequently for those that were heavy wetters. The Administrator said he expected the nurse aides to follow the incontinent procedures. The Administrator said the DON and ADON were responsible for providing oversight, but currently there was no ADON. The Administrator said not providing prompt and proper incontinent care was a potential for infection issues. 2. Record review of Resident #54's face sheet, dated 05/02/24, indicated Resident #54 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included insomnia, high blood pressure, Dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), stroke, and diabetes. Record review of Resident #54's quarterly MDS assessment, dated 02/27/24, indicated Resident #54 sometimes understood and was sometimes understood by others . Resident #54's BIMS score was 00, which indicated she was severely cognitively impaired. Resident #54 required extensive assistance with toileting, limited assistance with personal hygiene, transfer, dressing, bed mobility, and set-up with eating. The MDS indicated she was occasionally incontinent of bowel and bladder. Record review of Resident #54's physician orders dated 04/28/24, indicated Nitrofurantoin (Macrobid) Oral Capsule 100 MG, Give 1 capsule by mouth two times a day for UTI (urinary tract infection) for 7 Days. Record review of Resident #54's comprehensive care plan, dated 12/11/23, indicated Resident #54 was at risk of ADL self-performance for bowel and bladder incontinence. The interventions were for staff to assist with toileting x 1 assistance and monitor for signs and symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, and change in behavior. Record review of Resident #54's MAR dated 04/01/24 through 04/30/24 revealed Nitrofurantoin (Macrobid) Oral Capsule 100 MG, give 1 capsule by mouth two times a day for UTI (urinary tract infection) for 7 Days- started 04/28/24. During an observation on 04/30/24 at 10:21 a.m., CNA C was providing care to Resident #54, who was incontinent of bowel and bladder. CNA C explained what she was going to do. She wiped her genital area using a front-to-back motion. She then turned her on her side while touching her shoulder and side with the same dirty gloves. She proceeded to wipe her buttocks using only one front-to-back motion. She did not wipe her entire buttock which contained urine. She then changed her gloves without hand hygiene and applied her brief. CNA C then left the room without hand hygiene. During an interview on 04/30/24 at 10:44 a.m., CNA C said she was supposed to wipe front to back and clean the entire buttock area. She said she should have performed hand hygiene after removing her soiled gloves and applying new gloves, and before exiting the room. She said she did not wipe or do hand hygiene correctly which could lead to infection. CNA C said she was not aware Resident #54 had a UTI. She said she knew the correct way to provide incontinent care but was nervous and, in a hurry, to get other residents as it was getting close to lunch. During an interview on 05/02/24 at 6:51 p.m., the DON said she expected incontinent care to be performed correctly. The DON said she expects the CNAs to clean all areas that contain urine or bowel. She said she expected them to perform hand hygiene before and after providing incontinent care, change their gloves when going from dirty to clean, and in between glove changes. She said she randomly checked staff while doing incontinent care but felt she needed more time than she had to watch everyone. The DON said not performing incontinent care and hand hygiene correctly could lead to infection. During an interview on 05/02/24 at 7:54 p.m., the Administrator said he expected staff to perform incontinent care and hand hygiene properly. He said if proper incontinent care and/or hand hygiene was not provided correctly it could lead to infection. Record review of the facility's policy titled, Perineal Care, effective date 05/11/22, indicated, . This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections . Female resident: Working from front to back, wipe . Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke. 20) Reposition the resident to their side 21) Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area . 24) Doff gloves and PPE 25) Perform hand hygiene 26) Provide resident comfort and safety by re-clothing (if applicable - incontinence pad(s) and briefs), straightening bedding, adjusting the bed and/or side rails, and placing call light within resident's reach 27) Clean and store reusable items 28) If visibly soiled or contaminated during the procedure, disinfect or discard the barrier towel on the table 29) Return resident items on the table 30) Tie off the disposable plastic bag of trash and/or linen 31) Perform hand hygiene . Important Points . Do not wipe more than once with the same surface . Always perform hand hygiene before and after glove use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of the face sheet, dated 04/29/2024, revealed Resident #8 was a [AGE] year-old-female who admitted to the facility on [DATE], with diagnoses of dementia( the loss of cognitive abilities that affect a person's ability to think, remember, and make decision) acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissue in your body), unspecified lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements), Record review of the MDS assessment, dated 03/13/2024, revealed Resident #8's BIMS score was 12 indicating Resident #8 was moderately cognitively impaired, she understood as well as being understood by others. The MDS assessment revealed Resident #8 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS assessment indicated Resident # 8 was receiving oxygen therapy. Record review of Resident #8's care plan, revision date 03/11/24, indicated Resident #8 received oxygen therapy. Record review of Resident #8's order summary, dated 04/29/2024, indicated Resident #8 received oxygen therapy at 2-4 liter per minute via nasal canula continuous. During observation and interview on 04/28/2024 at 10:43 a.m., Resident #8 was lying in bed and oxygen nasal cannula was on the floor. Resident #8's oxygen concentrator filter was covered in gray fuzzy material. Resident #8 stated she wore oxygen all the time, but the tubing had water in it and the nurse had to get her new tubing. During observation on 04/29/2024 at 8:10 a.m., Resident #8 was lying in bed, watching TV, the nasal cannula was on the floor, and the oxygen concentrator filter was covered with gray fuzzy material. During an interview on 04/29/2024 at 5:32p.m., LVN S confirmed Resident #8's oxygen nasal cannula was on the floor and the oxygen concentrator filter was covered with gray fuzzy material. LVN S stated it was the nurse's responsibility for ensuring the nasal cannula was on the resident or properly stored and to clean the concentrators. LVN S stated it was important to clean the oxygen concentrator and properly store nasal cannula to prevent bacteria and other organisms from growing in the line. LVN S stated the risk associated was Resident #8 could get a respiratory infection or the oxygen concentrator could catch on fire with a dirty filter. During an interview on 05/02/2024 at 6:38 p.m., the DON stated it was the nurse's responsibility to clean the oxygen concentrators on Sunday night. The DON stated it was important to keep the oxygen concentrator filters clean and the tubing properly stored to prevent infection. The DON stated the risk to the resident was infection. During an interview on 05/02/2024 at 7:35 p.m., the ADM stated he expects the nurse staff to store the nasal cannula in a plastic bag and clean the oxygen concentrator when they were soiled. The ADM stated it was the responsibility of the nurse to monitor. The ADM stated the risk to the resident was infection. Record review of the facility's policy titled, Oxygen Administration . Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated. Oxygen concentrators should be cleaned according to manufacturer recommendations. Change or clean oxygen concentrator filters according to manufactures' recommendations . Based on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 4 residents (Residents #19 and Resident #8) reviewed for respiratory care. 1. The facility failed to ensure Resident #19's handheld nebulizer was properly stored. 2. The facility failed to properly store Resident #8's nasal cannula. 3. The facility failed to properly clean Resident #8's oxygen concentrator. These failures could place residents requiring respiratory care at risk for respiratory infections or complications. Findings included: 1. Record review of a face sheet dated 05/02/24 indicated Resident #19 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #19 was able to make herself understood and usually understood others. The MDS assessment indicated Resident #19 had a BIMS score of 13, which indicated her cognition was intact. The MDS assessment did not indicate the use of oxygen therapy. Record review of Resident #19's care plan last reviewed on 02/20/24 indicated she had chronic obstructive pulmonary disease to administer aerosol or bronchodilators (medications used to treat shortness of breath) as ordered. Record review of the Order Summary Report dated 04/28/24 indicated Resident #19 had orders for furosemide (medication used to treat shortness of breath) 4 ml inhale orally via nebulizer every 6 hours as needed for shortness of breath, ipratropium-albuterol solution (medication used to treat wheezing and shortness of breath) 3 milliliter inhale orally every 6 hours as needed for shortness of breath or wheezing via nebulizer, and glycopyrrolate (medication used to treat shortness of breath) 14 mcg 1 capsule inhale orally via nebulizer every 4 hours as needed for increased secretions mix with 3 ml of normal saline 0.9% and give via nebulizer. During an observation on 04/28/24 at 10:20 AM, Resident #19's handheld nebulizer was lying at the bedside not stored in a bag exposed to the air and surroundings. During an interview on 05/02/24 at 5:46 PM, LVN N said handheld nebulizers should be stored in a bag when not in use. LVN N said everybody was responsible for ensuring they were stored in a bag. LVN N said she did not notice Resident #19's handheld nebulizer was not stored in a bag. LVN N said it was important for the handheld nebulizers to be stored in a bag to ensure germs would not get on them. LVN N said leaving them at the bedside exposed to the air could lead to an infection and respiratory illnesses. During an interview on 05/02/24 at 6:48 PM, the DON said handheld nebulizers should be stored in a plastic bag. The DON said the nurses working at night should ensure they were stored in a bag. The DON said she provided oversight to ensure the nurses were storing the handheld nebulizers properly. The DON said it was important to store the handheld nebulizers in a bag for infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents were given psychotropic medications to treat specific diagnoses for 1 (Resident #46) of 5 Residents, reviewed for pharmacy services. The facility failed to ensure that Resident #46 did not receive an antipsychotic (Seroquel/Quetiapine Fumarate) that was not necessary to treat Vascular Dementia. This failure could place residents at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The findings included: Record review of Resident #46's face sheet indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses of Vascular Dementia (a series of strokes that caused decreased oxygen to the brain and neurological deficits), anxiety disorder (unpleasant state of inner turmoil), chronic obstructive pulmonary disease (progressive lung disease characterized by long term respiratory symptoms), hypertension (high blood pressure), and cerebral infarction (disrupted blood flow to the brain causing parts to die). Record review of Resident #46's significant change MDS assessment dated [DATE] indicated she had a BIMS score of 08 which indicated she had moderate cognitive impairment. The MDS also did not indicate resident had a diagnosis to support the use of the use of the anti-psychotic medication Seroquel/Quetiapine, but Resident #46 received the medication on a routine basis. Record review of Resident #46's care plan revised 03/05/24 indicated Focus Resident requires antipsychotic medications r/t anxiety. Interventions included Administer medications as ordered. Monitor/document for side effects and effectiveness Record review of Resident #46's order summary report dated 05/02/24 indicated she had an order for Quetiapine Fumarate Tablet 25mg (an antipsychotic medication used to treat schizophrenia and bipolar disorder) Give 1 tablet by mouth two times a day related to Vascular Dementia with a start date of 03/05/24. Record review of the psychotropic medication utilization report dated 03/31/24 indicated the pharmacy consultant was aware that Resident #46 had started the Seroquel 03/05/24 for the diagnosis of dementia and no recommendations were made. During an interview on 05/02/24 at 05:47 PM LVN B said the only diagnoses that could be used for the medication Seroquel was Huntington's, schizophrenia, and another one that she could not think of. She said staff could not give Seroquel to residents with dementia, and she thought there was a black box warning, but she was not the doctor. LVN B said it also affected quality measures at a nursing facility. LVN B said she knew Resident #46 took Seroquel but did not realize her diagnosis was for dementia. She said her taking the medication without the proper diagnosis placed her at risk for increased confusion, worse side effects or adverse reactions, or increased behaviors. LVN B said the facility doctor and hospice doctor was responsible for adding the medication Seroquel for the dementia, but she did not agree with it. During an interview on 05/02/24 at 07:15 PM, the DON said the approved diagnosis for Seroquel use was schizophrenia. She said dementia was not an approved diagnosis for Resident #46 to be taking the medication Seroquel. The DON said Resident #46 was not a new resident to the facility and had been taking the Seroquel for a while. She said she had not talked to the doctor about the medication yet, but she would be contacting him regarding the medication. The DON said Resident #46 taking Seroquel without the proper diagnosis placed her at a higher risk for contraindications, worsening side effects, or confusion. During an interview on 05/02/24 at 8:32 PM the Administrator said he was not familiar with the antipsychotic medications nor what they are given for. Record review of the facility's policy for Pharmacy Policy and Procedure Manual revised 10/25/17 indicated: Consultant Pharmacist The facility will contract the services of a pharmacist to provide consultation on all aspects of pharmaceutical services . Medication Regimen Review .3. Unnecessary drug is defined as and drug used; a. In excessive dose .d. without adequate indications for its use;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that it was free of medication error rates of 5 percent or greater. The facility had a medication error rate of 10.0%, based on 4 errors out of 40 opportunities, which involved 2of 6 residents (Resident #165 and Resident #12) reviewed for medication administration. 1. The facility failed to ensure RN A administered the correct dose of Aspirin 81 MG and Omeprazole 40 MG, (Aspirin and omeprazole combination is used in patients who need aspirin to prevent heart and blood vessel problems (e.g., heart attack, stroke). RN A failed to administer Lyrica 75MG (used to treat pain caused by nerve damage due to diabetes) on 04/29/24 as ordered. 2. The facility failed to ensure RN A administered the correct dose of Aspirin 81MG (a type of NSAID that can treat mild to moderate pain and inflammation. It also lowers your risk of heart attack, stroke, or blood clot) on 04/29/24. This failure could place residents at risk of not receiving the therapeutic effects of their medications and possible adverse reactions. Findings included: 1.Record review of Resident #165's face sheet, dated 05/02/24 indicated Resident #165 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Fracture of the right leg, Diabetes, Coronary artery disease {CAD} (narrowing or blockage of your coronary arteries, which supply oxygen-rich blood to your heart), and hypertension (high blood pressure). Record review of Resident #165's electronic health record on 05/02/2024 indicated the MDS assessment had not been completed yet. Record review of Resident #165's comprehensive care plan, dated 04/27/24 indicated Resident #165 had a potential for pain related to multiple surgeries. The intervention of the care plan was for staff to administer medication as ordered, anticipate the resident's need for pain relief, and respond immediately to any discomfort related to pain. Record review of Resident #165's physician orders dated 04/24/24, indicated: Aspirin 81 Oral Tablet Chewable 81 MG (Aspirin), give 1 tablet by mouth one time a day for prevention. Pregabalin Oral Capsule 75 MG (Pregabalin), give 1 capsule by mouth two times a day for pain. Omeprazole Oral Capsule Delayed Release 40 MG (Omeprazole), give 1 capsule by mouth one time a day related to gastro reflux disease. During an observation on 04/29/24 at 8:36 a.m., RN A gave Resident #165 his am medications. RN A gave Aspirin 81 MG enteric coated 1 tab and Omeprazole 20mg, 1 tab. RN A did not administer Resident #165's Lyrica. 2.Record review of Resident #12's face sheet dated 05/06/24, indicated a [AGE] year-old female was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Diabetes mellites (diabetic), (high blood pressure), and Congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply). Record review of Resident #12's quarterly MDS assessment dated [DATE], indicated she understood and was understood by others. Resident #12's BIMs score was 14, which indicated her cognition was intact. The MDS indicated she received antiplatelets during the look-back period. Record review of Resident #12's comprehensive care plan dated 10/26/19, indicated she had CHF. The interventions were for staff to give medication as ordered. Record review of Resident #12's physician orders dated 02/02/24, indicate: Aspirin 81 Oral Tablet Chewable 81 MG (Aspirin) give 1 tablet by mouth one time a day every Monday, Wednesday, and Friday for CHF. During an observation and interview on 04/29/24 at 8:23 a.m., RN A gave Resident #12 her am medication. RN A gave her Aspirin 81 MG enteric coated. RN A said she did not realize it was the wrong medication. During an interview on 05/02/24 at 6:57 p.m., the DON said nurses learned how to pass medication in school. She said nurse management was responsible for overseeing medication administration. The DON said medication administration was monitored through competencies and observations. She said the pharmacy consultant observed medication administration randomly. The DON said that she had not had the opportunity to observe medication administration the way she needed because of staffing issues. The DON sad she was not aware of RN A given medication passed the administration times. She said she was aware Resident #165 had not received his Lyrica. She said the doctor should have been notified for the late and missed medications. The DON said it was important to administer medications as ordered for the medications to be at therapeutic levels for the residents. During an interview on 05/02/24 at 7:54 p.m., the Administrator said the nurse managers were responsible for overseeing that medications were administered as ordered. The Administrator said he expected the residents to receive their medications as ordered. The Administrator said it was important for the residents to receive their medication as ordered. Record review of the facility policy titled, Medication Administration Procedures, dated 10/25/17, indicated, 11. All current medications and dosage schedules are to be listed on the resident's current medication administration record. 15. Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence.

