**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 1 facility reviewed for accident hazards. The facility failed to develop and implement a policy and procedure to properly handle the care of Hoyer lift slings including interventions to inspect the Hoyer sling for signs of damage before each use and not removing damaged slings from service. This deficient practice could result in falls and injuries if damaged lift sling broke during mechanical lift transfers. The findings were: 1. Record review of a facility face sheet dated 07/30/2024 indicated Resident #43 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses of muscle weakness, diabetes (high glucose level in the blood), and essential (primary) hypertension (high blood pressure). Record review of a comprehensive care plan revised 06/17/2024 indicated Resident #43 was a lift transfer for all transfers. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #43 had a BIMS score of 7 indicating severe impaired cognition, impairment of both lower extremities, and dependent for all transfers. 2. Record review of a facility face sheet dated 07/30/2024 indicated Resident #36 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses of history of breast cancer and essential (primary) hypertension (high blood pressure). Record review of a comprehensive care plan revised 06/06/2024 indicated Resident #36 was a mechanical lift transfer for all transfers. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #36 had a BIMS score of 14 indicating intact cognition, impairment of both lower extremities, and dependent for all transfers. During an observation on 07/29/2024 at 10:11 AM, Resident #43 sitting in a wheelchair with a lift sling underneath her buttocks, the straps were faded in color, the blue strap was almost gray in color, the care tags were illegible, torn, crinkled, and [NAME]. During an observation and interview on 07/30/2024 at 10:40 AM Resident #43 was in bed sleeping. A lift sling was lying on Resident #43's wheelchair. The Hoyer sling straps were light in color almost gray, the tag was illegible, torn, and shredded. CNA A said he worked when needed, he was agency staff. CNA A said he would take any Hoyer sling out of service that had tears or fraying and does not know how long they stay in service before they were removed. CNA A was not aware the manufacturer recommended for them to be taken out of service if the sling had a change in color or the label was illegible, that it indicated it had been worn, bleached, or was compromised. He said he would remove the sling being used for Resident #43 because it was unsafe. CNA A said he had several residents that required a Hoyer lift for transfers. CNA A said that if a sling was not available on the hallway he would go to the linen closet and retrieve one for use. CNA A said the resident could suffer an injury or could be scared to get up with a lift if they were dropped. During an observation and interview on 07/30/24 at 11:15 AM of the laundry area revealed there were 4 Hoyer slings hanging to dry. Laundry Staff B worked at the facility for 2 years and Laundry Staff C worked here for 16 years and said she had received training to air dry the Hoyer slings, remove slings that have ravels on the edges, and threads that were pulling out. Laundry Staff B and Laundry staff C were not aware the manufacturer recommended for the Hoyer slings to be taken out of service if the sling had a change in color or the label was illegible, that it indicated it had been worn, bleached, or was compromised. During an observation and interview on 07/30/24 at 11:35 AM Resident #36 had a Hoyer sling sitting on her wheelchair, straps were faded light in color, the tag was crinkled. Resident #36 said the sling was provided by her hospice service and she had no issues with the staff using it for her transfers. During an interview on 07/30/24 at 11:45 AM the Hospice Nurse said the sling was provided by the hospice company for Resident #36. She said she was not aware that the slings were to be removed from service if they were faded or the tags were illegible. The Hospice Nurse called the Hospice durable medical equipment representative for a replacement sling and to initiate inspection of all slings provided to the facility. During an interview with the DON on 07/30/2024 at 12:15 PM, the DON said she worked for the facility for almost 6 months. She said she removed slings if they have holes, frays, or strings but she was not aware the manufacturer recommended for them to be taken out of service if the sling had a change in color or the label was illegible, that it indicated it had been worn, bleached, or was compromised. The DON said the resident could suffer an injury if the straps broke and it was all the staff's responsibility to remove defective slings from service. During an interview on 07/31/2024 at 9:30 AM, the Administrator said she was aware the slings required special care, the facility needed to follow manufacturers suggested guidelines. She said if the sling broke it could cause injury to the resident being transferred . A record review of Full Body Slings- Medline, Instructions for use www.medline.com accessed 07/23/2024 reflected .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use Sling maintenance best practices .Check condition before each use. If there is any fraying or visible wear and tear, do not use. Reusable slings should be replaced every six months. Follow care instructions on wash tag. If illegible, do not use. Keep at least two reusable slings per patient on hand-one available and one in the laundry. A record review of a facility policy for Safe Resident Handling/Transfers dated 06/03/2024 indicated .It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with the current standards and guidelines .16. Slings will be laundered according to manufacturer's instructions and any damaged, broken, or unsafe slings will be removed from service and replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 24 residents (Resident #81, and Resident #68) and 2 of 5 medication rooms (Medication room [ROOM NUMBER] and #2) reviewed for medication administration. The facility failed to dispose of expired medications from Medication Rooms #1 and #2 on 7/29/2024 These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization. Findings included: 1. Record review of an admission Record for Resident #81 dated 7/30/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, anxiety disorder (disorder involves persistent and excessive worry that interferes with daily activities), depression (feeling of sadness or loss of interest), and hypertension. Record review of a Quarterly MDS Assessment for Resident #81 dated 5/7/2024 indicated she had severe impairment in thinking with a BIMS score of 2. Special Treatments, Procedures, and Programs indicated she received hospice care while a resident. Record review of a care plan for Resident #81 revised on 1/23/2023 indicated she had impaired cognitive function/dementia or impaired thought processes with interventions to administered medications as ordered. Monitor/document for side effects and effectiveness. Record review of active physician orders for Resident #81 dated 7/30/2024 indicated an order for scopolamine stick 0.2% apply behind ear topically every 6 hours as needed for secretions, apply 2 clicks with a start date of 2/2/2024. During an observation on 7/29/2024 at 3:18 PM in the Medication room [ROOM NUMBER] with Agency Medication Aide revealed: 1 bottle of aspirin with an expiration date of 4/2024. A refrigerator had medication for Resident #81 for scopolamine 0.2% topical compound filled 2/2/2024 with a discard date of 7/14/24. During an interview on 7/29/2024 at 3:25 PM, the Agency Medication Aide said that she had only been to the facility twice and that day was her second time working at the facility. She said she was not sure who was responsible for checking the medication rooms for expired medications . 2. Record review of an admission Record dated 7/30/2024 for Resident #68 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of chronic systolic heart failure (the heart is weak, and the left ventricle is unable to contract (squeeze) normally when the heartbeat), depression, dementia with agitation, and hypertension. Record review of a care plan for Resident #68 dated 7/4/2023 indicated he had an alteration in neurological status related to dementia with interventions to give medications as ordered. Monitor/document for side effects and effectiveness. Record review of a Quarterly MDS Assessment for Resident #68 dated 6/22/2024 indicated he had moderate impairment in thinking with a BIMS score of 8. Record review of active physician orders for Resident #68 dated 7/30/2024 indicated an order for acetaminophen suppository 650 mg, insert 650 mg rectally every 6 hours as needed for pain with a start date of 6/15/2022. During an observation on 7/29/2024 at 4:00 PM in Medication room [ROOM NUMBER] with LVN K revealed: a refrigerator that had 8 rectal suppositories of Tylenol 650 mg for Resident # 68 with a discard date of 7/25/24. During an interview on 7/29/2024 at 4:10 PM, the DON said the facility had three-unit managers who were the ADON's in the facility that were responsible for checking the medication rooms and carts. She said each unit had an assigned unit manager. During an interview on 7/31/2024 at 8:25 AM, the ADON said she had been employed at the facility for a year and was the unit manager for Medication room [ROOM NUMBER]. She said she was responsible for checking the medication rooms and carts weekly for expired medications. She said the last time she checked Medication room [ROOM NUMBER] one day last week. She said she forgot to check the refrigerator that had medications. She said there was a risk of accidentally giving the medications to a resident if the medications were expired. During an interview on 7/31/2024 at 10:10 AM, the DON said she had been employed at the facility since February 2023. She said the ADON's were responsible for checking the medication rooms and carts for expired medications. She said there was a risk of medication errors or if given past their discard or expiration dates, they could be less effective. During an interview on 7/31/2024 at 11:00 AM, the Administrator said the charge nurses and medication aides were responsible for checking the medication rooms and carts with the ADON's as backup. She said there was a risk of decreased effectiveness of if given medications that were past their expiration dates . Record review of a facility policy titled Administering Medications revised December 2012 indicated, .Medications shall be administered in a safe and timely manner, and as prescribed. 9. The expiration/beyond use date on the medication label must be checked prior to administering . Record review of a facility policy titled Storage of Medications revised date of April 2007 indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs and biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 of 5 medication storage rooms (Medication room [ROOM NUMBER]) and 1 of 24 residents (Resident #30) reviewed for medication administration. The facility did not ensure medications were not stored at the bedside for Resident #30 on 7/29/2024. The facility failed to ensure Medication room [ROOM NUMBER]'s refrigerator was free of contaminants on 7/29/2024 when it was observed leaking water inside and had a medicine cup of white capsules that water was dripping on. This failure could place all residents at an increased risk of receiving contaminated medications/supplements resulting in adverse health consequences. Findings included: 1.Record review of an admission record for Resident #30 dated 7/30/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of senile degeneration of brain (age related decline in thinking), COPD (a group of lung diseases that make it difficult to breathe), major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest), and muscle wasting (loss of muscle mass). Record review of a care plan for Resident #30 dated 7/15/2022 indicated she had impaired cognitive function/dementia or impaired thought processed related to dementia with interventions that included to administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of active physician orders for Resident #30 dated 7/30/2024 indicated an order for glycopyrrolate capsule (used to treat excessive drooling) 14 mcg give 3 ml by mouth every 4 hours as needed for increased secretions open capsule and mix with 3 ml 0.9% normal saline nebulize with a start date of 7/10/2024. Record review of Medication Administration Record (MAR) for Resident #30 dated 7/1/2024-7/31/2024 indicated an order for glycopyrrolate 14 mcg give 3 ml by mouth every 4 hours for increased secretions with a start date of 7/10/2024 indicated from 7/10/2024-7/30/2024 that the medication was not administered. Record review of a Significant Change MDS assessment dated [DATE] indicated she was unable to complete the interview with a score of 99. Special Treatments, Procedures, and Programs indicated the resident received hospice while a resident. During an observation on 7/29/2024 at 9:46 AM Resident #30 was in bed resting with her eyes closed. There were eleven vials of normal saline on the nightstand next to a nebulizer. During an observation and interview on 7/29/2024 at 3:18 PM in the medication storage room with the Agency Medication Aide revealed a refrigerator that was leaking water and had a medicine cup of white capsules that the water was dripping on. She said the white capsules were lactobacillus capsules (used to promote good bacteria in the gut). She said she was not aware that the refrigerator was leaking and would let someone know. During an interview on 7/29/2024 at 3:25 PM, the Agency Medication Aide said that she had only been to the facility twice and that day was her second time working at the facility. She said she was not sure who was responsible for checking the medication rooms for expired medications. During an observation on 7/29/2024 at 3:50 PM in the room of Resident #30 who was not in the room revealed eleven vials of normal saline still on the nightstand. During an interview on 7/29/2024 at 3:52 PM in the room of Resident #30 who was not in the room. LVN E observed the eleven vials of normal saline on the nightstand. LVN E said Resident #30 did not get any scheduled inhalers or nebulizer medications. She said Resident #30 did have a medication that was supposed to be mixed with normal saline. She said she only gave Resident #30 medications prn and had not given her anything that day. She said she was agency staff and her last day worked in the facility was a day the week prior. She said there was a risk of overdose of medication and improper use if medications were left at the bedside. She said medications were not allowed to be left in rooms and must be kept on the medication carts. During an interview on 7/29/2024 at 4:10 PM, the DON said the facility had three-unit managers who were the ADON's in the facility that were responsible for checking the medication rooms and carts. She said each unit had an assigned unit manager. During an interview on 7/31/2024 at 8:25 AM, the ADON said she had been employed at the facility for a year and was the unit manager for Medication room [ROOM NUMBER]. She said she was responsible for checking the medication rooms and carts weekly for expired medications. She said the last time she checked Medication room [ROOM NUMBER] one day last week. She said she forgot to check the refrigerator that had medications. She said there was a risk of accidentally giving the medications to a resident if the medications were expired. During an interview on 7/31/2024 at 10:10 AM, the DON said she had been employed at the facility since February 2023. She said medications should never be left at the bedside because there was a risk of overdose or someone else coming in the room and taking them. She said the ADON's were responsible for checking the medication rooms and carts for expired medications. She said there was a risk of medication errors or if given past their discard or expiration dates, they could be less effective. During an interview on 7/31/2024 at 11:00 AM, the Administrator said she was made aware of medications being left at the bedside and the other meds that were in the refrigerators. She said the charge nurses and medication aides were responsible for checking the medication rooms and carts with the ADON's as backup. She said medications should not be left at the bedside unless a resident had been deemed appropriate to take their own medications. She said there was a risk of decreased effectiveness of if given medications that were past their expiration dates. Record review of a facility policy titled Administering Medications revised December 2012 indicated, .Medications shall be administered in a safe and timely manner, and as prescribed. 9. The expiration/beyond use date on the medication label must be checked prior to administering . Record review of a facility policy titled Storage of Medications revised date of April 2007 indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs and biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #80) and 1 of 8 staff (CNA F) reviewed for infection control. CNA F did not sanitize or wash her hands between glove changes when providing incontinent care to Resident #80 on 7/30/2024. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: Record review of an admission Record for Resident #80 dated 7/31/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of myopathy (disease that makes the muscles weak), atrial fibrillation (irregular heartbeat), major depressive disorder (persistent sadness or loss of interest that interferes with daily life), and hypertension. Record review of a Quarterly MDS Assessment for Resident #80 dated 5/20/2024 indicated she had severe impairment in thinking with a BIMS score of 3. She was dependent on staff for personal hygiene. She was frequently incontinent of bladder/bowel. Record review of a care plan for Resident #80 dated 10/23/2023 indicated she had an ADL self-care performance deficit related to impaired balance with interventions for toilet use: the resident was not toileted. She required assistance of staff x1. During an observation on 7/30/2024 at 10:31 AM, CNA F and CNA G were both in the room of Resident #80 to provide incontinent care. Both washed their hands in the bathroom, and donned (put on) PPE that consisted of a gown and gloves. Resident #80's brief was opened by CNA F and pulled down between her legs. CNA F removed a wipe from the package, wiped the resident's right inner thigh, folded it over, wiped the left inner thigh, and placed the wipe in the trash. CNA G rolled Resident #80 onto her right side. CNA F removed a wipe from the package and wiped Resident #80's rectum from front to back and removed the brief and placed them in the trash. CNA F applied barrier cream to Resident #80's buttocks and removed her gloves and placed them in the trash. CNA F put on gloves without washing or sanitizing her hands and placed a clean brief underneath the resident's buttocks. Resident #80 was rolled onto her left side by CNA G and then positioned onto her back and the brief was secured. CNA F removed her gloves and placed them in the trash, took a shirt out of the dresser drawer, and placed it on the bed. CNA F placed gloves on her hands without washing or sanitizing them, removed the shirt that was on the resident and put it in a laundry hamper. CNA F placed the clean shirt on the resident and repositioned the resident in bed. Both CNA F and CNA G removed their gloves and gown and placed them in the trash. Both washed their hands in the bathroom before exiting the room. During an interview on 7/30/2024 at 10:44 AM, CNA F said she had been employed at the facility for many years. She said during the care provided to Resident #80, she should have used sanitizer between glove changes. She said she just forgot to grab the hand sanitizer and usually kept it in her pocket. She said residents could be at risk for infections. She said she had skills check off on incontinent care in the past few months. Record review of a validation checklist for hand hygiene for CNA F dated 6/24/2024 indicated she was satisfactory with hand hygiene. Record review of a skill assessment for CNA F dated 2/8/2024 indicated she was satisfactory with hand hygiene and incontinent care. During an interview on 7/31/2024 at 8:25 AM, the ADON said she had been employed at the facility for a year. She said she and the other the ADON's and the DON were responsible for conducting skill checkoffs with the staff. She said they conduct check offs for new hires before they were allowed to provide direct patient care and yearly thereafter. She said hands should be sanitized or washed before care was started, during care provided, after changing gloves, when going from dirty to clean, and after care was completed. She said there was a risk of passing germs from their hands to someone else if they did not wash or sanitize their hands. During an interview on 7/31/2024 at 10:10 AM, the DON said she had been employed at the facility since February 2023. She said staff should be washing or sanitizing their hands before care, after removing gloves, during care, and after care was provided. She said CNA F had a check off on hand hygiene during incontinent care not long ago and had another one today. She said residents could be at risk for infections if staff did not wash or sanitize their hands. During an interview on 7/31/2024 at 11:00 AM, the Administrator said she was made aware of the incident with hand hygiene not being performed yesterday on 7/30/2024 with CNA F. She said hand hygiene should be performed prior to providing care, after removing gloves, when hands were visibly soiled, when care was completed, and before leaving the room. She said there was a risk for spreading infections if staff did not. Record review of a facility policy titled Hand Hygiene dated 6/13/2024 indicated, .All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program and ensure it was free of pests for 2 of 4 halls ([NAME] Lane and [NAME] Center) reviewed for incidents and accidents related to pests. The facility failed to ensure ants were kept out of the rooms and beds for Resident #31 and Resident #75. This failure could place residents at risk for injury due to an ineffective pest control program at the facility. Findings included: 1. Record review of a facility face sheet dated 7/29/24 for Resident #31 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: chronic obstructive pulmonary disease (a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), convulsions, and history of pulmonary embolism (blood clot located in the lung). Record review of a Quarterly MDS assessment dated [DATE] for Resident #31 indicated that she had a BIMS score of 9, which indicated that she had moderately impaired cognition. She required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She required supervision with eating. Record review of a comprehensive care plan dated 7/22/24 for Resident #31 indicated she had impairment to skin integrity of the right upper extremity (RUE) related to ant bites. Interventions included to Identify/document potential causative factors and eliminate/resolve where possible. 2. Record review of a facility face sheet dated 7/31/24 for Resident #75 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Sarcopenia (the age-related loss of muscle mass and strength that affects older adults), anxiety disorder, and dementia. Record review of a Quarterly MDS assessment dated [DATE] for Resident #75 indicated that she had a BIMS score of 4, which indicated that she had severely impaired cognition. She required moderate to maximum assistance with bed mobility, dressing, toilet use, and personal hygiene. She required set up help with eating. Record review of a comprehensive care plan for Resident #75 indicated that it did not address ant bites or ants in her room. During an observation and interview on 7/30/24 at 3:30 pm Resident #31 said the bites never itched or bothered her. No bites seen at this time. Bed linen appeared clean. No food was observed in room. No ants were observed in room. Resident #31 had no complaints with facility's handling of the incident. During an observation and interview on 7/31/24 at 10:00 am Resident #75 was observed in bed asleep. No ant bites were observed. Resident #75 had been moved from her original room while the original room was being treated for ants. LVN M said when she came to work the resident was out of the room and there were some ants by the wall with the window and air conditioner. She said Maintenance had sprayed the room and was told pest control was coming in as well. Record review of an incident report dated 7/16/24 for Resident # 31 read .The resident was noted with several ants in her bed, was noted with 3-4 small bites to her right upper extremity . and .Resident removed from bed, skin assessment, ants removed by maintenance, bed linen changed, and room inspected for ants. Resident was eating in her bed. Area treated . During an interview on 07/30/24 at 3:45 PM the Administrator said no other residents had been bitten. She said that residents could be at risk of an allergic reaction, skin eruption, and itching if they were bitten by ants. She said the maintenance man was responsible for pest control in the facility. During an interview on 7/31/24 at 11:06 AM the Maintenance Man said he treated for ants weekly on the grounds and treated rooms when identified. He said Pest Control also treated when they came once a month. He said he had come today and treated the entire premises along with the room on secured unit that had been identified. He said residents could be at risk if bitten and they were allergic to ants. During an interview on 7/31/24 at 1:57 PM the Administrator said she now has a PIP in place for pest control and they have added a full treatment for fire ants monthly along with their regular treatment. She said the Maintenance Man walks the perimeter twice weekly looking for ants and treats as needed. She said she would also be doing twice monthly rounds with the Maintenance Man looking specifically for ants. She said residents could be at risk of ant bites and allergic reactions if ants were to get inside the facility. Record review of a pest control log form for Pest Control in a binder for [NAME] Lane indicated that staff had seen ants in 3 different rooms on 7/23/24. Record review of a pest control invoice dated 6/19/24 from Pest Control indicated they treated the facility for ants and used a product called FastCap (Esfenvalerate) 6.4% and Delta Dust (Deltamethrin) 0.05%. Invoice indicated that he treated/inspected the exterior perimeter of the facility, the kitchen, landscaped areas, offices, and dishwashing room. Record review of a pest control invoice dated 7/18/24 from Pest Control indicated they treated the facility for ants and used a product called Extinguish (Hydramethylon) 0.365%, Shockwave 1 (Pyrethrins) 0.50%, and Talstar P (Bifenthrin) 7.9%. Invoice indicated that he treated/inspected the dining/break rooms, kitchen, landscaped areas, public areas, and warming area. Record review of a facility policy titled Pest Control Program dated 4/14/24 read .It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents . and .Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats) .

