**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure residents had the right to receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 23 residents (Resident #76) reviewed for accommodation of needs. The facility treatment nurse failed to ensure Resident #76's lunch meal was fully accessible for her to eat on 11/04/2024 at the lunch meal, when the Treatment Nurse served Resident #76 her lunch meal and did not remove it off the tray and kept her plate on the warmer and covered with a lid. This failure could have placed resident at risk of having nutritional needs gone unmet. Findings included: Record review of Resident #76's face sheet dated 11/06/2024 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses vascular dementia(disease in which it causes memory loss in older adults), glaucoma of left eye severe stage(eye condition that causes blindness), high blood pressure, depression(condition associated with lowering of a person's mood), anxiety(intense worry or fear), and need for assistance with personal care. Record review of Resident #76's quarterly MDS dated [DATE] indicated she was able to make herself understood, she could understand others, and she had impaired vision. The MDS also indicated she had a BIMS score of 8 which meant she had moderately impaired cognition. Record review of Resident #76's care plan revised 08/20/24 indicated Resident #76 had an ADL self-care performance deficit with interventions for supervision and setup for eating. During an observation of lunch in the dining room on 11/04/2024 starting at 12:15 PM, the Treatment Nurse served Resident #76 her lunch meal and did not remove it off the tray and kept her plate on the warmer and covered with a lid. The Treatment Nurse then walked away. Resident #76 said she could not see what was on her plate because she was blind in one eye. The resident next to Resident #76 assisted her by removing the lid off her plate, turning the plate towards and closer to Resident #76, so she could eat. During an interview on 11/04/2024 at 2:27 PM, the Treatment Nurse said she was familiar with Resident #76, but she was not in the dining room a whole lot. The Treatment Nurse said Resident #76 did not have any vision issues. The Treatment Nurse said she was new, and she did not know if she was supposed to uncover the residents' meals, but she was under the impression not to uncover the plates. The Treatment Nurse said she did not know if it was okay to leave the plates on the tray or not. The Treatment Nurse said from her observations at mealtimes sometimes the plates were left on the trays and sometimes they were not. The Treatment Nurse said to her it was not a big deal whether the plate was left on the tray or not. The Treatment Nurse said it was important to uncover the plate for the residents and ask them if they needed assistance. The Treatment Nurse said she had not asked Resident #76 because she knew Resident #76 did not require assistance and she could set up her own tray. The Treatment Nurse said it was important to assist the residents with their meals so they could have the same quality as those who can set up their meals themselves and it would not be fair to them to not have the assistance they require. During an interview on 11/06/24 at 5:46 PM the DON said she expected all of staff in the dining room assisting with meals to set the plates up for the residents and provide salt and pepper, or whatever else the resident may need during that meal. She said the failure placed a risk for residents not eating what they need. The DON said the failure could also cause a decline or weight loss in the residents. The DON said everyone who passed trays in the dining room were responsible. During an interview on 11/06/24 at 6:05 PM the Administrator said whoever passed the trays in the dining room for meal services was responsible for setting up the trays for each resident and ensuring the resident had what they needed. The Administrator said the failure placed a risk for malnutrition and weight loos for the residents. Record review of the policy Resident Rights dated 2/20/2021 indicated: Policy: The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility . Resident rights. The resident [NAME] the right lo a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 1. Exercise of rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen of the United States . 4. Respect and dignity. The resident has a right to be treated with respect and dignity, including .c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 2 residents (Resident #40) reviewed for grievances. The facility did not ensure a grievance was filed and Resident #40 was appropriately apprised of progress toward resolution when Resident #40's pink pants were not returned from the laundry. This failure could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of a face sheet dated 11/06/2024 indicated Resident #40 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included sequelae of unspecified cerebrovascular disease (medical conditions that affect the blood vessels of the brain and circulation of blood to the brain). Record review of the MDS assessment indicated Resident #40 was understood by others and was able to understand others. The MDS assessment indicated Resident #40 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #40 was dependent for dressing, toileting, personal hygiene, and bathing/showering. During an interview on 11/04/2024 at 2:52 PM, Resident #40 said she had told the laundry aide she was missing a pair of pink capri pants. Resident #40 said the laundry aide told her she did not remember washing that color capri for her, but she would keep her eye out for them. Resident #40 said it had been about a month and the laundry aide had not let her know anything. During an interview on 11/06/2024 at 11:39 AM, Laundry Aide B said Resident #40 had reported to her she was missing a pair of pink pants. Laundry Aide B said it had been a while since Resident #40 reported the missing pants. Laundry Aide B said when the residents were missing clothing, they would look through the clothes, the lost and found, and if she was unable to find the missing item, tell the resident she was still looking for the clothes. Laundry Aide B said she had notified her supervisor, the Environmental Services Manager, that Resident #40 was missing a pair of pink pants. Laundry Aide B said the Environmental Services Manager was responsible for filing a grievance when a resident's clothing was not found. Laundry Aide B said she did not think a grievance had been filed yet. Laundry Aide B said it was important for the residents' clothing to be returned to them because they did not have much, and everybody needed their clothes. Laundry Aide B said it was important for a grievance to be filed in case the clothes were not found, so they could be in the process of replacing them. During an interview on 11/06/2024 at 11:49 AM, the Environmental Services Manager said if the resident was missing something they would let the Social Worker know for her to file a grievance. The Environmental Services Manager said she did not know anything about Resident #40 missing a pair of pink pants. the Environmental Services Manager said Laundry Aide B usually notified her if something was missing, but she was not aware of Resident #40 missing a pair of pink pants. Therefore, she had not notified the Social Worker for a grievance to be filed. The Environmental Services Manager said it was important for the residents to get their clothing back because they needed them, and it was their personal property. The Environmental Services Manager said it was important for a grievance to be filed so they could work together as a team to recover the lost items, and everyone was aware of it. During an interview on 11/06/2024 at 5:57 PM, the Administrator said if clothes were missing, they would look for them and then write a grievance. The Administrator said if the missing clothes were not found they would replace them. The Administrator said a grievance should have been filed for Resident #40's missing pink pants, and anybody could have filed the grievance. The Administrator said whoever took the residents grievance should write it up and give it to the Social Worker. The Administrator said it was important for the residents to have their clothing returned so they had something to wear. Record review of the facility's, Grievance Policy, revised 07/22/2023, indicated, .Resident concerns should be taken seriously and that the ability to voice a grievance is an important right and protection for residents .The right to file grievances orally, or in writing in the language he/she understands .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 23 residents (Resident #63) reviewed for ADL (activities of daily living) care. The facility failed to provide nail care by removing black material from under fingernails for dependent female Resident #63 on 11/04/2024,11/05/2024, and 11/06/2024. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of the face sheet, dated 11/06/2024, revealed Resident #63 was a [AGE] year old female with diagnoses which included malignant neoplasm of unspecified part of the right bronchus or lung (cancer that forms in tissues of the lungs, usually in the cell lining air passages), chronic respiratory failure with hypoxia (chronic respiratory failure with hypoxia), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side ( caused by damage to the right side of the brain). Record view of the MDS, dated [DATE], revealed Resident # 63 had a BIMS of 04 indicating severe cognitive impairment. Resident #63 required assistance of two person for dressing, bathing, and personal hygiene ADLs. Record view of the MDS, dated [DATE], revealed Resident # 63 had a BIMS of 04 indicating severe cognitive impairment. Resident #63 required assistance of two person for dressing, bathing, and personal hygiene ADLs. The MDS revealed Resident #63 did not reject care. Record review of care plan, with a revision date of 07/24/2024, indicated Resident # 63 has an ADL self-care performance deficit. Goal: Resident # 63 will maintain a sense of dignity be being clean, dry, odor free and well groomed. Interventions: Resident #63 prefers to have long fingernails. Bathing total care dependent times two person assist, provide shower, shave oral care, hair care, and nail care per schedule when needed. During an observation on 11/04/2024 at 9:48 a.m. Resident # 63 was observed black material under fingernails. During an observation on 11/05/2024 at 9:32 a.m. Resident # 63 was observed black material under fingernails. During an observation on 11/06/2024 at 9:35 a.m. Resident # 63 was observed black material under fingernails. During an interview on 11/06/2024 at 8:58 a.m., CNA K stated it was the CNAs responsibility to ensure the residents fingernails were clean during showers or when needed. CNA K stated it was important to keep resident fingernails clean to keep bacteria down. CNA K stated Resident # 63 could put her hand in her mouth and the bacteria cause sores in her mouth or infection. During an interview on 11/06/2024 at 2:58 p.m., the DON stated it was the CNAs usual cleaned the resident's fingernails on bath days. The DON stated it was important to keep Resident #63 fingernails clean for infection control and dignity purposes. The DON stated she would monitor by making frequent rounds. During an interview on 11/06/2024 at 4:48 p.m., the Administrator stated he expected the CNAs to keep residents clean and dry. The Administrator stated Resident #63 requires long fingernails and digs in her brief. The Administrator stated there could be a risk to Resident #63 putting dirty fingernails in her mouth. The Administrator stated he would monitor by making rounds. Record review of the facility's policy titled Activities of Daily Living Care Guideline dated 2/11/2021, A resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene

**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 the bladder and had an indwelling urinary catheter received appropriate treatment and services for 1 of 2 residents (Resident #72) reviewed for urinary catheters. The facility failed to ensure CNA H provided proper catheter care to Resident #72 on 11/06/2024. This failure could place residents at risk of injury, urinary tract infections, and a decreased quality of life. Findings included: Record review of a face sheet dated 11/06/2024 indicated Resident #72 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and urinary retention. Record review of a Comprehensive MDS assessment dated [DATE] indicated Resident #72 was sometimes able to make herself understood and was sometimes able to understand others. The MDS assessment indicated Resident #72 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #72 was dependent on staff for all ADLs. The MDS assessment indicated Resident #72 had an indwelling catheter. Record review of Resident #72's care plan revised 10/30/2024 indicated she had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner and required substantial/maximum assistance with toileting. Resident #72's care plan indicated she had a urinary catheter and was at risk for urinary tract infections and injury. Resident #72's care plan indicated catheter care every shift. The care plan indicated Resident #72 required enhanced barrier precautions to wear gown and gloves during high-contact resident care activities. Record review of Resident #72's Order Summary Report indicated to provide catheter care every shift with a start date of 09/26/2024. During an observation and interview on 11/06/2024 starting at 2:12 PM, CNA G and CNA H provided incontinent care to Resident #72. CNA G and CNA H put on PPE and gloves. CNA H cleaned Resident #72's left peri area and wiped down the middle. CNA H did not wipe Resident #72's right peri area and she did not clean the foley catheter tubing (thin, flexible tube used to drain urine out of your body from your bladder). Resident #72 was turned on her side. When she was turned on her side Resident #72 got a hold of her catheter tubing. CNA G cleaned Resident #72's back peri area. CNA G changed gloves and Resident #72 was turned back onto her back. Resident #72 was still holding her catheter tubing. CNA H removed her gloves. Resident #72 was still holding her catheter tubing when they covered her up. After this, CNA H and CNA G decided Resident #72 needed to be pulled up in the bed. When CNA H and CNA G pulled up Resident #72 in the bed she started pulling at the catheter. CNA H intervened and stopped Resident #72 from pulling the catheter further, and they finished repositioning her in the bed. CNA H said she thought she had cleaned both sides of Resident #72's front peri area. CNA H said when cleaning a resident with a catheter she should hold the tubing and wipe down it to clean it. CNA H said she should clean the peri area properly and the catheter tubing properly because they could have bacteria and germs and so the resident would not get an infection. CNA H said when providing care to Resident #72 she should be looking at the foley catheter tubing. CNA H said it was important to pay attention to where the foley catheter tubing was so it would not get pulled out and rupture something. During an interview on 11/06/2024 at 4:38 PM, ADON O said when performing incontinent care, the CNAs should clean from inside/out, clean the foley from top to bottom. ADON O said they should clean the tube, but make sure they do not pull it. ADON O said the CNAs should be aware of where the catheter tubing was at all times, and they should be aware of where the residents' hands and limbs were. ADON O said it was important for them to be aware of where the foley catheter tube was because it could cause trauma, pain, injury, and it was a risk for infection. ADON O said when providing incontinent care, the CNAs should be trying to clean the residents completely. ADON O said it was important to keep the skin clean and to prevent infections. During an interview on 11/06/2024 at 5:22 PM, the DON said during incontinent care the CNAs were supposed to clean both sides on the front peri area, and they should be cleaning the foley catheter tubing when providing incontinent care on someone with a foley catheter. The DON said it was important to completely clean the residents and clean the catheter tubing to prevent urinary tract infections, infections, and skin breakdown. The DON said the CNAs should be paying attention to where the residents foley catheter tubing was located while providing incontinent care. The DON said it was important to prevent trauma and risk for infection. The DON said the CNAs practiced incontinent care on the mannequins, and she randomly observed the CNAs perform incontinent care. The DON said she had not noticed any issues with incontinent care. During an interview on 11/06/2024 at 5:50 PM, the Administrator said he expected for the CNAs to provide proper incontinent care and fully clean the residents. The Administrator said he expected the CNAs to keep the residents from pulling the catheter tubing because this could cause trauma to the urethra (tube connected to the bladder for removal of urine). Record review of the facility's policy titled, Urinary Catheter Management, review date 08/20/2021 indicated, Residents with indwelling catheters (urethral or suprapubic) shall receive appropriate care and services to prevent and manage catheter-related complications . Properly position drainage bag and tubing below the level of the bladder and in a dependent position to facilitate flow of urine. Avoid allowing the drainage bag or tubing to touch the floor. Avoid positioning resident on tubing. Do not coil drainage tubing on bed or chair. Avoid loops in tubing: when in bed, hang drainage bag on bed frame (not side rail) towards the foot of the bed; when up in wheelchair or geri-chair, use a leg bag instead of a bedside drainage bag unless contraindicated by resident's condition .Provide perineal/catheter care with a perineal cleanser or mild soap and water at least once daily and promptly after fecal soiling to reduce the potential for bacterial contamination .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 2 residents (Residents #2) reviewed for respiratory care. The facility failed to ensure Resident #2 had an order for oxygen. This failure could place residents requiring respiratory care at risk for respiratory complications. Findings included: Record review of a face sheet dated 11/06/2024 indicated Resident #2 was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain causes problems with reasoning, planning, judgment, and memory) and shortness of breath. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #2 was sometimes understood by others and understood others. The MDS assessment indicated Resident #2 had a short-term and long-term memory problem. The MDS assessment indicated Resident #2 required partial/moderate assistance with eating, oral hygiene, substantial/maximal assistance with personal hygiene, and dependent for bathing/showering. The MDS assessment did not indicate Resident #2 used oxygen. Record review of Resident #2's care plan revised 09/17/2024 did not indicate the use of oxygen. Resident #2's care plan indicated she had hospice/terminal prognosis with interventions to coordinate with the hospice to ensure the resident's spiritual, emotional, physical, intellectual, and social needs were met. Record review of Resident #2's Order Summary Report dated 11/04/2024 indicated oxygen at 2-4 liters via nasal canula for shortness of breath or saturation less than 90% as needed with an order date of 10/28/2024 and a start date of 11/04/2024. Record review of Resident #2's progress notes indicated 10/28/2024 hospice here stated oxygen saturation 78 placed on oxygen at 2 liters via nasal canula, signed by RN C. During an observation on 11/04/2024 starting at 9:23 AM, Resident #2 was in bed, an oxygen concentrator with a nasal cannula attached was at Resident #2's bedside, but not in use. LVN E entered the room, checked Resident #2's oxygen saturation and applied the oxygen via nasal cannula at 2 liters. During an interview on 11/04/2024 at 2:29 PM, LVN E said she had noticed Resident #2 had oxygen in her room, but when she checked Resident #2's physician's orders she had not seen an order for oxygen. LVN E said she read a note in Resident #2's progress note that indicated she was started on oxygen on 10/28/2024. LVN E said she asked the hospice nurse about the oxygen order, and they said Resident #2 should have had an order from 10/28/2024. LVN E said it was important for Resident #2 to have an order for oxygen, so everyone knew she was supposed to receive oxygen and to ensure she was receiving the amount of oxygen she needed per the doctor's order. During an interview on 11/04/2024 at 3:27 PM, Hospice RN D said she had visited Resident #2 on 10/28/2024 and her oxygen saturation was low, so she placed oxygen on her at 2 liters via nasal cannula. Hospice RN D said she had given RN C a verbal order for oxygen 2-4 liters per min as needed. Hospice RN D said the facility did not have written orders for them to write down physicians' orders, so the hospice nurse went back to the hospice office put in the order and took kit back to the facility the same day. Hospice RN D said she was not able to remember if she had sent an order over to the facility. Hospice RN said it was important for the orders to be communicated so that everybody was aware of what was going on and the resident was given the care they needed. Hospice RN D said Resident #2 not having an order for oxygen could result in her oxygen getting too low. During an interview on 11/06/2024 at 11:18 AM, RN C said the hospice nurse visited Resident #2, and told her that her oxygen saturation was 70 something and she had put oxygen on Resident #2. RN C said since Resident #2 was a hospice patient and the hospice nurse had put oxygen on her, RN C said she had assumed that Resident #2 had an order for oxygen. RN C said the hospice nurse had not given her a new order for oxygen. RN C said she should have checked for an oxygen order and not just assumed Resident #2 had an order for oxygen. RN C said it was important for there to be an oxygen order for the residents to be more oxygenated and to help them stay alive. During an interview on 11/06/2024 at 5:17 PM, the DON said the nurse had taken the verbal order from the hospice company for Resident #2's oxygen, and normally the hospice faxed over the order, and it was placed in the resident's electronic health record. The DON said if the nurses noticed there was not order for oxygen, they should contact the hospice for an order. The DON said the hospice should have provided the order for the oxygen. The DON said it was important for Resident #2 to have an order for oxygen because she could decline and could pass away if her oxygen was too low or have respiratory distress, and so they could practice within their scope of practice. Record review of the facility's policy titled, Respiratory: Oxygen Administration, review date 02/10/2020, indicated, To describe method for delivering oxygen in order to improve tissue oxygenation, prevent hypoxia, decrease work of breathing and prevent shortness of breath with activity . Verify Physician's order . Hook cannula tubing behind ears and under chin .Set flow rate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #15's face sheet dated 11/05/2024, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included bipolar disorder current episode mixed severe with psychotic features (characterized by the presence of either delusion or hallucinations or both), Post-traumatic stress disorder, chronic (mental health condition that occurs when symptoms of PTSD last for more than three months after traumatic event), generalized anxiety disorder (a mental disorder that causes people to experience excessive and uncontrollable worry about everyday events and activities). Record review of Resident #15's MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS indicated Resident #15 had a BIMS score of 14, indicating cognition was intact. The MDS in the section of Social Isolation D0700 indicated Resident #15 always felt lonely or isolated from others. Record review of Resident #15's care plan dated 10/19/2022, revision date 08/09/2024, indicated intervention for PTSD but failed to address trigger for PTSD. During an observation and interview on 11/04/2024 at 3:27 p.m., Resident #15 stated she does not get out of her private room very often. Resident #15 stated she was afraid to get close to people because she would lose them. During an interview on 11/06/2024 at 1:56 p.m., the Social Worker stated she was not sure who was responsible for updating PTSD triggers on the care plan. The Social worker stated Resident # 15 never mentioned any PTSD triggers to her. The Social Worker stated she did not work at the facility for Resident #15 initial trauma assessment and has not done a trauma assessment at this time. The Social worker stated it was important for PTSD triggers to be on the care plan to provide the appropriate cate. During an interview on 11/06/2024 at 2:58 p.m., the DON stated PTSD triggers should be on the care plan. The DON stated the social worker was responsible for the trauma assessments at admission and change of condition. The DON stated Resident #15 was being seen by psychiatric services. Record review of the facility's policy Trauma Informed Care dated 10/24/2022 The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify wat to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. While most triggers are highly individualized, some common triggers may include, but are not limited to: a. Experiencing a lack of privacy or confinement in a crowded or small space. b. Exposure to loud noises, or bright/flashing lights. c. Certain sights, such as objects that are associated with their abuser. d. Sounds, smells, and physical touch Based on observations, interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 2 of 2 residents (Resident #15 and Resident #46) reviewed for trauma-informed care 1. The facility did not ensure Resident #46 had an accurate trauma screen that identified possible triggers when Resident #46 had a history of trauma. 2. The facility did not ensure Resident #15's trauma screening was completed with triggers upon admission to the facility. These failures could place residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: 1. Record review of a face sheet dated 11/06/2024 indicated Resident #46 was a [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included major depressive disorder, recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), and mild cognitive impairment. Record review of a face sheet dated 10/25/2024 indicated Resident #46 was understood by others and was able to make herself understood. The MDS assessment indicated Resident #46 was independent for eating, toileting, personal hygiene, and required partial/moderate assistance with showering/bathing. The MDS assessment indicated Resident #46 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #46 had anxiety and depression. Record review of Resident #46's care plan revised 10/29/2024 indicated she had alteration in mood related to disease process, diagnosis of depression and anxiety. Resident #46 care plan included interventions to administer medications as ordered, assist the resident to identify strengths, positive coping skills, and reinforce these, monitor/record mood to determine if problems seem to be related to external causes, monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills, and the resident needs encouragement/assistance/support to maintain as much independence and control as possible. Resident #46's care plan did not indicate she had a history of trauma. Record review of Resident #46's Comprehensive Trauma Screening with effective date 04/15/2022 completed by the previous social worker did not indicate Resident #46 had a history of trauma. During an interview on 11/04/2024 at 11:14 AM, Resident #46 said when she was growing up, she was smothered on purpose. Resident #46 said she had post-traumatic stress disorder due to this and she had told the social worker and the staff about it. During an interview on 11/06/2024 at 10:46 AM, the Social Worker said that she was not aware of Resident #46 having a history of trauma. The Social Worker said trauma assessments were done on admission and occasionally if the resident went to the hospital the system would trigger for a trauma assessment to be completed, and she would re-do it. The Social Worker said she had not completed Resident #46's trauma assessment because she was new at the facility (started in February 2024). The Social Worker said addressing trauma informed care was important because it could affect the residents well-being and quality of life, how they interacted with staff and each other and it could affect their sleep. During an interview on 11/06/2024 at 3:24 PM, LVN A said Resident #46 had not told her she was smothered in the past. LVN A said she was aware Resident #46's family member was abusive towards her when she was younger. LVN A said some time back Resident #46 was crying and had reported her family member was abusive to her. LVN A said she had reported it to the previous social worker, and she had talked to her about it. LVN A said it was important for history of trauma and triggers to be identified so that the staff would not trigger Resident #46's anxiety or go in her room and say something that was going to upset her because Resident #46 did have a lot of anxiety. During an interview on11/06/2024 at 4:30 PM, phone interview was attempted to the previous social worker with no answer. During an interview on 11/06/2024 at 5:10 PM, the DON said she was not aware of Resident #46 having any trauma. The DON said she knew Resident #46 was admitted to the facility because she lived in bad apartments with her family member and they were stealing her pills, but she was unaware of any trauma. The DON said if Resident #46 had trauma it should be on her trauma assessment and in her care plan. The DON said the previous social worker would have identified the trauma and put it in the care plan. The DON said it was important for trauma to be identified because the resident's treatment would be different, and they would have to look for mannerisms, behaviors, triggers, and offer psych services, counselor services. The DON said it was important for it to be included on the resident's care plan, so they knew how to care for them. During an interview on 11/06/2024 at 5:44 PM, the Administrator said he expected the Social Worker to address trauma on the trauma assessment and for trauma and triggers to be included in the residents' care plans. The Administrator said the Social Worker was responsible for this. The Administrator said it was important for trauma and triggers to be identified so it could be treated, if necessary. The Administrator said if trauma was not identified it could affect the resident's quality of life mentally. The Administrator said triggers needed to be identified so they could treat and evaluate the resident's mental status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents were free of significant medication errors for 2 of 23 residents reviewed for pharmacy services. (Resident # 15 and Resident # 68) The facility failed to ensure Resident #15's Metoprolol and Hydralazine (blood pressure medication) was not administered when her blood pressure was outside of the ordered parameters (systolic blood pressure less than 100 and diastolic blood pressure less than 60) on 10/06/2024. The facility failed to ensure Resident #68's Hydralazine (blood pressure medication) was not administered when her blood pressure was outside of the ordered parameters on 10/24/2024. These failures could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: 1. Record review of Resident #15's face sheet dated 11/05/2024, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included bipolar disorder current episode mixed severe with psychotic features (characterized by the presence of either delusion or hallucinations or both), Post-traumatic stress disorder, chronic (mental health condition that occurs when symptoms of PTSD last for more than three months after traumatic event), generalized anxiety disorder (a mental disorder that causes people to experience excessive and uncontrollable worry about everyday events and activities). Essential (primary) hypertension (high blood pressure that doesn't have a single identifiable cause). Record review of Resident #15's MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS indicated Resident #15 had a BIMS score of 14, indicating cognition was intact. Record review of Resident #15's care plan dated 08/09/2024, indicated Resident #15 has a history of hypertension and was at risk for fluctuations in blood pressure. Interventions administer antihypertensive medications as ordered. Monitor for side effects such. as orthostatic hypotension, headache, vertigo, chest pain, and decreased heart. Record review of Resident #15's physicians order summary dated 11/05/2024, indicated Resident #15 had orders for Metoprolol 50 mg tablet give one tablet two times a day with instructions to hold for SBP less than 100 or DBP less than 60 with a start date of 10/24/2024 and Hydralazine 100mg give one tablet by mouth three times a day with instructions to hold for SBP less than 100 or DBP less than 60 with a start date of 01/10/2024. Record review of Resident #15's medication administration record dated 10/1/2024 - 10/31/2024, indicated Resident # 15 had received Metoprolol 50 mg tablet when her blood pressure was 143/55 on 10/06/2024 with instructions to hold for SBP less than 100 or DBP less than 60 and Hydralazine 100mg when her blood pressure was 143/55 on 10/06/2024 with instructions to hold for SBP less than 100 or DBP less than 60. *On 10/06/2024 at 7:00 a.m., Resident #15's blood pressure was 143/55. The medication administration record had a check mark which indicated Resident #15 was administered Metoprolol 50 mg tablet and Hydralazine 100mg outside the parameters. 2. Record review of Resident #68's face sheet dated 11/06/2024, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included chronic combined systolic (congestive) and diastolic (congestive) heart failure (a condition where the heart muscle was simultaneously impaired in both its ability to contract and squeeze blood out (systolic dysfunction) and its ability to relax and fill with blood properly (diastolic dysfunction), leading to chronic congestion in the body due to poor blood circulation), pulmonary hypertension, unspecified (a serious condition that occurs when blood pressure in the lungs was higher than normal), essential (primary) hypertension (a type of high blood pressure that doesn't have an identifiable cause). Record review of Resident #68's MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS indicated Resident #68 had a BIMS score of 12, indicating moderate cognitive impairment. Record review of Resident #68's care plan dated 08/28/2024, indicated Resident #68 has a history chronic combined systolic (congestive) and diastolic (congestive) heart failure. Interventions give cardiac medications as ordered. Record review of Resident #68's physician order summary dated 11/05/2024, indicated Resident #15 had orders for Hydralazine 100mg give one tablet by mouth three times a day with instructions to hold for SBP less than 100 or DBP less than 60 with a start date of 06/21/2023. Record review of Resident #68's medication administration record dated 10/1/2024 - 10/31/2024, indicated Resident # 68 had received Hydralazine 100mg when his blood pressure was 99/60 on 10/24/2024 with instructions to hold for SBP less than 100 or DBP less than 60. *On 10/24/2024 at 4:00 p.m., Resident #68's blood pressure was 99/60. The medication administration record had a check mark which indicated Resident #68 was administered Hydralazine 50mg outside the parameters. During an interview on 11/06/2024 at 8:58 a.m., MA L stated she gave the medication to Resident #15 because her systolic blood pressure was 143. MA L stated she was not allowed to contact the doctor when the blood pressure was out of parameter. MA L stated she was supposed to notify the charge nurse, but she could not remember if she notified the charge nurse or not. MA L stated it was important to not give blood pressure medication outside of the parameter because that was what the doctor ordered. MA L stated the risk to Resident # 15 would be her blood pressure dropping to low. During an interview on 11/06/2024 at 9:10 a.m., LVN M stated she did not give Resident #68 the Hydralazine 50 mg on that day. LVN M stated it was important not to give medication outside of the parameters because the resident's blood pressure could become to low. LVN M stated the risk to the resident giving medication outside of parameters was drowsiness or loss of consciousness. During an interview on 11/06/2024 at 1:56 p.m., the DON stated it was the nurse or the medication aide's responsibility to call the doctor if the residents blood pressure was out of the parameters. The DON stated it was important to get an order from the doctor to hold blood pressure medication when residents blood pressure was out of parameter. The DON stated the risk was the residents blood pressure could bottom out. The DON stated she would monitor by medication administration audits. During an interview on 11/06/2024 at 4:48 p.m., the Administrator stated the person administering the medication was responsible for ensuring the medications were being administered as ordered. The Administrator stated he expected medications to be administered per the physician's orders. The Administrator stated when the blood pressure was outside of parameters the doctor should be notified for orders. The Administrator stated blood pressure medication given outside of parameters could cause all kinds of problems. The Administrator stated he would monitor by reviewing the MAR. Record review of the facility's policy Medication-Treatment Administration and Documentation Guidelines revised on 04/06/2023, indicated Medications are administered according to manufacturer's guidelines unless otherwise indicated by physician order verify and provide medication or treatment focused assessment i.e. BP, wound measurements as indicated by manufacturers guideline or physician orders. Administer the medication according to the physician order

Based on observation and interview, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 4 medication carts. LVN M failed to ensure the 100 Hall medication cart was locked when it was left unattended while she went to the restroom. This failure could place residents at risk of injury. Findings included: During an observation on 11/05/24 at 04:42 PM the hall 100 medication cart was unlocked, unattended, and parked beside the centralized nursing station. During an observation on 11/05/24 at 04:45 PM ADON N walked up to the hall 100 medication cart and locked it. She said the charge nurses were responsible for ensuring their medication carts were locked prior to walking away from them. She said there were all types of risks associated with the cart being left unlocked and unattended. ADON N said some of the risks associated with leaving the medication cart unlocked and unattended included theft of medications, poisoning for residents, and overdose. During an interview on 11/05/24 at 04:48 PM LVN P said she had left the 100 hall medication cart unattended by accident because someone had stopped her and asked her a question when she walked around the nurse's station while headed to the restroom. LVN P said it was her responsibility to ensure the medication cart was locked when left unattended. LVN P said the failure placed a risk for a resident, staff, or visitor to have access to the cart and take whatever they wanted. During an interview on 11/06/24 at 05:44 PM DON she said she expected the carts to be closed, locked, and the keys in their pockets at all times. She said all the charge nurses were responsible for their carts being locked if unattended. The DON said the failure placed a risk for a resident being poisoned, residents getting a hold of sharps, getting needle sticks, and residents getting a hold of medications in the cart. During an interview on 11/06/24 at 06:06 PM the Administrator said the medication carts should be locked at all times when they were not being used. He said the charge nurses were responsible for ensuring the carts were locked when they were unattended. The Administrator said the failure placed a risk for medications to be taken by residents that they were not prescribed to have. He said the failure also placed a risk for staff and visitors getting in the cart and taking the medications. Record review of the policy Medication Storage dated 1/20/2021 indicated: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stores, dated, and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments .b. Only authorized personnel will have access .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, 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 dietary services. 1) The Dietary staff failed to label and date all food items. 2) The Dietary staff failed to dispose of expired foods items located in the refrigerator and freezer. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During observations on 11/04/24 at 9:11 a.m., the following observations were made in the kitchen walk in freezer (1 of 1) (1) zip lock bag of frozen catfish had an open date of 10/26/24 and an expiration date of 11/2/24. (expired) (1) 1/2-quart container of celery had a preparation date of 10/21/24 and an expiration date of 10/27/24. (expired) During observations on 11/04/24 at 9:17 a.m., the following observations were made in the kitchen walk in Refrigerator (1 of 1) (1) container of tomato juice was not labeled and had no preparation date and no expiration date. During an observation and interview on 11/04/24 at 9:17 a.m., the Dietary Manager stated the container of red juice found in the refrigerator was tomato juice and should have been labeled and dated. The Dietary Manager disposed of the tomato juice found in the refrigerator. During an interview on 11/6/24 at 9:10 a.m., the Dietary Manager stated she had been employed at the facility for 12 years. The Dietary Manager stated the Administrator oversaw her at the facility. The Dietary Manger stated in-services on labeling, dating, and discarding expired foods was last completed within the past month or two. The Dietary Manager stated she was not aware of the items found in the kitchen prior to survey. The Dietary Manager stated she conducted walk throughs every morning, but she did not catch what the surveyor found in the kitchen on 11/4/24. The Dietary Manager stated the Administrator did not conduct walk thrus in the kitchen. The Dietary Manager stated it was important for staff to ensure they were labeling, dating, and discarding expired food items for the safety of the residents and so no residents would get sick. During an interview on 11/6/24 at 12:11p.m., the Administrator stated he had been the administrator for 14 months. The Administrator stated he oversaw the Dietary Manager. The Administrator stated, Yes, all foods were to be labelled dated, and discarded if expired. The Administrator stated, I do not know off the top of my head about the last in-services on labeling, dating and discarding expired foods but the Dietary Manager keep track of all in-services. The Administrator stated, Yes, I conducted walk throughs once a week on Fridays in the kitchen. The Administrator stated he did not have a chance to do walk through this week. The Administrator stated his next walk thru in the kitchen was scheduled for this this upcoming Friday 11/8/24. The Administrator stated he was not aware of the expired foods and the tomato juice found in the refrigerator not labeled. The Administrator stated, Yes, I expect the dietary staff to follow kitchen policies and procedures. The Administrator stated, It was important ensure staff were labeling, dating and discarding expired food so staff would not serve foods out of date and possibly spoil. Record review of the facility's policy titled Dry Food and Supplies Storage, revised 11/15/17 indicated, (7) All storage bags must also be properly sealed and labeled with the common name of the food; (9) All opened products must be resealed effectively and properly labeled, dated and rotated for use. This may require storage in an approved NSF container or food grade storage bag; (10) Use by, Best by, and Sell by, dates should routinely be checked to ensure that items which have expired are discarded appropriately. Record Review of FDA Food code dated 2022 indicated, 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents. (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act § 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest-prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 1 of 4 residents (Resident #8) reviewed for antibiotic use. The facility failed to ensure Resident #8 had documented signs and symptoms to support the use of prescribed antibiotics. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. The findings included: Record review of a face sheet dated 11/06/2024 indicated Resident #8 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #8 was able to make herself understood and was able to understand others. The MDS assessment indicated Resident #8's BIMS score was 11, which indicated her cognition was moderately impaired. The MDS assessment did not indicate Resident #8 used antibiotics. Record review of Resident #8's care plan with a target date of 02/09/2025 did not address the use of antibiotics or cellulitis (skin infection). Record review of Resident #8's Order Summary Report dated 11/06/2024 indicated Doxycycline Monohydrate (antibiotic) 100 mg give 1 capsule by mouth two times a day for cellulitis to left lower extremity for 7 Days was completed with a start date of 10/23/2024 and end date 10/30/2024. Record review of the progress notes, from 10/14/2024 to 10/23/2024, indicated Resident #40 had no documentation of signs or symptoms of an infection to indicate antibiotic use. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist (checklist used to monitor for proper antibiotic use), date of infection 10/23/2024, date reviewed 10/24/2024 for doxycycline twice daily for 7 days for cellulitis, indicated Resident #8 did not meet the criteria for antibiotic use for cellulitis, soft tissue, or wound infection. During an interview on 11/06/2024 at 4:51 PM, ADON O said she was the infection control preventionist, and she monitored and completed the tracking and tools used to ensure proper antibiotic use. ADON O said she was aware Resident #8 did not meet criteria for antibiotic use. ADON O said she had been working with the nurses to ensure they were properly documenting signs and symptoms of infections and she felt like there had been an improvement. ADON O said if the doctor ordered an antibiotic, they had to follow the doctor's orders. ADON O said she had provided the Medical Director with education regarding proper antibiotic use verbally, but she did not have any documentation of education she had provided to him. ADON O said it was important for the criteria for antibiotic use to be followed to ensure antibiotics were not used improperly. During an interview on 11/06/2024 at 5:38 PM, the DON said she was aware some of the antibiotics used were not meeting criteria. The DON said they were working on the tools for infection surveillance, but if the doctor prescribed an antibiotic, they gave it. The DON said signs and symptoms of infection and location should be documented by the nurses. The DON said it was important for the criteria for antibiotic use to be followed to make sure the residents had a good quality of life, and that the disease process was cured. The DON said giving antibiotics that did not meet criteria could lead to c. diff (c. difficile, bacterial infection usually a result of antibiotic use), super infections, and MRSA (methicillin-resistant Staphylococcus aureus, bacteria resistant to antibiotics). During an interview on 11/06/2024 at 6:00 PM, the Administrator said nurse management was responsible for antibiotic stewardship, and he expected for them to follow the policy and procedure. The Administrator said it was important for the policy and procedure on antibiotic stewardship to be followed so antibiotics were not overused. Record review of the facility's policy titled, Infection Prevention and Control Program, revised 03/26/2024, indicated, . a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility .7. Antibiotic Stewardship: a. An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. b. Antibiotic use protocols and a system to monitor antibiotic use are implemented as part of the antibiotic stewardship program. c. The Infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the antibiotic stewardship program. d. The Medical Director, consultant pharmacist, and laboratory manager will serve as resources for the antibiotic stewardship program .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 2 residents (Resident #2) reviewed for activities. The facility failed to ensure Resident #2's Activities Evaluation was accurately completed on 09/09/2024. The facility failed to ensure Resident #2 was provided in-room activities in August 2024, September 2024, and October 2024. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: Record review of a face sheet dated 11/06/2024 indicated Resident #2 was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain causes problems with reasoning, planning, judgment, and memory) and shortness of breath. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #2 was sometimes understood by others and understood others. The MDS assessment indicated Resident #2 had a short-term and long-term memory problem. The MDS assessment indicated it was not very important for Resident #2 to have books, newspapers, and magazines to read. The MDS assessment indicated Resident #2 required partial/moderate assistance with eating, oral hygiene, substantial/maximal assistance with personal hygiene, and dependent for bathing/showering. Record review of Resident #2's care plan indicated she was dependent on staff for cognitive stimulation, activity attendance, and social interaction related to cognitive impairment and was at risk for isolation. Resident #2's care plan indicated she would attend/participate in activities of choice 1-3 times weekly through the next review date. Resident #2's care plan indicated interventions to assist/escort the resident to activity functions, converse with resident while providing care, provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility, provide the resident with assistance as needed during the activity, and the resident's preferred activities are: TV, music, adult coloring, perk word search and family/friend visits. Record review of Resident #2's Activity Evaluation dated 09/09/2024 completed by the Activities Director indicated it was not very important for her to have books, newspapers, and magazines to read. The Activity Evaluation indicated Resident #2 was not interested in reading/audio books. The Activity Evaluation indicated Resident #2 preferred activities in her own room. The Activity Evaluation indicated Resident #2 had poor vision. Record review of the In Room Activity Visit Logs for August 2024, September 2024, and October 2024 indicated: 08/19 Resident #2 with no activity description, no start or end time, and no signature to indicate it was completed. No in-room activities for Resident #2 in September 2024. No in-room activities for Resident #2 in October 2024. During an observation and interview on 11/04/2024 at 9:37 AM, Resident #2 said the staff told her they would read to her, but they had not. Resident #2 said she loved for them to read to her because she was not able to see the books anymore. Resident #2 had books on her overbed table. During an interview on 11/05/2024 at 4:35 PM, the Activities Director said she started in August of 2024. The Activities Director said Resident #2 read her own books, looked at her own pictures, and liked to visit with her family. The Activities Director said Resident #2 was supposed to have in-room activities, and she thought she had been doing these. The Activities Director said she had not tried to read to Resident #2, and she completed activities on her own. The Activities Director said she guessed she had had filled out Resident #2's Activity Evaluation wrong because Resident #2 liked to read. During an interview on 11/06/2024 at 5:48 PM, the Administrator said if Resident #2 liked to be read to, he expected for this to be done for her. The Administrator said the Activities Director was responsible for doing activities and the activities assessments. The Administrator said Resident #2's activities preferences should be included on her care plan as well. The Administrator said this was important to maximize the resident's quality of life. Record review of the facility's policy, Recreational Services, revised 02/2022, indicated, Recreation becomes extremely significant in meeting each resident's needs for quality of life. Well planned programs must be designed to enhance residents' abilities to function at their highest practicable level as well as to allow them to realize their own abilities and their own potential for fulfillment. The process must include assessing the residents' functional abilities, interests and needs, developing mutual agreed upon goals and the use of specialized recreation services as approaches to meet the individualized goals .

