**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, homelike environment maintaining a comfortable noise level for 1 of 18 residents (Resident #39) reviewed for dining services. The facility failed to ensure the noise level in the dining room was kept at a comfortable level for Resident #39 on 08/25/25 during the lunch meal. This failure could place residents at risk for a decreased quality of life.The findings included: Record review of the face sheet, dated 09/02/25, reflected Resident #39 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of dementia (memory loss), history of a stroke, and a history of traumatic brain injury. Record review of the annual MDS assessment, dated 07/19/25, reflected Resident #39 had unclear speech, was usually understood by others, and was usually able to understand others. Resident #39's BIMS score was 3, which indicated severe cognitive impairment. The MDS reflected Resident #39 had no behaviors or refusal of care during the look-back period. Record review of the comprehensive care plan, revised 05/12/25, reflected Resident #39 had impaired cognitive function or thought processes. The interventions included: .reduce any distractions - turn off TV, radio, close door, etc. The care plan further reflected Resident #39 had potential for communication problems related to unclear speech. The interventions included: anticipate and meet needs. During an observation on 08/25/25 beginning at 11:44 AM, there were 18 residents sitting in the dining room. Gospel music was playing loudly, over a speaker. Resident #39 was sitting across the room in front of the television, which was on and playing. During an observation and interview on 08/25/25 beginning at 11:50 AM, Resident #39 placed her hands over her ears and stated, too loud. Resident #39 pointed at the television and shook her head side-to-side. Resident #39 shook her head yes, when asked if the music was often played too loudly. The surveyor alerted staff to Resident #39's request, and the music was turned down. During an interview on 08/27/25 beginning at 10:16 AM, LVN C stated the music was not normally played loudly with the television going at the same time in the dining room. LVN C stated Resident #39 had not complained about the music prior to 08/25/25. LVN C stated she was not in charge of the music in the dining room and was unsure who set it up. LVN C stated if the resident's complained about the noise level she would request the music be turned down. LVN C stated it was important to ensure the noise levels were kept at a comfortable level to make sure the environment remained comfortable. LVN C stated the facility was their home and it was hard to understand things happening elsewhere if the noise was too loud. During an interview on 08/27/25 beginning at 10:29 AM, the DON stated the AD was responsible for the entertainment in the dining room. The DON stated there had not been any complaints about the noise level in the dining room. The DON stated Resident #39 had not complained about the music being too loud. The DON stated it was important to ensure the noise level was kept at a comfortable level to maintain the residents best interest, cater to the residents, and ensure activities were conducted. During an interview on 08/27/25 beginning at 12:22 PM, the AD stated she was responsible for playing the music in the dining room. The AD stated the music and television were not usually playing at the same time. The AD stated if any resident's complained about the noise level of the music, it would have been turned down. The AD stated Resident #39 had not complained about the noise level of the music. The AD stated Resident #39 used to watch television in her room but had been watching television in the dining room more frequently. The AD stated it was important to ensure the noise level was kept at a comfortable level in the dining room because it was the residents right. During an interview on 08/27/25 beginning at 12:33 PM, the Administrator stated Resident #39 had not been herself recently because her long-time roommate was leaving the facility. The Administrator stated Resident #39 usually loved to listen to gospel music. The Administrator stated if any residents complained of the noise level of the music it should have been turned down. The Administrator stated all staff were responsible for monitoring the noise levels at the facility. The Administrator stated she expected the noise level to be kept at a comfortable level. The Administrator stated it was important to ensure the noise level was kept at comfortable levels so residents could hear what was going on during activities. Record review of the Resident Rooms and Environment policy, revised 08/2020, reflected .Facility staff aim to create a personalized, homelike atmosphere, playing close attention to the following.comfortable noise levels.

**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 2 of 19 residents (Resident #3 and Resident #12) reviewed for MDS assessment accuracy. The facility did not ensure Resident #3's and Resident #12's MDS assessments accurately identified a medication as an anti-platelet instead of an anticoagulant. These failures could place residents at risk for not receiving care and services to meet their needs.Findings included: 1. Record review of Resident #3's face sheet, dated 08/26/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (a group of conditions that cause a progressive decline in cognitive abilities), and type 2 diabetes mellitus (chronic disease where your body either doesn't produce enough insulin or doesn't use insulin properly, leading to high blood sugar levels). Record review of Resident #3's quarterly MDS assessment, dated 08/04/25, indicated she did not have a BIMS score due to her rarely/never being understood. She rarely/never understood others. The assessment further indicated she took an anticoagulant medication. Record review of Resident #3's physician's orders, dated 08/25/25, indicated the following orders:*Aspirin Low Dose oral tablet chewable 81mg (an antiplatelet medication used to prevent cardiovascular events like heart attacks and strokes) Give 1 tablet by mouth one time a day. The start date was 07/11/24.* Clopidogrel Bisulfate oral tablet 75mg (an antiplatelet medication used to prevent heart attack, stroke, and other cardiovascular problems) Give 1 tablet by mouth one time a day for cerebrovascular disease. The start date was 07/11/24.There was not an order for an anticoagulant medication. Record review of Resident #3's care plan, indicated a focus dated 05/10/25 of Resident #3 was on anti-platelet medication related to cerebrovascular accident (stroke). Interventions included monitor/document/report to MD PRN signs and symptoms of anti-platelet complications. 2. Record review of Resident #12's face sheet, dated 08/26/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included heart failure (a condition where the heart muscle is weakened or stiffened, making it unable to pump blood effectively) and chronic kidney disease (a condition where the kidneys gradually lose their ability to filter waste products from the blood). Record review of Resident #12's quarterly MDS assessment, dated 07/17/25, indicated he had a BIMS score of 11, which indicated moderate cognitive impairment. He was able to make himself understood and he was able to understand others. The assessment further indicated he took an anticoagulant medication. Record review of Resident #12's physician's orders, dated 08/25/25, indicated the following orders:*Aspirin Low Dose oral tablet chewable 81mg Give 1 tablet by mouth one time a day. The start date was 09/15/24.* Clopidogrel Bisulfate oral tablet 75mg Give 1 tablet by mouth one time a day. The start date was 09/15/24.There was not an order for an anticoagulant medication. Record review of Resident #12's care plan, indicated a focus dated 09/21/24 of Resident #12 was on anti-platelet therapy related to disease process. Interventions included monitor/document/report to MD PRN signs and symptoms of anti-platelet complications. During an interview on 08/27/25 at 12:08PM, the MDS Coordinator said she would have to modify the MDS assessments for Resident #3 and Resident #12. She said she was not sure how the residents' assessments were marked for anticoagulants. She said anticoagulant should have been marked no on both residents' assessments. She said the residents were taking antiplatelet medications. She said there was no risk to the residents because of the inaccurate MDS. During an interview on 08/27/2025 at 12:17 PM, ADON A said she had been one of the ADONs for about 4 months. She said the current MDS Coordinator was new. She said her expectation was that the MDS assessments were completed accurately. She said she was going to in-service and make sure the MDS assessments for Resident #3 and Resident #12 were corrected. During an interview on 08/27/25 at 12:31PM, the DON said she expected the MDS for Resident #3 and Resident #12 to be accurate. She said there was no risk to the resident due to the MDS being marked wrong for anticoagulant. During an interview on 08/27/25 at 12:39PM, the Administrator said she expected the MDS to be accurate. She said she did not think there was a risk to the resident due to the MDS being marked for anticoagulant. Record review of the facility's policy, Minimum Data Set Policy, last revised 03/14/24, reflected: .Procedure1. IDT to utilize RAI for all processes pertaining to MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 2 of 2 (Resident #1 and Resident #2) residents reviewed for gastrostomy tube. 1. The facility failed to ensure Resident #1 received potassium chloride (supplement), acidophilus (probiotic), Bactrim DS (antibiotic), and valproic acid (anticonvulsant) within the scheduled time frame on 08/26/25. 2. The facility failed to ensure Resident #2 received apixaban (anticoagulant), ferrous sulfate (iron supplement), furosemide (diuretic), and valproic acid (anticonvulsant) within the scheduled time from on 08/26/25. These failures could place residents at risk for medication errors and adverse effects from medication.The findings included: Record review of face sheet, dated 08/27/25, reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of mild cognitive impairment and dysphagia (difficulty swallowing). Record review of the admission MDS assessment, dated 08/11/25, reflected Resident #1 had unclear speech, was sometimes understood by others, and was sometimes able to understand others. Resident #1 had a BIMS score of 4, which indicated severe cognitive impairment. The MDS reflected Resident #1 had no behaviors or refusal of care during the look-back period. The MDS reflected Resident #1 used a feeding tube while a resident. Record review of the comprehensive care plan, revised 08/08/25, reflected Resident #1 required a feeding tube related to dysphagia. Record review of the order summary report, dated 08/27/25, reflected Resident #1 had the following orders:1. acidophilus probiotic - give 1 capsule via gastrostomy tube two times a day for probiotic support x 7 days with antibiotics.2. Bactrim DS 800-160 mg - give 1 tablet via gastrostomy tube two times a day for UTI x 7 days.3. potassium chloride solution - give 40 mEq via gastrostomy tube one time a day for supplement.4. valproic acid oral solution 250 mg/5 mL - give 5 mL via gastrostomy tube one time a day for mood disorder. Record review of Resident #1's MAR, dated August 2025, reflected the following:1. potassium chloride solution - give 40 mEq via gastrostomy tube one time a day for supplement was scheduled for 8 AM.2. acidophilus probiotic - give 1 capsule via gastrostomy tube two times a day for probiotic support x 7 days with antibiotics was scheduled for 8 AM.3. Bactrim DS 800-160 mg - give 1 tablet via gastrostomy tube two times a day for UTI x 7 days was scheduled for 8 AM.4. valproic acid oral solution 250 mg/5 mL - give 5 mL via gastrostomy tube one time a day for mood disorder was scheduled for 8 AM. 2. Record review of the face sheet, dated 08/27/25, reflected Resident #2 was a [AGE] year-old female who initially admitted on [DATE] with diagnoses of history of stroke, dysphagia (difficulty swallowing), and gastrostomy status (opening into the stomach from the abdominal wall, made surgically for the introduction of food). Record review of the quarterly MDS assessment, dated 08/06/25, reflected Resident #2 had no speech, was sometimes understood by others, and was sometimes able to understand others. Resident #2's staff assessment for mental status reflected a short-term memory problem, long-term memory problem, and severely impaired decision making skills. Resident #2 was unable to recall current season, location of own room, staff names and faces, and that they are in a nursing home. The MDS reflected no behaviors or refusal of care during the look-back period. Resident #2 had a feeding tube while a resident at the facility. Record review of the comprehensive care plan, revised 04/04/25, reflected Resident #2 required a feeding tube related to dysphagia secondary to stroke. Record review of the order summary report, dated 08/27/25, reflected the following:1. apixaban 2.5 mg - give 1 tablet via gastrostomy tube every morning and at bedtime for atrial fibrillation (irregular heart rhythm).2. ferrous sulfate oral solution 5 mg/20 mL - give 30 mL via gastrostomy tube two times a day for supplement.3. furosemide 40 mg - give 1 tablet via gastrostomy tube two times a day for edema and atrial fibrillation.4. valproic acid oral solution 250 mg/5 mL - give 2.5 mL via gastrostomy tube two times a day for tremors. Record review of Resident #2's MAR, reflected the following:1. apixaban 2.5 mg - give 1 tablet via gastrostomy tube every morning and at bedtime for atrial fibrillation was scheduled for 8 AM.2. ferrous sulfate oral solution 5 mg /20 mL - give 30 mL via gastrostomy tube two times a day for supplement was scheduled for 8 AM.3. furosemide 40 mg - give 1 tablet via gastrostomy tube two times a day for edema and atrial fibrillation was scheduled for 8 AM.4. valproic acid oral solution 250 mg/ 5 mL - give 2.5 mL via gastrostomy tube two times a day for tremors was scheduled for 8 AM. During an interview on 08/26/25 beginning at 6:45 AM, the Regional Nurse Consultant stated LVN C had already given Resident #1 and Resident #2 all the scheduled morning medications through the gastrostomy tube. The Regional Nurse Consultant stated the next medications due were at noon. During an interview on 08/27/25 beginning at 10:16 AM, LVN C stated she normally started her morning medication pass at around 6 AM. LVN C stated medications could have been given one hour before the scheduled time and one hour after the scheduled time. LVN C stated all medications should have been scheduled for the same time if possible. LVN C stated preferences should be considered within the timeframes for each resident. LVN C stated the charge nurses were responsible for putting orders into the computer and ADON D followed up to ensure the accuracy of the orders. LVN C stated Resident #1 and Resident #2's medications were usually given at the same time. LVN C stated it was important to ensure medications were given at the appropriate timeframes to prevent toxicity or drug interactions. LVN C stated some medications need to be given at certain times and could affect the absorption of the medication. During an interview on 08/27/25 beginning at 10:25 AM, ADON D stated ensuring medications were grouped together at the same time was a group effort. ADON D stated the nurse was responsible for putting the orders into the computer system. ADON D stated the nurse was responsible for administering the medication within the appropriate timeframes. ADON D stated medications should have been administered between one hour before the scheduled time or one hour after the scheduled time. ADON D stated Resident #1 and Resident #2's medications should have been scheduled at the time as possible. ADON D stated it was important to ensure medications were given within the appropriate timeframes to prevent drug interactions or overdose. During an interview on 08/27/25 beginning at 10:29 AM, the DON stated medications should have been given between one hour before or one hour after the scheduled time. The DON stated the nursing staff tried to group medications at the same time as possible. The DON stated she expected the nurse to explain or communicate any issues with medication administration to the management staff, such as inability to administer medications within the required timeframes. The DON stated nursing management could have consulted with the pharmacist and physician to ensure medications could have been given together during the same time. The DON stated it was important to ensure medications were given within the scheduled timeframes to ensure the best interest of the residents. During an interview on 08/27/25 beginning at 12:33 PM, the Administrator stated she expected the nurses to ensure medications were given according to the appropriate standards of practice and within the required timeframes. The Administrator stated nursing management was responsible for monitoring to ensure medications were given within the required timeframes. The Administrator stated it was important to ensure medications were given within the scheduled timeframes to prevent adverse drug side effects. Record review of the General Guidelines for Medication Administration policy, revised 08/2020, reflected .at a minimum, the 5 rights - .right time. - should be applied to all medication administration and reviewed at three steps in the process of preparation. medications are administered within 60 minutes of the scheduled administration time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote resident self-determination through support of resident choice for 4 of 19 residents reviewed for resident rights. (Resident #16, Resident #33, Resident #40, and Resident #64). The facility failed to ensure Resident #16, Resident #33, Resident #40, and Resident #64 were allowed to smoke two cigarettes during the facility smoking times. This failure could place dependent residents at risk for feelings of depression or lack self-determination and decreased quality of life.Findings included: 1. Record review of Resident #16's face sheet, dated 08/25/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and chronic obstructive pulmonary disease (a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction). Record review of Resident #16's admission MDS assessment, dated 07/14/25, indicated she had a BIMS score of 15, which indicated intact cognition. She was able to make herself understood and she was able to understand others. During an interview on 08/25/2025 at 10:06 AM, Resident #16 said she wished that she was able to smoke 2 cigarettes when she goes out to smoke at the designated smoking times. She said she had asked before and the staff always gave an excuse such as I forgot or I have to ask someone. She said the Administrator told her I have to ask corporate. She said she was going to go to the 10:30AM smoke time on this day and was going to ask the staff if she could have a second cigarette. During an interview on 08/25/25 at 10:41AM Resident #16 said at the 10:30AM smoke time on this day, she asked Dietary Aide B if she could have a second cigarette and Dietary Aide B would not let her have a second cigarette. She said the staff that supervised the residents during smoke times only brought enough cigarettes outside for each resident to have one cigarette. During an interview on 08/26/25 at 9:57AM Resident #16 said it made her upset that she was unable to have a second cigarette at the smoke times. She said she did not understand why she could not have 2 cigarettes in this facility when other nursing facilities allowed her to have two cigarettes at a smoke time. 2. Record review of Resident #33's face sheet, dated 08/25/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and chronic obstructive pulmonary disease (a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction). Record review of Resident #33's quarterly MDS assessment, dated 06/27/25, indicated he had a BIMS score of 12, which indicated moderate cognitive impairment. He was able to make himself understood and he was able to understand others. During an interview on 08/25/2025 at 9:50 AM, Resident #33 said he wished that he could have 2 cigarettes when he goes out to smoke at the designated smoking times. He said he thought the residents could not have 2 cigarettes when they go out to smoke. During an interview on 08/26/25 at 9:55AM, Resident #33 said it made him upset that the facility did not allow him to have two cigarettes at a smoking time. He said he has asked in the past and the staff would not let him have a second cigarette. 3. Record review of Resident #40's face sheet, dated 08/26/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction). Record review of Resident #40's admission MDS assessment, dated 08/15/25, indicated she had a BIMS score of 15, which indicated intact cognition. She was able to make herself understood and she was able to understand others. During an interview on 08/26/25 at 10:04AM Resident #40 said the staff did not allow the residents to smoke 2 cigarettes at a smoke time. She said she has asked in the past and the staff told her No, we cannot do that. She said the staff only brought enough cigarettes for each resident to have one. She said it made her upset she could not have two cigarettes at a smoke time because she was not always able to make it to all of the smoking times. She said she took a diuretic medication that makes her use the bathroom often and she was not always able to make it outside at the smoking times. 4. Record review of Resident #64's face sheet, dated 08/26/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included heart failure (a condition where the heart muscle is weakened or stiffened, making it unable to pump blood effectively). Record review of Resident #64's quarterly MDS assessment, dated 05/23/25, indicated she had a BIMS score of 14, which indicated intact cognition. She was able to make herself understood and she was able to understand others. During an interview on 08/25/25 at 10:50AM Resident #64 said the staff that took the residents outside to smoke would not allow them to have 2 cigarettes at a smoke time. She said she has asked the staff before, and they told her it was against facility policy. She said it made her upset that she could not have a second cigarette. During an observation on 08/25/25 at 10:31AM, there were 5 residents outside smoking, including Resident #64, Resident #16, and Resident #33. Dietary Aide B was outside supervising the residents. During the observation Resident #16 asked if she could have a second cigarette and Dietary Aide B told her no. During an interview on 08/25/25 at 10:39AM, Dietary Aide B said that she would allow the residents to smoke a second cigarette if they asked. She said she did not deny Resident #16 a second cigarette. She said Resident #16 said she was going to have a second cigarette at the next smoke time. During an anonymous resident group interview on 08/26/2025 at 2:00 PM, the group said the staff had never let them smoke more than 1 cigarette during a session. They further indicated they were told by staff that the staff made a decision on 08/25/25 that the residents were allowed to have 2 cigarettes and they were only still getting one. They said they felt degraded, and one resident in the group said they came to this facility because they allowed the residents to smoke. They said they felt it was their right to smoke more than one cigarette if they wanted. Record review of a Resident Council Report, dated 08/04/25, reflected: .Smokers would like to know if they can have 2 cigarettes instead of 1. During an observation on 08/27/25 at 9:35AM, ADON A pulled out the smoking supplies safe at the nursing station to show to the surveyor. The box had a sign taped to it and the sign reflected: 08/25/25 [Attention] Staff:Residents will be allowed to smoke 2 cigarettes during smoke break. The sign had the Administrator's signature at the bottom. During an interview on 08/27/2025 at 12:17 PM, ADON A said she had been one of the ADONs for about 4 months. She said the procedure was that the residents were only able to have 1 cigarette at each smoke time. She said it had been that way since she started at the facility. She said she did not think it was her place to question the residents only being allowed to have one cigarette. She said on Monday 08/25/25 the Administrator let the staff know that they should allow the residents to have 2 cigarettes at the smoke times. She said the residents should be allowed to have the right to have 2 cigarettes. She said if she was unable to have more than one cigarette she would be upset. During an interview on 08/27/25 at 12:31PM the DON said she felt the residents had the right to smoke 2 cigarettes at each smoke time. She said the staff recently had a discussion with the Administrator to allow the residents to smoke 2 cigarettes. She said they were now allowed to have two cigarettes when they smoked. She said the procedure that the residents were only allowed 1 cigarette came from everyone thinking it was common practice. She said a resident could be offended if they were denied 2 cigarettes. She said the facility was their home and they should be allowed to smoke two if they desire. During an interview on 08/27/25 at 12:39PM the Administrator said she was unaware of the residents only being allowed 1 cigarette. She said it was not a rule. She said she was okay with the residents having more than one cigarette if they wanted. She said she put a note on the smoking supplies box that the residents could have more than 1 cigarette if they wanted. She said there was not a policy or document that reflected the residents could only have one resident. She said she figured that the staff only gave each resident 1 cigarette because it was how they thought things were done. She said she thought the residents would be frustrated. She said she feels like it is a resident right to have more than one cigarette. Record review of the facility's policy, Resident Rights, last revised August of 2020, reflected: .residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. Record review of the facility's policy, Smoking by Residents, last revised June of 2020, reflected: .X. Smoking session will be limited to 15-minute segments.The policy did not address the number of cigarettes a resident would be allowed to smoke at a time.