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to ensure [NAME] wore a hair net effectively to cover all his hair on 7/30/2024. 2. The facility failed to ensure DA wore a hair net effectively and did not have hair out on the front and side of her head not covered by her hair covering on 7/31/24. 3. The facility failed to ensure all foods stored in the refrigerators, freezers, and dry pantry were labeled, dated, and not kept past their expiration dates. 4. The facility failed to ensure proper hand washing between tasks. 5. The facility failed to ensure ovens were clean and free of debris. 6. The facility failed to ensure the ice machine was free from a black, slimy substance. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation of the cooler/refrigerator on 7/29/2024 at 9:30am, the following items were observed: 1 pan of pre-wrapped pancakes with no use by date (out of original package). 1 box of red onions not dated or labeled. 1 box of lettuce wilted, uncovered, use date 7/29/2024. 1 pan of ribs not dated or labeled (out of original package). 1 10 lb. log of ground beef not dated or labeled. During an observation of the Dairy Cooler on 7/29/2024 at 9:37am, the following items were observed: 1 gallon zip loc bag of cheese slices with no label or date. 1 gallon package of diced chicken no date or label (out of original box). 1 package of beef patties sitting in original box open not sealed. 1 gallon zip loc bag of hamburger buns no date or label. During an observation of the Freezer on 7/29/2024 at 9:46am, the following items were observed: 1 gallon bag of Frozen chicken mushroom gravy with an open date of 3/5/24 with no expiration date. 1 cup of sherbet ice cream half thawed sitting on shelf alone with no expiration date. 1 box of pizza's open in original box uncovered or sealed. 1 gallon bag of Corn nuggets open not labeled or dated. 1 large bag of sweet potatoes with no expiration date. During an observation of the Refrigerator on 7/29/2024 at 9:56am, the following items were observed: 1-box of Whipped topping mix with no expiration date. 1-pan of pre portioned puree bread dated 7/20/24, expired 7/27/24. 1-Pan of pre portioned apple sauce in individual dishes with no expiration date. 1-Pan of pre portioned chocolate pudding in individual dishes with no expiration date. 1 zip loc bag of raisins with no expiration date. 1 pan of prebaked apple cobbler with no label or expiration date. During an observation on 7/29/2024 at 10:00am, the Tilt Cooler was observed with brown and black substance and food particles on both sides. During an observation on 7/29/2024 at 10:01am the oven appliance identified as extra oven and not in use per the DM with brown and black substance on the sides and top of the oven door. During an observation on 7/29/2024 at 10:03am the DM did not wash hands between discarding expired foods and prepping rolls to be cooked for lunch. The DM picked up a can of spray-on prep for rolls and sprayed the rolls, put the can down, and continued discarding expired items without washing hands. During an observation of the Pantry on 7/29/2024 at 10:05pm, the following items were observed: 2-quart size bottles of prune juice expired 6/14/2024. 1 container of Dijon mustard expired 5/22/2023. 4-quart size containers of sliced strawberry topping with no received or use by date. During an observation on 7/30/2024 at 10:27am the [NAME] was observed with a baseball cap on with a hair net under it. The hair net was not seen until he pulled off his cap. The [NAME] had hair out in the front, sides, and back of his head. During an observation on 07/31/24 at 9:00 AM the ice machine was observed with a black, slimy substance on the top left and right corners and sides of the ice machine. During an interview on 7/30/24 at 4:00pm the DA said she was designated to date, label, and put food in the freezer as one of her duties. She said she realized she needed to date and label all items when they arrived and add the dates the items were opened and the dates they should be discarded. The DA said she understood that out of date foods could put the residents at risk of getting sick. She said she would make sure things were dated and labeled in the future and would be more cautious of assuring the safety of the food for her residents. During an interview on 7/30/24 at 4:07pm the [NAME] said he was not aware that his baseball cap had raised his hair net off his hair. He said he understood that hair could get in food and cause illness, and he would make other accommodations to assure his hair was completely covered in the future. During an interview on 7/30/24 at 4:10 pm the DA said she did not realize her hair was out in the front and side of her hair covering. She said she understood that all hair should be covered, and it could get into food and that was not sanitary. In the future she said she would assure all her hair was covered. During an interview on 7/30/24 at 4:15pm the DM said she was responsible for all staff to ensure food cleanliness and safety. She did not realize the number of items with no date or label, expired food, hair coverings, or other inappropriate issues. She already started in-services with staff on dating and labeling all items on arrival and when opened and unused. She said she would complete more in-services and assure that in the future all items were properly stored or discarded. She said inappropriately stored food and out of date food put the entire facility at risk of food borne illnesses. During an interview on 7/30/24 at 4:25pm the [NAME] said she did not realize her puree bread was expired and some of her baked goods were not dated or labeled. She said she understood that bad food could make people sick and that in the future she would be mindful of her dates and labels to assure a safer environment for the residents. During an interview on 7/31/24 at 01:55 PM the Administrator said the DM had already begun some in-services regarding the kitchen food storage and sanitation. She said she was responsible for ensuring staff properly wore the hair nets and properly dated, labeled, and discarded expired foods and she expected her staff to follow proper procedures. She said residents could be at risk of food borne illnesses if proper food storage and kitchen sanitation were not followed. Record review of a facility policy titled Employee Sanitation read .Hairnets, headbands, caps, beard coverings, or other effective hair restraints must be worn to keep hair from food and food-contact surfaces . Facility uses manufacture recommendations to clean the ice machine. Record Review of manufacture recommendations state Hoshizaki recommends .cleaning and sanitizing this unit at least once a year. More frequent cleaning and sanitizing, however, may be required in some existing water conditions . Record review of a facility policy titled Date marking for Food Safety dated 4/14/2024 with revision date of 4/14/2024 read .the facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food . Record review of a facility policy titled Employee Sanitation read .The Nutrition & Food service employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes, in order to minimize the risk of infection and food borne illness .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #31) reviewed for infection control. The facility failed to ensure CNA B performed proper hand hygiene when providing incontinent care to Resident #31 on 6/3/2024. This failure could place residents at risk of exposure to communicable diseases and infections. Findings include: Record review of a facility face sheet dated 6/5/24 for Resident #31 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), depression, dementia, and hypertension (high blood pressure). Record review of a comprehensive MDS assessment dated [DATE] for Resident #31 indicated that he had a BIMS score of 4, which indicated that he had severely impaired cognition. Section H (Bowel and Bladder) indicated that he was always incontinent of bowel and bladder. Record review of a comprehensive care plan dated 5/27/23 for Resident #31 indicated that he was incontinent of bladder and bowel and included an intervention to clean peri-area after each incontinent episode. During an observation on 6/3/24 at 2:20 pm CNA B was observed inside the room of Resident #31. Resident #31 was observed lying in bed. CNA B was observed to lay a plastic bag on the bed for dirty brief, wipes, and trash. She was then observed to put on gloves and proceeded to undo resident's brief. She wiped the resident's peri area and then, keeping on same gloves, she rolled resident over to clean bottom area. Once bottom was cleaned, she removed the brief and placed it and used wipes in the plastic bag. She kept on the same gloves and put a clean brief on the resident and secured it. She then removed her gloves and exited the room without washing her hands. During an interview on 6/3/24 at 2:29 pm CNA B was observed at clean linen cart getting clean trash bags. She said she did not wash her hands yet because she still had to take the dirty linens out. She said she would wash them after that. During an interview on 6/3/24 at 3:30 pm DON said that she would expect her CNAs providing incontinent care to wash their hands before, during and after providing incontinent care to a resident. She said this was an agency CNA and she would ensure she got training today. During an interview on 6/4/24 at 8:30 am the Administrator said that CNA B would not be returning to facility. She said the DON was checking her off on female peri care and CNA B did not pass the proficiency. She said they had placed CNA B on a do not return list. During a joint interview on 6/6/24 at 5:30 pm DON and Administrator said they expect their staff to follow proper procedure during incontinent care and perform handwashing appropriately. They both said that residents could be at risk of infection if staff were not properly washing their hands. Record review of a facility policy titled Handwashing/Hand Hygiene dated 2001 and revised August 2015 read .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors . and use an alcohol-based hand rub containing at least 62% alcohol; or, alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: .h. before moving to a contaminated body site to a clean body site during resident care; .m. after removing gloves . and .Hand hygiene is the final step after removing and disposing of personal protective equipment . Record review of a facility policy titled Infection Control Guidelines for All Nursing Procedures dated 2001 and revised in August 2015 read .Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. before and after direct contact with residents .d. After removing gloves; e. After handling items potentially contaminated with blood, body fluids, or secretions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 7 of 10 residents (Resident #1, Resident #4, Resident #3, Resident #9, Resident #6, Resident #7, and Resident #10) reviewed for reporting abuse. The facility failed to ensure that allegations of resident-to-resident abuse were reported to appropriate State Agency in that: 1. The facility failed to protect Resident #1 from abuse from Resident #2, Resident #3, Resident #4, Resident #6, and Resident #10 between 5/8/23-1/11/24. on 1/11/24 Resident #6 slapped Resident #1 on his helmet. on 11/13/23 Resident #3 grabbed Resident #1's arm causing 2 skin tears. On 10/29/23 Resident #1 was in the lobby hollering and Resident #2 went over and flipped Resident #1 out of his wheelchair causing him to fall on the floor. On 10/29/23 Resident #3 grabbed Resident #1's right arm causing skin tears to right arm. On 9/29/23 Resident #1 sitting in recliner yelling and Resident #2 went over to Resident #1 and hit him in the mouth causing his lip to bust open. on 9/19/23 Resident #1 hit Resident #10 and Resident #10 hit Resident #1 back causing a skin tear to the right forearm. on 9/4/23 Resident #3 scratched the left side of Resident #1's chin leaving 3 scratches. On 9/3/23 Resident #2 flipped Res #1 out of his wheelchair on to the floor. On 8/20/23 Resident #2 walked over to Resident #1 and slapped him in the face. on 7/21/23 with Res #1 and Res #3. Res #3 scratched Res #1 on his right lower arm. On 7/20/23 Resident #2 walked over to Resident #1 and hit him on the left cheek and chin causing redness. On 7/10/23 Resident #3 pinched and scratched Resident #1 on the right side of his neck. On 7/8/23 Resident #2 lunged over to Resident #1 and put his hands around Res #1's neck. On 7/4/23 Resident #3 scratched Resident #1 with multiple skin tears and scratches to the face, neck, right finger, and left forearm. On 6/23/23 Resident #1 pinched Resident #3, Resident #1 also received a skin tear. On 6/5/23 Resident #4 grabbed Resident #1's arm. On 5/8/23 Resident #3 scratched Resident #1's left hand. 2. The facility failed to protect Resident #4 from abuse from Resident #1, and Resident #3 between 7/25/23- 3/8/24. On 7/25/23 Resident #1 grabbed Resident #4's right wrist and lower arm. On 3/8/24 Resident #3 grabbed Resident #4 by the wrist causing a skin tear to the left wrist. 3. The facility failed to protect Resident #3 from abuse from Resident #1 and Resident #8 between 6/23/23-5/1/24. On 6/23/23 Resident #1 pinched Resident #3, Resident #1 also received a skin tear. on 5/1/24 Resident #8 hit Resident #3 with a dinner plate causing a split between lip and nose. 4. The facility failed to protect Resident #9 from abuse from Resident #6 on 5/22/24 Resident #6 pulled Res #9's hair and pushed her down onto the floor. 5. The facility failed to protect Resident #6 from abuse from Resident #5 on 3/12/24. on 3/12/24 Resident #5 grabbed Resident #6 by the elbow causing a bruise. 6. The facility failed to protect Resident #7 from abuse from Resident #3 on 3/21/24. on 3/21/24 Resident #3 grabbed Resident #7 causing a skin tear to right forearm. 7. The facility failed to protect Resident #10 from abuse from Resident #1 on 9/19/23. on 9/19/23 Resident #1 hit Resident #10 and Resident #10 hit Resident #1 back causing a skin tear to the right forearm. 8. The facility failed to keep residents safe following resident to resident altercations to prevent further harm. . The facility failed to implement their abuse policy which stated .The Health Care Center will report all allegations and substantiated occurrences of abuse .to the state agency and to all other agencies as required by law . These failures could place residents at risk for continued alleged violations, diminished quality of life and harm due to allegations not being reported. Findings included: 1.Record review of Resident #1's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Dementia with other behavioral disturbance (problem in the brain affecting memory), schizoaffective disorder (hallucinations and mood symptoms), and sarcopenia (musculoskeletal disease in which muscle mass, strength, and performance are significantly compromised with age). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, which indicated residents' cognition was severely impaired. Resident #1's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #1's care plan dated 4/21/2023 revealed he had the potential to be physically and verbally aggressive related to dementia and schizoaffective disorder with interventions that included: . 5. Monitor/document/report as needed and signs or symptoms of resident posing danger to self and others. 6. Psychiatric/Psychogeriatric consult as indicated. Resident #1 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's dementia with interventions that included: . 3. Cue, reorient and supervise as needed. Resident #1 used psychotropic medications related to schizoaffective disorder with interventions that included: .3.Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Record review of an incident report dated 1/11/2024 indicated Resident #1 .was in the dining room hollering out repeatedly and another resident slapped him on his helmet. Record review of incident report dated 11/13/2023 indicated Resident #1 .was in bed in his room and hollered out. Another resident wandered into his room and grabbed his arm causing him to get 2 skin tears on his left forearm. Record review of incident report dated 10/29/2023 indicated Resident #1 .was in dining room at table yelling out. Another resident got frustrated with him hollering and grabbed his right arm causing skin tears. Record review of incident report dated 10/29/2023 indicated Resident #1 was .in the lobby and was hollering out randomly, .when another resident came over and flipped his wheelchair with him in it before staff could intervene. Record review of incident report dated 9/29/2023 indicated Resident #1 was .sitting in recliner yelling, before staff could intervene another resident approached him and hit him in the mouth, busting his lip open . Record review of incident report dated 9/19/2023 indicated Resident #1 .hit another resident and the other resident hit him back and he received a skin tear to right forearm . Record review of incident report dated 9/04/2023 indicated Resident #1 .was yelling. Another resident went up to him and scratched left side of chin leaving 3 marks . Record review of incident report dated 9/03/2023 indicated Resident #1 was in wheelchair .outside of dining room and another resident got mad at him because he was yelling out and dumped him out on the floor and the wheelchair fell on top of him. Record review of incident report dated 8/20/2023 indicated Resident #1 .was sitting at dining room table and another resident walked up and he stated, What are you going to do about it? and the other resident slapped him in the face. Record review of incident report dated 7/25/2023 indicated Resident #1 .grabbed another resident by her right wrist/lower arm. Residents immediately separated . Record review of incident report dated 7/21/2023 indicated Resident #1 .heard yelling and found Resident #3 near resident scratching him. Residents immediately separated. Scratches noted to right lower arm . Record review of incident report dated 7/20/2023 indicated Resident #1 was sitting in recliner and with Resident #2 standing over him. Resident #1 said Resident #2 hit him on the left side of chin and cheek with slight redness observed. Record review of incident report dated 7/10/2023 indicated Resident #1 .was having verbal outbursts and another resident rolled up to him and pinched and scratched resident near the right side of his neck. Record review of incident report dated 7/08/2023 indicated Resident #1 .was walking by another resident who was having verbal outbursts. The resident called out you son of a bitch and he lunged towards resident and put his hand around his neck, residents were immediately separated. Record review of incident report dated 7/04/2023 indicated Resident #1 .was yelling out loudly. Another resident rolled up to him and she began scratching and grabbing at him .staff was unable to get to the residents in time before contact was made. Resident received multiple skin tears and scratches. Record review of incident report dated 6/23/2023 indicated Resident #1 .reached out and pinched another resident while the resident was wheeling past him to go to dining room. Record review of incident report dated 6/05/2023 indicated Resident #1 .was dozing in quiet area when his arm was grabbed by a fellow resident. Record review of incident report dated 5/08/2023 indicated Resident #1 .was heard yelling no you get out of the way, when staff intervened resident was noted with scratch to left hand 3.0 x 1.0, both residents were separated and assessed . During an observation and interview on 6/03/2024 at 2:35 PM, Resident #1 was observed sitting up in wheelchair in common area in secured unit. Resident #1 was sitting at a table with 2 other residents with two building blocks on the table. Staff brought activities to the table after surveyor had started to interview Resident #1. Resident #1 said yes when asked if anyone had ever hurt him, Resident #1 was alert and did not answer additional questions appropriately due to cognition. Resident #1 had a soft helmet in place to the top of his head. 2.Record review of Resident #2's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Dementia with other behavioral disturbance (problem in the brain affecting memory), bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Alzheimer's disease (disease involves parts of the brain that control thought, memory, and language), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score was not able to be obtained. Staff assessment for mental status revealed Resident #2 had short- and long-term memory problem. Resident #2's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #2's care plan dated 7/11/2023 revealed he had potential to be physically aggressive related to bipolar disorder and dementia with actual physical aggression on 7/20/2023, 8/20/2023, 9/03/2023, 9/29/2023, 10/29/2023, 11/02/2023, 1/30/2024, 4/10/2024, 5/25/2024. Interventions: The resident's triggers for physical aggression are (the yelling out loud noises) resident's behaviors is de-escalated by (providing quiet environment redirecting attention removing from situation). Order to send to behavioral facility to evaluate and treat. Psychiatric/psychogeriatric consult as indicated. Request labs and do assessment to rule out medical reason for aggressive behaviors. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later when possible. The resident had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's with interventions that included: Cue, reorient and supervise as needed. Discuss concerns about confusion, disease process, and nursing home placement with resident/family/caregivers. Record review of incident report dated 10/29/2023 indicated Resident #2 .came into living area and flipped another resident's wheelchair on its side before staff could intervene. Record review of incident report dated 9/29/2023 indicated another resident sitting up in recliner in lounge area close to the dining room yelling when Resident #2 approached him and hit him in the mouth . Record review of incident report dated 9/03/2023 indicated Resident #2 .got angry at another resident due to him yelling. He then tipped wheelchair over making resident fall into floor and wheelchair went on top of resident . Record review of incident report dated 8/20/2023 indicated Resident #2 .was walking by another resident who was sitting in his wheelchair at table eating. Resident stated, what are you going to do about it? and resident then slapped the other resident in the face on the left cheek. Record review of incident report dated 7/20/2023 indicated Resident #2 was standing over Resident #1. Resident #1 said Resident #2 hit him on the left chin and cheek with slight redness noted. Record review of incident report dated 7/08/2023 indicated Resident #2 .was walking by another resident who was having verbal outbursts. The resident called out you son of a bitch and he lunged towards resident and put his hand around his neck . During an observation and attempted interview on 6/03/2024 at 3:08 PM, Resident #2 was observed lying in bed awake and alert. Resident #2 was attempting to hang call light on the wall. Resident #2 did not answer questions appropriately due to cognition. 3.Record review of Resident #3's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Alzheimer's disease (disease involves parts of the brain that control thought, memory, and language), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and schizophrenia (affects a person's ability to think, feel, and behave clearly). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score was 8 which indicated moderate cognitive impairment. Resident #3's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #3's care plan dated 5/04/2022 revealed She had potential to be physically aggressive towards another resident related to dementia with actual physical aggression on 3/21/2024, 3/08/2024, 1/06/2024, 11/13/2023, 9/04/2023, 7/19/2023, 5/25/2023, 5/19/2023, 5/06/2022, 5/05/2022. Interventions: If behavior is a threat to myself or others, immediately call for assistance. Psychiatric/psychological consult as indicated and ordered by physician. Triggers for physical aggression are other residents yelling out. The behavior is de-escalated by removing from the situation. Resident #3 had memory loss/dementia related to schizophrenia, delusional behaviors with interventions that included: Cue, reorient, and supervise or assist me as needed. Resident #3 had a behavior problem (including becoming physically violent toward other residents at times and refusing care at times related to advanced dementia/Alzheimer's with physical aggression on: 7/04/2023, 7/10/2023 and 8/08/2023, interventions included: monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Psych consult for medication review. Record review of incident report dated 11/13/2023 indicated Resident #3 .went into another residents room and grabbed his arm causing 2 skin tears to left forearm . Record review of incident report dated 10/29/2023 indicated Resident #3 .grabbed ahold of another residents arm causing skin tears. Record review of incident report dated 9/04/2023 indicated another resident was yelling and Resident #3 went up to him and scratched left side of chin. Record review of incident report dated 7/21/2023 indicated Resident #3 .was near Resident #1 scratching him. Residents immediately separated. Record review of incident report dated 7/10/2023 indicated Resident #3 .rolled up to another resident who was having verbal outbursts and pinched and scratched resident near the right side of his neck. Record review of incident report dated 7/04/2023 indicated Resident #3 .rolled up to another resident who was yelling out loudly. She began scratching and grabbing at him .Staff was unable to get to the residents in time before contact was made. Record review of incident report dated 6/23/2023 indicated Resident #3 .was wheeling past another resident when she yelled ouch. Record review of incident report dated 5/08/2023 indicated Resident #3 .was heard shouting at other resident stating get out of way, other resident heard stating no you move, staff intervened, and other resident noted with scratch to left hand 3.0 x1.0. Record review of incident report dated 5/01/2024 indicated staff heard but did not see residents arguing and possible hitting at each other. Then other resident slinging a plate leaving, then noted a split between upper lip and nose 2 x .1cm. She was bleeding from area. Record review of incident report dated 3/21/2024 indicated Resident #3 .went to another resident in the living area and grabbed ahold of her shirt and her right arm causing a skin tear to her lower right forearm. Record review of incident report dated 3/08/2024 indicated another resident tried to grab her tray and Resident #3 grabbed ahold of the resident and caused her to get a skin tear. During an observation on 6/03/2024 at 3:12 PM, Resident #3 was observed sitting up in wheelchair in secured unit common area. Resident #3 did not answer questions appropriately due to cognition. 4.Record review of Resident #4's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition affecting the brain in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and senile degeneration of the brain (loss of intellectual ability). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score was 8 which indicated moderate cognitive impairment. Resident #4's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #4's care plan dated 5/03/2023 revealed She had potential to be physically aggressive, and combative with staff during ADL care related to dementia with actual physical aggression on: 2/16/2024, 11/21/2023, 11/20/2023, 11/14/2023, 10/18/2023, 9/23/2023, 5/22/2023 with interventions that included: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Monitor/document/report PRN any signs/symptoms of resident posing danger to self and others. Psychiatric/Psychogeriatric consult as needed. Staff monitor for aggression and redirect as needed. Staff to monitor for personal space. When the resident becomes agitated: intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of incident report dated 7/25/2023 indicated another resident grabbed Resident #4 by her right wrist/lower arm . Record review of incident report dated 6/05/2023 indicated Resident #4 .was redirecting to a quiet area for safety when she reached out and grabbed another resident by the arm. Record review of incident report dated 3/08/2024 indicated Resident #4 .was in dining room and tried to take another resident's tray of food, before staff could get there, other resident grabbed her wrist causing a skin tear to left wrist area. During an observation on 6/03/2024 at 3:17 PM, Resident #4 was observed sitting up in wheelchair in secured unit common area. Resident #4 did not answer questions appropriately due to cognition. 5.Record review of Resident #5's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: unspecified dementia, unspecified severity, with other behavioral disturbance, (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), bipolar disorder severe with psychotic features (psychosis, including hallucinations, delusions, or jumbled thoughts) and unspecified psychosis (disconnection from reality). Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score was not able to be obtained. Staff assessment for mental status revealed Resident #5 had short- and long-term memory problem. Resident #5's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Resident #5 had difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said. Record review of Resident #5's care plan dated 01/31/2024 revealed he had potential to be physically aggressive related to poor impulse control and bipolar severe with psychotic features with actual physical aggression on 3/28/2024, 3/12/2024, and 1/22/2024. Interventions included: if behavior is a threat to themselves or others, immediately call for assistance. Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to self and/or others. Psychiatric/psychological consult as indicated and ordered by MD. The resident is/has potential to be verbally and physically aggressive towards staff (patient hit other patient with wet floor sign on 9/02/2023), tends to hold onto female residents, becomes angry and aggressive when redirected with interventions that included: Assess residents understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Psychiatric/Psychogeriatric consult as indicated. Record review of incident report dated 3/12/2024 indicated Resident #5 .went into another residents room and grabbed her left arm and elbow causing bruising. During an observation and interview on 6/03/2024 at 3:01 PM, Resident #5 was Observed sitting up in bed in room awake and alert. Resident #5 said no one had ever hurt him in any way. Resident #5 said staff did not always treat him nice but would not give any other details. Resident #5 said he took care of himself and did not let anyone treat him badly. 6. Record review of a facility face sheet dated 6/5/24 for Resident #6 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Alzheimer's disease, heart failure, type 2 diabetes mellitus and cerebral infarction (stroke). Record review of a quarterly MDS assessment dated [DATE] for Resident #6 indicated that she had a BIMS score of 5, which indicated that she had severe cognitive impairment. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan dated 4/17/23 with last revision date of 6/4/24 for Resident #6 indicated that she had the potential to be physically aggressive r/t paranoid schizophrenia with actual physical aggression on 04/04/2023, 05/03/2023, 06/29/2023, 10/22/20203, 12/12/2023, 01/09/2024, 01/11/2024, and 05/22/2024 with interventions including: .If behavior is a threat to myself or others, immediately call for assistance .; .Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to myself and/or others .; and .Triggers for physical aggression are (other residents in my personal space or messing with my belongings). The behavior is de-escalated by (keeping my personal space and no one messing with my belongings) . Record review of an incident report dated 5/22/24 for Resident #6 indicated that she .got agitated at another resident for banging on the door, pulled her hair and pushed her . 7. Record review of a facility face sheet dated 6/5/24 for Resident #7 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Sarcopenia (gradual loss of muscle mass, strength and function), dysphagia (trouble swallowing), bipolar disorder(a mental health condition that causes extreme mood swings between emotional highs and lows), and dementia. Record review of a quarterly MDS assessment dated [DATE] for Resident #7 indicated that she had a BIMS score of 2, which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #7 initiated on 6/2/22 and revised on 5/14/24 indicated that Resident #7 had physical aggressive behaviors at times r/t dementia, poor impulse control. Interventions included: .If I show signs of agitation, intervene before it escalates: remain calm, take a deep centering breath, stand out of reach, listen, and respond with empathy, guide away from source of distress; calmly engage in conversation. If response is aggressive, team member is to calmly walk away, ask others to leave the area, ensure everyone is safe, and immediately report this to nurse, discuss other approaches and approach later .; .Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to myself and/or others .; and .Talk with a low pitch, calm voice to decrease/eliminate undesired behavior & provide diversional activity . Record review of an incident report dated 3/21/24 for Resident #7 indicated that she suffered a skin tear when another resident grabbed her shirt and arm. 8. Record review of a facility face sheet dated 6/5/24 for Resident #8 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: dementia, dysphagia (trouble swallowing), major depressive disorder, and hyperlipidemia (high cholesterol). Record review of an annual MDS assessment dated [DATE] for Resident #8 indicated that he had a BIMS score of 6, which indicated that he was severely cognitively impaired. Record review of a comprehensive care plan for Resident #8 dated 5/18/22 and revised on 5/13/24 indicated that he had the potential to be physically aggressive r/t dementia, poor impulse control and was physically aggressive with another resident on 5/17/23 and 5/1/24. Interventions included: .Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document in notes .; .Modify environment: adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed .; and .Monitor for anxiety/aggression and redirect as needed . Record review of an incident report dated 5/1/24 for Resident #8 indicated that he was .slinging dinner plate, possibly hit another resident leaving a split between upper lip and nose 2 x 0.1 cm. She was bleeding from area . 9. Record review of a facility face sheet dated 6/5/24 for Resident #9 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia, repeated falls, osteoporosis (weak, brittle bones), and anxiety disorder. Record review of a quarterly MDS dated [DATE] for Resident #9 indicated that she had a BIMS score of 4, which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #9 indicated that she had potential to be physically aggressive (hitting staff and residents) r/t Dementia with physical Aggression received on 05/22/2024. Record review of an incident report dated 5/22/24 for Resident #9 indicated that she had her hair pulled and was pushed down by another resident. 10. Record review of a facility face sheet dated 6/5/24 for Resident #10 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: dementia, repeated falls, depression, and type 2 diabetes. Record review of a quarterly MDS assessment dated [DATE] for Resident #10 indicated that she had a BIMS score of 4 which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from fluctuating inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #10 dated 9/25/23 indicated that resident had potential to be physically aggressive r/t Dementia. Interventions included: .Administrator medications as ordered. Monitor/document for side effects and effectiveness .; .Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc .; and .Psychiatric/Psychogeriatric consult as indicated . Record review of an incident report for Resident #10 dated 9/19/23 indicated that she was involved in a physical altercation with another resident. During an interview on 6/04/2024 at 2:50 PM, SW said when there was a resident-to-resident altercation she would be notified by the charge nurse or the next day in the morning meeting or nurse meeting. SW said everyone on the secured unit was on psychiatric services. She said there was staff on the secured unit that were watching for behaviors. SW said Administrator was responsible for reporting resident to resident altercations to HHSC or any other appropriate agencies. During an interview on 6/04/2024 at 3:10 PM, DON said she had worked at the facility since February of 2023. DON said Administrator was responsible for reporting and was not sure what the last incident was that got reported. During an interview on 6/04/2024 at 3:26 PM, Administrator said she had worked at the facility since January of 2023. She said she was the abuse coor[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 of 2 residents (Resident #1 and #2) reviewed for oxygen. -The facility failed to ensure Resident #1 portable tank of oxygen had air. -The facility failed to properly store empty portable oxygen tank located in the medication room on Unit-RR. -The facility failed to properly remove all potentially flammable items from immediate area in Resident #2's room where the oxygen was to be administered. These failures could affect the residents, receiving respiratory care at risk of shortness of breath and a decline in heath. Findings included: 1.Record review of Resident #1's face sheet dated 1/13/24 indicated Resident #1 was an [AGE] year-old female who admitted to facility on 3/15/21 and readmitted on [DATE] with diagnoses including Alzheimer disease (a type of dementia that affects memory, thinking and behavior), acute upper respiratory infection (are short-term infections of the nose and throat caused by viruses or bacteria), acute respiratory failure with Hypoxia (occurs when you do not have enough oxygen in your blood.), chronic respiratory failure with hypercapnia (happens when you have too much carbon dioxide (CO2) in your blood. If your body can't get rid of carbon dioxide, a waste product, there isn't room for your blood cells to carry oxygen), shortness of breath (the feeling that you can't get enough air into your lungs. It might feel like your chest is tight, you're gasping for air or you're working harder to breathe) and generalized anxiety disorder (a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things. Record review of Resident #1's physician order dated 1/13/24 revealed an order for oxygen at 2 Liters Per Minute (LPM) via nasal cannula continuous every shift. Record review of Resident #1's revised care plan dated 09/13/23 indicated the following: Problem - The resident has oxygen therapy as needed due to chronic respiratory failure with hypercapnia. Goal - The resident will have no s/sx of poor oxygen absorption. Intervention - Monitor for s/sx of respiratory distress and report to MD PRN: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color. - Oxygen settings: oxygen at 2 Liters Per Minute (LPM) via nasal cannula. Record review of Resident #1's MDS assessment dated [DATE] indicated Resident #1 has ability to understand others and had the ability to express ideas and wants. She had Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately cognitively intact. Also, Section O under special treatments and programs was checked for oxygen therapy. Record review of intake investigation worksheet for complaint intake ID 476528 received on 1/12/24 revealed Resident #1 must be on continuous oxygen for shortness of breath. The facility staff did not check her tank regularly and on over 20 occasions the complainant had notified the tank was on red (out of oxygen). This would happen particularly on Sundays when the tank was on red. Resident #1 could be seen gasping for air and when she was in her room, she was supposed to be switched to the wall unit but that was not being done by some of the staff. Resident #1 was kept on the tank on her wheelchair, which tends to run out of oxygen quickly. The issue had been reported to the facility for the past two weeks with no resolution. During an observation and interview on 1/22/24 at 1:42 p.m., Resident #1 was in room up in wheelchair, wearing oxygen nasal cannula. The portable oxygen tank strapped to the back of her wheelchair gauge was in the red section and needle pointed past passed the number zero indicating the tank was empty. At time of the observation Resident #1 stated she felt good and was not short of breath. During an observation and interview via phone on 1/22/24 at 2:35 p.m., Resident #1's family member said another family member visited Resident #1 earlier that day before lunch and notified someone (unknown name) at the nurse station that Resident #1's tank was empty. The family member said Resident #1's portable oxygen tank recently had been emptied several times and facility had been made aware but was still an ongoing issue and concern. Resident #1 was on room concentrator at that time. During an interview on 1/22/24 at 2:55 p.m., LVN D she was not the staff who Resident #1 family member spoken to earlier and she was not aware Resident #1's family member voiced her portable oxygen tank was empty. She said she was the staff who transferred Resident #1 from the empty portable tank to the room concentrator. LVN D said she was on Unit- RR doing rounds when the DON was in Resident #1's room and notified her Resident #1's portable tank was empty. She said she was not aware how long Resident #1 had gone without oxygen. LVN D said on Unit- RR she had three total residents on oxygen , but Resident #1 was mainly her only resident who was up in wheelchair and used the portable oxygen tanks frequently. She said Resident #1 often ran out of air and Resident #1 was good about coming to her and letting her know and she would swap out her tank for another tank. LVN D pointed behind the nurse station at the portable tank refill machine and explained it would take up to 5 hours to refill an entire standard size portable oxygen tank. She said she had never been able to refill an entire tank during her shift and she often rotated between the tanks refilling so she could have more than one tank to choose from among the residents. LVN D said the portable tanks were not full when they are given to the residents and that was why Resident #1 tank was frequently going empty and needing to be changed out. LVN D said Resident #1's family had notified her in the past regarding Resident #1 tank was empty and whenever they tell her she would change it out. During an interview on 1/22/24 at 3:47 p.m., the DON said Resident #1 had voiced to her in the past about Resident #1's oxygen tank being empty. She said staff should check randomly if a resident was up and using portable tanks. The DON said she had visited with Resident #1 earlier and noticed the tank was low, so she asked LVN D to change it. During an observation and interview on 1/22/24 at 5:13 p.m., of the Medication room on Unit -RR was an empty oxygen tank stored in the corner on the floor, unsecured. The DON said the empty oxygen tank should not be stored on the floor and should be in a tank holder or properly stored in the oxygen storage closet on Unit-JC . The DON removed the oxygen tank and gave it to another staff to take away. 2. During an observation and interview on 1/13/24 at 12:09 p.m., and on 1/22/24 at 2:27 p.m., Resident #2 oxygen concentrator was stored next to the bedside table which had three 3oz bottles of Biofreeze Menthol 4% - manufacture label: Flammable; two 7.1 oz bottles of Theraworx Relief contains magnesium sulfate (muscle cramp and spasm relief); open undated box of 70 single use vials of lubricant eye drops, contains carboxymethylcellulose sodium 0.5% (moisturizes and relieves dry, irritated eyes); and an open 1.75 oz jar of Vaseline, contained 100% pure petroleum jelly; and One economy size bottle of lotion. Resident #2 said a family member had purchased most of the items on the bedside table and staff had not told her she was not allowed to have those items in her room. She said a family member or sometimes staff if she asked would help give and/or rub on the medications for her. During an observation and interview on 1/22/24 at 5:31p.m., the DON said said no medications should be left at bedside unless the resident was assessed to self-administer; she said the facility did not have any residents who self-administered therefore, no medications should be at bedside to self-administer. State Surveyor notified the DON regarding Resident #2's medications at bedside and the DON notified Resident #2 that she was not allowed to keep medications at bedside and she removed the following items: Three bottles of Bio Freeze, Two bottles of Theraworx, open box of vials of eye drops, one bottle of vitamins, and one saline bottle (DON said she did not know why saline bottle was in Resident #2's room because they mainly used saline for wounds and Resident #2 did not have any wounds). The DON said she was not aware at that time if Resident #2 had orders for any of the items she removed from Resident #2's room. During an interview on 1/22/24 at 7:42 p.m., the Administrator said they did not have an oxygen storage policy, but she contacted her regional nurse who notified her oxygen tanks are to be stored on a stand or secured. Record review of revised oxygen administration policy dated October 2010 revealed purpose of this procedure was to provide guidelines for safe oxygen administration . Equipment and Supplies: 1) Portable oxygen cylinder (strapped to the stand) .Steps in the Procedure: .4) Remove all potentially flammable items (e.g., lotions, oils, alcohol, smoking articles, etc.) from the immediate area where the oxygen is to be administered.