Based on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response for 8 of 8 confidential residents reviewed for resident council. The facility failed to ensure there was documentation of the facility's efforts to resolve concerns collected at the resident council meetings on 10/10/23, 11/14/23, 12/12/23, 01/09/24, 02/13/24, and 03/12/24. This failure could place residents at risk of not having their concerns and grievances followed through and a diminished quality of life. Findings included: Record review of the Resident Advisory Council Minutes for 10/10/23 indicated the call lights were not being answered timely. Record review of the Resident Advisory Council Minutes for 11/14/23 indicated the call lights were not being answered timely. Record review of the Resident Advisory Council Minutes for 12/12/23 indicated the call lights were not being answered timely. There were not enough aides, and the aides were standing around talking. Record review of the Resident Advisory Council Minutes for 01/09/24 indicated the call lights were not being answered timely. A resident waited 3 hours for a call light to be answered. Record review of the Resident Advisory Council Minutes for 02/13/24 indicated the call lights were not being answered timely. The staff was shorthanded and would go in, turn off the call light and never return, a resident waited 6 hours to be changed. Record review of the Resident Advisory Council Minutes for 03/12/24 indicated the call lights were not being answered in a timely manner. Record review of the grievances from January 2024-April 2024 did not indicate grievances to address resident councils concerns. During a confidential group interview on 04/29/24 starting at 3:09 PM, the resident group said the facility was shorthanded, people were not getting showers, people were not getting changed promptly and call lights were not answered timely. The resident group said every meeting they discussed the call lights not being answered timely. The resident group said they had invited some of the department heads and the AIT to the meetings and they were aware of the call lights not being answered timely. The resident group said they were told we will look into it or we will investigate it. The resident group said they did not get back with them on a resolution and had not given them an explanation as to why the call lights were not being answered timely. During an interview on 05/01/24 at 3:52 PM, the Social Worker said he was responsible for the grievances. The Social Worker said he did not know who handled the grievances voiced by the resident council. The Social Worker said he had only been at the facility for 3 months. The Social Worker said it was important for grievances to be filed so they could be documented and to ensure they were handled appropriately so it would not happen again. During an interview on 05/01/24 at 4:16 PM, the Activities Director said after the resident council meeting, she made 3 copies of the results of the meetings with the residents concerns and gave one to the DON, one to the Administrator, and one for the resident council meeting book. The Activities Director said sometimes she verbally told the Administrator and DON, but she always provided them a copy. The Activities Director said every month the residents complained about the call lights not being answered and the AIT, Administrator, and DON had been told about it. The Activities Director said they just say they would handle it. The Activities Director said she did not know how to file a grievance. The Activities Director said it was important for the residents' concerns/complaints to be addressed so they felt safe and were taken care of. During an interview on 05/02/24 at 6:46 PM, the DON said the concerns voiced at the resident council meeting should be filed as a grievance. The DON said the Social Worker was responsible for the grievances. The DON said she had only been at the facility since December 2023, and she had gone through two ADONs and three treatment nurses. During an interview on 05/02/24 at 8:13 PM, the Administrator said he had heard last month the concerns from the resident council meeting regarding the call lights not being answered timely. The Administrator said he did not recall any other times. The Administrator said the concerns had not been brought to him until he asked for them last month. The Administrator said he had only been at the facility for one month. The Administrator said the concerns from resident council should be brought to him and distributed to the department heads for the department heads to address the concerns. The Administrator said a grievance should have been filed for the concerns brought up in resident council. The Administrator said it should have been filed because it required an action place to correct it and to have documentation. The Administrator said he was responsible for everything that the Activities Director should have passed it to him, and the Social Worker should have been notified for a grievance to be filed. The Administrator said the resident councils concerns not being addressed could affect their care, and he expected for the residents needs to be responded to in a timely answer and if the staff were not answering the call lights, they would not be aware of what the residents' needs were. During an interview with the Corporate Nurse on 05/02/24 at approximately 5:10 PM, the policy regarding grievances was requested and not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.Record review of face sheet date 05/02/2024, revealed Resident #16 was a [AGE] year old male who admitted on [DATE] with diagnoses of Down Syndrome ( a genetic condition where a person was born with an extra copy of chromosome 21), developmental disorder of speech and language, unspecified (a communication disorder that interferes with learning, understanding, and using language), limitation of activities due to disability (dimension of health/disability capturing longstanding limitation in performing usual activities). Record review of MDS assessment, dated 12/08/2023, indicated Resident #16 had a BIMS score of 00, indicating Resident #16 had severe cognitive impairment. The MDS revealed Resident #16 had no behaviors or rejection of care during the look back period. The MDS revealed Resident #16 required supervision with a two-person assistance for dressing, toilet use, and personal hygiene. Record review of comprehensive care plan, dated 04/04/2024, revealed Resident #16 has an ADL self-care performance deficit. Care plan goals included maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. The care plan interventions include, Resident # 16 requires extensive assist of one staff toileting, dressing, transfers, mobility, and personal hygiene. During an observation on 04/28/2024 at 3:20 p.m., Resident # 16 was observed with long, broken, uneven fingernails with a brown material under them. During an observation on 04/29/2024 at 10:00 a.m., Resident # 16 was observed with long, broken, uneven fingernails with a brown material under them. During an observation on 05/01/2024 at 5:55 p.m., Resident # 16 was observed with long, broken, uneven fingernails with a brown material under them. During an interview on 05/01/2024 at 3:52 p.m., with CNA P stated it was the CNA's responsibility to do nail care on shower days or when needed on nondiabetic residents. CNA P stated it was important to keep the nail short to reduce the risk of bowel or dirt getting under them. CNA P stated the risk to the resident was the resident could scratch themselves or get an infection from eating with dirty fingernails. During an interview on 05/01/2024 at 5:55 p.m., LVN N stated nail care was the nursing staff's responsibility. LVN N stated the resident was not a diabetic and did not know why his nails have not been trimmed and cleaned. LVN N stated it was important for the residents to have clean nails for all around hygiene. LVN N stated the risk to the resident was infection. During an interview on 05/02/2024 at 6:38 p.m., the DON stated if the resident was diabetic the nurse or treatment nurse did nail care, if not the CNAs were responsible for nail care on shower days or when dirty. The DON stated it was important to trim resident's nails, so they do not scratch themselves or other people. The DON stated the risk was infection. The DON stated she would monitor by check off in the computer system. During an interview on 05/02/2024 at 7:35 p.m., the Administrator stated the CNAs were responsible for personal hygiene unless the resident was a diabetic. The Administrator stated it was important to keep residents nail clean and trimmed because you do not know what was underneath them. The Administrator stated the risk was infection. Record review of the facility's policy titled, Nail Care reflected Nail management was the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle area and was usually done during the bath . Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 3 of 22 residents (Resident #14, Resident #16, and Resident #31) reviewed for ADLs. 1. The facility failed to ensure Resident #14, and Resident #31 were routinely showered/bathed. 2. The facility failed to ensure Resident #16's nails were clean and free of a brown colored material. These failures could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem. Findings included: 1. Record review of a face sheet dated 05/02/24 indicated Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (weakness, paralysis of left side of the body after a stroke). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #14 was sometimes understood by others, and he was usually able to understand others. The MDS assessment indicated Resident #14 had a BIMS score of 8, which indicated his cognition was moderately impaired. The MDS assessment did not indicate any behaviors or rejection of care. The MDS assessment indicated Resident #14 was dependent for toileting hygiene, showering/bathing self and required partial/moderate assistance with personal hygiene. Record review of the care plan last reviewed 03/22/24 indicated Resident #14 had an ADL self-care performance deficit and required the assistance of 2 staff for bathing. Resident #14's care plan indicated provide the resident with a sponge bath when a full bath or shower cannot be tolerated. Record review of the Documentation Survey Report for April 2024 indicated Resident #14's bathing was on Monday, Wednesday, and Friday. For the month of April 2024 one bed bath was documented on 04/03/2024. During an observation and interview on 04/29/24 at 8:39 AM, Resident #14 said he was not always getting his baths. Resident #14's hair appeared greasy and disheveled his red shirt had white stains on it and skin appeared dry, flaky. During an observation on 04/29/24 at 9:40 AM, CNA L and the DOR assisted Resident #14 out of bed and assisted him with dressing. A red shirt with a small pocket on the front was placed on him. During an observation and interview on 04/30/24 at 12:20 PM, Resident #14 was in his bed, and he had the same red shirt with a small pocket on the front from the previous day. There were white stains on the front of his shirt. Resident #14 said he was not given a shower yesterday. During an observation and interview on 05/01/24 at 8:42 AM, Resident #14 was in bed. He had a red shirt on with a small pocket on the front. His shirt had multiple white stains on the front. His hair appeared greasy and disheveled. Resident #14 said he still had not been given a shower/bath. During an interview on 05/01/24 at 10:37 AM, CNA L said sometimes the there was a shower aide but sometimes there was not. CNA L said she had not given Resident #14 a bath/shower Monday (04/29/24) because he was supposed to receive his bath/shower on the 2-10 PM shift. During an interview on 05/02/24 at 2:09 PM, SNA H said she had not bathed/showered Resident #14 because she was not sure who she was supposed to give a shower to, and she was not told to give him a shower. SNA H said she could not remember why Resident #14's clothes were not changed on Tuesday (04/30/24). SNA H said the residents' clothes should be changed even if it was not their shower day. SNA H said it was important for the residents to be bathed/showered and their clothes changed for their personal hygiene and so they did not get bacteria. During an interview on 05/02/24 at 6:36 PM, the DON said the charge nurses should be making sure the showers were done before they left. The DON said she was aware of the residents missed baths/showers, and they were working on addressing it by changing the shower schedules. The DON said it was important for the residents to get their baths/showers because it was a hygiene issue. During an interview on 05/02/24 at 7:58 PM, the Administrator said he expected the residents to be bathed every third day and he did not expect them to go three days with just bed baths. If the residents were capable, they needed to be showered. The Administrator said the ADON was responsible for providing oversight on bathing, but right now it was getting pushed off on the Treatment Nurse and the DON. The Administrator said it was important for the residents to be bathed/showered for good hygiene, so they could rest better, and if they did not get bathed/showered it could result in skin breakdown. 2. Record review of Resident #31's face sheet dated 05/02/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses heart disease, congestive heart failure, kidney disease, high blood pressure and depression. Record review of Resident #31's quarterly MDs assessment dated [DATE] indicated he had a BIMS score of 08 which indicated he had moderately impaired cognition. The MDS also indicate he required limited assistance for bed mobility, extensive assistance for toileting, bathing, and transfers, and setup for eating. Record review of Resident #31's undated care plan indicated he required supervision of 1 staff for bathing. Record review of Resident #31's documentation survey report for baths dated April 2024 indicated he was scheduled for baths on Monday Wednesday and Fridays on the 2PM-10PM shift and received 2 out of the 13 scheduled baths for the month of April. During an interview on 04/28/24 at 03:54 PM Resident #31 said he does not get his showers as they are scheduled on Monday, Wednesday, and Friday, and he could not remember last time he got one. During an interview on 05/02/24 at 03:12 PM CNA L said Resident #31 used to get his showers on the 6AM-2PM shift on Monday, Wednesday, and Friday, and unless he felt bad, he did not ever refuse his baths. She said there had been some changes and the facility used shower sheets in the past to keep up with baths. She did not know why he did not get his bath, but she said it was considered neglect, laziness, and carelessness. During an interview on 05/02/24 at 8:26 PM the Administrator said bathing and showering for all residents should be performed 3 days a week. The Administrator said the CNAs were responsible for giving the baths by following the facility [NAME] (patient medical information system). He said the ADON was responsible for monitoring baths, but now the treatment nurse and the DON are responsible since the facility does not have an ADON. The Administrator said the failure of not giving baths place risk for residents not having good hygiene and skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 5 of 6 residents (Resident #12, Resident #26, Resident #39, Resident #165, and Resident #218) reviewed for pharmacy services. 