Based on interview and record review, the facility failed to promptly resolve grievances for 6 of 6 Anonymous residents reviewed for grievances during a confidential meeting. The facility failed to ensure 6 of 6 Anonymous residents' grievances related to wet napkins on room trays were promptly resolved. This deficient practice could place the residents at risk for decreased quality of life and feelings of neglect or hopelessness. The findings included: During a confidential interview on 8/26/25 at 2:00 P.M. 6 of 6 Anonymous residents indicated grievances were not addressed or resolved promptly. Anonymous residents indicated they had made complaints about the napkins being wet on the hall trays in several resident council meetings. Anonymous residents indicated the Activity Director was present during the resident council meetings and was aware of complaints about the wet napkins. Anonymous residents stated it was still happening during meal pass and made them feel like no cared how they felt. Record review of the resident council minutes for 6/2/25, 6/23/25, 6/30/25, 7/14/25, 7/21/25, 7/28/25, 8/4/25 and 8/12/25 indicated Napkins on trays are being wet when served to residents. During an interview on 8/27/25 at 12:25 P.M., the Activity Director stated she believed that complaints during resident council were considered grievances. The Activity Director stated she wrote down the minutes for the resident council meetings. She stated she wrote that the residents had been complaining about their napkins being wet on their trays. She stated the residents were saying the drinks on the tray was getting on the napkins. She stated she did not know exactly how many months the residents had complained about the wet napkins. She stated she wrote it down when the residents complained, she reported it in a stand down meeting and she reported it to the Dietary Manager. She stated she felt the wet napkins were an issue and if the residents were complaining about it the facility needed to fix it. She stated a negative effect of the wet napkins on the trays was the residents could not use the napkins. During an interview on 8/27/25 at 12:55 P.M., the Dietary Manager stated she thought she was notified about the wet napkins on the resident hall trays during the last resident council meeting and she thought the issue was resolved. She stated she was not aware that the residents had complained about the wet napkins for 3 months. She stated if she would have known the residents had complained that many times, she would have monitored the trays for wet napkins herself. She stated she did an in-service on the wet napkins before, and she thought it was all clear. She stated if the residents complained about something it should be taken care of. She stated a negative effect of residents having wet napkins would be they could not clean their hands and face. During an interview on 8/27/2025 at 1:07 P.M., the ADON D stated he was unaware of the numerous complaints of residents getting wet napkins with their meals. He stated a negative effect of wet napkins on trays was it would not allow residents to clean themselves appropriately and that no one wanted a wet napkin. He stated not resolving the complaints gave residents a sense that the facility did not care about them. During an interview on 8/27/25 at 1:11 P.M., the DON stated she was unaware of the resident council complaints. She stated she was not aware of the numerous complaints of wet napkins on trays. She stated she had never passed a tray with a wet napkin. She stated a negative effect of being served a wet napkin was the residents could not properly clean their hands with a wet napkin. She stated the residents' concerns needed to be addressed. She stated the residents needed to feel like they were being heard, because the facility was their home. During an interview on 8/27/25 at 1:25 P.M., the ADM stated that complaints during resident council were considered grievances. She stated she was unaware of the numerous complaints of wet napkins on the residents' trays. She stated the wet napkins was never brought up in a meeting. She stated she did not have an answer as to why the wet napkins were not corrected, because no one had mentioned it to her until today. She stated the Activity Director had never said a word to her about the residents complaining about wet napkins. She sated she truly did not know there was an issue with the napkins on the trays being wet. She stated the ADON had started an in-service to try to figure out why the napkins were getting wet on the trays. She stated a negative effect of wet napkins on the resident's food tray was they could not use them and the appearance of the wet napkins on the tray would not look nice. She stated it was important to address grievances and resident council complaints promptly, but she could not address what she did not know. Record review of Grievances and Complaints policy revised on February 2025 revealed Grievances Investigation: . A. Upon receiving a resident grievance/complaint form, the Grievance Official or designee begins an investigation into the allegations. The Grievance Official will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. The department director of an involved employee is notified of the nature of the complaint and that an investigation is underway. Record review of Resident Council policy revised on 06/2020 revealed Responsibilities of the Resident Council: . C. If the Council raises an issue of concern, the Department responsible for the issue or service is responsible for addressing the item(s) of concern promptly. D. The Facility will respond in writing to written request or concerns of the family council in a prompt and timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 4 of 7 (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for quality of care. The facility failed to ensure Resident #1's had a skin assessment performed weekly on 8/9/24 and 8/16/24 per facility policy. The facility failed to ensure Resident #2, Resident #3, and Resident #4 had skin assessment performed weekly on 8/16/24 per facility policy. These failures could result in skin issues on residents being missed, skin issues deteriorating without being monitored, and decreased quality of life. Findings Included: 1. Record review of the face sheet dated 8/28/24 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, hypertension (elevated blood pressure), muscle weakness, and depression. Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #1 was at risk for developing pressure ulcers. Record review of the care plan revised 7/5/24 indicated Resident #1 was at moderate risk for impaired skin integrity with interventions including licensed nurse would assess skin and document assessment weekly. Record review of the weekly skin assessment for August 2024 indicated Resident #1 had a skin assessment on 8/2/24 and 8/23/24. The weekly skin assessments indicated Resident #1 did not have a skin assessment on 8/9/24 or 8/16/24. Record review of the weekly skin assessment dated [DATE] indicated Resident #1 did not have any skin impairment. Record review of the weekly skin assessment dated [DATE] indicated Resident #1 did not have any skin impairment. 2. Record review of the face sheet dated 8/28/24 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, diabetes, psychosis (a mental disorder characterized by a disconnection from reality), and hypertension. Record review of the MDS dated [DATE] indicated Resident #2 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #2 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #2 was at risk for developing pressure ulcers Record review of the care plan revised 6/3/2024 indicated Resident #2 was at minimum risk for impaired skin integrity with interventions including licensed nurse would assess skin and document assessment weekly. Record review of the weekly skin assessment for August 2024 indicated Resident #2 had a skin assessment on 8/2/24, 8/9/24 and 8/23/24. The weekly skin assessments indicated Resident #2 did not have a skin assessment on 8/16/24. Record review of the weekly skin assessment dated [DATE] indicated Resident #2 had redness under her right breast. Record review of the weekly skin assessment dated [DATE] indicated Resident #2 redness/moisture under her left and right breasts. Record review of the weekly skin assessment dated [DATE] indicated Resident #2 had yeast rash/redness under her left and right breasts with a treatment in place. 3. Record review of the face sheet dated 8/28/24 indicated Resident #3 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, and lack of coordination. 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 06 and was severely cognitively impaired. The MDS indicated Resident #3 was at risk for developing pressure ulcers. Record review of the care plan revised 4/14/24 indicated Resident #3 had an ADL self-care deficit. Record review of the weekly skin assessment for August 2024 indicated Resident #3 had a skin assessment on 8/2/24, 8/9/24 and 8/23/24. The weekly skin assessments indicated Resident #3 did not have a skin assessment on 8/16/24. Record review of the weekly skin assessment dated [DATE] indicated Resident #3 did not have any skin impairment. Record review of the weekly skin assessment dated [DATE] indicated Resident #3 did not have any skin impairment. Record review of the weekly skin assessment dated [DATE] indicated Resident #3 did not have any skin impairment. 4. Record review of the face sheet dated 8/28/24 indicated Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, diabetes, hypertension, and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of the MDS dated [DATE] indicated Resident #4 usually understood others and was usually understood by others. The MDS indicated Resident #4 had a BIMS of 09 and was moderately cognitively impaired. The MDS indicated Resident #4 was not at risk for developing pressure ulcers. Record review of the care plan revised 6/4/24 indicated Resident #4 was at minimum risk for impaired skin integrity with interventions including licensed nurse would assess skin and document assessment weekly. Record review of the weekly skin assessment for August 2024 indicated Resident #4 had a skin assessment on 8/2/24, 8/9/24 and 8/23/24. The weekly skin assessments indicated Resident #4 did not have a skin assessment on 8/16/24. Record review of the weekly skin assessment dated [DATE] indicated Resident #4 did not have any skin impairment. Record review of the weekly skin assessment dated [DATE] indicated Resident #4 did not have any skin impairment. Record review of the weekly skin assessment dated [DATE] indicated Resident #4 had yeast rash/redness to her left and right breasts. During an interview on 8/28/24 at 2:13 p.m. the Treatment Nurse said she had been the Treatment Nurse for approximately 2.5 years. The Treatment Nurse said skin assessments should be performed weekly. The Treatment Nurse said skin assessments were documented in the residents' EMR. The Treatment Nurse said the importance of weekly skin assessments was to observe each resident's skin and catch any skin issues early. The Treatment Nurse said the reason she did not perform skin assessments on Resident #1, Resident #2, Resident #3, and Resident #4 the week of 8/12/24 through 8/16/24 was because she was off work on 8/14/24, 8/15/24, and 8/16/24. The Treatment Nurse said she did not know who was responsible for completing skin assessments while she was off. The Treatment Nurse said the DON would had to have assigned the skin assessments to someone. The Treatment Nurse said Resident #1 not having a skin assessment documented for 8/9/24 was an oversight on her part. The Treatment Nurse said she knows she did a skin assessment on Resident #1 that day, but it could not be proven she had performed a skin assessment or if the resident had any issues if it was not documented. The Treatment nurse said a yeast rash could worsen in a week's time. During an interview on 8/28/24 at 2:46 p.m. the DON said skin assessments should be performed weekly and as needed. The DON said the Treatment Nurse was responsible for performing weekly scheduled skin assessments. The DON said if the Treatment Nurse was off then either the charge nurse or another designated nurse was responsible for weekly scheduled skin assessments. The DON said she and the ADON would verbally tell the nurses and hang notes at each nursing station to let them know when they were responsible for the weekly scheduled skin assessments. The DON said the importance of weekly skin assessments was to inspect the skin for any rashes, wound, skin tears, bruising, etc. and monitor existing skin issues. The DON said on 8/14/24, 8/15/24, and 8/16/24 the charge nurses would have been responsible for completing the weekly skin assessments due to the Treatment Nurse being off. The DON said she would have expected the weekly skin assessment that were due to have been performed on 8/2/24 and 8/9/24. The DON said it was possible for skin issues to worsen in a week's time. During an interview on 8/28/24 at 3:27 p.m. the Administrator said she expected skin assessments to be performed weekly and on admission. The Administrator said the Treatment Nurse was responsible for weekly skin assessments and the admitting nurse was responsible for the skin assessment on admission. The Administrator said July 1, 2024, the facility got a new EMR system. The Administrator said with the new EMR system the skin assessments populate automatically to let the Treatment Nurse or charge nurse know a skin assessment was due. The Administrator said if the Treatment Nurse was off work, it was the responsibility of the charge nurses to complete the skin assessments. The Administrator said the importance of weekly skin assessments was to inspect for skin issues and ensure skin issues are not deteriorating. The Administrator said skin issues could happen quickly and deteriorate quickly sometimes in as little as 2 hours. Record review of the facility's Wound Management policy revised June 2020 indicated, To provide a system for the treatment and management of residents with wounds including pressure and non-pressure .A Licensed Nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ased on interview and record review the facility failed to provide respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of quality of life for 1 of 18 residents reviewed for resident rights. (Resident #178) The facility failed to treat Resident #178 with respect and dignity when staff told her to urinate in her brief. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: Record review of the face sheet dated 07/17/24 revealed Resident #178 was [AGE] years old female and admitted on [DATE] with diagnoses including Unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), insomnia (persistent problems falling and staying asleep) and Parkinsonism (brain conditions that cause slowed movements, rigidity (stiffness) and tremors). Record review of the MDS dated [DATE] revealed Resident #178 BIMS was not performed and required maximal assistance for toilet use and moderate assistance for transfers, dressing, personal hygiene, and bathing. Record review of the care plan dated 04/04/24 revealed Resident #178 was at risk for skin breakdown/pressure injury related to decreased mobility and incontinence. Interventions included: Complete Braden assessment for early identification of risk factors and interventions. Nursing assistants to examine resident's skin daily for signs of redness or discoloration especially areas prone to breakdown such as boney prominences. Provide peri-care after each incontinent episode. Monitor labs per physician orders. (Especially albumin and pre-albumin) Provide nutritional assessment per RD and administer vitamins/supplements/medications as ordered by MD. Licensed Nurse to complete skin checks weekly. During an interview on 07/15/24 at 6:48 PM, Family Member #1 of Resident #178 said she was on the phone with Resident #178 when she heard a staff member told her to urinate on herself. Family Member #1 said she called the nursing station to get Resident #178 assistance to the bathroom when staff would not answer Resident #178's call light. Family Member #1 said Resident #178's roommate heard the staff tell her to urinate in her brief. Family Member #1 said she took Resident #178 home that night from the facility. During an interview on 07/16/24 1:45 PM, Resident #13 said she remembered Resident #178. Resident #13 said staff always tried to help her, but she refused their help. It depends on which time of day it waws with the accuracy of how long it would take for someone to come help her. Resident #13 said when Resident #178 told staff she had to use the bathroom, the staff would take her and she would not be able to urinate for about 30-45 minutes with staff waiting, so staff told her to go in her brief and they would change her. Resident #13 said one night Resident #178 called Family Member #1 and she came to get her, then took her home. Resident #13 said she thought the facility took care of Resident #178 while she was in the facility, but she was very difficult to take care of. During an interview on 07/16/24 at 1:59 PM, Family member #2 said Resident #178 called Family Member #1, because she had called for staff to assist her to the bathroom, but no one came. Family Member #2 said Family Member #1 told her that a staff member told Resident #178 to urinate in her brief. Family Member #2 stated she assisted Family Member #1 with transferring Resident #178 to the car, to go home. Family member #2 said Resident #178 cried when she got in the car, because she said the staff member told her to urinate in her brief. During an interview on 7/17/24 at 9:06 AM, RN L said he remembered Resident #178 leaving the facility. RN L said there was nothing the staff or the facility could do was satisfactory to the resident or the family. RN L said at night Resident #178 was on the call light nonstop, calling for items she could do on her own, like turn the light on and turn the light off. RN L said Family Member #1 told him she was taking Resident #178 home, because we could not provide adequate care for her at the facility. RN L said he remembered if she needed to go to the restroom the staff would take her. RN L said he does not recall telling Resident #178 to urinate in her brief. RN L said he did remember telling Resident #178 if she did wet her brief, he would change her brief. RN L said he remembered a couple times taking Resident #178 to the bathroom and she was very weak, so changing her brief was probably a safety precaution. During an interview on 7/17/24 at 2:57 PM, the DON said a staff member should never encourage a resident to urinate in their brief if they were aware of when they need to go to the bathroom. The DON said if a staff member told a resident to urinate on themselves, that was a dignity issue and potential for skin breakdown. During an interview on 7/17/24 at 3:15 PM, ADM said it is not ok for a staff member to tell a resident to urinate in their brief. We want the residents to stay independent as long as possible. If it were me, I would feel like they would not want to help me. I feel I am an adult, and it is a huge blow to your dignity, and it would make me feel like staff did not have time for me. Record review of a facility resident admission agreement dated 12/1/23 revealed . the facility shall offer personal care . the facility will also offer nursing care, activities, restorative and rehabilitative services and psychosocial care as identified by the Resident's Plan of Care established by the Facility Standards and in accordance with the policies of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure residents had the right to a clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safety, for 1 of 5 residents (Resident #31) reviewed for a homelike environment. The facility failed to ensure Resident #31's wheelchair was clean. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: Record review of Resident #31's face sheet dated 07/16/24, indicated Resident #31 was an [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's disease (is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), muscle weakness, and abnormalities of gait and mobility. Record review of Resident #31's quarterly MDS assessment dated [DATE], indicated Resident #31 was sometimes understood and sometimes had the ability to understand others. Resident #31 was unable to complete the BIMS assessment. Resident #31 had short-and-long term memory recall problem and moderately impaired cognitive skills for daily decision making. Resident #31 used a wheelchair as a mobility device. Resident #31 required supervision for oral hygiene, maximal assistance for personal hygiene and putting on/taking off footwear, and dependence for toileting hygiene and dressing. Record review of Resident #31's care plan dated 12/28/23, edited on 06/19/24, indicated: *Resident #31 had ADL functional status/rehabilitation potential and self-care deficit with oral care, dressing, eating, bathing, grooming, and resistive to ADL assistance at times. Intervention included able to feed self after tray set-up. *Resident #31 had falls and was high risk related to cognitive deficits with poor safety awareness. Intervention included lock all moveable equipment before transferring residents. During an observation on 07/15/24 at 11:30 a.m., Resident #31 was a dining room table in her wheelchair. Resident #31 made constant noise, humming, or counting out load. Resident #31 was un-interviewable. Resident #31's wheelchair wheels had moderate amount of dried substance splattered throughout both wheels. Resident #31's wheelchair had a moderate amount of hair tangled where the wheels and the frame connected. During an observation on 07/16/24 at 9:00 a.m., Resident #31 was self-propelling herself aimlessly up and down the secured unit hallway. Resident #31's wheelchair wheels had moderate amount of dried substance splattered throughout both wheels. Resident #31's wheelchair had a moderate amount of hair tangled where the wheels and the frame connected. During an interview and observation on 07/17/24 at 3:48 p.m., CNA J said Resident #31 used her wheelchair to get around. She said maintenance was responsible for the upkeep of resident's wheelchairs. She said the CNAs were responsible for wiping down the wheelchairs. CNA J entered Resident #31's room and inspected her wheelchair. She said the wheelchair was dirty, but the CNAs normally cleaned the seat area not the wheels. She said maintenance would be able to take the wheels off and clean them better than the CNAs. She said residents should not have dirty wheelchair because of infection control. She said the dried food could attract pest and the dementia residents could eat the food particle from the wheelchair not knowing it was dirty. CNA J said she would take the wheelchair out of Resident #31's room so maintenance could look at it. CNA J left the secured unit to locate the maintenance supervisor. During an interview and observation on 07/17/24 at 4:07 p.m., the maintenance supervisor arrived on the secured unit and inspected Resident #31's wheelchair. He said Resident #31's wheelchair needed cleaning. He said the CNAs and maintenance was responsible for cleaning resident's wheelchairs. He said residents should not have dirty wheelchairs because of infection control. During an interview on 07/17/24 at 4:10 p.m., LPN M said the night shift CNAs were probably responsible for cleaning the resident's wheelchairs. She said that would be the best time since the residents would be asleep. She said but anyone who noticed a dirty wheelchair should clean it. She said a dirty wheelchair was unsanitary and staff who put the resident it the wheelchairs should be inspecting them for cleanliness all the time. During an interview on 07/17/24 at 5:07 p.m., the DON said anyone could clean resident's wheelchairs. She said maintenance was responsible for the upkeep of resident's wheelchairs, but staff had to inform him of the issue. She said it was an infection control issue if a resident was using a dirty wheelchair. During an interview on 07/17/24 at 6:00 p.m., the ADM said CNAs were responsible for cleaning resident's wheelchairs. She said it was important for residents to not have dirty wheelchairs because of esthetic and infection control. She said ultimately it was maintenance responsibility to maintain resident's wheelchairs. Record review of a facility's Cleaning and Disinfection of Environmental Surfaces and Equipment policy revised 06/2020 indicated .to ensure that the cleaning and disinfection of environmental surfaces is in accordance with Centers for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA) guidelines .non-critical items are those that come in contact with intact skin but not mucous membrane .most non-critical items can be decontaminated where they are used .