Based on observation, interview and record review, the facility failed to ensure medications were secured on 1 of 3 medication carts reviewed for pharmacy services. (Unit-RR Medication Aide Cart) -Medication Aide Cart for Unit-RR was left unlocked, unsecured, and unattended near the nurse station. -Seven medications were stored a bedside of Resident #2 . These failures could affect the residents, who resided on Unit-RR and received medications from these carts, by placing them at risk of drug diversions or misuse of medications. Findings included: During an observation on 1/13/24 at 11:03 a.m., revealed the Medication Aide Cart for Unit-RR had an unopened 30 count blister pack of Amlodipine Besylate 10 mg tablets (it works by relaxing your blood vessels to lower your blood pressure) unsecured and unattended on top of the cart. The cart was unlocked, and unattended stored against the wall in the dining room on Unit-RR for unknown amount of time. Residents and staff were observed passing by the medication cart. During an observation and interview on 1/13/24 at 12:09 p.m., and on 1/22/24 at 2:27 p.m., Resident #2 at bedside had an open undated bottle of 240 count women's multi dietary supplement (for energy, immunity, and healthy appearance); three 3oz bottles of Biofreeze Menthol 4% (relieves minor aches and pains of muscles and joint); two 7.1 oz bottles of Theraworx Relief contains magnesium sulfate (muscle cramp and spasm relief); open undated box of 70 single use vials of lubricant eye drops, contains carboxymethylcellulose sodium 0.5% (moisturizes and relieves dry, irritated eyes); and an open 1.75 oz jar of Vaseline, contained 100% pure petroleum jelly. Resident #2 said a family member had purchased most of the items on the bedside table and staff had not told her she was not allowed to have those items in her room. She said a family member or sometimes staff if she asked would help give and/or rub on the medications for her. During an observation on 1/20/24 at 8:37 p.m., revealed the Medication Aide Cart for Unit-RR was unlocked, and unattended stored against the wall in the dining room on Unit-RR for unknown amount of time. All the drawers of the medication could be opened, and the medication was easily accessible. A resident was observed wondering in the dining room on Unit-RR by the medication cart. During an interview on 1/20/24 at 8:45 p.m., Agency LVN B she was responsible for leaving the medication aide cart unlocked, she said staff from another hall was needing something from the cart and she unlocked the cart and forgot to lock the cart. Agency LVN B said the medication carts are never supposed to be left unlocked and don't know why she did it, was a mistake. During an interview on 1/22/24 at 2:55 p.m., LVN D said she was the charge nurse for Unit- RR and said there was no residents on her Unit who self-administered medications and was not aware of residents on her Unit who had medications at bedside. LVN D said if she was aware of medications in residents' room, she would remove it and notify DON. During an interview on 1/22/24 at CMA C said she was not aware of any residents who self-administered medications. Also, said residents were not allowed to keep medications in their room and she was not aware of any residents who had medications stored in their room. CMA C said if she was to see medications in a resident room she would remove it and notify the nurse. During an observation and interview on 1/22/24 at 5:31p.m., the DON said medication carts should remain locked and secured anytime not attended. She said no medications should be left at bedside unless the resident was assessed to self-administer; she said the facility did not have any residents who self-administered therefore, no medications should be at bedside to self-administer. State Surveyor notified the DON regarding Resident #2's medications at bedside and the DON notified Resident #2 that she was not allowed to keep medications at bedside and she removed the following items: Three bottles of Bio Freeze, Two bottles of Theraworx, open box of vials of eye drops, one bottle of vitamins, and one saline bottle (DON said she did not know why saline bottle was in Resident #2's room because they mainly used saline for wounds and Resident #2 did not have any wounds). The DON said she was not aware at that time if Resident #2 had orders for any of the items she removed from Resident #2's room. During an interview on 1/22/24 at 5:30 p.m., LVN D said she was aware Resident #2 had medications at bedside and said she did not give Resident #2 the medications and she instructed her CNAs to not give Resident #2 the bedside medications. LVN D said she did not notify DON or the Administrator regarding Resident #2's medications she had stored at bedside and said she probably should have. Record review of storage of medication revised policy dated April 2007 revealed The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . 7) Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement policies and procedures to prohibit abuse and neglect for 1 of 1 residents (Resident #1) reviewed for incident reporting. The facility did not report an allegation of rape by Resident #1 within the required time frame of the incident. This failure could place residents at risk of abuse, neglect, and not having incidents reported appropriately. Findings included: Record review of a current admission record indicated that Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), chronic obstructive pulmonary disease (a lung disease that causes difficulty in breathing due to inflammation and obstruction of the airways), hypertension (high blood pressure), dementia ( a group of symptoms that affects memory, thinking and interferes with daily life. It is caused by damage to or loss of nerve cells and their connections in the brain), and cognitive communication deficit (a difficulty with communication that is caused by a problem with cognition. Cognition refers to mental processes such as attention, memory, organization, planning, problem-solving, and safety awareness). Record review of the most recent MDS dated [DATE] indicated Resident #1 had moderately impaired cognition and was limited assist with ADLs with 1 person assist. Record review of a A current care plan dated 8/7/23 indicated Resident #1 had memory loss related to dementia, and hallucinations, some that involved making accusations against staff. Record review of nurses notes dated 8/7/23 at 11:18 a.m., documented by the DON indicated the following: It was reported to this nurse by the Administrator that Resident #1's Hospice CNA had called her social worker last Friday and told her Resident #1 had reported that 3 men were in her room the night before and had raped her, but it felt so good that she did not report it. Another nurse and I went to assess Resident #1 as soon as it was reported. While assessing Resident #1 she stated that she had been hallucinating. Resident #1 had hallucinated that her great granddaughter was in the courtyard and fell and was bleeding and she could not get to her and when she called out to her, she got up and ran away. Resident #1 also stated that the walls were moving like waves and that she had seen snakes in her room. DON performed a head-to-toe assessment and Resident #1 had no concerns. There was no bleeding, bruising, trauma or swelling present to any parts of Resident #1's body. Resident #1 denied any pain. When Resident #1 was asked about her personal safety she it was good, that the staff treated her with respect, and she had not seen staff treat others bad. Requested that psych service come out and evaluated Resident #1. Record review of a social services noted dated 8/7/23 at 11:30 a.m. indicated the following: SW consulted with Resident #1 regarding recent allegation. When asked about the recent allegation, Resident #1 stated I've been having hallucinations. Tell me what happened so I can apologize to people if I need to. Resident #1 reported she had been under more stress lately because her family was fighting amongst themselves. Resident #1 stated again, I can't think of anything that happened. I will ask the nurse; she will tell me. SW asked Resident #1 if she felt safe and Resident #1 responded yes. SW asked Resident #1 if anyone had threatened or hurt her in any way. Resident #1 responded no, they are afraid of me and I don't know why. SW encouraged Resident #1 to contact her if she had any concerns or needs. Record review of a social services noted dated 8/8/23 at 10:33 a.m. indicated the following: Referral for psych services faxed. Record review of a safe survey completed on 8/7/23 with Resident #1 indicated she denied knowledge of the allegation. Resident #1 stated she had been having hallucinations and asked for details of the allegations so she could apologize to any individuals that were involved but was unable to recall what happened or what was said. Record review of a witness statement dated 8/8/23 from LVN A indicated the following: On 8/4/23 Resident #1's hospice nurse aide came to the nurses station and told me that Resident #1 was making up stuff again. Hospice aide stated that Resident #1 said 3 maintenance men raped her but she didn't report it because she enjoyed it. Resident #1 came to the nurses station multiple times and I went to her room several times that day. Resident #1 never mentioned anything about it, and frequently made statements about things that did not happen. Resident #1 was not upset, her mood was good, and there was no evidence of any traumatic disturbance. Record review of witness statements from the maintenance supervisor, maintenance worker E and maintenance worker F, all indicated they were not present in the facility at the time allegation from Resident #1 were made. During entrance conference on 8/8/23 at 10:00 a.m., the Administrator said she had called in a self-report on 8/7/23. The Administrator stated it had to do with Resident #1 making and allegation of rape. The Administrator stated the incident occurred Friday, 8/4/23, but she did not find out about it until 8/7/23. The Administer stated Resident #1 told a Hospice aide that she had been raped by 3 maintenance men, on Thursday (8/6/23) evening, but did not report it because it felt good. The Administrator said the first time she was made aware of the incident was when the Hospice Social Worker called Monday 8/7/23 at around 10:31 a.m. and said she had left a voicemail on the facility's Social Worker's office phone Friday evening sometime between 4:15 and 5:00 p.m. The Hospice SW told the Administrator that she figured the SW was gone for the weekend, so she was calling to make sure they had received her message. The Administrator said she asked the Hospice SW if a Hospice nurse came out to assess Resident #1. The Hospice SW told her Hospice nurse C had come to the facility on Saturday 8/5/23 but did not know what time. The Administrator said she had no voicemail on her phone and had her SW check her messages. The SW checked her voicemails on Monday 8/7/23 and stated she had received a voice message on Friday at around 4:20 p.m. but did not see it at the time. The Administrator said she sent the DON immediately to assess Resident #1 and had the SW start safe surveys while she started gathering facts for the self-report. During an interview on 8/8/23 at 11:30 a.m., the Administrator stated that while getting staff statements she discovered that LVN A had been notified about the incident involving Resident #1 on 8/4/23 by the Hospice aide and never reported it. During an interview on 8/8/23 at 11:45 a.m., Resident #1 was sitting in her wheelchair in the dining area. Resident #1 stated she had lived in the facility for 5-6 months, but really wasn't sure. Resident #1 stated the staff all treated her well, and that the food was excellent. Resident #1 stated no one in the facility had ever harmed her or touched her inappropriately. Resident #1 stated, I am a tattle tale and would report it immediately. I have never seen it happen, nor has it happened to me. Resident #1 stated the only 3 men that had come in her room were the man who brought her diapers, the AC man, and the medication man. Resident #1 did not know their names. Resident #1 stated they were never in her room at the same time. Resident #1 stated that she did have hallucinations, and the last time she had a hallucination was last Friday, and that must have been what they were talking about, but no one has ever harmed me. Resident #1 stated she knew when she was having hallucinations and would ask for medicine but did not recall the name of it. During an interview on 8/8/23 at 1:20 p.m., LVN B stated Resident #1 was alert, but forgetful at times. LVN B stated that on this date her and the maintenance man went into Resident #1's room to fix her tv. LVN B stated that after the incident last Friday, maintenance was not to go in Resident #1's room alone. LVN B stated she had not taken care of Resident #1 before this date but had not heard her say anything inappropriate. During an interview on 8/8/23 at 2:06 p.m., LVN A said she was working Friday 8/4/23 when the Hospice aide (did not know her name), came to the desk and said, Resident #1 is making up stuff again saying that 3 maintenance men raped her, and I know it is not true. LVN A said she went to Resident #1's room but did not mention anything about it. LVN A said the resident was not upset. LVN A said the Resident told the Hospice aide, she did not report the incident because it felt good. LVN A said, if I asked her if it happened, she would have spiraled. LVN A stated that spiraled meant she would go off on other things that did not happen. LVN A stated Resident #1 was known for saying things that were not always true. LVN A stated the DON and the Administrator had talked to her on this date, and she knew now that she should have reported the incident on Friday when it happened. During an interview on 8/8/23 at 2:17 p.m., Hospice RN Case Manager stated she first learned of the incident on Friday 8/4/23 during their team meeting at approximately 4:00 p.m. Hospice RN Case Manager statedManager stated the Hospice Social Worker had called the facility after the meeting. Hospice RN Case Manager stated she did not know at the time, but later found out the facility phones had rolled over to the after 5:00 p.m. phone number and voicemail. Hospice RN Case Manager stated she went to the facility on Monday 8/7/23 at 8:00 a.m. and did a complete assessment of Resident #1, with no visible signs of injury noted. Hospice RN Case Manager stated she had spoken to the Administrator and DON 8/7/23 at 9:00 a.m. and both told her they had received voicemails from the Hospice SW on 8/4/23 around 4:30 p.m. but did not actually know about them until the morning of Monday 8/7/23. Hospice RN Case Manager stated Resident #1 had no recollection of what she had told the Hospice aide on 8/4/23 and asked who she needed to apologize to. Hospice RN Case Manager stated Resident #1 had a history of saying things such as the aide had not come to bath her, when she actually had. Sated that Resident #1 had told her at some point that she had hallucinations and would sometimes see the walls moving. Hospice RN Case Manager said the Hospice Social Worker was currently out sick. Hospice RN Case Manager said Hospice nurse C was the nurse on call 8/5/23 and had not been able to contact her to verify that she went to the facility to assess Resident #1. During an interview on 8/8/23 at 2:30 p.m. the facility maintenance supervisor stated he had been made aware of the allegation from Resident #1. Stated he had 2 other men that worked with him, and none of them were in the building at the time the allegation was made. Stated his staff had been instructed not to go in Resident #1's room alone for any reason. During an interview on 8/8/23 at 2:50 p.m. the DON stated she had found out about the incident with Resident #1 on Monday morning 8/7/23. Stated she and the Administrator talked to LVN A, and she was told an allegation is an allegation and needed to be reported. DON stated disciplinary action was taken. During an interview on 8/8/23 at 3:06 p.m., CNA D stated Resident #1 had bouts of confusion. Stated she had heard the resident on 2 separate occasions talk sexually to a female Hospice nurse. CNA D stated she did not remember exactly what was said, or dates of occurrence. During an interview on 8/9/23 at 9:39 a.m., Hospice aide stated on Friday 8/4/23, at 2:50 p.m. she entered the facility. She went into Resident #1's room and was getting her ready to take a shower. Resident #1 stated, You know I've been raped by 3 guys last night?. Hospice aide stated she told Resident #1 not to say that, because it would get somebody in trouble. Hospice aide finished the shower and returned Resident #1 to her room. Hospice aide stated before she left the facility, she went to the nurses station. Stated there were 3 employees at the desk. Stated she did not know their names, and knew one was a nurse, and was not sure who the other 2 were, as there was always someone new. Hospice aide stated she told them, to protect your maintenance men, the resident said she was raped by 3 men. Hospice aide said staff did not think it was true, as the Resident makes a lot of stuff up. Hospice aide stated Resident #1 did have a history of saying things that were not true but could not give an example. Hospice aide stated one of the staff said, well, that's a new one, never heard that before, and they all laughed. Hospice aide said she called her Case Manager 8/4/23 at 3:39 p.m. and did not get an answer. Stated she called her boss at 3:40 p.m. and got no answer. She called the Hospice SW at 3:41 p.m. with no answer. Stated she tried the SW again at 3:57 p.m. and she answered. Hospice aide stated she told the SW what had happened. The Hospice aide stated that during the residents shower, she did not notice any signs on injury, and Resident #1 did not mention the incident again. Hospice aide stated that Resident #1 had recently moved from another room and had been a bit confused thinking some of her belongings were missing. Hospice aide stated she felt it was important to report this incident, even though she did not feel it happened. Record review of a facility Abuse Prohibition Guideline 2023 document indicated the following: .the Health Care Center will thoroughly investigate all alleged violations/allegations and take appropriate action. No later than 2 hours if the allegation involves abuse or results in serious bodily injury, and no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury . .if there is an allegation of rape, offer the resident/responsible parting sending the resident to the emergency room for rape/rape kit examination .Any employee who becomes aware of an allegation of abuse, neglect shall report the incident to a supervisor, DON or Administrator immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 26 residents (Resident #100 and Resident #275) reviewed for resident rights in that: The facility did not ensure Resident #100's catheter bag (urine collection bag) had a privacy bag over it. Resident #275 was not informed of the puree menu served to him or the alternate puree menu. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. The findings included: 1.Record review of the face sheet for Resident #100 dated 4/25/23 indicated was he [AGE] years old admitted to the facility on [DATE] with diagnoses including history of stroke, chronic kidney disease (a disease process which involves a gradual loss of kidney function) and bladder- neck obstruction (condition in which the bladder neck does not open appropriately or completely during voiding), high blood pressure and type II diabetes. Record review of the MDS assessment dated [DATE] indicated Resident #100 had no cognitive impairment (BIMS of 15). The MDS indicated he had no behavior of rejecting care. The MDS indicated Resident #100 was totally dependent on staff for transfers, locomotion in his wheelchair and bathing. The MDS indicated he required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident #100 had an indwelling catheter. The MDS indicated he was always incontinent of bowel and bladder. The MDS indicated Resident #100 had an active diagnosis of Renal Insufficiency, Renal Failure, or End-Stage Renal Disease. Record review of the care plan revised on 11/30/22 indicated Resident #100 had an urinary obstruction and had an indwelling catheter related to a terminal condition. The care plan interventions included, position the catheter bag and tubing below the level of the bladder, and secure the catheter tubing to the leg to minimize trauma to the insertion site. During an observation and interview on 4/24/23 at 10:30 a.m., Resident #100 laid in his bed. His catheter reservoir bag hung on the frame on his bed. There was dark yellow urine in the bag. There was no dignity bag or cover over the catheter reservoir bag. Resident #100 said he use to care about stuff like that (no cover over his catheter bag) but said he had given up. When asked to clarify he said, I just don't care about stuff like that anymore. Resident #100 said he use to have a bag over his catheter bag and did not know why he did not have one anymore. During an interview on 4/24/23 at 11:00 a.m., LVN BB indicated she was the nurse which provided care for Resident #100 on that day (4/24/23). During an observation on 4/24/23 at 4:20 p.m., Resident #100 laid in his bed. His catheter reservoir bag hung on the frame on his bed. There was dark yellow urine in the bag. There was no dignity bag or cover over the catheter reservoir bag. During an interview on 4/26/23 at 1:00 p.m., CNA X indicated residents with catheters should have a dignity bag over the catheter reservoir bag. CNA X indicated she routinely cared for Resident #100. CNA X said she thought it was the nurse's responsibility to ensure there was a dignity bag/cover over resident catheters. CNA X said if a resident with a catheter did not have a bag in place, she would notify the nurse. CNA X said indicated it was important for residents with catheters to have a bag over their catheter because without one (dignity bag/cover) the resident could be embarrassed. During an interview on 4/26/23 at 1:10 p.m., CNA Y said she routinely cared for Resident #100. CNA Y indicated ensuring dignity bags/covers were in place was the responsibility of the nurses but indicated she would report to the nurse if she noticed Resident #100 did not have one (dignity bag/cover) in place while she provided care throughout the day. CNA Y indicated dignity bag/covers should be placed over catheter reservoir bags because it was dignity issue. During an interview on 4/26/23 at 1:15 p.m., LVN Z indicated she routinely cared for Resident #100. LVN Z said it was the nurse's responsibility to ensure a dignity bag/cover was in place over resident's catheter bags. LVN Z said there was no set time to check for dignity bags/covers and indicated it should be checked for at some point during the shift. LVN Z said dignity bags/cover should be in place to ensure resident privacy and dignity especially in the event of a visitor. A follow up interview was attempted with LVN BB via phone on 4/26/23 at 3:29 p.m. but was not completed. During an interview on 4/26/23 at 4:15 p.m., the DON said catheter bags not being covered with dignity bag/cover was a dignity issue. The DON said nurses should ensure the devices (dignity bags/cover) were in place for any resident with a catheter. The DON said there was no system in place to ensure the devices (dignity bags/cover) were in place but expected nurses to check for the devices during their shifts. During an interview on 4/26/23 at 4:40 p.m., the Administrator said she expected staff to ensure dignity bags were in place for residents that required catheters. The Administrator indicated catheter bags not being covered with dignity bag/cover was a dignity issue. The Administrator said there was no specific system in place to oversee staff in regard to the placement of dignity bags but indicated the lack of dignity bag should have been caught during administrative rounds. 2.Record review of a face sheet dated 04/25/2023 revealed Resident #275 was a 59- year-old- male, admitted on [DATE] with the diagnoses of malnutrition (occurs when the body doesn't get enough nutrients), dysphagia (swallowing difficulties), and exocrine pancreatic insufficiency (a condition caused by reduced or inappropriate secretion or activity of pancreatic juice and its digestive enzymes, pancreatic lipase in particular). Record review of an admission MDS dated [DATE] for Resident #275 revealed an incomplete BIMS. The MDS also revealed Resident #27 required limited assistance with eating. The MDS revealed Resident #275 had high visual impairment and received less than 25% of his nutrition from tube feeding. The MDS revealed Resident #275 was on a mechanically altered therapeutic diet. Record review of a baseline care plan completed on 04/04/2023 by LVN G, revealed Resident #275 was alert and cognitively intact. Record review of the April 2023 consolidated physician orders revealed Resident #275 had dietary orders for a puree reduced concentrated sweet diet with nectar thickened liquids. The orders also revealed Resident #275 was to receive Nepro/Carb steady oral liquid per PEG tube if less than 50% of meals were consumed. Resident #275 also had an order for a puree meal at midnight. During an interview on 04/24/2023 at 10:10 a.m., Resident #275 said he had only one complaint about his stay at the facility. Resident #275 said he was on a puree diet, and he would like to know what the meal was before he took a bite of it. He said sometimes he could not tell exactly what it was even when he ate it. Resident #275 said he asked the staff what he was eating, and they always answered they did not know what it was. Resident #275 said that frustrated him. Resident #275 said he did not understand why it was not listed on the meal ticket. Resident #275 said the meals were decent 50% of the time. During an observation on 04/24/2023 at 12:50 p.m., Resident #275 was served a divided plate with three compartments filled with puree food and one small bowl with puree food. Resident #275's meal ticket had his name, room number, and puree diet with nectar thicken liquid printed on it. Resident #275 asked LVN H, what his meal was. LVN H said she had no idea what it was. Resident #275 attempted to eat a few bites of each food. Resident #275 then asked LVN H, what the substitute was for the puree meal. LVN H said she would have to call the kitchen and ask. Resident #275 waited at the table while 10 other residents in the dining room ate. At 1:25 p.m., Resident #275 asked LVN H, what did the kitchen say about the substitute? LVN H replied what do you want me to do they have not called me back yet. Resident #275 left the dining room and headed to his room. Resident #275 said he ate the meat and potatoes, and it was not bad. He said it was just the point that he would like to be informed of what he was being served and have options if wanted something different. During an interview on 04/24/2023 at 1:30 p.m., LVN H said the kitchen was short staffed and no one had called her back, which meant no one was in the kitchen they were all out on the floor trying to serve lunch. LVN H said she was the nurse in the dining room and could not leave to go to the kitchen. During an interview on 04/26/2023 at 1:50 p.m., the DON said she expected the staff to communicate with the residents when they asked direct questions about what they were eating. The DON said she was unsure why the meal was not printed on the resident meal card. The DON said Resident #275 was visually impaired and needed the direction of staff to know what food he was eating. The DON said it was the responsibility of the staff nurse in the dining room to ensure every resident had enough food, knew what they were eating and was offered a substitute if they did not like the food that was served. The DON said the staff nurse should have called her or any department head staff and asked them to check on a substitute for Resident #275. The DON stated Resident #275 not knowing what he was eating could have made him feel rejected and angry. During an interview on 04/26/2023 at 2:20 p.m., the Administrator said she expected the staff to provide the residents with whatever they needed. She expected each resident would be fully aware of the meal they were eating prior to eating it. The Administrator said she expected the nurse to send a CNA or call a department head to find out what the substitute was for Resident #275. The Administrator said putting the meal on the ticket was an easy fix. Record review of the facility policy and procedure, revised August 2009 titled Quality of Life- Dignity, stated .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect .(1) Residents shall be treated with dignity and respect at all times (2) 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .(8) Staff shall keep the resident informed and orientated to their environment .(11) Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and residents as needed by: (a) Helping the resident to keep urinary catheter bags covered .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to review and revise by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment for 1 resident (Resident #52) of 24 residents reviewed for comprehensive person-centered care plans in that: The facility failed to revise Resident #52's care planned swallowing problem coded on the MDS. Finding included: 1. Record review of a face sheet dated 04/24/23 revealed Resident #52 was [AGE] year-old female admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and dysphagia (difficulty swallowing). Record review of Resident #52's consolidated physician order dated 09/13/22 revealed puree diet, pureed texture, honey consistency. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #52 was usually understood and usually understood others. The MDS revealed Resident #52 had a BIMS of 00 which indicated severe cognitive impairment. The MDS revealed Resident #52 swallowing disorder signs and symptoms included coughing or choking during meals or when swallowing medications. The MDS revealed Resident #52 had a mechanically altered diet. Record review of the care plan dated 09/14/22 revealed Resident #52 had a swallowing problem; the swallowing assessment results are that she aspirates and will now be on purred diet. Intervention included check mouth after meals for pocketed food and debris. Report to nurse. Provide oral care to remove debris. Alternate small bites and [NAME]. Use teaspoon for eating. Do not use straws. Record review of a speech therapy report dated 12/08/22 revealed Resident #52 had significant change in status due to decline, weight loss and reevaluation was necessary due to new onset of choking and coughing, and at risk for silent aspiration (a passage of food or liquids through and below the level of the true vocal folds, without producing a reflexive cough). Record review of Resident #25's MDS worksheet recommendation dated 12/08/22 revealed swallowing disorder signs and symptoms: complaints of difficulty or pain when swallowing, coughing during meals or when swallowing medications, and choking during meals or when swallowing medication. The Patient After Visit Summary revealed strategies recommended: small bites/[NAME], alternate bites/sips, patient to be fed, precautions during mouth feeding, Speech Licensed Therapist, and trained staff only, 1 on 1 feeding, cueing for strategies, and allow extra time. During an observation on 04/24/23 at 12:41 p.m., Resident #52 was at table alone with lunch plate. Resident #52 ate her food fast and started coughing. During an interview on 04/26/23 at 9:30 a.m., CNA S said Resident #52 used to have a small spoon to help her take smaller bites. She said Resident #52 coughed because she took big bites. CNA S said, when possible, staff did try to sit with Resident #52 during meals. She said she did not recall Resident #52 pocketing food in her mouth. CNA S said Resident #52's care plan should be updated let CNAs know what to look out for when she was eating. During an interview on 04/26/23 at 2:09 p.m., RN U said Resident #52 was supposed to have a teaspoon to eat her meals. She said staff tried to sit when staffing allowed to monitor her eating. RN U said Resident #52 had to eat slow to reduce coughing and choking because they suspected aspiration. She said the MDS coordinator, secured unit ADON or DON could update Resident #52's care plan to reflect new swallow problems. During an interview on 04/26/23 at 2:58 p.m., the DON said Resident #52's care plan regarding swallowing issues should be updated when the MDS reflected the information. She said if Resident #52 had a care plan meeting after the speech therapy report on 12/08/22 then anyone on the interdisciplinary team could have updated the problem and interventions. She said she did not know Resident #52 was supposed to have a teaspoon to eat her meals to help with aspiration. The DON said she recently started at the facility and was revamping a lot of processes and role responsibilities. Record review of a facility's Comprehensive Assessment and the Care Delivery Process dated 12/16 revealed .comprehensive assessments will be conducted to assist in developing person centered care plans .assess the individual lab and diagnostic test results .monitoring results and adjusting interventions includes .periodically reviewing progress and adjusting treatments .