1. The facility failed to ensure Resident #26's buspirone (anxiety medication), gabapentin (medication for nerve pain), duloxetine (medication for depression), and metoprolol succinate (blood pressure medication) were administered timely. 2. The facility failed to ensure Resident #218's spironolactone (medication used to treat fluid buildup), metoprolol (blood pressure medication), venlafaxine hydrochloride (medication for depression), and pregabalin (used to treat nerve pain) were administered timely. 3. The facility failed to administer the following medications as prescribed for Resident #165: Aspirin (medication works by stopping platelets from clumping together) Omeprazole (used to treat certain conditions where there is too much acid in the stomach), Lyrica (used to treat pain caused by nerve damage due to diabetes) and Carisoprodol ( used to relax certain muscles in your body and relieve the discomfort caused by acute (short-term), painful muscle or bone conditions). 4. The facility failed to administer the following medication timely as ordered for Resident #12 buspirone (anxiety medication) and Fluticasone nasal spray (used to treat sneezing, and itchy or runny nose) and RN A failed to give the prescribed Aspirin to Resident #12. 5. The facility failed to administer the following medication timely as ordered for Resident #39: gabapentin (medication for nerve pain) and Artificial tears (eye drops for dry eyes). These failures could place residents at risk of not receiving their medications as ordered, hospitalizations, and exacerbation of their disease processes. 1. Record review of a face sheet dated 05/02/24 indicated Resident #26 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included subacute osteomyelitis to right radius and ulna (infection of the bones in the right arm) and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #26 was able to make himself understood and understood others. The MDS assessment indicated Resident #26 had a BIMS score of 14, which indicated his cognition was intact. The MDS assessment indicated Resident #26 received antianxiety and antidepressant medication during the 7-day look back period. Record review of Resident #26's care plan date initiated 04/12/24 indicated he had a potential for uncontrolled pain and to give cardiac (heart) medications as ordered. Record review of Resident #26's Order Summary Report dated 04/28/24 indicated orders for buspirone 5 mg tablet give 1 tablet by mouth two times a day for anxiety with a start date of 04/12/24. gabapentin 300 mg give 1 capsule by mouth three times a day for pain with a start date of 04/11/24. duloxetine delayed release 30 mg give 1 capsule by mouth two times a day for depression with a start date of 04/11/24. metoprolol succinate extended release 24-hour tablet 25 mg give 1 tablet by mouth one time a day with a start date of 04/12/24. Record review of the Medication Admin Audit report for Resident #26 dated 04/21/24-04/30/24 indicated buspirone 5 mg tablet give 1 tablet by mouth two times a day for anxiety: Schedule Date 04/21/24 8:00 AM, Administration Time 04/21/24 9:46 AM, which indicated it was administered 46 minutes late, after the 1-hour grace period. Schedule Date 04/23/24 8:00 AM, Administration Time 04/23/24 10:17 AM, which indicated it was administered 1 hour and 17 minutes late, after the 1-hour grace period. Schedule Date 04/24/24 8:00 AM, Administration Time 04/24/24 10:15 AM, which indicated it was administered 1 hour and 15 minutes late, after the 1-hour grace period. Schedule Date 04/27/24 8:00 PM, Administration Time 04/27/24 9:56 PM, which indicated it was administered 56 minutes late, after the 1-hour grace period. Schedule Date 04/28/24 8:00 AM, Administration Time 04/28/24 12:00 PM, which indicated it was administered 3 hours late, after the 1-hour grace period. Schedule Date 04/29/24 8:00 AM, Administration Time 04/29/24 10:21 AM, which indicated it was administered 1 hour and 21 minutes late, after the 1-hour grace period. Record review of the Medication Admin Audit report for Resident #26 dated 04/21/24-04/30/24 indicated gabapentin 300 mg give 1 capsule by mouth three times a day for pain: Schedule Date 04/21/24 7:00 AM, Administration Time 04/21/24 9:46 AM, which indicated it was administered 1 hour and 46 minutes late, after the 1-hour grace period. Schedule Date 04/22/24 7:00 PM, Administration Time 04/22/24 8:50 PM, which indicated it was administered 50 minutes late, after the 1-hour grace period. Schedule Date 04/23/24 7:00 AM, Administration Time 04/23/24 10:17 AM, which indicated it was administered 2 hours and 17 minutes late, after the 1-hour grace period. Schedule Date 04/24/24 7:00 AM, Administration Time 04/24/24 10:15 AM, which indicated it was administered 2 hours and 15 minutes late, after the 1-hour grace period. Schedule Date 04/26/24 7:00 AM, Administration Time 04/26/24 9:32 AM, which indicated it was administered 1 hour and 32 minutes late, after the 1-hour grace period. Schedule Date 04/28/24 7:00 AM, Administration Time 04/28/24 12:02 PM, which indicated it was administered 4 hours and 2 minutes late, after the 1-hour grace period. Schedule Date 04/29/24 7:00 AM, Administration Time 04/28/24 10:21 AM, which indicated it was administered 2 hours and 21 minutes late, after the 1-hour grace period. Record review of the Medication Admin Audit report for Resident #26 dated 04/21/24-04/30/24 indicated duloxetine delayed release 30 mg give 1 capsule by mouth two times a day for depression: Schedule Date 04/21/24 7:00 AM, Administration Time 04/21/24 9:46 AM, which indicated it was administered 1 hour and 46 minutes late, after the 1-hour grace period. Schedule Date 04/22/24 7:00 PM, Administration Time 04/22/24 8:50 PM, which indicated it was administered 50 minutes late, after the 1-hour grace period. Schedule Date 04/23/24 7:00 AM, Administration Time 04/23/24 10:17 AM, which indicated it was administered 2 hours and 17 minutes late, after the 1-hour grace period. Schedule Date 04/24/24 7:00 AM, Administration Time 04/24/24 10:15 AM, which indicated it was administered 2 hours and 15 minutes late, after the 1-hour grace period. Schedule Date 04/26/24 7:00 AM, Administration Time 04/26/24 9:32 AM, which indicated it was administered 1 hour and 32 minutes late, after the 1-hour grace period. Schedule Date 04/28/24 7:00 AM, Administration Time 04/28/24 12:02 PM, which indicated it was administered 4 hours late, after the 1-hour grace period. Schedule Date 04/29/24 7:00 AM, Administration Time 04/28/24 10:21 AM, which indicated it was administered 2 hours and 21 minutes late, after the 1-hour grace period. Record review of the Medication Admin Audit report for Resident #26 dated 04/21/24-04/30/24 indicated metoprolol succinate extended release 24-hour tablet 25 mg give 1 tablet by mouth one time a day: Schedule Date 04/27/24 6:30 AM, Administration Time 04/27/24 11:34 AM, medication administration time was between 6:30 AM-10:30 AM, which indicated it was administered 1 hour and 4 minutes late. Schedule Date 04/28/24 6:30 AM, Administration Time 04/28/24 12:01 PM, medication administration time was between 6:30 AM-10:30 AM, which indicated it was administered 1 hour and 31 minutes late. 2. Record review of Resident #218's face sheet dated 04/30/2024, indicated a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses which included diabetes (a group of diseases that affect how the body uses blood sugar), hypertension (high blood pressure), congestive heart failure (the heart can't pump blood well enough to supply the body, unspecified wound to abdominal wall of right lower quadrant, and cellulitis (serious bacterial infection of the skin) right lower limb. Record review of Resident #218's care plan with date initiated 04/24/24 did not address the use of her spironolactone, metoprolol, venlafaxine hydrochloride, or pregabalin. Record review of Resident #218's electronic health record on 05/02/24 indicated the MDS assessment was in progress. Record review of Resident #218's Order Summary Report dated 04/28/2024, indicated: spironolactone 25 mg give 1 tablet by mouth one time a day with a start date of 04/25/24. metoprolol succinate extended release 24-hour tablet 25 mg give 1 tablet by mouth one time a day with a start date of 04/25/24. venlafaxine hydrochloride extended release 24-hour tablet give 1 tablet by mouth one time a day with a start date of 04/25/24. pregabalin 150 mg give 1 capsule by mouth two times a day with a start date of 04/25/24. Record review of the Medication Admin Audit report for Resident #218 dated 04/21/24-04/30/24 indicated spironolactone 25 mg give 1 tablet by mouth one time a day: Schedule Date 04/27/24 6:30 AM, Administration Time 04/27/24 11:37 AM, medication administration time was between 6:30 AM-10:30 AM, which indicated it was administered 1 hour and 7 minutes late. Schedule Date 04/28/24 6:30 AM, Administration Time 04/28/24 11:31 AM, medication administration time was between 6:30 AM-10:30 AM, which indicated it was administered 1 hour and 1 minute late. Schedule Date 04/29/24 6:30 AM, Administration Time 04/29/24 12:05 PM, medication administration time was between 6:30 AM-10:30 AM, which indicated it was administered 1 hour and 35 minutes late. Record review of the Medication Admin Audit report for Resident #218 dated 04/21/24-04/30/24 indicated metoprolol succinate extended release 24-hour tablet 25 mg give 1 tablet by mouth one time a day: Schedule Date 04/27/24 6:30 AM, Administration Time 04/27/24 11:45 AM, medication administration time was between 6:30 AM-10:30 AM, which indicated it was administered 1 hour and 15 minutes late. Schedule Date 04/28/24 6:30 AM, Administration Time 04/28/24 11:33 AM, medication administration time was between 6:30 AM-10:30 AM, which indicated it was administered 1 hour and 3 minutes late. Schedule Date 04/29/24 6:30 AM, Administration Time 04/29/24 12:05 PM, medication administration time was between 6:30 AM-10:30 AM, which indicated it was administered 1 hour and 35 minutes late. Record review of the Medication Admin Audit report for Resident #218 dated 04/21/24-04/30/24 indicated venlafaxine hydrochloride extended release 24-hour tablet give 1 tablet by mouth one time a day: Schedule Date 04/27/24 6:30 AM, Administration Time 04/27/24 11:37 AM, medication administration time was between 6:30 AM-10:30 AM, which indicated it was administered 1 hour and 7 minutes late. Schedule Date 04/28/24 6:30 AM, Administration Time 04/28/24 11:31 AM, medication administration time was between 6:30 AM-10:30 AM, which indicated it was administered 1 hour and 1 minute late. Schedule Date 04/29/24 6:30 AM, Administration Time 04/29/24 12:05 PM, medication administration time was between 6:30 AM-10:30 AM, which indicated it was administered 1 hour and 35 minutes late. Record review of the Medication Admin Audit report for Resident #218 dated 04/21/24-04/30/24 indicated pregabalin 150 mg give 1 capsule by mouth two times a day: Schedule Date 04/27/24 7:00 AM, Administration Time 04/27/24 11:35 AM, which indicated it was administered 3 hours and 35 minutes late, after the 1-hour grace period. Schedule Date 04/28/24 7:00 AM, Administration Time 04/28/24 11:29 AM, which indicated it was administered 3 hours and 29 minutes late, after the 1-hour grace period. Schedule Date 04/29/24 7:00 AM, Administration Time 04/29/24 12:04 PM, which indicated it was administered 4 hours and 4 minutes late, after the 1-hour grace period. Schedule Date 04/29/24 7:00 PM, Administration Time 04/29/24 8:56 PM, which indicated it was administered 56 minutes late, after the 1-hour grace period. 3. Record review of Resident #165's face sheet, dated 05/02/24 indicated Resident #165 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Fracture of the right leg, Diabetes, Coronary artery disease {CAD} (narrowing or blockage of your coronary arteries, which supply oxygen-rich blood to your heart), and hypertension (high blood pressure). Record review of Resident #165's electronic health record on 05/02/2024 indicated the MDS assessment had not been completed yet. Record review of Resident #165's comprehensive care plan, dated 04/27/24 indicated Resident #165 had a potential for pain related to multiple surgeries. The intervention of the care plan was for staff to administer medication as ordered, anticipate the resident's need for pain relief, and respond immediately to any discomfort related to pain. Record review of Resident #165's medication administration record (MAR) dated 04/01/24 through 04/30/24 revealed the following orders: Pregabalin (Lyrica) oral capsule 75MG, give 1 capsule by mouth two times a day. The MAR did not indicate Resident #165 received this medication on 04/28/24 or the morning dose on 04/29/24. Record review of Resident #165's medication administration audit report record dated 04/30/24 indicated: Carisoprodol Oral Tablet 350 MG, give 1 tablet by mouth three times a day for muscle relaxer for 10 Days. This medication was scheduled at 7:00 am on 04/29/24 and was given until 8:41 am. Docusate 100 MG, Give 1 capsule by mouth two times a day for constipation for 10 days. This medication was scheduled at 7:00 am on 04/29/24 and was not given until 8:39 am. During an observation on 04/29/24 at 8:36 a.m., RN A gave Resident #165 his am medication which his orders consisted of Aspirin 81 Mg chewable, give 1 tab daily and RN A gave Aspirin 81 MG enteric coated 1 tab .Omeprazole 40 MG, give 2 tabs daily and RN A gave Omeprazole 20mg, 1 tab. Resident #165 had an order for Lyrica 75MG, give 1 tab daily and RN A did not administer it. 4.Record review of Resident #12's face sheet dated 05/06/24, indicated a [AGE] year-old female was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Diabetes mellites (diabetic), (high blood pressure), and Congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply). Record review of Resident #12's quarterly MDS assessment dated [DATE], indicated she understood and was understood by others. Resident #12's BIMS score was 14, which indicated her cognition was intact. The MDS indicated she received antiplatelets during the look-back period. Record review of Resident #12's comprehensive care plan dated 11/06/23, indicated she had used anti-anxiety medications for diagnosis of anxiety. The intervention was for staff to administer medication as ordered. Record review of Resident #12's medication administration audit report record dated 04/30/24 indicated: Buspirone HCl Tablet 5 MG, Give 1 tablet by mouth two times a day for anxiety. This medication was scheduled at 7:00 am on 04/28/24 and was not given until 10:57 am. This medication was scheduled at 7:00 am on 04/29/24 and was not given until 10:39 am . Fluticasone Propionate Nasal Suspension 50 MCG, give 1 nasal spray in each nostril two times a day for nasal congestion. This medication was scheduled at 7:00 a.m. on 04/28/24 and was not given until 10:57 am. This medication was scheduled on 04/29/24 at 7:00 am and was not given until 8:39 am. 5. Record review of Resident #39's face sheet, dated 05/06/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which Cataract (a cloudy area in the lens of your eye), Neuropathy (results from damage to the nerves outside the spinal cord and the brain) and Depression (feeling of sadness). Record review of Resident #39's quarterly MDS assessment, dated 02/16/24, indicated Resident #39 was sometimes understood and was usually understood by others. Resident #39's BIMS score was 03, which indicated her cognition was severely impaired . The MDS indicated Resident #39 required limited assistance with dressing, personal hygiene, toileting, bathing, bed mobility, transfers, and set-up for eating. The MDS during the 7-day look-back period did not indicate Resident #39 was receiving oxygen. Record review of Resident #39's care plan dated 04/29/24 indicated, Resident #39 had an alteration in neurological status related to Neuropathy. The intervention was for staff to administer medication as ordered by the physician. Monitor and document for side effects. The care plan did not indicate any eye issues. Record review of Resident #39's medication administration audit report record dated 04/30/24 indicated: Gabapentin oral capsule 200 MG, give (2) 100 MG by mouth three times a day related to peripheral neuropathy. This medication was scheduled at 7:00 am on 04/29/24 and was not given until 9:07 am. This medication was scheduled at 7:00 am on 04/30/24 and was not given until 9:44 am. Artificial Tears Ophthalmic Solution 0.1-0.3%, instill 1 drop in both eyes three times a day for dry eyes. This medication was scheduled at 7:00 am on 04/29/24 and was not given until 9:13 am. This medication was scheduled at 7:00 am on 04/30/24 and was not given until 9:44 am. During an interview on 04/29/24 at 10:59 a.m ., RN A said after looking at Resident #165 's medications, she realized she did not give him the Aspirin 81MG chewable nor (2) 20 MG Omeprazole. She also said she did not give Resident #12 her Aspirin 81 MG chewable but the Aspirin 81 MG enteric coated. She said she was in a hurry and did not read the MAR correctly. She said she was not able to pass all of her medication timely because she had too many to pass. She said she had mentioned the number of meds she had to pass to the ADON before and nothing had changed. During an interview on 04/29/24 at 11:30 a.m., Resident #165 said he was not hurting related to not receiving the Lyrica but because it helped him, he would prefer to have it. During an interview on 05/01/24 at 7:52 a.m., RN A said she was Resident #165's nurse on 04/29/23 and 04/30/24. She said Resident #165's Lyrica was not in the building on 04/28/24 nor 04/29/24 am dose. She said it was not in the Stat safe (facility emergency medication kit) either. She said she had notified the DON on 04/28/24 about the medication not being in the Stat safe. She said the DON found the medication at about noon on 04/29/24 but she did not give it to him because it was well past the medication time. She said she did not notify the doctor about the missing doses of medication. She said she was told to notify the DON if a medication was not available. RN A said she had a challenging time giving medications on time because she had a lot of meds and did not have enough time to meet the time frame. During an interview and observation on 05/02/24 at 12:10 p.m., LVN B said she did not have time to pass all of her medications as ordered because they had a lot of meds to pass and the time frame was not doable. She said she had reported not being able to pass all her medications timely to the DON/ADON but nothing had been done. During an interview on 05/02/24 at 6:51 p.m., the DON said she was not aware of late medications. She said she looked at the MARS daily but mostly looked for holes in the MAR. She said staff had not told her they did not have time to complete their med pass timely. She said the staff was supposed to let her know if they were missing medications and she would notify the pharmacy. She said if medication was not available related to insurance, they were supposed to place a hold order in the computer system for that medication. She said she was the overseer of medication but could not fix the problem if she was not aware. She said the pharmacy consultant came monthly and had done a medication pass with the nurses. She said she had not had the time to do a medication pass with the nurses because of the staffing issues and her working the floor. The DON said if residents missed medication, or medications were not given timely, it could cause adverse effects on their health. During an interview on 05/02/24 at 7:54 p.m., the Adm said he expected the nurses to give all medication as prescribed. He said the DON/ADON s were responsible for ensuring residents received their medication as ordered. He said if a resident received their medication late or did not receive their medication, they could potentially have a negative outcome. A record review of the facility's Medication Administration Procedures, policy dated 05/2007, revealed, Policy Statement: 1. All medications are administered by licensed medical or nursing personnel. 