**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, including injuries of unknown source were reported immediately, but not later than 24 hours if the events that caused the allegation did not involve abuse and did 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 18 residents (Resident #35) reviewed for abuse and neglect. The facility failed to report Resident #35's injury of unknown origin to her face, within 24 hours to the state agency. This failure could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the allegations of abuse timely. Findings included: Record review of a facility's Abuse Prevention and Prohibition Program policy revised 10/24/22, indicated .to ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse .the administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems .reporting/response .the facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin .immediately, but no later than 2 hours after forming suspicion. Record review of Resident #35's face sheet fated 07/16/24, indicated Resident #35 was a [AGE] year-old female admitted on [DATE] and 04/17/24 with diagnoses including anxiety disorder and dementia. Record review of Resident #35's significant change in status MDS assessment dated [DATE], indicated resident #35 usually understood and sometimes had the ability to understand others. Resident #35 was unable to complete the BIMS assessment. Resident #35 had short-and-long term memory recall problem and moderately impaired cognitive skills for daily decision making. Resident #35 had other behavioral symptoms not directed toward others and daily behavior of rejection of care. The MDS indicated her current behavior status have worsen compared to prior assessment. Resident #35 required moderate assistance for toileting and personal hygiene, dressing, putting on/taking off footwear and dependent for shower/bathe self. Record review of Resident #35's care plan dated 04/16/24, indicated Resident #35 had an alteration in thought process related to dementia with memory deficits, impaired decision making, confusion/disorientation, making self-understood: impaired, and understanding others: impaired. Intervention included always approach in a calm nurturing manner. Record review of Resident #35's care plan dated 05/02/24, indicated Resident #35 had a risk for bruises/discoloration related to fragile skin, restless movements, repeated falls, aspirin use. Intervention included monitor arms and legs during transfer and ADL care. Record review of Resident #35's weekly skin check dated 07/01/24 indicated no skin impairments found. Record review of Resident #35's accident/incident report dated 07/01/24, indicated .Resident #35 .resident's room .incident time: 6:30 p.m.reported by: family member (present in room) .reported to: LVN N .family member in room alerted nurse small bruise noted to Resident's [#35] right jaw .dime size bruise black/blue in color .no indication of pain .no pain voiced .level of consciousness: alert and oriented x1 .injury: bruise . Record review of Resident #35's accident/incident final disposition report completed by LVN N on 07/01/24, indicated .Resident #35 .date of incident: 07/01/24 .type: bruise/right jaw .outcome of interview with staff: spoke with all nurses, cnas, and hospice staff regarding bruise, upon interviewing it was discovered that resident sleeps with bed controller close to face and occasionally wakes up with remote under head/face also sleeps with a baby doll in bed that stays by her face/head and has hard hands and feet .state cause: unknown .did occurrence require notification of state agency .no .was equipment involved .unknown .LVN N .DON .ADM . Record review of Resident #35's hospice coordination notes report dated 07/02/24 indicated .call center-general .time of call:0756 .caller: ADON .the HHA gave the patient a bath last evening and the facility staff noted a bruise to the patient's jawline shortly after .the caller reports that because it is a suspicious bruise, they are conducting an investigation .they would like to know if the patient had been combative or if this bruise was noticed by the HHA during the shower .the patient has a history of being combative during care . During an interview on 07/17/24 at 3:29 p.m., the ADM said she was the abuse coordinator. She said Resident #35 had a history of sleeping with a baby doll and the bed controller remote. She said Resident #35 could not tell how she got the bruise to her jaw. She said after her, ADON, and DON talked about the incident, they did not think it was an injury of unknown origin due to history of sleeping with a baby doll and remote near her face. She said she did not know Resident #35 had a history of being resistive to cares and agitation. She said injury of unknown origin was supposed to be reported to HHSC. She said she was responsible for investigating and reporting. She said when injury of unknown origin was not reported the resident could get injured. She said it was important to report because better safe than sorry. During an interview on 07/17/24 at 5:07 p.m., the DON said Resident #35's family member was visiting on 07/01/24 and noticed the bruise on her jawline. She said Resident #35's bruise was dime sized. She said nurses reported they sometimes find Resident #35 laying on her remote and she slept with a baby doll too. She said we attributed the bruise to her bed remote or baby doll. She said Resident #35 was confused and could be confused about what staff are doing to her. She said after the incident, staff were supposed to ensure Resident #35 was not laying on the remote or baby doll. She said HHA R bathed Resident #35 the morning of or within a 24-hour period of when the bruise being found. She said she did not think it was an injury of unknown origin. She said Resident #35 could not say what happened. She said the ADM was the abuse coordinator. She said the ADM was responsible for investigating and reporting to HHSC within 2 hours for allegation of abuse. She said not reporting to HHSC placed resident at risk for harm if abuse or neglect was suspected. She said the facility had implemented a new abuse policy on July 1st, 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 6 residents reviewed for new admissions. (Resident #69) The facility failed to complete a baseline care plan for Resident #69 within 48 hours of admission. The facility failed to provide Resident #69's RP, a copy of the summary of the baseline care plan. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #69's face sheet dated 07/16/24, indicated Resident #69 was an [AGE] year-old female admitted on [DATE] with diagnosis including dementia with other behavioral disturbance. The face sheet indicated Resident #69 family member were her responsible party. Record review of Resident #69's admission MDS assessment dated [DATE] indicated Resident #69 was usually understood and usually understood others. Resident #69's BIMS score was 08 which indicated moderately impaired cognition. Resident #69 required supervision for eating, maximal assistance for oral hygiene, shower/bathe self, dressing and personal hygiene and dependent for toileting hygiene. During an interview on 07/15/24 at 4:53 p.m., the responsible party for Resident #69 said Resident #69 was admitted to the facility for rehabilitation. She said she had not been involved in a care plan meeting to develop a baseline care plan and had not received a copy of a baseline care plan. She said she visited a lot and spoke to the rehab department about her family member's progress. She said a baseline care plan would have been nice to have. During an interview on 07/16/24 at 3:15 p.m., the MDS coordinator said she was not responsible for baseline care plans. She said the DON was responsible for initiating baseline care plan. She said that was the way with the old company but did not know how the new company was going to do it. During an interview on 07/16/24 at 3:20 p.m., the DON said she did not know she was responsible for initiating baseline care plans. She said she thought the MDS coordinator was responsible for baseline care plans. Requested copy of Resident #69's baseline care plan from the DON. Resident #69's baseline care plan was not received prior or after exit. During an interview on 07/17/24 at 3:10 p.m., the MDS Coordinator said before the current DON started in April (2024), the DON or a RN initiated the baseline care plans. She said after the DON or RN initiated the baseline care. The nurses completed it within 48 hours of admission. She said she was not responsible for the baseline care plans. During an interview on 07/17/24 at 4:10 p.m., LPN M said she had not done a lot of admission at the facility. She said she assumed the admission nurse started the baseline care plan. She said she assumed the ADON or DON ensured it was completed within 24-48 hours of admission. She said the care plan helped you know how to take care of the resident. During an interview on 07/17/24 at 5:07 p.m., the DON said the LVN on admission was responsible for resident's baseline care plans. She said baseline care plan needed to be completed within 24 hours of admission. She said the ADON or DON should ensure resident's baseline care plan were completed within 24 hours of admission. She said new admission were talked about in morning meeting and that where we should be making sure baseline care plans were completed. She said if baseline care plan were not done, it did not alert staff what patient care should be provided. She said without a baseline care plan, a standard of care was not established, and the facility would not know of the resident was progressing or if something needed to be changed. During an interview on 07/17/24 at 6:00 p.m., the ADM said the admitting nurse started the baseline care plan and the DON finished it within 48 hours of admission. She said all facility departments had input on the baseline care plan. She said the DON was responsible for ensuring the baseline care plan were completed timely. She said if baseline care were not done, staff may not know how to properly care for the resident. Record review of a facility's Care Planning policy revised 10/24/22, indicated .the Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA and MDS guidelines .the care plan serves as a course of action where the resident, resident's attending physician, and IDT work to help the resident move towards resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs .a licensed nurse will initiate the Care Plan, and will be finalized in accordance with OBRA/MDS guidelines .the Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission .once the baseline Care Plan is completed, the Facility must provide the resident and/or resident's representative with a written summary of the Baseline Care Plan .

**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 care plan to meet the medical, nursing, mental and psychosocial needs for 2 of 18 residents (Resident #17 and Resident #68) reviewed for care plans. 1. The facility failed to implement a comprehensive person-centered care plan for Resident #17's positioning rail. 2. The facility failed to ensure Resident #68 was care planned as smoker. 3. The facility failed to perform quarterly smoking assessments for Resident #68. 4. The facility failed to perform Resident #68's quarterly elopement risk assessments. These failures could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed to address their needs. Findings included: 1. Record review of Resident #17's face sheet dated 7/17/24 revealed he was [AGE] years old and admitted to the facility on [DATE]. Resident #17 had diagnoses of a cerebral infarction (stroke-occurs when there is a lack of oxygen to the brain and brain cells die), hemiplegia and hemiparesis of left side (muscle weakness or partial paralysis (not able to move) on one side of the body that affects arms, legs, and/or facial muscles) following a brain bleed, and weakness. Record review of Resident #17's annual MDS assessment dated [DATE] revealed he was understood and understood others. Resident #17 had a BIMS of 14, which indicated he was cognitively intact. The MDS indicated Resident #17 required total to maximum assistance for most ADLs. The MDS did not indicate the use of bed rail. Record review of Resident #17's undated Physician Orders revealed there were no orders for his positioning rail on his bed. Record review of Resident #17's undated care plan revealed he had a history of cerebral infarction and was at risk of complications r/t left sided hemiplegia with goals to maintain or improve current levels of ADLs and not have another cerebral infarction over the next 90 days. He had pain with interventions to assist with turning and repositioning to find a comfortable position. He had a history of falls. The care plan did not address Resident #17's use of a bed rail for positioning. Record review of Resident #17's therapy screening dated 7/15/24 revealed he was screened for the use of assist bar and was appropriate for assist bar to left side to facilitate mobility. During an observation and interview on 7/15/24 at 10:39 AM, Resident #17 said things were going pretty good. Resident #17 said he had a positioning bed rail on his left side of his bed, but he also needed one on his right side to assist with turning and it would make him feel safer when being turned to the right side during his incontinent care. Resident #17 had a positioning bed rail on his left side of the bed. During an interview on 7/17/24 at 1:45 PM, Resident #17 said he wanted a positioning bed rail on his right side to help with turning himself. Resident #17 said he was not able to use his left arm or leg. Resident #17 said he received his current bed three or four weeks ago and it came with the one positioning bed rail on his left side. Resident #17 said the bed he had prior to his current one had positioning bed rails on both sides. During an interview on 7/17/24 at 1:30 PM, CNA D said she had worked at the facility for five years and usually worked on the day shift. CNA D said she thought Resident #17 had his positioning bed rails since he had been in his room for some time. During an interview on 7/17/24 at 1:54 PM, the Regional Director of Therapy said she had screened Resident #17 on 7/15/24 because they were a new company for the facility as of 7/1/24 and their policy was to screen everyone and look at everyone to see if they were appropriate to use positioning rails, wheelchairs, etc. She said they had already scheduled to come to the facility that week to screen all the residents. She said she did not know what the previous company's policy was, but they required residents to be screened for positioning bed rails and to be care planned, and to have an order. During an interview on 7/17/24 at 1:57 PM, the Director of Therapy said previously, if nursing felt like a resident needed positioning bed rails, nursing would tell the Maintenance Supervisor and he would install the positioning bed rails on the bed. She said if therapy felt a resident needed the positioning bed rails, therapy would tell the nursing staff and the nursing staff would tell the Maintenance Supervision and he would put them on. She said therapy did not do screenings or evaluate residents for the use of positioning bed rails. During an interview on 7/17/24 at 2:05 PM, LVN B said she had worked at the facility for fourteen years. LVN B said if a resident needed positioning bed rails, they just called the Maintenance Supervisor, and he would put the positioning bed rails. LVN B said therapy would also tell them if a resident needed positioning bed rails and then nursing would notify the Maintenance Supervisor and he would install them. LVN B said they did not put orders in for the positioning bars with the previous company or do consents. LVN B said she did not know what the new company would require. LVN B said the MDS coordinator was responsible for doing any care plans and/or changes in the morning meetings. LVN B said the care plan was to go over expectations for staff to take care of the resident related to all aspects of life. LVN B said positioning bed rails should be care planned to monitor the resident for safety of the bars to help the resident turn and not get tangled up in them or anything that would negatively affect the resident. LVN B said she did not know how long Resident #17 had been using the positioning bed rail, but it had been over a year. During an interview on 7/17/24 at 2:15 PM, the MDS coordinator said she had worked at the facility for 16 years. She said she was responsible for the admission, quarterly, annual, and significant change MDSs and implementing/updating the care plans with each MDS schedule. She said she reviewed everything during the MDS assessment and updated the care plan as indicated and if she was asked to update a care plan she would, but she was not responsible for the acute care plan changes/updating. She said she believed nursing was responsible for the acute care plan changes/updates. She said she would update the care plan to include positioning bed rails and interventions for assessments and monitoring, if she knew a resident had the positioning bed rails. She said she would have to see documentation, such as an order, nurse's note, or have someone tell her if a resident had positioning bed rails to know to update the care plan. She said she did not know Resident #17 had positioning bed rails. She said the purpose of the care plan was so residents received the care needed and it was a guide to staff of what care the resident needed. She said the resident should be assessed to ensure they know how to use the positioning bed rails and were using them appropriately. She said the negative affect to the resident of not having something care planned would depend on what was not care planned. During an interview on 7/17/24 02:27 PM, LVN C said the MDS Coordinator, and the RNs were responsible for updating the care plans. LVN C said as an LVN, she was not allowed to do care plans. LVN C said she could update orders. LVN C said an order was needed for a resident to have positioning bed rails. LVN C said if a resident needed positioning bed rails, she would let therapy know and then tell the Maintenance Supervisor to install them. LVN C said positioning bed rails should be included on the care plan. LVN C said the purpose of the care plan was to guide the resident's care and if something was not care planned, then the resident may not receive the care they needed. During an interview on 7/17/24 at 3:44 PM, the DON said therapy should evaluate the resident to see if they could use positioning bed rails correctly and the Maintenance Supervisor installed the positioning bed rails on the resident beds. The DON said the positioning bed rails should be on the care plan to include assessments and monitoring for safety. The DON said the nurses initiated the base line care plan and the MDS Coordinator was responsible for the comprehensive care plan and for revising the care plans. The DON said the nurses and/or herself were responsible for revising the acute care plans with changes. The DON said the LVNs, and RNs could update/revise the care plans, but mainly the nurse managers did it. The DON said the positioning bed rails should have an order, consents signed, and be care planned, per their new company's policy, but she said she did not know what the old company required. The DON said once they get completely switched over to the new software system, when the nurses did their assessments, the system would automatically update the care plans. The DON said the purpose of the care plan was so everyone to be updated and everyone to be on the same page in what care the resident needed or required. The DON said if the positioning bed rails were not care planned, the rails could serve as a restraint, or the resident could injure themselves if not being assessed for safety and appropriate use. During an interview on 7/17/24 at 4:01 PM the ADM said the MDS nurse was responsible for the development and revising of the care plans. The ADM said the admitting nurse initiated the baseline care plans and the DON reviewed and signed off on it. The ADM said the DON also signed off on the comprehensive care plan when it was completed. The ADM said the care plan was the recipe to care for each resident and should be very specific to that resident on how to care for them and it was the prescription for the resident's care. The ADM said she would expect the positioning bed rails to be care planned with interventions to ensure the residents safety. The ADM said if not care planned the resident may not receive the care they needed. 2. Record review of Resident #68's face sheet dated 07/16/24, indicated Resident #68 was an [AGE] year-old, female admitted on [DATE] with diagnoses including dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), nicotine dependence, and tremors. Record review of Resident #68's admission MDS assessment dated [DATE], indicated Resident #68 was usually understood and usually understood others. Resident #68's BIMS score was 15 which indicated intact cognition. The MDS indicated Resident #68 did not wander or reject care. The MDS indicated Resident #68 was a current tobacco user. Record review of Resident #68's quarterly MDS assessment dated [DATE], indicated Resident #68 was understood and understood others. Resident #68's BIMS score was 14 which indicated intact cognition. The MDS indicated Resident #68 did not wander but rejected care. Record review of Resident #68's care plan dated 11/08/23, edited 04/29/24 indicated Resident #68 was at risk for elopement due to cognitive deficits, history of wandering behavior, and history of exit seeking. Resident #68 resided in secured unit of facility. Intervention included reassess secured unit placement quarterly and as needed with significant change. Resident #68's care plan did not indicate she was a smoker and to complete quarterly smoking assessments. Record review of Resident #68's elopement risk dated: *01/22/24 *07/16/24 Resident #68 did not have quarterly elopement assessment performed. Record review of Resident #68's smoking safety risk assessment dated [DATE], indicated Resident #68 used cigarettes and was a modified independent smoker. Resident #68 did not have quarterly smoking assessment. Record review of a Smokers list provided by the ADM on 07/15/24, indicated Resident #68 was a smoker on the secured unit. During an observation on 07/16/24 at 8:41 p.m., Resident #68 headed outside with a staff member to smoke. During an interview on 07/17/24 at 3:10 p.m., the MDS coordinator said she did resident's care plans. She said the resident's MDS coded for smoking should prompt staff to develop a smoking care plan. She said Resident #68 having a smoking care plan was important to know what care or supervision she required. She said without a smoking care plan, Resident #68 could not get the supervision she needed, and injury could happen. She said she did not know why Resident #68 did not have a smoking care plan. She said the ADON completed smoking assessments. She said nurses completed elopement risk assessments. During an interview on 07/17/24 at 4:10 p.m., LPN M said Resident #68 should have smoking on her care plan. She said the care plan let staff know about smoke breaks and what accommodations was needed. She said the care plan helped you know how to care for the resident. She said if the wrong accommodations were given to Resident #68 during smoking, injury could happen or if not taken when scheduled, Resident #68 could become combative. She said smoking and elopement risk assessments should be completed on schedule. She said the assessment were completed quarterly by the DON. During an interview on 07/17/24 at 5:07 p.m., the DON said nurses completed the smoking and elopement risk assessments. She said but anyone could complete the assessments if needed. She said elopement risk assessment should be completed quarterly and smoking assessments should be done on admission and quarterly. She said the ADON should be monitoring the completion of smoking and elopement risk assessments. She said the chart system also triggered when the resident's assessments are due. She said Resident #68's care plan should have smoking as a care area. She said the MDS coordinator or nurses were responsible for care planning smoking on resident's care plans. She said when smoking was not care planned, residents could be injured because they could be not safe smoking. She said when elopement risk assessments were not done, it placed resident at risk for elopement and being inappropriate placed on the secure unit. During an interview on 07/17/24 at 6:00 p.m., the ADM said each disciplinary made sure resident's intervention addressed the care area. She said the DON was responsible for reviewing the comprehensive care plan to ensure all care areas were addressed. She said smoking should be care planned for a resident who smoked. She said the MDS coordinator was responsible for care plan with the old company. She said smoking needed to be on the resident's care plan to know how to care and special needs of the resident. She said nurses were responsible for elopement risk assessments and safe smoking assessments. She said assessments were done on admission, quarterly, and as needed. She said when elopement risk assessment was not performed, staff could not be in tuned with residents attempts to elope. She said staff members could not pay close attention to the resident and the resident could elope. She said if smoking assessments were not done, then may not know if a resident is a safe smoker. She said staff may not know how to safely smoke the resident and injury can happen. She said the DON and MDS coordinator should ensure care plan are comprehensive. Record review of the facility's policy titled Care Planning dated revised October 24, 2022, revealed . the purpose of care planning was . to ensure that a comprehensive person-centered care plan was developed for each resident based on their individual assessed needs . the care plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's attending physician, and interdisciplinary team work to help the resident move toward resident specific goals that address the resident's medical, nursing, mental and psychosocial needs . a licensed nurse would initiate the care plan, and the plan would be finalized in accordance with . guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgement on an as needed bases . each resident's comprehensive care plan would describe the following . services that were to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . Record review of the facility's policy titled Bed Rails dated revised 06/2020, revealed . the purpose was to determine the appropriateness of bed rail use for individual residents . decisions to use or to discontinue the use of a bed rail would be made in the context of an individualized resident assessment using an Interdisciplinary Team and would take into account the resident's medical needs, comfort, and freedom of movement . the resident's plan of care would be updated to reflect the use of bed rails . the plan of care should also include documentation of the type of specific direct monitoring and supervision provided during the use of the bed rails and the identification of how needs would be met during the use of bed rails ( such as repositioning, hydration, etc.) . Record review of a facility's Smoking by Residents policy revised 06/2020, indicated .to respect resident choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers .residents who want to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke in these areas .a licensed nurse will complete a Safe Smoking Assessment for residents who wish to smoke .all smokers shall be assessed related to smoking safety at the time of admission and then at least quarterly as outlined by OBRA assessment timeframe .the IDT shall create a Smoking Care Plan for the resident . Record review of a facility's Secure Care Neighborhood policy revised 08/2020, indicated .the secure care neighborhood may be used to keep residents who are a high risk for elopement safe from exiting the facility .the resident should have an Elopement Risk Assessment completed with a physician order completed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 3 residents who were reviewed for quality of care. (Resident #279) 1. The facility failed to ensure Resident #279 had orders for the size and amount of fluid in the bulb of her indwelling urinary catheter (tube inserted into the bladder to drain urine). 2. The facility failed to ensure Resident# 279 had orders catheter care with an indwelling urinary catheter. The failures could place residents at risk for indwelling urinary catheter pain, urinary tract infections, and not receiving needed care. Findings included: 1. Record review of Resident #279's face sheet dated 7/17/24 indicated Resident #279 was a [AGE] year old female and admitted to the facility initially on 7/13/24 with diagnosis chronic kidney disease stage 3 unspecified (when the kidneys have mild to moderate damage and less able to filter waste and fluid out of your blood). Record review of Resident #279's quarterly MDS assessment dated [DATE] indicated Resident #279 was usually understood and understood others. The MDS indicated Resident #279 had no BIMs conducted. Resident #279 was maximal assistance on staff for toileting hygiene. The MDS indicated Resident #279 had an indwelling catheter (urinary catheter) and was always incontinent of bowel. Record review of Resident #279's baseline care plan dated 7/13/2024 indicated she was cognitively intact. She was always incontinent to urine. She had a wound to sacral area. She was on enhanced barrier precautions with interventions of gloves and gown should be donned (put on) if any of the following activities occurred: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bathing, or other high contact activity. Record review of Resident #279's Order Summary Report dated 7/16/24 revealed there was no order noted related to Resident #279's urinary Foley catheter size, amount of fluid in the bulb and no catheter care. During an interview on 7/17/24 at 9:30 AM the DON stated Resident #279's urinary catheter size, bulb and catheter care orders were not in the resident's chart, but she had updated the resident's chart and put the orders in after made aware by surveyor. During an interview on 7/17/2024 at 10:15 AM the Director of Operations voiced Resident #279's foley catheter orders were not in the system, but after notified by surveyor orders had been added to system. During an interview on 7/17/24 at 2:12 PM, revealed LVN C said the nurses had the residents' orders on the paper MAR and in electronic record. She said the orders should show the catheter size, how much fluid should be in the bulb and catheter care each shift or as needed. She said she could not find Resident #279's catheter orders on the medication administration report. During an interview on 7/17/24 at 2:37 PM, LVN P said normally the residents came to the facility with a catheter order on admission and the nurses should know to performed standard care with the catheter. She said if she could not find the resident's catheter orders she would call the physician to get orders. She said not performing catheter care could cause the resident discomfort or pain, it could have an effect on their vital signs and cause sepsis. During an interview on 7/17/24 at 2:57 PM, the DON said the foley catheter orders should be put in the system on resident's admission. She said the orders for an indwelling catheter should include a secured to leg device, check urine in bag and ensure proper placement. She said the order should had the size of the catheter, the amount of fluid in the bulb and when to change the catheter. The DON said the foley catheter on admission order was probably missed due to the facility changed to a new charting system and their nurse has not been trained on the system yet. The DON said the negative effects of catheter orders not available for nurses could cause urinary tract infections and sepsis for residents with catheters. She said if the catheter orders were not on the medication administration report it was not monitored. She said if a nurse could not find the catheter orders they should ask her or a co-worker with point click care knowledge or notify the physician that foley catheter orders were needed for a resident. During an interview on 7/17/24 at 3:15 PM, the ADM said there should be an order for an indwelling catheter. The ADM said when applying a catheter, the nurse should be following the physicians' orders. The ADM said the nurse should always make sure they have a supporting diagnosis for a catheter, if not call the physician get an order or to discontinue the order for the foley catheter. The nurse should follow their facility policy in taking care of a catheter. Our nursing staff had not been taught how to add orders to this new point click care system. We are in orientation on how to use this system. If Resident #279 had a catheter her orders should have been put in the system. The ADM said if a foley catheter was not cleaned properly, that could lead to urinary tract infection or sepsis. Review of a Catheter- Care of, Urinary Policy dated revised 6/2022 revealed .the purpose of this procedure is to prevent urinary catheter-associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary. Documentation of catheter care will be maintained in the resident's medical record. Review of Physician Orders Policy dated revised 6/2020 revealed .This will ensure that all physician orders are complete and accurate. The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary. Orders will include a description complete enough to ensure clarity of the physician's plan of care. Whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order. Medication/treatment orders will be transcribed onto the appropriate resident administration record. Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the MAR/TAR.

