**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 6 Residents (Resident #53) reviewed for PASSAR (Preadmission Screening and Resident Review Services). The facility failed to ensure Resident #53 had a new level 1 PASSAR completed with a diagnosis of bipolar disorder on admission [DATE]. These failures could place residents at risk of not receiving the needed PASSAR services to meet their individual needs and could result in a decreased quality of life. The findings included: Record review of a face sheet for Resident #53 dated 9/17/2024 for Resident #53 indicated she admitted to the facility 2/21/2024 and was [AGE] years old with diagnosis of acute and chronic respiratory failure (a condition that makes it difficult to breathe on your own), type 2 diabetes, COPD (a lung disease causing restricted airflow and breathing problems), osteoarthritis (inflammation of one or more joints) and bipolar disorder (a mental illness characterized by extreme mood swings) that was effective on 12/7/2023. Record review of a care plan for Resident #53 dated 12/19/2023 indicated she would have a PASSR screening according to regulatory guidelines. This was completed on 12/7/2023 and revealed a need for no specialized services. Record review of a Quarterly MDS assessment dated [DATE] for Resident #53 indicated she did not have any impairment in thinking with a BIMS score of 15. A referral was not made to the local contact agency because the referral was not wanted. During an interview on 9/17/2024 at 3:50 PM, the MDS Coordinator said she had been employed at the facility for 10 years and was responsible for the coordination of PASSR. She said she missed on the diagnosis list for Resident #53 that she had bipolar on admission to the facility on [DATE]. She said she was not aware of it until 9/16/2024 when the Surveyor questioned her about an evaluation for PASSR for the resident. She said Resident #53 should have had a PASSR evaluation on admission with her mental illness diagnosis of bipolar. She said she was responsible for looking at the orders and would run an order report daily and just missed recognizing that Resident #53 had a mental illness diagnosis of bipolar. She said she generated a new PASSR Level 1 (PL1) today 9/17/2024 and contacted the local authority to notify them to conduct an evaluation with the resident. She said residents could be at risk for a relapse or exacerbation of their mental illnesses if they did not get the services they qualified for. She said she submitted the new PL1 into the portal in SIMPLE and would be waiting on a response. She said she had training on PASSR in the past and was not sure how it was missed with Resident #53, and it was an error on her part. During an interview on 9/18/2024 at 2:27 PM, the Administrator said she was made aware on yesterday 9/17/2024 about Resident #53 not having a PASSR evaluation on admission to the facility. She said she was told it was an oversight on the MDS Coordinator's part. She said the MDS Coordinator has a regional support contact that provides offsite checks and going forward would have her supervisor check to ensure residents had coordination of services if necessary. She said they would put a plan in place to check in the facility and with corporate. A copy of a PASSR policy was requested from the facility and was told they did not have a policy and they followed the RAI manual for guidance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 1 of 11 resident's (Resident #54) personal refrigerators reviewed for food and nutrition services. The facility failed to ensure a personal refrigerator on 09/16/2024 for Resident #54 did not contain a jar of mayonnaise with an expiration date of 8/25/2024. These failures could place residents at risk for food borne illnesses. Findings include: Record review of a face sheet for Resident #54 dated 9/17/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of venous insufficiency (occurs when the veins in the legs have difficulty returning blood to the heart), malignant neoplasm of prostate (prostate cancer) and dementia. Record review of a resident/patient refrigerator log dated September 2024 indicated on 9/16/2024 the refrigerator was checked as indicated by the initials of RNA. Record review of an admission MDS Assessment for Resident #54 dated 7/29/2024 indicated he had moderate impairment in thinking with a BIMS score of 8. He required set up or clean up assistance with eating. Record review of a care plan for Resident #54 dated 7/26/2024 indicated he had an ADL self-care performance deficit related to activity intolerance with interventions for eating: required set up help from staff participation to eat. During an observation and interview on 9/16/2024 at 9:12 AM, Resident #54 was in his room sitting up in a wheelchair. He had a personal refrigerator in his room that had a jar of mayonnaise that expired 8/25/24. He said he ate foods from his refrigerator and that staff checked it. During an observation and interview on 9/18/2024 at 8:17 AM, Resident #54 was in his room and the jar of mayonnaise was not in his refrigerator. He said a staff member removed it on yesterday 9/17/2024. During an interview on 9/18/2024 at 8:25 AM, RNA said she had been employed at the facility for 11 1/2 years and was responsible for checking the personal refrigerators on halls 200 and 400. She said she checked the refrigerators daily for expired food items or foods that had been left for more than 3 days and then would throw them away. She said she checked Resident #54's refrigerator daily but did not remember seeing a bottle of expired mayonnaise. She said she did not keep a log of the refrigerators that she checked and only put the temperatures on the temperature log that was on the refrigerators. She said residents could be sick from eating foods that were expired especially mayonnaise. She said she had not removed anything from his refrigerator. She said some residents would get upset if they removed foods from their personal refrigerators but Resident #54 did not. During an interview on 9/18/2024 at 2:13 PM, the DON who said the personal refrigerators were the responsibility of the restorative aides. She said they were responsible for checking refrigerators daily for temperatures, foods that are not left more than 3 days, and milk to make sure it was not spoiled. She said residents could be at risk for food poisoning or getting sick if items were left in their refrigerators. During an interview on 9/18/2024 at 2:27 PM, the Administrator said the RNAs were responsible for checking the personal refrigerators daily for temperatures and foods. She said the department heads checked daily to be sure the temperatures were done and what was in the refrigerators. She said she removed the expired mayonnaise from Resident #54's refrigerator on Monday night 9/16/2024. She said going forward she would continue to have the RNA's check the refrigerators daily and would require the department heads to check daily as well. She said residents could get ill if they ate expired foods. Record review of a facility policy titled Foods Brought by Family/Visitors revised on 2/1/2021 reflected, .Staff must be aware of, and approve, food(s) [NAME] to a resident by family/visitors. 1. Family members should inform nursing staff of their desire to bring foods into the facility. 7. The nurse staff is responsible for discarding perishable foods on or before the use by date .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 6 of 15 residents (Residents #40, #53, #70, #74, #17, and #7) reviewed for MDS assessment accuracy. 1.The facility incorrectly coded Resident #40 as having received Insulin in previous 14 days while a resident on his MDS Assessment. 2.The facility failed to accurately code on the MDS assessments for Resident's #53 on 8/10/2024, #70 on 7/20/2024, #74 on 8/29/2024 and #7 on 8/7/2024 who had side rails on their bed. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1. Record review of the facility face sheet dated 9/17/2024 for Resident #40 reflected that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), reduced mobility and muscle weakness. Record review of a Quarterly MDS dated [DATE] for Resident #40 indicated that he had a BIMS score of 12, indicating that he had moderately impaired cognition. Section O, question O0100, 2c indicated that resident had received Insulin in the previous 14 days. Record review of the medication administration record for Resident #40 for the months of July 2024 and August 2024 indicated that he had not received insulin for the look-back period (previous 14 days) of the MDS. Resident received a weekly injection of Bydureon BCise 2 MG/0.85ML which was not insulin. Record review of Resident #40's care plan revised 6/22/24 indicated problem: Diagnosis of Diabetes with an intervention to monitor effectiveness of medications. Record review of Resident #40's physician orders dated July and August 2024 indicated that he had no orders for insulin. During an Interview on 09/18/24 at 11:20 AM the MDS Co-Ordinator said that she thought the Bydureon BCise 2 MG/0.85ML Auto-injector was a type of insulin and coded the MDS to reflect that in error. The MDS Co-Ordinator said the MDS must be completed accurately to ensure proper care is planned for the resident. 