2. Medications are to be poured, administered, and charted by the same licensed person . 6. If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes . 15. Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. 20. The 10 rights of medication should always be adhered to 1. Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right patient education 7. Right documentation 8. Right to refuse 9. Right assessment 10. Right evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY FTAGDIR 05/02/24 07:26 PM The treatment cart was left open, nurse [NAME] said he was not aware but could be potential Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 5 medication carts (Hall 200 medication cart, Treatment medication cart) and 1 of 22 residents (Resident #36) reviewed for pharmacy services. 1. The facility failed to ensure Resident #36 did not have prescribed and OTC medications at bedside. 2. The facility failed to ensure the treatment nurse ensured the medication cart, used for treatments, was locked when it was left unattended. 3. The facility failed to ensure LVN M ensured the 200 Hall medication cart was locked when it was left unattended. These failures could place residents at risk of injury from medication misuse or drug diversion. 1.Record review of Resident #36's face sheet dated 05/02/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses hemiplegia following cerebral infarction (disrupted blood flow to the brain causing parts to die), chronic pain, hypertension (high blood pressure), cognitive communication deficit (communication deficit that occurs after a stroke), and major depression (mood disorder that causes persistent feeling of sadness and loss of interest). Record review of Resident #36's quarterly MDS assessment dated [DATE] indicated that she had a BIMS score of 11 which indicated she had moderate cognitive impairment. The MDS also indicated she required maximal assistance with toileting, total assistance with bed mobility and transfers, and setup assistance with eating. Record review of Resident #36's care plan dated 02/20/24 indicated resident had impaired cognitive function/dementia with an intervention for the facility to administer meds as ordered. Record review of Resident #36's order summary report dated 04/30/24 indicated she had an order for: Silver Sulfadiazine Cream 1% Apply to Left buttock topically one time a day for MASD (moisture associated skin damage) that started 02/14/24 and discontinued with no specified end date. It also indicated Resident #36 did not have an order for Tums 500mg antacid tablets. Record review of Resident #36's order summary report dated 04/30/24 indicated she did not have an order for the stomach relief 262 mg tablets nor the tums 500mg antacid tablets found on her bedside table. During an observation on 04/29/24 at 9:10 AM Resident #36 had 1 bottle of Tums 500mg antacid tablets, 1 box of stomach relief 262 mg tablets, and a tube of silver sulfadiazine cream 1% on her bedside table. During an observation and interview on 04/30/24 at 5:46 PM, the DON was in Resident #36's and was shown the 1 bottle of Tums 500mg antacid tablets, 1 box of stomach relief 262 mg tablets, and a tube of silver sulfadiazine cream 1% on Resident #36's bedside table. The DON said Resident #36 was probably not supposed to have those medications in her room. She said no residents were able to self-administer medications. 2. During an observation and interview on 04/28/24 04:53 PM the Treatment Nurse left the medication cart used for treatments unlocked while she went into a resident's room and returned to the unlocked cart on 04/28/24 at 05:12 PM. The Treatment Nurse said she was nervous and forgot to lock the cart and anyone could have had access to the medications and treatments. 3. During an observation and interview on 04/28/24 at 10:20 a.m., LVN M was sitting at the nurse's station. The surveyor observed a medication cart on hall 200 unlocked. LVN M said he was not aware the medication cart was open or where the cart came from. He said the cart should not be open because it was a potential hazard for residents. During an interview on 05/02/24 at 05:47 PM, LVN B said medications should be on med cart, or the med room. LVN B said the risk was wanderers getting the medication and taking it and having bad reactions. LVN B said all staff were responsible for both, the medication carts and ensuring there were no medications at bedside. During an interview on 05/02/24 at 07:12 PM, the DON said everyone was responsible for ensuring the residents did not have medications at bedside. She said the failure placed a risk of overdose, another resident could have gotten the medication, or the medication could interact with other medications they were taking. The DON said all medications were to be kept in medication carts or in the medication room. She said all medication carts were expected to be locked by the nurses when unattended and the failure placed a risk for anyone to be able to get into the medication cart and retrieve the medications. During an interview on 05/02/24 at 08:28 PM, the Administrator said his expectation was for no medications to be left at the bedside. He said he was responsible for everything that happened at the facility. He said any staff that saw medications in a resident's room should have reported that the medications were in the room and the medications should have been removed. The Administrator said he expected medications to be kept in the medication carts or medication storage area. He said the failure placed a risk for the resident having medications taken without an order or drug interactions with other medications. The Administrator said no resident could administer their own medications because they could not be monitored. During an interview on 05/02/24 at 08:31 PM, the Administrator said the medication cart should be locked unless there was a staff standing there in front of it. He said the failure placed a risk for medications being used by residents or sharp objects could be obtained and hurt the residents. Record review of facility policy titled, Medication Administration Procedures, dated 10/25/17 indicated, 8. After the medication administration process, the medication cart must be completely locked, or otherwise secured. Record review of facility policy titled, Medication Carts, indicated, 1. The medication carts shall be maintained by the facility. 2. The carts are to be locked when not in use or under the direct supervision of the designated nurse. 4. Carts must be secured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure sufficient staff to provide nursing related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, for 2 of 22 residents (Resident #54 and Resident #219) and 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient staff to provide prompt and proper incontinent care for Resident #54 and Resident #219. This failure could place residents at risk of an unsafe environment, new pressure injuries, worsening of pressure injuries, falls, and exacerbations of disease processes. Findings Included: 1. Record Review of Time Sheets between 04/14/2024-05/02/2024 indicated number of CNAs worked: 04/14/20224: 1 CNA from 1:31pm- 9:56pm; 1 CNA from 6:19am-6:02 pm, 1 CNA from 6 pm-6:18am. 04/15/2024:1 CNA from 5:55 am-6:09 pm, 1 CNA from 1:39 pm-9:54 pm, 1 CNA from 5:52 am-6:16 pm, 1 CNA from 3:31 am -11:33am, 1 CNA from 7:35 am-3:33 pm. 04/16/2024:1 CNA from 5:56 pm-6:01am, 1 CNA from 5:52 am-6:16 pm, 1 CNA from 6:58 am -5:03 pm, 1 CNA from 7:37 am -3:31pm. 04/17/2024: 1 CNA from 6:05 am-5:59 pm, 1 CNA from 6:16 am -6:00 pm, 1 CNA from 5:34 am-4:32 pm, 1 CNA from 6:02 pm -6:26 am, 1 CNA from 7:42 am -3:28 pm. 04/18/2024: 1 CNA from 6:11 am- 5:58 pm, 1 CNA from 7:53 am- 7:14 pm, 1 CNA from 6:58 am -1:52 pm, 1 CNA from 5:57 pm -6:05 am, 1 CNA from 7:22 am -3:40 pm. 04/19/2024: 1 CNA from 5:56 am- 6:20 pm, 1 CNA from 1:30 pm -9:33 pm, 1 CNA from 8:22 am- 6:21 pm, 1 CNA from 5:54am -12:53 pm, 1 CNA from 7:32 am -3:29 pm. 04/20/2024: 1 CNA from 5:56 am- 6:14 pm, 1 CNA from 1:34 pm- 9:52 pm, 1 CNA from 9:55 pm- 6:06 am, 1 CNA from 6:36 am -2:04 pm. 04/21/2024: 1 CNA from 5:55 am -6:14 pm 1 CNA from 1:32 pm -9:43 pm, 1 CNA from 11:57 am -1:51 pm, 1 CNA from 10:00 pm - 6:01 am. 04/22/2024: 1 CNA from 6:00 am - 6:17 pm, 1 CNA from 6:05 am- 2:38 pm, 1 CNA from 7:36 am -3:33 pm, 1 CNA from 6:14 pm - 6:07 am. 04/23/2024: 1 CNA from 1:41 pm- 2:11 pm, 1 CNA from 6:00 am - 6:17 pm, 1 CNA from 6:59 am- 6:36 pm, 1 CNA from 6:00 am- 2:00 pm, 1 CNA from 6:00 pm- 6:00 am, 1 CNA from 2:30 pm- 8:28 pm, 1 CNA from 6:02 am- 5:53 pm, 1 CNA from 6:07 am- 4:42 pm, 1 CNA from 7:36 am -3:37 pm, 1 CNA from 6:05 pm - 6:08 am. 04/24/2024: 1 CNA from 5:55 am- 6:12 pm, 1 CNA from 1:40 pm - 8:45 pm, 1 CNA from 6:00 am- 2:00 pm, 1 non-CNA from 5:52 am- 6:17 pm, 1 CNA from 6:00 pm- 6:00 am, 1 CNA from 8:34 am- 6:17 pm, 1 CNA from 6:12 am- 3:30 pm, 1 CNA from 9:39 pm- 6:00 am, 1 CNA from 7:36 am -3:36 pm, 1 CNA from 6:57 am -7:14 pm. 04/25/2024: 1 CNA from 5:55 am- 6:09 pm, 1 CNA from 6:52 am- 2:32 pm, 1 CNA from 7:37 am -3:37 pm. 04/26/2024: 1 CNA from 10:00 pm- 6:00 am, 1 CNA from 5:47 am- 5:59 pm, 1 CNA from 6:13 am - 4:14 pm, 1 CNA from 7:35 am -3:30pm, 1 CNA from 5:57 pm- 6:05 am. 04/27/2024: CNA from 1:37 pm- 9:46 pm, 1 CNA from 6:02 am- 5:58 pm, 1 CNA from 6:09 am -2:03 pm, 1 CNA from 6:08 pm - 6:13 am. 04/28/2024: 1 CNA from 6:14 am- 6:07 pm, 1 CNA from 6:09 am -2:03 pm, 1 CNA from 6:08 pm - 6:13 am. 04/29/2024: 1 CNA from 5:53 am- 6:10 pm, 1 CNA from 6:09 am - 6:11 pm, 1 CNA from 6:00 am - 1:17 pm, 1 CNA from 7:33 am -3:37 pm. 04/30/2024: 1 CNA from 5:54 am- 6:52 pm, 1 CNA from 2:57 pm- 3:27 pm, 1 CNA from 9:20 pm- 6:02 am, 1 CNA from 6:08 am - 7:30 pm, 1 CNA from 6:30 am - 10:34 am, 1 CNA from 5:58 am - 6:00 pm, 1 CNA from 7:41 am -3:34 pm. 05/01/2024: 1 CNA from 6:41 am- 3:21 pm, 1 CNA from 5:55 am- 4:21 pm, 1 CNA from 7:36 am -3:38 pm, 1 CNA from 6:02 pm - 6:00 am. Record review of the Facility Assessment last reviewed on 4/16/24, indicated based on a census of 68, 110 hours worked by CNAs were required in a 24-hour period. This indicated if the CNAs worked 12-hour shifts, they required 9 CNAs in a 24-hour period. If the CNAs worked 8-hour shifts, they required 13 CNAs in a 24-hour period. 2. Record review of a face sheet dated 05/02/24 indicated Resident #219 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with behaviors). Record review of Resident #219's care plan date initiated 04/30/24 indicated she had an ADL self-care performance deficit and required the assistance of 1 staff for bathing, bed mobility and dressing and required assistance with personal hygiene. Resident #219's care plan indicated she had a potential for pressure ulcer development to provide incontinent care after each episode and apply moisture barrier. Record review of Resident #219's electronic health record on 05/02/24 indicated the MDS assessment had not been completed yet. During an observation and interview on 04/30/24 starting at 5:20 PM, a strong urine odor was noted in Resident #219's room. Resident #219 said she had not been changed but was unable to provide a timeframe. CNA G and SNA H provided incontinent care. CNA G and SNA H donned gloves. CNA G wiped Resident #219's front peri area, tucked the dirty brief and they turned Resident #219 on her side. Resident #219 had a dark brown stain extending up her buttocks with the edges darker brown then the center. The brown stain extended down to the mattress. The blue mattress was darker where Resident #219's buttocks were with stain-like areas extending out. CNA G said she did not feel the mattress was wet with urine. SNA H said she was not sure if it was wet or not. This Surveyor touched the mattress, and it was wet in the center, and the stain-like areas extending out were dry. SNA H wiped Resident #219's buttock because she also had a bowel movement. SNA H used the same wipe to clean Resident #219's buttocks multiple times. SNA H did not use a clean area of the wipe for each stroke. SNA H continued to wipe Resident #219's buttocks and peri area wiping with the same wipe multiple times. SNA H and CNA G proceeded to apply the clean brief and clean sheets. SNA H and CNA G did not change gloves. They used their dirty gloves to apply the clean brief and sheets. SNA H and CNA G had the clean sheet and dirty sheet and brief touching each other while tucking it under Resident #219. SNA H and CNA G turned Resident #219 to the opposite side and removed the dirty linens and dirty brief and disposed of it. SNA H and CNA G repositioned Resident #219 in bed and covered her up using the same dirty gloves. During an interview on 04/30/24 at 5:47 PM, CNA G said she had changed Resident #219 after lunch around 12:30 PM. CNA G said Resident #219 was a heavy wetter and she should be changed more frequently. CNA G said she was supposed to round on the residents and check them every 2 hours. CNA G said she had not checked on Resident #219 as frequently as she should because she had other duties to perform, and she got sidetracked. CNA G said she was supposed to change gloves a lot, but she had only taken one pair of gloves with her to provide incontinent care to Resident #219. CNA G said she should change gloves and perform hand hygiene when going from dirty to clean. CNA G said when wiping the residents, the same wipe should not be used multiple times. CNA G said it was important to provide incontinent care to the residents frequently so they did not have skin breakdown, and because they could get an infection. During an interview on 04/30/24 at 5:54 PM, SNA H said CNA G and herself were caring for Resident #219, and they were providing care for the residents on the hall together. SNA H said the last time they changed Resident #219 was before breakfast. SNA H said they were going to get Resident #219 out of bed at lunchtime, but she did not want to get out of bed. SNA H said they had not attempted to provide incontinent care. SNA H said they were supposed to check on the residents every hour at least. SNA H said when wiping the residents, she should only wipe once and discard the wipe. SNA H said the same wipe should not be used to wipe multiple times. SNA H said gloves should be changed after she cleaned the front area and before she touched the back area. SNA H said she did not wipe correctly and change gloves as she should because she was nervous. SNA H said it was important to provide prompt and proper incontinent care to prevent infections. During an interview on 04/30/24 at 6:05 PM, LVN F said the nurse was responsible for ensuring the nurse aides provided prompt and proper incontinent care. LVN F said it appeared as Resident #219 had not been changed all day. LVN F said the nurse aides should be checking on the residents at least every 2 hours. LVN F said when providing incontinent care gloves should be changed when moving from dirty to clean. LVN F said the same wipe should not be used to wipe multiple times because this could cause urinary tract infections. LVN F said not providing incontinent care promptly could cause bed sores and infections. During an interview on 05/02/24 starting at 6:28 PM, the DON said in the past the residents had complained about not getting changed promptly, and she had in serviced the CNAs. The DON said the nurse aides should be checking on the residents at least every 2 hours. The DON said when providing incontinent care gloves should be changed after cleaning the residents and before putting anything new on. The DON said the nurse aides should not use the same wipe to wipe multiple times that a clean area or new wipe should be used. The DON said the charge nurses and herself were responsible for ensuring the nurse aides provided prompt incontinent care. The DON said she provided oversight on proper incontinent care by randomly going in with the nurse aides to provide incontinent care. The DON said she had not noticed any issues with incontinent care. The DON said it was important to provide prompt and proper incontinent care for infection control. During an interview on 05/02/24 starting at 7:37 PM, the Administrator said the nurse aides should be checking on the residents every 2 hours and more frequently for those that were heavy wetters. The Administrator said he expected the nurse aides to follow the incontinent procedures. The Administrator said the DON and ADON were responsible for providing oversight, but currently there was no ADON. The Administrator said not providing prompt and proper incontinent care was a potential for infection issues. 