**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 reviewed for respiratory care. (Resident #35) The facility failed to ensure Resident #35's nasal cannula (is a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) was stored in a bag when not in use. The facility failed to ensure Resident #35's nebulizer mask (provide vaporized medicine into the airway) was stored in a bag after use. These failures could place residents at risk of respiratory infections. 1. Record review of Resident #35's face sheet fated 07/16/24, indicated Resident #35 was a [AGE] year-old female admitted on [DATE] and 04/17/24 with diagnoses including chronic obstructive pulmonary disease (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and acute and chronic respiratory failure with hypercapnia (is a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide). Record review of Resident #35's significant change in status MDS assessment dated [DATE], indicated resident #35 usually understood and sometimes had the ability to understand others. Resident #35 was unable to complete the BIMS assessment. Resident #35 had short-and-long term memory recall problem and moderately impaired cognitive skills for daily decision making. The MDS indicated Resident #35 had oxygen therapy while a resident and within the last 14 days. Record review of Resident #35's care plan dated 04/19/24, edited 05/19/24, indicated Resident #35 had oxygen use related to COPD, respiratory failure, and need for Bi PAP as ordered. Intervention included change oxygen tubing every week and as needed. Record review of Resident #35's order summary dated 07/16/24 indicated: *Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg/3 ml, 1 vial inhale orally three times a day related to chronic obstructive pulmonary disease. *Oxygen at 3 liters per minute per nasal cannula continuously, every shift. Started date 04/26/24. During an observation on 07/15/24 at 11:00 a.m., Resident #35's nasal cannula was wrapped and laying on top of the oxygen concentrator, not stored in a bag, in her room. On Resident #35's nightstand was a nebulizer mask not stored in a bag. During an observation on 07/15/24 at 1:00 p.m., Resident #35's nasal cannula was wrapped and laying on top of the oxygen concentrator, not stored in a bag, in her room. On Resident #35's nightstand was a nebulizer mask not stored in a bag. During an interview on 07/17/24 at 4:10 p.m., LPN M said Resident #35's nasal cannula and nebulizer mask should be stored in a bag when not in use. She said the staff member who removed the nasal cannula or nebulizer from Resident #35, was responsible for storing it correctly. She said the nasal cannula and nebulizer mask should be stored in a bag because it is sanitary. She said if the equipment was not stored correctly the resident could get sick because mold and bacteria grow in the cannulas and masks. During an interview on 07/17/24 at 5:07 p.m., the DON said the CNAs and LVNs were responsible for storing resident's nasal cannula and nebulizer mask when not in use. She said the nasal cannula and nebulizer mask should be stored in a clear bag when not in use. She said the nurse should ensure resident's respiratory equipment was stored in a bag. She said it was important to store the equipment correctly for infection control. She said the equipment could get contaminated from what it touched. She said the resident could get a respiratory infection. Record review of a facility's Cleaning and Disinfection of Environmental Surfaces and Equipment policy revised on 06/2020, indicated .semi-critical .items consist of items that come in contact with mucous membranes or non-intact skin (e.g., respiratory therapy equipment) .such devices are to be free from microorganisms .

Based on interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 1 of 7 (Dietary Aide A) reviewed for qualified dietary staff. The facility failed to ensure the DA A met the requirements for food handling by obtaining a food handler's certificate. This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses. Findings: During an interview and record review on 07/16/24 at 10:11 AM, the DM provided an undated Employee Demographics list that revealed DA A was hired 11/3/23. She said DA A did not have his food handler's certificate. She said he should have had it within 2 weeks of hire, but he did not get it. She said she talked to HR about it and let HR know he had not gotten it after she had reminded him numerous times. She said it was her responsibility and the responsibility of HR to make sure DA A got his food handler's certificate within 2 weeks of hire. She said she explained to DA A the importance of him getting the food handler's certificate and he still did not get it. During an interview on 07/16/24 at 11:13 AM, the Dietician said DA A did not have his food handler's certificate. She said if he hired on 11/3/23 he should have had it within 30 days. She said it was the DM's responsibility to make sure he had gotten it. She said she did not know who was responsible for making sure the DM had the food handler's certificates for the dietary staff. She said it was important for all staff to have the food handler's certificates so that they could handle food safely. During an interview on 07/16/24 at 1:16 PM, HR said the DM told her DA A did not have his food handler's certificate a week or so ago. She said they talked to the ADM, and they were supposed to get that done but they did not. She said it was a problem because DA A did not know the proper protocol for food safety. She said that could affect all residents that ate out of the kitchen. During an interview on 07/16/24 01:51 PM, the ADM said they did not have a policy regarding Food Handler's Certificates. During an interview on 07/16/24 at 4:02 PM, the DON said she was not aware DA A did not have a food handler certificate. She said if he was working in the kitchen, he should have one. She said it was important to learn how to handle food, prevent contamination, and food safely. She said that could affect all residents that ate from the kitchen which was every resident. She said it was the DM and HR's responsibility to make sure he had proper training. During an interview on 07/17/24, at 7:28 AM, DA A said he was hired 11/3/23 as a dishwasher. He said he was supposed to get a food handler's certificate right after he hired. He said he was reminded numerous times by the DM, but he was busy and never got it done. He showed this surveyor he was watching the videos now and said he would have it today. DA A said the food handler's certificate was important for food safety, learning about cross-contamination and keeping all residents safe and healthy. During an interview on 07/17/24 at 7:33 AM, the ADM said DA A was working on getting his food handler's certificate now. She said she was not sure what the holdup was or why he did not have it. She said it was the responsibility of the DM to make sure all her staff had training and were certified. The ADM said HR told her they were pressuring him to get the certificate. She said she oversaw all departments including HR and Dietary. She said she believed the ball dropped when the prior ADM left 1 week after she started, then the facility was sold. She said she took over the building on 4/1/24 and the facility was sold 7/1/24. She said there were too many things happening at once. The ADM said DA A not having his food handler's certificate could affect every resident in the building in that he would not be aware of food borne pathogens, required temperatures of food, and how things were reheated or stored. She said there was a potential for illness with all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure all patient care equipment was in safe operating condition for 1 of 4 resident (Resident#31) reviewed safe, functional equipment. The facility failed to ensure Resident #31's wheelchair brake handle was not loose. This failure could place resident at risk for usage of unsafe equipment. Findings included: Record review of Resident #31's face sheet dated 07/16/24, indicated Resident #31 was an [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's disease (is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), muscle weakness, and abnormalities of gait and mobility. Record review of Resident #31's quarterly MDS assessment dated [DATE], indicated Resident #31 was sometimes understood and sometimes had the ability to understand others. Resident #31 was unable to complete the BIMS assessment. Resident #31 had short-and-long term memory recall problem and moderately impaired cognitive skills for daily decision making. Resident #31 used a wheelchair as a mobility device. Resident #31 required supervision for oral hygiene, maximal assistance for personal hygiene and putting on/taking off footwear, and dependence for toileting hygiene and dressing. Record review of Resident #31's care plan dated 12/28/23, edited 06/19/24, indicated Resident #31 was high risk for falls related to cognitive deficits with poor safety awareness, unaware of environmental obstacles, visual deficits, loses balance easily, and attempts to transfer/stand/ambulate but limited with unsteady gait. Intervention included lock all moveable equipment before transferring resident. During an observation on 07/16/24 at 9:00 a.m., Resident #31 was self-propelling herself aimlessly up and down the secured unit hallway. Resident #31's wheelchair wheels had moderate amount of dried substance splattered throughout both wheels. Resident #31's wheelchair had a moderate amount of hair tangled where the wheels and the frame connected. During an interview and observation on 07/17/24 at 3:48 p.m., CNA J said Resident #31 used her wheelchair to get around. She said maintenance was responsible for the upkeep of resident's wheelchairs. CNA J entered Resident #31's room and inspected her wheelchair. She said Resident #31's right wheelchair brake handle was loose. She said if a resident's wheelchair brake did not work, she would not put the resident in the chair and notify maintenance. She said if a resident's wheelchair brake was loose or did not work, the resident could fall. She said if the resident fell, they could get bruises and fractures. She said she had not noticed Resident #31's loose brake handle. CNA J said she would take the wheelchair out of Resident #31's room so maintenance could look at it. CNA J left the secured unit to locate the maintenance supervisor. During an interview and observation on 07/17/24 at 4:07 p.m., the maintenance supervisor arrived on the secured unit and inspected Resident #31's wheelchair. He said Resident #31's wheelchair handle was loose, and he would take care of it. He said he was responsible for the maintenance of resident's wheelchairs. He said CNAs needed to let him know when resident's wheelchairs needed maintenance. He said he fixed wheelchairs when he was notified of an issue. He said once he was notified, he fixed the issue immediately. He said if a resident's wheelchair brake handle was loose, it placed resident at risks for falls. During an interview on 07/17/24 at 4:10 p.m., LPN M said whoever put the resident in their wheelchair should assess the brakes. She said if a resident stood up and the brake was not working, then the resident could fall and hurt themselves. She said maintenance was responsible for fixing wheelchairs. She said if something needed fix, she called maintenance and placed it on the 24-hour report. During an interview on 07/17/24 at 5:07 p.m., the DON said maintenance was responsible for the upkeep of resident's wheelchairs, but staff had to inform him of the issue. She said all staff should be inspecting resident's wheelchair. She said if a resident's wheelchair had a loose brake handle, it was a safety risk, and the resident could fall and sustain an injury. During an interview on 07/17/24 at 6:00 p.m., the ADM said the maintenance supervisor was responsible for wheelchair brakes and parts. She said the ADM was involved in ordering parts for wheelchairs. She said staff needed to communicate to the maintenance supervisor any malfunctions or issues with resident's equipment. She said staff verbally told the maintenance supervisor issues but there was a maintenance book also. She said if the resident could stand, the resident could fall and injury themselves or break a bone. She said ultimately it was maintenance responsibility to maintain resident's wheelchairs. A policy on maintenance responsibility regarding resident equipment was requested at this time. On 07/18/24 at 4:44 p.m., the ADM sent an email with some requested facility policies to this surveyor. The requested policy for Maintenance was not received in the email received on 07/18/24 at 4:44 p.m. On 07/18/24 at 4:48 p.m., Another email was sent requesting a policy on maintenance responsibility regarding resident equipment. The requested policy for Maintenance was not received after the email sent on 07/18/24 at 4:48 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #31's face sheet dated 07/16/24, indicated Resident #31 was an [AGE] year-old female admitted on [DATE] with diagnoses including pseudobulbar affect (is a condition that's characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), depression, anxiety disorder, and mood affective disorder (is a mental health condition that primarily affects your emotional state). The face sheet indicated Resident #31 family members were her responsible party. Record review of Resident #31's quarterly MDS assessment dated [DATE], indicated Resident #31 was sometimes understood and sometimes had the ability to understand others. Resident #31 was unable to complete the BIMS assessment. Resident #31 had short-and-long term memory recall problem and moderately impaired cognitive skills for daily decision making. Resident #31 was prescribed an antianxiety during the last 7 days of the assessment period. Record review of Resident #31's care plan dated 12/28/23, edited on 06/19/24, indicated Resident #31 had potential for drug related complication related to anxiolytic /sedative medications. Intervention included monitor side effects. Record Review of Resident #31's order summary report dated 07/16/24 indicated Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg, give 1 capsule by mouth two times a day for anxiety/agitation. Start date 07/05/24. Record review of Resident #31 MAR dated 07/01/24-07/31/24 indicated Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg, give 1 capsule by mouth two times a day for anxiety/agitation. Order date 07/05/24. On 07/17/24 at 12:57 p.m., requested Resident #31's Depakote consent from ADM and Regional DOO by email. Resident #31's consent was not received prior or after exit. 3. Record review of Resident #33's face sheet dated 07/16/24, indicated Resident #33 was a [AGE] year-old female admitted on [DATE] with diagnoses including depression, dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and bipolar disorder. Resident #33's face sheet indicated a family member was her responsible party. Record review of Resident #33's quarterly MDS assessment dated [DATE], indicate Resident #33 was usually understood and sometimes had the ability to understand others. Resident #33's BIMS score was 09 which indicated moderately impaired cognition. Resident #33's MDS indicated she had been prescribed an antipsychotic, antianxiety, and antidepression during the last 7 days of the assessment period. Record review of Resident #33's care plan dated 12/01/23, edited on 06/04/24 indicated Resident #33 had potential for drug related complication related to psychotropic drug use related to medical diagnoses of depression, bipolar, and insomnia. Resident #33 received antianxiety medication, antidepressant medication, and antipsychotic medication. Intervention included obtain consent for psychotropic drug use. Record review of Resident #33's order summary dated 07/17/24, indicated the following medications : *Seroquel Oral Tablet 25 mg, give 1 tablet by mouth one a day related to bipolar disorder. Start date 05/14/24. *Seroquel Oral Tablet 50 mg, give 1 tablet by mouth at bedtime related to depression. Start date 05/14/24. Record review of Resident #33's MAR dated 07/01/24-07/31/24 indicated: *Seroquel Oral Tablet 25 mg, give 1 tablet by mouth one a day related to bipolar disorder. Order date 05/14/24. *Seroquel Oral Tablet 50 mg, give 1 tablet by mouth at bedtime related to depression. Order date 05/14/24. On 07/17/24 at 8:34 a.m., requested Resident #33's Seroquel consent from ADM and Regional DOO by email. Resident #33's consent was not received prior or after exit. 4. Record review of Resident #35's face sheet fated 07/16/24, indicated Resident #35 was a [AGE] year-old female admitted on [DATE] and 04/17/24 with diagnoses including anxiety disorder and dementia. The face sheet indicated Resident #35 family member were her responsible party. Record review of Resident #35's significant change in status MDS assessment dated [DATE], indicated resident #35 usually understood and sometimes had the ability to understand others. Resident #35 was unable to complete the BIMS assessment. Resident #35 had short-and-long term memory recall problem and moderately impaired cognitive skills for daily decision making. The MDS indicated Resident #35 received an antianxiety and antidepressant during the last 7 days of the assessment period. Record review of Resident #35's care plan dated 04/16/24 indicated Resident #35 had potential for drug related complications related to antidepressant medications. Intervention included monitor side effects. Record review of Resident #35's order summary dated 07/16/24, indicated Paroxetine Oral Tablet 20 mg, give 1 tablet by mouth at bedtime for mood. Start date 07/02/24. Record review of Resident #35's MAR dated 07/01/24-07/31/24 indicated Paroxetine Oral Tablet 20 mg, give 1 tablet by mouth at bedtime for mood. Order date 07/02/24. On 07/17/24 at 10:16 a.m., requested Resident #35's Paroxetine consent from ADM and Regional DOO by email. Resident #35's consent was not received prior or after exit. 5. Record review of Resident #69's face sheet dated 07/16/24, indicated Resident #69 was an [AGE] year-old female admitted on [DATE] with diagnosis including dementia with other behavioral disturbance. The face sheet indicated Resident #69 family member was her responsible party. Record review of Resident #69's admission MDS assessment dated [DATE] indicated Resident #69 was usually understood and usually understood others. Resident #69's BIMS score was 08 which indicated moderately impaired cognition. The MDS indicated Resident #69 received an antianxiety and antipsychotic during the last 7 days of the assessment period. Record review of Resident #69's care plan dated 07/03/24, indicated Resident #69 had potential for drug related complication related to anxiolytic /sedative medications. Intervention included monitor side effects. Record review of Resident #69's order summary dated 07/17/24 indicated the following medications: *Hydroxyzine Oral Tablet 25 mg, give 1 tablet orally every 8 hours as needed for anxiety. Start date 06/22/24. *Mitrazapine Oral Tablet 7.5 mg, give 1 tablet by mouth at bedtime for appetite stimulation. Start dated 07/15/24. Record review of Resident #69's MAR dated 07/01/24-07/31/24 indicated: *Hydroxyzine Oral Tablet 25 mg, give 1 tablet orally every 8 hours as needed for anxiety. Order date 06/22/24. *Mitrazapine Oral Tablet 7.5 mg, give 1 tablet by mouth at bedtime for appetite stimulation. Order dated 07/15/24. On 07/16/24 at 2:07 p.m., called Resident #69's RP to discuss psychotropic consents. Resident #69's RP did not answer, and voicemail left with call back number. Call back was not received prior or after exit. On 07/17/24 at 10:16 a.m., requested Resident #69's Hydroxyzine and Mitrazapine consent from ADM and Regional DOO by email. Resident #69's consent was not received prior or after exit. During an interview on 07/17/24 at 4:10 p.m., LPN M said the nurses were responsible for obtaining consent for psychotropic medications. She said consent should be obtained before the medication was given. She said the power of attorney or resident should give consent for the psychotropic medication, verbally or in person. She said it was important to get consent for psychotropic medications to make sure the resident was not allergic to the medication and able to take the medication. She said if consent was not given, the resident or power of attorney may not be aware of the risk and benefits of the medication. During an interview on 07/17/24 at 5:07 p.m., the DON said the nurses were responsible for obtaining consent for psychotropic medications. She said consent should be obtained from the RP. She said consent should be done on admission and when the medication was ordered. She said the ADON was responsible for ensuring the nurses obtaining consent for psychotropic medications. She said she did not know the ADON's process in monitoring psychotropic consents being obtained by the nurses. She said it was important to obtain consent, so the facility was not medicating a resident without consent. She said it was important to obtain consent, so the RP and resident knew the risk and benefits and to decide if they want to take it. She said she did not know why Residents #21, #31, #33, #35, and #69 did not have consent for their psychotropic medications. She said the ADON was at home with a family situation. During an interview on 07/17/24 at 6:00 p.m., the ADM said the admitting nurse should get the psychotropic consents signed by the RP or resident on admission. She said verbal consent could be obtained and signed eventually when the family visited. She consents should be obtained prior to the medication being administered. She said getting consent was important so the RP and resident could make an informed decision and be clear on what the medication was treating. She said the DON should be monitoring resident's psychotropic consents. Record review of a facility's Psychotherapeutic Drug Management policy revised 10/24/22, indicated .attending medical practitioner responsibility .the psychotherapeutic medication order will include the following information .informed consent from resident and/or surrogate decision maker for each drug and for each increase in dosage .nursing responsibilities .the licensed nurse will not administer the psychotherapeutic medication until an informed consent form has been obtained and documented by the attending physician from the resident and/or surrogate decision maker, unless it is an emergency situation . Based on interviews and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 5 of 21 residents reviewed for the right to be informed. (Resident's #21, #31, #33, #35, and #69) 1. The facility failed to ensure Resident #21 had a signed psychotropic consent form for Duloxetine (antidepressant medication) or Haloperidol (antipsychotic medication). 2. The facility failed to ensure Resident #31's psychoactive (substances that, when taken in or administered into one's system, affect mental processes) medication therapy consent was completed for Depakote (is used to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder), and to prevent migraine headaches). 3. The facility failed to ensure Resident #33's psychoactive medication therapy consent was completed for Seroquel (is an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs)). 4. The facility failed to ensure Resident #35's psychoactive medication therapy consent was completed for Paroxetine (is used treat depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest), obsessive-compulsive disorder (is a long-lasting disorder in which a person experiences uncontrollable and recurring thoughts (obsessions), engages in repetitive behaviors (compulsions), or both) and anxiety disorders (persistent and excessive worry that interferes with daily activities)). 5. The facility failed to ensure Resident #69's psychoactive medication therapy consent was completed for Hydroxyzine (is used to treat anxiety disorders and allergic conditions, especially those that involve the skin) and Mirtazapine (is an atypical antidepressant (are prescription medicines to treat depression) and is used primarily for the treatment of a major depressive disorder (is a mood disorder that interferes with daily life)). These failures could place residents at risk for treatment or services provided without their informed consent. Findings included: 1 .Record review of the undated face sheet revealed Resident #21 originally admitted [DATE] and readmitted [DATE]. She was an [AGE] year-old female. Record review of the quarterly MDS dated [DATE] revealed Resident #21 understood others and was understood by others. She had a BIMS of 14 indicating her cognition was intact. The MDS revealed she had disorganized thinking that fluctuated in severity. She had a diagnosis of Schizophrenia. The MDS indicated she was taking an antipsychotic and antidepressant. Record review of the care plan dated 1/30/24 indicated Resident #21 had a potential for complications related to antipsychotic medication with a goal of stabilizing major psychiatric diagnosis, minimize agitated behaviors, and would not have side effects. Resident #21 had an alteration in thought process, memory impairment and confusion related to dementia .with paranoia/delusions (frequently speaks of her husband as having an affair, will say it is staff members at times,) history of behaviors, verbal and physical aggression, anger and wandering. She had a potential for psychotic behavior with a diagnosis of psychosis related to Schizophrenia. Record review of the physician's orders dated 7/17/24 revealed Resident #21 had diagnoses that included: dementia with behavioral disturbance (loss of cognitive functioning, including restlessness and accusatory behaviors), Parkinsonism (brain conditions that cause slowed movements, rigidity and tremors), and schizoaffective disorder (hearing voices, unusual beliefs, depression or mania). Further review of the orders included the following medications: *7/8/24 Duloxetine HCL Oral Capsule Delayed Release, give 1 capsule by mouth two times a day related to unspecified dementia, moderate, with other behavioral disturbance. *7/8/24 Haloperidol oral tablet 0.5 mg by mouth at bedtime related to unspecified dementia, moderate, with other behavioral disturbance. Give with 1 mg tablet for a total of 1.5 mg. *7/8/24 Haloperidol oral tablet 1 mg by mouth at bedtime related to unspecified dementia, moderate, with other behavioral disturbance. Give with 0.5 mg tablet for a total of 1.5 mg. During an interview on 07/17/24 at 2:26 PM, the DOO said they could not find the consents for Resident #21's Duloxetine or her Haloperidol. He said there was a problem with consents, and they were currently doing an audit.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 4 of 6 staff (CNA F, CNA H, CNA G, the DOR) reviewed for abuse policy. 1. The facility failed to ensure CNA F, CNA G, and DOR had criminal history background checks in their personnel file. 2. The facility failed to ensure CNA H had EMR in the personnel file. These failures could place residents at risk for unsafe environment and abuse. Findings included: Record review of a facility's Abuse Prevention and Prohibition Program policy revised 10/24/22, indicated .to ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse .the administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems .screening .the facility does not knowingly employee anyone who has disciplinary action .a finding entered into the state nurse aide registry related to abuse .reporting/response .the facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin .immediately, but no later than 2 hours after forming suspicion . 1. Record review of the Personnel File Review completed on 07/16/24, indicated CNA F, CNA G, and DOR did not have a criminal history on file. The personnel file review indicated CNA H did not have a EMR report on file. The personnel file review indicated the DOH (date of hire) for CNA F was 04/27/2010, CNA G 08/06/2013, DOR 11/02/2020, and CNA H 01/22/2002. During an interview on 07/17/24 at 4:59 p.m., the HR Payroll said she had been at the facility for 4 months. She said she was responsible for background checks and running EMR reports. She said the previous HR Payroll did not tell her how often she was supposed to do background checks and EMR reports. She said with the new company, which took over at the beginning of the month (July 2024), their policy was to do it on hire and yearly. She said if the background checks or EMR report were not done, resident were at risk for abuse and facility hiring sex offenders. During an interview on 07/17/24 at 5:07 p.m., the DON said HR was responsible for running background checks and EMR on employees. She said not doing background checks and EMR reports risked the facility employing someone with a criminal history or misconduct on their license. During an interview on 07/17/24 at 6:00 p.m., the ADM said HR was responsible for performing background checks and EMR reports upon hire and annual. She said HR was responsible for the information being on the employee's file. She said when background checks and EMR reports were not done it risked sex offender being employed and employing someone with a conviction on the barred from hiring list. Record review of the facility's 2024 Employee Handbook dated 11/2020 indicated .criminal and other background checks .at the company, we pride ourselves on providing the highest level of quality care .one of the best ways to give our residents/patients and their families peace of mind that we have a safe and secure environment is to ensure we hire and maintain a workforce of high integrity .we therefore conduct reference checks, criminal background checks, and other background checks on hire and as required or appropriate at other times, to the extent permitted by law .