2. Record review of a face sheet for Resident #53 dated 9/17/2024 for Resident #53 indicated she admitted to the facility 2/21/2024 and was [AGE] years old with diagnosis of acute and chronic respiratory failure (a condition that makes it difficult to breathe on your own), type 2 diabetes, COPD (a lung disease causing restricted airflow and breathing problems) and osteoarthritis (inflammation of one or more joints). Record review of active physician orders for Resident #53 dated 9/17/2024 indicated an order with a start date of 12/7/2023 for use of enabler bars to turn and reposition in bed. Record review of a Quarterly MDS assessment dated [DATE] for Resident #53 indicated she did not have any impairment in thinking with a BIMS score of 15. She used a walker or wheelchair in the 7 day look back period. She was independent with the ability to roll left and right, sit to lying and lying to sitting on side of bed. Physical restraints of bed rails were not used. Record review of a care plan for Resident #53 dated 12/19/2023 indicated she had an ADL self-care performance deficit related to activity tolerance with interventions for bed mobility: requires 1 staff participation to reposition and turn in bed. May use enabler bars to turn/position in bed added on 9/17/2024. During an observation and interview on 9/16/2024 at 11:56 AM, Resident #53 was in her room sitting on the side of her bed. She said she had been at the facility since December 2023. She had 1/4 rails on both sides of the bed. During an observation and interview on 9/18/2024 at 8:14 AM, Resident #53 said on admission to the facility bed rails were on the bed when she arrived, and no one asked her if she wanted to keep them or not. She said she always kept the rails in the upright position, so they were positioned by her head to grab. 1/4 rails were observed in the upright position on both sides of the bed. Record review of an admission Record dated 9/17/2024 for Resident #70 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of unspecified tracheostomy (tube that in in the neck that allows them to breathe through the tube instead of their mouth or nose) and hypertension. Record review of active physician orders dated 9/17/2024 for Resident #70 indicated an order that may use enable bars to turn and reposition in bed that started on 5/31/2023. Record review of a Quarterly MDS Assessment for Resident #70 dated 7/20/2024 indicated she did not have any impairment in thinking with a BIMS score of 15. She used a walker and wheelchair during the 7 day look back period. Restraints and alarms indicated no use of bed rails. Record review of a care plan for Resident #70 dated 4/13/2023 indicated she had an ADL self-care performance deficit related to mobility status with an intervention for bed mobility: requires 1 staff participation to reposition and turn in bed. May use an enabler bar to turn/reposition in bed dated 9/17/2024. During an observation and interview on 9/16/2024 at 9:31 AM, Resident #70 was in bed awake, using oxygen via (through) her trach. She had ¼ rails on both sides of the bed. Record review of a face sheet for Resident #7 dated 9/17/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of type 2 diabetes, anemia, contracture of left hand (a shortening and hardening of the muscles) and hypertension. Record review of active physician orders for Resident #7 dated 9/17/2024 indicated an order that they may use enabler bars to turn and reposition in bed dated 5/21/2023. Record review of a Quarterly MDS Assessment for Resident #7 dated 8/7/2024 indicated he had moderate impairment in thinking with a BIMS score of 6. He was dependent on staff with assistance with rolling left and right, sitting to lying, and lying to sitting on side of bed. The use of bed rails was not used. Record review of a care plan for Resident #7 dated 6/15/2016 indicated he had an ADL self-care performance deficit related to limited mobility with interventions of bed mobility: may use enabler bars for help with repositioning and turning in bed dated 6/27/2016. During an observation on 9/16/2024 at 9:21 AM, Resident #7 was in bed resting with eyes closed. He had ¼ rails on both side of the bed in the middle with sheep skin covering them. During an observation on 9/17/2024 at 12:20 PM. Resident #7 was in bed watching tv and the ¼ rails that were on the bed were up in the middle of the bed. The rails had sheep skin covering both of them. Record review of a facility face sheet dated 9/17/24 for Resident #74 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Urinary tract infection, type 2 diabetes mellitus, and reduced mobility. Record review of a comprehensive MDS assessment dated [DATE] for Resident #74 indicated that she had a BIMS score of 7, which indicated that she had severely impaired cognition. She was dependent on staff for transfers, rolling left to right, sitting to lying, and lying to sitting on side of bed. Assessment indicated that bed rails were not used. Record review of a comprehensive care plan dated 8/27/24 for Resident #74 indicated that she had an ADL self-care performance deficit, required 2 staff participation to reposition and turn in bed, and may use enabler bar to turn/reposition in bed was added on 9/17/24. Record review of a physician's order summary report dated 9/17/24 indicated that Resident #74 had the following order dated 8/26/24: .may use enabler bars to turn and reposition in bed . Record review of a Side Rail/Mobility/Positioning Bar Assessment - V 1 dated 9/10/24 for Resident #74 read .Please specify the type of rails being used . and form then read .1/4 rails, enabler bars, both sides . Record review of a facility form titled Physical Device Consent and Acknowledgement dated 5/30/24 for Resident #74 read .Type of Device Recommended by Inter-Disciplinary Team (IDT): .Side rails; ¼ side rails and ½ side rails . During an observation on 9/16/24 at 10:11 am Resident #74 was observed lying in bed with ¼ rails observed on both sides of bed. Resident did not speak. During an interview on 9/17/2024 at 2:27 PM, MDS Coordinator said she had been employed at the facility for 10 years. She was responsible for the care plans, MDS assessments and PASSR. She said she revised care plans every day and quarterly with MDS assessments. She said what the Surveyors are calling side rails in the facility were enabler bars and that what was told to them by their corporate staff. She said she did not code side rails on the MDS assessments as side rails because they consider them enabler bars until the Surveyors brought it to their attention on 9/16/2024. During an interview on 9/17/2024 at 2:48 PM, the Regional Nurse said she had been in her position for 13 years. Said that bed rails in the facility were classified as enabler bars to assist in bed with mobility. They looked at the side rails as ½ rails that covered 3/4 of the side of the bed and they were used as enabler bars but said she would go and look facility wide at the side rails. During an interview on 9/17/2024 at 2:59 PM, the DON said she had been employed at the facility for 4 years. She said they always classified the bars on beds as enablers as it allowed the residents to help turn themselves and they were able to hold on if they wanted to while being turned. She said rails were on the beds on admission to the facility. She said side rails were not a restraint. During a follow up interview on 9/17/2024 at 3:16 PM, the Regional Nurse said the problem with the side rails on the bed were the placements of some of them being in the middle of the bed. She said residents could be at risk for entrapment. During an interview on 09/18/24 12:04 PM, the Administrator said the MDS assessments should reflect accurate information to ensure the highest level of well-being for the resident. Record review of a facility polity titled Resident Assessment Instrument (MDS 3.0) revised 3/1/2022 indicated, .A comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. 1. Within fourteen (14) days of the resident's admission, a comprehensive assessment of the resident's needs will be made by the Interdisciplinary Assessment Team. 6. Within seven (7) days of the completion of the resident assessment, a comprehensive care plan will be developed. 4. Information derived from the comprehensive assessment enables the staff to plan care that allows the resident to reach his/her highest practicable level of functioning and to meet their unique care needs. 7. All persons who have completed any portion of the MDS 3.0 Resident Assessment Form must electronically sign each document attesting to the accuracy of such information . Record review of manufacturer www.astrazeneca-us.com accessed 09/18/2024 indicated Bydureon BCise Auto injector, generic name: exenatide extended release, drug class Incretin Mimetics (GLP-1 Agonists) Record review of facility policy titled Certifying Accuracy of the Resident Assessment dated 2001 with revision date of November 2019 indicated .The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 5 of 18 residents (Residents #53, #70, #13, #74, and #130) reviewed for care plans in that: The facility failed to develop a comprehensive care plan for the use of enabler bars for Resident #13 that were put into use on 4/3/21. The facility failed to develop a comprehensive care plan for the use of side rails for Resident #74 that were put into use on 5/29/24. The facility failed to develop a comprehensive care plan for the use of a side rails for Resident #130 that was put into use on 7/30/24. The facility failed to develop a comprehensive care plan for the use of side rails for Resident #53 that was put into use on 12/7/2023. The facility failed to develop a comprehensive care plan for the use of side rails for Resident #70 that was put into use on 5/31/2023. This failure could place residents at risk of inappropriate care and decreased quality of life. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings included: Record review of a facility face sheet dated 09/17/24 for Resident #130 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia (Inability to adequately maintain adequate oxygen in the blood), reduced mobility and gastro-esophageal reflux disease (heart burn). Record review of a comprehensive MDS dated [DATE] for Resident #130 Section C (Cognitive Patterns) indicated that he was moderately cognitively impaired. Section P indicated no use of bed rails. Record review of a comprehensive care plan dated 08/05/24 for Resident #130 indicated interventions for use of an enabler bar for bed mobility, requires 1-2 staff participation to reposition and turn in bed. May use enabler bars to turn/reposition in bed. Use of side rails were not addressed. Record review of a face sheet for Resident #53 dated 9/17/2024 for Resident #53 indicated she admitted to the facility 2/21/2024 and was [AGE] years old with diagnosis of acute and chronic respiratory failure (a condition that makes it difficult to breathe on your own), type 2 diabetes, COPD (a lung disease causing restricted airflow and breathing problems) and osteoarthritis (inflammation of one or more joints). Record review of active physician orders for Resident #53 dated 9/17/2024 indicated an order with a start date of 12/7/2023 for use of enabler bars to turn and reposition in bed. Record review of a Quarterly MDS assessment dated [DATE] for Resident #53 indicated she did not have any impairment in thinking with a BIMS score of 15. She used a walker or wheelchair in the 7 day look back period. She was independent with the ability to roll left and right, sit to lying and lying to sitting on side of bed. Physical restraints of bed rails were not used. Record review of a care plan for Resident #53 dated 12/19/2023 indicated she had an ADL self-care performance deficit related to activity tolerance with interventions for bed mobility: requires 1 staff participation to reposition and turn in bed. May use enabler bars to turn/position in bed added on 9/17/2024. Record review of an admission Record dated 9/17/2024 for Resident #70 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of unspecified tracheostomy (tube that in in the neck that allows them to breathe through the tube instead of their mouth or nose) and hypertension. Record review of active physician orders dated 9/17/2024 for Resident #70 indicated an order that may use enable bars to turn and reposition in bed that started on 5/31/2023. Record review of a Quarterly MDS Assessment for Resident #70 dated 7/20/2024 indicated she did not have any impairment in thinking with a BIMS score of 15. She used a walker and wheelchair during the 7 day look back period. Restraints and alarms indicated no use of bed rails. Record review of a care plan for Resident #70 dated 4/13/2023 indicated she had an ADL self-care performance deficit related to mobility status with an intervention for bed mobility: requires 1 staff participation to reposition and turn in bed. May use an enabler bar to turn/reposition in bed dated 9/17/2024. Record review of a facility face sheet dated 9/17/24 for Resident #74 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Urinary tract infection, type 2 diabetes mellitus, and reduced mobility. Record review of a comprehensive MDS assessment dated [DATE] for Resident #74 indicated that she had a BIMS score of 7, which indicated that she had severely impaired cognition. She was dependent on staff for transfers, rolling left to right, sitting to lying, and lying to sitting on side of bed. Assessment indicated that bed rails were not used. Record review of a comprehensive care plan dated 8/27/24 for Resident #74 indicated that she had an ADL self-care performance deficit, required 2 staff participation to reposition and turn in bed, and may use enabler bar to turn/reposition in bed was added on 9/17/24. Record review of a physician's order summary report dated 9/17/24 indicated that Resident #74 had the following order dated 8/26/24: .may use enabler bars to turn and reposition in bed . Record review of a Side Rail/Mobility/Positioning Bar Assessment - V 1 dated 9/10/24 for Resident #74 read .Please specify the type of rails being used . and form then read .1/4 rails, enabler bars, both sides . Record review of a facility form titled Physical Device Consent and Acknowledgement dated 5/30/24 for Resident #74 read .Type of Device Recommended by Inter-Disciplinary Team (IDT): .Side rails; ¼ side rails and ½ side rails . During an observation on 9/16/24 at 10:11 am Resident #74 was observed lying in bed with ¼ rails observed on both sides of bed. Resident did not speak. Record review of a facility face sheet dated 9/17/24 for Resident #13 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: congestive heart failure, reduced mobility, and repeated falls. Record review of a Quarterly MDS assessment dated [DATE] for Resident #13 indicated that he had a BIMS score of 7, which indicated that he had severely impaired cognition. He was dependent with transfers, required substantial/maximal assistance with sitting to lying and with lying to sitting, and required partial/moderate assistance with rolling left to right. Assessment indicated that bed rails were not used. Record review of an Order Summary Report dated 9/17/24 for Resident #13 indicated that he had the following order dated 5/31/23: .May use enabler bars to turn and reposition in bed . Record review of a comprehensive care plan dated 7/2/24 for Resident #13 indicated that he was at risk for falls and had an ADL self-care performance deficit. Care plan did not address the use of enabler bars or side rails. Record review of a facility form titled Physical Device Consent and Acknowledgement for Resident #13 read .Type of restraint recommended by inter-disciplinary team (IDT) .Side Rails - 1/4 side rail . During an interview on 9/17/2024 at 2:27 PM, MDS Coordinator said she had been employed at the facility for 10 years. She was responsible for the care plans, MDS assessments and PASSR. She said she revised care plans daily and quarterly with MDS assessments. She said what the Surveyors were calling side rails in the facility were called enabler bars and that was what corporate staff told them they were . She said the care plans already had enablers on them and they do not consider them as side rails. During an interview with the MDS Co-Ordinator on 09/18/24 09:49 AM the MDS Co-Ordinator said she had worked at the facility for 10 years and she used the orders and observations to code the MDS and complete the care plan for resident #130. She said she uses the term enabler when addressing the rails on resident's beds. During an interview on 09/18/24 at 9:55 am Administrator said that going forward she was expecting the MDS nurse to complete assessments and care plans accurately. She said residents could be at risk of not getting the care they needed since care plan focus areas were pulled over from assessment data on the MDS. Record review of a facility policy titled Care Plan Revised date 03-01-2022, read .An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical. nursing, mental, and psychological needs is developed for each resident .3. Each resident's Comprehensive Care Plan has been designed to: a. Incorporate identified problem, area: Incorporate risk factors associated with identified problems. Record review of a facility policy titled Care Plans-Comprehensive revised on 3/1/2022 indicated, .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents' medical, nursing, mental and psychological needs is developed for each resident. 4. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). 5. Care plans are revised as changes in the resident's condition dictate. Care plan are reviewed at least quarterly and any significant change in status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 2 of 11 residents reviewed for quality of care, (Resident #6 and #281) in that: The facility failed to remove worn, damaged and bleached mechanical lift slings from service for Residents #6 and #281. The facility failed to obtain physician orders for mechanical lift transfers for Resident #6. This deficient practice could result in a loss of quality of life due to injuries. Findings included: Record review of a facility's face sheet dated 5/21/24 for Resident #6 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Lack of co-ordination, osteoarthritis (degeneration of the bones) and muscle weakness. Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated that she was rarely/never understood, and that Resident #6 was severely cognitively impaired. Assessment also indicated that she was totally dependent with transfers. Record review of a comprehensive care plan dated 8/27/24 indicated that Resident #6 was totally dependent on a mechanical lift with the assistance of 2 persons for transfers. Record review of a physician order report dated 09/17/24 for Resident #6 indicated that she did not have a physician order for mechanical lift transfers. Record review of a facility face sheet dated 09/16/2024 indicated Resident #281 was an [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of displaced intertrochanteric fracture of right femur (common hip fracture), reduced mobility and chronic obstructive pulmonary disease (a condition that limits airflow into and out of the lungs). Record review of a comprehensive care plan initiated 06/24/2024 indicated Resident #281 required transfer assist of 2 staff with or without mechanical device. Record review of an admission MDS assessment dated [DATE] indicated Resident #281 had a BIMS of 07 indicating severely impaired cognition. Resident required moderate to maximal assistance with transfers and moderate assist with rolling left to right. During an observation on 09/16/2024 at 10:11 AM, of a Hoyer lift sling under Resident #281 while he was sitting in his wheelchair, the colored connection tabs were faded, light in color and the care label was illegible and shrunken. During an observation and Interview on 09/16/24 at 10:15 AM Resident #6 in room sitting in chair watching TV dressed neatly, denies any problems with staff. She was sitting in a chair with a Hoyer lift sling underneath her. The straps are faded in color they all appear to be a light purple pink not bright Blue, Bright Purple, or Bright green. During an interview with the DON on 9/17/2024 at 07:49 AM who said that she was aware that the resident was in a sling that needed to be replaced and that a new sling was being delivered and would be replaced as soon as it arrived. During