3. Record review of Resident #54's face sheet, dated 05/02/24, indicated Resident #54 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included insomnia, high blood pressure, Dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), stroke, and diabetes. Record review of Resident #54's quarterly MDS assessment, dated 02/27/24, indicated Resident #54 sometimes understood and sometimes understood others. Resident #54's BIMS score was 00, which indicated she was severely cognitively impaired. Resident #54 required extensive assistance with toileting, limited assistance with personal hygiene, transfer, dressing, bed mobility, and set-up with eating. The MDS indicated she was occasionally incontinent of bowel and bladder. Record review of Resident #54's physician orders dated 04/28/24, indicated Nitrofurantoin (Macrobid) Oral Capsule 100 MG, Give 1 capsule by mouth two times a day for UTI (urinary tract infection) for 7 Days. Record review of Resident #54's comprehensive care plan, dated 12/11/23, indicated Resident #54 was at risk of ADL self-performance for bowel and bladder incontinence. The interventions were for staff to assist with toileting x 1 assistance and monitor for signs and symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, and change in behavior. Record review of Resident #54's medication administration (MAR) record dated 04/01/24 through 04/30/24 revealed Nitrofurantoin (Macrobid) Oral Capsule 100 MG, give 1 capsule by mouth two times a day for UTI (urinary tract infection) for 7 Days- started 04/28/24. During an observation on 04/30/24 at 10:21 a.m., CNA C was providing care to Resident #54, who was incontinent of bowel and bladder. CNA C explained what she was going to do. She wiped her genital area using a front-to-back motion. She then turned her on her side while touching her shoulder and side with the same dirty gloves. She proceeded to wipe her buttocks using only one front-to-back motion. She did not wipe her entire buttock which contained urine. She then changed her gloves without hand hygiene and applied her brief. CNA C then left the room without hand hygiene. During an interview on 04/30/24 at 10:44 a.m., CNA C said she was supposed to wipe front to back and clean the entire buttock area. She said she should have performed hand hygiene after removing her soiled gloves and applying new gloves, and before exiting the room. She said she did not wipe or do hand hygiene correctly which could lead to infection. CNA C said she was not aware Resident #54 had a UTI. She said she knew the correct way to provide incontinent care but was nervous and, in a hurry, to get other residents as it was getting close to lunch. During an interview on 05/02/24 at 6:51 p.m., the DON said she expected incontinent care to be performed correctly. The DON said she expects the CNAs to clean all areas that contain urine or bowel. She said she expected them to perform hand hygiene before and after providing incontinent care, change their gloves when going from dirty to clean, and in between glove changes. She said she randomly checked staff while doing incontinent care but felt she needed more time than she had to watch everyone. The DON said not performing incontinent care and hand hygiene correctly could lead to infection. During an interview on 05/02/24 at 7:54 p.m., the Administrator said he expected staff to perform incontinent care and hand hygiene properly. He said if improper incontinent care and/or hand hygiene was not provided correctly it could lead to infection. During an interview on 05/02/24 at 12:04 PM, Anonymous Staff Member #1 said most of the time they had to work a hall with one person and almost the whole hall required the assistance of 2 staff with the residents weighing from 200-500 lbs., and they had to wait a long time to get someone to assist them with the residents that required the assistance of 2 staff. Anonymous Staff Member #1 said they had missed showers because they did not have enough help. Anonymous Staff Member #1 said they had told the Administrator and the AIT and they made promises for more staff, but they were never fulfilled. Anonymous Staff Member #1 said the DON did not help them on the floor, and the management staff that had helped them quit. Anonymous Staff Member #1 said the Treatment Nurse had worked 12 days straight trying to fill the call ins. Anonymous Staff Member #1 said being short staffed affected the residents because they did not receive the proper care they needed. During an interview on 05/02/24 at 12:27 PM, Anonymous Staff Member #2 said when they arrived for their shift that morning, they were working 2 halls and the other CNA was late and worked the other 2 halls. Anonymous Staff Member #2 said they were expected to provide care for all the residents and get them up for breakfast with a lot of the residents requiring 2 staff for transfers. Anonymous Staff Member #2 said it was difficult to provide care for the residents that they were understaffed. Anonymous Staff Member #2 said they had missed giving showers because they were short staffed. Anonymous Staff Member #2 said they reported it to the charge nurses, and they don't really say anything. Anonymous Staff Member #2 said management was aware they were short staffed and did not help. Anonymous Staff Member #2 said being short staffed placed the residents at risk for bed sores, skin breakdown and falls. During an interview on 05/02/24 at 8:03 PM, the Administrator said the nurses and the CNAs had complained about not being able to complete tasks due to the staffing issues. The Administrator said he was trying to recruit staff but there did not appear to be a huge pool. The Administrator said he was advertising daily and offering sing on bonuses. The Administrator said he attempted to borrow CNAs and nurses from sister facilities to help. The Administrator said he was not allowed to use agency to help fill the spots. The Administrator said he was aware they are not following their facility assessment. The Administrator said he had notified his Area Director of Operations of the staffing issues at the facility, but he has not received approval to contract agency staff. The Administrator said not having enough CNAs working the floor resulted in the facility staff not providing the care the residents needed and the care was not as good as it should be. During an interview on 05/02/24 at 9:08 PM, the Area Director of Operations said she was aware the facility was short CNAs, but she was not told the facility was not abiding by the facility assessment's requirements for nurse aides. The Area Director of Operations said not having enough CNAs could affect the safety of the residents. During an interview with the Corporate Nurse on 05/02/24 at approximately 5:10 PM, the policy regarding staffing was requested and not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9.During an observation on 04/29/2024 at 10:52 p.m., PVC plastic clean linen cart sitting in the hallway with cover was open. During an interview on 04/29/2024 at 11:03 p.m., NA Q stated the PVC plastic linen cart cover should always be closed. NA Q stated it was his responsibility to make sure he closed the cover. NA Q stated it was important to keep the cover closed so microorganisms in the hallway would not get on the liens. NA Q stated the failure would be the supplies and linens getting contaminated and cause infection. During an interview on 04/29/2024 at 11:20 p.m., LVN T stated the linen cart cover should be closed. LVN T stated it was the CNAs responsibility to close the cover when they were done. LVN T stated she would do an in-service. LVN T stated the charge nurse was responsible for making sure the CNAs did their jobs. LVN T stated it was important to keep the cover closed for infection control. LVN T stated the failure was the linens could become soiled and the resident could get an infection. During an interview on 05/02/2024 at 6:38 p.m., the DON stated she expected the staff to always close the cover when not being used because that was part of infection control. The DON stated it was her responsibility to monitor. The DON stated it was important to keep the cover closed for infection control. The DON stated the failure was the residents could get into the clean linens and soil them. During an interview on 05/02/2024 at 7:35 p.m., the Administrator stated he expects the staff to close the linen cart cover. The Administrator stated it was the responsibility of the nurse to monitor that the CNAs were closing the cover. The Administrator stated it was important to close the cover for infection control. The Administrator stated the failure was the linens could become contaminated. Record review of the facility's policy titled, Linens . All clean linen will be stored in a secured area. The linen cart will be covered . Record review of the facility's policy titled, Perineal Care, effective date 05/11/22, indicated, . This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition . 8) Prepare and set up the workstation on the overbed or bedside table i. Remove all resident items ii. If visibly soiled, wipe down the table with facility approved disinfectant or place a barrier towel on top if using a washbasin . 10) Perform hand hygiene 11) [NAME] gloves and all other PPE per standard precautions i. Choose your PPE by considering the type of exposure, the durability and appropriateness for the task 12) Soak towels in a washbasin filled with warm water (make sure it is at a comfortable temperature) and facility approved cleansing agent or remove an adequate number of pre-moistened cleansing wipes . Female resident: Working from front to back, wipe . Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke. 20) Reposition the resident to their side 21) Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area . 24) Doff gloves and PPE 25) Perform hand hygiene 26) Provide resident comfort and safety by re-clothing (if applicable - incontinence pad(s) and briefs), straightening bedding, adjusting the bed and/or side rails, and placing call light within resident's reach 27) Clean and store reusable items 28) If visibly soiled or contaminated during the procedure, disinfect or discard the barrier towel on the table 29) Return resident items on the table 30) Tie off the disposable plastic bag of trash and/or linen 31) Perform hand hygiene . Important Points . Do not wipe more than once with the same surface . Always perform hand hygiene before and after glove use . Record review of the facility's policy titled, Enhanced Barrier Precautions, effective date 04/01/24, indicated, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . EBP are indicated for residents with any of the following: . Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid®) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers . 6. Record review of a face sheet dated 05/02/24 indicated Resident #215 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease without dyskinesia, without mention of fluctuations (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of Resident #215's care plan date initiated 04/17/24 indicated he was on enhanced barrier precautions. Resident #215's care plan indicated gloves and gown should be donned if any of the following activities were to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Resident #215's care plan indicated he had an unstageable wound to the right ankle. Record review of Resident #215's Order Summary Report dated 04/28/24 did not indicate an order for enhanced barrier precautions. Record review of Resident #215's electronic health record on 05/02/24 indicated his MDS assessment had not been completed. During an observation on 04/28/24 at 10:31 AM, Resident #215's emergency bathroom light was activated. CNA O went into Resident #215's bathroom to assist him and only put on gloves. CNA O did not put on a gown. CNA O came out of the bathroom with no gown on with Resident #215. CNA O then went on to remove Resident #215's bed linens and bag them only wearing gloves. No gown was donned. During an interview on 04/28/24 at 10:37 AM, Resident #215 said the staff were not wearing gloves and gown when providing his care. During an interview on 04/28/24 4:30 PM, CNA O said Resident #215 required enhanced barrier precautions because he had a wound on his ankle. CNA O said he was supposed to wear gloves and a gown when he had contact with Resident #215. CNA O said he had not put on a gown when assisting Resident #215 because he required standby assistance. CNA O said he was not sure if he was supposed to wear a gown when changing Resident #215's linens. CNA O said he had done a training on the computer on enhanced barrier precautions, but he had not received any other training or instructions regarding the use of enhanced barrier precautions. CNA O said enhanced barrier precautions were used to prevent infection. 7. Record review of a face sheet dated 05/02/24 indicated Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (weakness, paralysis of left side of the body after a stroke). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #124 was sometimes understood by others, and he was usually able to understand others. The MDS assessment indicated Resident #14 had a BIMS score of 8, which indicated his cognition was moderately impaired. The MDS assessment did not indicate any behaviors or rejection of care. The MDS assessment indicated Resident #14 was dependent for toileting hygiene, showering/bathing self and required partial/moderate assistance with personal hygiene. The MDS assessment indicated Resident #14 was always incontinent of bowel and urine. Record review of the care plan last reviewed 03/22/24 indicated Resident #14 had an ADL self-care performance deficit and required assistance with his personal hygiene. Resident #14's care plan indicated he was incontinent of bowel to provide peri care after each incontinent episode. During an observation on 04/29/24 at 9:40 AM, CNA L provided incontinent care with the assistance of the DOR. CNA L and the DOR donned gloves. CNA L and the DOR unfastened Resident #14's brief and CNA L cleaned his front peri area. They turned Resident #14, and CNA L cleaned Resident #14's back area and removed his dirty brief. CNA L removed her dirty gloves and discarded them. CNA L applied new gloves and grabbed the new brief to place under Resident #14 with the assistance of the DOR. After applying the clean brief, CNA L removed her gloves to look for some cream for Resident #14's buttocks. CNA L looked through Resident #14's drawers. CNA L applied new gloves and applied the barrier cream. The DOR removed her gloves and applied clean ones. CNA L and the DOR failed to perform hand hygiene in between glove changes throughout the incontinent care. CNA L and the DOR changed Resident #14's clothes and transferred him to his wheelchair. CNA L gathered the trash and removed her gloves. The DOR removed her gloves, and both performed hand hygiene upon exiting the room. During an interview on 04/29/24 at 10:04 AM, CNA L said hand hygiene should be performed before and after providing care and in between glove changes. CNA L said she did not perform hand hygiene in between glove changes because she was nervous. CNA L said it was important for hand hygiene to be performed to prevent bacteria from spreading and for cleanliness. During an interview on 05/02/24 at 4:21 PM, the DOR said she assisted CNA L because Resident #14 required the assistance of 2 staff. The DOR said hand hygiene should be performed in between glove changes. The DOR said the day she assisted CNA L was not a regular day and she must have forgotten to perform hand hygiene in between glove changes. 