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 8 of 81 residents residents (Residents #68, #79, #3, #11, #62, #48, #45, and #13) and 1 of 3 meals (lunch meal) reviewed for palatability, attractiveness, and appetizing. The dietary staff failed to provide food that was palatable and appetizing temperature for lunch meal observed on 11/5/24. Resident's #68, #79, #3, #11, #62, #48, #45, and #13 complained that food tasted bad, was not cooked properly and was served cold. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Record Review of the menu indicated the lunch meal items on 11/5/24 included (A) fried chicken, mash potatoes, spinach, dinner roll and ice cream; (B) steak, egg noodles, green peas, dinner roll and ice cream. During an interview on 11/04/24 9:17 a.m., Resident #68 stated the food was bad every day. During an interview on 11/4/24 at 9:53a.m., Resident #79 stated the food was bad and he did not like his food grinded up. During an interview on 11/04/2024 at 9:58 a.m., Resident #3 stated the food could be better; Resident # 3 stated I feel like I eat a lot of sandwiches all the time. Resident # 3 stated she wanted more of a variety of other foods. During an interview on 11/04/24 10:14 a.m., Resident #11 stated she can't eat rice, corn, berries and gets it on her tray. Resident #11 stated, I had burnt toast this morning and I sent it back. Resident #11 stated the green beans were stringy and felt like she was eating hair. Resident #11 stated her dinner roll was not done yesterday (11/05/24). Resident #11 stated the inside of her dinner roll raw. Resident #11 stated she got cold coffee. During an interview on 11/04/2024 at 10:49 a.m., Resident #62 stated he would not feed the food to a hog. Resident #62 stated most of time the food was not done or was overdone. Resident #62 stated most of the time the pasta noodles were not eatable. During an interview on 11/4/24 at 10:06 a.m., Resident #48 stated he hated getting cold eggs unless the eggs were boiled. Resident #48 stated he liked his eggs over easy and the kitchen fried his eggs too hard. During an interview on 11/04/24 11:23 a.m., Resident #45 food stated the food was horrible, and her family brought her food, or she would starve. During an interview on 11/5/24 at 10:37 a.m., Resident #13 stated the food was not good and meat was tough. During observation and tasting of lunch meal (A) on 11/5/24 at 12:22 p.m., the Dietary Manager stated the steak needed more seasoning, egg noodles tasted like egg noodles and the peas was warm. The frozen ice cream was not sampled during tasting. During observation and tasting of lunch meal (B) on 11/5/24 at 12:30 p.m., the Dietary Manager stated the fried chicken did not look burnt, but the fried chicken did have a dark color to it. During the tasting, surveyors stated the fried chicken skin tasted burnt and was dark in color. The Dietary Manager stated the mash potatoes was warm but needed a little more seasoning. The Dietary Manager stated the spinach tasted like spinach but could use more seasoning. The frozen ice cream was not sampled during tasting. During an interview on 11/06/24 at 9:15 a.m., The Dietary Manager stated she had been employed at the facility for 12 years. The Dietary Manager stated the administrator oversaw her at the facility. The Dietary Manager stated she tasted the foods served at every meal and every meal serving. The Dietary Manager stated she did not test taste the foods on 11/5/24 for lunch because she was cooking and was trying to make sure her staff was on point with everything in the kitchen. The Dietary Manager stated the cooks and aide also tasted the foods prior to serving meals that they prepared. The Dietary Manager stated her cooks and aides have completed in-services on following the recipe recently this year (2024). The Dietary Manager stated she did not exact on the actual month the aides and cooks completed in-services on following the recipe. The Dietary Manager stated she handled food complaints from the residents by communicating with the resident personally. The Dietary Manager stated, For the targeted complainers that she would print the menus for the residents, and she would let the family make their choices on the food's preferences for the resident. The Dietary Manager stated by letting the family make the food choices for the resident that it had had helped her targeted complainers calmed down on the food complaints. The Dietary Manager stated for residents complaining about food, that she would adjust the resident's meal choices based on the notes the resident left for her to read. The Dietary Manager stated it was important to ensure the food was palatable, attractive, and appetizing to the residents to make the residents happy and for the resident nutrition. During an interview on 11/6/24 at 12:04 p.m., the Administrator stated he had been the administrator for 14 months. The Administrator stated he oversaw the Dietary Manager. The Administrator stated he ordered test trays from the kitchen. The Administrator stated he was having lunch from the kitchen today. The Administrator stated the results from his last test tray was good. The Administrator stated the Dietary manager would go and talk to each resident who complain of food when he received food complaints to try to resolve the food complaints. The Administrator stated he handled food complaints by writing grievance on the food complaints from the residents. The Administrator stated he had one resident that always had something to say about everything prepared from the kitchen. Stated he recently talked to one resident who complained about the food and was told from that resident that the food was better and had been good lately. The Administrator stated he did not remember off the top of his head of when the last in-service on following the menu was completed by the dietary staff. The Administrator stated it was important to ensure the food was palatable, attractive, and appetizing for the resident for quality of life, weight loss prevention and for enjoyment. Record review of the facility Policy, titled, Menus and Nutritional Adequacy, revised Dated on 5/30/2012, indicated, Menus are planned to meet the average resident nutritional needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident #2, Resident #53, and Resident #72) reviewed for infection control. 1. The facility failed to ensure LVN E and CNA F provided proper incontinent care to Resident #2. 2. The facility failed to ensure Resident #53's bagged, dirty briefs were taken out of her bathroom. 3. The facility failed to ensure CNA H provided proper catheter care to Resident #72, and the facility failed to ensure CNA H followed enhanced barrier precautions when she failed to wear gloves as she repositioned and touched Resident #72's sheets. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: 1. Record review of a face sheet dated 11/06/2024 indicated Resident #2 was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain causes problems with reasoning, planning, judgment, and memory) and shortness of breath. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #2 was sometimes understood by others and understood others. The MDS assessment indicated Resident #2 had a short-term and long-term memory problem. The MDS assessment indicated Resident #2 required partial/moderate assistance with eating, oral hygiene, substantial/maximal assistance with personal hygiene, and dependent for toileting and bathing/showering. Record review of Resident #2's care plan revised 09/17/2024 indicated she had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner. Resident #2's care plan indicated substantial assistance with toileting. Resident #2's care plan indicated she was incontinent of bowel and bladder to check her frequently for wetness and soiling and change her as needed. During an observation of incontinent care on 11/04/2024 at 9:46 AM, LVN E and CNA F provided incontinent care to Resident #2. LVN E and CNA F put on gloves, unfastened Resident #2's dirty brief, cleaned her front peri area, Resident #2 was turned on her side. LVN E removed the dirty brief, LVN E cleaned resident back peri area, wiped from front to back but used the same wipe to wipe multiple times, she did this several times while cleaning the back peri area, changed gloves, did not perform hand hygiene in between glove changes, applied clean gloves, tucked in the dirty sheets, changed gloves, did not perform hand hygiene in between glove changes and applied the clean sheets and brief. Resident #2 was rolled to the other side CNA F removed the dirty linens and unrolled the clean sheets from underneath resident. CNA F did not change gloves and perform hand hygiene after removing the dirty linens and before touching the clean sheets. CNA F with her dirty gloves repositioned the resident in the bed. After repositioning Resident #2, CNA F removed the dirty gloves and performed hand hygiene and LVN E removed her gloves and performed hand hygiene. During an interview on 11/04/2024 at 2:29 PM, LVN E said when performed incontinent care, she should only wipe once and discard. LVN E said this was important for infection control. LVN E said wiping more than once could result in urinary tract infections. LVN E said hand hygiene should be performed before and after care and in between glove changes. LVN E said she had not realized she failed to perform hand hygiene in between gloves changes. LVN E said gloves should be changed after cleaning the front, after cleaning the back, and when gloves were soiled, and when moving from dirty to clean. LVN E said CNA F should have changed her gloves after removing the dirty linens, before applying the clean linens. LVN E said ADON O was responsible for ensuring the CNAs were performing proper incontinent care. LVN E said hand hygiene was important to be done when required for infection control. During an interview on 11/05/2024 at 3:12 PM, CNA F said gloves should be changed and hand hygiene performed after touching anything contaminated. CNA F said gloves should be changed after removing the dirty linens, before applying the clean linens. CNA F said she had not changed her gloves because she did not think about it. CNA F said it was important to change gloves to prevent contamination. 2. Record review of Resident #53's face sheet dated 11/06/2024 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #53's Quarterly MDS assessment indicated she was able to make herself understood and was able to understand others. The MDS assessment indicated Resident #53 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #53 was independent for toileting and personal hygiene. The MDS assessment indicated Resident #53 did not exhibit rejection of care or behaviors. Record review of Resident #53's care plan with a target date of 01/27/2025 indicated she had an ADL self-care performance deficit related to cognitive decline, episodes of incontinence, unsteady gait, and was at risk for not having her needs met in a timely manner. Resident #53's care plan indicated she was independent for toileting. During an observation and interview of Resident #53's bathroom, there were 2 bags on the floor under the sink each bag contained dirty briefs. There was a strong urine odor in Resident #53's bathroom. Resident #53 said she tried to stay out of the bathroom because of the strong urine odor. Resident #53 said she told the nurses about the dirty briefs in the bathroom and they laugh and they do not take them out. Resident #53 said it was like talking to the air. Resident #53 was unable to say how long the bags with the dirty briefs had been in the bathroom, but she said they had been there a while. During an observation and interview on 11/04/2024 3:58 PM with CNA F, Resident #53 had bags with dirty briefs in her bathroom under the sink. CNA F said the CNAs were responsible for taking out the dirty briefs. CNA F said, I haven't gone in there today, I have been busy and did not have time. CNA F said Resident #53's bathroom smelled like urine. CNA F said it was important for the trash bags with briefs to not be left in the bathroom for sanitizing and to prevent contamination. CNA F said the bathroom smelling like urine could make Resident #53 feel like she was not being cared for. 3. Record review of a face sheet dated 11/06/2024 indicated Resident #72 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and urinary retention. Record review of a Comprehensive MDS assessment dated [DATE] indicated Resident #72 was sometimes able to make herself understood and was sometimes able to understand others. The MDS assessment indicated Resident #72 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #72 was dependent on staff for all ADLs. The MDS assessment indicated Resident #72 had an indwelling catheter. Record review of Resident #72's care plan revised 10/30/2024 indicated she had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner and required substantial/maximum assistance with toileting. Resident #72's care plan indicated she had a urinary catheter and was at risk for urinary tract infections and injury. Resident #72's care plan indicated catheter care every shift. The care plan indicated Resident #72 required enhanced barrier precautions to wear gown and gloves during high-contact resident care activities. Record review of Resident #72's Order Summary Report indicated to provide catheter care every shift with a start date of 09/26/2024. During an observation and interview on 11/06/2024 starting at 2:12 PM, CNA G and CNA H provided incontinent care to Resident #72. CNA G and CNA H put on PPE and gloves. CNA H cleaned Resident #72's left peri area and wiped down the middle. CNA H did not wipe Resident #72's right peri area and she did not clean the catheter tubing. Resident #72 was turned on her side. When she was turned on her side Resident #72 got a hold of her catheter tubing. CNA G cleaned Resident #72's back peri area. CNA G changed gloves and Resident #72 was turned back onto her back. Resident #72 was still holding her catheter tubing. CNA H removed her gloves and covered Resident #72 up, CNA H touched Resident #72's sheets and blankets without gloves. Resident #72 was still holding her catheter tubing when they covered her up. After this, CNA H and CNA G decided Resident #72 needed to be pulled up in the bed. When CNA H and CNA G pulled up Resident #72 in the bed she started pulling at the catheter. CNA H intervened and stopped Resident #72 from pulling the catheter further, and they finished repositioning her in the bed. CNA H said she thought she had cleaned both sides of Resident #72's front peri area. CNA H said when cleaning a resident with a catheter she should hold the tubing and wipe down it to clean it. CNA H said she should clean the peri area properly and the catheter tubing properly because they could have bacteria and germs and so the resident would not get an infection. CNA H said Resident #72 was on enhanced barrier precautions. CNA H said she was able to touch Resident #72's sheets and reposition her without gloves. CNA H said when providing care to Resident #72 she should be looking at the foley catheter tubing. CNA H said it was important to pay attention to where the foley catheter tubing was so it would not get pulled out and rupture something. During an interview on 11/06/2024 at 4:38 PM, ADON O said when providing incontinent care, the staff should wipe and toss, wipe and toss. ADON O said the same wipe should not be used to wipe multiple times because this could cause urinary tract infections. ADON O said anytime they went from dirty to clean, gloves should be changed. ADON O said hand hygiene should be performed in between glove changes. ADON O said if the staff were still cleaning the dirty, they could skip the hand hygiene in between. ADON O said hand hygiene should be performed at the required times to prevent the spread of infection. ADON O said for enhanced barrier precautions the staff did not have to wear glove if they were not touching the resident's skin. ADON O said the staff was able to touch the residents' surroundings with no gloves. ADON O said it was okay for CNA H to reposition and touch Resident #72's sheets without gloves. ADON O said when performing incontinent care, the CNAs should clean from inside/out, clean the foley from top to bottom. ADON O said they should clean the tube, but make sure they do not pull it. ADON O said the CNAs should be aware of where the catheter tubing was at all times, and they should be aware of where the residents' hands and limbs were. ADON O said it was important for them to be aware of where the foley catheter tube was because it could cause trauma, pain, injury, and it was a risk for infection. ADON O said when providing incontinent care, the CNAs should be trying to clean the residents completely. ADON O said it was important to keep the skin clean and to prevent infections. ADON O said the CNAs and any of the staff should have attempted to take out Resident #53's bagged, dirty briefs out of her bathroom. ADON O said the bagged, dirty briefs should not be left on the floor for cleanliness and hygiene, and they were a breeding ground of infection and bugs. During an interview on 11/06/2024 at 5:22 PM, the DON said gloves should be changed when going from dirty to clean. The DON said if the staff was cleaning the dirty, they removed their gloves, applied new ones, and kept cleaning the dirty, they did not have to perform hand hygiene. The DON said the staff should change gloves and hand sanitize after removing dirty linens. The DON said during incontinent care the CNAs were supposed to clean both sides on the front peri area, and they should be cleaning the foley catheter tubing when providing incontinent care on someone with a foley catheter. The DON said it was important to completely clean the residents and clean the catheter tubing to prevent urinary tract infections, infections, and skin breakdown. The DON said the CNAs should be paying attention to where the residents foley catheter tubing was located while providing incontinent care. The DON said it was important to prevent trauma and risk for infection. The DON said the CNAs practiced incontinent care on the mannequins, and she randomly observed the CNAs perform incontinent care. The DON said she had not noticed any issues with incontinent care. The DON said for enhanced barrier protections PPE and gloves should be worn when touching the residents' sheets and covering them up. The DON said it was important to follow the enhanced barrier precautions for infection control and to protect themselves from the quantity of infections going around. During an interview on 11/06/2024 at 5:50 PM, the Administrator said he expected for the staff to use hand hygiene and glove changes as necessary when needed. The Administrator said nursing administration was responsible for ensuring the staff perform proper hand hygiene and glove changes. The Administrator said he expected for the CNAs to provide proper incontinent care and fully clean the residents. The Administrator said he expected the CNAs to keep the residents from pulling the catheter tubing because this could cause trauma to the urethra (tube connected to the bladder for removal of urine). The Administrator said he expected for the staff to follow the enhanced barrier precautions. The Administrator said nursing administration was responsible for overseeing this. The Administrator said not following the enhanced barrier precautions could be a risk for contamination. Record review of the facility's policy titled, Urinary Catheter Management, review date 08/20/2021 indicated, Residents with indwelling catheters (urethral or suprapubic) shall receive appropriate care and services to prevent and manage catheter-related complications .Provide perineal/catheter care with a perineal cleanser or mild soap and water at least once daily and promptly after fecal soiling to reduce the potential for bacterial contamination . Record review of the facility's policy titled, Incontinence Care, review date 02/14/2020 indicated, .put on non-sterile, latex-free gloves .cleanse peri-area and buttocks with cleansing agent wiping from front of perineum toward rectum. Turn patient side to side to cleanse entire affected area, as needed. Rinse with water, if needed or per incontinent product manufacturer's instructions . remove and discard gloves 16. Wash hands 17. Apply clean linen/underpad, brief or other incontinent products, as needed . Record review of the CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, accessed on 11/13/2024 indicated, .5a. Hand Hygiene .use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately after glove removal . Record review of the CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), accessed on 11/13/2024 indicated, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: 1. Wounds or indwelling medical devices .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation or resident property, and exploitation for 1 of 17 residents (Resident #1) reviewed for abuse. The facility failed to keep Resident #1 free from abuse when CNA A roughly provided incontinent care to him on 06/07/2024. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation and a decreased quality of life. Findings include: Record review of a Grievance/Complaint Report dated 06/07/2024, received by ADON B reflected Resident #1's family member requested gentle movements of his legs during care. Documented facility follow-up action was to in-service staff members with 1:1 education and physical therapy in-service regarding transfer of resident out of bed. Record review of Resident #1's face sheet, dated 10/17/2024, reflected a [AGE] year old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning), congestive heart failure (a chronic condition where the heart does not pump blood as well as it should), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), hypertension (high blood pressure), protein-calorie malnutrition the state of inadequate intake of food), cramp and spasm, pain in thoracic spine (the middle section of the back), muscle wasting, lack of coordination and cognitive communication deficit. Record review of Resident #1's Quarterly MDS assessment, dated 09/24/2024, reflected Resident #1 was understood and was able to understand others. Resident #1 had a BIMS score of 12, which indicated his cognition was moderately impaired. Resident #1 had no delusions or hallucinations. Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment reflected functional limitation on both sides of upper and lower extremities and dependent for assistance with transfers, toileting, shower, upper and lower body dressing and personal hygiene. Record review of Resident #1's comprehensive care plan, dated 10/01/2024, reflected Resident #1 had activities of daily living self-care performance deficit and was at risk for not having his needs met in a timely manner. The care plan goal included resident to maintain a sense of dignity by being clean, dry, odor free and well-groomed through the next review date. The interventions included the following: up to dining room as tolerated or permitted by family, provide shower, shave, oral care, hair care, and nail care per schedule when needed, encourage resident to participate to fullest extent, encourage resident to use call light to call for assistance before attempting any activities of daily living. During an observation on 10/15/2024 at 12:10 PM of a video, date stamped 06/07/2024, with muffled audio and visual revealed Resident #1 lying in the middle of the bed on his back with the bed in a flat position. Resident #1 was not heard groaning or making any indications of pain. CNA A and CNA C provided incontinent care to Resident #1. In attempts to roll Resident #1 onto his right-side CNA A pushed Resident #1 with one hand on his hip and the other on his upper torso, when Resident #1 did not roll onto his right side she used more force and repeatedly and aggressively pushed on his buttocks and mid back to get him to stay on his right side. CNA C did not attempt to assist CNA A with rolling Resident #1 onto his right-side. Once Resident #1 was on his right-side CNA C held Resident #1 so he would stay on his side. CNA A snatched the soiled brief out from under Resident #1 and threw it from where she stood on his left side to the trash can across the bed on the right side of the room. CNA A stuck a clean brief under Resident #1 then hastily tugged and pulled Resident #1 to the left side towards her by his upper left shoulder and posterior upper left leg causing Resident #1's legs to come off the side of the bed swiftly . During an interview on 10/15/2024 at 12:45 PM, Resident #1 stated he had been handled roughly by two staff members at the facility. Resident #1 stated he did not know the names of the staff, but he knew one aide continued to work at the facility after the incident occurred on 06/07/2024 but not on his hall. Resident #1 said he saw the aide around the dining area on several occasions. Resident #1 said he had not seen the other aide in a good while, so he was not sure if she worked at the facility any longer. Resident #1 said it scared him when CNA A provided care because the movement was rough and fast and made him feel unsafe like he was going to fall out of bed onto the floor. Resident #1 stated the staff started to use the Hoyer lift today, but they usually did not. During an interview on 10/15/2024 at 01:21 PM, Resident #1's family member stated she was very upset upon viewing the camera video of how rough the aide was during the incontinent care and transfer. Resident's #1's family member stated she immediately contacted ADON B and the DON regarding the unnecessary roughness used when providing care to Resident #1 on 06/07/2024. Resident #1's family member said she provided ADON B and the DON with the two videos which included incontinent care and a transfer. She said the video with the incontinent care showed all the aggressiveness and roughness by CNA A. Resident #1's family member said the second video showed the aide getting the nurse to help Resident #1 get up to hold his walker because he was having difficulty opening his hand. Resident #1's family member stated ADON B and the DON both stated they could not see the videos that the screens were just black. Resident #1's family member stated she offered to come to the facility on this date and show the DON the videos and the DON declined the offer. Resident #1's family member stated she did not know the aides name that provided the care so aggressive and roughly. Resident #1's family member stated to her knowledge CNA A had not been back into Resident #1's room since she reported the incident except for one time around or about 06/10/2024 in the morning. Resident #1's family member stated she saw CNA A in the facility on a different hall on several occasions after the incident. Resident #1's family member stated a care plan meeting was held on 06/10/2024 after the incident on 06/07/2024, at her request. Resident #1's family member stated she offered again to review the videos with the Administrator, DON and ADON B wherein the offer was declined. Resident #1's family member stated during the meeting she verbally requested CNA A not be allowed in Resident #1's room any longer. Resident #1's family member stated the roughness that took place in the video, dated 06/07/2024, by CNA A was discussed and documented in the care plan notes. During an interview on 10/16/2024 at 12:30 PM, the Ombudsman stated Resident #1's family member stated during the care plan meeting Resident #1 was handled roughly while care was being provided. The Ombudsman stated Resident #1's family member offered to review the videos at that time of the incident on 06/07/2024 wherein the Administrator stated the DON and ADON B had already seen the videos. During an interview on 10/16/2024 at 07:35 AM, CNA D stated she had worked at the facility for 2 years and most of that time was on Hall 400. CNA D stated she was recently educated on abuse and neglect probably 2 maybe 3 weeks ago. CNA D was able to identify the types of abuse. CNA D stated physical abuse would include hitting or forcibly pushing or touching a resident. CNA D said any suspicion or abuse allegations should be reported immediately to the Abuse Coordinator/Administrator. CNA D stated when she provided care to a resident such as incontinent care or repositioning, she utilized the draw sheet to prevent injury to the residents. CNA D said the residents' skin was mostly fragile, so it was best to not have skin to skin friction to prevent any injuries. CNA D stated she saw CNA A swing Resident #1's legs out of the bed but not in a quick manner. CNA D stated CNA A used to work hall 400 and take care of Resident #1. CNA D said if she saw any type of abuse including being rough, she would immediately protect the resident and report the abuse. CNA D said she recalled when Resident #1 said he was scared, and CNA A was moved to another hall. CNA D said in-services were provided by the DON and ADON B. CNA D was shown the video of incontinent care provided to Resident #1, dated 06/07/2024, and gasped. CNA D identified the staff as CNA A on the left side of Resident #1 and CNA C on the right side and quickly turned away and stopped watching the video. CNA D stated the care provided by CNA A was aggressive, harsh and rough and made her sick to her stomach. CNA D stated it was abuse and should have been reported immediately. During a telephone interview on 10/16/2024 at 1:35 PM, CNA C stated she resigned her position with the facility on 06/25/2024 due to several health problems. CNA C stated she was a CNA since 2016. CNA C said she had never had any allegation of abuse against her. CNA C said the facility had frequent in-services regarding abuse and neglect usually monthly. CNA C stated any type of rough handling such as tugging/pulling or pushing would be considered abuse and she would immediately report to the abuse coordinator. CNA C said she utilized the draw sheet to reposition residents for care. CNA C stated she recalled a time when she asked CNA A to help her with Resident #1. CNA C stated that CNA A informed her she was not allowed in Resident #1's room or to help with his care any longer. CNA C stated she worked with Resident #1 until she departed from the facility. CNA C denied any issues involving Resident #1's care . During an interview on 10/16/2024 at 06:35 PM, CNA A stated she had worked at the facility for approximately 4 years. CNA A stated she was in-serviced on abuse and neglect within the last 30 days. CNA A stated the DON and ADONs provided in-services on abuse and neglect usually to cover themselves from the state. CNA A stated if a resident accused the facility or staff of something like abuse then the staff were in-serviced. CNA A stated she had allegations of abuse made against her but only by a resident who did not like her or a staff member saying she was rough because that was their perception. CNA A stated sometimes she could not find anyone to help her provide care, so you did what you got to do to hold up the resident . CNA A stated being rough with a resident was considered abuse. CNA A stated moving fast could be perceived as being rough handling. CNA A stated the resident could be scared or resistant to care if care was provided too roughly or quick. CNA A said that could decrease their quality of life if the resident was not getting adequate care. CNA A stated she heard CNA E and CNA F had been rough handling residents . CNA A stated she did not know the residents, nor the co-workers involved with the allegations against CNA E or CNA F. CNA A denied ever seeing or suspecting abuse or rough handling. CNA A stated she would report any allegations of abuse to the Administrator. CNA A stated all suspected abuse should immediately be reported to the Administrator, so the resident was protected. CNA A stated she worked the 6PM to 6AM shift on hall 100. CNA A stated she preferred to be on days but was moved to the night shift because the DON was picking and she was not aware of why the shifts were changed. CNA A stated she had worked with Resident #1 and provided his care. CNA A stated as she provided incontinent care or repositioned a resident, she always used the draw sheet to prevent any bruises to the resident's skin. CNA A stated she would let the resident know what care she was going to provide prior to doing the care. CNA A stated it was important to let the resident know so they would not be scared. CNA A was shown the video, dated 06/07/2024. CNA A identified CNA C in the video immediately. CNA A stated the care being provided was rough and was considered abuse. CNA A was hesitant to answer on the identity of the second CNA in the video. CNA A stared at the video and finally responded that it looked like her but asked what did the State Surveyor think. CNA A stated quietly the more I look at it, damn - I think it is me, but I don't have that kind of hair - it might be CNA G. CNA A continued to stare at the video on replay . Attempted telephone call to CNA G on 10/16/2024 at 07:52 PM was unable to leave a voice message (currently, CNA G was on medical leave). During an interview on 10/16/2024 at 08:00 PM, the Staffing Coordinator identified the two CNAs in the video, dated 06/07/2024, as CNA A and CNA C. The Staffing Coordinator stated the actions by CNA A in the video were aggressive and uncalled for and could have resulted in harm to Resident #1. The Staffing Coordinator stated there was no reason to be using that much force and Resident #1's lower extremities should not have flew off the bed. During an interview on 10/16/2024 at 8:07 PM, ADON B stated she was educated and trained on abuse and neglect. ADON B stated she had also provided training on abuse and neglect for the facility to the staff. ADON B was able to identify the types of abuse. ADON B stated rough handling could be considered abuse depending on the situation such as some residents were stiff and required more strength to move them. ADON B stated abuse should be reported to the Abuse Coordinator/Administrator immediately to allow a proper investigation to be conducted to protect the residents. ADON B denied any allegation of abuse or rough handling being reported to her on any resident specifically Resident #1. ADON B stated Resident #1's family member attempted to send the videos for viewing but she was never able to see the videos due to the screen was black and the video did not play. ADON B stated Resident #1's family member did not ever use the words handled roughly when she received the grievance, dated 06/07/2024. ADON B stated she never viewed either video sent to her because she could not get them to play. ADON B viewed the video dated 06/07/2024 with the State Surveyor and became tearful and identified the aides in the video as CNA A and CNA C. ADON B stated CNA A was being too rough with Resident #1 during the incontinent care and the draw sheet should have been used to prevent the excessive pushing. During an interview on 10/16/2024 at 8:20 PM, the DON said the Administrator was the abuse coordinator. The DON stated she was educated and trained on abuse and neglect. The DON stated she had also provided training on abuse and neglect for the facility to the staff. The DON was able to identify the types of abuse. The DON stated abuse should be reported to the Abuse Coordinator/Administrator immediately to allow a proper investigation to be conducted to protect the residents from any further or potential abuse. The DON stated she had not viewed the videos because they would not show on her phone that the screen was black and blank. The State Surveyor requested to see the videos on the phone received from Resident #1's family member. Upon opening the video and pushing play, the video started playing of the transfer until the end of the video stopped. The DON stated she had watched the transfer video but could not hear any audio. The DON said the transfer of Resident #1 was the only video she received. The DON said she told Resident #1's family member that she had only received one video. The DON stated Resident #1's family member said she would resend the other video, but the DON said she never received it. The DON stated she asked for the second video again, but she had not received it. The DON stated she never declined Resident #1's family member's offer to show her the videos. The DON stated it was important to follow up on these allegations to protect the residents. The DON stated Resident #1 never used the term rough, rough handling, snatched, pulled, pushed to give any indication of abuse to be suspected. The DON said even suspected allegations of abuse should be reported and acted upon. The DON said during the care plan meeting with Resident #1's family member, she asked Resident #1's family member, are you saying this is abuse? The DON stated Resident #1's family member said, don't put words in my mouth. Therefore, the DON stated she did not feel this needed to be reported or investigated in an abuse form because she had not see the video to suspect allegations of abuse. The DON stated the care provided by CNA A to Resident #1 during the video was aggressive and rough. The DON stated if CNA A stated she was not allowed in Resident #1's room that was at her own preference. The DON stated she did not remove CNA A from the 6AM to 6PM schedule to 6PM to 6AM and from hall 400 to hall 100 related to the Resident #1's family members grievance. The DON stated that schedule and hall change was related to CNA A's inability to get along with a co-worker. The DON stated CNA A had been educated on abuse and neglect but often refused to sign the sign-in sheet because she was not allowed to write a statement on the sign in sheet. During an interview on 10/16/2024 at 08:41 PM, the Administrator stated he was the abuse coordinator for the facility and responsible to investigate and report any and all abuse allegations. The Administrator stated the importance of reporting and investigation timely was to prevent any further harm or harm to residents. The Administrator stated he had not seen any of the videos nor had the ADON B or the DON to his knowledge. The Administrator stated he did not tell the Ombudsman they had seen the videos prior to the care plan meeting. The Administrator stated he was not aware Resident #1's family member had videos during the meeting to be viewed. The Administrator stated he could recall from the care plan meeting Resident #1's family member stated, do not put words in my mouth when the DON asked are you alleging abuse. The Administrator stated the care provided to Resident #1 by CNA A was aggressive. The Administrator stated he should report and suspicion of abuse and then implement an investigation per the abuse policy. Record review of an in-service, dated 07/07/2024, provided by ADON B and the DON regarding the following topics: Resident #1's care - Respect resident's personal belongings and personal space, do not talk over resident or exclude resident while in conversations, attend physical therapy in-service regarding lifts/transfers, contact family with medication changes, continue to encourage resident to feed self, always use two employees for resident care, with all changes, notify the charge nurse and charge nurse to notify Resident #1's family member. The in-service indicated 14 staff members signed the in-service. CNA A was not included on the sign in sheet . Record review of an in-service, dated 06/10/2024, provided by the DON, regarding Sit-to-Stand Lift Usage Training and CNA skills review for transfers reflected 21 staff members signed the in-service. CNA A was included on the sign in sheet. Record review of an in-service, dated 06/11/2024, provided by the DON, regarding Hoyer Lift Usage and check offs training reflected 16 staff members signed the in-service. CNA A was included on the sign in sheet. Record review of an in-service, dated 06/11/2024, provided by DON, regarding Incontinence care for all residents training reflected 14 staff members signed the in-service. CNA A was included on the sign in sheet. Record review of the personnel chart of CNA A reflected completion of Abuse and Neglect training upon hire date of 09/15/2020 and yearly thereafter. The following Associate Disciplinary Memorandums for CNA A: 10/16/2024 regarding throwing soiled briefs on the floor of resident's room, 08/09/2024 regarding leaving shift without prior approval, 04/05/2024 regarding leaving shift without prior approval, 04/04/2024 regarding leaving shift without prior approval, 09/15/2022 regarding tardiness for shifts. 