**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 and follow infection control policies and procedures for 1 of 7 residents reviewed for infection control. (Resident #1) The facility failed to follow infection control guidelines and procedures when CNA B and CNA C performed catheter care for Resident #1 without donning appropriate PPE. The facility failed to follow infection control guidelines and procedures when CNA B and CNA C removed Resident #1's brief and performed catheter care without changing gloves, washing, or sanitizing their hands. This deficient practice could place residents at risk for cross contamination and/or spread of infection. Findings include: Record review of Resident #1's undated face sheet indicated she was an [AGE] year-old female admitted on [DATE] with diagnoses of chronic atrial fibrillation (irregular heartbeat), dementia (decline in cognitive function), acute cystitis (bladder inflammation), and chronic kidney disease. Record review of an MDS dated [DATE] indicated Resident #1 had a BIMS score of 9 which indicated moderate cognitive impairment, and she required assistance for ADLs. She required maximal assistance for bathing, upper and lower body dressing, and putting on and taking off footwear; she required set-up assistance for oral hygiene, eating, and personal hygiene; she was dependent on staff assistance for toileting hygiene. She was always incontinent of bowel and had an indwelling foley catheter (tube that drains urine from your bladder). Record review of a comprehensive care plan revision on 10/07/2024 indicated Resident #1 had an indwelling foley catheter related to urinary retention and she was on enhanced barrier precautions (a set of infection control measures that use gowns and gloves to reduce the spread of MDROs. There were care interventions in place indicating gloves and gown should be donned if catheter care is to occur. During an observation on 2/18/25 at 10:00 AM, CNA B and CNA C performed catheter care for Resident #1 without donning protective gowns. Prior to performing catheter care CNA B and CNA C removed the briefs Resident #1 was wearing and did not change gloves, wash hands, or sanitize hands before cleaning Resident #1's perineal area and foley catheter tubing. During an interview on 2/18/25 at 11:00 AM, CNA B said she received training in incontinent care and catheter care and had successfully passed yearly skills competency evaluations to be able to work on the floor. She said she should have removed Resident #1's brief prior to washing her hands and starting catheter care. During an interview on 2/18/25 at 11:15 AM, CNA C said she received training in incontinent and catheter care and passed a skills competency check prior to being able to work by herself. She said she should not have moved from a dirty area to a clean area while performing catheter care. During an interview on 2/18/25 at 2:30 PM, Treatment Nurse said all staff receive training in skills competencies and were checked off on each skill prior to being able to work on the halls. She said all residents who are on special precautions have a sign outside of their room, by the door, and staff were trained and expected to wear appropriate PPE when performing care activities for those residents. During an interview on 2/18/25 at 4:20 PM, LVN D said all nursing staff were trained in incontinent care, catheter care, and PPE use. She said staff were educated to identify residents with special precautions by looking for signs outside of their rooms and for bins with PPE supplies by door. She said CNAs were expected to wear the appropriate PPE when caring for residents with special precautions. During an interview on 2/18/25 at 5:00 PM, the DON said every CNA was trained and checked off by a nursing supervisor on all skills before being cleared to work. She said CNAs were trained to identify residents with special precautions by looking for signs and bins of PPE supplies by resident room doors. She said staff were expected to utilize PPE as necessary and to follow infection control guidelines and procedures. She said not wearing PPE and not following infection control guidelines puts residents at risk for infection. She said going forward she intended to in-service all direct care staff concerning cross-contamination and PPE usage. During an interview on 2/19/25 at 8:30 AM, the ADM said all employees received required training including incontinent care, catheter care and PPE use, and were in-serviced regularly. He said as the ADM he was responsible for ensuring all staff have completed required training. He said all direct care staff were educated about residents that require PPE for their care and signs are posted outside of resident's room to identify that need. Review of a CNA Proficiency Audit dated 10/29/24 indicated CNA B had successfully demonstrated all required skills and proficiencies. The audit was signed by ADON. Review of an undated CNA Proficiency Audit indicated CNA C had successfully demonstrated all required skills and proficiencies. The audit was signed by DON. Review of a facility policy titled Infection Control Plan: Overview last revised on 03/2024 indicated .The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection . Review of a facility policy titled Enhanced Barrier Precautions last revised on 4/1/24 indicated .EPB are used in conjunction with standard precautions and expand the use of PPE to donning gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and for 1 of 7 residents reviewed for physical environment. (Resident #3) The facility failed to ensure access to warm water for showering for Resident #3. This failure placed all residents in the facility at risk for discomfort, potential skin irritation, and a decline in the resident's quality of life. Findings: Record review of Resident #3's undated face sheet indicated he was an [AGE] year-old male admitted on [DATE] with diagnoses of left femur fracture, prostate cancer, and generalized muscle weakness. Review of an MDS dated [DATE] indicated Resident #3 had a BIMS score of 0 which indicated severe cognitive impairment, and he required assistance for ADLs. He required maximal assistance with toileting hygiene, shower/bathing, lower body dressing, and putting on/taking off footwear; he required moderate assistance with upper body dressing and personal hygiene; he required supervision for oral hygiene; he required setup assistance with eating. He was always incontinent of both bowel and bladder. Review of the comprehensive care plan revised on 10/21/24 indicated Resident #3 had impaired cognitive function and had an ADL self-care performance deficit. Care interventions in place included provide the resident with a homelike environment the resident prefers, and bathing assistance of 1-2 staff as needed. During an interview on 2/18/25 at 3:30 PM, CNA F said on 10/24/24 she and CNA G did assist Resident #3 with a shower. She said prior to starting Resident #3's shower she felt the water temperature with her hand, and it was warm. She said that CNA G and LVN D also verified the water was warm. She said LVN D asked Resident #3 to feel the shower water temperature and he said it was okay. She said there was no indication from Resident #3 that he was uncomfortable at any time. During an interview on 2/18/25 at 4:00 PM, LVN D said on 10/24/24 CNA F and CNA G took Resident #3 into the shower, and she went with them to cover a wound dressing on his leg so it would not get wet. She said Resident #3 appeared to be in good spirits when she left. She said Resident #3's sitter called her back to his room because he seemed uncomfortable. She said she asked Resident #3 what was wrong, and he said the water was too cold. She said she felt the water temperature with her hand, and it was cool, but not cold. She said she instructed CNA F and CNA G that if the water did not warm up, they would have to take Resident #3 to another room to shower. During an interview on 2/19/25 at 8:30 AM, the Maintenance Supervisor said the facility began having problems with the hot water on hall 400 toward the end of 2023, and he had a plumbing service company replace a mixing valve. He said he first became aware of new issues with water temperature after the incident on 10/24/24 and he assessed and adjusted the mixing valve himself. He said he checked a sample of rooms on each hallway every week and had not identified any new problems with the hot water supply. During an interview on 2/19/25 at 9:00 AM, the ADM said he was not aware of any problems with the water temperatures in resident rooms because he had only been working at the facility for 4 months. He said the Maintenance Supervisor kept a recorded log of water temperatures in resident rooms and should be checking every week to assure appropriate water temperatures. He said the facility suspended CNA F and CNA G from working at the facility until they completed individual counseling and 1-on-1 in-services related to ensuring that water temperatures are at a comfortable level for residents before beginning a bath or shower. Review of Water Temperature Logbook from 10/22/24 to 2/04/25 indicated all sampled resident rooms had warm water of appropriate temperature. Review of policy titled Resident Rights revised 11/2021 indicated residents .have the right to live in safe, decent, and clean conditions . and .have the right to make your own choices regarding personal affairs, care, benefits, and services .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 7 residents reviewed for pharmacy services. (Resident #1) The facility failed to provide a physician ordered medication of Estrace (estradiol), which was ordered to help reduce the thinning of vaginal and pelvic tissues, to Resident #1 for 32 days. This failure could place residents at risk for exacerbation of diagnoses or increased complications. Findings include: Record review of Resident #1's undated face sheet indicated she was an [AGE] year-old female admitted on [DATE] with diagnoses of chronic atrial fibrillation (irregular heartbeat), dementia (decline in cognitive function), neuromuscular dysfunction of bladder (nerves unable to communicate with muscles in the bladder), and chronic kidney disease. Review of an MDS dated [DATE] indicated Resident #1 had a BIMS score of 9 which indicated moderate cognitive impairment, and she required assistance for ADLs. She required maximal assistance for bathing, upper and lower body dressing, and putting on and taking off footwear; she required set-up assistance for oral hygiene, eating, and personal hygiene; she was dependent on staff assistance for toileting hygiene. She was always incontinent of bowel and had an indwelling foley catheter (tube that drains urine from your bladder). Review of a physician order dated 1/17/25 from an Obstetrics/Gynecology office indicated Resident #1 had a vaginal prolapse (weakened pelvic muscles allow pelvic organs to drop from their position) and a new medication order for Estrace (estradiol) Vaginal Cream 3 times a week was sent to the facility. Review of an Order Summary Report of Active Orders as of 2/18/25 indicated there was no pharmacy order for Estradiol. During an interview on 2/18/25 at 9:45 AM, Resident #1 said she had been to her Gynecologist (medical professional who specializes in the healthcare of the female reproductive system) last month and he sent the facility an order for an estrogen cream, but the facility was not administering it to her, and she did not know why. She said she had not discussed the medication with facility staff. During an interview on 2/18/25 at 4:00 PM, LVN D said she was familiar with Resident #1 and cared for her regularly. She said to her knowledge Resident #1 had never been ordered Estradiol and had not received it at the facility. She said orders received by telephone, fax, or electronically are entered into the resident chart by the nurse who received it. During an interview on 2/18/25 at 4:20 PM, LVN E said she knows Resident #1 and does not remember seeing an order for Estradiol in her chart. She said if a resident receives a medication order from an outside provider it should