an Interview on 09/16/24 10:31 AM with CNA A, unable to answer why or what she would look for to ensure the Hoyer sling was safe. During an interview on 09/16/24 10:32 AM with CNA B said she would look for rips or tears on the Hoyer sling before use. Asked her what is wrong with Resident #6's Hoyer sling, and she could not give an answer. During an observation and interview on 09/16/24 10:40 AM with the DON who said she was not aware faded slings needed to be taken out of service. She said the faded slings would be removed from service immediately. During an interview with the DON on 9/17/2024 at 07:49 AM she said that she was aware that the resident was in a sling that needed to be replaced and that a new sling was being delivered and would be replaced as soon as it arrived. During an interview on 9/17/24 at 10:06 AM, Laundry Aide said she had been employed at the facility for 11 years. She said the Hoyer lift slings were washed with personals, if there were a lot of them, they were washed by themselves. She said if a resident was in isolation and the laundry arrived in a yellow bag, the slings would be washed, and the wash included bleach. She said the slings were hung up to dry. She said they used a log in the past when the lift slings came into the laundry to keep track but no longer use it and no one has informed her that she needed to. She said once the slings were removed from the washer, she would inspect them for any tears or frays, if they had them would discard them in the trash. During an interview and observation on 09/17/24 at 10:10 am, the DON said sling pads should be inspected by the staff before using them to transfer a resident and that worn sling pads could put residents at risk for falls. During an interview on 09/17/24 at 11:00 am, Med Aide D said she had been employed 10 years. She said she looked for signs of wear on the lift pads such as loose strings and faded coloring on the straps. She said if she observed any signs of wear, she would not use the lift pad to transfer a resident. She said worn pads could break causing a resident to fall. During an interview on 09/17/24 at 11:10 pm, Med Aide E said she had been employed for about two years. She said she would look for loose seams, faded colors, rips and tears on the lift pads before use. She said that lift pads that had faded coloring, loose seams, and rips or tears could break while using them, and a resident could fall. During an observation on 09/17/24 at 12:30 pm, Medical Record Staff brought in approximately 12 new Hoyer lifts slings for the staff to put in rotation and remove any faded and worn slings out of rotation. During an interview on 09/18/24 at 10:30 pm, the Administrator said there could be a chance of the sling breaking if it was worn. She said they ordered new slings, and the DON would be inspecting them routinely from then on. She said they educated the CNAs, and they would be expecting the CNAs to inspect all slings prior to using them for a resident. Record review of the facility's policy titled Lifting Machine, using a Portable revised March 2014 read .The purpose of this procedure is to help lift residents using a manual device . There were no interventions to ensure the sling were examined before use for rips, frays, tearing or other indications of potential failure as specified by the manufacturer. Record review of the facility's policy titled Safety and Supervision of Residents revised March 2014 read .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Record review of manufacture guidelines Full Body Slings - Instructions for use accessed at www.medline.com on 09/18/24 read .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 . and .Do not remove sling labels. If sling labels are removed or no longer legible, sling must be immediately removed from use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 4 of 24 residents (Resident #53, #70, #74,and #16) reviewed for bed rails. 1.The facility failed to attempt to use an alternative for the use of bedrails and complete quarterly side rail assessments for Resident #53 who re-admitted to the facility on [DATE] and a order with a start date of 12/7/2023 for use of enabler bars to turn and reposition in bed. 2.The facility failed to attempt to use an alternative for the use of bedrails and complete quarterly side rail assessments for Resident #70 who admitted to the facility on [DATE] and an order for Resident #70 that reflected the use of enable bars to turn and reposition in bed that started on 5/31/2023. 3.The facility failed to attempt to use an alternative for the use of bedrails for Resident #74 who admitted on [DATE] and an order dated 8/26/24: .may use enabler bars to turn and reposition in bed . 4. The failed to attempt to use an alternative for the use of bedrails and complete quarterly side rail assessments for Resident #16 who admitted to the facility on [DATE] and a siderail assessment was done one time in past 12 months on 05/16/2024 This failure could place residents at risk of entrapment or injury. Findings included: 1.Record review of a face sheet for Resident #53 dated 9/17/2024 indicated she re-admitted to the facility 2/21/2024 and was [AGE] years old with diagnosis of acute and chronic respiratory failure (a condition that makes it difficult to breathe on your own), type 2 diabetes, COPD (a lung disease causing restricted airflow and breathing problems) and osteoarthritis (inflammation of one or more joints). Record review of active physician orders for Resident #53 dated 9/17/2024 indicated an order with a start date of 12/7/2023 for use of enabler bars to turn and reposition in bed. Record review of a Quarterly MDS assessment dated [DATE] for Resident #53 indicated she did not have any impairment in thinking with a BIMS score of 15. She used a walker or wheelchair in the 7 day look back period. She was independent with the ability to roll left and right, sit to lying and lying to sitting on side of bed. Physical restraints of bed rails were not used. Record review of a Side Rail/Mobility/Positioning Bar assessment dated [DATE] for Resident #53 indicated the resident made the request for side rails, no diagnoses was indicated, type of rails used 1/4 rails for both sides for bed mobility, and indicated it was care planned. Record review of a care plan for Resident #53 dated 12/19/2023 indicated she had an ADL self-care performance deficit related to activity tolerance with interventions for bed mobility: required 1 staff participation to reposition and turn in bed. May use enabler bars to turn/position in bed was added on 9/17/2024. Record review of a Side Rail/Mobility/Positioning Bar assessment dated [DATE] for Resident #53 indicated the resident made the request for side rails, no diagnoses was indicated, type of rails used 1/4 rails for both sides for bed mobility, and indicated it was care planned. Record review of a physical device consent and acknowledge form for Resident #53 dated 12/7/2023 indicated use of 1/4 side rails to assist with self-care-bed mobility was signed by the residents RP. During an observation and interview on 9/16/2024 at 11:56 AM, Resident #53 was in her room sitting on the side of her bed and said she had been at the facility since December 2023. She had 1/4 rails on both sides of the bed. During an observation and interview on 9/18/2024 at 8:14 AM, Resident #53 was in her room. She said on admission to the facility, the bed rails were on the bed when she arrived, and no one asked her if she wanted to keep them or not. She said she was able to move them up and down and did not remember if she signed a consent or not. She said she always kept the rails in the upright position, so they were positioned by her head to grab. Observation of 1/4 rails were in the upright position on both sides of the bed. 2. Record review of an admission Record dated 9/17/2024 for Resident #70 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of unspecified tracheostomy (tube that in in the neck that allows them to breathe through the tube instead of their mouth or nose) and hypertension. Record review of active physician orders dated 9/17/2024 for Resident #70 indicated an order that reflected Resident #70 may use enable bars to turn and reposition in bed that started on 5/31/2023. Record review of a Quarterly MDS Assessment for Resident #70 dated 7/20/2024 indicated she did not have any impairment in thinking with a BIMS score of 15. She used a walker and wheelchair during the 7 day look back period. Restraints and alarms indicated no use of bed rails. Record review of a Side Rail/Mobility/Positioning Bar Assessment for Resident #70 dated 4/19/2024 indicated the request for use of side rails was done by the resident for right sided weakness. Type of rails used were 1/4 rails. Alternatives tried prior to the use of side rails were staff and was care planned. Record review of a care plan for Resident #70 dated 4/13/2023 indicated she had an ADL self-care performance deficit related to mobility status with an intervention for bed mobility: requires 1 staff participation to reposition and turn in bed. May use an enabler bar to turn/reposition in bed dated 9/17/2024. Record review of a physical device consent and acknowledgement for Resident #70 dated 3/27/2023 for use of 1/4 side rails as enablers indicated the resident signed consent electronically on 3/27/2023. Record review of a Side Rail/Mobility/Positioning Bar Assessment for Resident #70 dated 4/19/2024 indicated the request for use of side rails was done by the resident for right sided weakness. Type of rails used were 1/4 rails. Alternatives tried prior to the use of side rails were staff and was care planned. During an observation and interview on 9/16/2024 at 9:31 AM, Resident #70 was in bed awake, using oxygen via (through) her trach. She had ¼ rails on both sides of the bed. During an observation on 9/16/2024 at 9:45 AM, ¼ rails were on the bed in an upright position that looked like assist bars on the bed. During an observation and interview on 9/18/2024 at 8:20 AM, Resident #70 was in her room eating breakfast and 1/4 rails were in the upright position on both sides of the bed. She said when she admitted to the facility no one asked her if she wanted the bed rails or not. She said they did not explain to her any risks associated with having the bed rails on the bed. She said she was able to let the bed rails up and down on her own. She said she did remember signing a consent form for the rails when she admitted . 