8. During an observation and interview on 04/30/24 starting at 5:20 PM, CNA G and SNA H provided incontinent care. CNA G and SNA H donned gloves. CNA G placed the packet of wipes on Resident #219's bed. CNA G pulled out wipes and wiped Resident #219's front peri area. CNA G grabbed the wipes container with her dirty gloves and got more wipes to clean Resident #219's front peri area. CNA G tucked Resident #219's dirty brief under her front area and they turned Resident #219 on her side. CNA G handed SNA H the wipes packet and SNA H took out wipes and placed it on the bed. SNA H wiped Resident #219's buttock because she also had a bowel movement. SNA H used the same wipe to clean Resident #219's buttocks multiple times. SNA H did not use a clean area of the wipe for each stroke. SNA H had to get more wipes and she grabbed the wipes container with her dirty gloves. SNA H continued to wipe Resident #219's buttocks and peri area wiping with the same wipe multiple times. SNA H removed Resident #219's dirty sheet and placed it on the floor. SNA H and CNA G proceeded to apply the clean brief and clean sheets. SNA H and CNA G did not change gloves. They used their dirty gloves to apply the clean brief and sheets. SNA H and CNA G had the clean sheet and dirty sheet and brief touching each other while tucking it under Resident #219 to switch the out. SNA H and CNA G turned Resident #219 to the opposite side and removed the dirty linens and dirty brief and disposed of it. SNA H and CNA G repositioned Resident #219 in bed and covered her up using the same dirty gloves. CNA H and CNA G performed hand hygiene upon exit of the room. CNA G returned the packet of wipes to the clean utility closet. During an interview on 04/30/24 at 5:47 PM, CNA G said she was supposed to change gloves a lot, but she had only taken one pair of gloves with her to provide incontinent care to Resident #219. CNA G said she should change gloves and perform hand hygiene when going from dirty to clean. CNA G said when wiping the residents, the same wipe should not be used multiple times. CNA G said the sheets should not be placed on the floor. They should be bagged and placed at the foot of the bed, but she felt like she did not have enough space. CNA G said the packet of wipes should not have been touched with dirty gloves and since she placed it on the bed and touched it, it should not have been returned to the clean utility closet. CNA G said touching the packet of wipes and returning it to the clean utility closet resulted in cross contamination. CNA G said gloves should be changed and hand hygiene performed during incontinent care to cut down on infection control. CNA G said the sheets should not be placed on the floor for infection control. During an interview on 04/30/24 at 5:54 PM, SNA H said when wiping the residents, she should only wipe once and discard the wipe. SNA H said the same wipe should not be used to wipe multiple times. SNA H said gloves should be changed after she cleaned the front area and before she touched the back area. SNA H said hand hygiene should be performed before and after leaving a resident's room and in between glove changes. SNA H said she did not wipe correctly and change gloves as she should have because she was nervous. SNA H said it was important to provide proper incontinent care to prevent infections. SNA H said she should not have touched the wipes container with her dirty gloves. She said she should have gotten a barrier for the bedside table and put all her supplies on it instead of putting it on the bed to prevent cross contamination. SNA H said dirty linens/sheets should not be placed on the floor they should be placed in a bag. SNA H said placing the dirty linen on the floor could result in the spread of bacteria. During an interview on 04/30/24 at 6:05 PM, LVN F said the nurse was responsible for ensuring the nurse aides provided proper incontinent care. LVN F said when providing incontinent care gloves should be changed when moving from dirty to clean. LVN F said hand hygiene should be performed in between glove changes. LVN F said hand hygiene and glove changes should be done to prevent the spread of infection. LVN F said the same wipe should not be used to wipe multiple times because this could cause urinary tract infections. LVN F said not providing incontinent care promptly could cause bed sores and infections. LVN F said the nurse aides should not have taken the wipes container back to the clean utility if they had touched it with their dirty gloves because this could cause cross contamination. LVN F said dirty linen should not be placed on the floor it should be bagged to prevent cross contamination. During an interview on 05/02/24 starting at 6:28 PM, the DON said the charge nurses and herself were responsible for ensuring the nurse aides provided proper incontinent care. The DON said when providing incontinent care gloves should be changed after cleaning the residents and before putting anything new on. The DON said the nurse aides should not use the same wipe to wipe multiple times that a clean area or new wipe should be used. The DON said hand hygiene should be performed in between glove changes. The DON said dirty linen should not be placed on the floor it should be bagged. The DON said wipes should be removed from the container prior to starting to prevent going back into the wipes. The DON said she provided oversight on proper incontinent care by randomly going in with the nurse aides to provide incontinent care. The DON said she had not noticed any issues with incontinent care. The DON said it was important to provide proper incontinent care for infection control. The DON said when residents required enhanced barrier precautions, they should wear gown and gloves. The DON said this was required when having close contact with a resident on enhanced barrier precautions. For example, when bathing them, incontinent care, and linen changes. The DON said the staff were provided an in-service on enhanced barrier precautions and they completed computer training on enhanced barrier precautions. The DON said it was important to follow the enhanced barrier precautions for infection control because they did not want anything to be passed on to the other residents. During an interview on 05/02/24 starting at 7:37 PM, the Administrator said he expected the nurse aides to follow the incontinent procedures. The Administrator said the DON and ADON were responsible for providing oversight, but currently there was no ADON. The Administrator said not providing prompt and proper incontinent care was a potential for infection issues. The Administrator said he expected for the staff to follow the enhanced barrier precautions. The Administrator said he did not know how much training the staff received on enhanced barrier precautions. The Administrator said he assumed if the enhanced barrier precautions were not followed the organism could spread. 3.Record review of Resident #54's face sheet, dated 05/02/24, indicated Resident #54 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included insomnia, high blood pressure, Dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), stroke, and diabetes. Record review of Resident #54's quarterly MDS assessment, dated 02/27/24, indicated Resident #54 sometimes understood and sometimes understood others. Resident #54's BIMS score was 00, which indicated she was severely cognitively impaired. Resident #54 required extensive assistance with toileting, limited assistance with personal hygiene, transfer, dressing, bed mobility, and set-up with eating. The MDS indicated she was occasionally incontinent of bowel and bladder. Record review of Resident #54's comprehensive care plan, dated 12/11/23, indicated Resident #54 was at risk of ADL self-performance for bowel and bladder incontinence. The interventions were for staff to assist with toileting x 1 staff member and monitor for signs and symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, and change in behavior. Record review of Resident #54's physician orders dated 04/28/24, indicated Nitrofurantoin (Macrobid) Oral Capsule 100 MG, Give 1 capsule by mouth two times a day for UTI (urinary tract infection) for 7 Days. Record review of Resident #54's medication administration (MAR) record dated 04/01/24 through 04/30/24 revealed Nitrofurantoin (Macrobid) Oral Capsule 100 MG, give 1 capsule by mouth two times a day for UTI (urinary tract infection) for 7 Days- started 04/28/24. During an observation on 04/30/24 at 10:21 a.m., CNA C was providing care to Resident #54, who was incontinent of bowel and bladder. CNA C explained what she was going to do. She wiped her genital area using a front-to-back motion. She then turned her on her side while touching her shoulder and side with the same dirty gloves. She proceeded to wipe her buttocks using only one front-to-back motion. She did not wipe her entire buttock which contained urine. She then changed her gloves without hand hygiene and applied her brief. CNA C then left the room without hand hygiene. During an interview on 04/30/24 at 10:44 a.m., CNA C said she was supposed to wipe front to back and clean the entire buttock area. She said she should have performed hand hygiene after removing her soiled gloves and applying new gloves, and before exiting the room. She said she did not wipe or do hand hygiene correctly which could lead to infection. CNA C said she was not aware Resident #54 had a UTI. She said she knew the correct way to provide incontinent care but was nervous and, in a hurry, to get other residents as it was getting close to lunch. 4. Record review of Resident #23's face sheet, dated 05/02/24 indicated Resident #23 was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Diabetes, seizures, and high blood pressure. Record review of Resident #23's quarterly MDS assessment, dated 03/13/24, indicated Resident #23 was sometimes understood and was sometimes understood by others . Resident #23's BIMS score was 07, which indicated his cognition was moderately impaired. Resident #23 required assistance with toileting, personal hygiene, transfers, dressing, bed mobility, and supervision with eating. The MDS indicated Resident #23 received insulin during the 7-day look-back period. Record review of Resident #23's comprehensive care plan, dated 05/03/19 indicated Resident #23 had a diagnosis of Diabetic Mellitus. The intervention of the care plan was for staff to administer diabetes medication as ordered by the doctor and monitor/document for side effects and effectiveness. Record review of a face sheet dated 05/02/2024 indicated Resident #219 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with behaviors). Record review of Resident #219's electronic health record on 05/02/2024 indicated the MDS assessment had not been completed yet. Record review of Resident #219's care plan dated 04/28/24 indicated she had a diagnosis of Diabetic Mellitus. The intervention was for staff to administer her diabetes medication as ordered by the doctor and monitor/document for side effects and effectiveness. Record review of Resident #219's physician's orders dated 04/24/24 indicated: Check blood sugar before meals and at bedtime. During an observation on 04/28/24 at 4:26 p.m., LVN M checked Resident #23's blood sugar and then went to Resident # 219's room and checked her blood sugar without cleaning the glucometer before checking Resident 219's blood sugar. During an interview on 04/28/24 at 4:30 p.m., LVN M said he did not clean the glucometer between Resident #23 and Resident #219. He said he had been trained on infection control and how to clean the glucometer. He said he should have cleaned the glucometer between the residents to prevent the spread of infection. 5.Record review of a face sheet dated 05/02/24 indicated Resident #26 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included subacute osteomyelitis, right radius, and ulna (infection of the bones in the right arm) and type 2 diabetes mellitus without complications (a chronic condition that affects the way the body processes blood sugar). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #26 was able to make himself understood and understood others. The MDS assessment indicated Resident #26 had a BIMS score of 14, which indicated his cognition was intact. Record review of Resident #26's care plan date initiated 04/12/24 indicated he required enhanced barrier precautions related to a PICC line. Resident #26's care plan indicated gloves and gown should be donned if any of the following activities were to occur linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, bathing, or other high-contact activity. Record review of Resident #26's physician order dated 04/19/24 revealed: Vancomycin HCl Intravenous Solution 1250 MG/250ML (Vancomycin HCl) Use 1.25 gram intravenously two times a day related to Osteomyelitis (infection in the bones) of the right radius and ulna. Give in a 250ml piggyback every 12hrs x 6 weeks until 05/17/24. Record review of Resident #26's Order Summary Report dated 04/28/24 did not indicate an order for enhanced barrier precautions. During an observation and interview on 04/28/24 at 4:36 p.m., RN E went into Resident #26 room to start his IVABT . RN E did not apply the PPE for his enhanced precautions. RN E said she thought she was supposed to wear PPE if she was providing incontinent care, not IV care. She said she was going to ask the DON about the correct procedure. RN E came back to the surveyor and said she was supposed to wear a gown and gloves when providing IV care for Resident #26 to prevent the spread of infection. During an interview on 05/02/24 at 6:51 p.m., the DON said she expected incontinent care to be performed correctly. She said she expected staff to perform hand hygiene before and after providing incontinent care, change their gloves when going from dirty to clean, and in between glove changes. The DON said nurses were responsible for cleaning the glucometer between each resident to prevent the spread of infection. She said anytime a staff member performed care with a resident that required enhanced barriers, should have on a gown and gloves (i.e.: incontinent care, IV care, or wound care). She said they had at least two in-services on the new enhanced barrier procedure. The DON said not wearing PPE when required, providing hand hygiene when needed, or performing incontinent care correctly could lead to infection control issues. During an interview on 05/02/24 at 7:54 p.m., the Administrator said he expected staff to perform incontinent care and hand hygiene properly. He said he expected nurses to clean the glucometer between each resident. He said the enhanced procedure was new to him but knew they should wear their PPE when providing care. He said improper incontinent care, hand hygiene, cleaning of the glucometers, and not following the enhanced barriers procedure correctly could lead to infection control issues. 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 diseases and infections for 7 of 7 residents (Resident #36, Resident #115, Resident #14, Resident #219, Resident #215, Resident #54, Resident #26) and 2 linen carts (Hall 200 linen cart, facility clean linen cart) reviewed for infection control practices. 1.CNA UU failed to wash or sanitize hands when changing gloves between dirty and clean while providing peri care for Resident #36 and prevent hall 200 linen cart to be contaminated by placing the used wipes and barrier cream from Resident #36 on the clean cart. 2.The Treatment Nurse failed to use PPE related to enhanced barrier precautions while completing a dressing change for Resident #115. 3. The facility failed to ensure CNA C properly cleaned the peri area, changed gloves, and used hand hygiene before going from dirty to clean while providing incontinent care to Resident #54. 4. The facility failed to ensure LVN M, cleaned the glucometer between Resident #26 and Resident #219. 5. The facility failed to ensure RN E followed the enhanced barrier precautions for Resident #26. 6. The facility failed to ensure CNA O followed the enhanced barrier precautions for Resident #215. 7. The facility failed to ensure CNA L and the DOR performed hand hygiene in between glove changes when providing incontinent care to Resident #14. 8. The facility failed to ensure CNA G and SNA H changed gloves, performed hand hygiene, and did not touch the wipes container with dirty gloves while providing incontinent care to Resident #219. 9. The facility failed to ensure SNA H did not place a dirty sheet on the floor while providing incontinent care to Resident #219. 10. The facility failed to ensure SNA H used a clean wipe for each stroke when providing incontinent care to Resident #219. 11. The facility failed to ensure the clean linen cart was covered. These failures could place residents and staff at risk for cross contamination and the spread of infection. Findings included: 1.Record review of Resident #36's face sheet dated 05/02/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses hemiplegia following cerebral infarction, chronic pain, hypertension (high blood pressure), cognitive communication deficit, and major depression. Record review of Resident #36's quarterly MDS dated [DATE] indicated that she had a BIMS score of 11 which indicated she had moderate cognitive impairment. The MDS also indicated she required maximal assistance with toileting, total assistance with bed mobility and transfers, and setup assistance with eating. The MDS also indicated Resident #36 was at risk for pressure ulcers. Record review of Resident #36's care plan dated 02/20/24 indicated resident had impaired cognitive function/dementia with an intervention for the facility to administer meds as ordered. The care plan also indicated she had an ADL self-care performance deficit and required assistance from staff for toileting, bed mobility, dressing, and bathing. During an observation and interview on 04/30/24 at 10:21 AM CNA UU was in the hallway 200 and said she is going to change Resident #36. CNA UU grabbed wipes and a set of gloves off the linen cart and entered Resident #36's room without using hand sanitizer. She then donned gloves and grabbed a brief out Resident #36's closet. CNA UU closed the blinds, pulled the privacy curtain, and moved bedside table to the side. CNA UU placed wipes on bedside table and unfastened resident brief provided perineal care, cleaned bowel movement, and applied cream. CNA UU rolled to left side pulled brief and fastened clean brief and repositioned draw sheet. CNA UU never changed gloves or used hand hygiene during entire procedure. During an interview on 04/30/24 at 10:39 AM, CNA UU said she should have cleaned her hands with hand sanitizer before care, changed gloves after cleaning the dirty areas as well as the bowel movement from Resident #36, and after care. She said the failure placed a risk for contamination and infection. She said the staff performed peri care proficiency check offs, but she only grabbed one glove when she entered the room and failed to change her gloves and use hand sanitizer. CNA UU then placed wipes from Resident #36's room back on the linen cart. CNA UU stated she should not have placed the wipes back on the linen cart for hall 200 because she contaminated everything on the cart as well as risked spreading germs to other residents. CNA UU said that was how they were taught and said the CNA staff would get in trouble for leaving the wipes in the rooms. 