be entered into the resident chart by the nurse who received the order. During an interview on 2/18/25 at 5:00 PM, the DON said she was not aware Resident #1 ever received an order for Estradiol. She said the nurse who received the order should have entered it into the resident chart so the pharmacy could fill the medication order. During a second interview on 2/19/25 at 8:15 AM, the DON said the facility had corrected the deficiency and Resident #1 would begin receiving Estradiol that evening. She said going forward she would personally review all new orders daily and will in-service all nurses on entering physician orders. During an interview on 2/19/25 at 8:30 AM, the ADM said the charge nurse on duty who received the new physician order was expected to enter it into the resident chart. He said nursing managers should have been checking to ensure all new orders are entered correctly. He said the risk to residents not receiving ordered medications could vary from none to severe harm, depending on what the medication was and for what it was prescribed. Review of undated Pharmacy Policy & Procedures Manual 2003 indicated the following: .NEW VERBAL/TELEPHONE The nurse documents an order on the telephone order sheet or enters the order into PCC

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to resident 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 for 2 of 10 residents (Resident #3 and Resident #18) reviewed for call lights. The facility failed to ensure the emergency call light in Resident #3's and #18's shared bathroom was accessible from the floor on 10/7/24. These failures could affect residents who used their call lights or desire to use the call lights and place them at risk of not being able to notify staff of their needs. Findings include: Record review of a facility face sheet dated 10/7/24 for Resident #3 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: type 2 diabetes (uncontrolled blood sugar) and muscle wasting and atrophy (the loss of muscle mass and shortening of muscle fibers). Record review of a comprehensive MDS assessment dated [DATE] for Resident #3 indicated that she had a BIMS score of 11, indicating that she had moderately impaired cognition. She required moderate to maximal assistance with toileting hygiene and personal hygiene. She required partial/moderate assistance with toileting transfers. She was frequently incontinent of bladder and bowel. Record review of a comprehensive care plan dated 7/30/24 for Resident #3 indicated that she was at risk for falls and had an intervention that read: .be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . Record review of a facility face sheet dated 10/7/24 for Resident #18 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: anemia (a condition where your blood produces a lower-than-normal amount of healthy red blood cells, leading to a lack of oxygen in the body), hypertension (high blood pressure), and myocardial infarction (heart attack). Record review of a comprehensive MDS assessment dated [DATE] for Resident #18 indicated that she had a BIMS score of 9, indicating that she had moderately impaired cognition. She required moderate to partial assistance with toileting and supervision/touching assistance with personal hygiene. She required partial/moderate assist with toilet transfers. She was occasionally incontinent of bladder and frequently incontinent of bowel. Record review of a comprehensive care plan dated 8/13/24 for Resident #18 indicated that she was at risk for falls and had an intervention that read .be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . During an observation and interview on 10/7/24 at 11:01 am the emergency call light in Resident #3's and #18's shared bathroom was observed with no string on the emergency call light. Resident #18 said that she did use the restroom independently and had not had any falls in the restroom. When exiting room, Resident #18 was observed ambulating into the restroom independently. CNA C was observed entering the room to assist the resident. During an observation on 10/7/24 at 11:28 am Resident #3 was observed ambulating independently into the restroom. During an interview on 10/7/24 at 10:38 am CNA C said that she had been employed here about a month. She said she would have maintenance fix the call light string. She said if a resident were to fall in the restroom, they would need to be able to reach the light to call for help. If they could not reach the light, they would be unable to call for help. During an interview on 10/9/24 at 11:28 am the Administrator said all staff were responsible for checking for bathroom call lights during their rounds. He said maintenance was responsible for installing the call light strings. He said residents could be at risk of a number of things and if they were in distress, the distress could escalate if they were not able to call for help. He said going forward they would be in-servicing the staff and making sure that administrative staff checked the call lights during their Champion Rounds and discuss the findings in the daily morning meetings. During an interview on 10/9/24 at 11:39 am the DON said all staff would be responsible to check the call lights during their Champion Rounds. She said a resident could potentially fall and not be able to call for help. She said they could possibly lay there for a long time. She said going forward they would be holding in-services and checking during their rounds. During an interview on 10/9/24 at 11:45 am the Maintenance Man said that he was responsible for ensuring the call lights were installed and functional. He said a resident could lay there a while without being able to call for help if they fell. He said he would be in-servicing staff and checking lights to ensure strings were there. Record review of a facility policy titled Resident Rights undated, read .the resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #15) reviewed for infection control. CNA D did not wash or sanitize her hands when changing gloves while performing foley catheter care for Resident #15. CNA D wiped down the catheter tubing and without changing the washcloth picked up the washcloth and started at the top of the catheter and wiped down again while performing catheter care for Resident #15. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: 1. Record review of a Face Sheet dated 10/08/2024 for Resident # 15 indicated he admitted to the facility on [DATE] and was [AGE] years old. His diagnoses included dementia (a decline in cognitive abilities), acute cystitis with hematuria (irritation of the bladder with blood in the urine), and encephalopathy (brain dysfunction). Record review of a Care Plan dated 2/20/2022 for Resident # 15 indicated he had an indwelling suprapubic urinary cathete r with interventions to position catheter bag and tubing below the level of the bladder and in a privacy bag. Record review of a Quarterly MDS dated [DATE] for Resident # 15 indicated a BIMS score of 12 which indicated moderate cognitive impairment. He required substantial to maximal assistance with dressing, toileting hygiene, and showering. He was always incontinent of bowel and bladder. During an observation on 10/8/2024 at 2:02 pm in Resident # 15's room revealed, CNA D and LVN E were present to provide foley catheter care. Both staff washed their hands in the bathroom of Resident # 15's room and donned gloves. CNA D and LVN E positioned Resident # 15 in supine position to perform his foley catheter care. CNA D removed the blanket from Resident # 15. CNA D removed a washcloth from a basin on the over the bed table and began cleaning around the foley catheter insertion site working in a downward motion. CNA D after wiping downward on the catheter tubing picked up the washcloth and without turning the washcloth started back at the top of the catheter tubing wiping in a downward motion again. CNA D doffed gloves and without washing hands or sanitizing donned new gloves. CNA D then began drying the catheter tubing wiping in a downward motion and without turning the towel started back at the top of the catheter again wiped in a downward motion. CNA D then applied barrier cream around the catheter insertion site and on the catheter tubing. CNA D then retrieved trash bag with dirty linens and removed them from Resident #15's room. Both CNA D and LVN E went to the hall shower room across from Resident # 15's room and washed hands. During an interview on 10/08/2024 at 2:31 PM, LVN E said when asked if CNA D should have done anything differently with the foley catheter care provided to Resident #15, she said she should not have put barrier cream around the foley catheter insertion site and catheter tubing. She said CNA D had wiped down the catheter tubing without changing to a clean portion of the washcloth. She said while drying the catheter she wiped in a downward motion and without changing to a clean portion of the towel and started back at the top of the catheter tubing and wiped down again. She said she did notice that CNA D did not wash or sanitize her hands between glove changes . LVN E said CNA D's failures could cause the resident to get an infection. During an interview on 10/08/2024 at 2:37 PM, CNA D said after the catheter care while her and LVN E were washing their hands in the shower room, LVN E told her she should not have put barrier cream around the foley catheter insertion site and catheter tubing. She said she was nervous and had hand sanitizer in her pocket but had forgotten to use it in between glove changes. She said she always got confused when she tried to fold the washcloth to use it multiple times and must have forgotten to fold the washcloth to a clean area when she was wiping the catheter tubing . CNA D said by not using the correct procedure could cause the resident to get an infection. Record review of C.N.A Proficiency Audit dated 9/16/2024 for CNA D indicated she had been trained and had demonstrated handwashing and male foley catheter care procedure in accordance with the facility's standard of practice. During an interview on 10/09/2024 at 11:32 AM, the Administrator said the nurse managers were responsible for training CNA's in performing catheter care. He said going forward there would be a plan in place for training CNA's to properly perform catheter care. He said the potential risk if catheter care was not performed correctly was a possible infection for the resident. During an interview on 10/09/2024 at 11:35 AM, the DON said the nurse managers were responsible for making sure CNAs are trained properly to perform catheter care. She said if catheter care was not done properly the resident would be put at risk for infection at the catheter insertion site and internally. She said all nursing staff would be educated on infection control and catheter care with check offs. Record review of a facility policy titled Catheter Care with a revised date of February 13, 2007, indicated, .16. Gently wash, rinse and dry around the juncture of the catheter and meatus . 17. Then wash the catheter from the meatus down the tube about 3 inches. 18. Dispose of wash cloths. 19. Remove gloves. 20. Straiten clothing and bedding. 21. Wash Hands .