3. Record review of a facility face sheet dated 9/17/24 for Resident #74 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Urinary tract infection, type 2 diabetes mellitus, and reduced mobility. Record review of a comprehensive MDS assessment dated [DATE] for Resident #74 indicated that she had a BIMS score of 7, which indicated that she had severely impaired cognition. She was dependent on staff for transfers, rolling left to right, sitting to lying, and lying to sitting on side of bed. Assessment indicated that bed rails were not used. Record review of a comprehensive care plan dated 8/27/24 for Resident #74 indicated that she had an ADL self-care performance deficit, required 2 staff participation to reposition and turn in bed, and may use enabler bar to turn/reposition in bed was added on 9/17/24. Record review of a physician's order summary report dated 9/17/24 indicated that Resident #74 had the following order dated 8/26/24: .may use enabler bars to turn and reposition in bed . Record review of a Side Rail/Mobility/Positioning Bar Assessment - V 1 dated 9/10/24 for Resident #74 read .Please specify the type of rails being used . and form then read .1/4 rails, enabler bars, both sides . Record review of a facility form titled Physical Device Consent and Acknowledgement dated 5/30/24 for Resident #74 read .Ineffective alternatives for use of this device to manage the medical symptom have included: lowest level intervention/first intervention . During an observation on 9/16/24 at 10:11 am Resident #74 was observed lying in bed with ¼ rails observed on both sides of bed. Resident did not speak. 4. Record review of a facility face sheet dated 09/17/2024 indicated Resident #16 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of muscle weakness (generalized), moderate dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and muscle wasting. Record review of a comprehensive care plan initiated 04/30/2018 and updated 9/17/2024 indicated Resident #16 had an ADL self-performance deficit and bed mobility requires 2 staff participation to reposition and turn in bed and that she may use enabler bar to turn and reposition in bed and an intervention of side rails to aid in mobility and promote independence. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #16 had a BIMS of 09 indicating moderately impaired cognition. She was totally dependent on staff for transfers and rolling left to right. Record review of active physician orders for Resident #16 dated 9/18/2024 indicated an order with a start date of 05/31/2023 for use of enabler bars to turn and reposition in bed. Record review of quarterly assessments and a siderail assessment for Resident #16 show that they were done one time in past 12 months on 05/16/2024. During an observation on 09/16/2024 at 10:11 AM, Resident #16 was lying in bed. She was on an air mattress and quarter siderails were raised on left and right side of bed. During an observation on 09/17/2024 at 07:35 AM, Resident #16 was lying in bed. She was on an air mattress and quarter siderails were raised on left and right side of bed. During an observation on 09/18/2024 at 8:45 AM, Resident #16 was lying in bed. She was on an air mattress and quarter siderails were raised on left and right side of bed. During an interview on 9/17/2024 at 2:27 PM, MDS Coordinator said she had been employed at the facility for 10 years. She was responsible for the care plans, MDS assessments and PASSR. She said she revised care plans every day and quarterly with MDS assessments. She said what the Surveyors are calling side rails in the facility were enabler bars and that what was told to them by their corporate staff. came from corporate staff. She said she did not code side rails on the MDS assessments as side rails because they consider them enabler bars until the Surveyors brought it to their attention on 9/16/2024. During an interview on 9/17/2024 at 2:34 PM, the Maintenance Supervisor said he had been employed at the facility since July 31, 2024. He said he had never worked in maintenance before. He said she inspected the rails on the beds monthly, 2nd week of the month and checked all of the beds in the facility. He said his first inspection was in August 2024 and did not find anything on his first assessment. He said he had a form that he used to check for the zones in the beds for measuring the space between the mattress and the frame of the bed. He said if he had a question that the Administrator would not answer, then he would call the corporate maintenance for answers. He said he also checked the assist bars to ensure they were able to go up and down but had not changed a bed side rail out and did not know if they were the correct ones that went with the beds. He said as far as he knew, all the bed rails in facility came on the beds that they were on and he just checked the functionality of them. He said if he noticed they were loose, he would tighten them. During an interview on 9/17/2024 at 2:48 PM, the Regional Nurse said she had been in her position for 13 years. Said that bed rails in the facility were classified as enabler bars to assist in bed with mobility. They looked at the side rails as ½ rails that covered 3/4 of the side of the bed and they were used as enabler bars but said she would go and look facility wide at the side rails. During an interview on 9/17/2024 at 2:59 PM, the DON said she had been employed at the facility for 4 years. She said they always classified the bars on beds as enablers as it allowed the residents to help turn themselves and they were able to hold on if they wanted to while being turned. She said rails were on the beds on admission to the facility. She said side rails were not a restraint. When residents come in to admit, they ask the resident or family if they want the enabler bars on bed. She said they did offer alternatives but was not sure and told the Surveyors that they would have to ask staff if they ask that. She said consents were included in the admission packet and signed before admission in the facility. She said if a resident/family requested not to have rails, then they would offer a lower bed, or other alternatives, and etc. She said the side rail assessments should be completed every 3 months and the charge nurses were responsible for completing them. She said they did check the mattresses in the facility for risk of entrapment. During a follow up interview on 9/17/2024 at 3:16 PM, the Regional Nurse said the problem with the side rails on the bed were the placements of some of them being in the middle of the bed. She said residents could be at risk for entrapment. Record review of facility log forms titled Bed Rail Inspection dated 6/19/24, 7/17/24, 7/18/24, and 8/15/24 indicated that facility was inspecting beds in the facility with bed rails for entrapment risk. Record review of a facility policy titled Proper Use of Side Rails revised 11/27/2017 indicated, .The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfers of residents. 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. bed mobility; b. ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. risk of entrapment from the use of side rails; and d. that the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails .

**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 assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 4 residents (Resident #39) reviewed for pharmacy services. The facility did not ensure medications were properly administered to Resident #39. This failure could place residents at risk for the unsafe administration of medications and not receiving prescribed doses of ordered medications. Findings: Record review of facility face sheet dated 8/15/2023 indicated Resident #39 was admitted on [DATE] with diagnoses of respiratory failure with hypoxia (low oxygen level) and end stage renal disease. Record review of quarterly MDS dated [DATE] revealed Resident #39 had a BIMS of 12 indicating mild cognitively impairment. Record review of comprehensive care plan dated 06/28/2023 did not indicate Resident # 39 could safely self-administer medications. Record review of physician order dated 9/13/2020 indicated Resident #39 took Carafate 1 gram 1 tablet by moth four times a day. Physician order dated 6/12/2023 indicated Resident #39 took Sevelamer 800mg 1 tablet by mouth three times a day. During an observation on 08/14/23 at 09:50 am Resident # 39 had a medicine cup with 2 tablets present: 1 white imprinted with R789 and 1 pink imprinted with 1712. Resident #39 stated he was asleep, and the worker left the medicine for him to take. Resident #39 stated the staff handed him the medicine cup and did not watch him take his medicine. During an interview on 8/14/2023 at 12:36 pm MA A stated she had been a medication aide since 1995 and employed at the facility for 8 years. She stated she gave Resident # 39's medicine and she watched him turn the medicine cup up to his mouth before she walked out of the room but did not ensure he took them. She stated the medicines in the medicine cup were Carafate and sevelamer. She stated she had been trained on proper medication administration and ensuring residents took their medicine and by not doing so could affect the resident or other residents if they were to take medicine that was left in the room. During an interview on 08/15/23 at 8:38 am the DON stated she and the