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #100) reviewed appropriate treatment and services related to indwelling catheters. The facility failed to ensure Resident #100 indwelling catheter had a catheter secure device in place. The facility failed to ensure Resident #100's catheter tubing was free of dependent loops (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag). This failure could place residents at risk for urethral injury and urinary tract infections. Findings included 1.Record review of the face sheet for Resident #100 dated 4/25/23 indicated was he [AGE] years old admitted to the facility on [DATE] with diagnoses including history of stroke, chronic kidney disease (a disease process which involves a gradual loss of kidney function) and bladder- neck obstruction (condition in which the bladder neck does not open appropriately or completely during voiding), high blood pressure and type II diabetes. Record review of the MDS assessment dated [DATE] indicated Resident #100 had no cognitive impairment (BIMS of 15). The MDS indicated he had no behavior of rejecting care. The MDS indicated Resident #100 was totally dependent on staff for transfers, locomotion in his wheelchair and bathing. The MDS indicated he required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident #100 had an indwelling catheter. The MDS indicated he was always incontinent of bowel and bladder. The MDS indicated Resident #100 had an active diagnosis of Renal Insufficiency, Renal Failure, or End-Stage Renal Disease. Record review of the care plan revised on 11/30/22 indicated Resident #100 had an urinary obstruction and had an indwelling catheter related to a terminal condition. The care plan interventions included, position the catheter bag and tubing below the level of the bladder, and secure the catheter tubing to the leg to minimize trauma to the insertion site. During an observation on 4/24/23 at 10:30 a.m., Resident #100 laid in his bed. His catheter tubing formed a dependent loop (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag). During an interview on 4/24/23 at 11:00 a.m., LVN BB indicated she was the nurse which provided care for Resident #100 on that day (4/24/23). During an observation on 4/24/23 at 4:20 p.m., Resident #100 laid in his bed. His catheter tubing formed a dependent loop (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag). During an observation and interview on 4/25/23 at 9:22 a.m., Resident #100 laid in his bed. His catheter tubing formed a dependent loop (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag). Resident #100 had no catheter secure device in place (adhesive catheter anchoring device designed to reduce urinary tract infections and minimize catheter dislodgements) or tape to secure the catheter tubing. Resident #100 indicated sometimes the facility staff placed a catheter secure on his leg to keep the tubing from pulling but could not say when he last had one of the devices in place. During an observation on 4/25/23 at 1:47 p.m., Resident #100 laid in his bed. His catheter tubing formed a dependent loop. Resident #100 had no catheter secure device or tape in place to secure the catheter tubing. During an observation on 4/25/23 at 4:51 p.m., Resident #100 laid in his bed. His catheter tubing formed a dependent loop. Resident #100 had no catheter secure device or tape in place to secure the catheter tubing During an observation on 4/26/23 at 8:00 a.m., Resident #100 laid in his bed. His catheter tubing formed a dependent loop. Resident #100 had no catheter secure device or tape in place to secure the catheter tubing. During an observation on 4/26/23 at 9:00 a.m., Resident #100 laid in his bed. His catheter tubing formed a dependent loop. Resident #100 had no catheter secure device or tape in place to secure the catheter tubing. During an interview on 4/26/23 at 1:00 p.m., CNA X indicated she regularly cared for Resident #100. CNA X said catheter tubing should not form any dependent loops or kinks in the tubing because they (dependent loops or kinks) would cause urine not to flow into the catheter bag. CNA X indicated Resident #100 should have a catheter secure device in place to reduce the risk of tearing the skin at the insertion sight. CNA X indicated CNAs checked for both (dependent loops/kinks and catheter secure devices) during routine care. CNA X indicated she would fix the tubing and notify the nurse if there was no catheter secure device in place for Resident #100. During an interview on 4/26/23 at 1:10 p.m., CNA Y indicated she regularly cared for Resident #100. CNA Y said catheter tubing should not form any dependent loops or kinks in the tubing because they (dependent loops or kinks) would cause urine to back up and could cause infection. CNA Y indicated Resident #100 should have a catheter secure device in place to reduce the risk of injury and the risk of the catheter pulled out. CNA y indicated CNAs checked for both of these (dependent loops/kinks and catheter secure devices) during routine care. CNA Y indicated she would fix the tubing and notify the nurse if there was no catheter secure device in place for Resident #100. During an interview on 4/26/23 at 1:15 p.m., LVN Z indicated she routinely cared for Resident #100. LVN Z said she had to change Resident #100's catheter yesterday (4/25/23). LVN Z said she must have forgotten to place a catheter secure device after changing the catheter. LVN Z said it was important for Resident #100 to have a catheter secure device in place because without it, the catheter could dislodge and cause Resident #100 pain or injury. LVN Z said she had not noticed dependent loops in Resident #100's catheter tubing. LVN Z said it was important for catheter tubing to remain free of dependent loops because the reflux of urine could promote infection. During an interview on 4/26/23 at 4:15 p.m., the DON said she expected staff to ensure catheter tubing was secured to prevent injury with a catheter secure device and positioned to ensure there were no dependent loops, as they (dependent loops) could impede the flow of urine and facilitate bacterial growth. The DON said she was very upset there was not a catheter secure in place for Resident #100 because she had entered an order which created a check off on the nurse MAR/TAR to ensure it (catheter securement device) was in place each shift. The DON logged onto the EMAR record for Resident #100 and said it appeared someone had deleted her order. The DON said since her order was deleted there was in fact no check off on the MAR/TAR to prompt nurses to ensure the device was in place. The DON indicated there was not an administrative system in place to oversee nurses in regard to catheter securement device placement and catheter tubing placement to prevent dependent loops. During an interview on 4/26/23 at 4:40 p.m., the Administrator said she expected staff to ensure catheter tubing was secured and positioned in matter to facilitate the flow of urine and decrease the risk of infection. The Administrator indicated a system would be put in place to ensure nurses placed catheter secure devices and positioned catheter tubing prevent dependent loops. The facility policy and procedure revised September 2014 titled Catheter Care, Urinary, stated .The Purpose of this procedure is to prevent catheter-associated urinary tract infections .(3) The urinary drainage nag must held or positioned lower than the bladder at all times to prevent the urine in the tubing from flowing back into the bladder . Changing Catheters .(2) Ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion sight[Note: Catheter tubing should be secured strapped to the resident's inner thigh.) .(18) Secure catheter utilizing a leg band. (19) Check drainage tubing and bag to ensure the urine is draining properly . The website, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4423413/ accessed on 5/1/23, stated . A dependent loop is formed by excess drainage tubing in a urine drainage system where urine or liquid can accumulate. Dependent loops trap drained urine and are suspected of impeding bladder drainage and increasing the residual volume of retained urine in the bladder. Dependent loops have been associated with an odds ratio of 2.1 for developing catheter-associated urinary tract infection (CAUTI) . Current best practices require that urinary drainage tubing not rest on the floor, as contamination of collection tubing or drainage bag is associated with an increased risk of CAUTI due to migration of organisms up the tubing to the patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an acceptable parameter of nutritional status was maintained for 1 of 24 residents (Resident #121) who was reviewed for nutritional status, in that: 1. Resident #121 had a significant weight loss of 26 pounds, a 21.13% loss, in less than 30 days. The facility did not provide nutritional supplements as ordered, did not notify the physician, did not notify the RD, and did not notify the family of the significant weight loss. This failure could place residents at risk for further weight loss and decline in health due to nutritional needs not being met. Finding included: 1. Record review of a face sheet dated 04/25/2023 revealed Resident #121 was a 95- year-old- female, admitted on [DATE] with the diagnoses of malnutrition (occurs when the body doesn't get enough nutrients), pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid), and rhabdomyolysis (a serious medical condition that can be fatal or result in permanent disability). Record review of an admission MDS assessment dated [DATE] for Resident #121 revealed a BIMS of 14, which indicated no cognitive impairment. The MDS indicated Resident #121 used oxygen daily. The MDS indicated Resident #121 weighed 123 pounds and was 64 inches tall. The MDS indicated Resident #121 had no skin issues on admission. The MDS indicated Resident #121 had no problems with chewing, swallowing, and no dental or mouth pain. Record review of the weight log revealed the following weights: 03/27/2023- 123 pounds 04/10/2023- 99 pounds---24-pound loss in 15 days 19.5% 04/17/2023- 97 pounds-26-pound loss in < 30 days 21.13% Record review of an RD assessment dated [DATE] indicated Resident #121 weighed 123 pounds. The RD assessment indicated Resident #121 always required assistance while eating and recommended house shakes 4 ounces three times daily and a snack once daily related to increased need for nutrition for new wounds and COVID diagnosis. No RD assessment was completed after significant weight loss was discovered. Record review of the physicians' consolidated orders for April 2023 indicated Resident #121 had an order dated 04/13/2023 for a regular diet, mechanical soft consistency. The orders also indicated on 04/07/2023 a snack once daily and health shake 4 ounces three times daily were ordered. The orders indicated a (wound care doctor) consult dated 04/14/2023, and weekly weights dated 04/26/2023. Record review of a skin assessment dated [DATE] indicated Resident #121 had a Stage II pressure ulcer measuring 2.5cm by 0.5 cm to coccyx. Record review of wound care doctor note dated 04/07/2023 indicated Resident #121 had a new Stage III pressure to Right upper back measuring 5.0 cm by 4.5 cm x 0.1cm with some necrtoic tissue at base. A deep tissue injury to the left heel measuring 0.5 cm x 0.3 cm was noted on wound care doctor note. Record review of the progress notes dated 04/01/2023 to 04/24/2023 indicated no notification of the RD, physician, or family. Record review of meal consumption for Resident #121 from 04/01/2023-04/24/2023 revealed the following: 10 meals- 0% to 25% consumed 15 meals- 26% to 50% consumed 20 meals- 51% to 75% consumed 8 meals 76% to 100% consumed 8 meals- refused Record review of the snack consumption for Resident #121 from 04/07/2023 to 04/24/2023 revealed only one day when a snack was accepted. All other days the snack was marked refused. Record review of the CNA documentation of level of assistance needed for eating for Resident #121 from 04/01/2023 to 04/24/2023 revealed the following: 38 meals- resident was independent with eating 7 meals - resident required supervision only for eating 12 meals- resident required limited assistance from 1 staff member to eat 8 meals- resident required extensive assistance from 1 staff member to eat 2 meals- resident required total assistance from 1 staff member to eat During an observation on 04/24/2023 at 10:05 a.m., Resident #121 was sitting in her wheelchair in her room. No snack or health shake was offered. During an observation on 04/24/2023 at 1:10 p.m., Resident #121 was eating lunch alone in her room and no health shake was noted on the tray. Resident #121 fed self but spilled 25% of her meal on herself and the floor. Resident #121's lunch ticket indicated health shakes three times a day, but none were provided. During an observation on 04/24/2023 at 2:15 p.m., Resident #121 was sitting in her wheelchair in her room. No snack or health shake was offered. During an observation and interview on 04/24/2023 at 5:12 p.m., Resident #121 was in bed eating supper and no health shake was noted on her tray. Resident #121 said she did not get milk shakes every day, just when they felt like putting it on her tray. Resident #121 said the food did not taste bad there was just too much of it and seeing all that food made her not hungry. Resident #121 said she had trouble keeping the chopped- up meat on the fork and making it to her mouth. During an interview on 04/25/2023 at 10:10 a.m., RN K said snacks were delivered by the kitchen and passed by the CNAs at 10a.m., 2 p.m., and bedtime. RN K said she did not go behind the CNAs to ensure they were passing them out. RN K said Resident #121 received health shakes with meals and was sent a snack out every day. RN K said she had not worked with Resident #121 long because she was on the main floor and about a week later went to the COVID hall for a couple weeks. RN K said Resident #121 was not a person that ate 100%. Resident #121 ate 50% most of the time. RN K said Resident #121 liked the house shakes and drank those well in the past. During an interview on 04/25/2023 at 11:00 a.m., RNA J said monthly weights were not to be started before the 1st of the month and must be but in the book by the 10th of each month. All new admits were weighed weekly for 4 weeks and then would be discussed in the standard of care meeting. The standards of care meetings were held weekly. RNA J said a few weights were missed when residents had COVID and a couple of standards of care meetings were missed because the ADON was on vacation and then was sick. RNA J said she could not recall directly if Resident #121's 04/03/2023 weekly weight was missed because Resident #121 was on the COVID hall. RNA J said she was instructed to limit her time on the COVID unit and most of the time agency worked the COVID unit. During an interview on 04/26/2023 at 9:10 a.m., Resident #121's family member said she was not informed of any weight loss prior to 04/25/2023 by the facility. Resident #121's family member said she was informed of a weight loss of over 20 pounds when the nurse called. Resident #121's family member said she brought some things the resident liked to eat when she was at home and planned to be at the facility more during mealtime. An attempt to reach the RD was made at 11:10 a.m., 1:30 p.m., and 3:30p.m. on 04/26/2023. Voicemail was recorded and no return call was received prior to exit. An attempt to reach the physician was made at 11:15 a.m. and 3:15 p.m. on 04/26/2023. Messages were left with an answering service. No return call was received prior to exit. During an interview on 04/26/2023 at 1:50 p.m., the DON said she was now over the weight system (records) as of 04/26/2023. The DON said the facility identified some missing and late weights, and she was going to do a full investigation into what occurred. The DON said the normal procedure was the RNAs got the weights for new admits, weekly weights, daily weights, and monthly weights. They had books on each hall they recorded the weights in and the ADON was to input those weights into the EMR weekly before standards of care meeting. At the standards of care meeting the weight loss and gains were discussed and the physician was notified, as well as the family. The DON said she did not think notification of the RD, physician or family had taken place for Resident #121 regarding weight loss. The DON explained because of COVID in the building and the ADON being on vacation and becoming sick things were missed. The DON said she expected residents with COVID to be taken care and get food, supplements, weighed, and therapy services just like those without COVID. The DON said nutrition was very important to the elderly. It ensured health and skin integrity. The DON said poor nutrition led to weight loss, no energy, and skin breakdown. During an interview on 04/26/2023 at 2:15 p.m., the Administrator said it was brought to her attention by the DON that the weight system needed to be more closely monitored and the DON had taken over the weight system monitoring as of 04/26/2023. The Administrator said all the weights at that point were current and the physicians and family had been notified of any weight gains and losses. A policy dated September 2012; titled Nutrition-Unplanned Weight loss indicated. The physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include: a. evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals c. recognizing the emergence of new risk factors for example pressure ulcers, fever, and/or acute illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 3 residents reviewed for dialysis services. (Residents #84) The facility failed to keep ongoing communication with the dialysis facility for Resident #84. The facility failed to complete ongoing assessment of Resident #84's condition before, during and after dialysis. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: 1.Record review of the face sheet for Resident #84 dated 4/26/23 indicated was he [AGE] years old admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis, heart failure, and type II diabetes. Record review of the MDS dated [DATE] indicated Resident #84 had no cognitive impairment (BIMS of 14). The MDS indicated he required extensive assistance with bed mobility, transfers, locomotion in his wheelchair, dressing, toilet use and personal hygiene. The MDS indicated Resident #84 was totally dependent on staff for bathing. The MDS indicated he was always incontinent of bowel and bladder. The MDS indicated Resident #100 had an active diagnosis of Renal Insufficiency, Renal Failure, or End-Stage Renal Disease. The MDS indicated Resident #84 had received dialysis treatment while a resident during the 14-days look- back period. Record review of the care plan revised on 1/23/23 indicated Resident #84 received hemodialysis related to renal failure. The care plan interventions included monitor labs and report to doctor as needed, do not draw blood, or take blood pressure in the arm with graft (dialysis machine is connected to your blood vessels using an access such as a fistula or graft. A graft is created by connecting a vein to an artery using tubing). During an interview on 4/24/23 at 10:02 a.m., Resident #84 said he went to dialysis every Tuesday, Thursday, and Saturday. Record review of the active physician order dated 4/27/23 indicated Resident #84 went to the outpatient dialysis center every Tuesday, Thursday, and Saturday for dialysis. Record review of the facility pre/post dialysis communication logs indicated not pre/post communication had been obtained/sent between the facility and outpatient dialysis center since 2/14/23. Record review of the nursing progress notes from 2/15/23 to 4/26/23 indicated communication between the outpatient dialysis center and the facility occurred had only occurred on the following dates: *4/21/23- the nursing note indicated the outpatient dialysis center contacted the facility regarding a new order for Sevelamer 800mg two tabs PO (by mouth) with meals and one tab PO with snacks. The note provided no further information related to dialysis. *2/17/23- the nursing note indicated Resident #84 had refused to go dialysis and the outpatient dialysis center had been notified by the facility. *The nursing notes contained no other documentation of communication between the outpatient dialysis center and the facility. Record review of the Resident #84's nursing progress notes and Resident #84's assessments from 2/15/23 to 4/26/23 indicated focused dialysis assessment only occurred on 3/14/23. During an interview on 4/26/23 at 12:47 p.m., the outpatient dialysis administrative assistant indicated he filed all communication forms received (and then returned) to the nursing facilities. He said there had been no communication forms received from the facility since February 2023. The administrative assistant said he had no documentation that the facility had inquired regarding Resident #84's dialysis treatment documentation (which include pre/post; weights, vital signs, and assessments) until earlier that day (4/26/23). During an interview on 4/26/23 at 1:44 p.m., the outpatient dialysis nurse said the facility use to send communication forms but could not remember the last time she got a communication form for Resident #84. The outpatient dialysis nurse the dialysis center documented all relevant assessment information related to dialysis treatment for Resident #84 but indicated the facility had not inquired about documentation until today (4/26/23). The outpatient dialysis nurse indicated she just tried to contact the facility by phone in the event of a new order or abnormality with Resident #84. The outpatient dialysis nurse said she did not understand why she did not receive communication forms for Resident #84 because she cared for another resident at the facility and always received communication forms for her (the other resident at the facility). During an interview on 4/26/23 at 2:53 p.m., LVN Z said she had not been completing dialysis communication forms for Resident #84. LVN Z said she had asked management (she would not specify whom she asked) about dialysis communication forms because she thought it was important the forms be completed for the continuity of care when Resident #84 transferred to her area of the facility. LVN Z said she did evaluate Resident #84 before and after dialysis but was not sure if those evaluations were documented. During an interview on 4/26/23 at 4:15 p.m., the DON said dialysis communication forms should have been completed by the nurses. The DON said the nurses were expected to ensure pre/post dialysis assessment and documentation was completed. The DON said she believed the failure resulted when Resident #84 transferred to another area of the building in February 2023. The DON said other dialysis residents continued to have communication forms completed. The DON said he importance of ensuring dialysis communication forms were filled out was to ensure continuity of care and to catch potential complications early. During an interview on 4/26/23 at 4:40 p.m., the Administrator said she expected dialysis assessments to be done and communication forms to be completed for every dialysis resident. The ADM said the charge nurses were responsible for ensuring the communication forms were filled out. The Administrator said Resident# 84 transferred from one area to the building to another in February 2023 which seemed to be when the communication forms stopped being sent to the dialysis center. The Administrator said there had been no system in place to ensure nurses were completing dialysis assessments and communication forms but indicated that would change. Record review of the facility policy and procedure revised September 2010, titled Hemodialysis Access Care, stated .The general medical nurse should document in the resident's medical record every shift as follows: (1) Location of the catheter (2) Condition of the dressing [interventions if needed] (3) If dialysis was done during the shift. (4) Any part of report from the dialysis nurse post-dialysis being given. (5) Observations post dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 2 of 24 residents reviewed for pharmacy services. (Resident # 73 and Resident #23) The facility failed to keep in stock all medications for Resident #73 and #23. This failure could place residents at risk for inaccurate drug administration and cause Resident #73 increased pain. This failure could place resident at risk for inaccurate drug adminsitration and cause Resident #23 to have bradycardia. Findings included: 1. Record review of the face sheet 04/25/23 indicated Resident #73 was [AGE] years old and was admitted on [DATE] with diagnoses including Trigeminal Neuralgia (a chronic pain condition affecting the trigeminal nerve in the face), atypical facial pain (abnormal face pain), and neuritis (inflammation of a peripheral nerve or nerves, usually causing pain and loss of function). Record review of consolidated physician's orders dated 4/25/23 for Resident #73 indicated an active order for Keta/Gaba/[NAME]/Lido/Acyclovir 15 Grams (a compounded topical cream for pain) to left side of face and jaw 2-3 times a day as needed for pain. Record review of the MDS dated [DATE] indicated Resident #73 was understood and understood others. The MDS indicated a BIMS score of 13 indicating Resident #73 was cognitively intact. The MDS indicated Resident #73 required extensive assistance from staff for activities of daily living. Record review of a care plan revised on 03/17/23 indicated Resident #73 had arthritis but did not indicate the resident's facial pain. Record review of a treatment administration record dated 04/01/23 - 04/26/23 indicated there was an order for Keta/Gaba/[NAME]/Lido/Acyclovir 15 Grams (a compounded topical cream for pain) to left side of face and jaw 2-3 times a day as needed for atypical facial pain. Resident #73 received Keta/Gaba/[NAME]/Lido/Acyclovir 15 Grams on 04/02/23 and 04/10/23. Record review of a nurse's note dated 04/20/2023 at 12:38 p.m. indicated, .spoke with daughter about cream, pharmacy said family or facility needed to pay for med, daughter paid, and pharmacy stated the cream should come tomorrow night. Record review of an Investigation Worksheet dated 01/11/23 indicated a complaint concerning Resident #73 was reported to the State Agency. The complaint indicated Resident #73 .is not getting her pain medication for her trigeminal nerve pain. She is prescribed medication by mouth as well as a cream for her face. The pain is debilitating She is unable to eat or do anything else when the facility runs out of her medication or staff do not follow the doctor's orders. She has gone a week without her medication and hasn't been able to leave her room for activities or anything else. The facility finally admitted today they had run out of her medication. During an interview on 04/24/23 11:15 a.m., Resident #73's roommate said Resident #73's medications were out, and she was not sure if it had been replenished. She said it was a medicine for Resident #73's neuropathy in her face. During an observation and interview on 04/25/23 at 3:28 p.m., LVN O said Resident #73 had been of her medication cream for her facial pain since Thursday, 04/20/23. LVN O checked the medication cart, and the medication was unavailable at this time. She said the medication was a compound and was not covered by Resident #73's insurance. She said the medication was supposed to be sent on Friday, 04/21/223. She said the Resident #73's daughter had to pay $65.00 for the medication because her insurance would not pay. She said the doctor was supposed to be figuring out a different mediation. She said they were treating the resident's pain with oral medications. She said the resident was being given Ibuprofen and Tramadol. She said the resident has said the pain was dulled. She said the medication was at the pharmacy in [NAME]. During an interview on 04/26/23 at 9:15 a.m., Resident #73 said she knew she was out of her face cream medication because she had asked for the medication. She said she was told it would be in the other night and it didn't come in. She said the oral pain medicine she was taking helped, but only dulled the pain. She said she would like her cream because it helps with the pain. She said she also did without her cream some time back in January. During an interview on 04/26/23 at 9:18 a.m., Resident #73's roommate said in the past she had seen Resident #73 with tears rolling out of her eyes before when she did not have her medication. She said the staff do not take her seriously. I've seen her suffer so much. During an interview on 04/26/23 11:55 a.m., LVN O said Resident Eldridge' face cream came in the evening of Tuesday, 04/25/23. She said the medication was a PRN (as needed) medication. She said it was unavailable from Thursday, 04/20/23 to Tuesday, 4/25/23. She said she was under the impression that the medication was going to be at the facility on Friday evening. She said the nurses order the mediation when they were unavailable, but the ADON had to order this medication. During an interview on 04/26/23 at 1:58 p.m., ADON P said she called in the order for Resident #73's face cream on Thursday, 04/20/23, morning around 7 a.m. She said the pharmacy told her the medication would be sent out that evening. She said she did call the pharmacy to check on the order because she did not know it had not come in. During an interview on 04/26/23 at 2:58 p.m., the DON said medication aides, or the nurse should be contacting the pharmacies to order needed medications. She said any over the counter medication should be ordered by purchasing staff. She said any controlled medications would be ordered by the ADON. She said if the medication was ordered by 3 p.m. and was not received that evening, the ADON should have called the pharmacy on Friday and Saturday to check on the medication. She said the medication should have been stat (immediately) and the medication should have been at the facility. She said regardless the nurse should have called to find out why the medication was delayed. She stated a resident not receiving an ordered medication could cause the resident to have different reactions. She said Resident #73 not having her face cream could cause her to be in pain. She said the nurses could address the pain in other manners. During an interview on 04/26/23 at 3:36 p.m., the administrator said the nurse orders a medication and she should have called to see why the medication was not received, or the next nurse on duty should have called to see why the medication was not delivered last week. She said a resident not having an ordered medication was unacceptable. She said the medication not being available should have been reported to the physician, even for a PRN (as needed) medication. She said she did not have a policy concerning unavailable medication, but it is basic nursing. If you don't have a medication, you notify the physician. During an interview on 04/26/23 at 4:14 p.m., Family Member #1 said she did not have exact dates, but she knew Resident #73 had been out of her medication at least 3 times. She said she had a spell back in January, but they were out of the medication. She said she thought there was another time around November 2022 that she was out of her medications and was having pain. She said when Resident #73 had the periods of pain, the pain was excruciating. During an interview on 04/26/2026 at 4:16 p.m., Family Member #2 said he had tried to talk to staff a few times about Resident #73's medication and he got the run around. He said if they would just give Resident #73 her medication, they could keep the pain under control. He said he felt like family and Resident #73 were just blown off. 2. Record review of Resident #23s face sheet dated 4/24/23 revealed she was a [AGE] year-old female, who readmitted to the facility on [DATE]. Resident #23 had diagnoses of atrial fibrillation (irregular, often rapid heart rate that causes poor blood flow), and heart failure (the heart cannot pump or fill adequately). Record review of Resident #23's quarterly MDS dated [DATE] revealed she had a BIMS of 14, which indicated she was cognitively intact. Resident #23 required extensive to total assistance of two persons for most ADLs. Record review of Resident #23's care plan dated 6/27/22 revealed the resident had altered cardiovascular status related to atrial fibrillation with interventions to observe and report to the nurse any adverse reactions of digoxin therapy: lack of appetite/eating, complaints of nausea, vomiting, diarrhea, extreme headache, or complaints of vision changes such as blurred vision or seeing yellow. The care plan also revealed the resident was on digoxin related to atrial fibrillation and heart failure with interventions to report to physician if pulse falls below 60 or above 110, or if detected skipped beats or changes in rhythm. Record review of Resident #23's Order Summary Report dated 4/26/23 revealed an order for digoxin 125 mcg one tablet by mouth once daily and to hold (not give) if pulse rate less than 60. Record review of Resident #23s MAR dated 4/01/23-4/30/23 revealed an order for digoxin 125 mcg one tablet by mouth once daily and to hold (not give) if pulse rate less than 60. During an observation of medication pass on 4/25/23 at 8:25 AM, MA E administered Resident #23's digoxin 125 mcg 1 tablet and did not check the resident's pulse per the physician's orders prior to administering the medication. During an observation and interview on 4/25/23 at 4:00 PM, MA E said when giving digoxin, she should check the resident's blood pressure and if the diastolic blood pressure was under 60 then she would not give the medication. MA E read off Resident #23's order for digoxin and it said to give the medication if the heart rate was below 60. MA E showed surveyor on her computer screen that there was not a place to document a heart rate or a prompt to obtain a heart rate prior to administering digoxin, therefore, she did not know she needed to check the heart rate prior to administering the medication. MA E said she did not check a heart rate or blood pressure on Resident #23 prior to administering the digoxin. MA E said she did not know what effects of a low heart rate could cause to a resident on digoxin. During an interview on 4/25/23 at 4:09 PM LVN D said a resident could have a cardiac arrhythmia (improper beating of the heart) which could lead to cardiac arrest (heart stops beating) if digoxin was given, and their heart rate was already too low. LVN D said digoxin will lower the resident's heart rate. During an interview on 4/26/23 at 2:58 PM the DON said a resident's pulse should be checked prior to administering digoxin. The DON said MA E should have checked Resident #23's pulse prior to administering her digoxin and should not give the medication if the resident's heart rate was below 60. The DON said she would expect the MA to follow physicians' orders to check the resident's pulse prior to administering digoxin for the safety of the residents . During an interview on 4/26/23 at 3:53 PM the Administrator said the normal expectation for digoxin administration would be for the MA to check the resident's heart rate prior to administering the medication, because digoxin lowers the heart rate. The Administrator said a low heart rate was also a sign of digoxin toxicity (too much of the medication in the body) which could be life threatening. The Administrator said she would expect the MA to follow the physician's orders to check the pulse rate prior to administering the medication. Record review of the facility's policy titled Administering Medications dated December 2012 revealed . medications shall be administered in a safe and timely manner, and as prescribed . medications [NAME] be administered in accordance with the orders . the following information must be checked/verified for each resident prior to administering medications . vital signs, if necessary . Review of a facility Administering Medications policy dated December 2012 indicated, Medications shall be administered in a safe and timely manner, and as prescribed .medications must be administered in accordance with orders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed for incontinent care. (Resident #23) The facility failed to ensure CNA C changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #23. The facility failed to ensure CNA C secured her hair to prevent contact with the resident's female perineum area between her upper inner thighs while providing incontinent care. This failure could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: Record review of Resident #23s face sheet dated 4/24/23 revealed she was a [AGE] year-old female, who readmitted to the facility on [DATE]. Resident #23 had diagnoses of chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the lungs or cannot get rid of enough carbon dioxide from the body), chronic obstructive pulmonary disease (constriction of the airways and difficulty or discomfort in breathing), heart failure (the heart cannot pump or fill adequately), and a rash and other skin eruption (outbreak of red, bumpy, scaly, or itchy patches of skin, possibly with blisters or welts). Record review of Resident #23's quarterly MDS dated [DATE] revealed she had a BIMS of 14, which indicated she was cognitively intact. Resident #23 required extensive to total