Based on observations, interviews, and record review, the facility failed to follow their own established smoking policy for 1 of 1 smoking area reviewed for smoking. The facility failed to follow their policy on smoking on 10/08/24 when an empty cigarette package and paper towels were observed in an ashtray in smoking area. These failures could place residents at risk of injury, burns, and an unsafe smoking environment. Findings included: During an observation on 10/08/24 at 9:35 am a tall silver and black metal ashtray with a push button that emptieds the contents of the upper portion of the ashtray to the lower portion of the ashtray was observed in smoking area. When the lid to the trash can was opened, an empty cigarette package and paper towels were observed in the bottom of the ashtray with multiple used cigarette butts. There was a separate red metal trash can with a pad lock securing it closed. During an interview on 10/08/24 at 9:40 am the Maintenance Director said the previous housekeeping supervisor had the key to the red metal trash can and usually emptied the red trash can. He said the previous housekeeping supervisor had not worked at the facility for the last 3 to 4 weeks therefore it had not been emptied. He said he was looking for the key but had not been able to locate it. He said starting that day he would be emptying the ashtray and the red metal trash can. He said there should not have been an empty cigarette pack or paper towels in the ashtray because it was a fire hazard. During an interview on 10/09/24 at 11:28 am the Administrator said the previous housekeeping supervisor was responsible for emptying the ashtray and red metal trash can. He said they were going to have to figure out a plan because the administrator had the only key to the red metal trash can. He said he talked to housekeeping yesterday and they would be taking responsibility for that task. He said the potential risk for an empty cigarette package and paper towels being in the ashtray was that it could have caused a fire. Record review of a facility policy titled Smoking Policy dated 11/1/17 read . ashtrays on noncombustible materials and safe design will be provided in all areas where smoking is permitted. Ashtrays will be a metal container with a self-closing cover device into which ash trays may be emptied. Ashtrays will be readily available in all areas where smoking is permitted .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents (Resident # 9 and Resident # 25) reviewed for quality of care. The facility failed to ensure Residents # 9 and Resident # 25's indwelling catheters (drains urine from your bladder into a bag outside your body) had a securement device to anchor their catheters. This failure could place residents at risk for urinary tract infections and catheter related injuries. Findings: 1.Record review of a facility face sheet dated 10/7/24 for Resident # 9 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: type 2 diabetes (uncontrolled blood sugar), hypertension (high blood pressure), and chronic kidney disease (a gradual loss of kidney function that can lead to kidney failure). Record review of a Quarterly MDS assessment dated [DATE] for Resident # 9 indicated that she had a BIMS score of 9, indicating that she had moderately impaired cognition. Section H (Bladder and Bowel) indicated that she had an indwelling catheter. Record review of a comprehensive care plan dated 9/17/24 for Resident # 9 indicated that she had an indwelling catheter and had an intervention that read: .ensure tubing is anchored to the resident's leg or linens so that tubing is not pulling on the urethra . Record review of a physician's order summary report dated 10/7/24 for Resident # 9 indicated that she had the following order dated 3/15/24: .Ensure catheter strap in place and holding every shift . During an observation and interview on 10/7/24 at 3:46 pm Resident # 9 was observed lying in bed. She had no strap or anchor on the catheter tubing. She said she could not remember the last time she had one on it. She said it felt a little uncomfortable when moving because it felt like it was pulling on her bladder. 2. Record review of facility face sheet dated 10/07/2024 revealed Resident # 25 was an [AGE] year-old male that admitted on [DATE] with diagnoses of encephalopathy (a brain disease that alters brain function or structure), diabetes (high blood glucose), and urinary retention (difficulty emptying bladder). Record review of admission MDS assessment dated [DATE] revealed Resident # 25 had a BIMS score of 04, indicating severe impairment in thinking. Section H (bladder and bowel) indicated indwelling catheter was present at the time of MDS. Record review of comprehensive care plan initiated on 09/26/2024 and revised 10/01/24 revealed Resident # 25 had an indwelling catheter at the time the care plan was initiated with intervention to ensure tubing was anchored to the resident's leg or linens so that the tubing was not pulling on the urethra. Record review of the physician order summary, indicated an order dated 09/26/24 that read: Resident # 25 may have an indwelling catheter and had an order to . Ensure catheter strap in place and holding, every shift change as needed . Resident #25 had an order with a revision date of 10/07/2024 to . ensure catheter strap in place and holding every shift until 10/11/24. Record review of nurses note dated 09/27/24 revealed Resident # 25 admitted from the hospital on [DATE] with an indwelling catheter due to urinary retention. Record review of a Treatment Administration Record (TAR ) for Resident #25 for 10/01/24 to 10/07/24 had no indication for monitoring placement of a catheter strap. Record review of nurses note dated 10/08/224 read: Urology faxed orders for foley catheter to be discontinued 10/11/24 @0800. Resident has appointment with urology that same day AT 1515. NP notified; family aware . During an observation and interview on 10/07/24 at 10:15 am, Resident # 25 had an indwelling catheter present in a privacy bag and the tubing was not secured with a securement device. Resident # 25's family representative stated he was at the hospital a few weeks ago and they put the catheter in due to retention caused by an enlarged prostate. During on observation on 10/07/2024 at 10:30 am, Resident # 25 received catheter care by CNA B. Resident # 25 did not have a catheter tubing securement device in place. During an observation on 10/07/24 at 3:35 pm, Resident # 25 had his arm looped around the foley catheter drain line and draped across his shoulder, the catheter was not secured with a securement strap as ordered. During an observation and interview on 10/08/24 at 8:00 am, CNA A said that Resident #25 had a strap applied to secure his foley catheter earlier this morning by the nurse. CNA A said that not having a securement strap could cause harm or pain to the resident from the pulling or weight of the drainage bag pulling on the urethra. During an interview on 10/09/24 at 09:05 am, the DON said the nurses were responsible for assessing residents with indwelling catheters to ensure there was a securement device in place. She stated the charge nurse should also assess the securement device on each shift to ensure the resident was not having any discomfort from tension or pulling of the tubing. The DON stated she expected every resident with an indwelling catheter to have a securement device. The DON said she would be in servicing the staff. During an interview on 10/09/2024 at 11:35 am, the Administrator stated the nursing staff were responsible for ensuring catheters were secured and in place. He stated by not having a device it could cause discomfort, infections, and dislodgement. He stated he expected each resident with a catheter to have a securement device. He stated all physician orders should be followed. Record review of Nursing Policy and Procedure Manual for Catheter Care General Guidelines revised 2/13/2007 had no indication for application of a urinary securement strap.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for a PASSR Level II resident review upon a significant change of condition for 1 of 4 Residents (Resident #36) reviewed for PASSAR (Preadmission Screening and Resident Review Services). The MDS Coordinator failed to refer Resident #36 for a resident review after being diagnosed with major depression, (05/23), bipolar disorder, (06/7/23) anxiety, (06/17/22), and schizoaffective disorder, (06/17/22). This deficient practice could place residents at risk of not receiving the needed PASRR services. The findings were: Record review of a face sheet for Resident #36 dated 08/29/23 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of pneumonia due to Sar's-Associated coronavirus, acute respiratory failure, major depressant disorder, hyperlipidemia, (elevated level of lipids), pneumonia, type 1 diabetes, altered mental status, (change in mental statis), unspecified, bipolar disorder (mental illness that causes shifts in a person's mood), and dementia with behavioral disturbance (mental disorder that causes a person to lose the ability to think, remember, learn, make decisions, and solve problems). Record review of a PL1 (PASSR Level 1 Screening) for Resident #36 was completed on 08/29/23 and was negative for a primary diagnosis of dementia, following a hospital stay, and indicated the resident was negative for mental illness (MI). Record review of Resident of resident #36's PASSR screening indicated the facility failed to send a form 1012 to physician for signature. Record review of an admission MDS dated [DATE] for Resident #36 indicated he was not considered by the state PASSR process to have serious mental illness and/or intellectual disability or a related condition, He did not have any impairment in cognition with a BIMS score of 14. He had a psychiatric mood disorder with diagnoses of anxiety disorder, depression and bipolar disorder. Record review of a care plan dated 6/7/2023 for Resident #36 indicated he had a diagnosis of bipolar. Interventions included to administer medications as ordered. He required antidepressant medication for depression. Record review of Form 1012 titled Mental Illness/Dementia Resident Review for Resident #36 was submitted to the physician and signed on 9/13/2023 and indicated the resident did have a dementia diagnosis. The nursing facility action was PASSR Level 1 Screening remains negative and no new PL1 needs to be completed. The nursing facility files the completed form in the resident's chart. Record review of a new PASSR Level 1 Screening was completed on 8/29/2023 and indicated the resident was negative for mental illness. During an interview on 09/12/23 at 2:30 PM, the Regional Compliance Nurse said Resident #36 had a negative PL1 and was not referred based on the screening that was completed by hospital staff prior to admission to the facility on [DATE]. She said the only time she referred residents for a PASSR evaluation was if the PL1 indicated the resident was positive for mental illness, intellectual disability, or developmental delay and Resident #36 did not have a mental illness diagnosis on admission. She said it was the MDS nurse's responsibility to check the PL1s on admission for accuracy. This failure could place residents at risk for not receiving needed PASSR services. During an interview on 9/12/23 at 4:02 PM, the MDS Coordinator said she had been employed at the facility since 06/13/2022. She said if a resident identified as having a newly evident or possible MI, ID, or related condition after admission, the MDS nurse should have entered the diagnoses in the charting system as an active diagnosis and they would discuss in the care plan meetings with new diagnoses, new medications, or changes. She said the facility did have a psychiatrist that came to the facility and Resident #36 was receiving counseling services and was taking any antipsychotic medications. She said she was responsible for making the referrals to the local authority and entering the PASSR information into the portal. She said she resubmitted a new PL1 for Resident #36 yesterday 09/12/23 after this surveyor questioned if Resident #36 had a mental illness diagnoses without a PASSR evaluation to indicate Resident #36 was positive for MI and sent the form 1012 (Mental Illness/Dementia Resident Review) to the physician for review. During an interview on 09/13/23 at 9:15 AM, the Regional Reimbursement Nurse she said she comes to the facility once or twice every three months. Regional Reimbursement Nurse said she was responsible for overseeing the PASSR process for all the residents in the facility. She said she was aware that Resident #36 had a diagnosis of bipolar and schizophrenia but was not responsible for the PASSR information. She said the MDS nurse was responsible for adding diagnosis and completing a form 1012 as needed. MDS Coordinator was responsible for reviewing diagnoses from hospital records and physician orders and would enter them into the charting system as active diagnoses for the residents. She said the physician would review the diagnoses and sign the orders if applicable. She said if a resident had a new diagnosis, the MDS Coordinator was aware, and the information came from hospital records after a hospital stay or a change in condition. During an interview on 09/13/23 at 9:25 AM, the Administrator said he had been employed at the facility since 12/19/22 and was not aware of the circumstances for Resident #36. He said the MDS Coordinator informed him on yesterday 09/12/23 that she had submitted a form 1012 for Resident #36 related to his diagnoses. He said going forward the facility would ensure all residents would receive correct services and follow the regulations. He said the PASSR information and diagnoses would be reviewed from day one of admission and after a hospitalization. He said a resident was at risk of not being appropriately cared for and or receiving needed services. A policy PASRR Level 1 Screen Policy and Procedure revised 03/06/2019 did not address a Form 1012.