ADON were responsible for all training and MA A had been properly trained on medication administration. She stated she expected all staff passing medications ensured medications were taken by the resident and by not doing so could cause the resident not to get the benefit of their medicine or another resident could take them. During an interview on 8/16/2023 at 9:48 am the Administrator stated the medication aide and nurses were to make sure all medications were taken before leaving the resident's room. She stated she expected no medications were left at the bedside to prevent an adverse event from occurring with the resident. Record review of Personnel Competency Review dated Second Quarter 2023 for Med Pass indicated in checklist, Resident is observed to ensure medication is swallowed. Record review of medication pass audit dated 2/10/2023 indicated, 24. Medication is not left at the bedside Record review of facility policy titled Administering Medications dated 11/25/2017 indicated, .Medications shall be administered in a safe and timely manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the residents had the right to make choices about aspects of his or her life in the facility that were significant for 1 (Resident #31) of 17 residents reviewed for self-determination. The facility failed to honor Resident #31's wishes to shower on Thursday's morning at 6 a.m. This failure could place residents at risk for not having the opportunity to exercise their rights of autonomy. Findings included: Record review of the consolidated physician orders dated 6/29/22 revealed Resident #31 was [AGE] years old, female and admitted on [DATE] with diagnoses including anemia (A condition in which the blood doesn't have enough healthy red blood cells), history of falling, chronic kidney disease, syncope (Fainting, or a sudden temporary loss of consciousness) and collapse. Record review of the MDS dated [DATE] revealed Resident #31 was usually understood and usually understood others. The MDS revealed Resident 31 # had a BIMS score of 15 which indicated intact cognition and required limited assistance for dressing and personal hygiene, extensive assistance for toilet use, and supervision for eating and bathing. Record review of the undated care plan revealed Resident #31 had ADL self-care performance deficit related to activity intolerance. Intervention included bathing with physical assistance three times a weekly and as necessary. Record review of the shower scheduled dated 6/24/22 revealed Resident shower days were Mondays, Wednesdays, and Fridays. During an interview on 6/28/22 at 10:20 a.m., Resident #31 said she liked to take her once a week shower before breakfast around 6 a.m. She said it was too much for her to get dressed for breakfast then undress for a shower after breakfast. She said she was getting showers at 6 a.m. then she started to get push back about. She said CNA F and CNA G told her they would make sure when they worked on Thursdays, they would make sure she got a shower at 6 a.m. She said it made her feel terrible when she could not get her showers on Thursdays at 6 a.m. She said it hurt her feelings to see other residents get showers before breakfast, but it was a big deal for her to get a shower before breakfast. During an interview on 6/28/22 at 11:02 a.m., CNA F said Resident #31 wanted her showers once a week on Thursdays. She said the shower schedule said three times a week on Mondays, Wednesdays, and Fridays. She said Resident #31 normally sits by the shower room on Thursday at 6 a.m. She said she normally worked the 200 hall and would come to the 400 hall when possible, where Resident #31 resided to give her showers at 6 a.m. She said it was important to honor Resident #31's wishes to have a shower at 6 a.m. on Thursdays so she could feel comfortable and get what she wants. During an interview on 6/29/22 at 11:26 a.m., CNA G said she had returned to the facility 4 weeks ago but had been employed 3 years ago. She said she was the CNA for Hall 400B where Resident #31 resided. She said Resident #31 only wanted her showers on Thursdays at 6am. She said when she was previously employed, Resident #31 only wanted shower on Fridays. She said when she started 4 weeks ago, Resident #31, other CNAs, and nursed told her she preferred her showers once a week. She said her shower schedule says three times a week on Mondays, Wednesdays, and Fridays. She said it was frustrating to ask her three times a week and must chart refused. She said charting refusal on Resident #31's chart, made her look non-complaint. She said Resident #31 probably feels frustrated and her wishes are not being honored. She said Resident #31 gets upset when CNAs ask her if she wants a shower on M, W, F. She said when she worked on Thursdays, she tried to make sure Resident #31 got her showers at 6 a.m. During an interview on 6/29/22 at 11:39 a.m., with a family member and Resident #31. Resident #31 said she wanted her showers once a week. She said her shower preference was not bought up in the care plan meetings. The family member of Resident #31 said the questions they ask during the meetings, do not trigger them to mention the shower schedule preference. The family member said during the meetings, they do not ask about preferences. The family member said Resident #31 has told she could not get her showers on Thursday at 6a.m. Resident #31 said about three months ago, staff told her she could not get showers in the morning before breakfast. She said she gets most of her showers on Thursday mornings, but it was only because she waits at the shower door with her stuff. She said she felt like if she did not sit by the shower room, CNAs would not come and get her for showers. She said some CNAs made her feel like it was a burden to give her a shower at 6 a.m. During an interview on 6/29/22 at 12:09 p.m., the DON said she knew Resident #31 wanted her showers once a week but could not recall the exact day. She said she did not know why her shower schedule and care plan had three times a week. She said Resident #31 wanting showers at 6 a.m., was inconvenient because it was shift change and CNAs were getting other residents up for breakfast. She said she did not know why Resident #31 felt like she would only get her showers at 6 a.m. if she waited by the shower room. She said the facility tried to accommodate her but Resident #31 may have felt like she was not important which could upset her. She said charting refusal on Resident #31's chart, made her look non-complaint. During an interview on 6/29/22 at 2:21 p.m., the Administrator said changes in preference was asked during care plan meetings. She said Resident #31 could feel angry or sad her preference was not documented. She said a staff member was sent to get validation from Resident #31 of what day she wanted her showers so her care plan could be updated. Record review of a facility's Residents' Right policy dated April 2019 revealed .be treated with dignity, courtesy, consideration and respect .make your own choices regarding personal affairs, care, benefits, and services .

**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 practices for 2 of 16 residents reviewed for respiratory care. (Resident #13 and Resident #22) The facility failed change Resident #13's nasal cannula weekly, have an oxygen concentrator filter free of gray, fuzzy particles, and water in the humidification bottle. The facility failed to ensure the oxygen concentrator tubing and humidification bottles were dated when changed for Resident #22. These failures could place residents at risk of not receiving appropriate respiratory care and contribute to respiratory infections. Findings included: 1. Record review of the consolidated physician orders dated 6/29/22 revealed Resident #13 was [AGE] years old, female and admitted on [DATE] with diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own. Record review of Resident #13's consolidated physician order dated 1/10/21 revealed she was ordered: oxygen at 3 liters per minute nasal cannula continuous. Record review of the MDS dated [DATE] revealed Resident #13 was usually understood and usually understood others. The MDS revealed Resident #13 had a BIMS score of 9 which indicated moderately impaired cognition and required extensive assistance for ADLs. The MDS revealed Resident #13 had oxygen therapy while a resident. Record review of the undated care plan revealed Resident #13 was on oxygen therapy. The care plan revealed Resident #13 had ADL self-care performance deficit related to activity intolerance. During an observation on 6/27/22 at 10:24 a.m., Resident #13 was laying bed with a nasal cannula on her face. The nasal cannula was dated 6/2/22 and the humidifier bottle was without water. The oxygen concentrator had a black filter with white and gray particles. During an observation on 6/28/22 at 9:51 a.m., Resident #13 was sitting up in her wheelchair with a nasal cannula on her face. The nasal cannula was dated 6/2/22 and the humidifier bottle was without water. The oxygen concentrator had a black filter with white and gray particles. 