08/22/2022 regarding incompletion of timely monthly Relias training. Record review of the schedule, dated 06/07/2024, reflected CNA was scheduled to work hall 400 from 6AM to 6PM. Record review of CNA A's Employee Timecard report, dated 06/07/2024, time reporting period was created on 10/22/2024 by the BOM. The report indicated CNA A worked: 06/07/2024 05:29 AM to 12:44 PM 06/07/2024 02:33 PM to 17:00 PM Record review of Resident #1's care plan meeting, dated 06/11/2024 at 11:00AM, and signed by the Social Worker and approved by ADON B. The participants of Resident #1's care plan meeting included the Administrator, DON, ADON B, Dietary Manager, Social Worker, Activity Director, Director of Rehabilitation, Resident #1's family member and the Ombudsman. Social Services Summary (7a) reflected Resident #1's family member voiced concerns with care and sit to stand procedures. Family is updated on recent in-services and re-education with staff regarding problems and concerns. 9. Resident/Family concerns expressed during care plan concerns reflected: Staff rough when getting out of bed, can't hold bar on sit to stand at times, can't always open hands .CNA A not be back in Resident #1's room. Record review of the facility's policy, titled Abuse, Neglect and Exploitation, last revised on 10/24/2022, reflected, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .' Protection of Resident The facility makes efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. B. Physical exam of the alleged victim for any sign of injury such as a. physical harm, b. pain, c. mental anguish, or d. emotional distress including a psychosocial assessment if needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 17 residents (Resident #1) reviewed for abuse and neglect. The facility failed to report to Health and Human Services Commission Resident #1's family member's allegation that CNA A roughly provided incontinent care to the resident on 06/07/2024. This failure could place residents at risk for abuse, humiliation, intimidation, fear, shame, agitation, and a decreased quality of life. Findings include: Record review of a Grievance/Complaint Report dated 06/07/2024 received by ADON B indicated Resident #1's family member requested gentle movements of his legs during care. Documented facility follow-up action was to in-service staff members with 1:1 education and physical therapy in-service regarding transfer of resident out of bed. Record review of Resident #1's face sheet dated 10/17/2024, indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses which include dementia (a group of thinking and social symptoms that interferes with daily functioning), congestive heart failure (a chronic condition where the heart does not pump blood as well as it should), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), hypertension (high blood pressure), protein-calorie malnutrition the state of inadequate intake of food), cramp and spasm, pain in thoracic spine (the middle section of the back), muscle wasting, lack of coordination, cognitive communication deficit. Record review of Resident #1's Quarterly MDS assessment dated [DATE], indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 12, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated functional limitation on both sides of upper and lower extremities and dependent for assistance with transfers, toileting, shower, upper and lower body dressing, and personal hygiene. Record review of Resident #1's comprehensive care plan dated 10/01/2024, indicated Resident #1 had activities of daily living self-care performance deficit and was at risk for not having his needs met in a timely manner. The care plan goal included resident to maintain a sense of dignity by being clean, dry, odor free and well-groomed through the next review date. The interventions included the following: up to dining room as tolerated or permitted by family, provide shower, shave, oral care, hair care, and nail care per schedule when needed, encourage resident to participate to fullest extent, encourage resident to use call light to call for assistance before attempting any activities of daily living. During an observation on 10/15/2024 at 12:10 PM of a ring video date stamped 06/07/2024. with muffled audio and visual revealed Resident #1 lying in the middle of the bed on his back with the bed in a flat position. CNA A and CNA C provided incontinent care to Resident #1. In attempts to roll Resident #1 onto his right-side CNA A pushed Resident #1 with one hand on his hip and the other on his upper torso, when Resident #1 did not roll onto his right side she used more force and repeatedly and aggressively pushed on his buttocks and mid back to get him to stay on his right side. CNA C did not attempt to assist CNA A with rolling Resident #1 onto his right-side. Once Resident #1 was on his right-side CNA C held Resident #1 so he would stay on his side. CNA A snatched the soiled brief out from under Resident #1 and threw it from where she stood on his left side to the trash can across the bed on the right side of the room. CNA A stuck a clean brief under Resident #1 then hastily tugged and pulled Resident #1 to the left side towards her by his upper left shoulder and posterior upper left leg causing Resident #1 's legs to come off the side of the bed swiftly. During an interview on 10/15/2024 at 12:45 PM, Resident #1 stated he had been handled roughly by two staff members at the facility. Resident #1 stated he did not know the names of the staff, but he knew that one aide continued to work at the facility after the incident that occurred on 06/07/2024 but not on his hall. Resident #1 said he had seen the aide around the dining area on several occasions. Resident #1 said he had not seen the other aide in a good while, so he was not sure if she worked at the facility any longer. Resident #1 said it scared him when CNA A provided care because the movement was rough and fast and made him feel unsafe like he was going to fall out of bed onto the floor. Resident #1 stated the staff started to use the Hoyer lift today, but they usually did not. During an interview on 10/15/2024 at 01:21 PM, Resident #1's family member stated she was very upset upon viewing the camera video of how rough the aide was during the incontinent care and transfer. Resident's #1's family member stated she immediately contacted ADON B and the DON regarding the unnecessary roughness used when providing care to Resident #1 on 06/07/2024. Resident #1's family member said she provided ADON B and the DON with the two videos which included incontinent care and a transfer. She said the video with the incontinent care showed all the aggressiveness and roughness by CNA A. Resident #1's family member said the second video showed the aide getting the nurse to help Resident #1 get up to hold his walker because he was having difficulty opening his hand. Resident #1's family member stated ADON B and the DON both stated they could not see the videos that the screens were just black. Resident #1's family member stated she offered to come to the facility on this date and show the DON the videos and the DON declined the offer. Resident #1's family member stated she did not know the aides name that provided the care so aggressive and roughly. Resident #1's family member stated to her knowledge CNA A had not been back into Resident #1's room since she reported the incident except for one time the around or about 06/10/2024 in the AM. Resident #1's family member stated she had seen CNA A in the facility on a different hall on several occasions after the incident. Resident #1's family member stated a care plan meeting was held on 06/10/2024 after the incident on 06/07/2024, at her request. Resident #1's family member stated she offered again to review the videos with the Administrator, DON, and ADON B wherein the offer was declined. Resident #1's family member stated during the meeting she verbally requested CNA A not be allowed in Resident #1''s room any longer. Resident #1's family member stated the roughness that took place in the video dated 06/07/2024 by CNA A was discussed and documented in the care plan notes. During an interview on 10/16/2024 at 12:15 PM, the Administrator stated the Grievance by Resident #1's family member was not reported to HHSC and there was not a Provider's Investigation Report. The Administrator stated he was the abuse coordinator for the facility. During an interview on 10/16/2024 at 12:30 PM, the Ombudsman stated Resident #1's family member stated during the care plan meeting that Resident #1 was handled roughly while care was being provided. The Ombudsman stated Resident #1's family member offered to review the videos at that time of the incident on 06/07/2024 wherein the Administrator stated that the DON and ADON B had already seen the videos. During an interview on 10/16/2024 at 07:35 AM, CNA D stated she had worked at the facility for 2 years and most of that time was on Hall 400. CNA D stated she was recently educated on abuse and neglect probably 2 maybe 3 weeks ago. CNA D was able to identify the types of abuse. CNA D stated physical abuse would include hitting or forcibly pushing or touching a resident. CNA D said any suspicion or abuse allegations should be reported immediately to the Abuse Coordinator/Administrator. CNA D stated when she provides care to a resident such as incontinent care or repositioning, she utilized the draw sheet to prevent injury to the residents. CNA D said the residents' skin is mostly fragile, so it is best to not have skin to skin friction to prevent any injuries. CNA D stated she had seen CNA A swing Resident #1''s legs out of the bed but not in a quick manner. CNA D stated CNA A used to work hall 400 and take care of Resident #1. CNA D stated Resident #1 told her he did not want to stand anymore because he was scared because CNA A was rough with him. CNA D said if she saw any type of abuse including being rough, she would immediately protect the resident and report the abuse. CNA D said she recalled when Resident #1 said he was scared, and CNA A was moved to another hall. CNA D said in-services were provided by the DON and ADON B. CNA D was shown the video of incontinent care provided to Resident #1 dated 06/07/2024 and gasped. CNA D identified the staff as CNA A on the left side of Resident #1 and CNA C on the right side and quickly turned away and stopped watching the video. CNA D stated the care provided by CNA A was aggressive, harsh and rough and made her sick to her stomach. CNA D stated it was abuse and should have been reported immediately. During a telephone interview on 10/16/2024 at 1:35 PM, CNA C stated she resigned her position with the facility 06/25/2024 due to several health problems. CNA C stated she had been a CNA since 2016. CNA C said she had never had any allegation of abuse against her. CNA C said the facility had frequent in-services regarding abuse and neglect usually monthly. CNA C stated any type of rough handling such as tugging/pulling or pushing would be considered abuse and she would immediately report to the abuse coordinator. CNA C said she utilized the draw sheet to reposition residents for care. CNA C stated she recalled a time when she asked CNA A to help her with Resident #1. However, CNA A stated she was not allowed in Resident #1's room or to help with his care any longer. CNA C stated she worked with Resident #1 until she departed from the facility. CNA C denied any issues involving Resident #1's care. During an interview on 10/16/2024 at 06:35 PM, CNA A stated she had worked at the facility for approximately 4 years. CNA A stated she had been in-serviced on abuse and neglect within the last 30 days. CNA A stated the DON and ADONs provided in-services on abuse and neglect usually to cover themselves from the state. CNA A stated if a resident accused the facility or staff of something like abuse then the staff got in-serviced. CNA A stated she had allegations of abuse made against her but only by a resident that did not like her or a staff member saying she was rough because that was their perception. CNA A stated sometimes nobody can help you, so you do what you got to do to hold up the resident. CNA A stated that being rough with a resident is considered abuse. CNA A stated moving fast can be perceived as being rough handling. CNA A stated the resident could be scared or resistant to care if care was provided too roughly or quick. CNA A said that could decrease their quality of life if the resident was not getting adequate care. CNA A stated she had heard that CNA E and CNA F had been rough handling residents. CNA A stated she did not know the residents, nor the co-workers involved with the allegations against CNA E or CNA F. CNA A denied ever seeing or suspecting abuse or rough handling. CNA A stated she would report any allegations of abuse to the Administrator. CNA A stated all suspected abuse should immediately be reported to the Administrator, so the resident was protected. CNA A stated she worked the 6PM to 6AM shift on hall 100. CNA A stated she preferred to be on days but got moved to the night shift because the DON is picking and she was not aware of why the shifts got changed. CNA A stated as she provided incontinent care or repositioned a resident, she always used the draw sheet to prevent any bruises to the resident's skin. CNA A stated she would let the resident know what care she was going to provide prior to doing the care. CNA A stated it was important to let the resident know so they would not be scared. CNA A was shown the video dated 06/07/2024. CNA A identified CNA C in the video immediately. CNA A stated the care being provided was rough and was considered abuse. CNA A was hesitant to answer the surveyor on the identity of the second CNA in the video. CNA A stared at the video and finally responded that it looked like her but what did the surveyor think. CNA A stated quietly the more I look at it, damn - I think it is me, but I don't have that kind of hair - it might be CNA G. CNA A continued to stare at the video on replay. Attempted telephone call to CNA G on 10/16/2024 at 07:52PM was unable to leave a voice message (currently, CNA G was on medical leave). During an interview on 10/16/2024 at 08:00 PM, the staffing coordinator identified the two CNAs in the video dated 06/07/2024 as CNA A and CNA C. The staffing coordinator stated the actions by CNA A in the video were aggressive and uncalled for and could have resulted in harm to Resident #1. The staffing coordinator stated there was no reason to be using that much force and Resident #1's lower extremities should not have flew off the bed. During an interview on 10/16/2024 at 8:07 PM, ADON B stated she had been educated and trained on abuse and neglect. ADON B stated she had also provided training on abuse and neglect for the facility to the staff. ADON B was able to identify the types of abuse. ADON B stated rough handling could be considered abuse depending on situation such as some residents are stiff and required more strength to move them. ADON B stated abuse should be reported to the Abuse Coordinator/Administrator immediately to allow a proper investigation to be conducted to protect the residents. ADON B denied any allegation of abuse or rough handling being reported to her on any resident specifically Resident #1. ADON B stated Resident #1's family member attempted to send the videos for viewing but she was never able to see the videos due to the screen was black and the video did not play. ADON B stated Resident #1's family member did not ever use the words handled roughly when she received the grievance dated 06/07/2024. ADON B stated she never viewed either video sent to her because she could not get them to play. ADON B viewed the video dated 06/07/2024 with the surveyor and became tearful and identified the aides in the video as CNA A and CNA C. ADON B stated CNA A was being too rough with Resident #1 during the incontinent care and the draw sheet should have been used to prevent the excessive pushing. During an interview on 10/16/2024 at 8:20 PM, the DON said the Administrator was the abuse coordinator. The DON stated she had been educated and trained on abuse and neglect. The DON stated she had also provided training on abuse and neglect for the facility to the staff. The DON was able to identify the types of abuse. The DON stated abuse should be reported to the Abuse Coordinator/Administrator immediately to allow a proper investigation to be conducted to protect the residents from any further or potential abuse. The DON stated she had not viewed the videos because they would not show on her phone that the screen was black and blank. The surveyor requested to see the videos on the phone received from Resident #1's family member. Upon opening the video and pushing play, the video started playing of the transfer until the end of the video stopped. The DON stated she had watched the transfer video but could not hear any audio. The DON said the transfer of Resident #1 was the only video she received. The DON said she told Resident #1's family member that she had only received one video. The DON stated that Resident #1's family member said she would resend the other video, but the DON said she never received it. The DON stated she asked for the second video again, but she had not received it. The DON stated she never declined Resident #1's family member's offer to show her the videos. The DON stated it was important to follow up on these allegations to protect the residents. The DON stated that Resident #1 never used the term rough, rough handling, snatched, pulled, pushed to give any indication of abuse to be suspected. The DON said even suspected allegations of abuse should be reported and acted upon. The DON said during the care plan meeting with Resident #1's family member, she asked Resident #1's family member, are you saying this is abuse? The DON stated Resident #1's family member said, don't put words in my mouth. Therefore, the DON stated she did not feel this needed to be reported or investigated in an abuse form because she had not seen the video to suspect allegation of abuse. The DON stated the care provided by CNA A to Resident #1 during the video was aggressive and rough. The DON stated if CNA A stated she was not allowed in Resident #1's room that was at her own preference. The DON stated she did not remove CNA A from the 6AM to 6PM schedule to 6PM to 6AM and from hall 400 to hall 100 related to the Resident #1's family members grievance. The DON stated that schedule and hall change was related to CNA A's inability to get along with a co-worker. During an interview on 10/16/2024 at 08:41 PM, the Administrator stated he was the abuse coordinator for the facility and responsible to investigate and report any and all abuse allegations. The Administrator stated the importance of reporting and investigation timely is to prevent any further harm or harm to residents. The Administrator stated he had not seen any of the videos nor had the ADON B or the DON to his knowledge. The Administrator stated he did not tell the Ombudsman that they had seen the videos prior to the care plan meeting. The Administrator stated he was not aware that Resident #1's family member had videos during the meeting to be viewed. The Administrator stated he can recall from the care plan meeting Resident #1's family member stating, do not put words in my mouth when the DON asked are you alleging abuse. The Administrator stated the care provided to Resident #1 by CNA A was aggressive. The Administrator stated he should report and suspicion of abuse and then implement an investigation per the abuse policy. Record review of the facility's policy, titled, Abuse, Neglect and Exploitation, last revised on 10/24/2022, reflected, . 1. Reporting allegations involving staff to-resident abuse, resident-to resident altercations, injuries of unknown source, misappropriation of resident property/exploitation, and mistreatment. 2. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 3. Assuring that reporters are free from retaliation or reprisal. . B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies Administrator .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #1) reviewed for infection control practices. 1. CNA A failed to change her gloves and perform hand hygiene after removing Resident #1's soiled brief on 06/07/2024. 2. CNA A failed to dispose of Resident #1's soiled brief properly after removing it during incontinent care on 06/07/2024. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings include: Record review of Resident #1's face sheet dated 10/17/2024, indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses which include dementia (a group of thinking and social symptoms that interferes with daily functioning), congestive heart failure (a chronic condition where the heart does not pump blood as well as it should), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), hypertension (high blood pressure), protein-calorie malnutrition the state of inadequate intake of food), cramp and spasm, pain in thoracic spine (the middle section of the back), muscle wasting, lack of coordination, cognitive communication deficit. Record review of Resident #1's Quarterly MDS assessment dated [DATE], indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 12, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated functional limitation on both sides of upper and lower extremities and dependent for assistance with transfers, toileting, shower, upper and lower body dressing, and personal hygiene. Record review of Resident #1's comprehensive care plan dated 10/01/2024, indicated Resident #1 had activities of daily living self-care performance deficit and was at risk for not having his needs met in a timely manner. The care plan goal included resident to maintain a sense of dignity by being clean, dry, odor free and well-groomed through the next review date. The interventions included the following: up to dining room as tolerated or permitted by family, provide shower, shave, oral care, hair care, and nail care per schedule when needed, encourage resident to participate to fullest extent, encourage resident to use call light to call for assistance before attempting any activities of daily living. During an observation on 10/15/2024 at 12:10 PM of a video, date stamped 06/07/2024, revealed CNA A and CNA C provided incontinent care to Resident #1. Once Resident #1 was on his right-side CNA C held Resident #1 so he would stay on his side. CNA A snatched the soiled brief out from under Resident #1 and threw it from where she stood on his left side to the trash can across the bed on the right side of the room. CNA A used a wipe across Resident #1 peri area and threw the dirty wipe behind her onto the floor. CNA A stuck a clean brief under Resident #1 then hastily tugged and pulled Resident #1 to the left side towards her by his upper left shoulder and posterior upper left leg causing Resident #1 's legs to come off the side of the bed swiftly. CNA A did not change her gloves and perform hand hygiene after removing Resident #1's soiled brief and continued to touch the resident and other surfaces with the contaminated gloves . During an interview on 10/16/2024 at 06:35 PM, CNA A stated she had worked at the facility for approximately 4 years. CNA A stated she was in-serviced on incontinent care on several occasions probably in the last few weeks. CNA A stated the DON and ADONs provided in-services on incontinent care usually to cover themselves from the state. CNA A stated she had residents accuse her of not doing incontinent care the right way because she was fast. CNA A stated she would let the resident know what care she was going to provide prior to doing the care. CNA A stated it was important to let the resident know so they would not be scared. CNA A stated she always took extra supplies into the resident's room for incontinent care such as trash bags, gloves and wipes. CNA A stated she placed the extra trash bag inside the trash can. CNA A stated she would put the trash can beside her on the floor next to the bed to prevent spreading any germs and infections while getting rid of the soiled diaper. CNA A stated she changed her gloves after cleansing her hands with hand sanitizer between dirty and clean diapers before touching any other surfaces or the resident. CNA A stated once she changed her gloves or took them off and put it in the trash, she would reposition the resident in the bed. CNA A said, she would gather the trash bag with the dirty diaper and remove it from the resident's room. CNA A stated the purpose of preventing cross contamination was to keep the residents healthy. CNA A was shown the video, dated 06/07/2024, CNA A identified CNA C in the video immediately. CNA A stated the incontinent care being provided to Resident #1 was done incorrectly and throwing a soiled brief over the resident across the room was cross contamination and an infection control issue. CNA A stated peri care was not performed in the correct manner and the resident was at a risk of infection such as a UTI from not properly cleaning the private area. CNA A stated the gloves should have been changed between dirty and clean diaper changes and hand hygiene should have been performed to prevent cross contamination. Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 17 residents (Resident #1) reviewed for abuse and neglect. During an interview on 10/16/2024 at 8:20 PM, the DON said she was the Infection Control Preventionist and ultimately responsible for infection control procedures. The DON said she, the charge nurses, the ADONs were responsible for ensuring the CNAs were performing adequate hand hygiene and infection control measures during incontinent care. The DON said she completed 1:1 skill checks off during in-servicing on incontinent care recently. After viewing the video, dated 06/07/2024, the DON stated CNA A had not followed the infection control policy for incontinent care, The DON said it was important to perform hand hygiene, practice proper infection control measures while performing incontinent care because the residents could get a urinary tract infection and sepsis (infection in the bloodstream) and spread other infections. During an interview on 10/16/2024 at 08:41 PM, the Administrator said he expected all the staff to follow the policy on hand washing, changing gloves, and proper incontinent care to prevent any infection risk to the residents. After viewing the video, dated 06/07/2024, the Administrator stated CNA A had not followed the infection control policy for incontinent care. Record review of the facility's policy titled infection Prevention and Control Program, updated on 3/26/2024, reflected Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

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 promoted maintenance or enhancement of his or her quality of life for 1 of 20 (Resident #33) residents reviewed for resident rights. The facility failed to ensure RN D fed Resident #33 while sitting down. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. Findings included: During a dining observation on 09/25/2023 at 11:57 a.m., RN D was standing up while feeding Resident #33 green peas and a piece of cod fish. During an interview on 09/25/2023 at 2:29 p.m., Resident #33 was non-interviewable as evidenced by confused conversation. During a telephone interview on 09/27/2023 at 3:13 p.m., RN D stated she knew she had to sit at eye level while feeding Resident #33, but she was the nurse for the dining room and had to oversee all residents. RN D further stated Resident #33 was blind and had to be assisted with his meals. RN D stated it was important to treat residents with dignity and respect. During an interview on 09/27/2023 at 4:38 p.m., the DON stated she expected RN D to sit at eye level while assisting the resident with lunch. The DON stated rounds were made randomly during mealtimes to ensure that infection control was followed, and the residents are not having dignity issues while being assisted. The DON stated her last round was 9/22/23. The DON stated no issues was noted during rounds. The DON stated if issues were noted staff was verbally corrected. The DON stated it was important to treat residents with dignity and respect because it was their rights and dignity need to remain intact. During an interview on 09/27/2023 at 8:54 p.m., the Administrator stated he expected staff to sit at eye level while assisting with meals. The Administrator stated it was important to treat residents with dignity and respect. Record review of the facility's policy titled Promoting/Maintaining Residents Dignity last reviewed on 02/16/2020, indicated, It is the practice of the facility to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect 1. All staff members are involved in providing care to residents to promote and maintain resident dignity 5. When interacting with a resident, pay attention to the resident as an Individual .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 1 of 5 residents reviewed for the right to be informed. (Resident #2 and Resident #33) 1. The facility failed to ensure Resident #2 had a signed psychotropic consent form for alprazolam (antianxiety medication), Belsomra (sedative-hypnotic medication), and Remeron (antidepressant medication). 2. The facility did not ensure Resident #33 had a signed informed consent based on information of the need, benefits, and risk prior to administering Ativan (a medication used to treat anxiety). These failures could place residents at risk for treatment or services provided without their informed consent. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #2 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of recurrent depressive disorders (episodes of depression after periods of time without symptoms), anxiety disorder (characterized by significant and uncontrollable feelings of anxiety and fear), and unspecified atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Record review of the MDS assessment, dated 06/30/2023, revealed Resident #2 had clear speech and was understood by staff. The MDS revealed Resident #2 was able to understand others. The MDS revealed Resident #2 had a BIMS of 5, which indicated severe cognitive impairment. The MDS revealed Resident #2 had a PHQ-9 score of 1, which indicated minimal depression. The MDS revealed Resident #2 had no behaviors or refusal of care. The MDS revealed Resident #2 took an antidepressant and antianxiety medications 7 out of 7 days during the look-back period. Record review of the comprehensive care plan, revised on 05/23/2023, revealed Resident #2 used psychotropic medications (antidepressants and antianxiety). Record review of the order summary report, dated 09/26/2023, revealed Resident #2 had an order, which started on 07/07/2023, for alprazolam (an antianxiety medication). The order summary report revealed an order, which started on 07/05/2023, for Belsomra (a sedative-hypnotic medication). The order summary report further revealed an order, which started on 09/19/2023, for Remeron (an antidepressant medication). Record review of the MAR, dated September 2023, revealed Resident #2 received Belsomra, Remeron, and alprazolam as ordered by the physician. Record review of the electronic medical record, accessed on 09/27/2023 at 4:40 PM, revealed no consent forms for Belsomra, Remeron, or alprazolam. Record review of the Antipsychotic Binder 2023, accessed on 09/27/2023 at 4:42 PM, revealed no consent forms for alprazolam, Remeron, or Belsomra. During an observation and interview on 09/25/2023 at 9:36 AM, Resident #2 was sitting up in her recliner with hair combed and clothing neat and clean. Resident #2 was pleasant during interview. Resident #2 stated she was aware she was taking several psychotropic medications including one that increased her appetite. Resident #2 stated she also took a few other medications but could not recall the names. Resident #2 stated she could not remember if she signed a consent form but stated she needed her medications. During an interview on 09/27/2023 at 7:28 PM, RN R stated she recently started working for the facility in August 2023. RN R stated she was unsure who was responsible for completing the psychotropic consent forms, but she assumed it was the admission nurse. RN R stated she had not completed any admissions since starting work at the facility. RN R stated an informed consent form should have been obtained for an antidepressant, antianxiety, sedative-hypnotic, and antipsychotic medications prior to the medication being administered. RN R stated it was important to ensure psychotropic medication consent forms were obtained prior to administering the medications to ensure the resident had given consent and knew the risks and benefits. During an interview on 09/27/2023 at 7:46 PM, ADON V stated the ADONs, and DON were responsible for ensuring psychotropic consent forms were obtained prior to administering the medications. ADON V stated when a resident was admitted to the facility, the ADONs or DON would have filled out a consent form and printed it off in advanced. ADON V stated the nurses were responsible for ensuring the printed consent form was signed. ADON V stated a consent from should have been obtained for Resident #2's Belsomra, Remeron, and alprazolam. ADON V stated the consent forms were missing because of a probable oversight. ADON V stated it was important to ensure consent forms were completed prior to administering medications so that resident's and their family were aware of the medication, side effects, risks, and benefits. ADON V stated it was important so the residents could have made an informed decision. During an interview on 09/27/2023 at 8:35 PM, the DON stated the ADONs, and the DON was responsible for ensuring psychotropic consent forms were completed. The DON stated part of the admission process was reviewing the medication list for psychotropic medications. The DON said the consent forms were filled out in advanced and printed off to be signed by the admitting nurse. The DON stated Resident #2 was missing consent because it was an oversight. The DON stated the consent forms for Resident #2 were being completed since she was made aware. The DON stated it was important to ensure psychotropic consent forms were obtained prior to administering the medications so the resident was aware of the medication, side effects, risks, and benefits. The DON stated it was important so the residents could have made an informed decision. During an interview on 09/27/2023 at 9:07 PM, the Administrator stated he expected psychotropic consent forms to be obtained prior to administering psychotropic medications. The Administrator stated nursing management was responsible for monitoring psychotropic consent forms. The Administrator stated it was important to ensure psychotropic consent forms were obtained prior to administering the medications to ensure the residents were informed of the risks and benefits and provided informed consent. 