**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's status for 3 of 10 resident reviewed for assessments. (Resident #31, Resident #33, and Resident #54) The facility failed to ensure Resident #31's diagnoses of anxiety (persistent and excessive worry that interferes with daily activities) and depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest) was coded on her MDS. The facility failed to ensure Resident #33's diagnoses of bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and depression was coded on her MDS. The facility failed to ensure Resident #54's diagnosis depression was coded on her MDS. These failures could place residents at risk of not having individual needs met. Findings included: 1. Record review of Resident #31's face sheet dated 07/16/24, indicated Resident #31 was an [AGE] year-old female admitted on [DATE] with diagnoses including depression and anxiety disorder. Record review of Resident #31's quarterly MDS assessment dated [DATE], indicated Resident #31 was sometimes understood and sometimes had the ability to understand others. Resident #31 was unable to complete the BIMS assessment. Resident #31 had short-and-long term memory recall problem and moderately impaired cognitive skills for daily decision making. Resident #31 was prescribed an antianxiety during the last 7 days of the assessment period. The MDS did not indicate Resident #31 had diagnoses including anxiety and depression. Record review of Resident #31's care plan dated 12/28/23, edited on 06/19/24, indicated Resident #31 had potential for drug related complication related to anxiolytic /sedative medications. Intervention included monitor side effects. 2. Record review of Resident #33's face sheet dated 07/16/24, indicated Resident #33 was a [AGE] year-old female admitted on [DATE] with diagnoses including depression and bipolar disorder. Record review of Resident #33's quarterly MDS assessment dated [DATE], indicate Resident #33 was usually understood and sometimes had the ability to understand others. Resident #33's BIMS score was 09 which indicated moderately impaired cognition. Resident #33's MDS indicated she had been prescribed an antipsychotic, antianxiety, and antidepression during the last 7 days of the assessment period. The MDS did not indicate Resident #33 had diagnoses including bipolar and depression. Record review of Resident #33's care plan dated 12/01/23, edited on 06/04/24 indicated Resident #33 had potential for drug related complication related to psychotropic drug use related to medical diagnoses of depression, bipolar, and insomnia. Resident #31 received antianxiety medication, antidepressant medication, and antipsychotic medication. Intervention included obtain consent for psychotropic drug use. 3. Record review of Resident #54's face sheet dated 07/15/24 indicated Resident #54 was a [AGE] year-old, female admitted on [DATE] with a diagnosis of depression . Record review of Resident #54's quarterly MDS assessment dated [DATE], indicated Resident #54 was usually understood and sometimes understood others. Resident #54 had a BIMS of 00 which indicated severe cognitive impairment. The MDS indicated Resident #54 had received an antianxiety and antidepressant during the last 7 days of the assessment period. The MDS did not indicate Resident #54 had diagnosis including depression. Record review of Resident #54's care plan dated 03/14/24, edited on 06/07/24, indicated Resident #54 had depression as evidence by diagnosis/history of depression and mood disorder, and wandering. Intervention included administer anti-depressant medication as ordered by MD. During an interview on 07/17/24 at 3:10 p.m., the MDS coordinator said she was responsible for resident's MDSs. She said medical records put diagnoses in the electronic computer system. She said active resident's diagnoses were obtained from physician notes and the diagnoses list. She said some of the resident's diagnoses may not be added because another staff member in training completed their MDS. She said RUGS, during their yearly review, recommended MDSs have active diagnoses only which are obtained from the most recent physician's progress notes. She said the other staff member in training probably followed those recommendations when she completed Residents #31, #33, and #54's MDS. She said she did not check over every MDS the staff member in training completed independently to make sure they were correct. She said all of Resident #31, #33, and #54's mental health diagnoses should be coded on their MDSs. She said she did check the progress notes for active diagnoses but if the resident was on a medication to treat a diagnosis not listed, she coded it on the MDS anyway. She said it was important for MDSs to be accurate so it could be reflected on the resident's care plan. During an interview on 07/17/24 at 5:07 p.m., the DON said the MDS coordinator was responsible for coding resident diagnoses. She said resident's psychiatric diagnoses should be coded on their MDSs. She resident's MDS should reflect the condition of the resident. She said the new company's regional MDS coordinator was the one who provided oversight and monitored the MDS coordinator. She said inaccurate MDSs affected the resident's plan of care and the facility's billing. During an interview on 07/17/24 at 6:00 p.m., the ADM said the RN who reviewed the MDS before submission was responsible for the MDS accuracy. She said she expected resident's mental illnesses to be coded on their MDS. She said MDSs should be accurate because it ensured care of the resident and proper medication and treatment. She said the RN coordinator or MDS coordinator should monitor the submitted MDSs for accuracy. Requested an accuracy of assessment policy from the ADM. Record review of a facility's Documentation-Nursing policy revised 06/2020, indicated .minimum data set (MDS) completion per CMS and Medicare guidelines .

ased on interview and record review the facility failed to complete a performance review of each Certified Nurse Assistant (CNA) at least once every 12 months, for 5 of 5 (CNA J, CNA F, CNA H, CNA K, and CNA G) reviewed for annual competency evaluations. The facility failed to complete annual CNA competency evaluations for CNA J, CNA F, CNA H, CNA K and CNA G based on the personnel file review results. This failure could affect residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs. Findings included: Record review of the Personnel File Review completed on 07/16/24, indicated CNA J, CNA F, CNA H, CNA K, and CNA G did not have a competency evaluation on file. The Personnel File Review indicated CNA J's date of hire was 03/07/17, CNA F 04/27/10, CNA H 01/22/02, CNA K 06/17/02, and CNA G 08/06/13. During an interview on 07/17/24 at 5:07 p.m., the DON said the staffing coordinator was responsible for the CNA trainings and competency evaluations. She said CNAs evaluation were supposed to be done annually. She said when trainings and evaluations were not done, CNAs were working but not trained correctly. She said this risked the residents not getting the care they needed, and it being done incorrectly. During an interview on 07/17/24 at 6:00 p.m., the ADM said if CNAs were not trained properly or evaluated, CNAs may not be aware of changes, informed of new processes, and new information the facility wanted them to know. She said staff would be working with a lack of knowledge which placed residents at risk. A policy regarding staff development and training was requested at this time. On 07/18/24 at 4:29 p.m., the ADM sent an email stating the facility did not have a policy for staff development and training. The employee handbook was requested at this time. Record review of the facility's 2024 Employee Handbook dated 11/2020, indicated .the purpose of a performance review is to evaluate your past performance and to guide you to maintain and/or improve your future job performance .generally, your job performance may be reviewed 90 days after hire, transfer or promotion, and annually thereafter .all performance reviews become part of your personnel file .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring) for 4 (Resident # 33, Resident #35, Resident #54, Resident #69) of 5 residents whose medications were reviewed in that: 1. The facility failed to ensure Resident #33 had side effect monitoring (are defined as unintended responses to approved pharmaceuticals (is any kind of drug used for medicinal purposes) given in appropriate dosages) for her prescribed Seroquel ((is an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia (is a serious mental illness that affects how a person thinks, feels, and behaves) and bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration)), Buspirone (antianxiety; is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety, and Venlafaxine (antidepressant; is used to treat depression) and Remeron ((is an atypical antidepressant (are prescription medicines to treat depression)) for July 2024. 2. The facility failed to ensure Resident #35 had behavior monitoring (monitor activities and mood) for her prescribed Paroxetine ((antidepressant; is used treat depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest)) and Lorazepam (antianxiety; is used to treat anxiety) for July 2024. 3. The facility failed to ensure Resident #35 had side effect monitoring for her prescribed antidepressant and antianxiety for July 2024. 4. The facility failed to ensure Resident #54 had side effect monitoring for her prescribed Depakote (anticonvulsant; is used to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder), and to prevent migraine headaches) used to treat a mood disorder for July 2024. 5. The facility failed to ensure Resident #69 had an appropriate diagnosis for her prescribed Seroquel and Hydroxyzine (Antihistamines (medicines often used to relieve symptoms of allergies,), Miscellaneous anxiolytics (are medications that can treat anxiety and related conditions), sedatives, and hypnotics (used to reduce tension and anxiety and induce calm (sedative effect) or to induce sleep (hypnotic effect)); is used to treat anxiety disorders and allergic conditions, especially those that involve the skin). 6. The facility failed to ensure Resident #69 had behavior monitoring for her prescribed Seroquel and Hydroxyzine for July 2024. 7. The facility failed to ensure Resident #69 had side effect monitoring for her prescribed Seroquel and Mirtazapine (Remeron) for July 2024. These failures could place residents at risk of not receiving the intended therapeutic benefits of their psychotropic medications. Findings included: 1. Record review of Resident #33's face sheet dated 07/16/24, indicated Resident #33 was a [AGE] year-old female admitted on [DATE] with diagnoses including depression, dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and bipolar disorder. Record review of Resident #33's quarterly MDS assessment dated [DATE], indicate Resident #33 was usually understood and sometimes had the ability to understand others. Resident #33's BIMS score was 09 which indicated moderately impaired cognition. Resident #33's MDS indicated she had been prescribed an antipsychotic, antianxiety, and antidepression during the last 7 days of the assessment period. Record review of Resident #33's care plan dated 12/01/23, edited on 06/04/24 indicated Resident #33 had potential for drug related complication related to psychotropic drug use related to medical diagnoses of depression, bipolar, and insomnia. Resident #31 received antianxiety medication, antidepressant medication, and antipsychotic medication. Intervention included obtain consent for psychotropic drug use. Record review of Resident #33's order summary dated 07/17/24, indicated: *Buspirone tablet 5 mg, give 1 tablet by mouth two times a day related to depression. Started date 11/20/23. *Venlafaxine Oral Tablet 37.5 mg, give 1 tablet by mouth one time a day related to depression. Started date 11/20/23. *Remeron Oral Tablet 15 mg (Mirtazapine), give 1 tablet by mouth at bedtime related to depression. Started date 05/15/24. *Seroquel Oral Tablet 25 mg, give 1 tablet by mouth one a day related to bipolar disorder. Started date 05/14/24. *Seroquel Oral Tablet 50 mg, give 1 tablet by mouth at bedtime related to depression. Started date 05/14/24. Further review revealed there was no order for side effect monitoring noted for AP, AA, and AD. Record review of Resident #33's MAR dated 07/01/24-07/31/24 indicated there was no documentation of behavior or side effect monitoring noted for AP, AA, and AD. On 07/17/24 at 2:37 p.m., requested behavior and side effect monitoring for July 2024 from the ADM and Regional DOO by email. Only received behavior monitoring flowsheet for AP, AA, and AD for Resident #33. 2. Record review of Resident #35's face sheet fated 07/16/24, indicated Resident #35 was a [AGE] year-old female admitted on [DATE] and 04/17/24 with diagnoses including anxiety disorder and dementia. Record review of Resident #35's significant change in status MDS assessment dated [DATE], indicated resident #35 usually understood and sometimes had the ability to understand others. Resident #35 was unable to complete the BIMS assessment. Resident #35 had short-and-long term memory recall problem and moderately impaired cognitive skills for daily decision making. The MDS indicated Resident #35 received an antianxiety and antidepressant during the last 7 days of the assessment period. Record review of Resident #35's care plan dated 04/16/24 indicated Resident #35 had potential for drug related complications related to antidepressant medications. Intervention included monitor side effects. Record review of Resident #35's order summary dated 07/16/24, indicated: *Paroxetine Oral Tablet 20 mg, give 1 tablet by mouth at bedtime for mood. Started date 07/02/24. *Ativan Oral Tablet 1 mg (Lorazepam), give 1 tablet by mouth in the morning related to anxiety disorder. Started date 07/03/24. *Ativan Oral Tablet 0.5 mg (Lorazepam), give 1 tablet by mouth every 4 hours as needed for anxiety related to anxiety disorder. Started date 07/02/24. Further review revealed there was no order for behavior or side effect monitoring noted for AD and AA. Record review of Resident #35's MAR dated 07/01/24-07/31/24 indicated there was no documentation of behavior or side effect monitoring noted for AD and AA. On 07/17/24 at 2:37 p.m., requested behavior and side effect monitoring for July 2024 from the ADM and Regional DOO by email. Received June 2024 behavior and side effect monitoring flowsheet for AD and AA for Resident #35. 3. Record review of Resident #54's face sheet dated 07/15/24 indicated Resident #54 was a [AGE] year-old, female admitted on [DATE] with diagnoses including dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), depression, and mood affective disorder (is a mental health condition that primarily affects your emotional state). Record review of Resident #54's quarterly MDS assessment dated [DATE], indicated Resident #54 was usually understood and sometimes understood others. Resident #54 had a BIMS of 00 which indicated severe cognitive impairment. The MDS indicated Resident #54 had received an antianxiety and antidepressant during the last 7 days of the assessment period. The MDS did not indicate Resident #54 had diagnosis including depression. Record review of Resident #54's care plan dated 03/14/24, edited on 06/07/24, indicated Resident #54 had depression as evidence by diagnosis/history of depression and mood disorder, and wandering. Intervention included administer anti-depressant medication as ordered by MD. Record review of Resident #54's order summary dated 07/17/24, indicated: *Depakote Extended-Release Oral Tablet 24-hour 250 mg, give 1 tablet by mouth one time a day for mood disorder. Started date 02/26/24. *Depakote Delayed Release Oral 500 mg, give 1 tablet by mouth at bedtime for mood disorder. Started date 03/02/24. Further review revealed there was no order for side effect monitoring noted for an AC. Record review of Resident #54's MAR dated 07/01/24-07/31/24, indicated there was no documentation of behavior or side effect monitoring noted for AC: On 07/17/24 at 2:37 p.m., requested behavior and side effect monitoring for July 2024 from the ADM and Regional DOO by email. Received side effect and behavior monitoring for AD and AA for Resident #54. 4. Record review of Resident #69's face sheet dated 07/16/24, indicated Resident #69 was an [AGE] year-old female admitted on [DATE] with diagnosis including dementia with other behavioral disturbance. No diagnosis of anxiety noted. No appropriate diagnosis for AP noted. Record review of Resident #69's admission MDS assessment dated [DATE] indicated Resident #69 was usually understood and usually understood others. Resident #69's BIMS score was 08 which indicated moderately impaired cognition. The MDS indicated Resident #69 received an antianxiety and antipsychotic during the last 7 days of the assessment period. Record review of Resident #69's care plan dated 07/03/24, indicated: *Resident #69 had potential for drug related complication related to anxiolytic /sedative medications. Intervention included monitor side effects. *Resident #69 had potential drug related complication to antipsychotic medication. Intervention included monitor for side effects of antipsychotic medication every shift. Record review of Resident #69's order summary dated 07/17/24 indicated: *Seroquel Oral Tablet 25 mg, give 1 tablet by mouth at bedtime for antipsychotic. Started date 06/22/24. *Hydroxyzine Oral Tablet 25 mg, give 1 tablet orally every 8 hours as needed for anxiety. Start date 06/22/24. *Mitrazapine Oral Tablet 7.5 mg, give 1 tablet by mouth at bedtime for appetite stimulation. Start dated 07/15/24. Further review revealed there was no order for behavior and side effect monitoring for AP ,hypnotic , and AD noted. Record review of Resident #69's MAR dated 07/01/24-07/31/24 indicated there was no documentation of behavior or side effect monitoring noted for AP, hypnotic, and AD. On 07/17/24 at 2:37 p.m., requested behavior and side effect monitoring for July 2024 from the ADM and Regional DOO by email. Received side effect monitoring for hypnotic only for Resident #69. During an interview on 07/17/24 at 3:10 p.m., the MDS coordinator said medical records put diagnoses in the electronic computer system. She said active resident's diagnoses were obtained from physician notes and the diagnoses list. During an interview on 07/17/24 at 4:10 p.m., LPN M said behavior and side effect monitoring was done every shift by the nurse. She said when the psychotropic medication was ordered, the nurse should also add behavior and side effect monitoring that correlated with the medication. She said it was important to assess behaviors and potential side effects to understand why the medication was prescribed and treating and to know if the medication was helping with the resident's behaviors. She said if the side effect were not being monitored, side effect to the medication could be missed. She said the orders for behavior and side effect monitoring noted behaviors and side effects to look for, which helped staff know what side effects and behaviors to look for. She said she did not know who was responsible for resident's having appropriate diagnoses for antipsychotic medications. During an interview on 07/17/24 at 5:07 p.m., the DON said the nurse on admission and/or the nurse who took the psychotropic medication order was responsible for ordering behavior and side effect monitoring for each type of medication ordered. She said the ADON and DON should be ensuring psychotropic medication had side effect and behavior monitoring. She said the ADON reviewed new medication orders and should at that time ensure monitoring was ordered. She said behavioral monitor let you know if the medication was effective treating the diagnosis or behavior. She said the behavior monitoring could also show if the medication was too effective. She said if monitoring was not done, staff did not know if the medication was helping or not and if the resident was experiencing adverse side effects. She said the MDS coordinator and nurses were responsible in ensuring residents had an appropriate diagnosis for medications. She said antipsychotic on Resident #69's order as being the diagnosis, was not an appropriate diagnosis for Seroquel use. She said the facility should have contacted Resident #69's previous admitting facility to get appropriate diagnosis for Seroquel and Lorazepam or contact the transferring hospital. She said the facility could have also contacted her physician about her diagnoses. She said appropriate diagnoses for psychotropic medications were important to make sure residents were not being treated with the wrong medication, helped prevent oversedation, and helped them not receive a medication not needed. She said the ADON reviewed admission orders and should be noticing inappropriate diagnoses for medication. She said another way to ensure psychotropic medication had an appropriate diagnosis was the facility should request medical records from the admitting facility on admission to get or add the appropriate diagnosis from the documentation received. During an interview on 07/17/24 at 6:00 p.m., the ADM said the DON and ADON should ensure residents had appropriate diagnoses for psychotropic medications. She said the DON should be monitoring the process to ensure it was being done. She said appropriate diagnoses were important to ensure the diagnosis fit the medication ordered. She said there were medications that were approved for off labeled use so making sure there was an appropriate diagnosis was important. She said the diagnosis needed to fit what it was manufactured for. Record review of a facility's Psychotherapeutic Drug Management policy revised 10/24/22, indicated .to ensure the resident receives only those medications, in dose and for duration clinically indicated to treat the resident's assessed condition(s) .to ensure that any potential contributions the medication regimen has to an unanticipated decline or newly emerging or worsening symptoms is recognized and evaluated .the Facility will make every effort to comply with state and federal regulations .side effects .psychotropic medications .are drugs that affect brain activities associated with mental processes and behavior .categories of medications which affect brain activity include antihistamines .and central nervous system agents used to treat conditions such as seizures, mood disorders, pseudobulbar affect .the requirement pertaining to psychotropic medications apply to these types of medications when their documented use appears to be substitution for another psychotropic medication rather than the original or approved indication .attending medical practitioner responsibility .the psychotherapeutic medication order will include the following .diagnosis for the medication .indications and manifestations of the disorder treated .nursing responsibilities .will monitor psychotropic drug use daily noting any adverse effects .monitoring should also include evaluation of the effectiveness of non-pharmacological approaches .will monitor the presences of target behaviors on a daily basis charting by exception .