assistance of two persons for most ADLs. Resident #23 required oxygen therapy. Record review of Resident #23's Order Summary Report dated 4/26/23 revealed an order for nystatin powder applied to the peri-area topically every shift. There were also orders for preventative skin care to apply moisture barrier every shift and as needed and an order to apply barrier cream to buttocks/gluteal folds every shift until resolved. Record review of Resident #23s MAR dated 4/01/23-4/30/23 revealed an order for Diflucan (used to treat fungal or yeast infections) 200 mg by mouth in the afternoon related to a rash and other skin eruption with a start date of 4/19/23 and a stop date of 4/23/23. During an observation of incontinent care on 04/25/23 starting at 4:53 PM, CNA C performed hand hygiene and put on gloves. CNA C pulled off Resident #23's covers, unsecured her adult brief and pulled it down from the front and pushed it down between her legs. Resident #23 was soiled with urine and liquidity stool. CNA C then obtained wipes from the package on the bedside tablet and wiped Resident #23's front peri area in a downward motion and then obtained more wipes from the package on the bedside table and wiped again in a downward motion. CNA C then with the same gloves on, placed one gloved hand on the resident's shoulder and the other gloved hand on the residents unclothed hip and turned resident #23 onto her left side. CNA C with same gloves on, reached onto the bedside table and grabbed the package of wipes and pulled several wipes from the package and placed back on the resident's bedside table. With the same gloves, CNA C then cleaned the resident's back peri area, then obtained and placed a clean blue pad and a clean adult brief halfway under the resident and rolled the dirty adult brief up under resident #23. With the same gloves, CNA C then proceeded to reach over to the resident's shelf and obtained two packets of barrier cream, opened them, and applied the cream to the resident's red back peri area. Then with the same soiled gloves, CNA C then proceeded to lean over the top of Resident #23's body and grabbed the dirty adult brief on the opposite side and removed it and placed in a plastic bag on bed, then rolled the clean blue pad and adult brief out flat on the bed. While CNA C was leaned over Resident #23, her long braided hair fell in between resident's front peri area and her upper thighs. Then with the same soiled gloves, CNA C rolled resident onto her back and CNA C's hair braids came out from in between the resident's front peri area and upper thigh areas. CNA C then with same gloves, applied barrier cream to Resident #23's front peri area in all the skin folds and then secured the resident's clean adult diaper. CNA C then removed her soiled gloves and discarded them in the trash. CNA C did not perform hand hygiene prior to applying clean gloves and proceeded to assist resident change into a clean gown and then pulled Resident #23's covers back up over her. CNA C then removed the package of wipes off the resident's bedside table and she did not clean the table prior to replacing the Rresident's personal items back on the table. CNA then removed her gloves, discarded them, and left the room and did not sanitize or wash hands prior to exiting the room. During an interview on 4/25/23 at 5:08 PM CNA C said she should change her gloves as many times as needed when providing incontinent care to a resident. CNA C said she did not change her gloves while performing incontinent care to Resident #23 until after applying the resident's cream to all her peri area. She said she changed her gloves after applying the cream to the resident so she would not get the cream on the resident's clothes. She said she did not change her gloves or perform hand hygiene after performing incontinent care to the resident and applied cream to her back peri area and then to front peri area. CNA C said she did not change her soiled gloves or perform hand hygiene prior to putting Resident #23's clean adult brief on. CNA C said the resident could get an infection if she did not change her gloves and perform hand hygiene when going from a dirty area to a clean area while providing incontinent care. CNA C said she realized when she leaned over the resident that her long braids had come in contact with the resident, but she did not realize her braids had fell between the resident's legs in her front peri area. CNA C said she should have pulled her back prior to performing incontinent care to prevent the spread of infection to other residents. CNA C said Resident #23 had a yeast infection in her peri area and she could potentially spread it to other residents. During an interview on 4/26/23 at 2:58 PM, the DON said when providing incontinent care, the CNAs should perform hand hygiene prior to starting and before putting on clean gloves. The DON said the CNAs should change gloves and perform hand hygiene when moving from a dirty area to a clean area. The DON said CNA C should have changed her gloves and performed hand hygiene at least 3 times during the incontinent care and as needed when gloves became soiled. The DON said CNA C and all staff should have their hair pulled back while providing care to any resident, so not to transfer bacteria from one resident to another resident. The DON said she was responsible for ensuring the CNAs provided proper incontinent care. The DON said she would be in-servicing staff to educate them on proper incontinent care. The DON said not providing proper incontinent care and not performing hand hygiene appropriately could cause an infection in the resident and it was an infection control issue. During an interview on 4/26/23 at 3:53 PM, the Administrator said staff should keep their hair pulled back or put up during resident care and their hair should not come in contact with the resident to prevent spread of infection. The Administrator said CNA C should have changed her gloves and performed hand hygiene at least 3 times while providing Resident #23's incontinent care and CNA C's hair should not have been allowed to fall between the resident's legs and front peri area. The Administrator said staff should practice good incontinent care to prevent the spread of infections, development of urinary tract infections, and it was just unsanitary. Record review of the competency for incontinent care dated 10/18/21 revealed CNA C demonstrated competency in providing incontinent care. Per the incontinent care competency procedure check off list, staff should: wash hands, put on gloves, remove brief, then clean from the front to back, then remove gloves, sanitize hands, put on new gloves, roll the resident to side, clean resident all over, remove brief and discard, change gloves, sanitize hands, apply new brief, apply barrier cream, change gloves, position resident, remove gloves, then wash hands. Requested policy on incontinent care on 4/26/23 at 1:00 PM and the facility provided a policy titled Urinary Incontinence-Clinical Protocol, but it did not address the procedure of performing incontinent care. Record review of the facility's policy titled Handwashing/Hand Hygiene dated revised August 2015 revealed . the facility considers hand hygiene the primary means to prevent the spread of infections . all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . wash hands with soap and water for the following situations: when hands visibly soiled and after contact with a resident with infectious diarrhea . use alcohol based hand rub for following situations: . before and after direct contact with residents . before moving from a contaminated body site to a clean body site during resident care . after contact with a resident's intact skin . hand hygiene was the final step after removing and disposing of personal protective equipment . use of gloves does not replace handwashing/hand hygiene . integration of glove use along with routine hand hygiene was recognized as the best practice for preventing healthcare-associated infections .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their established smoking policy for 1 or 1 residents reviewed for smoking. The facility failed to follow their smoking policy and allowed Resident #78 to smoke on their smoke-free facility premises and keep his cigarettes and lighter in his room. Findings included: Record review of Resident #78's face sheet dated 4/24/23 revealed he was an [AGE] year-old male, who was admitted to the facility on [DATE] with the diagnoses of heart disease, anxiety (feeling of worry or unease about an uncertain outcome), weakness, unsteadiness on feet, and lack of coordination. Record review of Resident #78's quarterly MDS dated [DATE] indicated he had a BIMS of 15, which indicated he was cognitively intact. Resident #78 required supervision with one person assist for most ADLs. Record review of Resident #78's undated care plan revealed there were no problem areas or interventions related to the resident smoking. During an observation and interview on 4/24/23 at 12:34 PM surveyor smelled an overwhelming scent of stale cigarette smoke upon entering Resident #78's room. Resident #78 said he smoked and wheeled himself outside at night to smoke. Resident #78 said he kept his cigarettes and lighter hid in his room, but he said he never smoked inside the facility. Resident #78 said he did not know what the smoking policy was for the facility. During an interview on 4/25/23 at 4:39 PM CNA C said she had worked at the facility for a year and a half and normally worked on the hall Resident #78 resided on. CNA C said Resident #78 went outside to smoke and she said she did not know where he kept his smoking supplies. CNA C said Resident #78 was not supervised when he smoked, but he was with it. CNA C said Resident #78 had been going outside to smoke for as long as she had worked at the facility. CNA C said she assumed everyone already knew he smoked, because he was doing it before she started working at the facility. CNA C said she did not report to anyone that Resident #78 smoked. CNA C said she did not know what the facility's smoking policy was for the residents. During an interview on 4/25/23 at 5:17 PM LVN D said the facility was a smoke free facility and they do not have any residents that smoked. LVN D said she had not seen or smelled anything to prompt her that someone was smoking. LVN D said in the past she knew about a resident who had an electronic cigarette, and it was confiscated. During an interview on 4/25/23 at 5:25 PM the DON said she was not aware a resident was smoking or had smoking supplies in their room. The DON said she was not aware there was staff with knowledge of Resident #78 smoking. The DON said the staff should have reported the resident was smoking, because the facility was a smoke free facility. The DON said she would inform Resident #78 immediately of the facility's smoke free policy and he could not keep smoking supplies in his room. During an interview on 4/26/23 at 11:30 AM the DON said she had worked at the facility since February 2023. The DON said she was not aware there was a resident in the facility that was smoking or keeping his smoking supplies in his room. The DON said the facility was a smoke free facility. The DON said residents were informed of the non-smoking policy and were required to sign a non-smoking policy upon admission. The DON said residents should not have smoking supplies (cigarettes or lighters) in their rooms and it was against the facility's policy. The DON said she was not aware Resident #78 was smoking on the premises or that he had smoking supplies in his room. The DON said she was not aware staff were aware of Resident #78 smoking and did not report it. The DON said she in-serviced all staff on the smoking policy and when/what to report. The DON said she had the social worker discuss the smoking policy with Resident #78 and removed his smoking supplies from his room. The DON said Resident #78's family was also contacted to pick up the smoking supplies from the facility. The DON said a resident having smoking supplies in their room posed a threat to the other residents that wandered in the facility, who could find the smoking supplies and potentially burn the facility down. During an interview on 4/26/23 at 3:53 PM the Administrator said they determined the resident had been hiding his smoking supplies in his room and had been placing the smoked ends of the cigarettes in a plastic baggy and keeping in his room. The Administrator said the Social Worker had discussed the smoking policy with the resident and notified his family to pick up his smoking supplies. The Administrator said she was not aware Resident #78 had been smoking on the facility's premises or had smoking supplies in his room until surveyor informed them on 4/25/23. The Administrator said it was against the smoking policy for residents to smoke on the premises or keep smoking supplies in their rooms. The Administrator said Resident #78 had signed the non-smoking policy upon admission. Record review of the facility's undated admission agreement titled Smoking Policy revealed . it is the policy of the facility to provide a smoke-free environment for residents . residents may not use or keep cigarettes, cigars, matches or any smoking paraphernalia in their room or on their person at any time during their stay at the facility . failure to adhere to the policy could result in immediate discharge .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included 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 or treatment options and to choose the alternative or option he or she preferred, for 3 of 26 residents ( Resident #52, Resident #104 and Resident #327) reviewed for resident rights . The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available from Resident #52 prior to administering Quetiapine (antipsychotic). The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available from Resident #104 prior to administering Seroquel (antipsychotic). The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available from Resident #327 prior to administering Risperidone [an anti-psychotic medication used to treat certain mental/mood disorders, such as schizophrenia, disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder (disorder associated with episodes of mood swings), and irritability associated with autistic disorder (developmental disability caused by differences in the brain)] . These failures could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. Findings included: 1. Record review of a face sheet dated 04/24/23 revealed Resident #52 was [AGE] year-old female admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and insomnia (a sleep disorder in which you have trouble falling and/or staying asleep). Record review of Resident #52's consolidated physician order dated 04/26/23 revealed the following orders: *Quetiapine 50MG, give 2 tablets by mouth at bedtime started 01/02/23, *Quetiapine 50MG, give 1 tablet once a day started 12/13/22, and *Quetiapine 25MG, give 1 tablet in the afternoon started 12/08/22. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #52 was usually understood and usually understood others. The MDS revealed Resident #52 had a BIMS of 00 which indicated severe cognitive impairment. The MDS revealed Resident #52 wandered 1 to 3 days out of the week. The MDS revealed Resident #52 required supervision for transfer and walking in corridor, limited assistance for bed mobility, walking in room, dressing, toilet use, and personal hygiene, extensive assistance for eating, and total dependence for bathing. The MDS revealed Resident #52 had verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others) which occurred 1 to 3 days a week. The MDS revealed Resident #52 received 7 days of an antipsychotic. Record review of Resident #52's undated care plan did not address antipsychotic usage. Record review of the Resident #52's MAR dated 04/01/23-04/30/23 revealed Quetiapine 25MG was administered as ordered. MAR revealed Quetiapine 50MG was administered as ordered. The MAR revealed Quetiapine 50MG was administered as ordered. Record review of Resident #52's Consent for use of Psychoactive Medication Therapy dated 10/06/23 revealed Quetiapine (Seroquel) to treat dementia with psychotic features, no notation of I Do or I Do Not, and no resident or resident representative signature noted. Record review of Resident #52's undated Consent for Antipsychotic or Neuroleptic Medication Treatment revealed loud screaming in resident and hitting on tables as psychiatric condition and/or maladaptive behavior, unspecified dementia as diagnosis based on the following diagnostic criteria and assessment findings exhibited, medication of Seroquel 50 MG every day. MD signed on resident and resident representative line. 2. Record review of a face sheet dated 04/24/23 revealed Resident #104 was a [AGE] year-old female admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) with agitation, depressive episodes (are periods of low mood and other symptoms of depression), and insomnia (a sleep disorder in which you have trouble falling and/or staying asleep). Record review of Resident #104's consolidated physician order dated 04/26/23 revealed to administer Zyprexa 5MG, give 1 tablet by mouth twice a day started on 01/17/23. Record review of the annual MDS assessment dated [DATE] revealed Resident #104 was sometimes understood and rarely/never understood others. The MDS revealed Resident #104 was unable to complete the BIMS. The MDS revealed Resident #104 had short-and-long term memory problem and moderately impaired cognitive skills for daily decision making. The MDS revealed Resident #104 required limited assistance for walking in room and transfer, extensive assistance for bed mobility, dressing, eating, toilet use, and personal hygiene, and total dependence for bathing. The MDS revealed Resident #104 received antipsychotic and antidepressant in the last 7 days. Record review of a care plan dated 03/22/23 revealed Resident #104 used the psychotropic medication (Zyprexa). Intervention included administer psychotropic medications as ordered by physicians. The care plan revealed Resident #104 used antidepressant medications related to depression. Intervention included administer antidepressant medications as ordered by physician. Record review of Resident #104's MAR dated 04/01/23-04/30/23 revealed Zyprexa 5MG was given as ordered. Record review of Resident #104's Consent for Antipsychotic or Neuroleptic Medication Treatment dated 06/08/22 revealed Depression as psychiatric condition and/or maladaptive behavior, depression as diagnosis based on the following diagnostic criteria and assessment findings exhibited, for medication Seroquel 25 MG every day. The need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medication is indication was not noted. No resident of resident's representative signature noted. 3. Record review of a face sheet dated 04/24/23 revealed Resident #327 was [AGE] year-old male admitted on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of Resident #327's consolidated physician order dated 04/26/23 revealed to administer Risperidone 1MG, give 1 tablet by mouth at bedtime started on 11/30/22. Record review of the annual MDS assessment dated [DATE] revealed Resident #327 was usually understood and usually understood others. The MDS revealed Resident #327 had a BIMS of 03 which indicated severe cognitive impairment. The MDS revealed Resident #327 required supervision eating and walk in room, extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. The MDS revealed Resident #327 received antipsychotic in the last 7 days. Record review of a care plan dated 04/21/23 revealed Resident #327 used a psychotropic medication (Risperidone) related to schizoaffective disorder. Intervention included administer psychotropic medication as ordered by physician. Record review of Resident #327's MAR dated 04/01/23-04/30/21 revealed Risperidone 1MG was administered as ordered. Record review of Resident #327's Consent for Antipsychotic or Neuroleptic Medication Treatment dated 12/23/22 revealed schizoaffective disorder as psychiatric condition and/or maladaptive behavior, no noted diagnosis based on the following diagnostic criteria and assessment findings exhibited, for medication Risperidone 1 MG at bedtime. No signature noted for resident or resident's representative. During an interview on 04/26/23 at 2:09 p.m., RN U said nurses were responsible for obtaining medical consents for psychotropic medications. She said the doctor and the resident or family member was supposed to sign consent. RN U said nurses and ADONs should ensure consents were properly filled out and signed. She said consent should be obtained prior to starting medications. RN U said consents were important, so resident and family member know what they are on. She said if a doctor did not sign the consent, it was like not getting permission to give the medication. RN U said not having the resident or resident's representative sign consents made them not informed of care and treatment. During an interview on 4/26/23 at 2:58 PM the DON said the charge nurses were responsible for getting the consents signed for antipsychotics and psychotropic medications. The DON said consents should be obtained prior to administration. She said sometimes it was hard to reach family to get consent and the resident needed the medication as soon as it was ordered. The DON said the medication orders and consents should have a proper diagnosis to treat the resident. During an interview on 04/26/23 at 4:24p.m., the ADM was asked for a policy regarding informed consent of treatment was requested. The policy was not received prior to exit. During an interview on 05/01/23 at 9:13 a.m., the Consulting Pharmacist said the facility had not been scanning the antipsychotic or psychotropic medication consents to the computerized software and she often would send the blank consents to the facility and ask them to complete them. The Consulting Pharmacist said the consents for antipsychotic or psychotropic medications should be completed and include an appropriate diagnosis for the medication, what behaviors were being treated, the medication and dosage of the medication, and the possible side effects of taking the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of a face sheet dated 04/24/23 revealed Resident #52 was a [AGE] year-old female admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition). Record review of the quarterly MDS assessment dated [DATE] revealed Resident #52 was usually understood and usually understood others. The MDS revealed Resident #52 had a BIMS of 00 which indicated severe cognitive impairment. The MDS revealed Resident #52 wandered 1 to 3 days out of the week. The MDS revealed Resident #52 required supervision for transfer and walking in corridor, limited assistance for bed mobility, walking in room, dressing, toilet use, and personal hygiene, extensive assistance for eating, and total dependence for bathing. Record review of Resident #52's care plan dated 03/03/23 revealed had an actual fall on 02/26/23. Intervention included evaluate the environment at the time and location of the fall and attempt to identify any factors that may have contributed to the fall. During an observation on 04/25/23 at 8:45 a.m. revealed Resident #52's room had a rolled up white towel and sheet noted at the base of two walls. The towel and sheet were slightly damp with wet footprint noted in the middle of the room. During an interview on 04/25/23 at 11:30 a.m., AF#1 said Resident #52 had water in the room after any heavy rainstorm. AF#1 said the last time Resident #52 had water leak through the outer walls was about 3 weeks ago. AF#1 said the facility was aware of the water leakage because they opened a hole in the bathroom ceiling thinking the issue was coming from there, but the issue was from outside. AF #1 said on one of the walls the water comes in, the sofa laid against it would wet and would eventually attract pest. During an observation on 04/26/23 at 9:00 a.m., heavy rain was falling with gusty wind and thunder. During an interview on 04/26/23 at 9:30 a.m., CNA S said she had been employed at the facility for 10 years but recently returned in June 2022. She said since June 2022, Resident #52's room had water leakage. CNA S said the facility had tried to patch the issue, but the water would start leaking again. 3. Record review of a face sheet dated 05/01/23 revealed Resident #10 was a [AGE] year-old female admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and abnormalities of gait and mobility. Record review of the annual MDS assessment dated [DATE] revealed Resident #10 was usually understood and usually understood others. The MDS revealed Resident #10 had unclear speech, minimal difficulty hearing, and impaired vision with corrective lenses. The MDS revealed Resident #10 had a BIMS of 02 which indicated severe cognitive impairment. The MDS revealed Resident #10 required supervision for eating, extensive assistance of bed mobility, transfer, dressing, toilet use, and personal hygiene, and total dependence for bathing. Record review of Resident #10's care plan dated 07/19/22 revealed at risk for falls related to amputation, balance problems, history of falls, impaired mobility, incontinence, poor communication/comprehension, poor safety awareness, short term memory loss, unaware of safety needs, wandering and weakness. Intervention included provide a safe environment. During an interview on 04/26/23 at 10:00 a.m., MA Q said Resident #10's room had a water leak for the last 2 years and Resident #52 at least the last 6 months. She said the Maintenance workers had gone in the ceiling of the bathroom and patched something, but it did not work. MA Q said the Maintenance responded to work orders promptly but felt the water leak issue was beyond their skill set. She said water being on Resident #10 and Resident #52's floor was unsafe and could cause falls. MA Q said Resident #10's family had bought very nice furniture and unfortunately any time it rained, it got wet and ruined. She said the DON and the ADM were aware of the issue and they tell staff members to lay blanket down to attempt to absorb the water. MA Q said Resident #10's room smelled horrible and probably had mold growing in the walls. She said Resident #10 had to sleep in her room with that horrible smell. During an observation on 04/26/23 at 10:10 a.m., Resident #10's room was located at the end of the hall. In Resident #10's room, coming from underneath her bed was a moderate amount of water seeping out into the middle of the floor. Underneath Resident #10's bed, on the wall was two saturated, rolled up blankets and a power cord to the bed was almost in the puddle of water. During an observation of Resident #10's room on 04/26/23 at 10:40 a.m., a large amount of coming from underneath her bed was a large amount of water seeping out into the middle of the floor. Underneath Resident #10's bed, on the wall was two saturated, rolled up blankets and a power cord to the bed in the puddle of water. Resident #10's room had a strong odorous smell of mildew. During an interview on 04/26/23 at 2:09 p.m., RN U said she had been employed at the facility since March 2023. She said Resident #10 and Resident #52's room had water leaking from the baseboards since the beginning of her employment. RN U said the DON and Maintenance were aware of the issue. She said earlier staff attempted to clean up the water on Resident #10's floor but it was so much water, housekeeping had to be called to assist. RN U said she had to unplug the bed because she noticed the power cord in the water. She said Resident #10's room smelled like mold. RN U said the water leakage issue was problematic because it could cause falls and the mold smell could cause respiratory issues leading to pneumonia. During an interview on 04/26/23 at 2:58 p.m., the DON said today was the first time she heard about Resident #10 and Resident #52's room had water leaks. She said no staff members had ever told her about the issue. The DON said staff placed work orders in a computerized maintenance log and the maintenance workers managed it. She said the system allowed work orders to be prioritized according to the urgency of the issue. The DON said the water leak issue placed the residents at risk for falls and not having a clean environment. During an interview on 04/26/23 at 4:24 p.m., the ADM said she and maintenance were responsible for the upkeep of the facility. She said she tried to ensure the facility's upkeep by doing rounds and use of an electronic maintenance log. The ADM said she expected issues to be fixed in a timely manner, but it also depended on the type of issue. She said the facility needed a new roof and had been getting bids. The ADM said the facility had attempted to patch the roof. She said Resident #10's room smelled damp, but she had heard from staff members it had only leaked it her room twice. The ADM said she had heard about Resident #52's water leak but did not know how long it had been happening. She said Resident #10 had not been moved until the water leak was permanently fixed. The ADM said she would move Resident #10 if the water leak could not be temporarily fixed. During an interview on 04/26/23 at 4:45 p.m., MS T said he had been employed at the facility for a month and half but had worked for the company for several years. He said he had only received 2 work orders since he started pertaining to the water leaks in Resident #10 and Resident #52's room. MS T said the facility placed a bid to fix the roof about 1.5 to 2 weeks ago. He said he had patched the roof twice 2 weeks ago. MS T said Resident #10's room had a strong mildew smell. He said the facility had never tried to move Resident #10 and her roommate out of the room until the roof was fixed. He said no staff member on the secured unit notified the maintenance staff when Resident #10 or Resident #52's rooms started leaking today. MS T said work orders were placed in a computerized maintenance log and could be prioritized low, medium, high, and critical. MS T said he did not know why a bid to fix the facility's roof was not placed before 2 weeks ago. Record review of the Maintenance Work History Report dated in the last 12 months revealed only scheduled maintenance services. The Maintenance Work History Report did not reveal roof inspection. Record review of an undated open and in progress work orders report revealed .roof leaking .high priority .Resident #10's room .leak outside [NAME] center .high priority .hallway [NAME] center . Record review of a facility's Maintenance Service policy dated 10/09 revealed .maintenance service shall be provided to all areas of the building, grounds .the maintenance department is responsible for maintaining the buildings .building in good repair and free from hazards . Review of a Quality of Life - Homelike Environment facility policy dated May 2017 indicated, Residents are provided with a safe, clean, comfortable, homelike environment .staff shall provide person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences .the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include clean, sanitary, and orderly environment . pleasant neutral scents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment 3 of 26 residents reviewed for environment. (Resident #73, Resident #52, Resident #10). The facility failed to properly make the bed of Resident #73. The facility failed to ensure Resident #52 did not have a water leak in their bedroom. The facility failed to ensure Resident #10 did not have a water leak and a strong odor in her bedroom. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: 1. Record review of the face sheet 04/25/23 indicated Resident #73 was [AGE] years old and was admitted on [DATE] with diagnoses including muscle wasting (decrease in size and wasting of muscle tissue), depressive episodes (episodes of depressed moods), and abnormalities of gait and mobility (impaired strength). Record review of the MDS assessment dated [DATE] indicated Resident #73 was understood and understood others. The MDS indicated a BIMS score of 13 indicating Resident #73 was cognitively intact. The MDS indicated Resident #73 required extensive assistance from staff for activities of daily living. Record review of a care plan revised on 03/17/23 indicated Resident #73 had an ADL self-care performance deficit related to balance issues, cognitive impairment, CVA (stroke), and limited mobility. Record review of Resident Council Minutes dated 02/03/23 indicated, Resident #73 indicated the Bed is not made daily. During an interview on 04/24/23 at 11:15 a.m., The roommate of Resident #73 said Resident #73's bed never got made. She said there were days it did not get made until Resident #73 got ready to go to bed. She said Resident #73's preacher visited at times between 10 and 12 o'clock and there would be wet chuck pads on the bed. She said she was embarrassed for Resident #73, and she wished she could help her more. She said on 04/24/23 the bed was not made, only the blankets were pulled up. She said staff sat on their bottoms and play on their phone. She said she had to help her roommate a lot. During an observation and interview on 04/24/23 at 11:18 a.m., Resident #73 said her bed did not get made up unless one specific CNA was working. She said her bed was not made up at this time. She said it just had the blankets pulled up on it. The bed was observed to have the blankets pulled up. The throw pillows were noted to be piled in the bedside chair. She said her bed not being made, made her feel terrible. She said she liked her bed made up. During an interview on 04/25/23 at 8:01 a.m., Resident #73's roommate said Resident #73 made her own bed the morning of 04/25/23 because she did not want the surveyor to see it unmade. During an interview on 04/25/23 at 8:45 a.m., Resident #73 said the CNA did pull up her blankets on her bed, but she had to put the throw pillows on the bed because she did not want anyone to see the bed unmade. During an interview on 04/26/23 at 10:22 a.m., CNA N said when she worked Resident #73's bed got changed on shower days and was made every day she worked. She said she worked the same days as a nutritional aide that made all the beds. She said she could not speak for the days she was not working. During an interview on 04/26/23 at 11:55 a.m., LVN O said she has not known of any times when Resident 73's bed had not been made. She said the CNAs made the beds. She said normally they make the bed when they get the resident up or when they are at breakfast. During an interview on 04/26/23 at 2:58 p.m., The DON said beds should be made when the resident was gotten up in the morning or as soon as possible after breakfast. She said the CNAs were responsible for making the beds, but anyone can make a bed. She said she would expect the bed to be fully made up and Resident 73's pillows to be placed on her bed. She said Resident #73 could be embarrassed by her bed not being made. During an interview on 04/26/23 at 3:36 p.m., the administrator said staff should have been making the beds properly as soon as the resident was up and especially if it was embarrassing the resident. During an interview on 04/26/23 at 4:14 p.m., a family member of Resident #73 said when she had visited she had not ever seen the bed unmade. She said if it was something Resident #73 complained about she knew it happened because Resident #73 was very sweet and hated to complain.