2. Record review of Resident #33's face sheet, dated 09/27/2023, indicated Resident #33 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included Parkinson's (brain disorder that causes unintended or uncontrollable movements) and anxiety disorder. Record review of the order summary report dated 09/27/2023 indicated Resident #33 had an order for Ativan (antianxiety) with a start date 09/16/2023. Record review of the significant change in status MDS assessment, dated 08/28/2023, indicated Resident #33 made himself understood and usually understood others. The assessment indicated Resident #33 had a BIMS of 2, which indicated his cognition was severely impaired. The assessment indicated Resident #33 had trouble concentration on things, such as reading the newspaper or watching television 2-6 days during the 14-day look-back period. The assessment indicated Resident #33 had no behaviors or refusal of care. The assessment did not indicate Resident #33 received an antianxiety medication during the look-back period. Record review of the comprehensive care plan, revised on 03/05/2023, indicated Resident #33 used psychotropic medications related to depression and generalized anxiety disorder. The care plan interventions included review GDR as needed, administer medications as ordered and monitor and document for side effects effectiveness. Record review of the MAR dated 09/01/2023-09/30/2023 indicated Resident #33 received Ativan on 09/17/2023, 09/20/2023, 09/21/2023 and 09/25/2023. Record review of the facility's electronic charting system on 09/27/2023 did not reveal a consent form signed by the resident or resident representative signature. During an observation and interview on 09/25/2023 at 2:29 p.m., Resident #33 was sitting in his wheelchair watching television, no s/sx of anxiety observed or adverse effects. Resident #33 was non-interview able as evidenced by confused conversation. During a telephone interview on 09/27/2023 at 5:56 p.m., Resident #33's family member stated she received a phone call on 09/27/2023 indicating Resident #33 received Ativan for anxiety. Resident #33's family member stated she was explained the risk and benefits of the medication. During an interview on 09/27/2023 at 4:38 p.m., the DON stated her and the ADON's were responsible for ensuring consent forms were signed prior to administering, such as antianxiety. The DON stated a consent form should have been obtained for Resident #33's Ativan. The DON stated she was unsure why the consent was not obtained. The DON stated her and the ADON were responsible for monitoring to ensure the consent forms were kept up to date. The DON stated it was important to ensure consent forms were obtained to make sure the family and residents were aware of the medication, side effects and to ensure their rights were respected. During an interview on 09/27/2023 at 8:54 p.m., the Administrator stated he expected consents to be signed prior to administration. The Administrator stated it was important to ensure consent forms were obtained to make sure the family and residents were aware of the medication, side effects and to ensure their rights were respected. Record review of the facility's policy titled Antipsychotic Medication last reviewed on 02/10/2020, indicated, It is the facility's policy that each resident's drug regimen is free from unnecessary drugs, including unnecessary antipsychotic drugs 12. Consents will be obtained as per state guidelines .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 2 of 18 residents reviewed for advanced directives. (Resident #10 and Resident # 73) The facility failed to ensure Resident #10 and Resident # 73's code status was accurate and consistent with all records at the facility. This failure placed the residents at risk of not having their end of life wishes honored. Findings included: Record review of Resident #10's face sheet dated 9/26/23, revealed Resident #10 was a [AGE] year-old female with a diagnose of vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls), hypertension (when the pressure in your blood vessels is too high (140/90 mmHg or higher), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs) osteoarthritis (degeneration of joint cartilage and the underlying bone) diverticulosis (a condition that occurs when small pouches, or sacs, form and push outward through weak spots in the wall of your colon) Record review of Resident #10's MDS dated [DATE] indicated Resident #10 was able to understand and was understood by others. The MDS indicated Resident #10 had a BIMS score of 15. The assessment indicated Resident #10 required limited assistance with bed mobility, dressing, toilet use and personal hygiene and was independent with transfers, walking, and eating. Record review of Resident #10's care plan dated 3/25/21 with an update of the care plan on 1/11/2022 indicated Resident #10 had requested a code status of do not resuscitate. The goal was her wishes regarding her code status will be maintained on an ongoing basis by the staff being informed of his code status, and to make changes to her code status at her request. Record review of Resident #10's physician order summary report, dated 9/22/23, indicated an active physician's order for code status: DNR with an order date 3/3/2021. Record review of Resident #10's OOH-DNR dated 1/12/2016 revealed missing signature of responsible party and missing signature of witnesses. Record review of Resident #73's face sheet dated 9/26/23, revealed Resident #73 was an [AGE] year-old male with a diagnose of chronic obstructive systolic and diastolic heart failure (In systolic heart failure, the heart muscle is weak, and the ventricle can't contract normally. With diastolic heart failure, the heart muscle is stiff, and the left ventricle can't relax normally), chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional), atherosclerosis of the right leg (occurs due to narrowing of the arteries in the legs), gout (a disease in which defective metabolism of uric acid causes arthritis), gastroesophageal reflux disease (a common condition in which the stomach contents move up into the esophagus). Record review of Resident #73's MDS dated [DATE], indicated Resident #73 was able to understand and was understood by others. The MDS indicated Resident #73 had a BIMS score of 15. The assessment indicated Resident #73 required assistance with bed mobility, dressing, toilet use and personal hygiene, transfers, walking, and eating. Record review of Resident #73's care plan dated 9/6/23, indicated Resident #73 had requested a code status of do not resuscitate. The goal was her wishes regarding her code status will be maintained on an ongoing basis by the staff being informed of his code status, and to make changes to her code status at her request. Record review of Resident #73's physician order summary report, dated 9/4/23, indicated an active physician's order for code status: DNR with an order date 10/11/22. Record review of the Resident #73's OOH-DNR dated 5/26/22, revealed missing date of witness. During an interview on 9/27/2023 at 5:13 PM, the Social Worker stated she was she was responsible for ensuring DNRs were accurately completed and documented. The Social Worker stated the DNR was missing a missing signature by the responsible party and witnesses. The Social Worker stated anytime the DNR was not completed it isn't legal. During an interview on 9/27/23 at 9:00 PM, the Administrator stated he expected DNRs to be filled out, including signatures and dates. The Administrator stated the Social Worker was ultimately responsible for ensuring the DNRs were completed fully. The Administrator stated ensuring the DNRs were completed was important to make sure the resident's and family wishes were honored. Record review of the facility's policy titled, Emergency Management: Identification Code Status dated 4/21/2015 revised 1/25/21 indicated, To establish a process for filling and posting patient information in the clinical record so that an accurate code status and advanced directives can be accessed quickly during an emergency

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 2 of 20 (Residents #46 and #135) residents reviewed for notification of change of condition. 1. The facility did not ensure RN D notified the physician when Resident #46 fell on [DATE]. 2. The facility failed to notify and consult with the physician about the changes in Resident #135's fall. This failure could place residents at risk of a delay in treatment, and a worsening of their condition. Findings included: 1. Record review of Resident #46's face sheet, dated 09/27/2023, indicated Resident #46 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included fracture of right femur (the bone of the thigh) and essential hypertension (high blood pressure). Record review of the Quarterly MDS assessment, dated 08/18/2023, indicated Resident #46 sometimes made himself understood, and usually understood others. The assessment indicated Resident #46 had a BIMS of 6, which indicated his cognition was severely impaired. The assessment indicated Resident #46 had 1 fall since admission /entry or reentry or the prior assessment. Record review of the comprehensive care plan, revised on 08/16/2021, indicated Resident #46 had a potential for fall related to poor balance, history of falls prior to admits, poor safety awareness and weakness. The care plan interventions included anticipate and meet the resident's needs, fall risk screening upon admission and quarterly to identify risk factors and floor mat. Record review of the incident report dated 08/04/2023 at 11:12 a.m., indicated Resident #46 was called to the room by a CNA. The report indicated Resident was on a pad on the floor bedside the bed. The report indicated no apparent injury, assisted Resident #46 to the recliner. Record review of the facility's electronic charting system, accessed on 09/27/2023, revealed there was no documentation of notification made to the physician. During an interview won 09/27/2023 at 3:13 p.m., RN D stated Resident #46 was found on the floor on the right side of the bed on the floor mat by his family member. RN D stated she completed a head-to-toe assessment with no injuries noted at that time. RN D stated she should have contacted the physician after the fall. RN D stated that day was so bad. RN D stated it just slipped my mind. RN D stated it was important notify the physician to ensure Resident #46 wellbeing and safety. During a telephone interview on 09/27/2023 at 3:33 p.m., Physician W stated he expected to be notified when Resident#46 had a fall. Physician W stated if he would have been notified, an x-ray to the pelvis would have been ordered. Physician W stated it was important to notify the physician so he could rule out trauma and/or abuse. During an interview on 09/27/2023 at 4:38 p.m., the DON stated she expected the physicians to be notified immediately after the fall. The DON stated RN D was responsible for notifying the physician when Resident #46 fell. The DON stated there was not a system prior to this incident but with this incident she had implemented an in-service/teaching on immediate notification of herself and the MD. The DON stated it was important to notify the physician for continuity of care. During an interview on 09/27/2023 at 8:54 p.m., the Administrator stated he expected RN D to contact the MD immediately after Resident #46 had a fall. The Administrator stated it was important to notify the physician to see if he would like to order anything or send the resident out. 2. Record review of Resident #135's face sheet dated 05/25/23, indicated Resident #135 was a [AGE] year-old female with a diagnose of chronic obstructive systolic and diastolic heart failure (In systolic heart failure, the heart muscle is weak, and the ventricle can't contract normally. With diastolic heart failure, the heart muscle is stiff, and the left ventricle can't relax normally), orthostatic hypotension (a condition in which your blood pressure suddenly drops when you stand up from a seated or lying position), chronic kidney disease, stage 4 (kidneys are moderately or severely damaged and are not working as well as they should to filter waste from your blood), Left Bundle-Branch Block (occurs when something blocks or disrupts the electrical impulse that causes your heart to beat. ), Hypertensive retinopathy, bilateral (is an eye condition in which high blood pressure damages the layer of tissue at the back of your eyeball (retina)), nonrheumatic aortic (valve) stenosis (a narrowing of the aortic valve opening) Record review of Resident #135's MDS dated [DATE], indicated Resident #135 was able to understand and was understood by others. The MDS indicated Resident #135 had a BIMS score of 15. The assessment indicated Resident #135 required assistance with bed mobility, dressing, toilet use and personal hygiene, transfers, walking, and eating. Record review of Resident #135's care plan dated 04/20/23, indicated Resident #135. The interventions of the care plan were to anticipate and meet the resident's needs. Place frequently used items within reach. Place call light within reach and encourage the resident to use it for assistance as needed. Review information on past falls and attempt to determine cause of falls. Educate resident and family as to causes. Record review of Resident #135's progress notes dated 05/19/23, reveals Resident #135 was sent to the emergency room on5/18/23 for chest pain, shortness of breath but no documentation regarding a fall. During an interview on 09/26/23 at 2:35 p.m., LVN X stated she was called to the room where Resident #135 was sitting on the floor. LVN X stated she took Resident #135's vitals. LVN X stated the resident said she got up and missed her chair. LVN X stated she asked Resident #135 if she wanted to go to hospital and she said no. LVN X stated she reported the fall to someone in the office, but she didn't remember who. LVN X stated she always reports her stuff, but she didn't who it was I reported it to, but it wasn't a witnessed fall. LVN X stated she always contacts the family. LVN X stated the types of abuse are verbal, sexual, mental, physical, funds. LVN X stated the administrator was our abuse coordinator. During an interview on 09/27/23 at 2:00 p.m., CNA BB stated she didn't witness the fall. CNA BB stated she went into Resident #135's room and she was sitting on the floor. CNA stated she immediately went to get the nurse. CNA BB stated they got Resident #135 up and back to her chair. CNA BB stated the nurse assessed her from head to toe. CNA BB stated Resident #135 had no complaints of pain. CNA BB stated Resident #135 said she was trying to get in chair and didn't make it. CNA BB stated she reported to LVN X. CNA BB stated the types of abuse are physical, mental, misappropriation of funds, sexual and verbal. CNA BB stated she reports abuse to the administrator. During an interview on 9/27/23 at 4:57 p.m., the DON stated Resident #135 started complaining of chest pain. The DON stated the CNA came in her office saying Resident #135 had chest pain. The DON stated she went to assess Resident #135. The DON stated she grabbed a nurse doesn't remember who the nurse was. The DON stated after assessing she made the decision to call EMS and sent her out to the hospital. The DON stated the family was then notified. The DON stated when Resident #135 got to the emergency room she had a spinal fracture. The DON stated she immediately started the investigation. The DON stated she spoke with Resident #135's niece because Resident 135's nephew was out of town. The DON stated she started interviewing people on 5/18/2023 reinterviewed on 5/22/2023 and 5/23/2023. The DON stated CNA BB told her that she was walking by and saw Resident #135 sitting on the floor. The DON stated that CNA BB asked Resident #135 if she fell, and Resident #135 said she didn't fall. The DON stated CNA BB went and got LVN X, they assessed Resident #135 and helped her to her recliner. The DON stated Resident #135 denied fall. The DON stated from what she concluded Resident #135 fell but she doesn't know the exact date. The DON stated the fall was prior to 5/18/23. The DON stated the current administrator is the abuse coordinator. The DON stated the types of abuse physical, neglect, sexual, psychosocial and misappropriation of funds. Record review of the facility's policy titled Fall Management System revised on 01/03/2017, indicated It is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on the resident's assessed needs D. Documentation requirements for residents sustaining a fall . 2. The licensed nurse will document the fall on the nurses notes of the medical record. The documentation will reflect notifications lo legal representatives and attending physician or their agent of the fall . Record review of the facility's policy titled Notification of Changes reviewed on 02/10/21, indicated To provide guidance on when to communicate acute changes in status to MD, NP, and/ responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: 1. An accident resulting in injury to the resident that potentially requires physician intervention

Based on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 3 of 20 staff members (Physical Therapist, House Keeping and Food Service Supervisor) reviewed for develop and implement abuse policies. The facility failed to ensure the Human Resource (HR) Coordinator implemented the facility's abuse/neglect policy and procedure when she failed to complete an Employee Misconduct Registry (EMR) check for CNA G upon hire and annually for the Maintenance Supervisor, Activity Director, and Food Service Supervisor. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included: Record review of the facility's Abuse, Neglect and Exploitation policy revised on 10/24/2022, indicated . It is the police of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Screening: Criminal History and Background checks . 2. All potential employees will be screened for history of abuse, neglect or mistreating of elderly/individuals as defined by the applicable requirements 483.12 (c) (1) (ii) (A) and (B). The facility will not knowingly employee individual with convictions barring employment as noted in section 250.006 of the Texas Health and Safety Code . 4. The facility will obtain verification from appropriate licensing boards and registries and maintain verification of results . 7. Employee will be screened for abuse, neglect, and exploitation of the elderly by accessing the Employee Misconduct Registry. The hiring authority will follow the automated response prompts to screen the employee for abuse, neglect, exploitation of a resident or misappropriation of resident's or consumer's misconduct registry checks on every employee . The policy did not indicate how often the EMR should be checked. Record review of Physical Therapist personnel file on 09/27/23, Indicated he was hired on 5/8/23. Physical Therapist employee misconduct registry was not completed upon hire. Physical Therapist EMR was completed on 05/15/23. Record review of House Keeping Supervisor's personnel file on 09/27/23, Indicated he was hired on 03/30/21. House Keeping Supervisor's employee misconduct registry was not completed upon hire. House Keeping Supervisor's EMR was completed on 7/20/22. During an interview with the Payroll Coordinator on 9/27/23 at 7:22 PM. The Payroll Coordinator stated employee misconduct registry should be ran monthly. The Payroll Coordinator stated the Physical Therapist was a rehire. The Payroll Coordinator stated the Physical Therapist has been employed here before. The Payroll Coordinator stated the Physical Therapist employee misconduct registry should have been done prior to his hire date but he didn't sign the new hire paperwork so she could run it. The Payroll Coordinator stated the Food Service Supervisor, and the House Keeping Supervisor's employee misconduct registry should be run annually within their hire month, The Payroll Coordinator stated she was responsible for the employee misconduct registry. The Payroll Coordinator stated she has a list of all the employees. The Payroll Coordinator stated the employee misconduct registry was supposed to be done upon hirer and annually in their hire month. The Payroll Coordinator stated she goes down the employee sheet monthly, and during evaluation she run the employee misconduct registry again. The Payroll Coordinator stated she didn't realize she was supposed to run the Food Service Supervisor and the House Keeping Supervisor employee misconduct registry. The Payroll Coordinator stated its important to make sure the employees are not on the employee misconduct registry, because it could put the residents at risk for abuse. During an interview on 09/27/23 at 9:00 PM, the Administrator stated the Payroll Coordinator was responsible for ensuring the employee misconduct registry was checked upon hire and annually. The Administrator stated it was important to check the employee misconduct registry because the employee could be on there for abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 2 of 20 residents (Resident #34 and Resident #42) reviewed for MDS assessment accuracy. The facility did not ensure Resident #34's and Resident #42's MDS assessments were accurately coded to reflect their level II PASRR (Preadmission Screening and Resident Review) status for mental illness. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of a face sheet dated 09/27/2023, indicated Resident #34 was an [AGE] year-old female initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks with hallucinations or delusions), recurrent, severe with psychotic symptoms, anxiety disorder, unspecified (mental illness defined by feelings of uneasiness, worry and fear), and unspecified atrial fibrillation (rapid, irregular heart rate). Record review of the Comprehensive MDS assessment, dated 11/25/2022, indicated Resident #34 was not considered by the state level II PASRR process to have serious mental illness. Record review of Resident #34's care plan, last revised 08/08/2023, did not address Resident #34's PASRR status. Record review of the Level II PASSR evaluation, dated 08/23/2021, indicated Resident #34 met the PASRR definition of mental illness. 2. Record review of a face sheet dated 09/27/2023, indicated Resident #42 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included bipolar disorder, in partial remission, most recent episode depressed (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), major depressive disorder, recurrent, unspecified (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks) , and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). Record review of the Comprehensive MDS assessment, dated 06/21/2023, indicated Resident #42 was not considered by the state level II PASRR process to have serious mental illness. Record review of the care plan, initiated on 07/20/2022, indicated Resident #42 was deemed PASRR positive by the PASRR Evaluation related to a history of a mental illness, bipolar disorder. Record review of the Level II PASSR evaluation, dated 07/13/2022, indicated Resident #42 met the PASRR definition of mental illness. During an interview on 09/27/2023 at 4:03 PM, MDS Coordinator A said MDS Coordinator B and herself were responsible for completing the MDS assessments. MDS Coordinator A said Resident #34's and Resident #42's positive PASRR status should have been coded on the MDS assessment. MDS Coordinator A said it was not coded accurately because it was missed. MDS Coordinator A said corporate monitored the MDS assessments randomly for accuracy, but she was unaware of how often they did the random checks. MDS Coordinator A said it was important for the MDS assessments to be coded accurately because the MDS assessments painted a clear picture of the residents and for the staff to know how to care for the residents. During an interview on 09/27/2023 4:22 PM, MDS Coordinator B said MDS Coordinator A and herself were responsible for completing the MDS assessments. MDS Coordinator B said when she signed an MDS completed she did not review the MDS prior to signing it. MDS Coordinator B said she had not noticed that Resident #34's and Resident #42's PASRR positive status was not coded on the MDS assessment. MDS Coordinator B said corporate performed random audits on the MDS assessments to check them for accuracy. MDS Coordinator B said it was important for the MDS assessments to be completed accurately for reimbursement and financial reasons, and to ensure the residents receive the care they need. During an interview on 09/27/2023 at 4:58 PM, the Administrator said he expected the MDS assessments to be completed accurately. The Administrator said the MDS Coordinators were responsible for completing the MDS assessments and ensuring they were completed accurately. The Administrator said it was important for the MDS assessments to be completed accurately to make sure everything was captured for each resident because that directed the level of care and payment received for each resident, and because it was part of the regulation. Record review of the facility's policy revised 10/24/2022, titled, MDS Accuracy Guidelines, indicated, Purpose The purpose of the MDS guideline is to ensure each resident receives an accurate assessment by qualified staff that are familiar with his/her physical, mental, and psychosocial well-being in order to identify the specific needs of the resident in accordance with the RAI Manual . The assessment must accurately reflect the resident's status .

**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 were provided such care, consistent with professional standards of practices for 2 of 5 residents (Resident #17, #69) reviewed for respiratory care. 1. The facility failed to ensure Resident #17's oxygen was set at 3 LPM as ordered by the physician. 2. The facility failed to ensure Resident #69 oxygen concentrator filters were cleaned. These failures could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #17 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and shortness of breath. Record review of the MDS assessment, dated 09/27/2023, revealed Resident #17 had clear speech and was understood by staff. The MDS revealed Resident #17 was able to understand others. The MDS revealed Resident #17 had a BIMS of 15, which indicated she was cognitively intact. The MDS revealed Resident #17 had no refusal of care. The MDS revealed Resident #17 received oxygen while a resident at the facility during the 14-day look-back period. Record review of the comprehensive care plan, revised 10/19/2022, revealed Resident #17 used oxygen therapy routinely and was at risk for ineffective gas exchange. The interventions included: Administer oxygen therapy per physician's orders. Record review of the order summary report, dated 09/27/2023, revealed Resident #17 had an order, which started on 07/14/2023, for oxygen at 3 LPM via N/C. Record review of the MAR, dated September 2023, revealed Resident #17 wore oxygen daily. During an observation and interview on 09/25/2023 beginning at 11:24 AM, Resident #17's was wearing a nasal cannula and her oxygen concentrator was set at 2.5 LPM. Resident #17 stated the facility staff was responsible for adjusting her oxygen settings. Resident #17 stated she preferred her oxygen at 2.5 liters per minute because she did not like to hear the oxygen blowing. Resident #17 stated her oxygen was set at 3 LPM a couple of weeks ago and she made them adjust it. During an observation on 09/25/2023 at 4:32 PM, Resident #17 was wearing a nasal cannula and her oxygen concentrator was set at 2.5 LPM. During an observation on 09/26/2023 at 10:43 AM, Resident #17 was wearing a nasal cannula and her oxygen concentrator was set at 2.5 LPM. During an interview on 09/27/2023 at 7:28 PM, RN R stated oxygen should have been set at the correct LPM. RN R stated a new physician order should have been obtained if a resident preferred her oxygen at a different level than what was prescribed. RN R stated she personally had never looked at Resident #17's oxygen settings, she just obtained her oxygen level. RN R stated it was important to ensure the orders for oxygen settings were correct to reflect the correct care and services provided to the resident. RN R stated oxygen administered at a lower rate could have made Resident #17's oxygen level drop. During an interview on 09/27/2023 at 8:35 PM, the DON stated the charge nurse was responsible for ensuring oxygen settings were set at the correct LPM. The DON stated it was monitored by nursing management through walking rounds and random observations. The DON stated the doctor should have been notified if Resident #17 preferred her oxygen set at lower rate. The DON stated it was important to ensure the physician orders were followed and oxygen was set at the correct LPM to ensure continuity of care. The DON stated oxygen administered at a lower rate could have made Resident #17's respiratory status decline. During an interview on 09/27/2023 at 9:07 PM, the Administrator stated he expected staff to ensure oxygen was set at the prescribed LPM. The Administrator stated he expected staff to notify the doctor if a resident preferred a lower rate of administration. The Administrator stated the charge nurse was responsible for ensuring the oxygen was set at the correct LPM. The Administrator stated it was important to ensure the physician orders were followed and oxygen was given at the prescribed rate to prevent respiratory distress. 2. Record review of Resident #69's face sheet, dated 09/27/2023, indicated Resident #69 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and dependence on supplemental oxygen. Record review of the order summary report dated 09/27/2023 indicated Resident #69 had an order for oxygen at 2 liters per minute via N/C with a start date 09/19/2023. Record review of the admission MDS assessment, dated 09/25/2023, indicated Resident #69 made himself understood and understood others. The assessment indicated Resident #69 had a BIMS score of 15, which indicated her cognition was intact. The assessment indicated Resident #69 was receiving oxygen therapy. Record review of the comprehensive care plan, revised on 09/19/2023, indicated Resident #69 used oxygen therapy routinely or as needed and was at risk for infective gas exchange related to COPD. The care plan interventions included oxygen at 2 liters per minute via N/C, monitor O2 saturation, and monitor for signs and symptoms or respiratory distress (a life-threating lung injury that allows fluid to leak into the lungs) and report to the physician as needed. During an observation and interview on 09/25/2023 at 10:40 a.m., Resident #69 was lying in bed watching tv. Resident #69 was wearing oxygen via nasal cannula at 3 liters per minute. Resident #69's oxygen concentrator filter had a thick grey, fuzzy material. Resident #69 stated he wore oxygen all the time because of COPD. During an observation on 09/26/2023 at 9:43 a.m., Resident #69 was lying in bed visiting with his spouse. Resident #69 was wearing oxygen via nasal cannula at 2 liters per minute. Resident #69's oxygen concentrator filter had a thick grey, fuzzy material. During an observation on 09/27/2023 at 9:30 a.m., Resident #69 was lying in bed watching tv. Resident #69 was wearing oxygen via nasal cannula at 2 liters per minute. Resident #69's oxygen concentrator filter had a thick grey, fuzzy material. Record review of the MAR dated 09/01/2023-09/30/2023 indicated RN S cleaned or changed Resident #69's filter on 09/20/2023. An attempted telephone interview on 09/27/2023 at 4:17 p.m. with RN S, the RN that documented she changed or cleaned Resident #69's oxygen filter, was unsuccessful. During an interview on 09/27/2023 at 4:38 p.m., the DON stated she expected the oxygen filters to be changed or cleaned weekly on Wednesdays. The DON stated the 6pm-6am charge nurse was responsible for cleaning the filters. The DON stated rounds were done randomly to monitor oxygen filters. The DON stated the last wound was done on 9/20/23 prior to Resident #69 being readmitted to the facility. The DON stated if RN S documented that she completed the task she expected her to clean or change the oxygen filter. The DON stated the risk associated with not changing the filters could cause a respiratory infection. During an interview on 09/27/2023 at 8:54 p.m., the Administrator stated he expected filters to be cleaned/changed weekly and as needed. The Administrator stated if RN S documented that she completed the task he expected the task to be done. The Administrator stated the risk associated with not changing the filters could cause a respiratory infection. Record review of the facility's policy titled Oxygen Administration last reviewed on 01/05/2020, indicated, Procedure 1. Verify the physician order Concentrator 1. Clean filter weekly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 2 of 2 nurses' carts (Nurse Cart Hall 1&4, and Nurse Cart Hall 2&3) reviewed for drugs and biologicals and storage of medications. The facility failed to ensure Nurse Cart Hall 1&4, and Nurse Cart Hall 2&3 were secured and unable to be accessed by unauthorized personnel. The facility failed to ensure 1 insulin pen (device used to administer insulin to residents with high blood sugars) on the Nurse Cart Hall 2&3 was dated when opened. These failures could place residents at risk of misuse of medications, drug diversions, and not receiving the therapeutic benefit of medications Findings included: During an observation and interview on [DATE] at 7:06 AM, LVN X left nurse cart unlocked while in resident room performing blood sugar check. LVN X stated the cart should be locked. LVN X stated she just forgot to lock the nurse cart. LVN X stated it was important to keep the cart lock to protect the residents. LVN X stated residents could overdose if they took medication from the cart. During an observation and interview on [DATE] at 4:10 PM, RN Z walked away from unlocked nurse cart to assist a resident. RN Z stated the cart should be locked. RN Z stated she was getting ready to go home when the resident needed her, and she forgot to lock the cart. RN Z stated it was important to lock the cart to keep residents and other employees from taking medications from the cart. RN Z stated the resident could be harmed if they ingested the medication. During an observation and interview on [DATE] at 1:18 PM, LVN AA was observed sitting down at the nurse's station talking to other staff members. The nurse cart was facing away from nurse's station unlocked. When LVN AA noticed surveyors looking at nurse cart, she jumped up, walked around nurses' station and she locked the cart. LVN AA stated she forgot to lock cart. LVN AA stated the cart should have been locked. LVN AA stated it was important to lock the cart, so the residents don't get into cart. LVN AA stated residents could be harmed if they took medication. During an observation on [DATE] at 9:45 AM, 1 insulin pens on nurse cart hall 2&3 were opened and not dated. LVN Y stated the pen should have open date. During an interview on [DATE] at 4:29 PM, LVN Y stated insulin pens should be dated after opened because they were only good for 28 days. LVN Y stated she opened the pen that morning, she grabbed it out of the refrigerator and hadn't had time to date. LVN Y stated the person that opened a medication was responsible for putting the open date on it. LVN Y stated it was important to put open date on the insulin pens because they were only supposed to be open for 28 days. LVN Y stated it was important to put an open date on the pen to ensure you're not using past the expiration date and the insulin was still good. During an interview on [DATE] at 8:45 PM, the DON stated she expected the staff to always lock the nurse carts. The DON stated audits are done of everything in the carts and she walks around to check carts daily. The DON stated if the cart was left unlocked the resident could be injured. The DON stated it was important to lock the carts for safety of the residents and visitors. The DON stated the nurse are responsible for ensuring the insulin pens are dated correctly. The DON stated it was important for the insulin pen to be labeled and dated so the nurse doesn't give expired medication or the wrong insulin. The DON state this could harm the resident if wrong dose or medication were given. During an interview on [DATE] at 9:00 PM, the Administrator stated he expected staff to lock the nurse carts. The Administrator stated it was important to lock the carts to ensure the safety of the drugs. The Administrated stated he expected the staff to label and date insulin pen. The administrator state it was important to label and dated insulin pens to ensure staff was not giving something that was expired. Record review of the facility's policy titled, Medication Storage dated [DATE], revealed, medication housed on premises will be stored dated and labeled according to manufacturer's recommendations. Medication must be under direct observation of the person administering medications or locked in medication storage area/cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assist residents in obtaining routine dental services to meet the needs of 1 of 20 (Resident #60) residents reviewed for dental services. The facility failed to ensure Resident #60 obtained prompt dental services when he had cracked teeth and a tooth infection. These failures could place residents at risk of not receiving needed dental care and a decreased quality of life. Findings included: Record review of a face sheet dated 09/27/2023 indicated Resident #60 was a [AGE] year-old male initially admitted to the facility on [DATE], readmitted on [DATE], with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (weakness of the left side of the body caused by decreased circulation to the brain), heart failure, unspecified (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and unspecified atrial fibrillation (rapid, irregular heart rate). The face sheet indicated Resident #60's primary payer was Medicaid. Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #60 understood others and was able to make herself understood. The MDS assessment indicated Resident #60 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #60 was independent for bed mobility, transfers, dressing, toilet use, personal hygiene, and supervision for eating. The MDS assessment indicated The MDS assessment indicated Resident #60 had not had any weight loss. The MDS assessment indicated Resident #60 did not have mouth or facial pain, discomfort or difficulty chewing. Record review of the Order Summary Report dated 03/01/2023-09/30/2023, indicated Resident #60 had an order for Cleocin (antibiotic) 300 mg by mouth three times a day for a tooth infection for 7 days with a start date of 04/22/2023 and an end date of 04/29/2023. Record review of the progress notes indicated: 05/14/2023 6:17 PM, RN D indicated, Dentist here and unable to extract teeth due blood thinners. 07/23/2023 9:19 PM, LVN E indicated she had notified the doctor around 7:00 PM that Resident #60 was scheduled for a tooth extraction on Wednesday, and he (the physician) instructed not to stop the residents blood thinners. 09/07/2023 9:54 AM, the Social Worker indicated Resident #60 and his mother had been questioning why his tooth had not been pulled. The Social Worker indicated she had contacted the dentist and the dental office said they were waiting on medical clearance from the facility doctor and heart doctor. The Social Worker indicated the dentist office called her back and informed her Resident #60 had called them last week and requested a refund so unless he called them back to keep the money, they could not continue services. The Social Worker indicated she would follow up with the resident and see what he wanted to do about getting the tooth pulled. The Social Worker indicated she had contacted the mobile dentist company advisor and he had instructed her to try to get releases from Resident #60's doctors and send them to him, so he could have the mobile dentist company pay the local dentist office. The Social Worker indicated she would do this, so she could try to get the resident's money back to his mother. Record review of a History and Physical performed by the mobile dental company dentist dated 05/14/2023 indicated an evaluation was done due to pain on the lower left side and an infection. Resident #60 had broken teeth on the lower right and upper right and required extraction of the teeth. The History and Physical indicated Resident #60 was on blood thinners and the Medical Director had not taken him off of them and did not want to take him off of them. The History and Physical indicated Resident #60 was at high risk for bleeding and she recommended the extraction be performed at an oral surgeon. Record review of the care plan date initiated 09/14/2023 did not indicate Resident #60 had a cracked tooth and required oral surgery to remove the tooth. During an interview on 09/25/2023 at 3:47 PM, Resident #60's mother said the facility did not offer to pay for Resident #60's dental procedures to be performed. Resident #60's mother said they were told by the Social Worker they would have to pay the dentist for his tooth to be extracted. Resident #60's mother said she did not remember when Resident #60 started having issues with his teeth. Resident #60 said they were waiting from clearance from the heart doctor so Resident #60 could have his tooth removed. During an interview on 09/25/2023 at 4:01 PM, Resident #60 said the tooth on his bottom left side was cracked, and it had been infected. Resident #60 said when the tooth was infected, he had some pain but was managed with Tylenol. Resident #60 said the pain resolved after the antibiotics. Resident #60 said sometimes it was hard to eat on that side, but he used the other side to eat. Resident #60 denied any pain. Resident #60 said the cracked tooth was not disrupting his sleep. Resident #60 denied any weight loss. Resident #60 said he was told he would have to pay for the extraction of his tooth and was currently awaiting clearance from the heart doctor. Resident #60 said he had an appointment with the heart doctor at the beginning of October. During an interview on 09/26/2023 at 2:15 PM, the Social Worker said she was responsible for referring the residents for dental services. The Social Worker said she was having a huge problem with the new mobile dental company that was seeing the residents. The Social Worker said she was having difficulty having them come to the facility to see the residents. The Social Worker said around April 2023 Resident #60 had to be treated with antibiotics for an abscessed tooth, and she had referred him to the mobile dental company. The Social Worker said she spoke with the previous Administrator regarding Resident #60's infection and need for the tooth to be extracted and he said because it was emergent the facility would pay for the tooth to be extracted. The Social Worker said Resident #60 was seen 05/14/2023 by the mobile dental company, and they were unable to extract his teeth because he was on blood thinners. The Social Worker said oral surgery was recommended from this visit. The Social Worker said she was having difficulty finding a local dentist office that would take his insurance. The Social Worker said Resident #60 was seen by the local dentist office on 07/26/2023 and was told he would need to get clearance from his heart doctor before they could do the oral surgery. The Social Worker said Resident #60 had an appointment with the heart doctor on 10/11/2023. During an interview on 09/27/2023 5:46 PM, the DON said for routine services the mobile dentist saw the residents periodically. The DON said for emergent dental services the residents should be taken locally. The DON said an emergent dental service would be tooth pain, tooth infection, broken teeth. The DON said the Social Worker was responsible for referring the residents for dental services. The DON said Resident #60 had a tooth infection back in April 2023 and was seen by the mobile dentist on 05/14/2023. The DON said the mobile dentist would not do the extraction because Resident #60 was on blood thinners and recommended oral surgery for Resident #60. The DON said Resident #60 had an appointment at the local dentist office on 07/26/2023 and was told he needed clearance from the heart doctor to have the oral surgery. The DON said currently they were waiting for Resident #60 to go to the appointment with the heart doctor. The DON said it was important for the residents to receive dental services and emergent dental services because it was their right to be free of pain and for their overall health. During an interview on 09/27/2023 at 4:59 PM, the Administrator said the Social Worker was responsible for referring residents for dental care. The Administrator said if the residents required emergent dental care, they should be taken to a local dentist office for care. The Administrator said an example of an emergent situation would be if the resident had a tooth abscess or pain. The Administrator said it was important for the residents to receive prompt dental care because of the pain and it could cause weight loss. Record review of the facility's policy reviewed 05/02/2019, titled, Dental Services, indicated, Policy Statement The facility will assist residents in obtaining routine and emergency dental care that meets the person centered-care needs . Social Services/designee will arrange or obtain from an outside resource routine and emergency dental service to meet the needs of each resident . Provide assistance to residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan as applicable .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 2 of 9 residents (Resident #2 and Resident #25). 1. The facility failed to ensure Resident #2 received her health shake with her lunch meal as ordered by the physician. 2. The facility failed to ensure Resident #25 received a mechanical soft diet during the lunch meal as ordered by the physician. These failures could place residents with a therapeutic diet at risk for poor intake, weight loss, not meeting their nutritional needs and choking. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #2 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of recurrent depressive disorders (episodes of depression after periods of time without symptoms), anxiety disorder (characterized by significant and uncontrollable feelings of anxiety and fear), and unspecified atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Record review of the MDS assessment, dated 06/30/2023, revealed Resident #2 had clear speech and was understood by staff. The MDS revealed Resident #2 was able to understand others. The MDS revealed Resident #2 had a BIMS of 5, which indicated severe cognitive impairment. The MDS revealed Resident #2 had no behaviors or refusal of care. The MDS revealed Resident #2 had no significant weight loss. Record review of the comprehensive care plan, revised on 07/14/2023, revealed Resident #2 was at nutritional risk. The interventions included: provide and serve diet as ordered. Record review of the order summary report, dated 09/26/2023, revealed Resident #2 had an order, which started on 06/06/2023, for Regular texture, thin liquids with mighty milk shake with meals and gravy to meat . Record review of the meal ticket for lunch, dated 09/25/2023, revealed Resident #2 should have been served a health shake. During an interview on 09/25/2023 at 9:36 AM, Resident #2 stated she had recently loss her appetite and was not eating well. Resident #2 stated she had some weight loss as well. Resident #2 stated staff was providing her with shakes during meals. Resident #2 stated she was also started on a medication to help with increasing her appetite. Resident #2 stated her appetite had not improved much. During an observation and interview on 09/25/2023 at 11:56 AM, Resident #2 was sitting up in her recliner with her meal tray placed on the bedside table located in front of her. Resident #2 did not have a health shake on her tray. Resident #2 stated the facility staff probably forgot about it. 2. Record review of the face sheet, dated 09/27/2023, revealed Resident #25 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), essential (primary) hypertension (high blood pressure), and chronic atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Record review of the MDS assessment, dated 07/29/2023, revealed Resident #25 had clear speech was understood by staff. The MDS revealed Resident #25 was able to understand others. The MDS revealed Resident #25 had a BIMS of 14, which indicated she was cognitively intact. The MDS revealed Resident #25 had no behaviors or refusal of care during the 7-day look-back period. The MDS revealed Resident #25 had no significant weight changes. Record review of Resident #25's comprehensive care plan, last revised on 07/27/2023, revealed she was at risk for weight loss. The interventions included serve diet and supplements per order. Record review of the order summary report, dated 09/27/2023, revealed Resident #25 had an order, which started on 07/17/2023, for Mechanical soft texture, thin liquids diet. Record review of the meal ticket for lunch, dated 09/25/2023, revealed Resident #25 should have been served ground backed chicken breast with chicken gravy and mashed potatoes. The meal ticket revealed Resident #25 was served a regular diet. During an interview on 09/25/2023 at 10:27 AM, Resident #25 stated she had her top teeth pulled and was having trouble chewing her food. Resident #25 stated the facility had not modified her diet texture and she had some weight loss. During an observation and interview on 09/25/2023 at 11:51 AM, Resident #25 was sitting up in her recliner with the lunch tray sitting on the bedside table located in front of her. Resident #25 had a regular tray that consisted of one flour tortilla with diced chicken fajita meat. Resident #25 also had a bowl with a salad. Resident #25 stated she unable to eat the meal as she was having trouble chewing it. Resident #25 stated she was going to fix her own lunch from items located in her personal refrigerator. Resident #25 stated the facility staff did not offer her a substitute. During an attempted telephone interview, on 09/27/2023 at 7:11 PM, to gather additional information, RN D did not answer the phone. A brief message was left, and the call was not returned upon exit of the facility. During an interview on 09/27/2023 at 7:46 PM, ADON V stated CNAs or nurses should have checked the meal ticket against the tray prior to entering the resident's room. ADON V stated if a meal ticket did not match the food on the tray, she expected staff to request the correct tray from the dietary staff. ADON V stated she expected the correct diet and all supplements to have been given. ADON V was unsure why Resident #2 did not receive her health shake. ADON V was unsure why Resident #25 received the incorrect diet texture. ADON V stated it was important to follow the physician orders regarding diet, so residents received the proper nutrition and did not choke. During an interview on 09/27/2023 at 8:06 PM, the DM stated it was her responsibility to ensure the meal tickets match the diet orders in the charting system. The DM stated the person putting the tray together was responsible for ensuring health shakes were included. The DM stated Resident #25's order was probably changed without a communication slip being given from the nursing department. The DM stated Resident #2's health shake was just overlooked. The DM stated it was important to ensure residents received the correct diet texture and supplements to prevent further weight loss or decline in nutritional status and to ensure residents did not choke. During an interview on 09/27/2023 at 8:35 PM, the DON stated she expected nursing staff to ensure the correct diet texture and supplements were served to the residents. The DON stated she was monitoring different meal services sporadically during the day. The DON stated the staff had improved during meal service and she felt they no longer required monitoring. The DON stated it was important to ensure residents were served the correct diet texture and supplements for their overall health and nutrition. The DON stated a resident could have choked or aspirated if they were served the incorrect diet texture. During an interview on 09/27/2023 at 9:07 PM, the Administrator stated he expected facility staff to ensure residents received the correct diet texture and supplements that were ordered by the physician. The Administrator stated the dietary staff was responsible for monitoring meal trays. The Administrator stated it was important to ensure residents received the correct diet texture and supplements to maintain nutritional status and prevent weight loss. Record review of the Diets, Nutrition and Hydration policy, revised August 2023, revealed Each meal will be provided according to physician orders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure each resident received and the facility provided food that accommodates resident preferences 1 of 78 residents (Resident #29) reviewed for resident food preferences. The facility failed to ensure Resident #29 received her preferred meal choice. This failure placed residents at risk for not having their nutritional needs met and a decreased quality of life. Findings included: Record review of Resident #29 face sheet dated 9/26/2023 revealed resident was a [AGE] year-old female admitted to facility on 10/11/2021 had diagnosis of muscle weakness generalized (lack of muscle strength), dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells) hyperlipidemia (blood has too many lipids (or fats), unspecified constipation and essential hypertension (high blood pressure). Record review of Resident #29 MDS assessment dated [DATE] revealed Resident #29 had clear speech, made self-understood and was understood by others. The MDS Assessment indicated Resident #29 had a BIMS score of 8 which indicated resident #29 cognition was moderately impaired. The MDS Assessment indicated Resident #29 was assessed to have feelings of being feeling tired or having little energy 2-6 days during assessment period. The MDS assessment indicated Resident #29 was independent with eating and required setup help only. Record review of Resident #29 Comprehensive Care Plan initiated on 3/14/2023 and revised on 3/14/2023 indicated resident was on a Regular Diet. The Comprehensive Care Plan Indicated Resident #29 had nutritional and hydration risk related to diabetes, constipation and anemia. The Comprehensive Care Plan Intervention indicated staff were to provide, serve diet as ordered; Dietary Manager to discuss food preferences with resident or family upon admission and then as needed to meet resident's dietary needs; Registered Dietitian to evaluate and make diet/supplement change recommendations as needed and encourage the resident to follow dietary guidelines; explain the consequences of refusal and malnutrition risk factors. During observation on 9/25/23 at 11:53 a.m., lunch meal ticket for Resident #29 indicated Resident #29 was on a regular diet. Resident #29 did not receive milk for lunch as indicated on meal ticket. Resident #29 meal ticket for lunch indicated Resident #29 were to receive 1 tong each of chicken Fajitas, 1 teaspoon of chopped cilantro, half cup of shredded lettuce and diced tomato, 1 portion of flour tortilla, 1 portion of margarine, 1 portion of oatmeal raisin cookie, 8 fluid ounce of whole milk and 6 fluid ounces of hot coffee or hot tea. During an interview on 9/25/23 at 11:53 a.m., Resident #29 stated she had never received milk for lunch or supper. Resident #29 stated she did received milk every morning for breakfast. During Interview on 9/26/23 at 2:51 p.m., Resident #29 stated she preferred to receive milk for supper and not for lunch. Resident #29 stated she did not like to drink tea. Resident #29 stated she received tea and water on every lunch and supper serving. During an interview on 9/27/23 at 3:33 p.m., [NAME] Aide O stated she was responsible for ensuring the residents received their meal preferences as indicated on their meal tickets. [NAME] Aid O stated she was not aware of Resident #29 not receiving her milk for lunch on 9/25/23. [NAME] Aid O stated she was expected to make sure residents received his/her diet as ordered. [NAME] Aid O stated she was not aware of completing any in-services on serving meals as ordered. [NAME] Aid O stated it was important to ensure residents diets were being followed as directed to prevent weight loss. During an interview on 9/27/23 at 3:14 p.m., the Dietary Manager stated she and the dietary staff was responsible for ensuring the residents received their meal preferences as indicated on their meal tickets. The Dietary Manager stated she was aware of Resident #29 not receiving milk for lunch as indicated on her meal ticket. The Dietary Manager stated residents were required at least two beverages per meal serving. The Dietary Manager stated she was using a new tray card system. The Dietary Manager stated that she wasn't sure if the milk could be updated on the tray system because she needed more training on how to update the resident's preferences. The Dietary Manager stated she left notes on resident's meal tickets when documenting resident's meal preferences. The Dietary Manager stated she did expect her dietary staff to make sure the residents received his/her diet as ordered. The Dietary Manager stated she did not have documentation on staff in-services on serving meals as ordered. The Dietary Manager stated she did agree that her dietary staff should be reeducated on serving meals as ordered. The Dietary Manager stated it was important to ensure the resident were being served meals as ordered to ensure the residents were receiving the proper nutrition. During a second attempted interview on 9/27/23 at 6:30 p.m., the Dietician was unable to reach by phone for an interview; voicemail was left for a return call and not returned prior to exit. During an interview on 9/27/23 at 4:43 p.m., the Administrator stated he was not aware of Resident #29 not receiving her milk on 9/25/23 for lunch. The Administrator stated he did expect staff to ensure the residents were receiving his or her diet as ordered. The Administrator stated he was not aware of the dietary staff completing any in-services on serving meals as ordered. The Administrator stated it was important to ensure the residents were being served meals as ordered to ensure the resident did not have a decrease in nutrition intake and to prevent weight loss. Record Review of facility policy on Menus and Nutritional Adequacy with a revision date of 5/30/2012 indicated, The meal planning guide in the facility diet manual is used as the basis for menu planning. The Menus and Nutritional Adequacy policy indicated residents were to receive a minimum daily serving of 5 ounces of meat or equivalent, 2-3 servings of vegetables, 2 servings fruits, 5-6 servings of starches or grains and 2 servings of milk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 20 residents reviewed for care plans. (Resident #25, #34, and #60) 1. The facility failed to care plan Resident #25's refusal of showers. 2. The facility failed to care plan that Resident #34 was PASRR (Preadmission Sceening and Resdient Review) positive. 3. The facility failed to care plan Resident #60's cracked teeth. These failures could place residents at risk for inaccurate care plans and decreased quality of care. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #25 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), essential (primary) hypertension (high blood pressure), and chronic atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Record review of the MDS assessment, dated 07/29/2023, revealed Resident #25 had clear speech was understood by staff. The MDS revealed Resident #25 was able to understand others. The MDS revealed Resident #25 had a BIMS of 14, which indicated she was cognitively intact. The MDS revealed Resident #25 had no behaviors or refusal of care during the 7-day look-back period. The MDS revealed Resident #25 required limited, one-person assistance with bathing. The MDS revealed Resident #25 required supervision or touching assistance with showering. Record review of Resident #25's comprehensive care plan, last revised on 07/26/2023, did not address her refusal of care during showers. Record review of the shower sheets for July 2023, August 2023, and September 2023, revealed Resident #25 refused her shower on the following dates: 07/17/2023, 07/21/2023, 08/07/2023, 08/18/2023, and 08/28/2023. During an interview on 09/25/2023 at 10:27 AM, Resident #25 was sitting up in her recliner. Resident #25 had clean hair and nails. Resident #25 had clean clothes and was free of odors. Resident #25 stated she did not always get her showers when they were scheduled. Resident #25 stated she received her scheduled shower that morning. During an interview on 09/27/2023 at 6:31 PM, CNA T stated Resident #25 refused her showers sometimes. CNA T stated if a resident refused their shower, she was supposed to let the nurses know. CNA T stated the nurses were supposed to have charted if a resident refused a shower. CNA T stated it also was documented on the shower sheet and placed in the shower book. CNA T stated she was able to access the [NAME] (simplified and pertinent information in the electronic charting system that is generated from care plan interventions), which revealed residents who refused care. CNA T was unsure if Resident #25's [NAME] indicated a refusal of showers. CNA T stated it was important to ensure refusal of showers was included on the care plan to come up with other ways and interventions for residents who refused showers. During an interview on 09/27/2023 at 7:28 PM, RN R stated nursing management was responsible for ensuring the care plan was updated. RN R stated she was made aware Resident #25 refused her showers by staff. RN R stated refusal of care or showers should have been included on the care plan. RN R stated it was important to ensure refusal of care and showers was included on the care plan, so the residents were not forced to take showers against their rights. RN R stated it was important to include refusal of shower on the care plan to make sure everyone was on the same page. During an interview on 09/27/2023 at 7:46 PM, ADON V stated Resident #25 did refuse to take her showers sometimes. ADON V stated she found out Resident #25 refused her showers today as she was going through the shower book. ADON V stated refusal of care and showers should have been included on the care plan. ADON V stated the ADON, and DON were responsible for ensure the care plan was updated. ADON V stated Resident #25's refusal of care or showers might have been missed because it was not reported to the management staff. ADON V stated CNAs should write refusal of showers on the shower sheet and report it to the charge nurse. ADON V stated the charge nurse should have talked to the resident, and then call the family and doctor with the reason. ADON V stated she expected the nursing staff to communicate continued refusal of care or showers to the management staff, so it was addressed. ADON V stated it was important to ensure refusal of care was included on the care plan for continuity of care. During an interview on 09/27/2023 at 8:35 PM, the DON stated care plans were completed and updated with an IDT approach. The DON stated refusal of care or showers should have been included on the care plan. The DON stated she was unaware Resident #25 refused her showers. The DON stated Resident #25's refusal of showers should have been reported to nurse management so it could have been addressed and included in the care plan. The DON stated it was important to ensure refusal of care or showers was included on the care plan to ensure continuity of care. During an interview on 09/27/2023 at 9:07 PM, the Administrator stated he expected refusal of care to be included on the care plan. The Administrator stated the IDT was responsible for monitoring to ensure the care plan was updated. The Administrator stated it was important to ensure refusal of care and showers was included on the care plan to ensure staff was aware of the residents wishes and normal status. The Administrator stated it was also important for the continuity of care. 2. Record review of a face sheet dated 09/27/2023, indicated Resident #34 was an [AGE] year-old female initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks with hallucinations or delusions), recurrent, severe with psychotic symptoms, anxiety disorder, unspecified (mental illness defined by feelings of uneasiness, worry and fear), and unspecified atrial fibrillation (rapid, irregular heart rate). Record review of the Comprehensive MDS assessment, dated 11/25/2022, indicated Resident #34 was not considered by the state level II PASRR process to have serious mental illness. Record review of the Level II PASSR evaluation, dated 08/23/2021, indicated Resident #34 met the PASRR definition of mental illness. Record review of Resident #34's care plan, last revised 08/08/2023, did not address Resident #34's PASRR status. 3. Record review of a face sheet dated 09/27/2023 indicated Resident #60 was a [AGE] year-old male initially admitted to the facility on [DATE], readmitted on [DATE], with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (weakness of the left side of the body caused by decreased circulation to the brain), heart failure, unspecified (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and unspecified atrial fibrillation (rapid, irregular heart rate). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #60 understood others and was able to make herself understood. The MDS assessment indicated Resident #60 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #60 was independent for bed mobility, transfers, dressing, toilet use, personal hygiene, and supervision for eating. The MDS assessment indicated The MDS assessment indicated Resident #60 had not had any weight loss. The MDS assessment indicated Resident #60 did not have mouth or facial pain, discomfort or difficulty chewing. Record review of the Order Summary Report dated 03/01/2023-09/30/2023, indicated Resident #60 had an order for Cleocin (antibiotic) 300 mg by mouth three times a day for a tooth infection for 7 days with a start date of 04/22/2023 and an end date of 04/29/2023. Record review of the care plan date initiated 09/14/2023 did not indicate Resident #60 had a cracked tooth and required oral surgery to remove the tooth. Record review of the progress notes indicated: 05/14/2023 6:17 PM, RN D indicated, Dentist here and unable to extract teeth due blood thinners. 07/23/2023 9:19 PM, LVN E indicated she had notified the doctor around 7:00 PM that Resident #60 was scheduled for a tooth extraction on Wednesday, and he instructed not to stop the residents blood thinners. 09/07/2023 9:54 AM, the Social Worker indicated Resident #60, and his mother had been questioning why his tooth had not been pulled. The Social Worker indicated she had contacted the dentist and the dental office said they were waiting on medical clearance from the facility doctor and heart doctor. The Social Worker indicated the dentist office called her back and informed her Resident #60 had called them last week and requested a refund so unless he called them back to keep the money, they could not continue services. The Social Worker indicated she would follow up with the resident and see what he wanted to do about getting the tooth pulled. The Social Worker indicated she had contacted the mobile dentist company advisor and he had instructed her to try to get releases from Resident #60's doctors and send them to him, so he could have the mobile dentist company pay the local dentist office. The Social Worker indicated she would do this, so she could try to get the resident's money back to his mother. Record review of a History and Physical performed by the mobile dental company dentist dated 05/14/2023 indicated an evaluation was done due to pain on the lower left side and an infection. Resident #60 had broken teeth on the lower right and upper right and required extraction of the teeth. The History and Physical indicated Resident #60 was on blood thinners and the Medical Director had not taken him off of them and did not want to take him off of them. The History and Physical indicated Resident #60 was at high risk for bleeding and she recommended the extraction be performed at an oral surgeon. During an interview on 09/25/2023 at 4:01 PM, Resident #60 said the tooth on his bottom left side was cracked, and it had been infected. Resident #60 said when the tooth was infected, he had some pain but was managed with Tylenol. Resident #60 said the pain resolved after the antibiotics. Resident #60 said sometimes it was hard to eat on that side, but he used the other side to eat. Resident #60 denied any pain. Resident #60 said the cracked tooth was not disrupting his sleep. Resident #60 denied any weight loss. Resident #60 said he was told he would have to pay for the extraction of his tooth and was currently awaiting clearance from the heart doctor. Resident #60 said he had an appointment with the heart doctor at the beginning of October. During an interview on 09/27/2023 at 4:25 PM MDS Coordinator A said Resident #34's PASRR status and Resident #60's dental issues could have been put in the care plan by her or the IDT. MDS Coordinator A said these things were missed. MDS Coordinator A said Resident #60's cracked teeth should be in his care plan. MDS Coordinator A said it was important for this to be in the care plan to ensure all the staff were aware of this problem. MDS Coordinator A said Resident #34's PASRR status should have been included in the care plan. MDS Coordinator A said it was important for the care plans to include the residents needs to ensure all the staff knew how to care for the residents and they could see what interventions were in place and to give the CNAs information on how to care for the residents. During an interview on 09/27/2023 at 4:28 PM, MDS Coordinator B said she could have put in the care plan Resident #60's dental issues and Resident #34's PASRR status. MDS Coordinator B said somehow these got missed. MDS Coordinator B said she checked the care plans after the completion of the MDS assessments to ensure they were complete. MDS Coordinator B said she performed occasional, random audits on the care plans to see if anything was missing. MDS Coordinator B said it was important for the residents' care plans to include all of their needs and problems, so the IDT knows what is going on with the residents, and the care plan was a line of communication for the residents' needs. During an interview on 09/27/2023 at 5:41 PM, the DON said the IDT completed the care plan. The DON said the IDT should have care planned Resident #34's PASRR status and Resident #60's dental issues. The DON said it was important for the residents' care plans to include all their needs for continuity of care. During an interview on 09/27/23 4:57 PM, the Administrator said he expected for the residents' care plans to include all their needs and ongoing problems. The Administrator said the IDT and the MDS Coordinators were responsible for ensuring the care plans were complete. The Administrator said it was important for the residents' care plans to include all the residents needs so the residents were taken care of and could maintain their best quality of life. Record review of the Comprehensive Care Plans policy, implemented on 02/10/2021, revealed 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. B. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. C. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meals (the lunch meal) reviewed for nutritional adequacy, as evidenced by: The facility served the residents on a pureed food consistency diet the wrong scoop size servings on the buttered broccoli florets for the noon time (lunch) meal on 9/26/23. This failure had the potential to affect all residents in the facility who required pureed food consistency by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: Record review of the facility diet and nourishment roster on 09/25/2023 indicated there were 8 residents in the facility on pureed food consistency diet. Record Review of the week 1 menu dated on 9/20/23, indicated the lunch meal (A) items included Fried Cod, Lemon Wedge, French Fries, [NAME] Slaw, Dinner roll, Margarine, Chocolate Brownie, whole milk, hot coffee or hot tea, tartar sauce lunch meal (B) ) hamburger patties with beef gravy, buttered broccoli florets, mashed potatoes, dinner roll, chocolate brownie; (Substitute) Chicken soup . Record Review of the facility extended menu on 9/26/23 indicated the pureed buttered broccoli florets were to be served with the 3ounce scoop size. During an Observation and interview on 926//2023 at 10:47a.m., [NAME] N in the facility only kitchen preparing to serve puree food on the lunch menu for 9/26/2023. [NAME] N was observed preparing Pureed food prior to serving puree foods for lunch on 9/26/23. After [NAME] N checked temperature for the puree food, [NAME] N proceeded to grab scoop inside the kitchen drawer, and she then placed each scoop inside the puree foods. When asked, How you know what scoop size to use per food item? [NAME] N replied, I just know, I checked the scoop size prior to preparing puree foods. During an Observation on 9/26/23 at 11:29 a.m., [NAME] N was informed by the Dietary manager to refer to the extended menu for checking the scoop sizes per servings. [NAME] N reviewed the extended menu to check scoop sizes per food item. [NAME] N informed the Dietary manager that she needed the 3- ounce scoop size to serve the buttered broccoli florets puree diet food. [NAME] N could not find the 3- ounce scoop size and proceeded to use the 2.5- ounce scoop to serve the pureed buttered broccoli florets. During observation and Interview on 9/26/23 beginning at 10:50a.m., the Dietary Manager stated the kitchen did not have 3-ounce scoops. The Dietary Manager stated she was made aware in August 2023 that no 3-ounce scoop sizes were available in the kitchen. The Dietary manager stated she informed the facility Regional Office and her supplier about her requests for 3-ounce scoops back in August of 2023. The Dietary Manager stated she did not an update regarding the status of her request for the 3-ounce scoops needed for the kitchen. During a phone Interview on 9/27/2022 at 3:07 p.m., [NAME] N stated she was responsible for making sure the correct scoop size was used prior to serving the residents on a pureed food consistency diet for lunch. [NAME] N stated she were not to use the same scoop size for all food items. [NAME] N stated she were to review the extended menu book that informed her of the scoop sizes required for each meal. [NAME] N stated that she did not have the correct 3-ounce scoop size for the buttered broccoli florets, so she used the 2.5-ounce scoop size. [NAME] N stated she was aware that the 2.5 scoop size was smaller than the 3-ounce scoop size. [NAME] N stated she had completed in services on scoop sizes and serving from the menus book but could not recall when in-services had been completed. [NAME] N stated it was important to serve with the correct scoop size to ensure the residents nutrition needs were met. During an Interview on 9/27/23 at 4:03 p.m., the Dietary Manager stated she and the cook were responsible for ensuring the correct portions sizes were served for every meal serving. The Dietary Manager stated the cook were to check the extended menu for the correct scoop size per food item. The Dietary Manager stated that she verbally trained the dietary staff on the extended menu but was not sure if she physically documented the in-services about scoop sizes. The Dietary Manager stated she observed the preparation and serving of meals every day. The Dietary Manager stated she did notice problems in the kitchen with the dietary staff not serving with the correct scoop sizes per food item. The Dietary Manager stated she would pick up each scoop size from the kitchen and show the dietary staff how to find the scoop sizes on the scoops. The Dietary Manager stated she would ask the dietary staff to direct her to the correct scoop per food items so that these issues could be addressed in the kitchen. The Dietary Manager stated she did expect the dietary staff to verify scoop sizes in the extended menu prior to serving each meal item. The Dietary Manager stated she was currently waiting on a reply from her vendor regarding the shipping status of the 3-ounce scoops. The Dietary Manager stated it was important to serve with the correct scoop size to ensure the residents get the right portion size for nutrition for their meals. During a second attempted phone interview on 9/27/23 at 6:30 p.m., the Dietician was unable to be reach by phone for an interview; voicemail was left for a return call and call not returned prior to exit. During a phone interview on 9/28/23 at 6:55 p.m., the Lead Dietician stated she only does the hiring for the facility dieticians. The lead Dietician stated the current Dietician had worked at the facility for a few months. The Lead Dietician stated the new Dietitian will start on October 1, 2023. During an interview on 9/28/23 at 4:43 p.m., the administrator stated that he was not aware of the kitchen needing 3-ounce scoops for meal servings. The Administrator stated he did expect the dietary staff to follow the facility policy. The Administrator stated that he was not aware of any in-services being completed in the kitchen. The Administrator it was important for the dietary staff to use the correct scoop sizes in the kitchen to prevent the residents from losing weight. Record review of facility's undated Pureed program policy indicated, When a variety of food is eaten the Pureed diet will provide the nutrients required to meet the current Recommended Dietary Allowances of the National Research Council. The Pureed diet provides similar calories and protein as the Regular diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 3 meals reviewed for palatability and temperature. The facility failed to provide food that was palatable and appetizing temperature for 1 of 3 meal observed on 9/26/23 (lunch) meal. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During an interview on 09/25/23 at 9:45 AM, Resident #42 stated the food was usually cold and They act like they don't know how to cook. Resident #42 stated the Meat was bad, and sometimes she could not even cut it. During an interview on 09/25/23 at 9:59 AM, Resident #54 stated the food did not have any seasoning at all and that it was bland. During an interview on 09/25/23 at 10:16 AM, Resident #57 stated the food was not cold, but it was not warm enough. During an interview on 09/25/23 at 11:10 AM, Resident #60 stated the food was always cold. During an interview on 09/25/23 at 3:39 PM, Resident #15 stated the Meat was tough, the food did not have any flavor, and the food was cold most of the time. Record Review of the facility week 1 menu dated on 9/20/23, indicated the lunch meal (A) items included Fried Cod, Lemon Wedge, French Fries, [NAME] Slaw, Dinner roll, Margarine, Chocolate Brownie, whole milk, hot coffee or hot tea, tartar sauce lunch meal (B) ) hamburger patties with beef gravy, buttered broccoli florets, mashed potatoes, dinner roll, chocolate brownie; (Substitute) Chicken soup. During an observation on 9/26/23 at 11:21 a.m., observations of food temperatures were made on the steam table by [NAME] N. The results were as followed, regular Beef hamburger patties was 160°F; the regular mashed potatoes were 178°F; the pureed mashed potatoes was 150°F; the regular Fried Cod 152°F; the mechanical soft Fried Cod 166°F; french fries 199°F; the mechanically soft buttered broccoli florets was 202°F and the soup were 167°F. During an observation, interview and tasting from the Dietician Manager of the puree food diet for lunch meal served on 9/26/2023 at 11:38 a.m., the Dietician Manager was observed tasting the pureed mashed potatoes. The Dietician stated the pureed mashed potatoes were overly seasoned. The Dietician Manager was asked, Do you taste the food items prior to serving? The Dietary Manager stated she usually taste the foods prior to serving for each meal but forgot to taste the foods during survey observation from the surveyor. During an observation on 9/26/23 at 11:38 a.m., the Dinner roll was on the counter at the service line at room temperature and not on any source of heating or cooling. No temperature was taken. During an observation on 9/26/23 beginning at 12:35 p.m., the regular foods were sampled. The results of the test were as followed, the beef hamburger patties with beef gravy were not warm; the regular mashed potatoes needed more seasoning; the regular, buttered broccoli florets were bland, and the regular chocolate brownie had a good tasting consistency flavor. During an interview on 9/27/23 at 3:07 p.m., [NAME] N stated she was responsible for making sure the food was palatable, attractive, and correct temperature prior to serving. [NAME] N stated she did not taste the food prior to serving lunch on 9/26/23. [NAME] N stated she stated she conducted temperature checks for hot food items but did not conduct temperature checks for cold food items because she did not know that she was required to do so. [NAME] N stated hot food temperatures should be 165 and above, and for cold foods, she could not remember the temperatures for serving cold food items. [NAME] N stated the reason why she did not taste the food items prior to serving lunch because she was nervous of being observed by surveyor. [NAME] N stated she had received food complaints in the past from a resident receiving burnt fried chicken in August of 2023. [NAME] N stated she fried the chicken in old cooking oil. [NAME] N stated she was made aware to change the cooking oil prior to cooking food items by the Dietary Manager. [NAME] N stated the Dietary Manager was made aware last month of the food complaint regarding the fried chicken being cooked in old cooking oil. [NAME] N stated the Dietary Manager verbally spoke with her about cooking in cooking oil. [NAME] N stated the food should be palatable, attractive and correct temperature so the resident will eat it. During an interview on 9/27/23 at 4:09 p.m., the Dietary Manager stated she and the cook were responsible for making sure the food was palatable, attractive and correct temperature prior to serving. The Dietary manager stated that she does taste the food prior to serving at every meal serving. The Dietary Manager stated she does expect food the taste good. The Dietary Manager stated she had received food complaints on yesterday about a resident not receiving what she had ordered. The Dietary Manager stated that the residents will be happier and feel at home if the food served was palatable, attractive, and cooked at a correct temperature. During a second attempted interview on 9/27/23 at 6:30 p.m., the Dietician was unable to reach by phone for an interview; voicemail was left for a return call and not returned prior to exit. During an interview on 9/27/23 at 4:43 p.m., the Administrator stated the Dietary Manager, and the cooks were responsible for ensuring the foods served were palatable, attractive, and correct temperature prior to serving. The Administrator stated he had heard of one complaint of burnt chicken. The Administrator stated he talked to the Dietary Manager about the burnt fried chicken and issue was corrected. The Administrator stated the Dietary Manager had spoken to the cook regarding the burnt fried chicken food compliant from a resident. The Administrator stated he randomly checked the tray line before the food was served to the residents. The Administrator stated nursing staff checked trays prior to the CNA's serving meal trays to the resident's rooms. The Administrator stated the food should be palatable, attractive, and at correct temperature prior to serving to prevent weight loss. Record review of the facility policy, titled, Menus and Nutritional Adequacy, revised Dated on 5/30/2012, indicated, Menus are planned to meet the average resident nutritional needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 3 resident (Residents #31,#44 and #51) reviewed for hospice services. The facility did not ensure Resident #31, #44 and #51's hospice records were a part of their records in the facility. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: 1. Record review of Resident #31's face sheet, dated 09/27/2023, indicated Resident #31 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included cancer of right breast. Record review of the order summary report dated 09/27/2023 indicated Resident #31 had an order to admit to hospice with an order date 09/07/2023. Record review of the significant change in status MDS assessment, dated 09/06/2023, indicated Resident #31 made herself understood and understood others. The assessment indicated Resident #31 had a BIMS score of 15, which indicated her cognition was intact. The assessment indicated Resident #31 had a life expectancy of less than 6 months and received hospice services. Record review of the comprehensive care plan, revised on 09/13/2023, indicated Resident #31 had a terminal illness and was receiving hospice or palliative care. The care plan interventions included coordinate with hospice to ensure the resident's spiritual, emotional, intellectual, physician and social needs were met. Record review of Resident #31's hospice binder, accessed on 09/27/2023 at 8:15 a.m. revealed no CTI or updated nurses, aides, and chaplain notes since the last IDT meeting. During an interview on 09/27/2023 at 10:17 a.m., the Administrator for the hospice company stated Resident #31 was admitted to hospice on 08/31/2023 for cancer of the right breast. The Administrator stated the last visit was on 09/25/2023. The Administrator stated the nurses were required to see her two times a week, aides three times a week and chaplain once a week. The Administrator stated she was unaware that the contract included the interdisciplinary notes would be brought in every 14 days because it's not a condition pf participation for hospice. The Administrator stated the process for coordinating with the facility was completed verbally and written with the nurses. 2. Record review of Resident #44's face sheet, dated 09/27/2023, indicated Resident #44 was a [AGE] year-old male, admitted on [DATE] with diagnoses which included cerebral infarction (stroke). Record review of the summary report dated 09/27/2023 indicated Resident #44 had an order to admit to hospice with an order date 09/26/2023. Record review of the significant change in status MDS assessment, dated 09/21/2023, indicated Resident #44 rarely/never made herself understood or rarely/never understood others. The assessment did not address the BIMS score. The assessment indicated Resident #44 had a life expectancy of less than 6 months and received hospice services. Record review of the comprehensive care plan, revised on 09/26/2023, indicated Resident #44 had a terminal illness and was receiving hospice or palliative care. The care plan interventions included coordinate with hospice to ensure the resident's spiritual, emotional, intellectual, physician and social needs were met. Record review of Resident #44's hospice binder, accessed on 09/27/2023 at 8:30 a.m. revealed no CTI (certification for terminal illness) or updated nurses and aides notes since the last IDT meeting. During an interview on 09/27/2023 at 10:17 a.m., the Administrator for the hospice company stated Resident #44 was admitted to hospice on 09/14/2023 for CVA (stroke). The Administrator stated the last visit was on 09/25/2023. The Administrator stated the nurses were required to see her two times a week, aides three times a week and chaplain once a week. The Administrator stated sometimes it take a minute before the CTI was placed in the chart due to the MD dictation was delayed. The Administrator stated she was unaware that the contract included the interdisciplinary notes would be brought in every 14 days because it's not a condition pf participation for hospice. The Administrator stated the process for coordinating with the facility was completed verbally and written with the nurses. 3. Record review of Resident #51's face sheet, dated 09/27/2023, indicated Resident #51 was a [AGE] year-old male, originally admitted on [DATE] with diagnoses which included nontraumatic intracerebral hemorrhage (ruptured blood vessel causes bleeding inside the brain). Record review of the summary report dated 09/27/2023 indicated Resident #51 had an order to admit to hospice with an order date 08/20/2022. Record review of the annual MDS assessment, dated 08/24/2023, indicated Resident #51 rarely/never made herself understood or rarely/never understood others. The assessment did not address the BIMS score. The assessment indicated Resident #51 had a life expectancy of less than 6 months and received hospice services. Record review of the comprehensive care plan, revised on 08/25/2022, indicated Resident #51 had a terminal illness and was receiving hospice or palliative care. The care plan interventions included coordinate with hospice to ensure the resident's spiritual, emotional, intellectual, physician and social needs were met. Record review of Resident #51's hospice binder, accessed on 09/27/2023 at 9:00 a.m. revealed no admission notes, consents, updated POC, nurses/aide's notes, and aide care plan since the last IDT meeting. During an interview on 09/27/2023 at 11:13 a.m., the Case Manager for the hospice company on 08/20/2022 for CVA. The Case Manger stated the last visit was on 09/26/2023. The Case Manager stated the nurses were required to see her once a week and the aides were required to see her daily. The Case Manager stated the updated POC, nurses/aide's visits, and aide care plan should be printed during the IDG meeting and the case manager should have brought it on the next visit which was 09/21/2023. The Case Manager stated the admission notes and consents should have been placed in the binder when the resident was admitted to the facility. The Case Manager stated the process for coordinating with the facility was completed verbally and written documents with the nurses. During an interview on 09/27/2023 at 4:38 p.m., the DON stated she was unaware the binders were not updated. The DON stated she expected the binders to be updated after the IDT meetings. The DON stated the charge nurses communicated verbally one on one with the hospice. The DON stated it was important to ensure recent hospice documentation was in the facility for continuity of care and so the residents received the correct care. During an interview on 09/27/2023 at 8:54 p.m., the Administrator stated he expected the hospice to update the binder. The Administrator stated it was important to ensure recent hospice documentation was in the facility for continuity of care. Record review of the Service Agreement, dated 09/12/2018, indicated, .1 Compilation of Records: Hospice shall ensure that the Nursing Facility's current clinical record includes the following: (A)Texas Medicaid Hospice Recipient Election/Cancellation form; (B)Minimum Data Set (MOS) assessments; (C) Physician Certification of Terminal Illness form; (D)Medicare Election Statement, if dually eligible; (E)verification that the recipient does not have Medicare Part A; (F)hospice interdisciplinary assessments; (G) hospice plan of care; and (H) and current interdisciplinary notes , which include the following (i) nurses notes and summaries (ii) physician orders and progress notes; and (iii) Medication and treatment sheets during the hospice period Record review of the Service Agreement, dated 06/09/2021, indicated, 5.1 Compilation of Records: Hospice shall ensure that the Nursing Facility's current clinical record includes the following: (A)Texas Medicaid Hospice Recipient Election/Cancellation form; (B)Minimum Data Set (MOS) assessments; (C) Physician Certification of Terminal Illness form; (D)Medicare Election Statement, if dually eligible; (E)verification that the recipient does not have Medicare Part A; (F)hospice interdisciplinary assessments; (G) hospice plan of care; and (H) and current interdisciplinary notes , which include the following (i) nurses notes and summaries (ii) physician orders and progress notes; and (iii) Medication and treatment sheets during the hospice period Record review of the facility's policy titled Coordination of Hospice Services implemented on 04/21/2021, indicated When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being 2. The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident's representative, to the extent possible

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 4 of 4 residents and reviewed antibiotic use. (Resident #21, Resident #46, Resident #48, Resident #64) The facility failed to ensure Resident #21, Resident #46, Resident #48, and Resident #64 had documented signs and symptoms, appropriate lab work, and diagnoses to support the use of prescribed antibiotics. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #21 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of chronic kidney disease (condition characterized by a gradual loss of kidney function) and acquired absence of left leg below knee (amputation). There was no diagnosis to support antibiotic therapy. Record review of the MDS assessment, dated 07/03/2023, revealed Resident #21 had clear speech and was understood by staff. The MDS revealed Resident #21 was able to understand others. The MDS revealed Resident #21 had a BIMS of 15, which indicated she was cognitively intact. The MDS revealed Resident #21 had no behaviors or refusal of care. The MDS assessment did not address Resident #21's current antibiotic use. Record review of the comprehensive care plan, revised on 08/23/2023, revealed Resident #21 had a pressure ulcer to her right heel and was at risk for infection. The interventions included: monitor and document for signs and symptoms of infection . Record review of the order summary report, dated 09/27/2023, revealed Resident #21 had an order, which started on 09/15/2023, for metronidazole [antibiotic] 250mg - apply to right heel topically every day for wound care, crush and sprinkle on wound. There was no diagnosis to support antibiotic therapy. Record review of the MAR, dated September 2023, revealed Resident #21 received an antibiotic daily during wound treatment. Record review of the progress notes, from 09/10/2023 to 09/15/2023, revealed Resident #21 had no documentation of signs or symptoms of a wound infection to indicate antibiotic use. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist, dated 09/15/2023, revealed Resident #21 did not meet the criteria for antibiotic use for skin and soft tissue infection. Record review of the Monthly Surveillance Log, dated September 2023, revealed Resident #21 had a skin/wound infection with no signs or symptoms documented that started on 09/14/2023. Record review of the Antibiotic Stewardship Surveillance Log, dated September 2023, revealed Resident #21's infection did not meet the definition guidelines. The log further revealed no lab work or cultures were obtained to confirm the presence of an infection. 2. Record review of the face sheet, dated 09/27/2023, revealed Resident #46 was a [AGE] year-old male who re-admitted to the facility on [DATE] with diagnoses of displaced fracture of right femur (broken right leg), hemiplegia and hemiparesis following a stroke affecting the right dominant side (weakness or paralysis to the right side of the body), and type 2 diabetes mellitus with diabetic neuropathy (high blood sugar with numbness and tingling to the feet). Record review of the MDS assessment, dated 08/18/2023, revealed Resident #46 had unclear speech and was sometimes understood by staff. The MDS revealed Resident #46 was usually able to understand others. The MDS revealed Resident #46 had a BIMS of 6, which indicated severe cognitive impairment. The MDS revealed Resident #46 had no behaviors or refusal of care. The MDS did not address Resident #46's antibiotic use. Record review of the comprehensive care plan, revised on 08/28/2023, revealed Resident #46 had a pressure ulcer and was at risk for infection. The interventions included: monitor and document for signs and symptoms of infection . Record review of the MAR, dated August 2023, revealed Resident #46 had an order, which started on 08/30/2023, for doxycycline hyclate (antibiotic) 100 mg - give one tablet by mouth two times a day for preventative. There was no diagnosis to support antibiotic therapy. Record review of the daily skilled note, dated 08/29/2023 at 7:05 AM, revealed Resident #46 had no signs of infection. The note further revealed the surgical incision to his right leg was slightly red. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist, dated 08/31/2023, revealed Resident #46 did not meet the criteria for antibiotic use for skin and soft tissue infection. Record review of the Monthly Surveillance Log, dated August 2023, revealed Resident #46 had a skin/wound infection with the sign and symptom of redness that started on 08/30/2023. Record review of the Antibiotic Stewardship Surveillance Log, dated August 2023, revealed Resident #46's infection did not meet the definition guidelines. The log further revealed no lab work or cultures were obtained to confirm the presence of an infection. 3. Record review of the face sheet, dated 09/27/2023, revealed Resident #48 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of hydronephrosis with renal and ureteral calculous obstruction (condition of excess urine accumulation in kidney(s) that causes swelling of kidneys) and cellulitis (infection of the skin). Record review of the MDS assessment, dated 06/30/2023, revealed Resident #48 had clear speech and was understood by staff. The MDS revealed Resident #48 was able to understand others. The MDS revealed Resident #48 had a BIMS of 15, which indicated no cognitive impairment. The MDS revealed Resident #48 had no behaviors or refusal of care. The MDS revealed Resident #48 had a diagnosis of sepsis (infection in the blood stream). The MDS revealed Resident #48 received antibiotics during the look-back period. Record review of the comprehensive care plan, revised on 07/14/2023, revealed Resident #48 was at risk of bowel and bladder incontinence. The interventions included: monitor for and report to MD s/sx UTI . The care plan did not address potential for skin infections. Record review of the MAR, dated June 2023, revealed Resident #48 had an order, which started on 06/15/2023, for meropenem (antibiotic) - use 1 gram intravenously two times a day for UTI, sepsis. The order ended on 06/24/2023. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist, dated 06/16/2023, revealed Resident #48 did not meet the criteria for antibiotic use for UTI. Record review of the progress notes, between 06/13/2023 to 06/16/2023, revealed Resident #48 had no documented signs or symptoms of an UTI. Record review of the Monthly Surveillance Log, dated June 2023, revealed Resident #48 had an UTI with signs and symptoms from the hospital. Record review of the Antibiotic Stewardship Surveillance Log, dated June 2023, revealed Resident #48's infection did not meet the definition guidelines. The log further revealed no lab work or cultures were obtained to confirm the presence of an infection. Record review of the MAR, dated July 2023, revealed Resident #48 had an order, which started on 07/20/2023, for Macrobid (antibiotic) 100 mg - give one capsule by mouth in the evening for prophylactic for 60 days. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist, dated 07/24/2023, revealed Resident #48 did not meet the criteria for antibiotic use for UTI, respiratory infection, skin or soft tissue infection, or gastrointestinal tract infection. Record review of the progress notes, between 07/17/2023 and 07/21/2023, revealed Resident #48 had no documented signs or symptoms of an infection. Record review of the Monthly Surveillance Log, dated July 2023, revealed Resident #48 had an unspecified infection with signs and symptoms prophylactic. Record review of the Antibiotic Stewardship Surveillance Log, dated July 2023, revealed Resident #48's infection did not meet the definition guidelines. The log further revealed no lab work or cultures were obtained to confirm the presence of an infection. Record review of the MAR, dated September 2023, revealed Resident #48 had an order, which started on 09/17/2023, for doxycycline monohydrate (antibiotic) 100 mg - give one capsule by mouth two times a day for cellulitis for 10 days. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist, dated 09/18/2023, revealed Resident #48 did not meet the criteria for antibiotic use for skin or soft tissue infection. Resident #48 had warmth and redness to the affected site but must have had at least 4 signs and symptoms. Record review of the progress note, dated 09/17/2023 at 2:47 PM, revealed Resident #48's bilateral lower extremities were red and warm to the touch. Record review of the Monthly Surveillance Log, dated September 2023, revealed Resident #48 had skin/wound infection with signs and symptoms of heat and pain. Record review of the Antibiotic Stewardship Surveillance Log, dated September 2023, revealed Resident #48's infection did not meet the definition guidelines. The log further revealed no lab work or cultures were obtained to confirm the presence of an infection. 4. Record review of face sheet, dated 09/27/2023, revealed Resident #64 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of surgical aftercare following a surgery on the digestive system, injury of duodenum (small intestine), perforation of intestine, abscess of lung with pneumonia, and urinary tract infection. Record review of the MDS assessment, dated 08/16/2023, revealed Resident #64 had clear speech and was understood by staff. The MDS revealed Resident #64 was able to understand others. The MDS revealed Resident #64 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #64 had no behaviors or refusal of care. The MDS revealed Resident #64 had an active infection and diagnosis of pneumonia. The MDS revealed Resident #64 received antibiotics during the look-back period. Record review of Resident #64's comprehensive care plan, revised on 08/28/2023, did not address risk for infection. Record review of the MAR, dated June 2023, revealed Resident #64 had an order, which started on 06/02/2023, for vancomycin (antibiotic) oral suspension - give 125 mg by mouth four times a day for c-diff positive. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist, dated 06/05/2023, revealed Resident #64 did not meet the criteria for gastrointestinal tract infection. Record review of the progress notes, between 06/01/2023 and 06/04/2023, revealed Resident #64 had no documented signs or symptoms of a gastrointestinal tract infection. Record review of the c. difficile (infectious organism that can cause severe diarrhea) test results, dated 06/01/2023, revealed positive test results. Record review of the Monthly Surveillance Log, dated June 2023, revealed Resident #64 had a gastrointestinal tract infection with no documented signs and symptoms. Record review of the Antibiotic Stewardship Surveillance Log, dated June 2023, revealed Resident #64's infection did not meet the definition guidelines. Record review of the MAR, dated August 2023, revealed Resident #64 had an order, which started on 08/11/2023, for amoxicillin-pot clavulanate (antibiotic) 875 - 125 mg - give one tablet by mouth tow times a day for hospital orders for 10 days. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist, dated 08/21/2023, revealed Resident #64 did not meet the criteria for skin or soft tissue infections. Record review of the progress notes, between 08/05/2023 and 08/10/2023, revealed Resident #64 had redness and swelling to right jaw and neck. Record review of the Monthly Surveillance Log, dated August 2023, revealed Resident #64 had skin/wound infection with signs and symptoms of redness and swelling. Record review of the Antibiotic Stewardship Surveillance Log, dated August 2023, revealed Resident #64's infection did not meet the definition guidelines. The log further revealed no lab work or cultures were obtained to confirm the presence of an infection. During an interview on 09/27/23 at 9:14 AM, ADON C stated she was responsible for completed the antibiotic stewardship reports and logs. ADON C stated she had taken the Infection Control Preventionist training and was acting as the infection control preventionist. ADON C said the process for antibiotic stewardship started with completing a facility map and color coordinating infection categories. ADON C stated she completed the antibiotic log to include the signs and symptoms, type of infection, and antibiotic information. ADON C stated a separate form was completed by hallways for antibiotic stewardship to include whether the antibiotic meets the definition guidelines. ADON C stated she then completed a McGeer criteria form for each resident who was prescribed antibiotics. She stated the facility policy was to use the McGeer's criteria. ADON C stated no interventions were implemented for a resident who doesn't meet the criteria for antibiotic use. ADON C stated the residents would have continued to the take the antibiotics as prescribed by the physician until completed. ADON C stated she did not notify the doctor or perform an antibiotic timeout to assess continued use of the antibiotic prescribed if the criteria were not met. ADON C stated antibiotic stewardship was reviewed monthly in the QAPI meetings with the Medical Director. ADON C stated no plans had been implemented to prevent or reduce the use of antibiotics that were prescribed with the criteria not met. ADON C stated she suspected the criteria was actually met but the nursing documentation was insufficient and did not reflect the appropriate charting. ADON C stated the facility staff did perform some training with the nurses regarding documentation, but it was ineffective. During an interview on 09/27/2023 at 11:23 AM, the Medical Director stated he was new to the position and had only attended two QAPI meetings. The Medical Director stated antibiotic stewardship was discussed during the meeting, but he did not notice any trends or issues. The Medical Director stated he was unaware that all antibiotics prescribed during June, July, August, and September did not meet the criteria for antibiotic use. The Medical Director was unaware of any processes in place to monitor antibiotic use at the facility. The Medical Director stated it could have been happening during the night while using the telemedicine service. The Medical Director stated the doctors used on the telemedicine service were unaware of the antibiotic stewardship policies of the nursing facilities. The Medical Director stated the policy at the facility in order to prescribe antibiotics was to ensure the McGeer's criteria was met. The Medical Director stated antibiotic stewardship was a complex situation and was a systemic problem in all nursing facilities. The Medical Director stated it was important to ensure the correct antibiotic was given for the correct situation. The Medical Director stated he did not believe the antibiotics that were prescribed did not meet the criteria. The Medical Director stated the charting was inappropriate and did not reflect the actual resident status. The Medical Director stated his next project was to implement new processes for the antibiotic stewardship program. During an interview on 09/27/2023 at 7:38 PM, RN U stated she was aware the facility had an antibiotic stewardship program. RN U stated she received training on antibiotic stewardship but was unable to specify dates. RN U stated part of the antibiotic stewardship program was checking the antibiotic again the order when it arrived from the pharmacy. RN U stated she normally worked during the evening and was not familiar with the McGeer's criteria. RN U stated the physician was notified when lab results were available. RN U stated she documented signs and symptoms and notification of the physician in the progress notes. RN U stated signs and symptoms might not have been documented in the progress notes related to getting busy and forgetting. RN U stated it was important to ensure antibiotic stewardship policies were followed to ensure residents did not get an antibiotic they did not need. RN U stated antibiotics that were given unnecessarily could put the residents at risk for super infections and multi-drug resistant organisms. During an interview on 09/27/2023 at 7:59 PM, ADON C stated the nurses were verbally given in-servicing on appropriate documentation regarding signs and symptoms of infection and antibiotic use. ADON C stated she had personally given them a copy of the McGeer's criteria she used to ensure criteria was met. ADON C stated she also educated them on non-pharmacological interventions such as increasing fluids. ADON C stated during her monitoring and tracking of infections she noticed the lack of documentation included all nurses, across all shifts. ADON C stated she had seen some improvement. ADON C stated antibiotic stewardship was important to ensure the medications were effective, the proper dosage was given, signs and symptoms were improved, and residents were not continuously having the same issues. ADON C stated it was important to ensure policies on antibiotic stewardship were followed to prevent residents receiving unnecessary medication. ADON C stated receiving unnecessary antibiotics could have caused super infections, multi-drug resistant organisms, dehydration, and side effects. ADON C stated residents could build up a resistant intolerance to antibiotics that would have caused them to become ineffective. During an interview on 09/27/2023 at 8:35 PM, the DON stated part of the antibiotic stewardship program was to monitor antibiotics for side effects and resident condition during treatment. The DON stated antibiotics were monitored and tracked on an antibiotic log that was filled out by ADON C. The DON stated no antibiotic time outs were performed. The DON stated antibiotic stewardship was part of the monthly QAPI meetings, but she was unaware all the antibiotics for June 2023, July 2023, August 2023, and September 2023 did not meet the McGeer's criteria. The DON stated education regarding antibiotic stewardship had not been provided to her knowledge. The DON stated it was important to ensure antibiotic stewardship policies were in place and followed so residents did not get multi-drug resistant organisms. During an interview on 09/27/2023 at 9:07 PM, the Administrator stated he expected the antibiotic stewardship program to have been appropriately implemented and monitored. The Administrator stated the DON was responsible for monitoring the antibiotic stewardship program. The Administrator stated the importance of the antibiotic stewardship program was to prevent multi-drug resistance organisms, super infections, and unnecessary medication. Record review of the Antibiotic Stewardship policy, reviewed on 12/12/202, revealed .committed to safe and appropriate antibiotic use that includes: .promoting and overseeing antibiotic stewardship, .accessing pharmacists and other with experience or training in antibiotic stewardship, . implement policies or practices to improve antibiotic use, .regular reporting on antibiotic use to relevant staff, . educate staff and residents about antibiotic stewardship. The policy did not address antibiotic use when the definition guidelines were not met.

Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 12 of 20 employees (RN D, Dietician, Occupational Therapist F, Physical Therapist G, Dietary Manager, Social Worker, CNA H, CNA K, CNA L, CNA M, Maintenance Director, Housekeeping Supervisor) reviewed for required trainings. The facility failed to ensure the Maintenance Director, the Housekeeping Supervisor, Occupational Therapist F, Physical Therapist G, CNA H, CNA K, CNA L, and CNA M received HIV and restraint training upon hire. The facility failed to ensure RN D, the Dietary Manager, the Social Worker, received annual HIV and restraint training. The facility failed to ensure the Dietician received annual restraint training. This failure could place residents at risk for inappropriate restraints and exposure to HIV. Findings included: Record review of the employee files revealed there was no HIV or restraint training completed upon hire for the following staff: Maintenance Director hire date 06/09/2023 Housekeeping Supervisor hire date 03/30/2021 Occupational Therapist F hire date 02/09/2023 Physical Therapist G hire date 05/08/2023 CNA H hire date 08/23/2023 CNA K hire date 06/20/2023 CNA L hire date 08/21/2023 CNA M hire date 06/29/2023 Record review of the employee files revealed there was no HIV or restraint training completed annually for the following staff: RN D hire date 03/31/2022 Dietary Manager hire date 02/08/2010 Social Worker hire date 06/15/2018 Record review of the employee files revealed there was no restraint training completed annually for the following staff: Dieticians hire date 11/29/1999 During an interview on 09/27/2023 at 7:45 PM, the Payroll Coordinator said she was responsible for ensuring the staff completed the HIV and restraint trainings. The Payroll Coordinator said the HIV and restraint trainings were supposed to be completed upon hire and annually. The Payroll Coordinator said she did not have a system in place to monitor for the completion of the HIV and restraint trainings. The Payroll Coordinator said the staff say they do not have time to complete the trainings because they are too busy working on the halls. The Payroll Coordinator said it was important for the HIV training to be completed annually and upon hire to prevent the spread of infection. The Payroll Coordinator said it was important for the restraint training to be completed upon hire and annually to prevent abuse. During an interview on 09/27/2023 at 9:08 PM, the Administrator said he expected for the staff to complete the HIV and restraint training annually and upon hire. The Administrator said the Payroll Coordinator was responsible for ensuring these were completed timely. The Administrator said it was important to complete the HIV and restraint trainings as required to keep the staff educated. Record review of the facility's policy dated 11/29/2022, titled, Training Requirements, indicated, It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals, providing services under a contractual arrangement, and volunteers, consistent with their expected roles . Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. 6. Training content includes, at a minimum . g. Restraints h. HIV .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, 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 dietary services, in that: 1) The facility failed to label and date all food items. 2) Dietary staff failed to dispose of expired foods items. 3) Dietary Staff failed to store (1) dented can in a separate area. 4) Dietary Staff failed to effectively reseal, label and date frozen food items. 5) Dietary Staff failed to label and date beverage items in the dining room for resident use. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During observations on 09/25/23 beginning at 9:26 am, the following observations were made in the kitchen walk-in freezer (1 of 1): -(1) pack of Pork Ribs had a prep date of 9/20/23 was missing the use by date. -(1) container of chicken breast had a prep date of 9/21/23 was missing the use by date. -(1) bag of french fries open and not sealed had a prep date of 9/14 and was missing the use by date. -(4) 6-pound bags of potatoes wedges had a prep date of 9/14/23 was missing a use by date. -(1) bag of cilantro open and not sealed was missing open and use by date. -(1) gallon of [NAME] salad dressing was received on 8/10/23, had an opened date of 9/6/23 and was missing the use by date. -(1) container of slice cheese was missing the use by date. -(1) gallon of thousand Island dressing had a received date of 11/5/22, was missing a use by date and open date. -(1) gallon of Teriyaki sauce had a received date of 3/9/22, open date of 9/1/22 and use by date of 9/3/23 (expired). During observations on 09/25/23 beginning at 10:00 a.m., the following observations were made in the kitchen dry storage (1 of 1 ): -(1) 6 quarts of food thicker in a container with a lid cover had a prep date 9/13/23 was missing the use by date. -(1) 8 quarts of bread crumps in a container with a lid cover had a prep date 9/14/23 was missing the use by date. -(1) 8 quarts of graham cracker crumps in a container with a lid cover had a prep date 9/14/23 was missing the use by date. -(1) 2 quarts of bacon bits in a container with a lid cover had an open date 9/14/23 was missing the use by date. (1) 6.5-pounds of Sliced peaches in a can was dented and found in dry storage area with the undented cans. -(1) 4 ounce of Organic rubbed sage food seasoning was received on 8/1/23 was missing a use by date and open date. -(1) 3.5 ounce of Tarragon leave had no received date, use by date nor open date. -(1) 16 ounces of Paprika had a receive by date of 7/28/22, was missing the use date and open date. -(1) 16 ounces of Cayenne had a receive date of 10/29/18 was missing the use by date and open date. -(1) 16 ounces of Cumin had a receive date of 10/28/21 was missing the use by date and open date. -(1) 16 ounces of Mediterranean style ground oregano had a receive date of 7/30/23 was missing open and use by date. -(1) container of Corn meal in a bid had no receive date, use by date nor open date. -(1) 16 ounces of Ground nutmeg had a received date of 12/02/21, was missing the open date and had a use by date of 8/30/2023 (expired). During observations on 9/25/23 beginning at 11:28 a.m., the following observations were made in the facility dining room (1 of 1): - (1) pitcher of brewed sweet tea was missing a prep date and use by date. - (1) pitcher of brewed unsweet tea was missing prep date and use by date. During an interview on 9/27/23 at 3:07 p.m., [NAME] aide O stated the Dietary Manager was responsible for all activity in the kitchen. [NAME] Aide O stated the Dietary Manager was responsible for labeling and dating food items and discarding expired food item. [NAME] aide O stated she had not completed in-services on labeling and dating food items. [NAME] aid O stated she was expected to follow policies and procedures in the kitchen. [NAME] Aide O stated it was important to ensure all items were labeled, dated, frozen food items sealed, and expired items were disposed to prevent the residents from getting sick. During an interview on 9/27/23 at 4:02 p.m., the Dietary Manager stated she was responsible for the overall activity in the kitchen. The Dietary Manager stated the entire team was responsible for labeling and dating food items in the kitchen. The Dietary Manager stated she labeled, dated, and discarded expired food items twice per week. The Dietary Manager stated she did expect staff to follow polices and procedure in the kitchen. The Dietary Manager stated she did expect food items in the kitchen to be labeled, dated, and expired items to be discarded. The Dietary Manager stated she did complete staff in-services on labeling and dating food items and would provide a copy of the in-services prior to exit. The Dietary Manager stated it was important to ensure expired items were discarded and food items were labeled and dated so the dietary staff could identify how long food items were to stay in the refrigerator or be discarded if expired and not served to residents. During an Interview on 9/27/23 at 7:00 p.m., the Dietary Manager later stated she did not have documentation to provide regarding in-services on labeling, dating, and discarding expired food items for the dietary staff. During a second attempted interview on 9/27/23 at 6:30 p.m., the Dietician was unable to reach by phone for an interview; voicemail was left for a return call and not returned prior to exit. During an interview on 9/27/23 at 4:43 p.m., the Administrator stated he was not aware of food items in the kitchen were not labeled and dated. The Administrator stated he was not aware of expired food items found in the kitchen. The Administrator stated he did conduct random observation rounds in the kitchen a few weeks after being hired in September of 2023. The Administrator stated the dietary staff were all responsible for ensuring all food items in the kitchen were labeled, dated, or discarded if expired. The Administrator stated he did expect staff to follow the kitchen policy and procedures. The Administrator stated he was not aware of any dietary staff in-services for labeling, dating, and discarding expired food items. The Administrator stated he did expect the dietary staff to expose of expired food items. The Administrator stated that it was important to ensure all food items in the kitchen were labeled, dated, and expired food items were discarded to prevent the dietary staff from serving anything that will be expired making the residents sick. Record review of the facility's policy titled Dry Food and Supplies Storage, revised 11/15/17 indicated, (7) All storage bags must also be properly sealed and labeled with the common name of the food; (9) All opened products must be resealed effectively and properly labeled, dated and rotated for use. This may require storage in an approved NSF container or food grade storage bag; (10) Use by, Best by, and Sell by, dates should routinely be checked to ensure that items which have expired are discarded appropriately and (11) Canned goods that have a compromised seal with be removed from service and stored in a separate area, until they are picked up by the distributer of discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit neglect and abuse for 1 of 15 residents reviewed for abuse. (Residents #2) The facility failed to report\per policy to the state agency within 24 hours of the suspicion of Resident #2's missing Tramadol medication. This failure could place residents at risk of unreported abuse, neglect and exploitation. Findings included: Record Review of a Face Sheet dated 05/22/2023 indicated Resident #2 was a [AGE] year-old male, admitted to the facility on [DATE] with a primary diagnosis of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). Record Review of Resident #2's MDS dated [DATE] indicated a BIMS of 99 (resident unable to complete the interview), and the resident was difficult to understand or be understood and had a functional level of total dependence. Record Review of Resident #2's Care Plan revised on 01/06/2023 indicated interventions for pain included an order for Tramadol 50mg 1tab by mouth every 6 hours with a focus on effective communication of pain needs. Record Review of the Provider Investigation Report dated 01/23/2023 indicated an Incident involving a drug diversion and misappropriation of medication was reported to the state agency on 01/23/2023 at 04:46 PM. Record Review of a witness statement dated 01/23/23 and signed by the previous DON indicated, On Friday, January 20, 2023, ADON called me regarding a resident running out of a medication too soon and the pharmacy wouldn't fill it. 01/23/2023 after being notified by the floor nurse administering medications that she did not have any Tramadol to administer to Resident #2 during the 06:00 AM medication pass. On 01/23/2023. During an interview on 05/22/23 at 4:24 PM, the ADON said she first learned of the resident's missing Tramadol medication on Friday, 01/20/2023. She said she notified the previous DON on 01/20/2023. The ADON said she verified with hospice the proper amount of Tramadol had been delivered to and received by the facility (120 pills). The ADON said she reported to the previous DON on 01/20/2023 of the suspicion of Resident #2's missing Tramadol dosages. During an interview on 05/22/23 at 04:44 PM, LVN M said the ADON notified the previous DON on 01/20/23 after RN N had contacted hospice for medication refills and was informed it was too early for a refill on the Tramadol 50 mg. LVN M said the ADON reported the information to the previous DON on 01/20/2023 of the suspicion of missing Tramadol dosages. During an interview on 05/23/2023 at 04:50 PM, the DON said the incident of the missing medication was not reported timely to the state agency after a suspicion of a drug diversion was found on 01/20/2023 within 24-hours. The DON said the incident should have been reported on 01/20/2023 according to facility policy. The DON stated it was important to report timely to ensure investigations are handled effectively to prevent and reconcile any type of misappropriation which could result in an increase in pain or suffering of the residents. The DON said she had been employed with the facility since March of 2023. The DON stated the current ADM is considered the Interim ADM and was assigned to the facility this month. During an interview on 05/23/2023 at 5:00 PM, the ADM said the incident of the missing medication was not reported within 24-hours. The ADM said the incident should have been reported on 01/20/2023 according to facility policy. The Interim ADM said he was assigned to the facility in May of 2023. He said the purpose of reporting timely was to ensure the investigations are handled quickly and prevent any type of harm to residents. During an interview by telephone on 05/24/2023 at 5:59 PM, the previous ADM said the incident was reported immediately and timely by him per policy upon his receipt of the information from the previous DON. He stated he did not recall the exact incident; however, he would have reported immediately upon gaining knowledge of any drug diversion. The previous DON was not reachable by telephone for interviewing purposes after 2 requested callback on 05/22/202 at 4:52 PM and 05/24/2023 at 09:52 AM. Record Review of Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/2022 reflected, a.Shall report to the state agency and one or more law enforcement entities . any responsible suspicion of a crime against any individual who is a resident of or receiving care from the facility B.Shall report immediately, but no later than 2 hours after forming the suspicion .result in serious bodily injury, or not later than 24 hours if the events causing the suspicion do not result in serious bodily injury. B. The Administrator will follow up with the government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident as required by state agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 15 (Resident #2) residents reviewed for abuse and neglect. The facility failed to follow their policy regarding abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property reported to the state agency within 24 hours of the suspicion of Resident #2's missing Tramadol medication. This failure could place the residents at risk for drug diversion, misappropriation of property, abuse and neglect not being investigated in a timely manner. Findings included: Record Review of a Face Sheet dated 05/22/2023 indicated Resident #2 was a [AGE] year-old male, admitted to the facility on [DATE] with a primary diagnosis of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). Record Review of Resident #2's MDS dated [DATE] indicated a BIMS of 99 (resident unable to complete the interview), and the resident was difficult to understand or be understood and had a functional level of total dependence. Record Review of Resident #2's Care Plan revised on 01/06/2023 indicated interventions for pain included an order for Tramadol 50mg 1tab by mouth every 6 hours with a focus on effective communication of pain needs. Record Review of the Provider Investigation Report dated 01/23/2023 indicated an Incident involving a drug diversion and misappropriation of medication was reported to the state agency on 01/23/2023 at 04:46 PM. Record Review of a witness statement dated 01/23/23 and signed by the previous DON indicated, On Friday, January 20, 2023, ADON called me regarding a resident running out of a medication too soon and the pharmacy wouldn't fill it. 01/23/2023 after being notified by the floor nurse administering medications that she did not have any Tramadol to administer to Resident #2 during the 06:00 AM medication pass. On 01/23/2023. During an interview on 05/22/23 at 4:24 PM, the ADON said she first learned of the resident's missing Tramadol medication on Friday, 01/20/2023. She said she notified the previous DON on 01/20/2023. The ADON said she verified with hospice the proper amount of Tramadol had been delivered to and received by the facility (120 pills). The ADON said she reported to the previous DON on 01/20/2023 of the suspicion of Resident #2's missing Tramadol dosages. During an interview on 05/22/23 at 04:44 PM, LVN M said the ADON notified the previous DON on 01/20/23 after RN N had contacted hospice for medication refills and was informed it was too early for a refill on the Tramadol 50 mg. LVN M said the ADON reported the information to the previous DON on 01/20/2023 of the suspicion of missing Tramadol dosages. During an interview on 05/23/2023 at 04:50 PM, the DON said the incident of the missing medication was not reported timely to the state agency after a suspicion of a drug diversion was found on 01/20/2023 within 24-hours. The DON said the incident should have been reported on 01/20/2023 according to facility policy. The DON stated it was important to report timely to ensure investigations are handled effectively to prevent and reconcile any type of misappropriation which could result in an increase in pain or suffering of the residents. The DON said she had been employed with the facility since March of 2023. The DON stated the current ADM is considered the Interim ADM and was assigned to the facility this month. During an interview on 05/23/2023 at 5:00 PM, the ADM said the incident of the missing medication was not reported within 24-hours. The ADM said the incident should have been reported on 01/20/2023 according to facility policy. The Interim ADM said he was assigned to the facility in May of 2023. He said the purpose of reporting timely was to ensure the investigations are handled quickly and prevent any type of harm to residents. During an interview by telephone on 05/24/2023 at 5:59 PM, the previous ADM said the incident was reported immediately and timely by him per policy upon his receipt of the information from the previous DON. He stated he did not recall the exact incident; however, he would have reported immediately upon gaining knowledge of any drug diversion. The previous DON was not reachable by telephone for interviewing purposes after 2 requested callback on 05/22/202 at 4:52 PM and 05/24/2023 at 09:52 AM. Record Review of Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/2022 reflected, a.Shall report to the state agency and one or more law enforcement entities . any responsible suspicion of a crime against any individual who is a resident of or receiving care from the facility B.Shall report immediately, but no later than 2 hours after forming the suspicion .result in serious bodily injury, or not later than 24 hours if the events causing the suspicion do not result in serious bodily injury. B. The Administrator will follow up with the government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident as required by state agencies.

**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 to help prevent the development and transmission of communicable diseases or infections and the facility failed to ensure linens were handled, stored, processed, and transported to prevent the spread of infection for 3 of 4 halls (100 hall, 200 hall, and 400 hall), and 6 out of 58 employees (CNA C, CNA D, CNA E, HA F, MA G, and CNA H) reviewed for infection control practices. 1. The facility did not ensure CNA D handled glasses of ice without her fingernails touching the ice inside of the glass and the facility did not ensure CNA D, CNA E, and HA F performed hand hygiene in between handling meal trays, during the lunch meal. 2. The facility did not ensure the clean linen carts on 100 hall, 200 hall, and 400 hall were completely covered while not being used. 3. The facility did not ensure CNA H placed soiled linen and trash in the appropriate barrels after providing care. These failures could place residents at increased risk for infection or cross-contamination that could diminish the resident's quality of life. The findings included: 1. During an observation on 05/22/2023 between 12:01 PM - 12:26 PM, CNA D, CNA E, and HA F were passing out meal trays on 200 hall. CNA D took a meal tray to a resident sitting in the dining room, did not perform hand hygiene, came back to the tray cart, did not perform hand hygiene, took another meal tray to room [ROOM NUMBER], and did not perform hand hygiene. CNA D went down the hallway to obtain several cups of ice, without performing hand hygiene. CNA D came back up the hallway carrying four clear, plastic cups filled with ice. CNA D was carrying the cups by holding the inside of the cups with one hand while her artificial fingernails were touching the ice in 2 out of 4 of the cups. CNA D took a cup of ice into room [ROOM NUMBER]. CNA D did not perform hand hygiene. CNA E took a meal tray into room [ROOM NUMBER], did not perform hand hygiene, came back to the tray cart, did not perform hang hygiene, took another meal tray into room [ROOM NUMBER], did not perform hand hygiene, came back to the tray cart, did not perform hand hygiene, took another meal tray into room [ROOM NUMBER], and did not perform hand hygiene. HA F took a meal tray into room [ROOM NUMBER], did not perform hand hygiene, came back to the tray cart, did not perform hand hygiene, took another meal tray into room [ROOM NUMBER], and did not perform hand hygiene. During an interview on 05/23/2023 at 1:54 PM, HA F stated staff should have performed hand hygiene between different resident's meal trays. HA F stated she normally performed hand hygiene while passing out meal trays, but she had some anxiety on 05/22/2023 because there was normally not that many people helping to pass out meal trays. HA F stated performing hand hygiene was important, so staff did not pass germs from room to room. During an interview on 05/23/2023 at 1:57 PM, CNA D stated staff should perform hand hygiene between different resident's meal trays. CNA D stated she should not have carried cups of ice holding the inside of the cups. CNA D stated her fingernails should not have been touching the ice. CNA D stated she did not have help and was in a hurry passing out the meal trays and just did not think about her hands touching the ice or performing hand hygiene. CNA D stated performing hand hygiene and ensuring cups were handled properly was important so staff did not pass anything on to anyone. During an interview on 05/23/2023 at 2:43 PM, CNA E stated staff should have performed hand hygiene while passing meal trays. CNA E stated she did not perform hand hygiene every time while passing out meal trays. CNA E stated cups should be carried by the handle or around the outside of the cup. CNA E stated carrying cups appropriately and performing hand hygiene while passing out meal trays was important to maintain hygiene for the resident's and for the staff. During an interview on 05/24/2023 at 6:09 PM, the DON stated she expected staff to perform hand hygiene, ensure cups were carried correctly, and ensure fingernails were not touching the ice while passing out meal trays. The DON stated this was monitored by random observations and education. The DON stated performing hand hygiene and ensuring cups were handled correctly was important because of infection control. During an interview on 05/24/2023 at 6:44 PM, the Administrator stated he expected staff to ensure cups were carried correctly, fingernails were not touching the ice, and hand hygiene was performed while passing out meal trays. The Administrator stated management staff were responsible for monitoring facility staff. The Administrator stated performing hand hygiene, ensuring cups were carried correctly, and ensuring fingernails were not touching the ice was important because of infection control. 2. During an observation on 05/23/2023 between 5:01 AM - 5:51 AM, the clean linen cart on 200 hall was open, with the front cover laying on top of the clean linen cart. Dirty linen and trash barrels were approximately 3 feet from the open clean linen cart. During an observation on 05/23/2023 between 5:04 AM - 5:12 AM, the clean linen cart on 100 hall was open, with the front cover laying on top of the clean linen cart. During an observation on 05/23/2023 between 5:09 AM - 5:28 AM, the clean linen cart on 400 hall was open, with the front cover laying on top of the clean linen cart. During an interview on 05/23/2023 at 5:44 AM, HA A stated clean linen carts should have been kept covered. HA A stated she probably forgot to close the clean linen cart on 400 hall because she was helping out on another hall. HA A stated it was important to ensure clean linen carts remained closed because of infection control. During an interview on 05/23/2023 at 5:51 AM, CNA B stated clean linen carts should have been covered and the front cover should have been down. CNA B stated he forgot to pull it down on 200 hall. CNA B stated it was important to ensure clean linen carts remained closed because it could have caused cross-contamination. During an interview on 05/23/2023 at 5:57 AM, CNA C stated clean linen carts should have been kept covered. CNA C stated she put the front cover down when she realized it was up on 100 hall. CNA C stated it was important to ensure clean linen carts remained closed to prevent cross-contamination. During an interview on 05/24/2023 at 6:09 PM, the DON stated she expected the nursing staff to ensure clean linen carts were kept covered. The DON stated that was monitored by random checks. The DON stated it was important to ensure linen carts were kept covered to prevent the spread of infection or cross-contamination. During an interview on 05/24/2023 at 6:44 PM, the Administrator stated he expected staff to ensure clean linen carts were covered. The Administrator stated management staff were responsible for monitoring. The Administrator stated it was important to ensure clean linen carts were kept covered to prevent the spread of infection or cross-contamination. 3. During an observation on 05/23/2023 at 2:32 PM, a soiled, used incontinent brief and draw sheet was laying in the floor behind Resident #1's door. CNA H entered Resident #1's room, donned gloves, removed the trash bag from Resident #1's trash can, and picked up the soiled, used incontinent brief and draw sheet, placed it in the bag, and took it out of Resident #1's room. During an interview on 05/23/2023 at 3:01 PM, CNA H stated she did not normally leave soiled linens and trash on the floor in resident's rooms. CNA H stated she had just finished providing care to Resident #1 and had not retrieved her barrel yet. CNA H stated it was important to ensure soiled linens and trash were not kept in the floor to prevent infections and ensure a sanitary environment. During an interview on 05/24/2023 at 6:09 PM, the DON stated she expected staff to ensure dirty, soiled linen and trash was placed in the appropriate barrels after care was provided. The DON stated that was monitored by random checks by the nurse management staff. The DON stated she recently hired another nurse manager that would be responsible for monitoring the CNAs. The DON stated it was important to ensure dirty, soiled linen and trash were not placed in the floor to prevent the spread of infection. During an interview on 05/24/2023 at 6:44 PM, the Administrator stated he expected staff to ensure dirty, soiled linen and trash was placed in the appropriate barrels after care was provided. The Administrator stated it was important to ensure dirty, soiled linen and trash were not placed in the floor to prevent the spread of infection. Record review of the Bedside Water Pass policy, dated 3/16/2014, revealed Do not allow ice to touch hands . The policy further revealed hands should have been washed or sanitized before and after the procedure. Record review of the Infection Prevention and Control Program policy, revised 04/12/2023, revealed 4. Standard Precautions: b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. The policy further revealed 11. Linens: d. Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets. E. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom.

Based on interview, and record review the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through the means other than a postal service for 1 of 9 confidential residents reviewed for weekend mail delivery. The facility failed to ensure residents received their mail on the weekend. This failure could place residents at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life. Findings include: During a confidential group interview 1 of the 9 residents said mail was not being distributed on Saturdays. They said mail did not get delivered until Monday morning by the Activity Director. During an interview on 07/20/22 at 11:02 a.m., the Activity Director indicated the residential mailbox was located outside and the weekend staff had access to the mailbox. The Activity Director said the mail was not available to the residents on Saturdays because the nurses were responsible for distributing the mail. The Activity Director indicated on Monday she would obtain the mail from the mailbox and distributed to the residents. The Activity Director indicated she was unaware of the requirements for the residents to have access to their mail on Saturdays. The Activity Director indicated the front desk screener on the weekends would ensure the residents had their mail. During an interview on 07/20/22 at 3:55 p.m., LVN A indicated she worked every other weekend and only delivered large packages when received. LVN A said the nursing staff on the weekend were responsible for ensuring the residents received their mail. LVN A said regular hand mail was placed in the Activity Director's office until Monday. LVN A indicated she was unaware of the requirements for the residents to have access to their mail on Saturdays. LVN A said this failure could make residents feel they did not have access to their personal property. During an interview on 07/20/22 at 7:23 p.m., the ADM indicated he expected the residents to receive their mail on Saturdays. The ADM indicated he was unaware of the requirements for the residents to have access to their mail on Saturdays. The ADM said he was responsible for monitoring and ensuring residents received their mail on Saturdays. The ADM said he would develop a plan to monitor and follow up on the effectiveness. The ADM said residents had a right to receive their mail in a timely manner. The ADM said this failure could affect their rights. Record review of the Resident Rights policy, revised on 02/20/21, revealed a resident has a right to be treated with respect and dignity . the resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 16 residents (Resident #23 and Resident #35) reviewed for ADL (activities of daily living) care. The facility failed to provide facial hair removal/shaving for dependent female Residents #23 and #35. The facility failed to ensure dependent Resident #35 was receiving her scheduled showers/baths. This failure could place residents at risk of not receiving care and services to meet their needs. Findings include: 1. Record review of the face sheet, dated 7/20/22, revealed Resident #23 was an [AGE] year old female who was admitted to the facility on [DATE] with diagnoses which included vascular dementia (memory loss caused from disruption of blood flow to the brain), cognitive communication deficit (difficulty communicating related to memory loss), diabetes, hypertension (high blood pressure), and muscle weakness. Record review of the Quarterly MDS, dated [DATE], revealed Resident #23 had a BIMS (Brief Interview for Mental Status) of 3, which indicated severe cognitive impairment. Resident #23 required extensive assistance of one person for dressing, bathing, and personal hygiene ADLs. The MDS revealed Resident #23 did not reject care or evaluation. Record review of Resident #23's care plan, dated 3/14/22, read in part: Problem #1: Resident #23 had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner. Goal: Resident #23 will participate to the best of their ability and maintain current level of functioning with ADLs through the next review date. Approach: Extensive assist of one person for bathing-provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Encourage resident to participate to the fullest extent possible with each interaction and praise when attempts were made. Problem #2: Resident #23 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to diagnosis of vascular dementia. Goal: Resident #23 will maintain current level of cognitive function without decline through next review date. Approach: Administer medications per physician's orders; monitor/document/report to physician any changes in cognitive function; explain all procedures with terms and gestures the resident can understand; stop and return if the resident becomes agitated; provide opportunities for resident to make simple choices with ADL cares. Record review of the ADL Documentation Survey Report, dated 7/19/22, revealed Resident #23's scheduled shower days were Tuesdays, Thursdays, and Saturdays between 6 AM-2 PM. She required total assistance of one person to perform personal hygiene which included combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands. There was not a specific area to check off shaving as a task. During observation and interview on 7/18/22 at 10:15 AM with Resident #23, revealed the resident laid in bed with approximately ½ inch long white hairs to her lower chin area and front of upper neck. The resident had a puzzled look when the state surveyor asked her about the hair on her chin and neck and did not answer. During an observation on 7/19/22 at 10:19 AM, revealed Resident #23 with approximately ½ inch long white hairs to lower chin area and upper front of neck area. During an observation on 7/19/22 at 02:54 PM, revealed Resident #23 with approximately ½ inch long white hairs to lower chin area and upper front of neck area. During a phone interview on 7/19/22 at 03:23 PM with Resident #23's family member, she said she did not know how Resident #23 would feel about having long facial hair to her chin or neck. During an observation on 7/20/22 at 10:48 AM, revealed Resident #23 walked in the hallway with her walker and she had approximately ½ inch long white hairs to her lower chin area and upper front of neck area. During an interview on 7/20/22 at 2:14 PM with CNA T, she said she worked at the facility for a little over a year. She said residents should be shaved on their shower days or sooner if they needed it. She said she would shave male and female residents on their shower days or would shave sooner if they grew facial hair sooner than on shower days. She said she did not usually shower residents on her shift, unless she came in early and would help with showers. She said she did not have any residents who refused care or showers. She said the CNA's were responsible to ensure the residents were shaved on their shower days. During an interview on 7/20/22 at 2:28 PM with CNA U, she said she started working at the facility on 7/11/22 . She said both male and female residents should be shaved on their shower days or sooner if the resident needed to be shaved. She said shaving the residents during their shower helps soften the facial hair and made it easier to shave the resident. She had not had any residents refuse care or to be shaved. During an interview on 7/20/22 at 2:35 PM with LVN A, she said she had worked at the facility for almost 10 years. She said residents should be shaved by the CNA's when they gave the residents their showers and as needed. 2. Record review of consolidated physician orders dated 7/20/2022 indicated Resident #35 was a [AGE] year-old female- admitted on [DATE] with diagnoses including dementia without behavioral disturbances, cognitive communication deficit, lack of coordination, muscle weakness, dysphagia (difficulty swallowing foods or liquids), and aphasia (loss of ability to understand or express speech). Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #35 usually understood others and was understood by others. The MDS indicated Resident #35 had a BIMS score of 07 and moderately cognitive impairment. The MDS indicated Resident #35 was not resistive to evaluation or care. The MDS indicated Resident #35 required extensive assistance with bed mobility, transferring, dressing, and toileting. The MDS indicated Resident #35 required limited assistance with personal hygiene. Record review of the care plan updated on 6/6/2022 indicated Resident #35 had an activities of daily living (ADL) deficit related to impaired mobility, dementia, history of falls and fractures, and balance problems. The care plan interventions included extensive assistance of one person with personal hygiene. Record review of Resident #35's Documentation Survey Report for May, June, and July 2022 indicated her bathing schedule was Tuesdays, Thursdays, and Saturdays on the 2:00 p.m.- 10:00 p.m. shift. The Documentation Survey Report indicated Resident #35 was not bathed on the following dates: Tuesday, May 3, 2022 Tuesday, May 17, 2022 Saturday, May 21, 2022 Tuesday, May 24, 2022 Thursday, June 2, 2022 Saturday, June 4, 2022 Saturday, June 11, 2022 Thursday, June 16, 2022 Thursday, June 23, 2022 Tuesday, June 28, 2022 Tuesday, July 5, 2022 Thursday, July 7, 2022 Saturday, July 9, 2022 Thursday, July 14, 2022 Tuesday, July 19, 2022 During an observation on 7/18/22 at 10:28 a.m. Resident #35 was observed with lip and chin hair approximately 1-2 centimeters (cm) in length. During an observation on 7/19/22 at 9:30 a.m. Resident #35 was observed with lip and chin hair approximately 1-2 centimeters (cm) in length. During an observation on 7/19/22 at 1:48 p.m. Resident #35 was observed with lip and chin hair approximately 1-2 centimeters (cm) in length. During an observation on 7/20/22 at 8:29 a.m. Resident #35 was observed with lip and chin hair approximately 1-2 centimeters (cm) in length. During an interview on 07/20/22 at 02:37 p.m. CNA E said she started at the facility on 7/18/22. CNA E said residents were assisted with facial hair removal during their bathing and as needed. CNA E said the importance of assisting female residents with facial hair removal was to improve confidence and quality of life. During an interview on 7/20/22 at 2:48 p.m. Hospitality Aide F said he worked at the facility for approximately 2 weeks. Hospitality Aide F said facial hair removal was performed during showers and as needed. Hospitality Aide F said he did not ask female residents if they wanted assistance with facial hair removal because it would be rude. During an interview on 7/20/22 at 2:57 p.m. LVN B said residents should be assisted with facial hair removal during their showers and as needed. LVN B said it was important to assist female residents with facial hair removal for their dignity. During an interview on 7/20/22 at 3:26 p.m. the DON said she expected staff to assist residents with facial hair removal during showers and as needed. The DON said facial hair removal should be offered to female and male residents. The DON said it was the nurse's responsibility for ensure facial hair was removed. The DON said the importance of female facial hair removal was dignity. Record review of the facility's in-service training report titled Shower/Bed Bath, dated 3/16/22, read in part .Showers/Bed baths are to be given per the shower schedule . Record review of the facility's Activities of Daily Living Care Guidelines policy revised on 2/11/2021 indicated, .Residents participate in and receive the following person-centered care: 1. Bathing: includes grooming activities such as shaving, brushing teeth, and brushing hair .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practices the comprehensive person-centered care plan, the residents goals and preference for 1 of 3 residents (Resident #55) reviewed for respiratory care. The facility did not ensure Resident #55's CPAP (a device that keep breathing airways open while sleeping) mask was bagged while not in use. The facility failed to document and monitor Resident #55's CPAP use. These failures could place residents at risk for respiratory infections and exacerbation of respiratory distress. Findings include: 1. Record review of the order summary report dated 07/20/22 indicated Resident #55 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), obstructive sleep apnea (intermittent airflow blockage during sleep) and essential hypertension (force of the blood against the artery walls is too high). The order did not address Resident #55 had an order for CPAP. Record review of the quarterly MDS dated [DATE] indicated Resident #55 understood others and made herself understood. The MDS indicated Resident #55 was cognitively intact with a (BIMS score of 15). The MDS indicated she required limited assistance with bed mobility, transfers, dressing, toileting, and personal hygiene: extensive assistance with bathing. The MDS indicated Resident #55 had active diagnoses which included hypertension, diabetes mellitus, dementia, and obstructive sleep apnea. The MDS did not indicate if Resident #55 became short of breath or trouble breathing with/without activity. The MDS indicated Resident #55 received oxygen therapy. Record review of the care plan dated 10/27/21 indicated Resident #55 used oxygen therapy as needed and was at risk for ineffective gas exchange. The care plan interventions were to administer oxygen per physician's orders. The care plan did not address the CPAP. During an observation on 07/18/22 at 9:35 a.m., Resident #55's CPAP mask was on the bedside dresser and was not covered. During an observation and interview on 07/19/22 at 10:04 a.m., Resident #55's CPAP was on the bedside dresser and was not covered. Resident #55 said she wore her CPAP at night but did not know the reason. During an observation on 07/19/22 at 1:43 p.m. Resident #55's CPAP mask was on the bedside dresser and was not covered. During an observation on 07/20/22 at 8:25 a.m., Resident #55's CPAP was lying across the head of the bed. During an interview on 07/20/22 at 3:55 p.m., LVN A said she was Resident #55's 6a-6p charge nurse. LVN A said she did not notice the CPAP mask was not properly stored. LVN A said she should have placed Resident #55 mask in a bag during rounds. LVN A indicated Resident #55 had the CPAP in use since admission. She said she was not aware Resident #55 did not have an order for a CPAP. LVN A said nurses must have an order for a CPAP to administer it and if there was no order, the nurse should call the physician to get an order. LVN A said she did not know why Resident #55 did not have an order for a CPAP. She said these failures could affect her breathing by not receiving the proper oxygenation. During an interview on 07/20/22 at 4:10 p.m., LVN B said the CPAP mask should be stored in a bag when not in use. LVN B said nurses must have an order for a CPAP to administer it and if there was not one seen, the nurse should call the physician to get an order. LVN B said this failure could place residents at risk for respiratory infection. During an interview on 07/20/22 at 4:59 p.m., the DON said she expected Resident #55's CPAP mask be stored in a bag when not in use. The DON said she was not aware Resident #55 did not have an order for a CPAP. The DON indicated Resident #55 had the CPAP in use since admission. The DON said there should had been an order clearly stating the settings and properly use of the CPAP. She said it was her responsibility to make sure the nursing staff were properly storing respiratory equipment. The DON said daily rounds were made by the charge nurse and administrative department (ADONs and RN Supervisor). The DON said it was her understanding rounds were made and Resident #55's CPAP mask was stored properly, and the order was current. The DON said this failure could place resident's respiratory health at risk. During an interview on 07/20/2022 at 4:59 p.m. a policy for a CPAP device was requested from the DON but was not provided upon exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 4 of 16 residents (Residents #4, #46, #53 and #58) reviewed for reasonable accommodations. The facility failed to ensure Residents #4, #46, #53 and #58 call light was accessible. This failure could place residents at risk of injuries, health complications and decreased quality of life. Findings included: 1.Record review of the order summary report dated 07/20/22 indicated Resident #46 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar) and atrial fibrillation (irregular, often rapid heart rate). Record review of the annual MDS dated [DATE] indicated Resident #46 sometimes understood others, and sometimes made herself understood. The MDS indicated Resident #46 was severely cognitively impaired with a (BIMS score of 1). The MDS indicated he required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing and limited assistance with eating. The MDS indicated Resident #46 had active diagnoses which included anxiety, depression, COPD and Alzheimer's. The MDS revealed Resident #46 had no falls since admission/entry, reentry, or prior assessment. Record review of the care plan dated 10/16/15 indicated Resident #46 had the potential for falls related to history of falls, impaired mobility, incontinent, balance problems, poor safety awareness. Interventions included floor mat, keep bed in lowest position when not providing care, and place the call light within reach and encourage the resident to use it for assistance as needed. During an observation on 07/19/22 at 9:12 p.m. Resident #46's door was closed. Resident #46's call light was tucked in the nightstand drawer and was out of reach. The resident was non-interviewable. During an observation on 07/19/22 at 10:48 p.m., Resident #46's door was closed. This surveyor knocked then entered the room to find Resident #46 awake. Resident #46's call light was tucked in the nightstand drawer out of reach. 