2.Record review of Resident #115's face sheet dated 05/02/24 indicate he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses aftercare for genitourinary surgery, hypertension (high blood pressure), and benign prostatic hyperplasia (enlarged prostate). Record review of Resident #115's admission MDS dated [DATE] indicated he had a BIMS score of 15 which indicated he was cognitively intact. The MDS also indicated he required supervision with toileting, dressing, and bathing. Record review of Resident #115's undated care plan indicated he had an ADL self-care deficit and required assistance by 1 staff for bathing, dressing, toileting, and personal hygiene. The[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide residents with personal privacy and confidentiality of his or her personal and medical records.for 2 of 5 (Resident #2 and Resident #3) residents reviewed for resident rights. 1. The facility did not ensure the door was closed during wound care on Resident #2 resulting in another resident trying to enter the room to speak with the nurse during Resident #2's wound care . 2. The facility failed to prevent RN A from discussing Resident #3 with Resident #2. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: 1. Record review of the face sheet dated 3/6/24 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection) of the right and left lower limb, lymphedema (swelling, most often in the arm or leg, caused by a lymphatic system (a network of delicate tubes throughout the body) blockage), diabetes, and chronic kidney disease. Record review of the MDS dated [DATE] indicated Resident #2 understood others and was understood by others. The MDS indicated Resident #2 had a BIMS of 14 and was cognitively intact. The MDS indicated Resident #2 had one venous or arterial artery present. Record review of the care plan revised 1/21/24 indicated Resident #2 had a venous stasis ulcer (a wound on the leg or ankle caused by abnormal or damaged veins) of the left calf related to poor circulation with interventions including wound care as ordered. During an observation and interview on 3/5/24 at 1:38 p.m. Observed RN performed wound care on Resident #2. RN a left the door open to Resident #2's room while setting up, removing dirty dressing, leaving the room to obtain scissors, and only shut the door when Resident #3 tried to enter the room in the middle of the wound care to talk to RN A. RN A said Resident #3 entered the room during wound care because RN A did not shut the door prior to starting wound care. RN A said the importance of shutting the door prior to providing care to a resident was for privacy and to prevent interruptions. During an interview on 3/6/24 at 1:35 p.m. RN B said when performing wound care, privacy should be provided. RN B said it was important to provide privacy during wound care for the resident's dignity. During an interview on 3/6/24 at 1:38 p.m. the DON said she expected staff to provide privacy when providing any type of care. The DON said the importance of providing privacy was dignity and resident rights. 2. Record review of the face sheet dated 3/6/24 indicated Resident #3 was an [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including dementia, cognitive communication deficit, and bipolar disorder. Record review of the MDS dated [DATE] indicated Resident #3 usually understood others and was usually understood by others. The MDS indicated Resident #3 had a BIMS of 4 and was severely cognitively impaired. Record review of the care plan revised 10/19/23 indicated Resident #3 had an impaired cognitive function/dementia or impaired thought processes. During an observation and interview on 3/5/24 at 1:38 p.m. RN A left the door open to Resident #2's room while setting up, removing dirty dressing, leaving the room to obtain scissors, and only shut the door when Resident #3 tried to enter the room in the middle of the wound care. RN A redirected Resident #3 out of Resident #2's room. RN A said to Resident #2 she believed that the full moon really did effect people. RN A said to Resident #2 she thinks the full moon effects people because Resident #3 had been very emotional today. RN A said Resident #2 and Resident #3 talked regularly. RN A said she was sure Resident #2 already knew Resident #3 was emotional today. During an interview on 3/6/24 at 12:53 p.m. Resident #2 said she did not know the resident who entered her room while wound care was being performed. Resident #2 said she had seen Resident #3 but did not know her. Resident #2 said she had only been at the facility since December 2023 and was just starting to really get to know some of the other residents. During an interview on 3/6/24 at 1:35 p.m. RN B said it was never ok to talk about another resident to a resident. RN B said it was a HIPAA violation and unprofessional to talk about one resident to another. During an interview on 3/6/24 at 1:38 pm the DON said staff should never talk about one resident to another resident. The DON said it was a HIPAA violation and a breach in confidentiality for staff to talk about one resident to another resident. Record review of the facility's Resident Rights policy revised 11/28/16 indicated, The resident had the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States .The resident has the right to be treated with respect and dignity .The resident has a right to personal privacy and confidentiality of his or her personal and medical records .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 (Resident #2) residents reviewed for quality of care. 1.The facility failed to ensure Resident #2's venous stasis ulcer (a wound on the leg or ankle caused by abnormal or damaged veins) treatment was performed daily as ordered. 2.The facility failed to ensure the nurses initialed and dated wound dressings when wound care was performed on Resident #2 . These failures could result in residents with venous stasis ulcer of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing. Findings included: 1. Record review of the face sheet dated 3/6/24 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection) of the right and left lower limb, lymphedema (swelling, most often in the arm or leg, caused by a lymphatic system (a network of delicate tubes throughout the body) blockage), diabetes, and chronic kidney disease. Record review of the physician orders dated 3/6/24 indicated Resident #2 had an order to cleanse left venous stasis ulcer to calf with normal saline, pat dry, apply leptospermum honey (used to treat wound infections), wrap with kerlix (bandage roll) and secure with paper tape daily starting 1/4/24. The physician orders indicated Resident #2 had an order to cleanse right lower leg with normal saline, pat dry, wrap with kerlix, and wrap with ace wrap every Monday, Wednesday, and Friday. Record review of the MDS dated [DATE] indicated Resident #2 understood others and was understood by others. The MDS indicated Resident #2 had a BIMS of 14 and was cognitively intact. The MDS indicated Resident #2 had one venous or arterial artery present. Record review of the care plan revised 1/21/24 indicated Resident #2 had a venous stasis ulcer of the left calf related to poor circulation with interventions including wound care as ordered. Record review of the TAR dated 2/1/24 through 2/29/24 indicated Resident #2's treatment to cleanse left venous stasis ulcer to calf with normal saline, pat dry, apply leptospermum honey, wrap with kerlix and secure with paper tape daily was only performed on 2/4/24, 2/6/24, 2/8/24, 2/9/24. 2/11/24, 2/13/24, 2/14/24,2/16/24, 2/17/24, 2/19/24, 2/20/24, 2/21/24, 2/2/24, 2/23/24, 2/24/24, 2/25/24, and 2/27/24. The TAR indicated Resident #2's treatment to cleanse right lower leg with normal saline, pat dry, wrap with kerlix, and wrap with ace wrap every Monday, Wednesday, and Friday was only performed on 2/9/24, 2/14/24, 2/16/24, 2/19/24, 2/21/24, and 2/23/24. During an interview on 2/29/24 at 12:30 p.m. the ADON said she had been performing wound care for approximately a month. The ADON said a nurse could check the TAR to indicated if a treatment had been done. The ADON said she did not date her treatments because she was the only one doing them. The ADON said the charge nurses were responsible for checking off on the TAR treatments were done when they finished them. The ADON said she did the treatments when she was working. The ADON said her normal schedule was Monday through Friday 8:00 am to 5:00 pm, but she had worked several different shifts and positions recently. The ADON said if the treatment was not signed off on the TAR it had been completed there was no way to prove it had been done. During an observation and interview on 3/5/24 at 1:38 p.m. RN A performed wound care on Resident #2. The wound dressing on Resident #2's left calf was dated 3/3/24. RN A completed wound care to the left calf and left the room to obtain betadine for Resident #2's heel. RN A confirmed she was completely finished with the wound care to the left calf. RN A said the dirty dressing had been dated 3/3/24 and indicated wound care had not been completed on 3/4/24. RN A said the importance of performing wound care daily as ordered was because Resident #2's wound had been infected and would easily become infected again especially with her diagnoses of diabetes. RN A said she needed to get a piece of tape to date the dressing to Resident #2's left calf. RN A said a wound dressing did not need to be initialed and dated if the same nurse was going to be performing the wound care the next day. RN A said if different nurses were working the hall, or the nurse was not going to be there the next day the dressing should be initialed and dated. During an interview on 3/6/24 at 1:35 p.m. RN B said when performing wound care privacy should be provided, the dressing should be dated and initialed, and the treatment should be signed off on the TAR. RN B said it was important to date and initial the wound dressings for proof wound care was completed. RN B said if wound care was not signed off on the TAR it could not be proved the wound care was performed as ordered. RN B said it was important to perform wound care as ordered to ensure proper healing. During an interview on 3/6/24 at 1:38 p.m. the DON said she expected staff to date and initial wound dressings. The DON said dating and initialing wound dressing verified the wound care was performed. The DON said she expected staff to sign off on the TAR when wound care was completed. The DON said if the TAR was not signed off there was no way to prove wound care had been performed as ordered. Record review of the facility's undated Dressing Change Checklist indicated, Verifies orders for wound treatment from the TARs and chart .document procedure per facility protocol. Record review of the facility's Skin Integrity Management policy dated 2003 indicated, .Wound care should be performed as ordered by the physician .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 5 (Resident #1) residents reviewed for pressure injuries. The facility failed to ensure Resident #1's wound care was performed daily as ordered . These failures could place residents at risk for worsening of existing pressure injuries, infection, pain, and decreased quality of life. Findings included: 1. Record review of the face sheet dated 3/5/24 indicated Resident #1 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses including dementia, diabetes, COPD, hydronephrosis, and chronic pain. Record review of the physician orders dated 3/5/24 indicated Resident #1 had an order to cleanse coccyx (small triangular bone at the base of the spinal column) with normal saline, pat dry, apply collagen (used to treat partial-thickness wounds and some pressure ulcers) to wound and a dry dressing one time a day for wound healing starting 1/4/24. The physician orders indicated Resident #1 had an order to cleanse MASD (moisture associated skin damage) area to coccyx with normal saline, pat dry, apply silver alginate (a wound dressing with antibacterial silver for moderate to highly exudating (fluids moving to the site of an injury)), and cover with a dry dressing daily until resolved starting 2/7/24. Record review of the comprehensive MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS score of 9 and was moderately cognitively impaired. The MDS indicated Resident #1 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device that was present on admission or re-entry. Record review of the care plan revised on 12/18/23 indicated Resident #1 had a pressure ulcer or potential for pressure ulcer development: Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed without slough (yellow/white material in the wound bed) or bruising) to coccyx. Record review of the TAR dated 2/1/24 through 2/29/24 indicated Resident #1's treatment to cleanse coccyx with normal saline, pat dry, apply collagen to wound and a dry dressing one time a day for wound healing on dates 2/1/24 through 2/13/24 was only performed on 2/6/24. The TAR indicated Resident #1's treatment to cleanse MASD area to coccyx with normal saline, pat dry, apply silver alginate, and cover with a dry dressing daily on dated 2/7/24 through 2/23/24 was only performed on 2/13/24, 2/16/24, 2/17/24, 2/18/24, 2/19/24, 2/20/24. Record review of the weekly ulcer assessment dated [DATE] indicated Resident #1 had a Stage 3 (an ulcer that has burrowed past the dermis (the skin's second layer) and reached the subcutaneous tissue (fat layers) beneath) to the sacrum measuring 1.2 cm x 0.6 cm x 0.72 cm that was not present on admission. During an interview on 2/29/24 at 12:30 p.m. the ADON said she had been performing wound care for approximately a month. The ADON said a nurse could check the TAR to indicated if a treatment had been done. The ADON said the charge nurses were responsible for signing off on the TAR treatments were done when they finished them. The ADON said if the treatment was not signed off on the TAR it had been completed there was no way to prove it had been done. During an interview on 3/6/24 at 1:35 p.m. RN B said when performing wound care privacy should be provided, the dressing should be dated and initialed, and the treatment should be signed off on the TAR. RN B said if wound care was not signed off on the TAR it could not be proved the wound care was performed as ordered. RN B said it was important to perform wound care as ordered to ensure proper healing. During an interview on 3/6/24 at 1:38 p.m. the DON she expected staff to sign off on the TAR when wound care was completed. The DON said if the TAR was not signed off there was no way to prove wound care had been performed as ordered. Record review of the facility's undated Dressing Change Checklist indicated, Verifies orders for wound treatment from the TARs and chart .document procedure per facility protocol. Record review of the facility's Skin Integrity Management policy dated 2003 indicated, .Wound care should be performed as ordered by the physician .