Based on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 19 of 74 residents (Residents #39, Resident #38, Resident #7, Resident #53, Resident #33, Resident #58, Resident #56, Resident #54, Resident #2, Resident #67, Resident #68, Resident #60, Resident# 107, Resident #51, Resident #72, Resident #108, Resident #44, Resident# 109, and Resident #110) reviewed for immunizations. The facility failed to offer and administer the influenza and pneumococcal vaccination to Residents #39, Resident #38, Resident #7, Resident #53, Resident #33, Resident #58, Resident #56, Resident #54, Resident #2, Resident #67, Resident #68, Resident #60. The facility failed to offer and administer the pneumococcal vaccination to Resident# 107, Resident #51, Resident #72, Resident #108, Resident #44, Resident# 109, and Resident #110. The facility failed to offer and administer the influenza vaccination to Resident #67, Resident #68, Resident #60. These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes. Findings included: Record review of a facility's Influenza and Pneumonia Vaccines list run date 05/30/34 was provided on 07/16/24. The list indicated Residents #39, Resident #38, Resident #7, Resident #53, Resident #33, Resident #58, Resident #56, Resident #54, Resident #2, Resident #67, Resident #68, Resident #60 had not received or refused influenza or pneumococcal vaccinations. The list indicated Resident# 107, Resident #51, Resident #72, Resident #108, Resident #44, Resident# 109, and Resident #110 had not received or refused pneumococcal vaccinations. The list indicated Resident #67, Resident #68, Resident #60 had not received or refused influenza vaccination and was not admitted out of influenza season. During an interview on 07/17/24 at 5:07 p.m., the DON said the ADON was responsible for ensuring residents were offered and received vaccinations. She said the DON should be ensuring the ADON kept an accurate record of resident's vaccination status and administered vaccinations. She said she was not aware 19 out of 74 residents had not received the influenza and/or pneumonia vaccine. She said vaccination was important for prevention. She said vaccinations helped prevent the resident from getting sick and reduced the resident's symptoms if the virus was contracted. She said residents not receiving vaccinations place residents at risk for contracting the virus and spreading the virus. During an interview on 07/17/24 at 6:00 p.m., the ADM said the DON was responsible in ensuring the resident were offered and received the flu and pneumonia vaccine. She said being vaccinated helped the resident, if contracted the virus, decreased the severity of the illness. She said vaccinations were a protection against viruses. During an interview on 07/22/24 at 2:28 p.m., the ADON said vaccines were offered to all residents during the admission process. He said he often had to reach out to families/PCPs to obtain prior vaccine information for residents. He said vaccines were an important prevention tool the facility used to decrease the risk of preventable infection for the resident. Record review of a facility's Influenza Prevention and Control policy revised 06/2020, indicated .to ensure that the Facility prevents and controls the spread of influenza in the Facility .influenza vaccinations of residents .residents are offered an influenza immunization during flu season annually, unless the immunization is medically contraindicated .the resident's medical record includes documentation that indicates, at a minimum .that the resident either received the influenza immunization or did not receive . Record review of a facility's Pneumococcal Disease Prevention policy revised 06/2020, indicated .to ensure that the Facility prevents and controls the spread of pneumococcal disease in the facility .the pneumococcal polysaccharide vaccine is recommended for the following .residents of nursing homes or long term care facilities . the resident's medical record includes documentation that indicates, at a minimum .that the resident either received the pneumococcal polysaccharide vaccine or did not receive .

ased on interview and record review, the facility failed to maintain ensure the required in-service trainings were sufficient for the continuing competencies of nurse aides but must be no less than 12 hours per year for 5 of 5 staff, (CNA F, CNA G, CNA H, CNA J, and CNA K) records reviewed for staff training. The facility failed to provide CNA F, CNA G, CNA H, CNA J, and CNA K 12 hours of training per year. This failure could place residents at risk of being cared for by untrained staff. Findings included: Record review of the Personnel File Review completed on 07/16/24, indicated CNA J, CNA F, CNA H, CNA K, and CNA G did not have 12 hours of training per year on file. The Personnel File Review indicated CNA J's date of hire was 03/07/17, CNA F 04/27/10, CNA H 01/22/02, CNA K 06/17/02, and CNA G 08/06/13. During an interview on 07/17/24 at 4:59 p.m., the HR Payroll said she had been at the facility for 4 months. She said she was responsible for training records, background checks, EMR and OIG results. She said she was responsible to notify the DON about training that needed to be completed. She said if trainings were not done, staff would not know the facility's protocols and procedures. During an interview on 07/17/24 at 5:07 p.m., the DON said she did not know the process or who was responsible for ensuring employees files were up to date. She said the staffing coordinator was responsible for the CNA trainings and competency evaluations. She said CNAs evaluation were supposed to be done annually. She said when trainings and evaluations were not done, CNAs were working but not trained correctly. She said this risked the residents not getting the care they needed, and it being done incorrectly. During an interview on 07/17/24 at 6:00 p.m., the ADM said HR was responsible for personnel files. She said records should be kept on want was completed upon hire and annually. She said if CNAs were not trained properly or evaluated, CNAs may not be aware of changes, informed of new processes, and new information the facility wanted them to know. She said staff would be working with a lack of knowledge which placed residents at risk. A policy regarding staff development and training was requested at this time. On 07/18/24 at 4:29 p.m., the ADM sent an email stating the facility did not have a policy for staff development and training to this surveyor. The employee handbook was requested at this time. Record review of the facility's 2024 Employee Handbook dated 11/2020, indicated .orientation& in-service training .ongoing training is necessary to provide the highest level of quality care to our resident/patients .you will be responsible for participating in orientation and training related to your position .your supervisor and/or Human Resources will communicate those requirements to you .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, The facility failed to comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives) for 1 of 3 (Resident #41) residents reviewed for advance directive The facility failed to ensure Resident #41 ' s code status was communicated and correctly indicated in his physical chart. This failure could result in residents receiving unwanted treatment or not receiving desired treatment. Findings include: Record review of Resident #41's face sheet, dated [DATE], indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included heart attack (when your heart muscle begins to die because it isn't getting enough blood flow), high blood pressure, dementia (impaired ability to remember, think, or make decisions), respiratory failure (when the respiratory system cannot adequately provide oxygen to the body), and anxiety (feelings of nervousness, panic and fear as well as sweating and a rapid heartbeat). Record review of Resident #41's admission MDS assessment, dated [DATE], indicated Resident #41 was understood and understood others. Resident #41's BIMs score was 12, which indicated he was moderately cognitively impaired. Resident #41 was independent with transfer, dressing, bathing, bed mobility, personal hygiene and required supervision with toilet use. The MDS indicate he received hospice care. Record review of Resident #41's physicians order dated [DATE] indicated: Code status Full Code. Record review of Resident #41's physical medical chart revealed behind the tab advanced directive a green sheet with the words, Full Code. Record review of Resident #41's hospice medical chart revealed a signed DNR dated [DATE]. Record review of Resident #41's comprehensive care plan, dated [DATE], indicated Resident #41 was a full code. The interventions of the care plan were for facility to honor full code status and staff would be advised of resident status of full code. During an interview on [DATE] at 10:08 a.m., Resident #41 said he wished to be a DNR. He said, He was ready when the Lord called him home. During an interview on [DATE] at 10:18 a.m., the hospice administrator said they completed the DNR paperwork with Resident #41 on [DATE]. She said they placed the DNR signed copy in his hospice book and made the facility aware of his DNR status on admission. During an interview and observation on [DATE] at 10:30 a.m., RN B said Resident #41 was a full code. RN B opened his electronic chart and it revealed he was a Full Code. RN B opened his physical medical chart and looked behind the advanced directive tab which revealed a green sheet with the words, Full Code. RN B said he was a Full Code. RN B then looked in Resident #41's hospice chart and it revealed a signed DNR. RN B said she was not aware Resident #41 was a DNR and failure of her knowing his code status could lead to CPR being performed against his wishes. During an interview on [DATE] at 1:57 p.m., the Social Worker said she had not spoken to Resident #41 about his code status. She said she only explains the process of DNR verse Full code and if a resident elects to become a DNR then the BOM completes the paperwork. The social worker said she was not aware Resident #41 was a DNR. She said she did not know all the steps after a resident elected DNR while at the facility. During an interview on [DATE] at 2:21 p.m., the ADON said he was not aware Resident #41 was an DNR. He said he was the overseer of all DNRs. The ADON said the normal process was once he received a signed DNR, he would write an order, place in the resident's chart, and give a copy to the BOM. He said if they were not made aware of someone's code status on admission, they were full code until determined otherwise. The ADON said this failure could cause residents to receive unwanted wishes of CPR. During an interview on [DATE] at 2:43 p.m., the DON said she was not aware Resident #41 was an DNR. The DON said she assisted with the admission paperwork process for Resident #41 and he nor his family mentioned being a DNR. The DON said if they were aware they would have written the order and placed in his chart. The DON said Resident #41 was admitted from home and she was unaware he had hospice until the next day ([DATE]). She said hospice came in the next day ([DATE]) and handed her their book and orders. The DON said she did not open the book but did go ask Resident #41 if he wished to continue with hospice and he said, yes. She said the orders hospice brought them for Resident #41 did not have any orders indicating he was a DNR. The DON said she have had residents on hospice before who were full code so she did not find it odd his code status was full code. The DON said not having the correct code status placed Resident #41 at risk of receiving CPR against his wishes. During an interview on [DATE] at 3:42 p.m., the administrator said she was unaware Resident #41 was an DNR. She said the normal process was for the SW to explain what a DNR versus a full code was to the resident and or family. She said if they chose to be a DNR then the BOM would complete the paperwork and notarize the DNR. The administrator said the BOM would give the signed DNR to the ADON and he would write the order for the DNR and then would let the charge nurses know the code status. The administrator said if they came in as a DNR then the ADON would write the order and let the charge nurses know the code status. The administrator said this process did not happen for Resident #13 because they were unaware, he was a DNR on admission and therefore it was missed. The administrator said the conflicting information on the resident's code status could place him at risk of receiving CPR against his wishes. Record review of the facility's policy titled, Advanced Medical Directives,' dated [DATE], indicated, The facility strives to comply with all valid Advanced Medical Directives (per state regulations). Inquire as to the existence of an Advanced Medical Directive at the time of admission. 2. Document in the resident/patient's medical record whether an Advanced Medical Directive has been executed by the resident/patient. 3. Place a copy of such Advanced Medical Directive in the permanent medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 1 (Resident #13) of 6 residents reviewed for privacy and confidentiality. The facility failed to ensure RN A protected Resident#13's Medication Administration Record (MAR). This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others. Findings included: Record review of Resident #13's face sheet, dated 06/13/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included diabetes (excess sugar in the blood), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), glaucoma (eye diseases that can cause vision loss and blindness) and anxiety ( feelings of nervousness, panic and fear as well as sweating and a rapid heartbeat). Record review of Resident #13's quarterly MDS assessment, dated 05/24/23, indicated Resident #13 was usually understood and understood others. Resident #13's BIMs score was 15, which indicated she was cognitively intact. Resident #13 required total assistance with transfer, toilet use, dressing, bathing, bed mobility and limited assist with personal hygiene. The MDS indicate she received insulin during the 7 days look back period. Record review of Resident #13's physicians order dated 11/15/22 indicated: Give Novolog 22 units subcutaneous (an injection given in the fatty tissue, just under the skin) at 11:30a.m. Record review of Resident #13's comprehensive care plan, dated 06/01/23, indicated Resident #13 received an antidiabetic/hypoglycemic agent and has the potential for alterations in blood glucose levels (Hyper/hypoglycemia) due to diabetes. The interventions of the care plan were for staff to administer insulin as ordered by physician, including sliding scale, monitor blood glucose levels as ordered by physician and to monitor for signs and symptoms of hyper/hypoglycemia such as alterations in level of consciousness, cool/clammy or hot flashes, and to notify the physician of abnormal findings. During an observation on 06/12/23 at 11:32 a.m., RN A went to obtain Resident #13's blood sugar. RN A left the MAR opened on top of medication cart #2 when entering Resident's#13's room. Staff and other residents observed in hallway. RN A came out of Resident #13's room to record her blood sugar and check insulin order. RN A went in to administer Resident #13's insulin leaving the MAR open again clearly displaying personal information. During an interview on 06/12/23 at 11:44 a.m., RN A said she forgot to close the MAR before walking into Resident #13's room. RN A said she was aware she was supposed to close the MAR anytime she stepped away. RN A said she knew she was supposed to provide privacy and maintain confidentiality for all residents. RN A said she did not provide privacy for Resident #13 when she left the MAR opened. During an interview on 06/14/23 at 2:21p.m., the ADON said he expected the nurses to ensure their MARs were closed when not being used. He said he and the DON were the overseer of MARs being closed but each nurse should be held accountable for leaving the MARs open. The ADON said failure to close the MAR when not in use could lead to privacy issues. During an interview on 06/14/23 at 2:43 p.m., the DON said all employees were expected to provide full visual privacy and confidentiality of information for all residents. The DON said failure to not protect the residents' information could lead to a HIPPA violation. During an interview on 06/14/23 at 3:42 p.m., the administrator said she expected the nurses to keep their MARs closed when not in use. The administrator said nurse managers were the overseer to ensure MARs were being closed when not in use. The administrators said the nurses should ensure MARs were closed when not used to provide privacy to all resident related to personal information. Record review of the facility's policy titled, Safeguarding and storing protected health information, dated September 2012 indicated, The purpose of this policy was to limit unauthorized disclosure of personal health information (PHI)that was contained in a residents medical record, while at the same time in ensuring such protective health information was easily accessible to those involved in the treatment of the resident. The policy of this facility was to ensure, to the extent possible, that PHI was not intentionally or unintentionally use or disclose in a manner that would violate the HIPAA privacy rule, facility policies and procedures or any other federal or state regulations governing confidentiality and privacy of health information. #4 medication administration records, treatment administration records, report sheets and other documents containing PHI shall not be left open and or unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents environment remained free of accident hazards by not adequately monitoring the proper storage of oxygen cylinders for 1 of 1 resident (Resident #16) reviewed for accident hazards. The facility failed to ensure Resident #16's oxygen cylinder was properly stored. This deficient practice could place residents at risk of injury. Findings included: Record review of Resident #16's face sheet, dated 06/13/23, indicated she was a [AGE] year-old female, admitted on [DATE]. She had diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), muscle weakness (a lack of strength in muscles) , and chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). Record review of Resident #16's quarterly MDS, dated [DATE], indicated she was usually able to make herself understood, and was usually able to understand others. She had a BIMS score of 14, which indicated intact cognition. She did not exhibit behaviors of rejection of care or wandering. She required extensive assistance to total dependence for all ADLs except for eating, which she required no assistance from staff. The MDS indicated she required oxygen therapy only while a resident in the facility. Record review of Resident #16's physician's orders, dated 06/01/23-06/30/23, indicated she had an order for 3L/min per nasal cannula continuously, every shift. The order start date was 06/02/23. Record review of Resident #16's care plan, dated 02/14/23, and revised on 05/17/23, indicated a problem of potential for ineffective breathing pattern related to chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). The goal was that resident will maintain adequate breathing pattern. The approaches included assess and report changes in level of consciousness, change oxygen tubing every week and as needed, elevate head of bed per request and to alleviate shortness of breath, monitor pulse oximetry per physician, and oxygen per physician's order. During an observation on 06/12/23 at 08:48 AM, Resident #16 was laying in bed in her room. There was a free-standing oxygen tank next to her oxygen concentrator. It was not attached to anything, and it was not in a cart or caddy. During an observation on 06/12/23 at 03:34 PM, Resident #16 was laying in bed in her room. There was a free-standing oxygen tank next to her oxygen concentrator. It was not attached to anything, and it was not in a cart or caddy. During an observation on 06/13/23 at 8:44 AM, Resident #16 was laying in bed in her room. There was a free-standing oxygen tank next to her oxygen concentrator. It was not attached to anything, and it was not in a cart or caddy. During an observation and interview on 06/13/23 at 11:07 AM, Resident #16 was laying in bed in her room. There was a free-standing oxygen tank next to her oxygen concentrator. It was not attached to anything, and it was not in a cart or caddy. Resident #16 said she was unsure how long the oxygen tank was there, and she was unable to recall any specific staff that could have brought it in her room. During an interview on 06/13/23 at 11:08 AM, CNA E said she was taking care of Resident #16 on 06/13/23. She said she was not sure who left the portable oxygen tank in her room without a caddy or cart. She said it should be in a caddy or cart. She said the tank was a hazard and could fall and hurt a resident. During an interview on 06/13/23 at 11:11 AM, RN B said she was unsure who left the portable oxygen tank in Resident #16's room. She said the portable oxygen tank should be in a portable oxygen cart or caddy. She said it could fall over and hurt or trip a resident. During an interview on 06/14/23 at 11:41 AM, the ADON said he expected oxygen tanks to have been stored in a caddy for portable oxygen tanks. He said the charge nurse was responsible for monitoring that oxygen tanks were properly stored. He said the ADON and DON were ultimately responsible for the proper storage of oxygen tanks. He said Residents could suffer possible injury as a result of tripping over the tank or injury as a result of it falling on them. During an interview on 06/14/23 at 11:50 AM, the DON said she expected the portable oxygen tanks to have been stored either on a wheelchair oxygen holder or in an oxygen caddy. She said charge nurses were responsible for ensuring that oxygen tanks were properly stored. She said the ADON and ultimately the DON were responsible for monitoring the storage of oxygen tanks. She said residents could suffer possible injury as a result of tripping over the tank or injury as a result of it falling on them. During an interview on 06/14/23 at 12:56 PM, the Administrator said she expected the oxygen tanks to have been stored per facility policy. She said they should have been in a caddy instead of free-standing on the floor. She said the nurses and aides were responsible for ensuring that oxygen tanks were properly stored. She said the ADON should have caught it on his rounds. She said the DON was also responsible and ultimately the Administrator as the head of the building. She said the residents could be at risk of being injured by the oxygen tank falling over and being damaged. She said it was possible the tank could explode if it was damaged. She said residents could also fall over and potentially trip on the tank if it fell. Record review of the facility's oxygen storage policy, effective March 2019, stated: Subject Oxygen Storage Standard The facility requires that all personnel observe the center and regulatory guidelines for storage of oxygen. A no smoking sign must be displayed in all areas where oxygen is stored. Procedure Compressed Oxygen Cylinders 1. Label and separate empty and full cylinders. 2. Keep Cylinders in an approved oxygen cart or storage bin. If cylinders are not in a storage cart or storage bin, they must be secured by a chain or other suitable retainer device. 3. Keep oxygen away from flammable materials