2. Record review of the order summary report dated 07/20/22 indicated Resident #53 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses including unspecified sequelae of unspecified cerebrovascular disease (residual neurological effects of a stroke), essential hypertension (force of the blood against the artery walls is too high) and major depressive disorder. Record review of the quarterly MDS dated [DATE] indicated Resident #53 understood others and made himself understood. The MDS indicated Resident #53 was severely cognitively impaired with a (BIMS score of 3). The MDS indicated he required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene: total dependence with bathing and required supervision with eating. The MDS indicated Resident #53 had active diagnoses which included hypertension, diabetes mellitus and CVA (stroke). The MDS did not address if Resident #53 had falls since admission/entry, reentry, or prior assessment. Record review of the care plan dated 3/25/17 indicated Resident #53 had the potential for falls related to balance problems, and weakness to left side. Interventions included anticipate and the meet the resident's need. Place items frequently used by the resident within easy reach when in the room and ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The care plan did not address call light. During an observation on 7/19/22 at 9:55 a.m., Resident #53 was noted to be in bed lying flat on his back. The call light was on the floor beside the bed out of reach The resident was non-interviewable. During an observation on 7/19/22 at 9:13 p.m., Resident #53 was noted to be in bed lying flat on his back. The call light was on the floor beside the bed out of reach. 3. Record review of the order summary report dated 07/20/22 indicated Resident #4 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (force of the blood against the artery walls is too high) and major depressive disorder and major depressive disorder. Record review of the annual MDS dated [DATE] indicated Resident #4 understood others and made herself understood. The MDS indicated Resident #4 was severely cognitively impaired with a (BIMS score of 7). The MDS indicated she required limited assistance with bed mobility, dressing, toileting: extensive assistance with transfers, personal hygiene, bathing, and supervision with eating. The MDS indicated Resident #4 had active diagnoses which included non-Alzheimer's dementia, hypertension, and depression. The MDS did not address if Resident #4 had falls since admission/entry, reentry, or prior assessment. Record review of the care plan dated 2/17/20 indicated Resident #4 had the potential for falls related to cognitive impairment. Interventions included anticipate and meet the resident's needs. Place items frequently used by the resident within easy reach when in the room and place resident's call light within reach and encourage the resident to use it for assistance as needed. During an observation on 7/19/22 at 2:05 p.m., Resident #4 was noted to be in bed lying flat on his back. The call light was lying across her recliner and was out of reach. The resident was non-interviewable. During an observation on 7/19/22 at 10:09 p.m., Resident #4's door was closed. The call light was lying across her recliner and was out of reach. 4.Record review of the order summary report dated 07/20/22 indicated Resident #58 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements), essential hypertension (force of the blood against the artery walls is too high) and major depressive disorder. Record review of the quarterly MDS dated [DATE] indicated #58 sometimes understood others, and usually made herself understood. The MDS indicated Resident #58 was severely cognitively impaired with (BIMS score of 6). The MDS indicated she required extensive assistance with bed mobility, transfers, dressing, toileting: supervision with eating and total dependence with bathing. The MDS indicated Resident #58 had active diagnoses which included non-Alzheimer's dementia, hypertension, and depression. The MDS did not address if Resident #58 had falls since admission/entry, reentry, or prior assessment. Record review of the care plan dated 6/29/2022 indicated Resident #58 had the potential for falls related to impaired mobility, incontinence, gait/balance problems and medication side effects. Interventions included anticipate and the meet the resident's need. Place items frequently used by the resident within easy reach when in the room and place her call light within reach and encourage the resident to use it for assistance as needed. During an observation on 7/19/22 at 9:10 p.m., Resident #58's door was closed. Resident #58's call light was on the floor beside the bed and was out of reach. During an observation on 7/19/22 at 10:58 p.m., Resident #58's door was closed. Resident #58's call light was on the floor beside the bed and was out of reach. During a confidential group interview on 07/19/22 at 3:00 p.m., the residents said call lights were not been answered at night and sometimes staff put call lights out of reach. During an interview on 7/20/22 at 3:39 p.m., CNA C said all staff were expected to put the call lights within reach of the residents. CNA C said rounds should be made every 2 hours to ensure call lights were in reach. CNA C said Resident #4, #46, and #53 did not use their call light. CNA C said Resident #58 knew how to use her call light. CNA C said Resident #53 hollered out and would not use his call light if it was accessible. CNA C said Resident #4 addressed her concerns during rounds but did not holler out. CNA C said Resident #4 would not use her call light if it was accessible. CNA C said Resident #46 hollered out and would not use his call light if it was accessible. CNA C said Resident #58 knew how to use her call light and would use her call light if it was accessible. CNA C said even if residents could not use the call light it should still be in reach. CNA C said it was important for the call light to be in reach because it was their way calling out for help. CNA C said the call light should be clipped on their dominant side or on their sheet/pillow. CNA C said not having call lights in reach could result in falls. During an interview on 7/20/22 at 3:55 p.m., LVN A said all staff were expected to put the call lights within reach of the residents. LVN A said rounds should be made every 2 hours to ensure call lights were in reach. LVN A said Resident #4, #46, and #53 did not know how to use their call light. LVN A said Resident #53 hollers out and would not use his call light if it was accessible. LVN A said Resident #4 did not holler out and would not use her call light if it was accessible. LVN A said Resident #46 did not hollered out and would not use her call light if it was accessible. LVN A said Resident #4 and Resident #46's concerns were addressed during rounds. LVN A said Resident #58 knew how to use her call light and would use her call light if it was accessible. LVN A said it was important for the call light to be in reach so residents could call out for assistance. LVN A said all residents call lights should be in reach. LVN A said not having call lights in reach could result in falls and lack of care. During an interview on 7/20/22 at 4:59 p.m., the DON said she expected the nurses and CNAs to put the call lights within reach of the residents even if they could not use it. The DON said call lights being in reach was important for the resident to be able to have access to call out for assistance and comforting in knowing the call light was there to call out for help. The DON said not having call lights in reach could result in a fall and a need unnoticed until a routine check. She said it was her responsibility to ensure all direct care staff placed the call lights within reach of each resident. The DON said daily routine rounds were made by the ADON to ensure call lights were in reach. The DON said it was her understanding that rounds were made, and call lights were in reach. During an interview on 07/20/2022 at 4:59 p.m. a policy for answering the call light was requested from the DON but was not provided upon exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment, which allowed residents to use his or her personal belongings to the extent possible for 4 of 24 residents room (#'s 45,53,55 and 29) reviewed for environment. The facility failed to repair deep scrapped areas on the walls of resident room #'s 45, 53 and 55. The facility failed to ensure resident #29 wall behind the head of the bed had matching paint. These failures could place the residents at risk for embarrassment due to room not appearing homelike. Findings include: During an observation on 07/19/22 at 9:25 a.m., resident room [ROOM NUMBER] had deep scratches down to the sheet rock on the wall to the right side of the bed. During an observation on 07/19/22 at 9:53 a.m., resident room [ROOM NUMBER] had deep scratches down to the sheet rock at the head of the bed. During an observation on 07/19/22 at 10:11 a.m., resident room [ROOM NUMBER] had deep scratches down to the sheet rock above the baseboard next to the window. During an observation on 07/19/22 at 12:05 p.m., resident room [ROOM NUMBER] wall behind the head of the bed was painted green with repaired areas painted tan. During an interview on 07/20/22 at 4:36 p.m., the maintenance manager indicated he was responsible for ensuring the resident room walls were maintained in resident rooms #'s 29, 45, 53 and 55. He indicated he was aware of the maintenance issues in these rooms. The maintenance manager indicated he was advised of rooms needing repair by the staff by receiving work orders. The maintenance manager said due to other issues such as call light replacements, plumbing etc. he had not had the time to repair resident room #'s 29, 45, 53 and 55. The maintenance manager indicated this failure could cause residents to be embarrassed by their home appearing unmaintained. During an interview on 07/20/22 at 7:23 p.m., the ADM said he expected the resident rooms to be repaired. The ADM said the maintenance manager was responsible for ensuring resident room walls were maintained. The ADM indicated he was unaware of the damage and a plan would be put in place to repair and monitor resident rooms. The ADM indicated this failure could cause residents to be embarrassed by their home appearing unmaintained. During an interview on 07/20/2022 at 4:59 p.m. a policy for maintenance work orders was requested from the DON but was not provided upon exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents environment remained free from accident hazards as possible for 4 out of 16 (Resident #'s 55,45,38,18) residents reviewed for accident hazards. The facility failed to ensure Resident #55 was free from a household chemical containing bleach. The facility failed to ensure oxygen cylinders in Resident #'s 45, 38 and 18 room was securely stored. These failures could place residents at risk of injury. Findings include: 1. Record review of the order summary report dated 07/20/22 indicated Resident #55 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), obstructive sleep apnea (intermittent airflow blockage during sleep) and essential hypertension (force of the blood against the artery walls is too high). Record review of the quarterly MDS dated [DATE] indicated Resident #55 understood others and made herself understood. The MDS indicated Resident #55 was cognitively intact with a (BIMS score of 15). The MDS indicated she required limited assistance with bed mobility, transfers, dressing, toileting, and personal hygiene: extensive assistance with bathing. The MDS indicated Resident #55 had active diagnoses of hypertension, diabetes mellitus, dementia, and obstructive sleep apnea. Record review of the care plan dated 10/27/21 indicated Resident #55 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to dementia. The care plan interventions were to administer medications per physician's orders and monitor for unusual/adverse reactions and effectiveness. Report abnormal finding to the physician. During an observation on 07/18/22 at 9:35 a.m., comet cleaner with bleach was noted in Resident #55 personal bathroom. During an observation and interview on 07/19/22 at 10:11 a.m., comet cleaner with bleach was noted in the bathroom. Resident #55 said she used the comet to clean her toilet. Resident #55 was not able to state where she got the comet from. During an observation on 07/20/22 at 8:25 a.m., comet cleaner with bleach was noted in bathroom. During an interview on 07/20/22 at 3:33 p.m., Housekeeper D said she cleaned Resident #55 room today but did not notice the comet cleaner in her bathroom. Housekeeper D said all staff were responsible for ensuring chemicals and cleaning supplies were stored properly. Housekeeper D said comet cleaner should not be left in Resident #55 room. Housekeeper D said comet cleaner should be stored in the cleaning supply closet. Housekeeper D said this failure could cause an accidental poisoning to the resident. Record review of the facility's policy tilted Care, Cleaning and Storage of Equipment dated 2/11/22 indicated . cleaning carts should be stored in the housekeeping closet . Record Review of \\bdc-msdgen\hse_files\archives\msds pgp\default\00314806.pdf (pgproductsafety.com) accessed on 7/21/2022 revealed [NAME] & Gamble Professional Material Safety Data Sheet . 1. Product and Company Identification Material name PGP Comet Cleaner with Bleach - Ready to Use . 2. Inhalation-Health injuries are not known or expected under normal use. Irritating to mucous membranes. Ingestion-Health injuries are not known or expected under normal use. Ingestion may cause gastrointestinal irritation, nausea, vomiting and diarrhea .4. Ingestion-Drink a few glasses of water or milk. Do NOT induce vomiting. Get medical attention. 2. During an observation on 07/20/22 at 9:25 a.m., an oxygen cylinder was placed in the upright position leaning on the wall in Resident #45 and Residents #38 room. During an observation on 7/19/22 at 3:30 p.m., an oxygen cylinder was placed in the upright position leaning on the dresser in Resident #18 room. During an observation on 07/20/22 at 9:25 a.m., an oxygen cylinder was placed in the upright position leaning on the wall in Resident #45 and Residents #38 room. During an observation on 7/20/22 at 3:30 p.m., an oxygen cylinder was placed in the upright position leaning on the dresser in Resident #18 room. During an interview on 07/20/22 at 3:39 p.m., CNA C was unsure why the oxygen cylinders were in Resident #'s 45,38,18 room. CNA C said the oxygen cylinder in Resident #45 and Resident #38 room had been in there for approximately 2 months. CNA C indicated she was aware unsecured oxygen cylinders could become harmful if it were to fall. CNA C said she forgot to report to the charge nurse about the oxygen cylinder in Resident #45 and #38 room. CNA C said this failure could cause an explosion. CNA C said oxygen cylinders should be stored in the oxygen room on a cannister rack. CNA C said comet should not be left in Resident #55's reach. CNA C said she was unaware there was comet in her bathroom. CNA C said comet cleaner should be stored in the cleaning supply closet. CNA C said all staff were responsible for ensuring chemicals and cleaning supplies were stored properly. CNA C said this failure could cause an accidental poisoning to the resident. During an interview on 07/20/22 at 3:55 p.m., LVN A said she was Resident #55 6a-6p charge nurse. LVN A indicated she was unsure of why the oxygen cylinders were in Resident #'s 45,38,18 room. LVN A said she was unaware unsecured oxygen cannister could become harmful if it were to fall. LVN A said oxygen cylinders should be stored in the oxygen room on the storage rack. This failure could cause an injury. LVN A said she was unaware comet was been in Resident #55 bathroom. LVN A said comet should not be left in Resident #55 reach. LVN A said comet should be stored in the cleaning supply room. LVN A said all staff were responsible for ensuring chemicals and cleaning supplies were stored properly. LVN A said this failure could affect Resident #55 breathing and could cause chemical burns. During an interview on 07/20/22 at 4:59 p.m., the DON said she was unaware of the oxygen cylinders in Resident #'s 45,38,18 room. The DON said she was unsure of why the cylinders were in the rooms. The DON said she was unaware of the comet in Resident #55 bathroom. The DON said she believed Resident #55's daughter bought the comet to her. The DON said these failures provided an unsafe environment that could cause injury. The DON said she was responsible for monitoring to ensure this did not happen. The DON said daily rounds were done by the ADONs and RN supervisor to ensure there were no environmental risks. The DON said from her understanding rounds were made and a safe environment was provided for the resident. Record review of the facility's policy titled Oxygen Safety dated 2/11/22 indicated . safety is the responsibility of all staff, residents, visitors, and the general public . cylinders will be properly chained or supported in racks or other fastening (i.e., sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected full or empty .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days for 1 of 16 residents (Resident #48) reviewed for unnecessary medications. The facility failed to ensure Resident #48's PRN Ativan (anti-anxiety medication) medication was discontinued after 14 days or a documented rational for the continued provision of the medication was provided. This failure could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings include: Record review of the physician order report dated 07/20/22 indicated Resident #48 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar) and atrial fibrillation (irregular, often rapid heart rate). Record review of the admission MDS dated [DATE] indicated Resident #48 usually understood others and made herself understood. The MDS indicated Resident #48 was severely cognitively impaired with (BIMS score of 4). The assessment indicated Resident #48 did not reject care. The MDS indicated no physical or verbal behaviors directed towards others. The MDS indicated she required extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene: total dependence with bathing. The MDS indicated Resident #48 transferred 1-2 times during the assessment period. The MDS did not indicate Resident #48 received psychotropic medications. Record review of the care plan dated 01/05/22 did not address the diagnosis of anxiety. Record review of the MAR for the month of June 2022 indicated Resident #48 received 2 doses of Ativan on 6/4/22 and 6/23/22 with start date 5/17/22. Record review of the nursing progress notes failed to indicate a behavior or symptoms that warranted the use of the Ativan. Record review of the pharmacy recommendation dated 6/29/22 indicated a rationale was needed for extending beyond 14 days and expected length of therapy added to order. During an interview on 07/20/22 at 3:55 p.m., LVN A said the charge nurse was responsible for ensuring as needed orders were renewed and discontinued every 14 days for psychotropic drugs. LVN A said the DON was responsible for following up on pharmacy recommendations and as needed medications. LVN A indicated she did not realize Resident #48 as needed ordered had not been discontinued LVN A said she was unaware as needed orders should have been ordered for 14 days only. During an interview on 07/20/22 at 4:59 p.m., the DON said she was responsible for ensuring as needed orders were renewed or discontinued every 14 days for psychotropic drugs. The DON said she did not realize Resident #48's as needed order for Ativan had not been discontinued in June. The DON said she was responsible for following up on pharmacy recommendations and as needed medications. The DON said she knew as needed orders should have been ordered for 14 days only. She said failure to do so could result in over sedation or falls. The DON said nurses were responsible for documenting behaviors in the progress note. The DON said she did not know why there was no documentation regarding the administration of Ativan on 6/4/22 and 6/23/22. The DON said she had only worked in this position for 2 weeks, but she had an appointment with the pharmacy consultant on 07/27/22 to discuss a plan and review all the current recommendations and follow ups on any outstanding recommendations. Record review of the facility policy Antipsychotic Medication , revised on 02/10/20 indicated . it is the facility's policy that each resident's drug regimen is free from unnecessary drugs, including unnecessary antipsychotic drugs the acute treatment period will be limited to seven days or less; and a clinician in conjunction with the interdisciplinary team will evaluate and document the situation within 7 days to identify and address any contributing and underlying causes of the acute condition and verify the continuing need for an antipsychotic drug.

Based on observation, interview, and record review, in accordance with State and Federal laws, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys on 2 of 4 medication carts reviewed for labeling and storage of medication. The facility did not ensure the medication carts were secured and unable to be accessed by unauthorized personnel. This failure could place residents at risk for not receiving drugs and biologicals as needed or a drug diversion. Findings include: During an observation on 7/19/22 at 10:34 a.m. LVN G had the nursing medication cart for Hall 300/400 parked outside of a resident room. LVN G entered the resident room to perform a blood sugar check and left the keys to the medication cart lying on top of the cart with the medication cart unlocked. LVN G exited the room to retrieve the resident's insulin from the medication cart. LVN G re-entered the resident's room to administer the insulin and left the keys to the medication cart lying on top of the cart with the cart unlocked. During an observation on 7/19/22 at 10:39 a.m. LVN G had the nursing medication cart for Hall 300/400 parked outside of a resident room. LVN G entered the resident's room to wash her hands and left the keys to the medication cart lying on top of the cart with the medication cart unlocked. LVN G exited the room to retrieve the glucometer (machine used to measure blood sugar) from the medication cart. LVN G re-entered the resident's room to the blood sugar and left the keys to the medication cart lying on top of the cart with the cart unlocked. During an observation on 7/19/22 at 11:40 a.m. LVN G entered a resident room on the on the 300 hall to clean their bedside table prior to administering G-tube (a tube inserted through the belly that brings nutrition directly to the stomach) medications and left the keys to the medication cart lying on top of the cart with the cart unlocked. During an observation on 7/19/2022 at 9:45 p.m. the medication cart for Halls 200 and 300 was parked by the nurse's station and unlocked. During an interview on 7/19/2022 at 9:55 p.m. LVN H said she was responsible for ensuring the medication cart was locked. LVN H said she was responsible for the medication cart for Halls 200 and 300 during the night shift. LVN H said the potential harm to leaving the medication cart unlocked residents overdosing on medication or hurting themselves with needles. During an observation on 7/20/22 at 1:34 p.m. The nursing medication cart for Hall 300/400 was parked at the nurse's station. The nursing medication cart was unlocked with keys in the lock. During an interview on 7/20/22 at 1:36 p.m. LVN A said she did not always leave her keys in the lock and her cart unlocked. LVN A said she only left the keys in the lock and the cart unlocked to go around the nurse's station to get the phone. LVN A said it was important to not leave keys in the cart because of the residents (LVN A did not clarify what she meant by because of the residents). LVN A said she was sitting right there and was not going to let anyone get in the cart. LVN A said she would not have an emergency and have to go down the hall or step away from the medication cart (LVN A did not explain how she knew she would not have an emergency). During an interview on 7/20/22 at 2:43 p.m. MA J said she started at the facility approximately a week ago. MA J said the keys to the medication cart should not be left on top of the cart or in the lock of the cart. MA J said the medication carts should not be left unlocked. MA J said it was important to keep the medication cart keys secured and the medication carts locked was to prevent theft, prevent drug diversion, it was not ethical, and it was unsafe for the residents. During an interview on 7/20/22 at 2:57 p.m. LVN B said the keys to the medication carts should not be left on top of the cart or in the lock of the cart. LVN B said the medication carts should not be left unlocked. LVN B said it was important to keep the medication cart keys secured and the medication carts locked was to keep medications secured and prevent residents from taking medications they were not prescribed. During an interview on 7/20/22 at 3:26 p.m. the DON said medication carts should not be left with keys on top or in the lock with medication cart unlocked even when in line of site. The DON said it was the charge nurses who were responsible for ensuring medication carts were locked and keys were secured. The DON said it was important to ensure medication carts were locked and the keys were secured because of dangerous medication that needed to be kept safe. Record review of the facility's Medication Storage policy dated 1/20/2021 indicated, .All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Only authorized personnel will have access to the keys to the locked compartments. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 16 residents (Resident #39 and Resident #223) reviewed for transmission-based precautions. 1. The facility failed to ensure staff wore N95 masks while working on the COVID-19 (coronavirus disease 2019) positive unit. 2. The facility failed to ensure staff changed PPE (personal protective equipment) between residents who were on droplet isolation. 3. The facility failed to ensure isolation receptacles were easily accessible. These failures could place residents at risk for being exposed to health complications and infectious diseases. Findings include: 1. Record review of Resident #39's face sheet, dated 7/20/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included dementia (memory loss), weakness, major depressive disorder (mental disorder with persistently depressed mood or loss of interest in activities and affects daily life), high blood pressure, and kidney disease. Record review of Resident #39's quarterly MDS, dated [DATE], revealed the resident was unable to complete the BIMS (Brief Interview for Mental Status). The MDS indicated the resident required extensive assistance of two persons for most ADLs (activities of daily living). Record review of Resident #39's order summary report, dated 7/20/22, revealed an order for droplet precautions, isolation related to positive COVID-19 status for ten days with an order date of 7/11/22. Record review of Resident #39's care plan read in part: Problem #1: Resident #39 was at risk for infection/signs and symptoms of COVID-19. Goal: Resident #39 will not exhibit signs/symptoms of COVID-19 through next review date. Approach: Educate staff, resident, family, and visitors of COVID-19 signs, symptoms, and precautions; follow facility protocol for COVID-19 screening/precautions; observe for and promptly report signs and symptoms of fever, coughing, shortness of breath, or other respiratory issues; provide alternate methods of communications with family/visitors; resident will wear mask for precaution. Problem #2: Resident #39 has diagnosis of COVID-19 and was at risk for respiratory complications, dehydration, pain and discomfort, unintended weight loss; required isolation and was at risk for loneliness, anxiety, and sadness related to isolation precautions. Goal: Resident #39 will maintain airway and oxygen exchange, be hydrated, be comfortable, will have support as needed for feeling of loneliness, anxiety, and sadness; food and fluid of choice as she was able to tolerate. Approach: Activities to help the resident maintain engagement and provide a calming atmosphere as preferred by the resident; administer oxygen as needed; droplet/contact precautions as ordered; maintain an environment conducive to rest and sleep; one on one visits with staff for resident desired activity; oral care as needed; turning and repositioning per schedule and as needed. 2. Record review of Resident #223's face sheet, dated 7/20/22, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included pleural effusion (a buildup of fluid between the tissues that line the lungs and chest), paroxysmal atrial fibrillation (occasional irregular often rapid heart rate that commonly causes poor blood flow), cerebrovascular disease (damage to the brain from interruption of its blood supply), heart failure, high blood pressure and major depressive disorder (mental disorder with persistently depressed mood or loss of interest in activities and affects daily life). Record review of Resident #223's admission MDS, dated [DATE], revealed the resident had a BIMS of 15, which indicated she was cognitively intact. The MDS indicated the resident required supervision to limited assistance of one person for most ADLs. Record review of Resident #223's order summary report, dated 7/20/22, revealed an order for droplet precautions, isolation related to positive COVID-19 test for ten days with an order date of 7/11/22. Record review of Resident #223's care plan read in part: Problem #1: Resident #223 was at risk for infection/signs and symptoms of COVID-19. Goal: Resident #223 will not exhibit signs/symptoms of COVID-19 through next review date. Approach: Educate staff, resident, family, and visitors of COVID-19 signs, symptoms, and precautions; follow facility protocol for COVID-19 screening/precautions; observe for and promptly report signs and symptoms of fever, coughing, shortness of breath, or other respiratory issues; provide alternate methods of communications with family/visitors; resident will wear mask for precaution. Problem #2: Resident #223 had impaired respiratory status and was at risk for shortness of breath, respiratory distress, increased anxiety, and hypoxia related to a diagnosis of pleural effusion. Goal: Resident #223 will have no reports of unrelieved shortness of breath through the next review date. Approach: Monitor for shortness of breath, respiratory distress, wheezing, fatigue, increased anxiety, and implement appropriate ordered interventions; assess lung sounds and monitor vital signs per physician orders. During an observation and interview on 7/18/22 at 2:05 PM revealed CNA S on the COVID-19 positive unit wearing only a KN95 mask and goggles in the hallway. She said she was assigned to the COVID-19 unit only. She said she entered and exited the facility from the door at the end of the hallway. She said she performed all CNA duties and housekeeping duties on the COVID unit. She said she had Resident #39 and Resident #223 on the COVID-19 unit. During an observation on 7/18/22 at 2:15 PM, revealed Resident 223's bed was on the wall closest to the door. Observed the isolation trash receptacles against the wall in the middle of room away from door and on the opposite side of the resident's bed. During an observation on 7/18/22 at 2:22 PM revealed Resident #39's bed was on the wall closest to the door. The isolation trash receptacles were against the wall in the middle of room away from door and on the opposite side of the resident's bed. During an observation and interview on 7/19/22 at 9:31 AM revealed CNA S, on the COVID-19 positive unit wearing a KN95 mask, goggles, and gown in the hallway. She said she was told by upper management that morning, she had to wear a gown, mask, and goggles all the time on the COVID positive unit and only had to discard her gloves when coming out of the resident's room. She said yesterday she was told she only had to wear her mask and goggles unless she was going into a resident's room, then she would need to put on full PPE (gown, gloves, mask, goggles, or a face shield). During an observation and interview on 7/19/22 at 10:33 AM with CNA S, she said she would wear the KN95 mask, gown, goggles, and she would put on gloves to provide care to residents. She said upper management told her she only had to doff her gloves in the resident's room and did not need to change her gown in between residents on the Covid-19 unit, unless her gown became soiled. During an observation on 7/19/22 at 12:20 PM, revealed CNA S took a disposable food tray into Resident #39's room wearing a gown, gloves, goggles, and a KN95 mask. She exited the room at 12:23 PM wearing all PPE except gloves. At 12:23 PM, observed CNA S sanitize her hands then she put on new gloves, wearing the same gown she had worn into Resident #39's room, a KN95 mask and goggles, took Resident #223's disposable food tray into her room and then exited the room at 12:25 PM wearing the same gown, KN95 mask and goggles. She had removed her gloves prior to exiting the room. During an observation on 7/19/22 from 2:41 PM-2:50 PM revealed CNA S entered Resident #39's room wearing a KN95 mask, gown, goggles, and gloves. She pulled back the resident's covers, removed the pillow between the resident's knees, then leaned in close to resident's face to talk to her due to the resident was hard of hearing. CNA S then repositioned the resident to the opposite side and repositioned with placing a pillow between her knees, a pillow behind her back, then repositioned her pillow under the resident's head, then covered her back up, and raised the head of bed. Prior to leaving the resident's room, she leaned in close to resident's face and asked her if she was okay in that position and the resident said yes and nodded her head. CNA S then discarded her gloves in the isolation receptable in the middle of the room against the wall and left the room wearing her gown into the hallway and did not doff her gown. She said upper management told her she did not need to change her gown between residents on the Covid-19 unit unless it became soiled. During an observation 7/20/22 at 9:00 AM revealed CNA S on the COVID-19 positive unit wearing a KN95 mask, gown, and goggles in the hallway. During on observation on 7/20/22 at 5:15 PM, observed LVN A enter Resident #223's room on the Covid-19 positive unit with a cup of water and small cup with medication wearing a KN95 mask, face shield, gown, and gloves upon entrance. She exited the room at 5:21 PM wearing KN95 mask and face shield. During an interview on 7/19/22 at 3:54 PM with CNA S in the Covid-19 staff break room, she said she was designated to the COVID positive unit. She said she should be wearing a N95 mask on the COVID unit. The state surveyor asked her what type mask she has been wearing and she said a N95, then took her mask off and looked at it and she said, this says it is a KN95. She said she thought it was a N95 mask and she had gotten it from upfront. During an observation and interview on 7/19/22 at 9:05 PM, revealed CNA C walked from the 300 hall toward the 200 hall, then she walked through the foyer to the screening table by the front door without wearing a mask. Observed her put on a mask at the screening table by the front door, then she let the state surveyors enter the building and were screened at the screening table. She said she was supposed to be wearing a mask at all times in the building and it was her fault she did not have a mask on. She said she could spread infection by not wearing her mask. During an interview on 7/20/22 at 9:15 AM with the DON, she said she did a root cause analysis of the COVID positive residents. She said Resident #223 was admitted from the hospital on 7/6/22 and tested positive on 7/11/22 and could have been exposed to COVID-19 in the hospital. She said Resident #39 had not left the building and tested positive on 7/11/22. She said she had 3 staff test positive for COVID-19 on 7/4/22, 7/5/22, and 7/6/22. She said the positive staff of 1 housekeeper and 2 direct care staff had worked the 100 hall where both residents had been prior to moving to the COVID-19 unit on 7/11/22. She said Resident #39 probably caught COVID-19 from the staff at the facility. She provided the state surveyor with the COVID Outbreak positive list which revealed a total of 3 residents and 5 staff members had tested positive from 7/4/22-7/14/22. During an observation and interview on 7/20/22 at 2:14 PM, revealed CNA T wore a KN95 mask, goggles, and a gown on the COVID-19 positive unit. CNA T said she worked at the facility for a little over a year. She said on the COVID-19 unit, staff should wear a mask, goggles, gloves, and a gown. She said staff should dispose of PPE in the biohazard receptacles in the room prior to leaving the resident's room. She said staff should wear a KN95 mask on the COVID-19 positive unit. During an interview on 7/20/22 at 2:28 PM with CNA U, she said she started working at the facility on 7/11/22 and normally worked the 200 hall or the COVID unit. She said when she worked the COVID unit, she had to wear gown, gloves, goggles, or a face shield. She said staff should wear a N95 mask on the COVID-19 unit, the one that goes over your head and not the one that goes over the ears like this one (KN95). During an interview on 7/20/22 at 2:35 PM with LVN A, she said she worked at the facility for almost 10 years. She said staff should wear a gown, gloves, and a mask on the COVID unit. She said staff should wear an N95 mask on the COVID unit, but it was okay to wear a KN95 on the COVID unit with a face shield and that was what she did. During an interview on 7/20/22 at 2:45 PM with RN V, she said she started at the facility 4/22, and staff should be wearing N95 masks on the COVID-19 unit and don (put on) and doff (take off) PPE in the room into the isolation biohazard receptacles. She said she always wore the N95 mask to protect herself and residents from exposure to COVID infection. During an interview on 7/20/22 at 4:10 PM with the DON, she said she had worked at the facility for about a year. She said she had been the MDS (Minimal Data Set) coordinator and had been the DON for only two weeks. She said staff should be wearing proper PPE, gowns, gloves, face shield or googles, and mask N95 or KN95 on the COVID unit. She said if there was an outbreak in the facility, all staff should be wearing KN95 masks. She said if staff were not wearing the proper PPE, it placed the residents and staff members at risk of exposure and/or infection of COVID. During an interview on 7/20/22 at 7:10 PM with the Administrator, he said staff should be wearing KN95 or N95 in the facility during an outbreak. He said he didn't know what the policy on the infection control mask requirements for the COVID-19 positive unit were, he said he thought it was a KN95 or N95. He said if staff did not wear the proper PPE, it placed the residents at risk of the spread of infection/COVID. Record review of the COVID Outbreak COVID positive list, labeled, dated, and provided by the DON on 7/20/22, revealed four staff members on the 100 hall had tested positive for COVID from 7/4/22 through 7/6/22 and Resident #39 and Resident #223 had tested positive 7/11/22. Record review of the facility in-service titled Donning and Doffing PPE in cold, warm, and hot areas, dated 7/19/22, revealed . staff are required to Donn (put on) PPE prior to entering covid hot (positive) area and doff (take off) PPE before you leave the covid hot area Record review of the facility in-service titled Infection Control (COVID-19)-Mask wearing, stop the spread, symptoms of COVID, PPE use, dated 2/18/22, revealed . preferred PPE use of a N95 mask or higher respirator when available, gown, face shield or goggles, and gloves Record review of the facility in-service titled Door screening, dated 1/14/22, revealed . all staff must wear masks . if caught without a mask, staff will be verbally warned then next time written up Record review of the facility's infection control policy titled Clinical Practice Guidelines Infection Control with revision date of 9/22/2017 revealed, . The purpose of this policy is to reduce and prevent the spread of infections by the use of evidenced based techniques established infection control policies and procedures . single use devices must be discarded after use and are never used for more than one resident Record review of CDC COVID Data Tracker: County View dated 7/21/22 revealed . the county the facility was located had a high COVID-19 Community level calculated from using data from 7/13/22 to 7/19/22 . Record review of the Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) | CDC last updated 2/2/22, revealed . recommended infection prevention and control practices when caring for a patient with suspected or confirmed SARS-CoV-2 (coronavirus disease 2019) infection . healthcare personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH (National Institute for Occupational Safety and Health) approved N95 or equivalent or higher level respirator, gown, gloves, and eye protection