**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 6 of 24 residents reviewed for new admissions (Resident #52, Resident #104, Resident #327, Resident #275, Resident #277, and Resident #121). 1. The facility failed to complete a baseline care plan for Resident #52, Resident #104, and Resident #327. 2. The facility did not provide a summary of the baseline care plan to Resident #275, Resident #277, and Resident #121 and/or their representatives. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1.Record review of a face sheet dated 04/24/23 revealed Resident #52 was [AGE] year-old female admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), seasonal allergic rhinitis (allergies), dysphagia (difficulty swallowing), and insomnia (a sleep disorder in which you have trouble falling and/or staying asleep). Record review of the admission MDS assessment dated [DATE] revealed Resident #52 was usually understood and usually understood others. The MDS revealed Resident #52 had a BIMS of 03 which indicated severe cognitive impairment. The MDS revealed Resident #52 required supervision for transfer, walk in room and corridor, and eating, extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and bathing. Record review of Resident #52's undated baseline care plan addressed the following sections: primary language, advanced directive, and code status. The baseline care did not address the following: identification, communication, vision and hearing, daily preferences that resident prefers, initial admission/discharge goals, education, functional status, mobility devices, health conditions/special treatments, level of consciousness/cognition, bowel and bladder, medications, pain, medical conditions, safety risk, dietary/nutritional status, therapy, and social services. The baseline care did not reveal signature of resident and representative or staff completing the care plan. 2. Record review of a face sheet dated 04/24/23 revealed Resident #104 was [AGE] year-old female admitted on [DATE] with diagnoses including hyperlipidemia (high levels of fat particles (lipids) in the blood), depressive episodes (periods of sadness), insomnia (a sleep disorder in which you have trouble falling and/or staying asleep), and hypertension (high blood pressure). Record review of the annual MDS assessment dated [DATE] revealed Resident #104 was sometimes understood and rarely/never understood others. The MDS revealed Resident #104 was unable to complete the BIMS. The MDS revealed Resident #104 had short-and-long term memory problem and moderately impaired cognitive skills for daily decision making. The MDS revealed Resident #104 required limited assistance for walking in room and transfer, extensive assistance for bed mobility, dressing, eating, toilet use, and personal hygiene, and total dependence for bathing. Record review of Resident #104 electronic chart reviewed on 04/25/23 did not reveal a baseline care plan. 3. Record review of a face sheet dated 04/24/23 revealed Resident #327 was [AGE] year-old male admitted on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), anxiety disorder (persistent and excessive worry that interferes with daily activities), mild protein-calorie malnutrition (when you are not consuming enough protein and calories), and hypertension (high blood pressure). Record review of the annual MDS assessment dated [DATE] revealed Resident #327 was usually understood and usually understood others. The MDS revealed Resident #327 had a BIMS of 03 which indicated severe cognitive impairment. The MDS revealed Resident #327 required supervision eating and walk in room, extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. Record review of Resident #327 electronic chart reviewed on 04/25/23 did not reveal a baseline care plan. During an interview on 04/26/23 at 2:09 p.m., RN U said baseline care plan should be started by the admission nurse and sections completed by the appropriate interdisciplinary team member. She said the ADONs assigned to the units should ensure the baseline care plans are completed and a copy given to the resident or resident's representative. RN U said baseline care plans were important know how to take care of the resident prior to the comprehensive assessment. She said resident not having baseline care plan were at risk for not getting their needs met and family not knowing the plan of care. 4.Record review of a face sheet dated 04/25/2023 revealed Resident #275 was a 59- year-old- male, admitted on [DATE] with the diagnoses of malnutrition (occurs when the body doesn't get enough nutrients), dysphagia (swallowing difficulties), and exocrine pancreatic insufficiency (a condition caused by reduced or inappropriate secretion or activity of pancreatic juice and its digestive enzymes, pancreatic lipase in particular). Record review of an admission MDS dated [DATE] for Resident #275 revealed an incomplete BIMS. The MDS also revealed Resident #27 required limited assistance with eating. The MDS revealed Resident #275 had high visual impairment and received less than 25% of his nutrition from tube feeding. The MDS revealed Resident #275 was on a mechanically altered therapeutic diet. Record review of a baseline care plan completed on 04/04/2023 by LVN G, revealed Resident #275 was alert and cognitively intact. The baseline care plan was unsigned by resident and representative in the designated area for signature of review. During an interview on 04/26/2023 at 10:30 a.m., Resident #275 said he never received a copy of his baseline care plan, a list of his medications, or any type of treatment plan for his stay in the facility. Resident #275 said he needed a copy of the baseline care plan to make sure the facility was on the same page as he and his family member were about his care. Resident #275 said his care was complicated with wounds, dialysis, a PEG tube, getting therapy, receiving nectar thicken liquids and having constant diarrhea. 5.Record review of a face sheet dated 04/25/2023 revealed Resident #277 was an [AGE] year-old female admitted on [DATE] with the diagnoses of COPD-chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), anxiety (a feeling of fear, dread, and uneasiness), and rheumatic disorder of the mitral valve (a complication of strep throat. This infection can scar the mitral valve, causing it to thicken with scar tissue and narrow). Record review of a baseline care plan dated 04/11/2023 revealed Resident #277 was lethargic but cognitively intact. The baseline care plan was blank under the areas of: fall history, social services, signature of resident and representative, and signature of staff completing baseline care plan. Record review of an admission MDS dated [DATE] revealed an incomplete MDS assessment. No BIMS and no ADLs were recorded. During an interview on 04/24/2023 at 10:45 a.m., Resident #277 said no one gave her a copy of the baseline care plan. She said she did not know what a baseline care plan was. Resident #277 said no one had gone over her orders or discharge plans with her but to ask her family. During an interview on 04/24/2023 at 10:50 a.m., Resident #277's family member said they never received a copy of the baseline care plan and were never asked questions about Resident #277's discharge plans. Resident #277's family member said they were present when Resident #277 admitted , and no one offered them a list of her medications or orders or asked them to sign the baseline care plan. 6.Record review of a face sheet dated 04/25/2023 revealed Resident #121 was a 95- year-old- female, admitted on [DATE] with the diagnoses of malnutrition (occurs when the body doesn't get enough nutrients), pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid), and rhabdomyolysis (a serious medical condition that can be fatal or result in permanent disability). Record review of an admission MDS dated [DATE] for Resident #121 revealed a BIMS of 14, which indicated no cognitive impairment. The MDS indicated Resident #121 required extensive assist with ADLs. Record review of a baseline care plan for Resident #121 dated 03/27/2023 revealed incomplete sections titled social services and signature of resident and representative. The nursing sections were signed completed by LVN G on 03/27/2023. During an interview on 04/24/2023 at 9:55 a.m., Resident #121 said she had not received a copy of her base line care plan, had not been talked to about discharge plans, and was not given a medication and treatment list. Resident #121 said she would like her family to be provided the information on her behalf, so someone knew what was going on with her care. During an interview on 04/26/2023 at 2:00 p.m., RN K said that the baseline care plan was completed by the floor nurse that received the resident for admission. RN K said it was one of many assessments that were completed on admission, but the baseline care plan, the admission assessment, and the skin assessment were priority to complete the day the resident was admitted because they were time sensitive. RN K said she was unsure who completed the social service section of the base line care plan. RN K said she had not given any resident a copy of their base line care plan, asked them to sign it, or given them a copy of their medication and treatments. RN K said she was unaware of the requirement to keep the resident informed by giving them a copy and having them sign their baseline care plan as proof. During an interview on 04/26/2023 at 2:15 p.m., the DON said base line care plans are used in place of a comprehensive care plan until one can be developed to direct resident care according to their goals and choices. The DON said the baseline care plan needed to be completed with each department and discussed with the resident and resident representative. The DON said the baseline care plan was given to the resident and family along with a list of any medications and treatments the resident received. The DON said it was her responsibility to inform the nurses of the facility policy on base line care plans. The DON said she was not aware the nurses were not providing the resident with the baseline care plans after completion or that the social work section of the baseline care plan was not being completed. The DON said the resident could have felt left out or rejected when not given the opportunity to take part in their care plan. During an interview on 04/26/2023 at 2:30 p.m., the Administrator said the baseline care plans were an interdisciplinary form that was discussed with the residents on admit. The Administrator said it was the DON's responsibility to ensure the floor nurses completed the baseline care plan and provided a copy to the resident and family. An attempted telephone interview on 04/26/2023 at 3:00 p.m. with LVN G, no return call was received. Review of the facility's policy dated December 2016; titled Baseline Care Plan revealed .1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission 4. The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: the initial goals of the resident; a summary of the resident's medications and dietary instructions; any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and any updated information based on the details of the comprehensive care plan, as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of a face sheet dated 04/24/23 revealed Resident #34 was a [AGE] year-old female admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), fracture of shaft of right femur (thigh bone), intracapsular fracture (a bone fracture located within the joint capsule) of right femur, chronic viral Hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #34's consolidated physician order dated 04/26/23 revealed Escitalopram (anti-depressant) 20MG, give 1 tablet by mouth one time a day for depression started on 09/02/22. Mirtazapine (anti-depressant) 15MG, give 1 tablet by mouth in the evening related to other specified depressive episodes started on 06/24/22. Trazodone (anti-depressant) 50MG, give 1 tablet by mouth at bedtime related to other general symptoms and signs and dementia without behavioral disturbance started 12/21/22. The MAR revealed scooped mattress to bed every shift dated 12/08/22 and fall mat in place while in bed (unscheduled other orders). Record review of the quarterly MDS assessment dated [DATE] revealed Resident #34 was usually understood and usually understood others. The MDS revealed Resident #34 had a BIMS of 00 which indicated severe cognitive impairment. The MDS revealed Resident #34 required supervision for eating, limited assistance for transfer, and extensive assistance with bed mobility, dressing, toilet use, personal hygiene, and bathing. The MDS revealed Resident #34 was always incontinent of bladder and bowel. The MDS revealed Resident #34 had active diagnoses of viral Hepatitis, hyperlipidemia (abnormally high levels of fats (lipids) in the blood), non-Alzheimer's dementia, malnutrition (lack of sufficient nutrients in the body), and depression. The MDS revealed Resident #34 had a mechanically altered diet (change in texture of food or liquids). The MDS revealed Resident #34 had received an antidepressant in the last 7 days. Record review of the care plan dated 03/28/23 revealed Resident #34 had an actual fall with serious injury. Actual fall on 03/28/23. Interventions included evaluate for changes in range of motion after fall, check on me at frequent intervals every 2 hours, evaluate and monitor me for three days after the day the fall occurred, evaluate the environment at the time and location of the fall and attempt to identify factors contributed to the fall. The care plan did not address placement of scoop mattress and fall mat while in bed. Record review of Resident #34's undated care plan did not address incontinent of bladder and bowel, diagnosis of Viral Hepatitis C and Depression, nor usage of antidepressant. During an interview and observation on 04/24/23 at 12:04 p.m., Resident #34 was in her room with the door and privacy curtain closed. Resident #34 was sitting on the side of her bed. No scooped mattress noted. A fall mat was noted underneath the bed. Resident #34 started rocking back and forth and pushing against her bedside table and wheelchair. Resident #34 asked if she could get up and when asked if she normally got up without assistance, she said, No, I'm too weak now since I hurt my hips. Resident #34 attempted to stand up twice without success. The surveyor asked Resident #34 to use the call light to get assistance and Resident #34 started pulling the call light from the side of bed, underneath. Resident #34 pulled the call light cord a few times but was unable to find the button. Resident #34 laid back in the bed. 5. Record review of a face sheet dated 04/24/23 revealed Resident #52 was [AGE] year-old female admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), dysphagia (difficulty swallowing), and insomnia (a sleep disorder in which you have trouble falling and/or staying asleep). Record review of Resident #52's consolidated physician order dated 04/26/23 revealed the following orders: *Quetiapine 50MG, give 2 tablets by mouth at bedtime started 01/02/23. *Quetiapine 50MG, give 1 tablet once a day started 12/13/22. *Quetiapine 25MG, give 1 tablet in the afternoon started 12/08/22. *Melatonin 5MG, give 4 tablets by mouth at bedtime started on 09/07/22, and *admit to a Hospice company for diagnosis of Alzheimer's disease. Record review of the admission MDS assessment dated [DATE] revealed Resident #52 was usually understood and usually understood others. The MDS revealed Resident #52 had a BIMS of 03 which indicated severe cognitive impairment. The MDS revealed Resident #52 required supervision for transfer, walk in room and corridor, and eating, extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and bathing. The MDS revealed Resident #52 had verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others) which occurred 1 to 3 days a week. The MDS revealed Resident #52 verbal behavioral symptoms significantly interfered with the resident's participation in activities or social interaction and significantly intrude of the privacy or activity of others. The MDS revealed Resident #52 daily wandering behavior significantly intruded on the privacy or activities of others. The MDS revealed Resident #52 had occasional urinary incontinence and frequent bowel incontinence. The MDS revealed Resident #52 had no natural teeth or tooth fragments. The MDS revealed Resident #52 received 7 days of an antipsychotic. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #52 was usually understood and usually understood others. The MDS revealed Resident #52 had a BIMS of 00 which indicated severe cognitive impairment. The MDS revealed Resident #52 wandered 1 to 3 days out of the week. The MDS revealed Resident #52 required supervision for transfer and walking in corridor, limited assistance for bed mobility, walking in room, dressing, toilet use, and personal hygiene, extensive assistance for eating, and total dependence for bathing. The MDS revealed Resident #52 had verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others) which occurred 1 to 3 days a week. The MDS revealed Resident #52 wandered 1 to 3 days out of the week. The MDS revealed Resident #52 had frequent urinary incontinence and frequent bowel incontinence. The MDS revealed Resident #52 received 7 days of an antipsychotic. The MDS revealed Resident #52 was on hospice. Record review of Resident #52's undated care plan did not address ADL requirement, frequent urinary and bowel incontinence, antipsychotic usage, hospice, nor video surveillance. Record review of Resident #52's Consent by Roommate for Authorized Electronic Monitoring dated 09/29/22 revealed .no restrictions on the authorized electronic monitoring .use of an audio electronic monitoring device is prohibited . During an observation on 04/25/23 at 8:45 a.m., Resident #52 was wandered the secured unit and screamed at nursing staff. During an observation on 04/25/23 at 8:50 a.m., in Resident #52's room, on the bookcase a white video camera was noted. 6. Record review of a face sheet dated 04/26/23 revealed Resident #58 was an [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's disease (a general term for memory loss and other cognitive abilities serious enough to interfere with daily life), sarcopenia (gradual loss of muscle mass, strength, and function), and muscle weakness. Record review the quarterly MDS assessment dated [DATE] revealed Resident #58 was usually understood and usually understood others. The MDS revealed Resident #58 was unable to complete the BIMS due to being rarely/never understood but had short-and-long term memory loss with moderately impaired cognitive skills for daily decision making. The MDS revealed Resident #58 required limited assistance for walking in room and corridor, transfer, and eating, extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and bathing. The MDS revealed Resident #58 had falls since admission/entry or reentry or prior assessment. The MDS revealed Resident #58 had one fall with injury except major (skin tears, abrasion, laceration, superficial bruise, hematomas, and sprains). Record review of a care plan dated 03/22/23 revealed Resident #58 was at risk for falls related to history of falls, impaired mobility, incontinence, short term memory loss, unaware of safety needs, and visual deficit. Actual falls 03/21/23 and 03/22/23. Intervention included provide safe environment, evaluate, interview, and document physical condition and cognitive status and observe environment to identify any potential contribute to a fall such as lighting, uneven/slippery/cluttered floor surfaces, improper footwear, failure to use assistive devices, and educate Resident #58 of potential hazards. Record review of Resident #58's fall risk assessment dated [DATE] revealed Resident #58 was a high risk for falling. Interventions included monitor closely and continue to assist with all ADLs. During an observation on 04/24/23 at 10:15 p.m., Resident #58 was asleep in her bed with a fall mat underneath the bed. 7. Record review of a face sheet dated 04/24/23 revealed Resident #104 was a [AGE] year-old female admitted on [DATE] with diagnoses including intracapsular fracture of right femur, dementia (a group of thinking and social symptoms that interferes with daily functioning) with agitation, muscle wasting and atrophy (shortening), and repeated falls. Record review of Resident #104's consolidated physician order dated 04/26/23 revealed Depakene (anticonvulsant) 250MG/5ML, give 2.5 ml by mouth in the morning started on 07/22/22. Record review of Resident #104's MAR dated 04/01/23-04/30/23 revealed Depakene 250MG/5ML, give 2.5 ML by mouth two times a day for behavior disorder started 07/22/22. Record review of the annual MDS assessment dated [DATE] revealed Resident #104 was sometimes understood and rarely/never understood others. The MDS revealed Resident #104 had short-and-long term memory problem and moderately impaired cognitive skills for daily decision making. The MDS revealed Resident #104 required limited assistance for walking in room and transfer, extensive assistance for bed mobility, dressing, eating, toilet use, and personal hygiene, and total dependence for bathing. Record review of the Resident #104's undated care plan did not reveal usage of an anticonvulsant. Record review of a care plan dated 03/28/23 revealed Resident #104 was at risk for falls related to confusion with actual fall on 03/28/23 and 04/05/23. Intervention encourage participation in activities that will increase strength and mobility and stay in common area to promote more supervision. Care plan started after previous, multiple falls. Record review of Resident #104's fall risk assessment dated [DATE] revealed high risk for falling. Intervention for therapy to evaluate. Record review of Resident #104's fall risk assessment dated [DATE] revealed high risk for falling. Interventions of client placed in bed and fall mat in place. Record review of Resident #104's fall risk assessment dated [DATE] revealed low risk for falling. Intervention to monitor. Record review of Resident #104's fall risk assessment dated [DATE] revealed low risk for falling. No interventions listed. Record review of Resident #104's fall risk assessment dated [DATE] revealed high risk for falling. Intervention at risk for falls increase when she has a urinary tract infection. During an observation on 04/24/23 at 10:50 a.m., Resident #104 was aimlessly wandering the secured unit with a stooped posture and shuffling gait. During an observation on 04/24/23 at 11:40 a.m., Resident #104 wandered into Resident #327 room and no staff members noticed. Resident #104 eventually came out of Resident #327's room with a small, clear trash bag. 8. Record review of a face sheet dated 04/26/23 revealed Resident #108 was a [AGE] year-old female admitted on [DATE] with diagnoses including muscle wasting and atrophy (shortening), stroke, sarcopenia (gradual loss of muscle mass, strength, and function) and history of falling. Record review a quarterly MDS assessment dated [DATE] revealed Resident #108 was usually understood and usually understood others. The MDS revealed Resident #108 had a BIMS of 03 which indicated sever cognitive impairment. The MDS revealed Resident #108 required limited assistance for transfer, toilet use, walk in room and corridor, extensive assistance with dressing, eating, personal hygiene, and total dependence for bathing. The MDS revealed Resident #108 was not steady, only able to stabilize with staff assistance. Record review of a care plan dated 07/12/22 revealed Resident #108 was at risk for falls related to confusion, history of falls, and impaired mobility. Intervention included evaluate, interview, and document physical condition and cognitive status and observe environment to identify any potential contribute to a fall such as lighting, uneven/slippery/cluttered floor surfaces, improper footwear, failure to use assistive devices, and educate Resident #108 of potential hazards. Record review of Resident #108's fall risk assessment dated [DATE] revealed high risk for falling. Intervention to continue with plan of care. During an observation on 04/25/23 at 11:12 a.m., Resident #108 was wandering the secured unit in white, regular skid socks. During an observation on 04/25/23 at 3:31 p.m., Resident #108 was wandering the secured unit with non-skid socks on. During an interview on 04/25/23 at 3:46 p.m., CNA V said she had been employed at the facility for one year. She said she gave Resident #108 a shower this afternoon and noticed she wore white skid socks. CNA V said after her shower, she placed non-skid socks on Resident #108. She said non-skid socks were important for fall prevention. CNA V said Resident #34 was supposed to have a fall mat out when she was in the bed. She said staff tried to keep Resident #34 out of her room to monitor. During an interview on 04/26/23 at 9:07 a.m., CNA R said she worked for an agency staff but had worked on the secured unit a couple of shifts. She said Resident #58 was supposed to have a fall mat out when she was in the bed in case she got up and fell. CNA R said Resident #34 was supposed to have a fall mat out when in the bed because she would try to get out of bed without assistance. She said she did not think Resident #34 knew how to use the call light so did not place it within reach when she worked. During an interview on 04/26/23 at 9:30 a.m., CNA S said Resident #34 was supposed to have a fall mat out when in the bed and bed in lowest position. She said she did not know about Resident #34 having a scooped mattress, but she currently did not have one. CNA S said Resident #52 did get in other resident's faces and yells at them. She said other residents do not like the yelling and Resident #52 had gotten hit before by other residents. CNA S said since she started working again at the facility about a year ago, Resident #52 had yelled at staff and residents. She said on 04/25/23, she did not notice Resident #108 wearing skid socks. CNA S said non-skid socks should be worn to help reduce risk of falls. She said Resident #58 was supposed to have a fall mat out at night because she has fallen out of the bed before. CNA S said Resident #52 did have a camera in the room and she tried to make sure to inform new hires or agency staff it was there because sometimes the resident ripped the video surveillance sign down. CNA S said CNAs were able to view resident care plan on their computerized charting system. She said care plans are important because it helped you know what your responsibilities are in caring for the resident. During an interview on 04/26/23 at 1:09 p.m., RN U said CNAs made sure fall interventions were implemented and nurses monitored the CNAs. She said the facility implemented interventions of keeping bedroom doors closed so wandering resident do not get hurt, keep CNAs in the gathering sections. RN U said nursing staff was responsible making sure residents had scooped mattresses. She said intervention were important to ensure resident's safety and not doing them risks injury to the residents and liability of the facility for not providing care to the resident. RN U said resident's diagnoses and medications should be on the care plan. She said she believed the MDS nurse should be responsible for ensuring diagnoses and medications were care planned. RN U said care plan were important because it was the plan of care, gave a picture of the resident, and let the family know what is going on. During an interview on 04/26/23 at 2:58 p.m., the DON said a nurse should start the fall care plan when the fall occurred, and the DON should develop intervention later. She said some of the interventions she implemented on the secured unit to reduce falls were nonskid socks, closed resident's bedroom doors, and gave nurses and CNAs laptops to chart outside of the enclosed nursing station. The DON said CNAs or nurses should ensure fall prevention interventions were in place. She said fall mats lessen the blow when resident had fallen, non-skid sock was a preventative measure. The DON the interventions helped prevent falls or lessen the severity of the fall. 9.Record review of Resident #111's face sheet dated 4/24/23 revealed she was an [AGE] year-old female, who readmitted to the facility on [DATE]. Resident #111 had diagnoses of congestive heart failure, atrial fibrillation (irregular, often rapid heart rate that causes poor blood flow), and hypertension (high blood pressure). Record review of Resident #111's significant change MDS dated [DATE] revealed she was receiving hospice care and her primary diagnosis was congestive heart failure. Record review of Resident #111's Out-of-Hospital DNR Order dated 2/09/23 revealed the resident did not want to be resuscitated (revived from death). Record review of Resident #111's undated comprehensive care plan revealed there were no problem areas or interventions related to the resident being on hospice services, having a DNR order, or having congestive heart failure. 10. Record review of Resident #6's face sheet dated 4/26/23 revealed she was a [AGE] year-old female, who readmitted to the facility on [DATE]. Resident #6 had diagnoses of dementia (progressive or persistent loss of intellectual functioning, memory, related to disease of the brain), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (persistent feeling of anxiety or dread that interferes with how you live your life). Record review of Resident #6's quarterly MDS dated [DATE] revealed she had a BIMS of 4, which indicated she had severe cognitive impairment. Resident #6 received antipsychotic medications 7 out of 7 days. Record review of Resident #6's order summary dated 4/26/23 revealed an order for Seroquel 50 mg one tablet by mouth two times daily for generalized anxiety disorder and other signs and symptoms. Record review of Resident #6's MAR dated 4/01/23-4/30/23 revealed she received Seroquel (antipsychotic) 50 mg one tablet by mouth two times daily for generalized anxiety disorder and other signs and symptoms. *Record review of Resident #6's undated care plan revealed there were no problem area or interventions related to Resident #6 being on antipsychotic medications. 