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident # 191) reviewed for accidents and hazards. The facility failed to ensure Resident # 191 had adequate supervision and was wearing appropriate footwear while in wheelchair to prevent a fall in room on 9/11/23. This deficient practice could place the residents at risk for harm, serious injury or death. Findings include: Record review of a facility face sheet dated 9/12/23 for Resident #191 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: cerebral infarction (stroke), type 2 diabetes, hypertension (high blood pressure), and aphasia (trouble speaking). Record review of a comprehensive MDS dated [DATE] for Resident #191 indicated that he had a BIMS score of 00, which indicated that he was unable to complete the interview. He required extensive assistance of 1-2 persons for personal hygiene and dressing. He was dependent for lower body dressing and putting on/taking off footwear. Record review of a care plan dated 8/30/23 for Resident #191 indicated that he was at risk for falls due to hemiparesis (weakness on one side of the body) with an intervention initiated on 9/9/23 of .ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair) . Record review of a fall risk assessment dated [DATE] for Resident #191 indicated that he had suffered 1-2 falls in previous 3 months and was at high risk for falls. Record review of an event nurses note dated 9/4/23 for Resident #191 indicated that he had sustained an unwitnessed fall on 9/4/23. Resident was found on fall mat next to bed. Resident non-verbal and unable to explain how fall occurred. Record review of an event nurses note dated 9/11/23 for Resident #191 indicated that he sustained an un-witnessed fall on 9/11/23 in his room by sliding out of his chair and was found sitting on floor in front of his wheelchair. During an observation on 9/11/23 at 10:03 am Resident #191 was observed sitting up in his room in the wheelchair. He was observed wearing white socks and no shoes. Resident did not speak to surveyor. During an observation on 9/11/23 at 12:00 pm Resident #191 was observed in the floor in front of his wheelchair in his room. Wheelchair was positioned beside bed, against the wall in his room, not visible from hallway. Resident was noted to have on white socks and no shoes. Shoes were observed on his bedside table next to the wheelchair. Residents' socks were not non-skid. During an interview on 9/12/23 at 2:15 pm Regional Nurse said that all staff contribute to the care plans, not just one person and she said that it depended on the resident as to what would be considered appropriate footwear. She said that Resident #191 did not have his shoes on because he would always kick them off. During an observation and interview on 9/13/23 at 8:40 am Resident #191 was observed in room, lying in bed with non-skid socks on. Resident had a mattress on the floor beside his bed. CNA B was in room sitting in chair and said that she had been employed here for about 5 years. She said that she was called in today on her day off to sit with the resident. She said that Resident #191 should always be wearing his non-skid socks. She said that she always put them on him when she would get him up and out of bed. She said that when she cares for him she also always put his shoes on him. She said that a lot of times he would kick them off, but she would try to keep them on him. She said that she always tried to bring him out to a common area so staff could keep an eye on him instead of leaving him in his room alone. She said that residents without proper footwear on were at risk for falls. During an interview on 9/13/23 at 9:20 am CNA D said that she had been employed here for about 1 year and said that Resident #191 was already up when she got here Monday morning (9/11/23). She said that night shift had gotten him up prior to her starting her shift that day at 6:00 am. She said that when they get him up, they always put his white socks on him because his family and brought him a new pack and wanted him to wear them. She said that she would always try to bring him out of his room when she was working, but sometimes he would refuse and want to stay in his room. She said that if he remained in his room, then she would check on him every 30 minutes. She said that he had been trying to get up since he was admitted on [DATE] and she had mentioned non-skid socks to them, but his had brought these socks and she wanted him to wear them. She said that a resident could be at risk for falls if they are up in a wheelchair without proper footwear on. During a telephone interview on 9/13/23 at 9:40 am CNA E, who had been employed here about 7 months said that he had gotten Resident #191 up the morning of 9/11/23 and showered him and dressed him. He said that he had put a black shirt and pants on him and his white socks. He said that he normally put his white socks on him, and he had not been told to put non-skid socks on him. He said that residents up in a wheelchair could be at risk for falls without proper footwear on. During an interview with Administrator on 9/13/23 at 10:10 am he said that he did not believe that footwear could have prevented the fall because the resident did not walk. He said that they had a Dycem (a non-slip pad to prevent sliding) in the chair to help prevent him from sliding out and they have now placed a camera in the room to monitor him more closely. He said that he believed that Resident #191 was moving around more because he was doing so much better since his admission on [DATE] and was learning to do new things. During an interview with the DON on 9/13/23 at 11:08 am she said that all residents that are up in wheelchairs should have on some type of non-skid footwear to prevent them from falling. She said that they have non-skid socks in the facility for staff to use for residents. She said that residents up in wheelchairs without proper footwear were at risk for falls and injuries such as fractures and head injuries. She said that going forward, she would in-service all staff on appropriate footwear and she would expect that all residents up in wheelchairs have on non-skid socks or shoes. Record review of facility policy titled Preventive Strategies to Reduce Fall Risk dated 2003 with revision date of October 5, 2016, stated .Footwear, shoes, slippers, etc., worn by residents should fit properly and have slip-resistant soles . and .Shoes and slippers with rubber or crepe soles will be used to provide adequate slip resistance on floors . Record review of a facility policy titled Event Reporting: Completion of, undated, stated .Include and care plan any required interventions or supervision to help prevent further occurrence of the event .

**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 5 staff (ADON) reviewed for infection control. ADON failed to clean the scissors used to cut wound care dressings for Resident #38 and she stored the scissors in her pocket. ADON failed to place wound care supplies on a clean surface while performing wound care to Resident #38. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of an admission Record for Resident #38 undated indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of acute cystitis without hematuria (bladder infection without bleeding), sepsis (extreme infection in the blood), dementia, and hydronephrosis with renal and ureteral calculous obstruction (swelling of the kidneys that blocks urine along with kidney stones in the ureters). Record review of an admission Medicare/5 Day MDS assessment for Resident #38 dated 9/1/2023 indicated she had severe impairment in thinking with a BIMS score of 6. She required extensive assistance with 1-2 person assist with bed mobility, dressing, toilet use and personal hygiene. She had an indwelling catheter and was always incontinent of bowel. Record review of a care plan for Resident #38 dated 8/28/2023 indicated she had a non-pressure ulcer to right hip. During an observation on 9/12/2023 at 2:00 pm, in Resident #38's room the ADON who was present to provide wound care to Resident #38. ADON washed her hands in Resident #38's bathroom. Wound supplies were observed on an over bed table which included: a bottle of wound cleanser, gloves, xeroform dressing (petrolatum gauze-non stick), gauze, and a red biohazard trash bag was taped to one end of the table. ADON applied gloves to both hands. ADON removed a dressing to Resident #38's right hip and placed it in the trash bag along with her gloves. ADON applied gloves without washing or sanitizing her hands and verbalized to the Surveyor that she would wash or sanitize her hands, but she could not use the soap in Resident #38's bathroom because it caused her hands to swell, and she forgot to bring in her hand sanitizer. ADON looked at the surveyor and said she was nervous, and Surveyor told her to do what she normally would while performing wound care. ADON removed the gloves from her hands and placed them in the trash and exited the room to get hand sanitizer from her cart that was in the hallway. ADON reentered the room and went into Resident #38's bathroom and washed her hands. ADON applied gloves to both hands and cleaned the wound on Resident #38's right hip using gauze and wound cleanser. ADON placed the gauze in the trash along with her gloves. ADON sanitized her hands and applied gloves to both hands. ADON removed scissors from a pocket on her pants and cut a petroleum gauze dressing to fit the wound and placed it on Resident #38's right hip and covered it with a bandage. ADON removed her gloves and placed them in the trash. ADON sanitized her hands and placed gloves on both hands and repositioned Resident #38 in the bed. ADON removed the biohazard trash bag and exited Resident #38's room. During an interview on 9/12/2023 at 2:10 pm, the ADON said she had been employed at the facility for over a year. She said she provided wound care to the residents in the facility. She said the wound care provided to Resident #38, she should have washed or sanitized her hands instead to telling the Surveyor that was what she was supposed to do and had to exit the room to get her hand sanitizer. She said she should have cleaned her scissors beforehand and placed them on the over bed table with the wound supplies and not kept them in her pocket. She said residents could be at risk of infection by not cleaning equipment or washing or sanitizing their hands between glove changes. Record review of a Licensed Nurse Proficiency Audit for ADON dated 4/18/2023 indicated she demonstrated competency with infection control with hand washing/hand hygiene. During an interview 9/13/2023 at 10:25 AM, the DON said she had been employed at the facility since March 27, 2023 and oversaw the infection control program at the facility and trained staff on infection control. She said she monitored staff frequently and conducted their proficiency skill check offs around the staff annual hire dates. She said staff were supposed to wash their hands before starting any procedure, any time between care and glove changes. She said any supplies used for treatments should be sanitized before and after. She said the over bed table should be cleaned and supplies placed on wax paper. She said the table should be separated between clean and dirty. She said going forward she would provide education and in-service and continue to monitor staff. She said residents could be at risk of infection to wounds. Record review of a facility policy titled Infection Control Policy and Procedure Manual 2019 indicated, .The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Hand Hygiene: You may use alcohol-based hand cleaner or soap/water for the following. After removing gloves . Record review of a facility policy titled Wound Care Policy and Procedure Manual 2003 indicated, .Treatment Table, 1. Wash hands. Put on gloves. 