2. Record Review of Resident #22 consolidated physicians' orders dated 12/16/2019 indicated Resident #22was an [AGE] year-old make that has a history of chronic obstructive pulmonary disease (respiratory disease) and chronic respiratory failure. An Order dated 12/16/19 indicated the resident was to receive O2 at 3LPM via NC continuous every shift. Record Review of the MDS dated [DATE] indicated under section C0400 Recall that Resident #22 has a BIMS score of 15 for cognitively intact. Pulmonary section of the MDS indicates a history of COPD, chronic respiratory failure and hypoxia or hypercapnia (respiratory disease). Section J1100 shortness of breath of the MDS was checked (z.) indicating none of the above. Section 0 of the MDS was checked indicating oxygen performed while a resident of the facility and within the last 14 days. Record Review of the care plan dated 1/20/22 indicated Resident #22 has COPD. The goal indicated that Resident #22 will be free of respiratory infections through the review date. Interventions indicated Resident #22 will be given oxygen therapy as ordered by the physician. During observation on 06/27/22 02:40 PM, Resident #22 was wearing O2 at 3L via n/c, the oxygen bag was dated 6/3/22, there was no date on the O2 tubing, indicating the tubing had not been changed. During observation on 06/28/22 at 08:59 AM Resident #22 was sitting up in bed watching TV, she had O2 in place, the oxygen tubing, and humidifier bottle were dated 6-3-22. During observation on 06/28/22 at 02:27 PM, Resident #22 was sitting up in wheelchair watching TV, her oxygen tubing and humidifier bottle were dated 6/28/22. During an interview with LVN C on 06/28/22 at 09:07 AM, LVN C stated she has worked at facility for 9 years. LVN C stated that it was the responsibility of the 10-6 nurse to change O2 tubing every Wednesday at night. LVN C stated that it was not documented anywhere that O2 tubing changes are done, and the staff just know when O2 tubing changes need to be done. LVN C stated that it was the responsibility of all nurses to check O2 tubing if they go into the resident's room to look at their O2 tubing. LVN C stated residents are at risk for infection if O2 tubing was not changed. During interview with LVN A on 06/29/22 at 10:19 AM (night shift nurse for all of B halls) stated that she had worked at the facility for 1 month. LVN A stated she worked Wednesday night and was responsible for changing all the O2 tubing weekly on Wednesday nights. LVN A stated that there was no reason why the O2 tubing should not have been changed. LVN A stated it was every nurse's responsibility to check the O2 tubing date when they go into the resident's room. LVN A stated that if O2 tubing was not changed it can lead to infection. During interview with DON on 06/28/22 at 02:36 PM, DON stated O2 tubing should be changed weekly on 10-6 shift by nursing staff. DON stated that every nurse or any staff goes into the resident's room should check O2 tubing date and water level in humidification bottle. DON stated she expected staff to make sure O2 tubing was changed weekly, water in humidification bottle, and dust free concentrator filters. DON stated the facility had staff assigned to each hall who ensure oxygen tubing was dated and changed weekly, clean filters, and water filled bottles. DON stated if O2 tubing was not changed weekly residents might not get good oxygen flow from the tubing. DON stated proper respiratory equipment management was important to prevent respiratory infection which could cause decreased quality of life for each resident. DON stated O2 tubing changes are not documented anywhere, and staff knows it is changed every Wednesday. During interview with ADMIN on 06/29/22 at 08:25 AM, ADMIN stated she has worked at facility since 2010. ADMIN stated the policy was to change O2 tubing weekly on Wednesday night. ADMIN stated she expected all staff to follow the policy. ADMIN stated O2 tubing changes are not documented anywhere, but staff should label the tubing, so they know it has been done. ADMIN stated everyone was responsible for checking O2 tubing dates when they go into resident rooms. ADMIN stated management does Guardian Angel rounds daily. ADMIN stated the department head for B-hall residents was out of the office this week and did not complete Guardian Angel rounds for B-Hall. ADMIN stated she did not think about covering those halls for the employee that was out. The ADMIN stated that there was always a potential for infection if O2 tubing was not changed per policy. Record Review of the facility's policy on oxygen administration does not indicate when disposable equipment should be changed. The policy indicated reporting information in accordance with facility policy and professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 4 of 17 residents reviewed for care plans. (Resident #53, Resident #29, Resident #32, and Resident #31). -Resident #53's order to be repositioned every hour was not addressed in the comprehensive care plan. - Resident #29's Incontinent of bowel and bladder status was not addressed in the comprehensive care plan. - Psychotropic Medications for Resident #32's was not addressed in the comprehensive care plan. - Resident #31's care plan had a status for wanting Cardiopulmonary resuscitation (CPR) and a Do-Not-Resuscitate (DNR). The care plan did not address her wishes to have a shower once a week in the AM on her care plan. These failures could place residents at risk of not having individual needs met, a decreased quality of life, developing a pressure injury and delay wound healing. Findings include: 1. Record review of the consolidated physician orders dated [DATE] revealed Resident #53 was [AGE] year-old, admitted on [DATE] with diagnosis of functional quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition). There was an active physician's order with a start date of [DATE] that read, Turn Q (every) 1 hour. Record review of the most recent MDS dated [DATE] indicated Resident #53 sometimes understood others and was sometimes understood. The MDS indicated a BIMS score of 1, indicating the resident was severely cognitively impaired. The MDS indicated Resident #53 was totally dependent on staff for bed mobility and dependent to roll to the left or to the right. Resident #53 had an active diagnosis of reduced mobility and a pressure ulcer of sacral region (area at the base of the spine). Record review of the comprehensive care plan dated [DATE] indicated Resident #53 had an actual skin impairment with a stage IV pressure area that he was receiving treatment for. An intervention was needing assistance to turn/reposition at least every 2 hours. An observation on [DATE] at 7:41 AM revealed Resident #53 was positioned to the left side with pillows under his right side. An observation on [DATE] at 8:45 AM revealed Resident #53 was positioned to the left side with pillows under his right side. An observation [DATE] at 9:44 AM revealed Resident #53 was positioned to the left side with pillows under his right side. An observation on [DATE] at 10:24 AM revealed Resident #53 was positioned to the left side with pillows under his right side. An observation on [DATE] at 10:45 AM revealed Resident #53 was positioned to the left side with pillows under his right side. During an interview on [DATE] at 08:48 AM, CNA D revealed she looked at the care plan every day because things could change for residents. She said Resident #53 was turned every 2 hours. She said she had been trained to check the care plan. She said she knew how often to turn the resident by looking at the care plan. She said she did not check the orders. She said it was the nurse's responsibility to check the doctor's orders. During an interview on [DATE] at 9:23 AM, LVN E revealed she checked the resident's orders every shift. She said Resident #53 was to be turned every hour. She said Resident #53 had a doctor's order to be turned every hour. She said the care plan indicated to turn Resident #52 every 2 hours, but the doctor did order for the resident to be turned every hour. She said it was standard practice for a resident to be turned every 2 hours. She said the resident not being turned per doctor's orders could put the resident at risk for further skin breakdown. She said it could also slow healing on his existing wound or cause the wound current wound to regress. During an interview on [DATE] at 9:57 AM, the DON revealed the MDS nurse was responsible for updating care plans. She said if there was an order with a specific intervention, she would expect for that order to be care planned. She said if there was a doctor's order for a resident to be turned every hour then the resident should be turned every hour. She said the resident not being turned per physician's orders could slow the healing process of his current wound. During an interview on [DATE] at 10:29 AM, the MDS Nurse said she was the one responsible for updating care plans. She said her process was to go through the orders and 24-hour reports for what needed to be updated in the care plan. She said it depended on the order or specific intervention if it should be care planned. She said the order for Resident #53 should have been care planned. She said she really was not sure how this could negatively affect the resident. During an interview on [DATE] at 10:59 AM, the Administrator said she would have expected the Q 1 hour turn order for Resident #51 to have been care planned. She said if she were the nurse on the floor her aides would know to turn the resident every hour because she would verbally tell them. She said the MDS Nurse was the one responsible for updating care plans and the corporate nurse was the one responsible for making sure the care plans are up to date. She said not following the physician's orders could negatively affect Resident #53 by slowing healing on his current wound. 