11.Record review of an undated face sheet revealed Resident #26 was an [AGE] year-old-female, admitted to the facility on [DATE] with diagnoses of Parkinson's disease, muscle weakness, difficulty in walking, ataxia, pneumonia, muscle wasting and atrophy, unsteadiness on feet, lack of coordination, dysphagia, aphasia, type two diabetes mellitus, anxiety, hyperlipidemia, metabolic encephalopathy, essential hypertension, atherosclerotic heart disease, chronic obtrusive pulmonary disease, gastro esophageal reflux disease, hirsutism, urinary tract infection, cognitive communication deficit. Record review of an MDS dated [DATE] revealed Resident #26 had a BIMS of 12, which indicated a moderate cognitive impairment. Resident #26 required extensive assistance for toileting, limited assistance for bed mobility, was frequently incontinent of the bowel, at risk for dehydration. The care plan dated 01/25/2023 revealed no care plan for urinary incontinence, pressure injuries, dehydration, ADLs, cognition loss as coded on the 01/20/2023 MDS. During an interview on 04/26/23 at 2:45 p.m., MDS Nurse A said he was responsible for updating residents care plans. He stated that they have been trying to catch up on care plans as the facility lacked a MDS nurse for six months prior to his employment. He stated that they try to complete the most complete and up to date care plans. He said that social, dietary, and activities do their own care planning. He stated that Resident #26 should have been care planned for urinary incontinence, risk for pressure injuries, dehydration, ADLs, and cognition loss, so staff would know how to treat her. He stated that a resident with an incomplete care plan would be placed at risk for not receiving correct care. 12.Record review of the face sheet for Resident #89 dated 4/26/23 indicated was she [AGE] years old admitted to the facility on [DATE] with diagnoses including Alzheimer's depression, high blood pressure, chronic pain, osteoarthritis (A type of arthritis that occurs when flexible tissue at the ends of bones wears down, causing pain and stiffness) and muscle wasting/ atrophy (weakening, shrinking, and loss of muscle caused by disease or lack of use). Record review of the MDS dated [DATE] indicated Resident #89 understood others and made herself understood. The MDS indicated Resident #89 had no cognitive impairment (BIMS of 13). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #89 the physical assistance of one person for locomotion in her wheelchair, dressing, eating, toilet use, and personal hygiene. The MDS indicated she required the physical assistance of two people for bed mobility and transfers. Record review of Resident #89's care plan revised on 2/9/23 did not address her need for assistance with personal hygiene or any other ADL activities. During an observation and interview on 4/24/23 at 10:20 a.m., Resident #89 laid in her bed. She had long hairs (approximately 1-2 cm) covering the surface of her chin. Resident #89 said she did not understand why a woman her age had to have a goatee and said she was embarrassed to have her chin covered in hair. Resident #89 said she could not remove the hair herself and wished the staff would help her. Resident #89 said staff had shaved the hair on her chin for her in the past but could not remember when it was last done. 13.Record review of a face sheet dated 04/26/23 revealed Resident #99 was [AGE] years old and was admitted on [DATE] with diagnoses including post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and a history of bladder cancer. Record review of the admission MDS for Resident #99 dated 05/11/22 indicated Psychosocial Well-Being and Mood State were triggered care areas and were included in the care planning decisions. The MDS indicated an active diagnosis of Post-Traumatic Stress Disorder (PTSD). Record review of a quarterly MDS dated [DATE] indicated Resident #99 was understood and understood others. The MDS indicated a BIMS of 10 indicating moderate cognitive impairment for Resident #99. The MDS indicated an active diagnosis of Post-Traumatic Stress Disorder (PTSD). Record review of a care plan dated 01/01/23 did not indicated Resident #99 had a diagnosis of Post-Traumatic Stress Disorder (PTSD). During an interview on 04/26/23 at 8:34 a.m., MDS Nurse A said the process for developing a care plan was to first complete the MDS. He said you go to the V section for the triggers. He said based on the triggers in V section, he builds a care plan. He said care plans were updated quarterly and with any changes. He said active diagnoses should have been care planned, especially if medications are associated. He said he could not give a good answer as to why Resident #99's Post-Traumatic Stress Disorder (PTSD) was not care planned. He said he was the MDS nurse responsible for Resident 99's care plan. During an interview on 04/26/2023 at 11:45 a.m., MDS Nurse B said when she was hired the MDS, and care plans were very behind. She said they struggled to play catch up with the MDSs and care plans. MDS Nurse B explained she was responsible for all resident with the last names beginning with the letter L through the letter Z and MDS Nurse A had all the residents with the last names A through L. MDS Nurse B said she was aware that all care areas that triggered on an admission, significant change and annual assessment were to be care planned. MDS Nurse B said all active diagnoses and major medications should be care planned, as well. MDS Nurse B said she did not feel any real harm came to the resident from the care plan not being completed. During an interview on 04/26/2023 at 1:50 p.m., the DON said she was aware that many people were missing important care plans and some residents were missing entire care plans. The DON said it was her responsibility to come up with a plan to get the care plans back on track. The DON said comprehensive care plans should be created when the MDS nurses complete an admission or annual assessment. The care plan should be updated quarterly with the new MDS, and as major change happened. The DON said not having up to date care plans could lead to residents not receiving interventions they need for certain care areas important to them. During an interview on 04/26/2023 at 2:25 p.m., the Administrator said she was aware of the care plan problem and she and the DON had created a plan of improvement to move forward with getting the care plans back on schedule. The Administrator said it was important for care plans to be created and maintained for all residents as a guide for individualized care. Record review of the facility's policy, Comprehensive Assessment and the Care Delivery Process revised dated December 2016 revealed, Comprehensive assessments will be conducted to assist in developing person-centered care plans. Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. Based on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs; and, services that were to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being for 13 (Residents #121, #69, #39, #34, #52,#104, #108, #111, #06, #26,#89, and #99) of 24 residents reviewed for care plans. * The facility failed to develop a care plan for the care areas assessments triggered on the admission MDS for Resident #121, Resident #69, and Resident #39. * The facility failed to develop and implement a care plan for Resident #34's scooped mattress and fall mat in place while in bed, ordered by the physician. * The facility failed to develop a care plan for Resident #34's bowel/bladder, diagnoses, medications coded on the MDS. * The facility failed to develop a care plan to address Resident # 52 having video surveillance in her room, bowel/bladder, psychotropic medication usage, verbal behavioral symptoms, and hospice. * The facility failed to develop a care plan for Resident #104's anticonvulsant usage and address multiple falls. * The facility failed to provide Resident #108 with proper footwear. * The facility failed to care plan Resident #111 was on hospice services, was a DNR, and had congestive heart failure (the heart cannot pump or fill adequately). * The facility failed to care plan Resident #6 was on antipsychotic medications. * The facility failed to develop a care plan for Resident #26's urinary incontinence, risk for pressure injuries, dehydration, ADLs, and cognition loss * The facility did not ensure Resident #89's need for ADL with personal hygiene was care planned. * The facility failed to develop a comprehensive person-centered care plan including an active diagnosis of Post-Traumatic Stress Disorder (PTSD) for Resident #99. These failures could place residents at risk for not receiving necessary care and services or having important care needs identified. 1. Record review of a face sheet dated 04/25/2023 revealed Resident #121 was a 95- year-old- female, admitted on [DATE] with the diagnoses of malnutrition (occurs when the body doesn't get enough nutrients), pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid), and rhabdomyolysis (a serious medical condition that can be fatal or result in permanent disability). Record review of an admission MDS assessment dated [DATE] for Resident #121 revealed a BIMS of 14, which indicated no cognitive impairment. The MDS indicated Resident #121 used oxygen daily. The MDS indicated Resident #121 had care area assessments triggered for ADLs, communication, urinary status, falls, hydration, and pressure ulcers. The MDS indicated Resident #121 had hearing difficulty in some environments, required extensive assistance with ADLs, was incontinent of bowel and bladder, had a history of falls, was at risk for skin impairment, and was at risk for dehydration related to diagnoses of pneumonia and sepsis. Record review of the comprehensive care plan dated 04/02/2023 for Resident #121 revealed an activity care plan, an incomplete discharge care plan, a care plan for impaired nutritional status, and 3 care plans for wounds developed in the facility. There were no other care plans were created for the triggered care area assessments for Resident #121. 2. Record review of a face sheet dated 04/25/2023 revealed Resident #69 was an [AGE] year-old male, admitted on [DATE] with the diagnoses of heart failure (occurs when the heart muscle doesn't pump blood as well as it should), pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid), and anxiety ( involves a persistent feeling of dread, which can interfere with daily life). Record review of an admission MDS dated [DATE] for Resident #69 revealed a BIMS of 07, which indicated moderate cognitive impairment, The MDS indicted Resident #69 used oxygen daily while a resident of the facility. The MDS had care area [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 5 of 24 residents reviewed for ADLs (Residents #17, #121, #51, #80, #89) The facility did not shave Resident #17, #121, #51, #80, and #89' s facial hair. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, feelings of poor self-esteem, lack of dignity and health. The findings included: 1. Review of Resident #17's electronic face sheet dated 06/06/2022 revealed she was admitted to the facility on [DATE] with diagnoses of anxiety disorder, major depressive disorder, cerebral palsy, cognitive communication deficit, speech disturbances, and lack of coordination. Record review of Resident #17's annual MDS assessment dated [DATE] revealed a BIMS with a score of 15, which indicated resident #17 was cognitively intact. The MDS also revealed, Resident #17, required extensive assistance with personal hygiene. Resident #17 required two-person physical assistance with personal hygiene, including shaving. During an observation and interview on 04/24/2023 beginning at 9:53 a.m. Resident #17 was observed lying in her bed. She appeared unkempt and had unshaved facial hair. Resident #17 stated that the staff did not shave her facial hair. She stated that she preferred her facial hair shaved and was embarrassed to be seen with facial hair. During an interview and observation on 04/25/2023 beginning at 7:26 a.m. it was observed that Resident #17's facial hair had yet to be shaved. She stated that she usually has her facial hair shaved on Sundays, but she did not get shaved this week. During an interview with the DON on 04/19/2023 at 9:01 a.m. she stated there should be a resident's preference on when to be shaved and shaving should be offered to residents. She said that females should be shaved when they request to be as it is a dignity issue. She stated that if a resident had facial hair that they did not want they would be placed at risk for poor self-esteem. She stated that residents should be shaved by any staff that are certified to provide one on one care on the floor, can shave a resident. 2. Record review of a face sheet dated 04/25/2023 revealed Resident #121 was a 95- year-old- female, admitted on [DATE] with the diagnoses of malnutrition (occurs when the body doesn't get enough nutrients), pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid), and rhabdomyolysis (a serious medical condition that can be fatal or result in permanent disability). Record review of an admission MDS dated [DATE] for Resident #121 revealed a BIMS of 14, which indicated no cognitive impairment. The MDS also revealed Resident #121 required extensive assistance with personal hygiene. During an interview and observation on 04/24/2023 beginning at 9:55 a.m., Resident #121 was noted to have multiple (6-8) long (½ inch) hairs noted to her chin. Resident #121 said she was up waiting to go to the beauty shop to get a perm. Resident #121 said she got her bath like she wanted but they never took care of her facial hair. Resident #121 said she may have the beautician perm her chin hair since they would not pluck her chin hair or shave her. Resident #121 said she asked the CNA each time they bathed her to please do something with the chin hair. During an interview on 04/25/2023 at 2:50 p.m., RN K said it was the responsibility of the CNAs to assist with all personal hygiene and grooming needs of the resident each day. RN K said it did not have to be a bath day to remove chin hairs. RN K said chin hair on a woman could make her feel self-conscious or non-attractive. RN K said she did try and look at fingernails, teeth, and hair when she was working with the residents and attend to those needs if she saw they were not well kept or inform the CNA to attend to the resident's grooming needs. RN K said she did not recall seeing chin hair on Resident #121. 3. Record review of the face sheet dated 03/26/23 revealed Resident #51 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), muscle wasting (decrease in size and wasting of muscle tissue), and hemiplegia (paralysis of one side of the body) to the left side. Record review of an annual MDS dated [DATE] revealed Resident #51 was usually understood and usually understood others. The MDS revealed Resident #51 had a BIMS score of 8 which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #51 required extensive assistance with personal hygiene. Record review of a care plan dated 04/19/23 indicated Resident #51 had an ADL self-care performance deficit related to stroke, pain, poor coordination, poor judgement, short term memory deficit, visual deficit, and weakness. Record review of Resident #51's Task ADL - Bathing report dated 03/28/23 - 4/25/23 revealed the resident received appropriated assistance with bathing. The report did not indicate any refusals of care. Record review of Resident #1's progress notes from 04/01/23 - 04/26/23 did not indicated any refusal of assistance with personal hygiene from Resident #51. During an observation on 04/24/23 at 3:00 p.m., Resident #51 had a few scattered hairs approximately 0.5 centimeters in length on her chin and upper lip. During an observation on 04/26/23 at 9:35 a.m., Resident #51 was sitting in dining room. Resident #51 had a few scattered hairs approximately 0.5 cm in length on her chin and upper lip. During an observation and interview on 04/26/23 beginning at 1:34 p.m., Resident #51 had a few scattered hairs approximately 0.5 centimeters in length on her chin and upper lip. She said the CNAs never remove her facial hair. She said the only time the hair is removed was when she goes to the beautician. She said the facial hair really bothered her when her daughter visited. 4. Record review of the face sheet dated 04/25/23 revealed Resident #80 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including anxiety, muscle wasting (decrease in size and wasting of muscle tissue), and lack of coordination. Record review of a MDS dated [DATE] revealed she was understood and understood others. The MDS revealed Resident #1 had a BIMS score of 9 which indicated Resident #80 had moderate cognitive impairment. The MDS revealed Resident #80 required limited assistance with personal hygiene. Record review of a care plan dated 10/07/2022 indicated Resident #80 had an ADL self-care performance deficit. Record review of Resident #80's Task ADL - Bathing report dated 03/28/23 - 4/25/23 revealed the resident received appropriated assistance with bathing. The report did not indicate any refusals of care. Record review of Resident #80's progress notes from 04/01/23 - 04/26/23 did not indicated any refusal of assistance with personal hygiene from Resident #80. During an observation on 04/24/23 at 9:54 a.m., Resident #80 had a few scattered chin hairs approximately 1 centimeter in length. During an observation and interview on 04/25/23 beginning at 3:20 p.m., Resident #80 had scattered chin hairs approximately 1 centimeter in length. She said the staff were not removing her chin hairs. She said she tried to keep them trimmed with scissors. She said she would pluck them, but it hurts. She said, They don't look very good, do they?. During an interview on 04/26/23 at 10:19 a.m., CNA M said it was the CNA's job to remove chin hairs. She said she removed chin hairs when she showered her residents. She said this was her first day on this hall. She said she had not showered Resident #51 or Resident #80, but their chin hairs should have been removed on shower days. During an interview on 04/26/23 at 10:22 a.m., CNA N said she trimmed female's facial hair on shower days. She said Resident #80 did not always let them shave her because she preferred the tweezers. During an interview on 04/26/23 at 11:55 a.m., LVN O said CNAs were responsible for removing chin hairs when they were showered if the resident would let them. She said Resident #80 did not always let staff remove facial hair. She said she really was not sure if there was a place to chart refusals. She said Resident #51 never refused to have facial hair removed. During an interview on 04/26/23 at 2:58 p.m., the DON said anyone that was licensed staff could provide one on one care and should provide ADL care. She said concerning facial hair, the resident should be asked every time they are showered if they want their facial hair removed and the hair should be removed at that time. She said facial hair on women could be embarrassing. She said any refusals should be charted in the progress notes. During an interview on 04/26/23 03:36 p.m., the administrator said if a woman does not want a beard the staff should be assisting them with proper grooming. 5.Record review of the face sheet for Resident #89 dated 4/26/23 indicated was she [AGE] years old admitted to the facility on [DATE] with diagnoses including Alzheimer's depression, high blood pressure, chronic pain, osteoarthritis (A type of arthritis that occurs when flexible tissue at the ends of bones wears down, causing pain and stiffness) and muscle wasting/ atrophy (weakening, shrinking, and loss of muscle caused by disease or lack of use). Record review of the MDS dated [DATE] indicated Resident #89 made understood others and made herself understood. The MDS indicated she had impaired vision in adequate light. The MDS indicated Resident #89 had no cognitive impairment (BIMS of 13). The MDS indicated she had mild depression (PHQ-9 score of 6). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #89 the physical assistance of one person for locomotion in her wheelchair, dressing, eating, toilet use, and personal hygiene. The MDS indicated she required the physical assistance of two people for bed mobility and transfers. Record review of Resident #89's care plan revised on 2/9/23 did not address her need for assistance with personal hygiene. During an observation and interview on 4/24/23 at 10:20 a.m., Resident #89 laid in her bed. She had long chin hairs (approximately 1-2 cm) covering the surface of her chin. Resident #89 said she did not understand why a woman her age had to have a goatee. Resident #89 said she was embarrassed to have her chin covered in hair. Resident #89 said she could not remove the hair herself and wished the staff would help her. Resident #89 said staff had shaved the hair on her chin for her in the past but could not remember when it was last done. During an observation and interview on 4/25/23 at 11:30 a.m., Resident #89 laid in her bed. She had long chin hairs (approximately 1-2 cm) covering the surface of her chin. Resident #89 said no one had offered to help her remove the hair from her chin since yesterday (4/24/23). During an observation and interview on 4/26/23 at 12:45 p.m., Resident #89 laid in her bed. She had long chin hairs (approximately 1-2 cm) covering the surface of her chin. Resident #89 said she wished someone would help her get the hair off of her chin because she did not want to look like a man. During an interview on 4/26/23 at 1:00 p.m., CNA X indicated it was the responsibility of CNAs to remove residents' facial hair. CNA X said facial hair was removed for female residents on their (residents) shower days and as needed. CNA X said as needed meant if staff noticed the hair needed to be removed or if a Resident requested the hair be removed. CNA X said she was not sure what day Resident #89's shower day was on. CNA X said she had not noticed Resident #89's facial hair and did not think she had requested it to be removed. During an interview on 4/26/23 at 1:10 p.m., CNA Y said facial hair was removed for female residents on their shower days and as needed. CNA Y indicated as needed meant if staff noticed the hair needed to be removed or if a Resident requested the hair be removed. CNA Y said she was not sure what day Resident # 89's shower was to be completed on. CNA Y said she had not noticed Resident #89's facial hair and indicated she had not requested it to be removed by her (CNA Y). During an interview on 4/26/23 at 1:15 p.m., LVN Z indicated Resident #89's facial hair should not have been long and should have been removed. LVN Z said she believed CNAs removed facial hair on the residents' shower days and as needed. LVN Z said Resident #89's facial hair certainly needed to be removed and would ensure it was completed. LVN Z said she had not noticed Resident #89's facial hair until the surveyor pointed it out. During an interview on 4/26/23 at 4:15 p.m., the DON said it was not acceptable for Resident #89 to have long facial hair. The DON said she expected staff to ensure facial hair was removed for residents to maintain residents' dignity. During an interview on 4/26/23 at 4:40 p.m., the Administrator said she expected staff to ensure facial hair was removed for any resident who wished to have facial hair removed. The Administrator indicated there was no specific system in place to ensure staff were removing resident facial hair but indicated Resident #89's long facial hair should have been caught during daily administrative rounds. The Administrator said every nurse manager was assigned and area in which they were to perform daily rounds. The Administrator said she could not remember off the top of her head who was responsible to round on the area which Resident #89 resided. Review of the facility policy and procedure on care of Quality of Life - Dignity dated revised August 2009 revealed that the purpose of the procedure is to ensure, Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.) Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self- esteem and self-worth. Review of the facility policy and procedure on Shaving the Resident dated revised October 2010 revealed that the purpose of the procedure is to promote, cleanliness and to provide skin care. Review the resident's care plan to assess for any special needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care are provided such care, consistent with professional standards of practice for 4 of 10 residents reviewed for respiratory care (Residents #23, #121, #69 and #37 ). The facility failed to change Resident #23's oxygen tubing every week on Sundays as ordered by the physician. The facility failed to ensure Resident #121 and #69's oxygen concentrator filters were free of dust and debris. The facility failed to change humification bottle for Resident #69 weekly. The facility failed to ensure Resident #37 had an oxygen concentrator filter in place. The facility failed to ensure Resident #37's portable oxygen tank had a sufficient level of oxygen. These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included: 1. Record review of Resident #23s face sheet dated 4/24/23 revealed she was a [AGE] year-old female, who readmitted to the facility on [DATE]. Resident #23 had diagnoses of chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the lungs or cannot get rid of enough carbon dioxide from the body), chronic obstructive pulmonary disease (constriction of the airways and difficulty or discomfort in breathing), and heart failure (the heart cannot pump or fill adequately). Record review of Resident #23's quarterly MDS dated [DATE] revealed she had a BIMS of 14, which indicated she was cognitively intact. Resident #23 required extensive to total assistance of two persons for most ADLs. Resident #23 required oxygen therapy. Record review of Resident #23's Order Summary Report dated 4/26/23 revealed an order for oxygen tubing to be changed every week on Sundays on the evening shift. Record review of Resident #23s Nursing MAR dated 4/01/23-4/30/23 revealed an order for oxygen tubing to be changed every week on Sundays on the evening shift. There was no documentation the oxygen tubing was changed on 4/02/23. There was documentation the oxygen tubing was changed on 4/09/23, 4/16/23, and 4/23/23. During an observation and interview on 4/24/23 beginning at 11:25 AM Resident #23 said she wears her oxygen most of the time. Resident #23 said she did not know how often the facility changed her oxygen tubing and she did not know when it was last changed. The oxygen tubing was dated 04/06/23. During an observation on 4/25/23 at 4:39 PM revealed Resident #23 continued to wear oxygen tubing dated 04/06/23. During an observation on 4/26/23 at 10:08 AM revealed Resident #23's oxygen tubing continued to be dated 04/06/23. During an interview on 4/26/23 at 2:21 PM LVN D said the night nurses were responsible for changing the residents' oxygen tubing and cleaning the oxygen filters on Sundays. LVN D said if the oxygen tubing was not changed or the oxygen filters cleaned weekly as ordered, the resident could develop a respiratory infection and it could cause worsening of the resident's respiratory disease. LVN D said she had not noticed Resident #23's oxygen tubing was dated 04/06/23. During an interview on 4/26/23 at 2:58 PM the DON said oxygen equipment should be changed weekly and as needed if it became contaminated. The DON said if the oxygen equipment was not changed weekly, it was an infection control issue. The DON said the nurses were responsible for changing the oxygen tubing weekly and it was scheduled on the evening shift on Sundays. The DON reviewed the 4/01/23-4/30/23 Nursing MAR and said the three nurses that documented the oxygen tubing was changed on 4/9/23, 4/16/23 and 4/23/23 were agency nurses. The DON said the oxygen tubing would not have been dated 04/06/23 if the agency nurses had changed it on 4/9/23, 4/16/23 and 4/23/23. The DON said she would place the three agency nurses on their do not return list and they would not be allowed back into the facility. During an interview on 4/26/23 at 3:53 PM the Administrator said the facility had orders on the residents' charts to change oxygen tubing every Sunday on the evening shift. The Administrator said the charge nurses were responsible for ensuring the oxygen tubing was changed as ordered. The Administrator said the facility did not have a policy specific to changing the oxygen tubing. The Administrator said she would expect the physician's orders to change the oxygen tubing weekly on Sundays to be followed. The Administrator said if the oxygen tubing was not changed as ordered, then it would be an infection control issue. 2.Record review of a face sheet dated 04/25/2023 revealed Resident #121 was a 95- year-old- female, admitted on [DATE] with the diagnoses of malnutrition (occurs when the body doesn't get enough nutrients), pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid), and rhabdomyolysis (a serious medical condition that can be fatal or result in permanent disability). Record review of an admission MDS dated [DATE] for Resident #121 revealed a BIMS of 14, which indicated no cognitive impairment. The MDS indicated Resident #121 used oxygen daily. During an observation on 04/24/2023 at 9:55 a.m., Resident #121's oxygen concentrator had a dirty filter. The filter was completely covered in a light grey coating of dust-like material. During an observation on 04/25/2023 at 10:02 a.m., Resident #121's oxygen concentrator filter had not been cleaned and remained with the light grey coating of dust-like material. During a record review of the consolidated orders for April 2023, an order for Resident #121 revealed oxygen to be administered at 3 liters per nasal cannula continuously. During a record review of April 2023's MAR, no orders were noted to change tubing or filters weekly for Resident #121. 3.Record review of a face sheet dated 04/25/2023 revealed Resident #69 was an [AGE] year-old male, admitted on [DATE] with the diagnoses of heart failure (occurs when the heart muscle doesn't pump blood as well as it should), pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid), and anxiety ( involves a persistent feeling of dread, which can interfere with daily life). Record review of a quarterly MDS dated [DATE] for Resident #69 revealed a BIMS of 14, which indicated no cognitive impairment, The MDS indicted Resident #69 used oxygen daily while a resident of the facility. During an observation and interview on 04/24/2023 at 11:00 a.m., Resident #69's oxygen tubing and humidification bottle were dated 04/10/2023. Resident #69's oxygen filter was covered in dust. Resident #69 said I do not know if they ever replace those filters. No telling what I'm breathing into my lungs. Resident #69 said he was unsure when the last time the filter was cleaned or replaced, and it had been a few weeks since he had gotten new tubing a humidification bottle. Record review of consolidated orders for April 2023 revealed an order dated 09/22/2023 for Resident #69 to have oxygen at 2 liters per minute continuously for shortness of breath. An order dated 09/25/2022 for Resident #69 revealed Resident was to have oxygen tubing changed every Sunday night. Record review of the April 2023 MAR showed Resident #69's oxygen tubing was changed by LVN L on 04/16/2023 and by LVN G on 04/23/2023. Attempts were made to contact LVN L and LVN G on 04/24/2023 and 04/25/2023. Voice messages were left for each nurse and no return calls were received prior to exit. During an interview on 4/26/23 at 3:00 p.m., LVN AA said filters on the oxygen concentrators were important because they filtered dust and debris away from the resident. LVN AA said nurses were responsible to ensure oxygen concentrator filters were cleaned and replaced weekly on Sundays by the night shift. LVN AA indicated she regularly provided care to Resident # 69 and Resident # 121 and would have changed a dirty filter if she had noticed it even though it was the responsibility of the Sunday night shift nurse. During an interview on 4/26/23 at 3:05 p.m., RN RR said filters on the oxygen concentrators were important because they ensure the oxygen concentrator functioned properly. RN RR said nurses were responsible to ensure oxygen concentrator filters were cleaned and replaced weekly on Sundays by the night shift. RN RR indicated she regularly provided care to Resident #69 and Resident # 121 and while there was no set system in place on the day shift to check oxygen concentrator filters, she would replace/clean them if she noticed they were dirty. 