2. Place wax paper on wound care bedside table or small cart. 3. One end will be considered clean, and the other end of table will be open for dirty. (To replace scissors, etc. to be cleaned). 5. On open end scissors on top of second cover of wax paper .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 1 of 8 residents (Resident # 25) reviewed for call lights. The facility failed to ensure Resident # 25's emergency call light in the bathroom would reach the floor. The call light cord for Resident # 25 was wrapped around the grab bar. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings: Record review of facility face sheet dated 09/12/2023 indicated Resident # 25 was an [AGE] year-old female admitted to the facility on [DATE] with dementia (impaired memory), encounter for fall, and vertebrae fracture (fractured back). Record review of quarterly MDS dated [DATE] indicated Resident # 25 had a BIMS of 05 indicating poor cognition. Functional status indicated Resident # 25 required limited assist times 1 person for transfers and extensive assist times 1 person for toileting. Bowel and bladder section indicated Resident #25 had frequent incontinence but did have at least 1 continent episode. Record review of comprehensive care plan with revision date of 08/01/2023 indicated Resident # 25 was at risk for falls and to ensure call light was within reach. During an observation on 09/11/2023 at 09:22 am Resident # 25 resided in room [ROOM NUMBER] and the call light was wrapped around grab bar in the bathroom. During an observation on 09/11/2023 at 3:00 pm the call light in the bathroom in room [ROOM NUMBER] was wrapped around the grab bar in the bathroom and unable to be activated when pulled. During an observation on 09/12/2023 at 7:58 am the call light in the bathroom in room [ROOM NUMBER] was wrapped around the grab bar in the bathroom and unable to be activated when pulled. During an interview on 09/12/2023 at 8:41 am Resident #25 stated she had been at the facility for 3-4 years and she was able to toilet herself and used her bathroom in her room. She stated she had not used the call light in her bathroom but if she fell, she might would need to. During an interview on 09/12/2023 at 10:45 am NA A stated she had worked at the facility since February 2023. She stated Resident # 25 was able to transfer by herself, but it was safer to have someone with her, but she did not always ask for help. She stated Resident #25 used her toilet in her bathroom a few times a day. She stated Resident #25 was instructed to use call light if she needed assistance but does not always do that. She stated she was not aware the call light was wrapped around the rail and would not activate if pulled. She stated the staff should make sure the light was accessible. She stated if the resident could not pull the light the staff would not know they needed help. During an interview on 09/12/2023 at 10:52 am CNA B stated she had been a CNA at the facility 1 year. She stated that call lights should always be in reach and accessible by the residents including the bathrooms. She stated Resident # 25 was able to toilet herself but did not toilet often and was mostly incontinent. She stated Resident #25 would go the bathroom and the staff were not aware she was in there and if she were to fall, she could not use her call light if it was wrapped around the grab bar. She stated this could cause a resident not getting quick response to a fall or injury. During an interview on 09/12/2023 at 10:55 am LVN C stated she had been employed at the facility 5 1/2 months. She stated Resident # 25 was able to transfer self with stand by assist but would often transfer herself without asking for help. She stated Resident # 25 would toilet in her bathroom but not often. She stated she was not aware of any falls but Resident # 25 was a fall risk and if she were to fall in the bathroom a delay in help could occur if her call light was not able to be pulled. During an interview on 09/12/2023 at 11:00 am the DON stated she had been the DON since March 2023. She stated it was the responsibility of all staff to ensure the call lights were accessible to the resident either in their room or bathroom. She stated all call lights should be checked every shift to ensure they can be used. She stated if a call light could not be activated when a resident was to fall serious injury or delay in treatment could occur. She stated she expected all call lights to be checked and never wrapped around the grab bar keeping them from being activated. During an interview on 09/12/2023 at 3:50 pm the regional compliance nurse stated the facility did not have a policy regarding call lights nor a monitoring system to ensure call lights were accessible. She stated all staff were trained on call lights being within reach. She stated she had in-serviced all staff on call lights and ensuring they were freely hanging to activate properly. She stated the importance was so the resident could use the light in event of an incident. During an interview on 09/13/2023 at 10:11 am the administrator stated all staff were responsible for ensuring call lights were accessible by the residents. He stated the risk to residents could be not getting the help they needed and expected all staff going forward to check call lights were accessible and were always in reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the completion of a significant change assessment for 1 of 13 residents reviewed for Significant Change Assessments. (Resident #9). Resident #9 did not have a significant change assessment completed following an admission to hospice services. This failure could place residents at risk of not receiving adequate services and reimbursement to meet their needs. Findings included: Record review of the Face Sheet dated 07/18/22 indicated Resident #9 was admitted [DATE] and was a [AGE] year-old female, with diagnoses of Parkinson's (progressive disorder of the nervous system marked by muscle tremors, muscle rigidity (stiffness), decreased mobility, stooped posture, slow voluntary movements, and a mask-like facial expression). Record review of the Quarterly MDS dated [DATE] revealed a BIMS of 02, indicating severely impaired cognition. This assessment noted no Hospice diagnosis at that time. Record review of the Comprehensive Care Plan for Resident #9 dated 09/21/21 with a revision date of 05/30/22 revealed the resident has a terminal (leads to death) prognosis and was receiving hospice services. Record review of the 05/30/22 Physician Order revealed the resident was placed on Hospice 05/30/22 with a terminal diagnosis of Parkinson's. Record review of the Resident # 9's electronic chart revealed there was no Significant Change MDS completed after admission to Hospice. During an interview with the MDS Coordinator on 07/20/22 at 08:47 AM, she stated she was not the MDS Coordinator at the time this MDS should have been completed. She stated she would have completed a Significant Change MDS for Resident #9 or any resident placed on Hospice within 14 days of the change. She stated if the Significant Change MDS was not completed, this throws the facility out of compliance with MDS schedules and the resident's Hospice would have to reimbursed due to the higher rate of reimbursement; she would complete a Significant Change MDS for Resident #9 immediately. During an interview with the DON on 07/20/22 at 03:19 PM, revealed the MDS Coordinator oversaw all MDSs completion, but she always reviewed vital portions of the residents MDSs. She stated an inaccurate or unchanged MDS could negatively affect the resident by giving a false narrative for the care plan and a Significant Change MDS should have been completed by the MDS Coordinator at that time for the Hospice admission because it could possibly affect the appropriate submission and reimbursement for the MDS. Record Review of the facility's Policy, MDS assessment Data Accuracy, undated revealed federal regulations require that the assessment accurately reflects the resident's status. The OBRA schedule and if applicable the Medicare PPS assessment schedule must be followed for setting of the ARD and completion of the MDS assessment. Please refer to CMSs RAI 3.0 Version Manual for the scheduling of assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all mechanical, electrical, and patient care equipment was in safe operating condition for 1 (Residents #14) of 13 residents reviewed for essential equipment. The facility failed to ensure Resident #14's lift recliner was in proper working condition after it had already malfunctioned. These failures could place residents at risk for equipment that is in unsafe operating condition. Findings included: Record review of the consolidated physician orders dated 7/20/22 revealed Resident #14 was [AGE] years old, female and admitted on [DATE] with diagnoses including memory deficit (inability to remember events for a period of time), congestive heart failure (heart doesn't pump blood as well as it should), atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and muscle weakness. Record review of the MDS dated [DATE] revealed Resident #14 was usually understood and understood others. The MDS revealed Resident #14 had a BIMS score of 7 which indicated severe cognitive impairment. The MDS revealed Resident #14 required supervision for ADLs. Record review of the care plan dated 5/2/22 revealed Resident #14 had impaired cognitive function/dementia or impaired thought process. The care plan revealed ADL self-care performance deficit. Interventions included staff x1 assistance for bed mobility and supervision for transfers. Record review of fall incident reported dated 7/17/22 completed by LVN B revealed Resident #14 was noted sitting on footrest of recliner. The fall incident report revealed Resident #14 reported, the button got stuck and the chair threw me. During an observation and interview on 7/18/22 at 10:25 a.m., Resident #14 was sitting in her wheelchair with her feet propped on the raised footrest of a recliner. Resident #14 said on 7/17/22, her recliner's remote control got stuck and threw her out of it. She said this was not the first time it had happened. She said the last time it malfunctioned, her family member purchased a new remote control and replaced it, assuming that was the issue. She said after the incident happened, staff unplugged the chair and recommended her not to use it. She said she would need to purchase another since she brought from her house and hoped the facility could help her figure something out. She said she was scared to use the recliner now because she did not want to break any bones. During a telephone interview on 7/19/22 at 2:25 p.m., LVN B said Resident #14 was found on 7/17/22 sitting on the footrest of her recliner. She said the recliner was stuck in the up position. She said she was told by a family member the recliner had malfunctioned before and the recliner's remote control was replaced. She said she did not know when it malfunctioned before. During a telephone interview on 7/19/22 at 2:49 p.m., ADON A said on 7/17/22 Resident #14 was found with her back on the footrest and her bottom on the floor. She said she was told by a family member, after the incident, the recliner had malfunctioned before and the recliner's remote control was replaced. She said after the incident, LVN B unplugged the recliner and recommended Resident #14 not use it. She said she asked the