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 2 of 2 residents reviewed for enteral nutrition (Resident #46 and Resident #215). The facility failed to follow the physician orders for enteral feedings (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) for Resident #215 and Resident #46. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk of health complications. Findings included: 1. Record review of Resident #215's face sheet dated 06/13/23, indicated a [AGE] year-old female who admitted to the facility on [DATE]. Resident #215's diagnoses included sepsis (a life-threatening complication of an infection), essential hypertension (high blood pressure), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), gastrostomy (artificial external opening into the stomach for nutritional support), and dysphagia (difficulty swallowing). Record review of Resident #215's baseline care plan dated 05/30/23, indicated Resident #215 had the potential for alteration in nutrition related to peg/enteral feedings. The baseline care interventions included to administer tube feedings/water flushes as ordered by the medical director. Record review of Resident #215's admission MDS assessment dated [DATE], indicated she rarely understood and rarely understood others. The MDS had no checked if a BIMS could be conducted, and the staff assessment for mental status indicated Resident #215 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident #215 required extensive assistance with bed mobility and was totally dependent on staff for dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #215 had a feeding tube. Record review of Resident #215's physician order report dated 06/1/23-06/30/23 indicated Resident #215 had an order for enteral feeding Jevity 1.5 at 40ml/hr with water flush at 40ml/hr every shift with a start date of 05/30/23. During an observation on 06/11/23 at 10:52 AM, Resident #215 was receiving Glucerna 1.2 at 40mls/hr with 40mls/hr water flushes via her gastrostomy tube. During an observation on 06/12/23 at 01:55 PM, Resident #215 was receiving Glucerna 1.2 at 40mls/hr with 40mls/hr water flushes via her gastrostomy tube. During an interview and record review on 06/12/23 at 04:27 PM, LVN C said Resident #215 should be receiving Jevity but they were substituting with Glucerna as they were out of Jevity. LVN C said Resident #215 should have an order to substitute with Glucerna 1.2 at 40mls/hr. LVN C reviewed Resident #215 medical chart and said Resident #215 did not have an order to substitute with Glucerna. LVN C said the nurse who received the order was responsible for writing the order. LVN C said Resident #215 not receiving the correct enteral feeding would be considered a medication error. Record review of Resident #215's medication administration record dated 06/01/23-06/30/23, indicated Jevity 1.5 at 40mls/hr had been administered until 06/12/23. The medication administration record also indicated Resident #215 had an order for may substitute Jevity 1.5 with Glucerna 1.2 at 40ml/hr with water flush at 40mls/hr with a start date of 06/12/23 (after the surveyor's observation). During an interview on 06/14/23 at 12:40 PM, the DON said she expected the correct enteral feeding to be administered and the correct order of the feeding in place. The DON said they had been consulting with the dietician regarding supply issues and requesting substitute orders. The DON said Resident #215 was at risk for weight loss due to not receiving the ordered enteral feeding. During an interview on 06/14/23 at 02:05 PM, the Administrator said she expected Resident #215 to receive the correct feeding per the physicians' orders. The Administrator said previously the nurses had orders to subtitute Jevity for Glucerna. The Administrator said the nurse receiving the order was responsible for ensuring the order for substituting the feeding was in place. The Administrator said the ADON reviewed the physician's orders for accuracy. The Administrator said by not receiving the correct feeding the Resident #215 was at risk for weight loss. 2.Record review of Resident #46's face sheet, dated 06/13/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (impaired ability to remember, think, or make decisions), and stroke( occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts). Record review of Resident #46's quarterly MDS assessment, dated 03/31/23, indicated Resident #46 was sometimes understood and sometimes understood others. Resident #46's BIMs score was 04s, which indicated she was severely cognitively impaired. Resident #46 required total assistance with eating, toilet use, dressing, and bathing, limited assist with bed mobility, transfer, and personal hygiene. The MDS indicate she received tube feeding during the 7 days look back period. Record review of Resident #46's physicians order dated 06/02/23 indicated: Enteral feedings: Jevity strength 1.5, flow rate at 70ml/hour x 14, water flush at 55ml/hour x 14hours. Special instructions: May give Glucerna 1.2 at 75ml/hr x 22 hours with 30ml of water flushes x 22 hours if Jevity not available. Record review of Resident #46's comprehensive care plan, dated 04/14/23, indicated Resident #46 had enteral feedings related to stroke, history of choking while swallowing and abnormal swallow study. The interventions were to administer tube feeding formula as ordered by the physician. Record review of Resident #46's medication administration record revealed Resident #46 received Jevity strength 1.5, flow rate at 70ml/hour x 14, water flush at 55ml/hour. x 14hours or Glucerna 1.2 at 75ml/hour x 22 hours with 30ml of water flushes x 22 hours if Jevity not available from 06/01/23 through 06/13/23. During an observation on 06/11/23 at 9:43 a.m., Resident #46 was in her bed receiving formula of Glucerna 1.2 at 80mls/hr with 55mls/hr of water via her gastrostomy tube. During an observation on 06/11/23 at 12:48 p.m., Resident #46 was sitting in the hallway in her wheelchair without any enteral feedings as ordered x 22 hours. During an observation on 06/12/23 at 9:52 a.m., Resident #46 was in her bed receiving formula of Glucerna 1.2 at 80mls/hr with 55mls/hr of water via her gastrostomy tube. During an observation on 06/12/23 at 1:48 p.m., Resident #46 was sitting in the hallway in her wheelchair without any enteral feedings as ordered x 22 hours. During an interview on 06/12/23 at 4:55 p.m., RN B said Resident #46 was on Jevity 1.5 but they were out so she had Glucerna 1.2 as the substitute. RN B said they started substituting with Glucerna 1.2 on Friday (06/09/23). RN B said she took down Resident #46's Glucerna 1.2 this morning (06/12/23) and yesterday (06/11/23) at 10:00am. During an interview on 06/13/23 at 1:34 p.m., the dietitian said she reviewed Resident #46's orders today (06/13/23) and recommended her orders to change to Glucerna 1.2 at 90mls/hr X14 hours with 35mls/hr of water to equal 1512kcal/day. The dietitian said she thought she had made formula recommendations in April 2023 but could not remember what the recommendations were. The dietitian said Resident #46 missed some calories if she was not receiving Glucerna 1.2 at 90mls/hr and could potentially cause weight loss and skin issues. During an interview on 06/13/23 at 1:50 p.m., RN B said prior to today (06/13/23) Resident # 46 should have received Glucerna 1.2 at 75mls/hr X 22 hours. She said she was not following the correct orders. RN B said not following physicians order for Resident #46 could potentially cause weight loss, lead to skin or overall health issues. During an interview on 06/14/23 at 2:21p.m., the ADON said he expected the nurses to follow the physician's orders. He said he and the DON were responsible to ensure orders were followed. The ADON said failure to follow Resident #46's orders for enteral feedings could lead to potential weight loss. During an interview on 06/14/23 at 2:43 p.m., the DON said she expected the nurses to read all residents' orders daily because they could change. She said if the nurses did not understand an order, they needed to call the doctor to get further orders. The DON said she thought Resident #46's order were a transcription error because she remembered talking to the dietitian about her requesting to be up and off enteral feedings. She said her and the ADON were responsible to ensure nurses were following prescribed orders. The DON said this failure could place Resident #46 at risk for weight loss. During an interview on 06/14/23 at 3:42 p.m., the administrator said she expected the nurse to read the MARs correctly. She said nurse management should be reviewing the orders for accuracy. The administrator said this failure could cause potential weight lost. Record review of the facility policy Physicians Orders effective December 2018 indicated .At the time each resident/patient is admitted , the facility will have physician's orders for their immediate care. If the admitting physician is not going to be the patients/resident's attending physician while in the facility, the physician's orders will be verified by the attending physician at the facility .10. Discontinue the original physician's order when the physician changes an order that is currently in place. Assure the new order reflects the change .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have target behavioral monitoring in place for behaviors associated with the use of psychotropic medications and documented in the clinical record for 2 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #25 and Resident #41). 1.The facility failed to adequately monitor Resident #25's behaviors regarding his antidepressant and antianxiety medications. 2.The facility failed to adequately monitor Resident #41's behaviors regarding his antianxiety medication. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: 1. Record review of Resident # 25's face sheet dated 06/14/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25's diagnoses included diabetes (a group of diseases that result in too much sugar in blood), dementia (memory loss), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and metabolic encephalopathy (problem in the brain that is caused by chemical imbalance in the blood). Record review of Resident #25's significant change in status MDS assessment dated [DATE], indicated he was usually understood and usually understood others. The MDS indicated Resident #25 had a BIMS score of 12 which indicated his cognition was moderately impaired. Resident #25 required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, personal hygiene and was totally dependent on staff on bathing. The MDS indicated Resident #25 received antianxiety medications 5 days of 7 days and received antidepressant medication for 7 of 7 days of the look back period. Record review of Resident #25's comprehensive care plan dated 04/05/23 indicated he had the potential for drug related complications related to anxiolytics and antidepressant medications. The care plan interventions included to monitor for side of effects and if any side effects were noted, document side effects in the medical record and notify the physician. Record review of Resident #25's physician order report dated 06/01/23-06/30/23, indicted he had the following orders: *Lorazepam (antianxiety medication) 0.5mg one tablet by mouth twice a day with a start date of 05/31/23 *Sertraline (antidepressant medication) 100mg one tablet by mouth twice a day with a start date of 05/31/23 *anti-anxiety medication use- observe resident closely for significant side effects: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash- every shift with a start date of 05/31/23. *anti-depressant medication use- observe resident closely for significant side effects: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity (skin), excessive weight gain- every shift with a start date of 05/31/23. The physician order report did not indicate Resident #25 had any behavior monitoring for the use of antidepressant or antianxiety medications. During an interview on 06/14/23 at 12:13PM, RN A said when she received an order for psychotropic medications a consent was obtained, and the resident was monitored for behaviors and side effects. RN A said was unaware of what triggered the target behavior monitoring sheet. RN A said behavior monitoring was documented for the first 3 days after starting a psychotropic medication but after the initial 3 days behavior monitoring was no longer documented. During an interview on 06/14/23 at 12:28 PM, the ADON said when a psychotropic medication was initiated the family was notified to obtain a consent for the psychotropic medication. The ADON said they would also monitor for side effects and behaviors. The ADON said it was important to monitor for side effects and behaviors to evaluate if the medication was effective. During an interview on 06/14/23 at 12:40 PM, the DON said when a resident was on a psychotropic medication, behavior monitoring should be documented. The DON said not having behavior monitoring was a medical records oversight. The DON said it was the medical records nurse to ensure the behavior monitoring was in place. The DON said there was not a process in place for monitoring residents receiving antipsychotics medications. The DON said by monitoring the resident's behaviors would determine if the medication was beneficial to the resident. During an interview on 06/14/23 at 01:18 PM, LVN L said she did medical records. LVN L said she did not put in the behavior monitoring unless she has received an order for it. LVN L said she was unsure if psychotropic medications required behavior monitoring. LVN L said when a resident was started on psychotropic medication, she was only aware she had to include the side effect monitoring for those medications. During an interview on 06/14/23 at 02:05 PM, the Administrator said she expected residents that were receiving psychotropic medications to have their behaviors monitored. The Administrator said by not monitoring the resident's behaviors they would not know the effectiveness of medications. The Administrator said the DON and ADON were responsible to ensure behavior monitoring was in place. 2. Record review of Resident #41's face sheet, dated 06/14/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included heart attack (when your heart muscle begins to die because it isn't getting enough blood flow), high blood pressure, dementia (impaired ability to remember, think, or make decisions), respiratory failure (when the respiratory system cannot adequately provide oxygen to the body),and anxiety (feelings of nervousness, panic and fear as well as sweating and a rapid heartbeat). Record review of Resident #41's admission MDS assessment, dated 05/21/23, indicated Resident #41 was understood and understood others. Resident #41's BIMs score was 12, which indicated he was moderately cognitively impaired. Resident #41 was independent with transfer, dressing, bathing, bed mobility, personal hygiene and required supervision with toilet use. The MDS indicate Resident #41 received 6 doses of antianxiety medication during the 7 days look back period. Record review of Resident #41's physicians order dated 03/28/23 indicated: Xanax (antianxiety) 1 mg, give 1 tablet at night. Record review of Resident #41's medication administration record indicated he received Xanax nightly from 06/01/23 thru 06/13/23. Record review of Resident #41's medication administration record did not indicate any behavior monitoring for Xanax. Record review of Resident #41's comprehensive care plan, dated 05/31/23, indicated Resident #41 had potential for drug complications related to anxiolytic/sedative medication. The interventions of the care plan were to consult pharmacy on medication regimen every month and as needed, monitor for fall risk, monitor for orthostatic hypotension, monitor for side effects, and review and discuss during behavior intervention team meetings. During an interview on 06/14/23 at 2:21p.m., the ADON said the facility should have behavior monitoring sheets in place to ensure the medication was working. He said if the resident had increased or decreased anxiety this was a way to prove the medication was or was not working. The ADON said nursing staff usually checks the behavior monitoring sheets at the beginning of each month to ensure residents who needed them were in place. He said apparently, some of the resident sheets were missed. The ADON said without monitoring the behavior effects of the medication, they would not know if the medication was effective. During an interview on 06/14/23 at 2:43 p.m., the DON said all residents who required behavior monitoring should have sheets in place. She said nursing staff usually reviewed them monthly. The DON said she was unaware Resident #41 did not have a behavior monitoring sheet in place. She said she and the ADON were going to put a system in place to ensure everyone who needed behavior monitor sheets were in place. The DON said failure to monitor behaviors could lead to residents continuing an unnecessary medication. During an interview on 06/14/23 at 3:42 p.m., the administrator said nurses should be monitoring behavior each shift for residents who required behavior monitor. She said nurse management should be following up on behavior monitoring sheets. The administrator said failure to monitor behaviors appropriately could lead to unnecessary medications. Record review of the facility's policy Psychotropic Medications effective August 2018 indicated .The facility strives to assure the appropriate use of psychotropic medications to enhance the quality of life of residents/patients who exhibit harmful behavioral symptoms .Verify the physician order contains the appropriate clinically supported diagnosis and reason for use . 13. Document frequency of behavioral symptoms on the Behaviors Tracking Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #13) reviewed for infection control. The facility failed to ensure RN A performed hand hygiene while preforming glucometer checks (a small, portable device that lets you check your blood sugars) and administering insulin for Resident #13. This deficient practice could place residents at risk for infection due to improper care practices. Findings include: Record review of Resident #13's face sheet, dated 06/13/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included diabetes (excess sugar in the blood), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), glaucoma (eye diseases that can cause vision loss and blindness) and anxiety ( feelings of nervousness, panic and fear as well as sweating and a rapid heartbeat). Record review of Resident #13's quarterly MDS assessment, dated 05/24/23, indicated Resident #13 was usually understood and understood others. Resident #13's BIMs score was 15, which indicated she was cognitively intact. Resident #13 required total assistance with transfer, toilet use, dressing, bathing, bed mobility and limited assist with personal hygiene. The MDS indicate she received insulin during the 7 days look back period. Record review of Resident #13's physicians order dated 11/15/22 indicated: Give Novolog 22 units subcutaneous (an injection given in the fatty tissue, just under the skin) at 6:30a.m.,11:30a.m., and 4:30p.m. Record review of Resident #13's comprehensive care plan, dated 06/01/23, indicated Resident #13 received an antidiabetic/hypoglycemic agent and has the potential for alterations in blood glucose levels (Hyper/hypoglycemia) due to diabetes. The interventions of the care plan were for staff to administer insulin as ordered by physician, including sliding scale, monitor blood glucose levels as ordered by physician and to monitor for signs and symptoms of hyper/hypoglycemia such as alterations in level of consciousness, cool/clammy or hot flashes, etc. and to notify the physician of abnormal findings. During an observation on 06/12/23 at 11:32 a.m., RN A performed a blood sugar check on Resident #13. RN A came out to nurses' cart without sanitizing her hands and started touching other residents' insulin in medication cart while searching for Resident #13's insulin. RN A went into Resident #13's room, gave her the ordered insulin and came out of room without sanitizing her hands, then went to the next resident's room. During an interview on 06/12/23 at 11:44 a.m., RN A said she did not sanitize her hands after completing blood sugar check, before administrating insulin or after she completed insulin. LVN B said she was supposed to but she did not. RN A showed surveyor the ABHR gel sitting on top of cart and again said, I should have hand sanitized before and after each procedure, but I did not. RN A said the failure of her not hand sanitizing could lead to infection control issues. During an interview on 06/14/23 at 2:21p.m., the ADON said he was the infection preventionist. He said he had done in-services on hand sanitizing. The ADON said all staff were required to hand sanitized before and after a procedure for sanitization, infection, and own personal hygiene. During an interview on 06/14/23 at 2:43 p.m., the DON said all staff should hand sanitize before and after a procedure to prevent the spread of infection. She said the ADON was the overseer of infection control. During an interview on 06/14/23 at 3:42 p.m., the administrator said she was not a nurse but knew nurses should preform hand hygiene before and after a procedure. She said nurse managers were the overseer for hand hygiene. The administrator said this was done to prevent infection control issues. Record review of competencies skills did not reveal RN A had been checked off on hand washing. Record review of the facility's policy, titled Handwashing/Hand Hygiene, dated September 2019, indicated The facility will follow the Center for Disease Control (CDC) guidelines for hand hygiene. Hand hygiene was the single most important procedure for preventing nosocomial infections. The facility requires personnel to wash hands thoroughly to remove dirt, organic material, and transient microorganisms. Hand washing or alcohol-based hand rub (ABHR) was mandated between resident/patient contact to prevent the spread of infection. Hands must be washed or ABHR after the following included, but not limited to: contact with body blood fluids, contact with mucus membranes, contact with residents or patients, touching wounds, contact with contaminated items or surfaces, removal of gloves following completion of a procedure, personal use of the toilet, and covering a cough or sneeze. Record review of the facility's policy titled, Infection Control, dated September 2019, indicated This facility strives to ensure the prevention and control of endemic or epidemic nosocomial infections for the protection of our residents, healthcare workers, and visitors. The goal of the program was to identify and reduce the risk of acquiring and transmitting infection among residents, employees, contract service workers, volunteers, students, and visitors. Healthcare workers will always utilize standard precautions and will utilize the transmission-based precautions such as contact, droplet or airborne as applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #215's face sheet dated 06/13/23, indicated a [AGE] year-old female who admitted to the facility on [DATE]. Resident #215's diagnoses included sepsis (a life-threatening complication of an infection), essential hypertension (high blood pressure), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), gastrostomy (artificial external opening into the stomach for nutritional support), and dysphagia (difficulty swallowing). Record review of Resident #215 baseline care plan dated 05/30/23, indicated Resident #215 had an alteration in urinary function related to indwelling catheter. The baseline care plan interventions included catheter care per facility protocol and physician orders, empty drainage bag every shift and change catheter per physician orders/facility protocol. Record review of Resident #215's physician order dated 05/30/23 indicate the following orders: * Foley catheter care every shift * Change 16 French foley as needed leakage and blockage * Change foley catheter drainage bag every two weeks Further review of this physician's order did not indicate a diagnoses for the use of the indwelling catheter. Record review of Resident #215's admission MDS assessment dated [DATE], indicated she rarely understood and rarely understood others. The MDS had no checked if a BIMS could be conducted. The MDS indicated Resident #251 required extensive assistance with bed mobility and was totally dependent on staff for dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #215 had an indwelling catheter. The MDS indicated Resident #251 had one unhealed stage four pressure ulcer present on admission. During an observation on 06/11/23 at 10:52 AM, Resident #251's foley catheter was hanging on the left side of the bed with a privacy covering on it. Resident #251 was not interviewable. During an observation on 06/13/23 at 10:00 AM, LVN F pulled back Resident #251's blankets and no catheter leg strap was observed. Resident's 251 foley catheter was attached to the left side of the bed. LVN F said Resident #251 should have had a leg strap to keep the catheter secured and prevent from pulling. During an interview on 06/13/23 at 10:12 AM, RN A said Resident #251 admitted to the facility with the indwelling catheter in place. RN A said she was unsure as to why Resident #251 had a catheter. RN A said Resident #251 should have a leg strap to keep the catheter secure and prevent from pulling. RN A said by not having the catheter leg strap in place could cause the catheter to be pulled out and injure the resident. RN A said the charge nurse was responsible for ensuring the leg strap was in place. During an interview on 06/14/23 at 12:13 PM, RN A said Resident #251 should have had an order for her catheter with the appropriate diagnoses. RN A said she was unsure as to why the order for the catheter was needed. RN A said the admitting nurse was responsible for ensuring the order for the catheter with appropriate diagnoses was written. RN A said she was the nurse who admitted Resident #251 to the facility. RN A said she had never written an order for the catheter itself. RN A said they used to transcribe orders for catheter care but unsure as to why they stopped. RN A said the CNAs usually informed her if the catheter was not attached to the leg strap, but it was ultimately her responsibility to ensure the catheters were properly secured. During an interview on 06/14/23 at 12:40 PM, the DON said Resident #251 should have an order for the indwelling catheter with appropriate diagnoses. The DON said anything that was considered invasive required a doctor's order. The DON said she expected the foley catheters to be properly secured to reduce the risk of dislodgement. The DON said the admitting nurse was responsible for ensuring an order for the foley catheter was obtained. The DON said the ADON and herself were also responsible for ensuring Resident #251 had an order for her foley catheter with appropriate diagnoses. During an interview on 06/14/23 at 02:05 PM, the Administrator said she expected Resident #251 to have an order for her foley catheter with appropriate diagnosis for use. The Administrator said by not having an order, nursing staff would not know it was there or be able to properly care for it. The Administrator said it was missed communication by not having the foley catheter order. The Administrator said the ADON and the DON were responsible for ensuring the foley catheter order was in place. 