4.Record review of the face sheet for Resident #37 dated 4/26/23 indicated was she [AGE] years old re-admitted to the facility on [DATE] with diagnoses including heart failure, chronic respiratory failure ( an ongoing slow developing condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body, history of acute respiratory failure (inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements happens quickly without much warning), history or respiratory infection, history or pulmonary edema (condition caused by too much fluid in the lungs), stage 3 chronic kidney disease (mild to moderate damage to kidneys resulting in the inability to filter blood as they should), anxiety, and Alzheimer's disease. Record review of the MDS dated [DATE] indicated Resident #37 made understood others and made herself understood. The MDS indicated Resident #37 had moderate cognitive impairment (BIMS of 10). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #37 required extensive assistance with bed mobility, transfers, locomotion in her wheelchair, dressing, toilet use, personal hygiene and bathing. The MDS indicated Resident #37 had an active diagnosis of respiratory failure. Record review of the care plan revised on 2/23/23 indicated Resident #37 was to be administered oxygen therapy as needed. The care plan interventions included, monitor for signs and symptoms of respiratory distress. The care plan indicated Resident #37 was to be administered oxygen at 2L/min (liters per minute) via nasal cannula (a device used to deliver oxygen through the nose). Record review of the active physician order dated 9/13/22 indicated Resident #37 was to be administered oxygen 2L/min via nasal cannula as needed, to maintain an oxygen saturation greater than 91 percent. During an observation on 4/24/23 at 10:10 a.m., an oxygen concentrator sat to the right side of Resident #37's bed. There was no filter in the oxygen concentrator filter. During an observation and interview on 4/24/23 at 3:30 p.m., Resident #37 sat in her wheelchair at her bedside. Her nasal cannula was connected to a portable oxygen tank placed on the back of her wheelchair. Resident #37 said she wore oxygen all the time. Resident #37 indicated when she was in her bed, the staff connected the nasal cannula to her oxygen concentrator and when she was up in her wheelchair staff connected her nasal cannula to a portable oxygen tank. At the end of interview Resident #37 seemed to be slightly short of breath and took occasional deep breaths that caused her shoulders to rise and fall. When asked if she was short of breath, Resident #37 nodded her head 'yes' and said, a little bit. The gauge on the portable oxygen tank read below 500 psi (pounds per square inch) and was in the red zone (an oxygen tank gauge is divided into red, white and green sections. If the needle is in the white or green zones, it indicates that there is enough oxygen in the tank for another use. If the dial is within or just outside of the red, it means that the cylinder is close to empty and needs to be refilled). During an observation and interview on 4/24/23 at 3:37 p.m., LVN BB stood beside Resident #37 in her (Resident #37's) room. LVN BB said the oxygen tank needed to be replaced. LVN BB replaced the portable oxygen tank with a new tank. Resident #37 took a few deep breaths after the tank had been replaced and indicated she was no longer short of breath. LVN BB said portable oxygen tanks were checked every morning to ensure there was adequate oxygen supply in the tank. LVN BB said she had checked the earlier in the morning and indicated the oxygen tank was in the green zone. LVN BB said Resident #37 just spent a lot of time up and about in her wheelchair, so the tank ran out of oxygen. During an observation on 4/25/23 at 3:30 p.m., Resident # 37 laid in her bed. She wore her nasal cannula, and it was connected to the oxygen concentrator to the right of her bed. The oxygen was set at 2L/min. There was no filter in the oxygen concentrator. During an observation and interview on 4/26/23 at 8:15 a.m., Resident #37 sat in her wheelchair in front of the nursing station. Her nasal cannula was connected to a portable oxygen tank placed on the back of her wheelchair. Resident #37 appeared short of breath and took deep breaths. The gauge on the portable oxygen tank read 0 psi and was in the red zone. During an observation and interview on 4/26/23 at 8:16 p.m., LVN Z stood beside Resident #37 in front of the nursing station. LVN Z said the oxygen tank was empty and needed to be replaced. After LVN Z replaced the oxygen tank, Resident #37 indicated she was no longer short of breath. LVN Z said the portable oxygen tanks were checked in the morning but said she had not yet checked Resident #37's portable tank because she was busy in the dining room with another resident. LVN Z said it was the nurse's responsibility to ensure portable oxygen tanks were in the green zone (the gauge read in the green zone) but indicated the CNAs were usually good about notifying the nurse if a tank needed to be replaced. During an interview on 4/26/23 at 8:25 a.m., MA W said she had just brought Resident #37 into the area in front of the nursing station after she (MA W) completed her (Resident #37's) shower. MA W said she was one that got her (Resident #37) out of bed this morning (4/26/23). MA W said she did not think to look at the portable oxygen tank before she took Resident #37 to the shower or when she brought her (Resident #37) to the nursing station. MA W indicated Resident #37 did not appear short of breath nor complained of shortness of breath during her shower. During an observation and interview on 4/26/23 at 8:29 a.m., an oxygen concentrator sat to the right side of Resident #37's bed. There was no filter in the oxygen concentrator filter. LVN Z said there should have been a filter in Resident #37's oxygen concentrator and was not sure how it was missing. LVN Z said filters on the oxygen concentrators were important because they filtered dust and debris away from the resident. LVN Z said nurses were responsible to ensure oxygen concentrator filters were cleaned and replaced weekly on Sundays by the night shift nurse. LVN Z said if she would have noticed there was no oxygen filter in place in Resident #37's oxygen concentrator she would have replaced it. Record review of the nursing note dated 4/23/23 at 4:08 a.m., indicated LVN DD had cared for Resident #37 on the Sunday night shift. An interview with LVN DD was attempted but not completed. During an interview on 4/26/23 at 4:15 p.m., the DON said it was the Sunday night shift's nurse responsibility to ensure oxygen concentrator filters were cleaned and replaced weekly (every Sunday night). The DON said she expected all nurses to ensure the filters were in place and to replace filters if they noticed one was missing from a concentrator. The DON said there was not currently a system in place, other than the scheduled Sunday night care related to oxygen filters. The DON explained the MAR/TAR (medication administration record or treatment administration record)had a sign off (an area of the MAR/TAR the nurse had to sign electronically) which prompted Sunday night nurses to ensure the 02 (oxygen) tubing and humidification was changed but was not sure if the MAR prompted nurses to clean/replace filters. The DON said it was important for oxygen filters to be in place/clean in the concentrators because the lack of the filter or a filter covered in dust could increase residents' risk for respiratory infections and respiratory complications. The DON said she expected nurses to ensure resident portable oxygen tanks were in the green zone before they were placed on a resident. The DON said it was not acceptable for Resident #37's oxygen tank to have been empty and could have caused Resident #37 to have a preventable respiratory event. The DON indicated there was no system in place to ensure staff placed only portable oxygen tanks in the green zone on residents. During an interview on 4/26/23 at 4:40 p.m., the administrator said she expected Residents' oxygen concentrator filters to be clean and in place. The administrator it was important for the filters to clean and in place to ensure the equipment (oxygen concentrator) functioned properly. The Administrator indicated the orders for weekly tubing/ humidification changes should have been a prompt for nurses to ensure concentrator filters were clean and in place. The Administrator said she expected staff to ensure oxygen tanks had plenty of oxygen before they were placed on a resident. The Administrator indicated these were not specifically items that were checked on during administrative rounds but that would change. The facility policy and procedure titled Departmental (Respiratory Therapy)- Prevention of Infection revised November 2011, stated .The Purpose of this procedure is to guide prevention of infection associated with respiratory therapy, tasks and equipment .(1) Distilled water used in respiratory therapy must be dated and initialed when opened, and discarded after twenty-four (24) hours .Infection Control Considerations Related to Oxygen Administration .(4) Check water levels of refillable humidifier units daily .Change the reservoir every forty -eight (48) hours .(5) Check water level of any pre-filled reservoir every forty-eight (48) hours. (6) Change pre-filled humidifier when the water level becomes low. (7) Change the oxygen cannula and tubing every seven (7) days, or as needed . (Wash Filters from oxygen concentrators every seven (7) days with soap and water. Rinse and squeeze dry .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 6 of 24 residents (Resident #6, Resident #34, Resident #52, Resident #93, Resident #104, Resident #327) reviewed for psychotropic medications. The facility failed to have an appropriate diagnosis or indication of use for Resident #6, Resident #52, and Resident #93's Quetiapine (antipsychotic). The facility failed to have an appropriate diagnosis or indication of use for Resident #34's Trazadone (anti-depressant). The facility failed to have an appropriate diagnosis or indication of use for Resident #104's Zyprexa (antipsychotic) The facility failed to have an appropriate diagnosis or indication for use for Resident #327's Venlafaxine (antidepressant). These failures could put residents at risk of receiving unnecessary psychotropic medications. Findings included: 1. Record review of a face sheet dated 04/24/23 revealed Resident #34 was a [AGE] year-old female admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and major depressive disorder (a persistent feeling of sadness and loss of interest and can interfere with your daily). Record review of Resident #34's MAR dated 04/01/23-04/30/23 revealed Escitalopram (anti-depressant) 20MG , give 1 tablet by mouth one time a day for depression started on 09/02/22. Mirtazapine (anti-depressant) 15MG, give 1 tablet by mouth in the evening related to other specified depressive episodes started on 06/24/22. Trazodone (anti-depressant) 50MG, give 1 tablet by mouth at bedtime related to other general symptoms and signs and dementia without behavioral disturbance started 12/21/22. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #34 was usually understood and usually understood others. The MDS revealed Resident #34 had a BIMS of 00 which indicated severe cognitive impairment. The MDS revealed Resident #34 required supervision for eating, limited assistance for transfer, and extensive assistance with bed mobility, dressing, toilet use, personal hygiene, and bathing. The MDS revealed Resident #34 was always incontinent of bladder and bowel. The MDS revealed Resident #34 had received an antidepressant in the last 7 days. Record review of Resident #34's undated care plan did not reveal usage of antidepressant. 2. Record review of a face sheet dated 04/24/23 revealed Resident #52 was [AGE] year-old female admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and insomnia (a sleep disorder in which you have trouble falling and/or staying asleep). Record review of Resident #52's consolidated physician order dated 04/26/23 revealed Quetiapine 50MG, give 2 tablets by mouth at bedtime started 01/02/23. The consolidated physician order revealed Quetiapine 50MG, give 1 tablet once a day started 12/13/22. The consolidated physician order revealed Quetiapine 25MG, give 1 tablet in the afternoon started 12/08/22. Record review of the Resident #52's MAR dated 04/01/23-04/30/23 revealed Melatonin 5MG, give 4 tablets by mouth at bedtime for sleep started 09/07/22. The MAR revealed Quetiapine 25MG, give 1 tablet in the afternoon related to dementia started on 12/08/22. The MAR revealed Quetiapine 50MG, give 1 tablet once a day related to dementia started 12/13/22. The MAR revealed Quetiapine 50MG, give 2 tablets by mouth at bedtime related to dementia started 01/02/23. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #52 was usually understood and usually understood others. The MDS revealed Resident #52 had a BIMS of 00 which indicated severe cognitive impairment. The MDS revealed Resident #52 wandered 1 to 3 days out of the week. The MDS revealed Resident #52 required supervision for transfer and walking in corridor, limited assistance for bed mobility, walking in room, dressing, toilet use, and personal hygiene, extensive assistance for eating, and total dependence for bathing. The MDS revealed Resident #52 had verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others) which occurred 1 to 3 days a week. The MDS revealed Resident #52 wandered 1 to 3 days out of the week. The MDS revealed Resident #52 received 7 days of an antipsychotic. Record review of Resident #52's undated care plan did not reveal antipsychotic usage. 3. Record review of a face sheet dated 04/24/23 revealed Resident #104 was a [AGE] year-old female admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) with agitation, depressive episodes (are periods of low mood and other symptoms of depression), and insomnia (a sleep disorder in which you have trouble falling and/or staying asleep). Record review of Resident #104's consolidated physician order dated 04/26/23 revealed Zyprexa 5MG, give 1 tablet by mouth twice a day started on 01/17/23. Record review of Resident #104's MAR dated 04/01/23-04/30/23 revealed Zyprexa 5MG, give 1 tablet by mouth two times a day related to depressive episodes started on 01/17/23. Record review of the annual MDS assessment dated [DATE] revealed Resident #104 was sometimes understood and rarely/never understood others. The MDS revealed Resident #104 was unable to complete the BIMS. The MDS revealed Resident #104 had short-and-long term memory problem and moderately impaired cognitive skills for daily decision making. The MDS revealed Resident #104 required limited assistance for walking in room and transfer, extensive assistance for bed mobility, dressing, eating, toilet use, and personal hygiene, and total dependence for bathing. The MDS revealed Resident #104 received antipsychotic and antidepressant in the last 7 days. Record review of a care plan dated 03/22/23 revealed Resident #104 used psychotropic medication (Zyprexa). The care plan revealed Resident #104 used antidepressant medications related to depression. 4. Record review of a face sheet dated 04/24/23 revealed Resident #327 was [AGE] year-old male admitted on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of Resident #327's consolidated physician order dated 04/26/23 revealed Venlafaxine 75MG, give 1 tablet by mouth twice a day started on 04/22/23. Record review of Resident #327's MAR dated 04/01/23-04/30/23 revealed Venlafaxine 75MG, give 1 tablet by mouth two times a day related to dementia with other behavioral disturbance started on 04/22/23. Record review of the annual MDS assessment dated [DATE] revealed Resident #327 was usually understood and usually understood others. The MDS revealed Resident #327 had a BIMS of 03 which indicated severe cognitive impairment. The MDS revealed Resident #327 required supervision eating and walk in room, extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. The MDS revealed Resident #327 received antipsychotic in the last 7 days. Record review of a care plan dated 04/21/23 revealed Resident #327 used a psychotropic medication (Risperidone) related to schizoaffective disorder. The care plan did not address usage of antidepressant. During an interview on 04/26/23 at 2:09 p.m., RN U said dementia was not an appropriate diagnosis for use of Trazodone. She said Trazodone was for depression. RN U said dementia was not an appropriate diagnosis for Seroquel or depressive disorder for Zyprexa. She said nurses then the MDS nurse, since they enter diagnoses and classified medications, were responsible for making sure psychotropic medication had an appropriate diagnosis or indication for use. She said it was important to have appropriate diagnosis with medication to know what you were giving it for, and you would not know what side effects to monitor for. 5. Record review of a face sheet dated 04/25/2023 revealed Resident #93 was an [AGE] year-old male that admitted on [DATE] with diagnoses that included dementia (a progressive disease that destroys memory and other important mental functions) anxiety (intense, excessive, and persistent worry and fear about everyday situations), and metabolic encephalopathy (a problem with the brain caused by a chemical imbalance in the blood). Record review of the admission MDS assessment dated [DATE], revealed Resident #93 had a BIMS of 03, which indicated severe memory and cognitive impairment. The MDS revealed Resident #93 had inattention, disorganized thinking, and altered level of consciousness. The MDS revealed Resident #93 required limited assistance with ADLs. The MDS revealed Resident #93 took antipsychotic and antianxiety medications routinely. Record of review of the consolidated MD orders for Resident #93 for April 2023 revealed quetiapine (antipsychotic) 25 mg once daily for depression. The orders also revealed an order to monitor for antidepressant side effects for quetiapine every shift. Side effects: diarrhea, nausea, dry mouth, constipation, oversedation, blurred vision, change in appetite, headache, insomnia, heartburn, hypotension. If side effects are observed, report and document in medical record. Record review of an incident report dated 04/04/2023 indicated Resident #93 lost his balance and fell hitting his head. Resident #93 sustained a laceration and hematoma to his head from the fall. Record review of an incident report dated 04/15/2023 revealed Resident #93 had a fall at 8:25 a.m., in which he was found bleeding from a hematoma to his head lying on the floor beside his bed. Record review of an incident report dated 04/15/2023 at 2:30 p.m., revealed Resident #93 fell and was discovered sitting on the floor in his bathroom. Record review of a care plan dated 04/07/2023 revealed a care plan for the use of psychotropic medication quetiapine for Resident #93. The goal was for the resident to be free of psychotropic drug related complications, that included movement disorder, discomfort, hypotension, and gait disturbance to include falls. 6. Record review of Resident #6's face sheet dated 4/26/23 revealed she was a [AGE] year-old female, who readmitted to the facility on [DATE]. Resident #6 had diagnoses of dementia (progressive or persistent loss of intellectual functioning, memory, related to disease of the brain), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (persistent feeling of anxiety or dread that interferes with how you live life). Record review of Resident #6's quarterly MDS dated [DATE] revealed she had a BIMS of 4, which indicated she had severe cognitive impairment. The MDS indicated Resident #6 did not have symptoms of psychosis, behavioral issues, and she did not reject care or wander. Resident #6's primary diagnosis was unspecified dementia without behavioral disturbances. The MDS also indicated she had a diagnosis of depression and there was no diagnosis of anxiety. Resident #6 received antipsychotic medications 7 out of 7 days. Record review of Resident #6's order summary report dated 4/26/23 revealed Seroquel (Quetiapine) 50 mg one tablet by mouth twice daily for generalized anxiety disorder and other general symptoms and signs. Record review of Resident #6's MAR dated 4/01/23-4/30/23 revealed she received Seroquel (Quetiapine) 50 mg one tablet by mouth two times daily for generalized anxiety disorder and other symptoms and signs. Record review of Resident #6's undated care plan revealed there was no problem areas or interventions related to antipsychotic medication use. Record review of Resident #6's consent for antipsychotic medication treatment dated 12/18/22 revealed she had a psychiatric condition and/or maladaptive behavior of dementia with behavioral disturbances. The consent did not list diagnostic criteria or assessment findings exhibited by Resident #6. The consent was for the antipsychotic mediation of Seroquel (Quetiapine) 50 mg twice daily. The consent also revealed the need for and benefits of the proposed treatment with antipsychotic medication was to continue as long as the benefits outweighed the perceived risk. During an interview on 4/26/23 at 9:47 AM MDS Nurse B said the only appropriate diagnoses for a resident being on an antipsychotic were Schizophrenia, Tourette's, and Huntington's disease. MDS Nurse B said she when a resident had antipsychotics marked on their MDS, she would look for an appropriate diagnosis and if there was not one, she would let the DON know. MDS Nurse B said she must have missed Resident #6 not having an appropriate diagnosis for being on the antipsychotic medication. MDS Nurse B said generalized anxiety was not an appropriate diagnosis for being on an antipsychotic medication. MDS Nurse B said if the resident does not have an appropriate diagnosis for being on an antipsychotic medication, they could be receiving a medication they did not need. During an interview on 4/26/23 at 2:21 PM LVN D said residents had to have consents for medications, such as antidepressants and antipsychotics. LVN D said all medications required a diagnosis for the medication. LVN D said she was not aware of any specific diagnoses required for the use of antipsychotic medications. LVN D said the diagnosis was usually already on the order before she received the order. During an interview on 4/26/23 at 2:58 PM the DON said she was not a fan of Seroquel, and it was not a good medication to use in the elderly population. She said the facility was working with their physicians and the hospice agencies in the area to educate them on utilizing other medications rather than Seroquel in the elderly. The DON said the charge nurses were responsible for getting the consents signed for antipsychotics and psychotropic medications. The DON said the medication orders and consents should have a proper diagnosis to treat the resident. The DON said residents should not be on an antipsychotic medication to treat generalized anxiety disorder. Trazadone was not for dementia but used for insomnia and depression. She said dementia was not an appropriate diagnosis for Seroquel. The DON said she though Zyprexa could be given for depression if taken in conjunction with Prozac, which Resident #327 was on both. The DON said the resident could be on a medication they do not need, and the medication could cause increased side effects in the elderly. During an interview on 4/26/23 at 3:53 PM the Administrator said residents should not receive antipsychotic medications without an appropriate diagnosis of schizophrenia, Tourette's, Huntington's disease, and bipolar. The Administrator said the physicians and the hospice agencies in the area had been difficult to work with regarding antipsychotic and psychotropic medications with appropriate diagnoses for the use of the medications in the elderly. The Administrator said they were working on a system to not accept orders from the physician without approved or appropriate diagnoses for the medications. The Administrator said they would be educating the physicians and the hospice agencies on appropriate antipsychotic and psychotropic medication usage and approved/appropriate diagnoses for use in the elderly. The Administrator said there were very few reasons to use antipsychotics in the elderly population due to the increased risk of side effects of the medications. She said the consulting pharmacist reviews the residents' medication records monthly and sends recommendations to the physician and she also reviews for appropriate diagnoses for use of the medications. During a phone interview on 5/01/23 at 9:13 AM the Consulting Pharmacist said she completed a medication record review monthly and would send her recommendations in an email to the DON. The Consulting Pharmacist said the DON was responsible for sending the recommendations to the physician for review. The Consulting Pharmacist said the facility had not been uploading the signed recommendations to the computerized chart and it made it difficult to follow up on whether the physician agreed to the recommendations or not. The Consulting Pharmacist said a diagnosis of generalized anxiety disorder alone was not an appropriate diagnosis for the use of an antipsychotic, such as Seroquel, in the elderly. The Consulting Pharmacist said Zyprexa was not indicated for dementia and she would have made a recommendation to the MD to please reconsider another medication or diagnosis. The Consulting Pharmacist said Resident #104 had an evaluation for falls in January and she noticed Resident #104 was on multiple central nerve system altering medications and she recommended the MD discontinue the Ambien and decrease the Zyprexa. She said the initial order for the Zyprexa had indication for mood or psychosis and psychosis would have been an appropriate diagnosis. The Consulting Pharmacist said Resident #34 had a Medication Regimen Review on 04/04/23 and the Trazadone order started on 10/09/22 had a diagnosis of major depressive disorder not dementia. She said she did not know how Resident #34's Trazodone order changed for use for dementia. The Consulting Pharmacist said she would recommend the physician consider another medication or diagnosis. The Consulting Pharmacist said the facility had not been scanning the antipsychotic or psychotropic medication consents to the computerized software and she often would send the blank consents to the facility and ask them to complete them. The Consulting Pharmacist said the consents for antipsychotic or psychotropic medications should be completed and include an appropriate diagnosis for the medication, what behaviors were being treated, the medication and dosage of the medication, and the possible side effects of taking the medication. Record review of a facility's Antipsychotic Medication use dated 12/16 revealed .resident will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective .diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident .antipsychotic medication shall generally be used for the following conditions .Schizophrenia .Schizo-Affective disorder .Schizophreniform disorder .Delusional disorder .Mood disorder .Psychosis in the absence of dementia .medical illness with psychotic symptoms and/or treatment-related psychosis or mania .Tourette's Disorder .Huntington Disease .Hiccups .Nausea and vomiting associated with cancer or chemotherapy .diagnoses alone do not warrant the use of antipsychotic medication

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 5 of 12 dining room chairs reviewed for environment. 1. The facility failed to ensure resident on the secured unit had clean, safe dining room chairs. This failure could place residents at risk for diminished quality of life due to lack of personal hygiene along with a safe, functional, sanitary, or comfortable environment. Findings included: During an observation on 04/25/23 at 8:45 a.m., 5 dining rooms chair in the dining had cloth, slightly torn cushion, moderate sized indentation in the middle of the seat, and wobble seat cushion. During an interview on 04/25/23 at 3:46 p.m., CNA V said the dining room chairs had holes in them and weak seat cushions. She said some resident urinated in the cloth seat cushion and staff tried to sanitize it with cleaner. CNA V said she thought some of the dining rooms chairs had been replaced because they had gotten so bad. She said she felt like the dining rooms chairs were not safe for residents, staff or family members. CNA V said she assumed upper management knew about the condition of the dining room chairs because the facility was repainting the walls and decorating the secured unit. She said she had not placed a work order regarding the dining room chairs but did know how to place one. During an interview on 04/26/23 at 9:07 a.m., CNA R said she worked for an agency company but had worked at the facility a couple of times. She said the dining room chairs were not in good shape. CNA R said she did not know if upper management knew about the dining room chairs. She said the facility had a maintenance book somewhere to place work orders in. CNA R said the facility had started cosmetically updating the secured unit about a month ago but had not replaced the dining room chairs. During an interview on 04/26/23 at 9:30 a.m., CNA S said the dining room chairs on the secured unit needed to change out. She said she felt like the bottom was about to fall out. CNA S said she had let nursing staff know about her concerns and maintenance knew about the condition of the chairs. During an interview on 04/26/23 at 2:09 p.m., RN U said the dining room chairs dipped in the middle and were weak from urine. She said she started March 2023 and did not know if upper management was aware of the issue. RN U said the chairs needed to be replaced so no one got hurt. During an interview on 04/26/23 at 2:58 p.m., the DON said none of the staff member had informed her of the condition of the secured unit dining room chairs. She said the secured unit was being remodeled. The DON said she expected the staff to put furniture issues in the electronic maintenance log. She said not having safe and clean furniture decreased resident's quality of life and risked their safety. The DON said it was the corporation responsibility to provide the resident a safe, clean environment. During an interview on 04/26/23 at 4:24 p.m., the ADM said no one had told her about the condition of the dining room chairs. She said she did make rounds and monitor the electronic maintenance log and did not recall seeing dining room chairs. The ADM said she expected her staff to put work orders in the electronic maintenance log or tell the ADON, charge nurse or ADM. She said Maintenance and herself were responsible for the facility's environment. Record review of a facility's Maintenance Service policy dated 12/09 revealed .maintenance service shall be provided to all areas of the building, grounds .the maintenance department is responsible for maintaining the buildings .building in good repair and free from hazards . Record review of a facility's Quality of life- Homelike Environment policy dated 05/17 revealed ' .residents are provided with a safe, clean, comfortable and home like environment .clean, sanitary and orderly environment .