maintenance man to look at it on 7/18/22. She said Resident #14 used the recliner to independently get up from it and elevate her feet. During an interview on 7/20/22 at 10:15 a.m., Resident #14 said maintenance had looked at the recliner, on 7/18/22 and did not find anything wrong. She said he plugged the recliner back up, but she was still afraid to use it. She said the recliner was important to her because it helped her independently get out of the recliner and elevated her feet to prevent swelling. During an interview on 7/20/22 at 10:17 a.m., CNA C said on 7/17/22 Resident #14 was found with her back on the footrest and her bottom on the floor. She said Resident #14 told her she was trying to work the recliner remote and when she stopped pushing the buttons, the recliner kept moving. CNA C said Resident #14 told her this was the third time, the recliner had malfunction. During a telephone interview on 7/20/22 at 3:29 p.m., the DON said Resident #14 used the recliner to independently get up from it and elevate her feet due to swelling. She said she did not know if the facility was responsible for maintenance of personal equipment. She said she would have to review the admission packet for guidance. She said if the facility was responsible for maintaining personal equipment, then it should be safe and functioning to prevent harm to the resident. During an interview on 7/20/22 at 4:00 p.m., Maintenance said on 7/18/22 he was told to check Resident #14's recliner. He said on Monday, the recliner remote button did not get stuck when he operated it. He said the recliner remote malfunctioned about a month ago and family ordered a new one. He said the family member put the new remote on the recliner and he did not maintenance it afterwards. He said he did maintenance Resident #13's recliner when she arrived, and it was working. He said he did not keep a log of things he maintenance unless the staff put in a work order online. He said he knew if it was not documented then it did not happen. He said the ADON A verbally told him about Resident #13's recliner and he had no documentation to provide. He said he currently felt Resident #13's recliner was safe for use. He said it was important to have safe functioning equipment because it could harm the resident. He said Resident #13 told him she was afraid to use the recliner now after the incident on 7/17/22. During an interview on 7/20/22 at 4:30 p.m., the Administrator said the facility was responsible for all assistive equipment to be in good working order. She said the Maintenance man was responsible for assistive devices maintenance but not required to keep a written log of completed work orders since staff verbally informed him about issues a lot. She said it was important to have safe equipment for personal use to reduce risk of injury. She said the facility did not have a policy regarding maintaining assistive devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure assessments accurately reflected the status for 5 of 13 residents reviewed for assessments. (Resident #21, Resident #14, Resident #42, Resident #25, Resident #3) - Resident #21's MDS did not address her falls and inaccurately coded the resident as having sepsis. -The facility inaccurately coded Resident #14's Plavix (antiplatelet) as an anticoagulant on the MDS. - Resident #42's discharge MDS, place of discharge was incorrectly coded. - Resident #25's MDS inaccurately indicated the use of a ventilator. -The facility failed to accurately code Resident #3's diagnoses of depression and anxiety. These failures could place residents at risk of not having individual needs met and a decreased quality of care. Findings included: 1. Record review of the consolidated physician orders dated 7/18/22 revealed Resident #21 was [AGE] years old, female, admitted on [DATE] with diagnoses including sepsis (a life-threatening complication of an infection) and history of falling. Record review of the MDS dated [DATE] revealed Resident #21 was understood and understood others. The MDS revealed Resident #21 had a BIMS of 8 which indicated mild cognitive impairment and required supervision for ADLs. The MDS revealed Resident #21 did not have any falls since admission/entry, reentry, or the prior assessment. Further review of the MDS indicated the residents fall on 2/18/22 was not coded on MDS. Record review of the MDS dated [DATE] revealed Resident #21 was usually understood and understood others. The MDS revealed Resident #21 had a BIMS of 8 which indicated mild cognitive impairment and required supervision for ADLs. The MDS revealed Resident #21 did not have any falls since admission/entry, reentry, or the prior assessment. Further review of the MDS indicated the residents fall on 5/15/22 was not coded on MDS The MDS revealed Resident #21 had an active diagnosis of septicemia (or sepsis, is the clinical name for blood poisoning by bacteria) in the last 7 days. The MDS revealed Resident #21 had not received the following medication by pharmacological classification, of an antibiotic (medication used to treat sepsis) within the last 7 days reviewed during assessment period. Record review of the undated care plan revealed Resident #21 was risk for falls, had an actual fall, and history of falls related to dementia. Intervention included call light within reach, call do not fall sign, and ensure proper footwear. Record review of a fall incident report dated 2/18/22 revealed Resident #21 had a witnessed fall in her room. Record review of a fall incident report dated 5/15/22 revealed Resident #21 had an unwitnessed fall in her room. Record review of the progress notes dated 5/15/22 written by LVN E revealed Resident #21 went to the hospital on 5/15/22 due to fall. Record review of the Resident #21's Progress notes reviewed from 4/4/22-5/26/22 had no documentation of the residents being in septic state. During a telephone interview on 7/20/22 at 3:29 p.m., the DON said Resident #21 did not currently have sepsis and she did not know why it was on the matrix. She said the facility did not remove medical diagnoses if they no longer applied but should probably change it to history of. She said Resident #21 was a fall risk and had fallen recently attempting to give herself a shower. During an interview on 7/20/22 at 3:48 p.m., the MDS coordinator said she was not employed when Resident #14 and Resident #21's MDSs were completed. She said the drug classification for Plavix can be confusing, since most people think it is an anti-coagulant not antiplatelet. She said the MDS specifically says drug class not how it is used. She said Resident #21 septic diagnoses on the MDS was probably a typo, but she did not know her enough to be sure. During an interview on 7/20/22 at 4:15 p.m., LVN B said she was not sure which drug class Plavix was. She said if it was an antiplatelet, it should not be classified as an anticoagulant. She said it was important to have the right drug class to know to know the correct labs to order and relay correct information to medical doctor. She said it was important information to know when shaving resident or after falls related to bruising. She said Resident #21 currently did not have sepsis. She said sepsis being on the matrix from MDS information, could affect the assessment of Resident #21 and have a nurse looking for antibiotics prescribed to treat the sepsis. She said Resident #21 had a history of falling, her most recent one sometime last month. 2. Record review of the consolidated physician orders dated 7/20/22 revealed Resident #14 was [AGE] years old, female and admitted on [DATE] with diagnoses including congestive heart failure (heart doesn't pump blood as well as it should), atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #14's consolidated physician orders dated 4/12/22 revealed Resident #14 was prescribed Clopidogrel Bisulfate (Plavix) tablet 75 mg, one time a day for antiplatelet related to cerebrovascular disease. Record review of the MDS dated [DATE] revealed Resident #14 received an anticoagulant within the last 7 days reviewed during assessment period. Record review of the care plan dated 5/2/22 revealed Resident #14 was on anticoagulant therapy. Interventions of labs as ordered, monitor/document/report signs and symptoms of anticoagulant complications and teach resident/family/caregiver. During an interview on 7/20/2022 at 3:40 p.m., the DON stated she reviewed only the vital parts of the MDS before signing them. She stated that it was the MDS nurse's responsibility to ensure all assessments were accurate. The vital parts of the MDS were diagnosis and ADL's according to the DON. The DON stated inaccurate coding on the MDS could affect resident care. The DON stated inaccurate coding on the MDS will make the care plan inaccurate and the care plan was the instructions to resident centered care. The DON said Plavix was not an anticoagulant but could be used as one. She said there was no information to collaborate her statement. During an interview on 7/20/2022 at 4:20 p.m., the Administrator stated that it was important for the MDS to be correct not only for the purpose of providing the correct amount and type of care to the resident but also for reimbursement purposes. Not having a correctly coded MDS could affect the care the resident receives by not receiving the right types of care and services that would allow them to meet their optimal level of existence. 3. Record review of the admission Face Sheet dated 06/07/22 indicated Resident #42 was an [AGE] year-old female, with diagnoses of HTN (high blood pressure), Atherosclerotic Heart Disease (buildup of fats, cholesterol, and other substances in and on the artery walls), GERD (acid reflux), Asthma (condition that affects the airways in the lungs) and abnormalities of gait (manner of walking)/mobility. Record review of the admission MDS dated [DATE] revealed a BIMS of 10, indicating moderately impaired cognition and the resident participated in the assessment. She had an active discharge plan noted, but her expectation was not noted. Record review of the 06/08/22 Comprehensive Care Plan revealed documentation lacked discharge information. Record review of the Discharge assessment dated [DATE] indicated a return not anticipated when Resident #42 was discharge to the hospital. Record review of the Discharge summary dated [DATE] revealed Resident #42 discharged home after completing therapy in the facility. Record Review of the undated MDS Policy for MDS assessment Data Accuracy revealed that federal regulations require that the assessment accurately reflects the resident's status. During the 07/20/22 at 08:47 AM interview with the MDS Coordinator, she stated she would need to modify and correct Resident #42's discharge MDS because the resident did not go to the hospital, she discharged home. She said this could have be a typographical error on her par and an incorrect MDS could affect quality measures, since the facility discharged her home and not to the hospital. During the 07/20/22 at 03:19 PM interview with the DON she revealed the MDS Coordinator was overseeing the MDSs completion, but she reviewed the vital portions of the residents MDS. She stated she really did not know what effect coding the place of discharge incorrectly could have on the resident, other than incorrect information to CMS about where the resident went; she did not know if that negatively affected the facility or resident other than that. 4. Record review of the face sheet dated 7/19/2022 indicated Resident #25 was [AGE] years old and was admitted [DATE] with diagnosis of dementia, low back pain, and history of falling. Record review of Resident #25's consolidated physician orders dated 7/19/22 did not indicate an order for use of a ventilator. Record review of the most recent MDS dated [DATE] indicated Resident #25 was understood and usually understood others. The MDS indicated a BIMS score of 4 indicating severe cognitive impairment. Section O of the MDS was coded for invasive mechanical ventilator (ventilator or respirator) while Resident #25 was a resident of the facility. Record review of Resident #25's care plan dated 