2. Record Review of Resident #29s consolidated physicians' orders, undated indicated Resident #29 was a 67 y/o male with a history of Diabetes, Congestive Heart failure (CHF), End Stage Renal disease and HTN (hypertension). Record Review of the MDS dated [DATE] indicated Resident #29 had a BIMS score of 10, he was moderately impaired in cognition. Section G Functional status of the MDS indicated Resident #29 was scored a 1 and 2 for section I. toilet use for supervision and one-person physical assist. MDS section H bowel and bladder indicated the resident was occasionally urinary incontinence and frequent bowel incontinence. Record Review of MDS dated [DATE] indicated Resident #29 had frequent bladder and bowel incontinence. Record Review of Resident #29s care plan dated 2-3-2020 indicated Resident #29 had an ADL self-care performance deficit r/t activity intolerance. The goal was Resident #29 will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. Interventions were for skin inspection daily (initiated on 2-3-2020), PT/OT, bell to call for assistance, skin inspection, bathing, oral care, dressing and eating. The MDS did not address interventions for toileting or bowel and bladder. During interview on [DATE] at 10:34 AM, The MDS coordinator stated all MDS indicators should be care planed. The MDS coordinator stated she was the one responsible for updating the care plans and MDS's and she does not have a backup to assist with updating the care plans while she was out on leave. The MDS coordinator stated she was RUGS (Resource Utilization Group) certified when asked who was responsible for training her. The MDS coordinator stated not care planning for Resident #29's bowel and bladder status could not negatively impact the resident because the nurses complete weekly skin assessments to monitor for skin breakdown. 3. Record Review of Resident #32s consolidated physicians' orders undated indicated that Resident #32 was a [AGE] year-old male with a history of Parkinson's disease (brain disease), dementia with Lewy Bodies and history of falling. Physician orders dated [DATE] indicate Resident #32 was taking Seroquel tablet 25 mg 1 tab by mouth at bedtime related to dementia with Lewy bodies. Record Review of Resident #32's undated care plan did not indicate psychotropic medications-antipsychotic medications. Record Review of Resident #32's MDS dated [DATE] indicated a BIMS score of 12 for mildly impaired cognition. Active diagnosis was for Non-Alzheimer's Dementia. The resident received r antipsychotic. During interview with LVN C on [DATE] at 09:07 AM, LVN C stated that it was the responsibility of the MDS coordinator to complete and update all care plans. During interview on [DATE] at 02:36 PM, the DON could not provide a care plan with psychotropic medication on it for Resident #32 she stated she would have to ask the MDS coordinator because she was responsible for completing the care plans. The DON stated psychotropic meds should be listed on the care plans. The DON stated psychotropic meds not being care planned could not impact the residents negatively that she knew of. The DON stated she does not know if bowel and bladder should be care planned or not if indicated on the MDS because she does not complete the MDS. The DON stated not care planning bowel and bladder cannot negatively impact the resident in any way that she knew of. The DON stated she was responsible for backing up the MDS coordinator when she was out on leave, but that never happened. The DON stated the MDS coordinator was sick with COVID and was working from home today. During interview on [DATE] 08:25 AM the ADMIN stated the MDS coordinator was responsible for completing care plans. She stated the MDS coordinator was out on leave this week and everyone was responsible for updating the care plans as needed, including the ADMIN and DON. The ADMIN stated corporate staff trained the MDS coordinator. The ADMIN stated they have meetings every morning and weekly to discuss any changes in the care plans. The ADMIN stated floor nurses inform management daily of changes and the IDT team/ therapy/MDS coordinator meet daily to discuss. The ADMIN expected the MDS coordinator to care plan the MDS triggers. The ADMIN stated if triggers such as bowel and bladder or psychotropic drugs were not on the care plan, it would not negatively impact the residents because staff knows our residents and provides good care. The ADMIN stated that management and floor nurses know which residents are incontinent and which ones could potentially lead to problems. 4. Record review of the consolidated physician orders dated [DATE] revealed Resident #31 was [AGE] years old, female and admitted on [DATE] with diagnoses including anemia (A condition in which the blood doesn't have enough healthy red blood cells), history of falling, chronic kidney disease, syncope (Fainting, or a sudden temporary loss of consciousness) and collapse. The consolidated physician orders dated [DATE] revealed Do Not Resuscitate order. Record review of the MDS dated [DATE] revealed Resident #31 was usually understood and usually understood others. The MDS revealed Resident 31 # had a BIMS score of 15 which indicated intact cognition and required limited assistance for dressing and personal hygiene, extensive assistance for toilet use, and supervision for eating and bathing. Record review of the undated care plan revealed Resident #31 had ADL self-care performance deficit related to activity intolerance. The intervention included bathing with physical assistance three times a weekly and as necessary. The care plan revealed Resident #31 was a full code. Interventions included MD/family will be notified of condition change, staff will honor resident with privacy during CPR, and if code status changes, code status will be posted in chart. The care plan also revealed Resident #31 was a DNR status. Interventions included code status documented in chart, if resident arrest, staff will not perform CPR and staff informed of code status. Record review of an out of hospital DNR order dated [DATE] revealed Resident #31 wanted DNR for code status. Record review of the shower scheduled dated [DATE] revealed Resident shower days were Mondays, Wednesdays, and Fridays. During an interview on [DATE] at 11:02 a.m., CNA F said Resident #31 wanted her showers once a week on Thursdays. She said the shower schedule said three times a week on Mondays, Wednesdays, and Fridays. She said it should be care planned for once a week, like she prefers. She said it was important to have accurate care plan documented so Resident #31 gets what she wants. During an interview on [DATE] at 11:39 a.m., with a family member and Resident #31. Resident #31 said she wanted her showers once a week. She said her shower preference was not bought up in the care plan meetings. The family member of Resident #31 said the questions they ask during the meetings, do not trigger them to mention the shower schedule preference. The family member said during the meetings, they do not ask about preferences. Resident #31 said her code status was DNR and she would want it on all documents. During an interview on [DATE] at 10:30 a.m., the MDS coordinator said Resident #31 should only have DNR code status on her care plan. She said she updated care plans when the residents received new orders, quarterly, and as needed. She said she never saw Resident #31 had two different code statuses. She said the full code status was not added by her and the person who added did not placed it in the nursing section. She said she normally only looked in the nursing section of the care plan. She said the corporate MDS coordinator was responsible for ensuring she has formulated accurate care plans. She said the corporate MDS coordinator reviews the care plans monthly for updates. She said the physician order of DNR status should match the care plan code status. She said Resident #31 having two different code status which could delay treatment or actions of the staff during an event. She said the last care plan meeting with Resident #31 and a family member, Resident #31 only mentioned she wanted showers in the morning. She said the CNAs or nurses should notify her of Resident #31's changes in preferences. She said care plans should be accurate because CNAs look on them to know how to care for the residents. During an interview on [DATE] at 11:26 a.m., CNA G said she had returned to the facility 4 weeks ago but had been employed 3 years ago. She said she was the CNA for Hall 400B where Resident #31 resided. She said Resident #31 only wanted her showers on Thursdays at 6am. She said when she was previously employed, Resident #31 only wanted shower on Fridays. She said when she started 4 weeks ago, Resident #31, other CNAs, and nursed told her she preferred her showers once a week. She said her shower schedule says three times a week which was probably on her care plan. During an interview on [DATE] at 12:09 p.m., the DON said she knew Resident #31 wanted her showers once a week but could not recall the exact day. She said she did not know why her shower schedule and care plan had three times a week. She said it should be on Resident #31 care plan, but all CNAs know her preference. She Resident #31 was a DNR code status and it should be the only status on her care plan. She said the DON, Admin, and corporate MDS coordinator monitor care plans and MDSs. She said care plans are reviewed for accuracy or updated when residents have new orders and care plan meetings. She said she did not know how Resident #31 two code status on her care plan got missed. She said code status are on the charts, at the nursing station, and on the crash cart but if staff only looked at the care plan, it could delay treatment. During an interview on [DATE] at 2:21 p.m., the Administrator said changes in preference was asked during care plan meetings. She said it was important to gain accurate information during care plan meetings so the resident feel like they have a part in their care. She said Resident #31 could feel angry or sad her preference was not documented. She said a staff member was sent to get validation from Resident #31 of what day she wanted her showers so her care plan could be updated. She said she expected Resident #31's care plan to only have a DNR code status which the MDS coordinator and corporate MDS coordinator was responsible for. Review of a facility's Care Plan - Comprehensive policy dated [DATE] indicated, .develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain .each resident's Comprehensive Care Pan has been designed to .incorporate identified problem areas .identify the professional services that are responsible for each element of care .aid in preventing or reducing declines int eh resident's functional status and/or functional levels .