Arbrook Plaza

**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, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Resident #1, Resident #51, Resident #111) of 5 residents reviewed for care plans. The facility failed to ensure the Care Plans for Resident #1, Resident #51, and Resident #111 reflected the use of grab/assist bars, the goal of having the grab/assist bars on the resident's beds, and the interventions previously attempted. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and the implementation of personalized plan of care developed to address their specific needs. Findings included: Record review of Resident #1's face sheet, dated 1/14/2026, revealed resident was originally admitted on [DATE] with pertinent diagnoses of Cerebral Infarction Due to Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery (stroke that affects the right side of the brain and often results in left-sided paralysis or neglect, impulsive behavior, and facial weakness), Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (chronic condition where the body either does not produce enough insulin or cannot use insulin effectively, leading to high blood sugar levels that have damaged the kidneys' filters leading to reduced waste removal, often accompanied by high blood pressure), Paroxysmal Atrial Fibrillation (irregular heartbeat where episodes start and stop on their own, typically within seven days, though they can last shorter or longer and often become more frequent or persistent over time), Dysphagia Following Other Cerebrovascular Disease (when damage disrupts the brain's swallowing control network, leading to risks like pneumonia, malnutrition, and dehydration, with symptoms including choking or food getting stuck), Pneumonitis Due To Inhalation Of Food And Vomit (lung inflammation/infection from breathing foreign material like gastric contents into the airways, causing cough, fever, chest pain, and shortness of breath), Spontaneous Tension Pneumothorax (rare, life-threatening condition where air leaks into the space between the lung and chest wall from a ruptured air-filled sac on the lung's surface, forming a one-way valve that traps air, rapidly increasing pressure, collapsing the lung, and compressing the heat and major blood vessels), Acute and Chronic Respiratory Failure with Hypoxia (sudden worsening of the chronic low blood oxygen, often needing oxygen, ventilation, and treatment for breathlessness, confusion, and rapid breathing), Muscle Weakness (Generalized), Abnormal Posture, Unspecified Displaced Fracture of Second Cervical Vertebra (break in the axis bone of the neck where the fragments have shifted from their normal alignment), Subsequent Encounter for Fracture with Routine Healing, Unspecified Fracture of Upper End of Left Humerus (broken upper arm bone near the shoulder joint), and Subsequent Encounter for Fracture with Routine Healing . Review of Resident #1's MDS assessment (admission), dated 12/05/2025, revealed the resident had a BIMS (assessment of cognitive functioning that is performance-based) score of 11 (a score of 8-12 indicates moderate cognitive impairment), is noted to not have been assessed for prior functioning: everyday activities. Resident #1 is noted to have functional limitation in range of motion with both lower extremities and used a manual wheelchair. Resident #1's mobility assessment indicated partial/moderate assistance needed for sit to lying, lying to sitting on side of bed, toileting hygiene, shower/bathe self, and upper body dressing; substantial/maximal assistance for tub/shower transfer, lower body dressing, putting on/taking off footwear, and personal hygiene; and dependent for sit to stand, chair/bed-to-chair transfer, toilet transfer, car transfer, and any walking. Record review of Resident #1's Care Plan, dated 1/14/2026 as reviewed, revealed no indication of grab/assist bar discussion of risks and benefits with Resident or responsible party. Resident #1's Care Plan has no reference to an assessment that was completed for bed rails or grab/assist bars. Record review of Resident #51's face sheet, dated 1/14/2026, revealed resident was originally admitted on [DATE] with diagnoses of Wedge Compression Fracture of First Lumbar Vertebra Subsequent Encounter for Fracture with Routine Healing (when the front part of the vertebra has collapsed forward, taking on a wedge shape, often from osteoporosis r trauma falls, causing pain, height loss, and a stooped posture); Muscle Wasting and Atrophy not Elsewhere Classified, Muscle Weakness (Generalized), Dysphagia Oropharyngeal Phase (difficulty moving food from the mouth to the esophagus leading to choking, coughing, nasal regurgitation, and a feeling of food sticking), Other Lack of Coordination, Cognitive Communication Deficit (difficulty speaking, listening, reading, or writing due to underlying thinking problems like poor memory, attention, problem-solving, or social understanding), Need For