4/12/2022 did not indicate the use of a ventilator. An observation on 7/18/22 at 10:32 a.m., revealed no ventilator or Bipap machine (a type of ventilator used to treat chronic conditions that affect breathing) at the bedside of Resident #25. Resident #25 was not present in her room. An observation and interview on 7/18/22 at 12:06 p.m., revealed Resident #25 sitting at a table in the dining room eating lunch with a family member. There was no ventilator or Bipap machine present and Resident #25 did not have a tracheostomy. The family member of Resident #25 revealed the resident had never been on a ventilator and had never used a Bipap machine. During an interview on 7/20/22 09:26 a.m., the MDS Coordinator revealed Resident #25 had never been on a ventilator. She said the ventilator coding was a typographical error. She said her process was to go through documentation and records and enter answers into the MDS. She said a regional team did sample audits of MDSs to check for accuracy. She said residents could be negatively affected by inaccurate assessments by not receiving the proper care they should be receiving. During an on 7/20/22 at 2:22 p.m., the Administrator revealed that it was important for the MDS to be correct not only for the purpose of providing the correct amount and type of care to the resident but also for reimbursement purposes. Not having a correctly coded MDS could affect the care the resident receives by not receiving the right types of care and services that would allow them to meet their optimal level of existence. During an interview on 7/20/22 at 3:19 p.m., the DON revealed Resident #25 had not been on a ventilator to her knowledge. She said the ventilator coding must have been a mistake. She said the MDS Coordinator oversees the MDS and then she signed them. She said she normally reviewed the vital portions of the MDS assessments before signing them. She said an inaccurate assessment could give a false narrative on the resident's history and the MDS directs the care plans. 5. Record review of the consolidated physician orders dated 7/18/2022 revealed Resident #3 was a [AGE] year-old male that admitted on [DATE] with the diagnosis of alcoholic cirrhosis of the liver with ascites (cirrhosis-a liver disease; ascites-a buildup of fluid in the abdomen), anxiety disorder, and asthma. Resident #3 was prescribed clonazepam (medication for anxiety) 1mg daily (1/25/2022) and Lexapro (medication for depression) 20mg daily (7/01/2021). Record review of the MDS dated [DATE] revealed Resident #3 was usually understood and usually understood others. The MDS revealed Resident #3 had a BIMS score of 11 which indicated mild cognitive impairment. The MDS revealed Resident #3 required supervision for ADLs. The MDS failed to indicate the diagnoses of anxiety and depression. Record review of the care plan dated 4/24/2022 revealed Resident #3 used anti-anxiety medication for an anxiety disorder. Record review of the care plan dated 7/7/2022 revealed Resident #3 had a mood problem and revealed Resident #3 had a diagnosis of depression. Record review of Resident #3's psychological service notes dated 4/4/2022 revealed diagnoses of major depressive disorder, dysrhythmic disorder (long term form of depression), and narcissistic personality disorder (disorder in which a person has an inflated sense of self-importance). During an interview on 7/20/2022 at 1:00PM, the MDS coordinator stated she had only been employed at the facility for one month. The MDS coordinator reviewed Resident #3's chart. The MDS Coordinator stated Resident # 3 had a diagnosis of both anxiety and depression. The MDS Coordinator stated the MDS dated [DATE], did not have anxiety or depression checked as active diagnosis. The MDS Coordinator stated she could not speak as to why the previous MDS Coordinator incorrectly coded the assessment. The MDS coordinator stated it was important to correctly code the MDS to ensure an accurate picture of each resident because that was what the care plan was based on. Inaccurate assessments and care plans could lead to residents getting inaccurate care. The MDS coordinator stated it was important to make sure the resident gets the correct medications and care. The surveyor attempted to contact previous MDS coordinator on 7/20/2022 at 1:15pm. The surveyor was unable to successfully contact previous MDS coordinator for interview. Review of the facility's undated Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy indicated, The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident .According to CMS's RAI Version 3.0 manual; the MDS is a core set of screening, clinical, and functional status elements .which forms the foundation of a comprehensive assessment for all residents of nursing homes .the items of the MDS standardize communication about resident problems and conditions with nursing homes, between nursing homes, and outside agencies .Federal regulations .require that .the assessment accurately reflects 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 develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 4 of 13 residents (Resident #37,Resident #3, Residents #21, Resident #30) reviewed for care plans. -The facility failed to initiate a comprehensive care plan with interventions for the triggered care area of falls for Resident #37. -The facility failed to update the mood care plan with individualized intervention after Resident #3 triggered for the care category of mood. -The facility failed to implement individualized intervention after Resident #3 displayed behaviors. -The facility failed to revise and implement individualized intervention after Resident #21's fall in the shower room. -The facility failed to care plan Resident #30's use of anti-anxiety and anti-depressant. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of the consolidated physician orders dated 7/19/22 revealed Resident #37 was [AGE] years old, male and admitted on [DATE] with diagnosis of difficulty in walking. Record review of the MDS dated [DATE] revealed Resident #37 was understood and understood others. The MDS revealed Resident #37 had a BIMS of 5 which indicated severe cognitive impairment and required extensive assistance and total dependence for ADLs. The MDS revealed Resident #37 had 2 falls with no injury since admission/entry, reentry, or the prior assessment. The MDS revealed Resident #37 was not steady, only able to stabilize with staff assistance for balance during transitions and walking. The MDS revealed Resident #37 used a wheelchair for a mobility device. Record review of the undated care plan revealed Resident #37 had impaired cognitive function/dementia or impaired thought processes. The care plan revealed Resident #37 was at risk for falls related to recent debilitation and prolonged illness. Goals were Resident #37 would be free of falls and not sustain serious injury. Interventions included staff x1 assist for transfer, call light within reach, ensure appropriate footwear when ambulating, keep furniture in locked position, keep needed items within reach, and safe environment. Record review of a fall incident report dated 5/31/22 at 9:20 p.m., completed by ADON A revealed Resident #37 had an unwitnessed fall in his room. Interventions initiated included fall mat and low bed. Record review of a fall incident report dated 6/2/22 at 2:00 p.m., completed by ADON A revealed Resident #37 had an unwitnessed fall in his room. Interventions initiated floor mat, scoop mattress, and baby monitor. Record review of a fall incident report dated 6/2/22 at 5:36 p.m., completed by ADON A revealed Resident #37 had an unwitnessed fall bending over on the floor in his room. Interventions initiated floor mat and scoop mattress. During an observation on 7/18/22 at 9:59 a.m., Resident #37 was not in his room. Viewed from the doorway no specialty mattress or fall mat. During an observation on 7/18/22 at 12:45 p.m., Resident #37 was sitting in his recliner. No floor mat, scoop mattress, or baby monitor observed. During an observation and interview on 7/19/22 at 2:07 p.m., Resident #37 was sitting in his recliner watching television. Resident #37 said he had never fallen but if he had, it was when he was a child. The wall near Resident #37's window was a call, do not fall sign posted. There was no fall mat, scooped mattress, or baby monitor in the resident's room. During a phone interview on 7/19/22 at 2:49 p.m., ADON A said Resident #37 had fallen on 5/31/22 and the facility's interventions was mattress until a fall mat could be found. She said Resident #37 fell again on 6/2/22 twice in one day. She said the facility then added a scoop mattress and baby monitor. She said she thought Resident #37 still had a scoop mattress, but the fall mat was removed when he was moved to the 100-hall. She said the baby monitor had been discontinued a few weeks ago. She said after each fall, she as the nurse who wrote the incident report, should have updated the care plan. She said an accurate care plan related to falls, were important so the facility had documentation of what did or did not work as fall interventions. She said an inaccurate fall care plan could cause harm to the resident. During an interview on 7/20/22 at 10:17 a.m., CNA C said Resident #37 was a fall risk. She said Resident #37 had a camera, fall mat, and scoop mattress but was discontinued last week some time. She said she looked at care plans and if fall interventions were not care planned the nurses would tell the CNAs what should be in place. 2 Record review of the consolidated physician orders dated 7/18/2022 revealed Resident #3 was a [AGE] year-old male that admitted on [DATE] with the diagnosis of alcoholic cirrhosis of the liver with ascites (cirrhosis-a liver disease; ascites-a buildup of fluid in the abdomen), anxiety disorder, and asthma. Record review of physician orders dated 1/25/22 revealed Resident #3 was prescribed clonazepam (medication for anxiety) 1mg daily. Record review of physician orders dated 7/01/21 revealed Resident #3 was prescribed Lexapro (medication for depression) 20mg daily (7/01/2021). Record review of the quarterly MDS dated [DATE] revealed Resident #3 failed to indicate the diagnoses of anxiety and depression. The MDS revealed a score of 07 on the PHQ-9 (mood interview) which indicated a mild to moderate mood disorder. Record review of the care plan dated 4/24/2022 indicated Resident #3 had a behavior of going to the shared shower room and using the shower nozzle to perform enemas on himself. Intervention for this behavior was listed to keep shower room doors locked. Record review of a care plan dated 7/7/2022 revealed Resident #3 had a mood problem, and no interventions were listed to monitor or improve Resident #3's mood problem. Record review of psychological service notes dated 4/4/2022 revealed diagnoses of major depressive disorder, dysrhythmic disorder (long term form of depression), and narcissistic personality disorder (disorder in which a person has an inflated sense of self-importance). During an observation on 7/19/2022 at 2:00 p.m., on the 300 hallway it was noted that the shower room door was unlocked. Dirty linen and trash barrels were stored in the shower room. Floor was tidy. No foul odor and the trash bins were empty. During an interview on 7/19/2022 at 2:05 p.m., LVN D stated the shower room should be locked because a resident had gotten into the shower room without anyone knowing and had fallen several months ago. LVN D stated the resident was not hurt but it was unsafe for residents to be in the shower room alone. Secondly, it prevented Resident #3 from going in the shower rooms unsupervised. She stated he had a history of sexually inappropriate behaviors with the shower equipment and attempting to drink hand sanitizer. During an interview on 7/19/2022 at 2:15 p.m., CNA C stated there were keys to the shower room doors, but they did not lock properly. She said all you needed to do was pull on the knob and the door would pop open. CNA C stated they stored barrels in the shower rooms when not doing incontinent rounds to keep the smell down on the hallway. She stated she knew the doors should be locked for resident safety. She stated if they are left unlock, residents can go in and fall or hurt themselves in an unattended shower. During an interview on 7/20/22 at 2:20 p.m., the Administrator stated it was important for the care plans to reflect accurate information and be updated timely. The Administrator stated an acute care plan was done in the morning meetings and during the weekly standard of care meeting. The entire IDT was responsible for updating the care plan when the interventions are discussed in these meetings. The care plan was what drives the residents care by directing the staff on resident specific interventions to provide quality care. If the care plan was not updated according with new information the residents could receive the wrong type of care decreasing their quality of life. During a telephone interview on 7/20/22 at 3:29 p.m., the DON said falls were discussed in mornings and during care plan meetings. She said fall interventions were decided by the interdisciplinary team. She said the DON, ADON, and MDS nurse were responsible for updating the care plans. She said all care plans should be accurate and updated after each fall. She said accurate care plan ensured individualized care for each resident. 