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 1 (Resident #1) residents reviewed for incontinence care. The facility failed to ensure Resident #1's discharge order for a urinary straight catheter (also called an intermittent catheter, is a soft, thin tube used to pass urine from the body) four times a day was initiated upon re-admission to the facility . This failure could place residents at risk for urinary retention (difficulty urinating and completely emptying the bladder), pain, and urinary tract infections. Findings included: 1. Record review of the face sheet dated 3/5/24 indicated Resident #1 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses including dementia, diabetes, COPD, hydronephrosis, and chronic pain. Record review of the physician orders dated 3/5/24 indicated Resident #1 did not have an order for a urinary straight catheter four times a day. Record review of the comprehensive MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS score of 9 and was moderately cognitively impaired. The MDS indicated Resident #1 had occasional urinary incontinence. Record review of the care plan revised on 12/18/23 indicated Resident #1 had a resident had an ADL self-care performance deficit with interventions including toileting assistance of one staff required. Record review of the hospital progress notes from 1/6/24 through 1/9/24 indicated Resident #1's assessment and plan included foley catheter (a semi-flexible tube inserted into the bladder and has a bag on the other end used when a person cannot urinate normally), then urinary straight catheter four times a day upon discharge. Record review of the hospital discharge orders dated 1/10/24 indicated Resident #1 discharged to the facility with an order for a urinary straight catheter four times a day. Record review of the urology progress note dated 2/15/24 indicated Resident #1 had a history of urinary retention and frequent urinary tract infections. The progress note indicated Resident #1 was without a foley catheter. The progress note indicated Resident #1 had complete urinary incontinence and emptied well. During an interview on 3/5/24 at 9:47 a.m. the DON said she was unsure what happened with Resident #1's order for a urinary straight catheter four times a day. The DON said she would have to find out what happened with the order for a urinary straight catheter not being entered in the computer. During an interview 3/6/24 at 11:23 a.m. the Nurse at Urologist office said importance of performing the in and out catheterization (urinary straight catheterization) as ordered was to prevent urinary retention which could lead to urine backing up into the kidneys and causing damage to the kidneys, bladder damage, and to prevent pain. The Urology Nurse said they would have expected the facility to have performed the in and out catheterizations as ordered until Resident #1 had her follow-up appointment with the Urologist. During an interview on 3/6/24 at 1:35 p.m. RN B said if a resident discharged from the hospital with orders for an in and out catheter the order should be implemented. RN B said it was important to implement orders for an in and out catheter to prevent urinary retention and UTI. During an interview on 3/6/24 at 1:38 p.m. the DON said she expected staff to implement all discharge orders from the hospital. The DON said the importance in ensuring discharge orders were implemented was for patient care and overall outcome. The DON said orders entered after an admission/re-admission were reviewed in the morning meeting or she would review them later. The DON said she did not see the order for Resident #1 to have an in and out catheter four times a day until the surveyor pointed it out. Record review of the facility's Catheter Care policy dated 2003 indicated, Determine if the resident's urine level has increased. If the level stays the same, or increases rapidly, report it to your supervisor. Should the resident indicate his or her bladder is full or that he or she needs to void (urinate), report immediately to your supervisor .Observe for and report to charge nurse .e. Urinary complaints such as dysuria (painful urination), burning, urgency, frequency, or flank pain. f. Other significant observations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 9 (Resident #1) residents reviewed for pharmacy services. The facility failed to only administer medication prescribed by the physician to Resident #1. The noncompliance was identified as PNC. The noncompliance began on 9/05/23 and ended on 9/07/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for adverse reactions. Findings Include: Record review of the face sheet dated 9/15/23 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, cerebral infarction (stroke), myocardial infarction (heart attack), hypertension (high blood pressure), chronic kidney disease, and cognitive communication deficit. Record review of the MDS assessment dated [DATE] indicated Resident #1 was understood by others and understood others. The MDS indicated Resident #1 had a BIMS of 06 and was severely cognitively impaired. Record review of the care plan 7/11/23 indicated Resident #1 was on diuretic (medication that helps your kidneys get rid of extra water in the body) therapy. Record review of the physician orders dated 9/15/23 indicated Resident #1 did not have an order for nebulized Furosemide (a medication converted a liquid to a fine spray, for inhalation of to relieve dyspnea (labored breathing) in patients with COPD and advanced cancer. Record review of a progress note dated 9/05/23 ad 5:12 am written by LVN A indicated, [Resident #1] was nonresponsive, eyes fixed, clammy at 98.4, and gurgling sound in throat. O2 saturation at 70 (how much oxygen if in the bloodstream with normal values being 95-100%), heart rate 121, abdominal breathing, called EMS for transport to hospital. Retrieved crash cart and began to suction resident . Applied O2 [oxygen] via nasal cannula and 4ml Lasix [Furosemide] could be administered via nebulizer. Was able to get O2 [oxygen] saturation to 74% (briefly then turned resident to her left side and suctioned her again, reapplying nebulizer mask. EMS arrived and transported resident to [hospital] . Record review of the Medication Error Report dated 9/05/23 indicated LVN A administered nebulized Furosemide to Resident #1 without a physician's order. The Medication Error Report indicated the LVN A's response regarding committing the violation was, I was going to get an order later. I was doing what I knew would help the resident. The Medication Error Report indicated the action taken to correct or prevent reoccurrence was education and in-service of nursing staff and termination of LVN A related to administering medication without a physician's order. Record review of the Medication Error Form dated 9/05/23 indicated medication was administered by LVN A without obtaining an order. The Medication Error Form indicated it was unclear where LVN A obtained the medication from. The Medication Error Form indicated LVN A's response to the violation was, I only did what I knew to be necessary. I figure we would get the order later. The Medication Error Form indicated LVN A had not been previously warned regarding this type of allegation. Record review of the Provider Investigation Report dated 9/07/23 indicated LVN A was terminated on 9/05/23 after LVN A stated she had used nursing judgement and administered nebulized Furosemide without a physician's order to Resident #1 when Resident #1 was unresponsive and had an oxygen saturation in the 70s. The Provider Investigation Report indicated EMS had been called and was enroute to the facility when LVN A administered nebulized Furosemide to Resident #1. The Provider Investigation Report indicated the hospital had informed the DON that Resident #1 had experienced a heart attack and they did not believe there were any adverse effects from the medication error. Record review of the Employer Report Form to the Texas Board of Nursing Regarding Violations indicated the facility filed a report with the Texas Board of Nursing against LVN A for administering nebulized Furosemide to Resident #1 without a physician's order. Record review of Medication Pass Guidelines dated 9/12/23 through 9/15/23 indicated nurses and MAs had been observed for medication cart and drug security, infection control precautions, medication administration, medication, medication refusal, resident assessment, and medication errors by the DON and ADON. The Medication Pass Guidelines indicated all nurses and MAs observed met all of the objectives satisfactorily. During an observation on 9/08/23 at 11:30 a.m., Resident #1 was lying in her hospital bed, intubated, and unresponsive. During an interview on 9/08/23 at 11:33 a.m., the ICU nurse said Resident #1 was admitted to the hospital with a diagnosis of acute respiratory failure hypoxia. During an interview on 9/08/23 at 1:11 p.m., the DON said she did not know where LVN A obtained the nebulized Furosemide that was administered to Resident #1. The DON said there were other resident on the same hall as Resident #1 that had orders for nebulized Furosemide. The DON said LVN A refused to tell her where the medication came from and was terminated for administering medication without an order. The DON said with nebulized Furosemide not being a narcotic there was not a count for the medication that would enable the facility to determine whether or not the medication was taken from another resident. During an interview on 9/14/23 at 8:54 a.m., the DON said she had just got off the phone with the Texas Board of Nursing regarding LVN A. The DON said she had referred LVN A to the Board of Nursing due to administration of nebulized Furosemide to a resident without an order. During an interview attempt on 9/14/23 at 9:07 a.m., LVN A did not answer the phone and did not have a voicemail setup. During an interview on 9/14/23 at 12:00 pm, The Administrator said after the medication error incident involving Resident #1 all nurse and med aides were in-serviced regarding medication errors, medication administration, and physician notification. The Administrator said they had an ad hoc QA meeting and the Medical Director was notified. During an interview on 9/14/23 at 12:20 p.m. the DON said LVN A had started at the facility in October 2022. The DON said LVN A had not had any medication errors at the facility until 9/5/23. The DON said LVN A had some one-on-one in-service regarding failing to enter new admission information into the computer. The DON said LVN A worked the night shift. The DON said when she reported LVN A to the Board of Nursing she was informed LVN A had a disciplinary action from the Board of Nursing in 2010, but they did not disclose what it was regarding. The DON said she started at the facility in April 2023 and there had not been any med errors from the time she started until 9/5/23. The DON said she expected the nurses to obtain an order from the physician prior to any medication being administered to a resident. The DON said she expected to be notified immediately of any medication error. During an interview on 9/14/23 at 1:22 p.m., the Medical Director said he was aware of the nebulized Furosemide being administered by LVN A to Resident #1 without an order. The Medical Director said he did not believe the administration of nebulized Furosemide would have been detrimental to Resident #1. The Medical Director said he did not understand the nurse's reasoning for giving the medication. The Medical Director said they had found in pulmonology journals nebulized Furosemide aided in opening the airways in the event of air hunger and hypoxia. The Medical Director said nebulized Furosemide tends to work best with COPD patients. The Medical Director said he would have expected the nurse to have obtained an order for the medication prior to administering it. The Medical Director said that Furosemide given in nebulized form does not act in the same way as when given in pill form or via IV. The Medical Director said Furosemide in nebulized form does not diurese a person it only opens up the airway. The Medical Director said the resident was not at risk for dehydration due to the form the medication was administered in. During an interview on 9/14/23 at 3:53 p.m., The Nurse Practitioner said he was aware of the medication error involving Resident #1. The Nurse Practitioner said administering nebulized Furosemide was not detrimental to Resident #1. The Nurse Practitioner said nebulized Furosemide did not have the diuretic effect oral and IV Furosemide did. The Nurse Practitioner said nebulized Lasix is used to open airways and most often used in heart failure, COPD, or Hospice patients. The Nurse Practitioner said nebulized Furosemide was more of a comfort measure. The Nurse Practitioner said he would have expected the nurse to have obtained an order for a medication before administering it to a resident. During an interview on 9/15/23 at 9:50 a.m., RN B named all rights of medication administration. RN B said staff knew what medications to administer by checking the physician orders. RN B said if a medication was not ordered it should not be given. RN B said an order should always be obtained prior to administering a medication. RN B said the DON should be notified of medication errors, falls, elopements, and new wounds. RN B said if there was a medication error the DON, physician, and resident's family should be notified. RN B said in the event of a medication error a medication error report should be completed. During an interview on 9/15/23 at 10:30 a.m. RN C named the 10 rights of medication administration. RN C said prior to giving a medication, the physician's order should be checked. RN C said a medication should never be administered that was not ordered by the physician. RN C said administering a medication that was not ordered by the physician would be considered a med error. RN C said medication error should be reported to the DON, physician, and resident's family. RN C said when a med error occurred, a med error form was required to be completed. During an interview on 9/15/23 at 11:13 a.m., MA D was able to name the 10 rights of medication administration. MA D said the physician orders were entered into the MAR and she was required to check the MAR and the medication cards to ensure they matched before giving a medication. MA D said if a resident wanted a medication that was not on her MAR, she would report to the charge nurse and the charge nurse would consult with the physician. MA D said if a medication error occurred she would report it immediately to her charge nurse. During an interview on 9/15/23 at 2:20 p.m., MA E was able to name the 10 rights of medication administration. MA E said the physician orders were entered into the MAR and she was required to check the MAR and the medication cards to ensure they matched before giving a medication. MA E said if a resident wanted a medication that was not on her MAR, she would report to the charge nurse and the charge nurse would consult with the physician. MA E said if a medication error occurred, she would report it immediately to her charge nurse. Record review of the facility's Medication Administration Procedures revised 10/25/17 indicated, .All current medications and dosage schedules are to be listed on the resident's current medication administration record. Medication prescribed for one resident are not to be administered to any other resident. A specific order must be obtained by the physician to change the dosage form of a resident's medication. Medication errors and adverse drug reactions are immediately reported to the resident's physician. In addition, the Director of Nurses and/or designee should be notified. Any medication error will require a medication error report that includes the error and action to prevent reoccurrence .The 10 rights of medication should always be adhered to: 1. Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right patient education 7. Right documentation 8. Right to refuse 9. Right assessment 10. Right evaluation. Record review of facility's undated When to Call the DON policy indicated, It is my expectation that I am called by the charge nurses in the following circumstances. If you are not able to reach me by phone, please send me a text message. If I have not gotten back to you within 10 minutes, please call the ADON .Anytime there is an incident or accident .d. medication errors .Anytime there is a change in condition or new medical concern for a resident .Anytime there is a medication that cannot be located. Anytime there is a discrepancy in a medication count . Record review of the facility's Medication Incident Report Procedure policy dated 2013 indicated, All medication incidents will be documented. Medication administration errors will be reported to the resident's attending physician and family member. The facility staff will take whatever immediate action is necessary to protect the resident's safety and welfare in the event of a medication administration incident. The attending physician and family will be promptly notified of any medication administration incident .Interventions will be put in place to attempt to prevent reoccurrence, i.e., staff education. The facility had corrected the noncompliance by the following: Terminating LVN A immediately Notification to the physician and nurse practitioner In-servicing nurses and medication aides regarding when to call the DON, medication pass, medication rights, and medication errors, medication errors/process, and medication administration. Ad hoc QA meeting regarding the medication error The surveyor confirmed the facility had corrected the non-compliance prior to survey through the following actions: Record review of the Employee Disciplinary Report dated 9/05/23 indicated LVN A was terminated due to failure to adherer to the Corporate Code of Conduct, acting outside of the scope of practice per professional standards of the Texas Board of Nursing, and administering medication without a physician's order. The Employee Disciplinary Report indicated LVN was terminated effective immediately. Record review of a Quality Assurance (QA) Meeting Sign-in Sheet dated 9/06/23 indicated the facility had an ad hoc QA meeting regarding the medication error on 9/05/23. The QA Meeting Sign-in Sheet indicated the physician and nurse practitioner had been notified of the medication error via telephone on 9/05/23. Record review of an in-service dated 9/05/23 indicated nurses, MAs, and CNAs were in-serviced regarding when to call the DON including medication errors, change in condition or new medical concern, any time there is a medication that cannot be located, and anytime there is a discrepancy in a medication count. Record review of an in-service dated 9/05/23 indicated nurses and MAs were in-serviced regarding medication pass, medication rights, and medication errors. Record review of an in-service dated 9/07/23 indicated nurses and MAs were in-serviced regard medication errors/process including ensure resident safety, notify the physician/nurse practitioner, complete any orders/instructions the physician/nurse practitioner had given, notify the DON and Administrator, notify the resident's family/responsible party, complete and event and all required documentation, and monitor the resident. Record review of an in-service dated 9/07/23 indicated all nurses and MAs had been in-serviced regarding medication administration including medications being residents property, nursing staff must follow the 10 right of medication administration (right patient, right medication, right dose, right route, right time, right patient education, right documentation, right to refuse, right assessment, and right evaluation), and any medication error witnessed or suspected must be reported to the DON, Administrator, and physician/nurse practitioner immediately. Interviews were conducted on 9/14/23 between 1:22 p.m. and 3:53 p.m. with the Medical Director and the Nurse Practitioner. The Medical Director and Nurse Practitioner confirmed they had been notified of the nebulized Furosemide being administered by LVN A to Resident #1 without an order. Staff interviewed (RN B, RN C, MA D, and MA E) on 9/15/23 between 9:50 a.m. and 2:20 p.m. were able to answer questions regarding trainings/in-services. The noncompliance was identified as PNC. The noncompliance began on 9/05/23 and ended on 9/07/23. The facility had corrected the noncompliance before the survey began.