3. Record review of Resident #18's face sheet, dated 06/13/23, indicated an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included urinary retention (a condition where your bladder doesn't completely empty each time you urinate), benign prostatic hyperplasia (when your prostate gland becomes larger than normal), and heart failure (occurs when the heart muscle doesn't pump blood as well as it should). Record review of Resident #18's significant change in status MDS assessment, dated 06/08/23, indicated Resident #18 was usually understood and usually understood others. Resident #18's BIMs score was 10, which indicated he was moderately cognitively impaired. Resident #18 required total assist with toilet use and dressing, limited assist with transfer, bed mobility, supervision with personal hygiene and independent with eating. Record review of Resident #18's physicians order dated 05/31/23 indicated: May have foley catheter 14 FR PRN for blockage with diagnosis of urinary retention. Record review of Resident #18's baseline care plan dated 05/26/23 indicated Resident #18 had a foley catheter. The interventions were catheter care per facility protocol/physician orders. Empty drainage bag every shift and change catheter per physician orders/facility protocol. Monitor for sign and symptoms of UTI and encourage fluids. During an observation on 06/12/23 at 9:20 a.m., Resident #18 was in his bed with no catheter leg strap. During an observation and interview on 06/13/23 at 3:28 p.m., Resident #18 was in his bed with no catheter strap. RN B entered room and verified Resident #18 had no catheter strap in place. RN B said this resident should have a catheter strap to prevent dislodgement. She said she would go get a strap. During an interview on 06/14/23 at 2:21p.m., the ADON said all foley catheters required a diagnosis, size, and frequency of changes. He said foley catheter care should be done with incontinent care. The ADON said all foley catheters should have a catheter secure strap. He said they were out of straps in the facility and had placed an order. The ADON said the catheter straps were used to secure the foley in place and prevent skin issues. During an interview on 06/14/23 at 2:43 p.m., the DON said all foley catheters required an order, size, and diagnosis. The DON said nurses were responsible to make sure residents with Foleys had a secure strap in place and she and the ADON were to make weekly spot checks. The DON said failure to have secure strap in place could cause dislodgement of the foley. During an interview on 06/14/23 at 3:42 p.m., the administrator said she knew secure catheter strap should be in place. She said the charge nurses were responsible to ensure catheter straps were in place and nurse management were to follow up. The administrator said the leg catheter straps were used to prevent foleys from coming out. Record review of the facility's policy titled, Urinary care and Maintenance, dated March 2019, indicated Standard precautions will be followed during the care and maintenance of urinary catheters and the collection system. The clinician will assess the catheter system for patency and integrity every shift and if the catheter system was damaged, blocked, leaking, or if any encrustation was present the catheter and catheter system will be changed. The purpose of the Foley catheter was to minimize the risk of urinary tract infection and to provide care and comfort to the residents or patient. #17 assure catheter was properly secured. #18 prevent catheter tubing from kinking. #33 check that the catheter was attached to the thigh or abdomen or as ordered. #44 monitor proper placement of the catheter cover, drainage bag and tubing every shift. Record review of the facility policy Physicians Orders effective December 2018 indicated .The facility would have physician's orders for their immediate care. Based on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services for 3 of 5 residents (Resident #13, #18, #215) reviewed for urinary catheters. 1.Resident #13 had an indwelling urinary catheter since admission on [DATE] without a physician's order with an acceptable diagnosis for use. 2.The facility failed to ensure Resident #215 had a physician's order for her indwelling urinary catheter with appropriate diagnosis for use. 3.The facility failed to ensure Resident #215's and Resident #18's foley catheters were properly secured to prevent pulling or trauma. These deficient practices could affect residents who had urinary catheters at risk of not receiving care needed. The findings included: 1.Record review of Resident #13's face sheet dated 06/14/23 indicated the resident was a [AGE] year old female who admitted to the facility on [DATE] with the diagnosis acute cystitis of the bladder (a urinary infection in the bladder), neuromuscular dysfunction of the bladder (the nerves don't work well to empty or fill the bladder), chronic obstructive pulmonary disease (lung disease causing difficulty breathing), chronic kidney disease, and heart failure. Record review of Resident #13's admission MDS assessment dated [DATE] indicated it was not due and not completed. Record review of Resident #13's admission orders date 06/07/23 indicated she had an order to Change F/C PRN for signs and symptoms of infection or obstruction. Resident #13's admission orders did not indicate resident had a foley catheter or for what diagnosis. Record review of Resident #13's Physician Order Report dated 06/01/2023-06/30/2023 indicated an order dated 06/07/2023, May change 16fr foley catheter PRN for blockage/leakage Every shift -PRN; PRN 1, PRN 2, PRN 3, PRN 4 with and end date open. During an observation on 06/11/23 at 10:46 AM Resident #13 had a foley catheter in place with a drainage bag hanging to the right side of her bed draining clear, yellow urine. During an observation on 06/12/23 at 08:54 AM Resident #13 had a foley catheter in place with a drainage bag hanging to the right side of her bed draining clear, yellow urine. During an observation on 06/14/23 at 2:20 PM Resident #13 had a foley catheter in place with a drainage bag hanging to the right side of her bed draining clear, yellow urine. Resident #13 refused foley care observation. During an interview on 06/14/23 the DON said that the admitting charge nurse was responsible for writing the order for the foley catheter upon admission. She said the medical records nurse should have placed order in the computer when she received it and should have recognized the order for the catheter and diagnosis being missing. She said her and the ADON also reviewed orders after they are input, and they failed to catch the order for the catheter and diagnosis not being in the orders. The DON said the failure could have placed Resident #13 at risk for infection. During a telephone interview on 06/14/23 at 3:57 PM RN A said she was the admitting nurse for Resident #13 and knew every resident with a catheter required an order, but she had missed placing the order for the catheter and was unsure of the diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: During an observation and interview on [DATE] at 02:00 PM, the following medications were observed in the controlled medication storage area waiting to be disposed: *Lorazepam 2mg/ml suspension- 22 mls RX# C743209 *ABH gel 2mg/25mg/5mg/ml- 4 mls RX# C742813 *Tramadol 50mg- 14 tablets RX# 4039352 *Lorazepam 1mg- 16.5 tablets RX# 529545 *Alprazolam 1mg- 29 tablets RX# 527251 *Tramadol 50mg- 8 tablets RX# 508628 *Lorazepam 0.5mg- 12 tablets RX# 527279 *Morphine 100mg/5ml- 18 mls RX# N743242 *Lorazepam 2mg/ml- 29.5 mls RX# 2406990 *Morphine 100mg/5mls- 15 mls RX# 3105239 *Diazepam 2mg- 25 tablets RX# 4052827 *Lorazepam 2mg/ml- 29mls RX# C742651 *Hydrocodone/APAP 5/325mg- 59 tablets RX# 110417 *Hydrocodone 10/325mg- 28 tablets RX # N742866 *Hydrocodone-APAP 10/325mg- 3 tablets RX N739199 *Clonazepam 1mg- 24 tablets- RX # C742371 The DON said she did not keep a log of the controlled medications awaiting to be disposed. The DON said she logged all discontinued or narcotic medications on the day of the medication destruction with the pharmacist. The DON said she had always logged them the day of medication destruction and it had never been a concern. The DON said her process when she reconciled medications that need to be disposed of was as follows: when medications were brought to her, she checked the narcotic medication count to ensure the correct count was there, and then placed the medication in the locked cabinet . The DON said she was the only one with the key to the locked cabinet. The DON said by not logging the narcotic medications as soon as she received them, anything could come up missing. The DON said it was her responsibility to reconcile the narcotic medications. Record review of the facility's medication destruction book on [DATE], indicated the last medication destruction was completed on [DATE]., During an interview on [DATE] at 02:05 PM, the Administrator said when narcotic medications were discontinued, the nurse takes the medication to the DON. The DON then checks the count and signs off the count was correct and locks the medication until the pharmacist comes to the facility for medication destruction. The Administrator said the DON logs the medications on the day they were destroyed. The Administrator said she was unsure if the DON logged the discontinued narcotic medication when she received them. The Administrator said it was best practice to log the medications as soon as they were received but it was not a requirement to log them. The Administrator said if the medications were not reconciled then you would not know if a medication was missing, diverted, or taken. The Administrator said the DON and the pharmacist were responsible of ensuring the narcotic medications were accurately reconciled. Record review of the facility's policy Medication- Controlled Administration effective [DATE], indicated .Medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and record keeping it the facility, in accordance with federal and state laws and regulations. 1. The Director of Nursing and the Consultant Pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications .3. Medications listed in Schedules, II, III, IV and V dispensed by the pharmacy will be adequately documented and accurately reconciled consistent with law and regulation .10. Controlled medications remaining in the facility after the order has been discontinued/expired are retained in the facility in a securely locked area with restricted access until destroyed by two licensed clinicians or as otherwise directed by state law .

Based on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 2 of 4 medication carts (#2 medication cart and treatment cart) and 1 of 1 medication room observed for medication storage. The facility failed to ensure the lock box that contained narcotic medications was permanently affixed to the refrigerator in the medication room. The facility did not ensure #2 medication cart and the treatment cart were secured and unable to be accessed by unauthorized personnel. These failures could place residents at risk for not receiving drugs and biologicals as needed, medications being used passed their effective or expiration date, and a drug diversion. Findings include: 1. During an observation and interview on 06/12/23 at 09:35 AM, the facility's medication room storage was reviewed and inside the medication refrigerator was a lock box that was not permanently affixed. LVN F said there were narcotic medications inside the lock box and RN B had the key. During an observation and interview on 06/13/23 at 09:40 AM, RN B entered the medication storage room and obtained the lock box from the fridge and placed it on the counter. RN B opened the lock box and inside were two bottles of dronabinol (narcotic) medication. RN B said dronabinol was considered a narcotic medication and the reason why it had to be locked. RN B said the lock box had not been attached to the fridge. The refrigerator did not have a lock either. RN B said by the lock box not being permanently attached to the fridge someone could take it. During an interview on 06/12/23 at 09:50 AM, the DON said the lock box inside the fridge in the medication room had not been permanently affixed to the fridge and the fridge itself had never had a lock on it either. The DON said by not having the lock box permanently affixed, medications could come up missing. The DON said she believed she was responsible for ensuring the narcotic medications were properly secured. During an interview on 06/14/23 at 02:05 PM, the Administrator said the lock box containing the narcotic medications should have been permanently affixed because if someone went inside the medication room that was not supposed to, could take the lock box. The Administrator said the nurse, DON and pharmacy consultant were responsible for ensuring the lock box was permanently attached to the refrigerator. 2.During an observation on 06/12/23 at 11:32 a.m., RN A left the medication cart #2 unlocked when entering a resident's room. Staff and other residents observed in hallway. RN A came back to the medication cart, left medication cart unlock again leaving access to unauthorized personal to enter the cart. During an interview on 06/12/23 at 11:44 a.m., RN A said she forgot to lock the medication cart before walking into the resident's room. RN A said she was aware she was supposed to lock the medication cart anytime she stepped away. RN A said failure to lock the medication cart could leave access for anyone to get into the cart and take medication. During an observation and interview on 06/13/23 at 8:53 a.m., RN B observed to walk down hallway leaving the treatment cart unlocked. Observed staff, residents and visitors walking the by the nurse's station unlocked treatment cart. RN B returned to the nurse's station and when questioned, said she did not lock the treatment cart because she did not have the key. She said she knew it could be a hazard to leave the treatment cart open because the residents could open the cart and take things out (the cart contained items such as: scissors, zinc oxide and bleach wipes that could potential be harmful). RN B said she would get with the DON about what steps she should take and ask about the key. During an interview on 06/13/23 at 9:15 a.m., the DON said the treatment nurse took the key home with her on yesterday (06/12/23). The DON said the ADON had a spare key to the treatment cart and they locked the treatment cart. The DON said she would get more keys made. During an interview on 06/14/23 at 2:21p.m., the ADON said he expected the nurses to always keep the medication and treatment carts locked for the security of the medications. He said he and the DON were responsible to ensure nurses locked the cart but all nurses should be accountability for their actions when medications carts were not locked while in use. The ADON said failure to lock the medication or treatment cart could lead to someone stealing medication or a resident opening the cart and taken the wrong medication. During an interview on 06/14/23 at 2:43 p.m., the DON said she expected the nurses to keep the treatment cart and medication cart locked while not in direction supervision. She said she and the ADON were the overseer of nurses locking their carts. The DON said leaving the treatment or medication cart open could potentially be harmful to residents who might take the scissors and hurt themselves or take medication thinking it was candy and overdose. During an interview on 06/14/23 at 3:42 p.m., the administrator said nurse management were the overseer of staff ensuring medication or treatment carts were locked. She said if carts were left open anyone could obtain anything off the carts without authorization. The administrator said she expect medication and treatment carts to be locked to ensure safety of others. Record review of the facility's policy Medication Administration Procedure, dated March 2019, indicated, Keep medication cart locked when not in use. Assure controlled substance are double locked. Maintain medication key with licensed nurse at all times. Record review of the facility's policy Medication- Controlled Administration effective December 2018, indicated .Medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and record keeping it the facility, in accordance with federal and state laws and regulations .c. Medications requiring refrigeration are stored in a refrigerator within a locked area, in a locked refrigerator, or in a locked and secured container within a refrigerator .

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerated foods were properly labeled and dated. 2. The facility failed to ensure expired foods were not in the refrigerator. 3. The facility failed to ensure food was thawed properly. These failures could place residents at risk for food-borne illness. Findings included: During an observation on 06/11/23 at 09:18 AM, two frozen pork loins and one roll of frozen ground beef were found in a sink full of water without running water. They were not labelled or dated. During an interview on 06/11/23 at 09:20 AM, [NAME] D said she was working in the kitchen on 06/11/23. She said she had just put the meat in the sink before surveyors arrived to the facility. She said she forgot to leave the water running over the thawing meat. She said there should have been running water over the thawing meat. She said residents could get sick if served improperly thawed food. During an observation of the refrigerators on 06/11/23 at 09:25 AM, there was one container labelled pureed desert without a date. There were two half-gallons of buttermilk that had expired on June 10th, 2023. There was a container labelled chicken noodle soup without an expiration date. During an interview on 06/11/23 at 9:30 AM, [NAME] D said she was unsure what the pureed desert was. She said it should have been labelled with the specific contents and should have been labelled with an expiration date. She said the chicken noodle soup should have been labelled with an expiration date. She said the buttermilk should have been thrown away when it was expired. She said residents could get sick if served expired food. During an interview on 06/12/23 at 12:10 PM, the Dietary Manager said she expected the kitchen staff to take out the meat the day before the meal to thaw. She said she expected the kitchen staff to submerge the meat in water and leave the faucet running with cold water to thaw the ground beef and pork loin. She said she expected the kitchen staff to label and date foods with the expiration date. She said she expected the staff to check for expired food daily and throw out expired food. She said residents could get sick if served improperly thawed or expired food. During an interview on 06/14/23 at 11:41 AM, the ADON said he was not aware of any residents that became sick directly because of the dietary department. He said he expected the kitchen staff to follow facility procedure and the regulation related to thawing food and storage and labeling of food. He said the DM was responsible for monitoring that the kitchen staff were properly thawing meat and properly storing and labeling foods. He said residents could suffer gastric upset, nausea, vomiting, or food poisoning if they were served improperly thawed or expired food. During an interview on 06/14/23 at 11:50 AM, the DON said she was not aware of any issues of any residents getting sick as a result of the dietary department. She said she expected the kitchen staff to follow facility procedure and regulations related to thawing food and storage and labeling of food. She said the DM was responsible for monitoring kitchen staff were properly thawing meat, labeling food items, and disposing of expired food. She said residents could suffer food poisoning, gastric upset, nausea vomiting, and diarrhea if they were served improperly thawed or expired food. During an interview on 06/14/23 at 12:56 PM, the Administrator said no residents had been sick due to the dietary department. She said she expected the kitchen staff to follow the facility policy and the regulations for thawing food and storage and labelling of food. She said the DM was responsible for monitoring that kitchen staff were thawing food correctly, and storing and labelling food correctly. She said ultimately the responsibility falls to the Administrator as the head of the building. She said residents could suffer illness as a result of food borne pathogens if served improperly thawed food or expired food. Record review of the facility's thawing policy, effective September 2018, stated: Subject Thawing Purpose To thaw foods properly to prevent foodborne illness Procedure 1. Identify those foods needing to be thawed prior to the cooking process. 2. Pull food items (meat, supplements) from freezer and place in refrigerator 48-72 hours in advance to ensure the item is completely thawed a. Never thaw food at room temperature. b. Date the product the day it is placed in the refrigerator. 3. Thaw foods in the refrigerator at a temperature of 41 degrees F or less. a. Another approved method is to thaw food in the microwave only if it will be cooked immediately afterward .5. Thaw foods during the cooking process (i.e., hamburger patties, Salisbury steak, etc.) as long as the product reaches the minimum of 165 degrees F. Record review of the facility's storage policy, effective September 2018, stated: Subject Storage Purpose To store food, chemicals, and dishware in a safe manner. Procedure . .Refrigerator storage . .6. Label products with delivery date indicating month, day, and year the product was received . .8. Label all leftovers with recipe name and date (month, day, year) of storage. 9. Discard refrigerated leftovers after 48 hours