3. Record review of the consolidated physician orders dated 7/18/22 revealed Resident #21 was [AGE] years old, female and admitted on [DATE] with diagnoses including Dementia, and history of falling. Record review of the MDS dated [DATE] revealed Resident #21 was understood and understood others. The MDS revealed Resident #21 had a BIMS of 8 which indicated mild cognitive impairment and required supervision for ADLs. The MDS revealed Resident #21 did not have any falls since admission/entry, reentry, or the prior assessment. The MDS revealed Resident #21 was not steady, but able to stabilize without staff assistance. The MDS revealed Resident #21 used a wheelchair for mobility. Record review of Resident #21's undated care plan revealed the resident had ADL self-care deficit related to dementia and occasional pain. Intervention included bathing, bed mobility, dressing, and toilet use required staff x1 for assistance. Resident #21 was at risk for falls, had an actual fall, and history of falls related to dementia. Intervention included call light within reach, call do not fall sign, and ensure proper footwear. There were no interventions noted to address the unwitnessed fall in the shower on 6/13/22. Record review of a fall event report dated 6/13/22 revealed Resident #21 was found in the shower room on the floor yelling for help. The report revealed Resident #21 was undressed and attempting to shower self. The report did not indicate if interventions was in place prior to fall and there was no indication the prepopulated intervention from the care plan were initiated after the fall. During an observation on 7/19/2022 at 1:40 p.m., the shower room door was unlocked on the 100 hallway, where Resident #21 resided. There were dirty linen and trash barrels stored in the shower room. The sharps container was full and shaving cream was on the counter. Several gloves were on the floor. They did not appear soiled. During an interview on 7/19/2022 at 4:00 p.m., the DON stated that Resident #21 was noted to have gotten into the shower room recently and fell attempting to give herself a shower. One of the interventions for her falls was to ensure the shower rooms were locked to prevent her and others from entering the shower unattended. The DON stated we just seem to have a problem keeping up with the keys. She said the facility really had to come up with a system that will ensure those rooms stay locked. The DON stated no one was technically assigned to monitor if the shower room doors are locked. The DON stated it would be the responsibility of everyone to ensure the doors remained locked. The DON stated no particular education or in-service was done on keeping the shower room doors locked it was just talked about in the morning meeting as an intervention for Resident #21's fall. The DON stated staff education was normally done by the DON or ADON in the form of a written in-service. The DON stated that the shower rooms being unlocked could result in residents like Resident #21 going into the shower room unattended and falling without anyone knowing. During an observation on 7/20/2022 at 3:00 p.m., the 100 hallway, where Resident #21 resided, the shower room door was unlocked. The shower room floor was wet and slippery. Barrels of dirty linen and trash were being stored in the shower room. During an interview on 7/20/2022 at 3:10 p.m., the ADON stated the doors should be locked in the residents' safety. The ADON said she had not seen an in-service on keeping the door locked but had talked about it in the morning meeting and IDT meetings. 4. Record review of the consolidated physician orders dated 7/20/22 revealed Resident #30 was [AGE] years old, female and admitted on [DATE] with diagnoses including dementia, mood disorder (elevation or lowering of a person's mood,), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and generalized anxiety disorder. Record review of Resident #30's physician orders dated 2/8/22 revealed Trazodone (is an antidepressant for treating major depressive disorders) 150 milligram, one time a day. Record review of Resident #30's physician orders dated 2/8/22 revealed Lorazepam (used to treat anxiety disorders) 0.5 mg, two times a day. Record review of the MDS dated [DATE] revealed Resident #30 was usually understood and usually understood others. The MDS revealed Resident #30 had a BIMS of 9 which indicated mild cognitive impairment and required supervision for ADLS except bathing required extensive assistance. The MDS revealed Resident #30 had active diagnoses of anxiety disorder and depression. The MDS revealed Resident #30 received an antianxiety and antidepressant. Record review of the undated care plan revealed Resident #30 had impaired cognitive function/dementia or impaired thought processes. The care plan revealed Resident #30 had ADL self-care performance deficit which required staff x1 assistance for ADLs. The care plan did not reveal use of antianxiety or antidepressant medications. During an interview on 7/20/22 at 4:15 p.m., LVN B said Resident #30 was prescribed medication for depression and anxiety. She said she believed Resident #30 had been prescribed these types of medications since admission. During an interview on 7/20/2022 at 4:30 pm, the Administrator stated that it was important for the care plans to reflect accurate information and be updated timely. The Administrator stated that acute care planning was done in the morning meetings and during the weekly standard of care meeting. The entire IDT was responsible for updating the care plan when the interventions were discussed in these meetings. The care plan was what drove the residents care by directing the staff on resident specific interventions to provide quality care. If the care plan was not updated with new information the residents could receive the wrong type of care decreasing their quality of life. A facility policy titled care plans indicated that care plans will be person-centered and reflect the resident's goals for admission and desired outcomes. Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident's life before coming to reside in the nursing home. Residents' goals set the expectations for the care and services he or she wishes to receive. Measurable objectives describe the steps toward achieving the resident's goals, and can be measured, quantified, and/or verified. Record review of the facility's undated facility comprehensive care planning policy, revealed .the facility will develop and implement a comprehensive person-centered for each resident .includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .the facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life .care planning drives the type of care and services that a resident receives .the comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives . Record review of the facility's undated prevention strategies to reduce fall risk policy, indicated .design interventions that minimize fall risk .individualized nursing care plans will be implemented to prevent falls .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts reviewed. (Nurse medication cart for the 300 Hall) LVN D failed to securely lock the nurse medication cart for the 300 Hall. This failure could place residents at risk of not having their medications available as prescribed or possible drug diversions. Findings included: Record review of a 672 provided by the facility dated 7/18/2022 indicated a census of 48. There were 4 independently ambulatory residents and there were 33 residents that could ambulate with assistance or an assistive device. Record review of a resident roster provided by the facility on 7/18/2022 indicated there were 21 residents residing on the 300 Hall. An observation on 7/19/22 at 7:49 a.m., revealed the 300 hall nurse medication cart sitting across the hall from room [ROOM NUMBER]. room [ROOM NUMBER]'s door was open and the resident was ambulating around the room. There was no staff present at the medication cart. The top drawer contained a tray of lancets, alcohol pads, 5 insulin pens and a glucometer. The second drawer contained 2 boxes of Arginaid, 20 carts of various medications (including Metoprolol, Metformin, Lisinopril, Keppra, Digoxin), 4 boxes of Ondansetron and 1 bottle of Lactulose. Drawer 3 contained topical medications. Drawer 4 contained oxygen tubing and a supply of plastic cups. During an interview on 7/19/22 at 7:57 a.m., LVN D revealed she was just nervous and forgot to lock the medication cart when she left it to pass medications in a room. She said she normally does lock the cart when she steps away from the cart. She said she knew she was supposed to lock the cart any time she stepped away from the cart. During an observation and interview on 7/19/22 at 3:11 p.m., the nursing medication cart for the 300 Hall was unlocked. The cart was located on the 300 Hall across the hall across from room [ROOM NUMBER]. There were no staff present in the hall. During the observation LVN D quickly walked up to the cart, locking it and said, I am doing the best I can. During an interview on 7/20/22 at 10:00 a.m., ADON A revealed all medication carts were supposed to be locked any time staff walked away or even had their back to the cart. She said the nurses or medication aide were responsible for locking the medication carts. She said if she saw one unlocked she would lock the cart and remind the nurse to keep the cart locked. She said herself and the DON made rounds to make sure the carts were being locked. She said carts being left unattended and unlocked could negatively affect residents because a resident could easily remove items from the cart and could take medications that could cause a reaction. She said there were residents that live in the facility that pull on the drawers on the medication carts. During an interview on 7/20/22 at 3:19 p.m., the DON revealed her expectations were to have medication carts locked at all time unless the nurse was standing directly in front of the cart. She said the nurse and the medication aides are the ones responsible for keeping the carts locked. She said she and the ADON make rounds constantly throughout the day to make sure these kinds of things were done. She said an unlocked medication cart would allow access for residents to take medications that could negatively affect them. During an interview on 07/20/22 at 3:29 p.m., the Administrator revealed all medication carts should be kept locked by staff and keeping the medication carts locked was policy. She said this was for safety purposes. She said residents could be negatively affected if someone got into an unlocked and unattended medication cart and took something out of the cart. Review of the facility's undated Medication Carts policy indicated, .the carts are to be locked when not in use or under the direct supervision of the designated nurse .carts must be secured .