Assistance With Personal Care, Unspecified Dementia Unspecified Severity with Other Behavioral Disturbance (cognitive decline that does not fit a specific dementia type), Paroxysmal Atrial Fibrillation (irregular heartbeat where episodes start and stop on their own, typically within seven days, though they can last shorter or longer and often become more frequent or persistent over time), Heart Failure Unspecified, Neuralgia and Neuritis Unspecified (nerve pain or inflammation when the specific nerve or cause is not identified, causing sharp pain, numbness, or weakness along the nerve pathway), and Unspecified Fall Subsequent Encounter. Review of Resident #51's MDS assessment (entry), dated 1/02/2026, revealed only identification information for the resident the resident as the full assessment had not been completed on 1/14/2026. Record review of Resident #51's Care Plan, dated 1/13/2026 as reviewed, revealed no indication of grab/assist bar discussion of risks and benefits with resident or responsible party. Resident #51's Care Plan has no reference to an assessment that was completed for bed rails or enabler bars. The care plan does have a focus area of Exhibits ADL Self Care Performance Deficit, requires assistance with interventions of Bathing: requires assist x 1 staff participation; Eating: requires assist x 1 staff participation assist; Toileting: requires assist x 1 staff participation assist; Transfer: requires assist x 1 staff participation assist; Praise resident for all efforts made; Refer to OT for any change in ADL self- performance. Focus area of at risk for falls with interventions of Anticipate and meet needs; Be sure call light is within reach and encourage to use it for assistance as needed.Respond promptly to all requests for assistance; Ensure a safe environment: floors even and free from spills or clutter, adequate light, bed in low position, personal items within reach. Record review of Resident #111's face sheet, dated 1/14/2026, revealed resident was originally admitted on [DATE], with diagnoses of Malignant Neoplasm of Head, Face and Neck (cancerous tumors developing in the mouth, neck, throat, voice box, sinuses, or lymph nodes, often starting from mucous membranes presenting as non-healing sores, lumps, or voice changes), Critical Illness Myopathy (severe muscle weakness and wasting condition developing in critically ill patients), Acute Respiratory Failure with Hypoxia (life-threatening condition where the lungs can not get enough oxygen into the blood, causing low blood oxygen and severe shortness of breath and confusion), Unspecified Osteoarthritis Unspecified Site (degenerative joint disease but specific joint or type is not documented), Acute Kidney Failure Unspecified, Syncope and Collapse (syncope is fainting or a temporary loss of consciousness due to a brief drop in blood flow to the brain, characterized by sudden limpness and quick recovery, while collapse can include syncope but also other serious events like seizures, strokes, or cardiac issues). Review of Resident #111's MDS assessment (preliminary), undated and unsigned, revealed the resident had a BIMS score of 14 (a score of 13-15 indicates intact cognition). Information on functional ability was not available on 1/14/2026 when information was reviewed. Record review of Resident #111's Care Plan, dated 1/12/2026 as reviewed, revealed no indication of grab/assist bar discussion of risks and benefits with Resident or responsible party. Resident #111's Care Plan has a focus area of at risk for falls d/t poor balance, use of psychoactive meds with interventions of Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Focus area of ADL Self Care Performance Deficit, requires assistance: limited mobility with interventions of Bathing: requires assist x 1 staff participation. Eating: requires assist x 1 staff participation assist. Toileting: requires assist x 1 staff participation assist. Transfer: requires assist x 1 staff participation assist. Praise resident for all efforts made. Allow resident time to complete tasks. Refer to OT for any change in ADL self performance. Focus area of (chronic) pain with interventions of Administer analgesia as per orders. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care. turn and reposition for comfort. Resident #111's Care Plan has no reference to an assessment that was completed for bed rails or grab/assist bars. Review of Bed Bar/Side Rail Assessment for Resident #111, dated 1/07/2026, revealed an assessment for use of grab/assist bars or bed rails that stated No to the Current Bed Bar/Side Rail question: Are bed rails/bar currently utilized by resident or indicated atthis time?.Review of Informed Consent for Use of Bed Rails form, dated 1/08/2026, for Resident #111 revealed a grab/assist bar consent for the 1/8 bed rails/grab/assist bars signed by the resident or resident's responsible party. Observations on 01/13/2026 at 11:06 AM, revealed Resident #1, Resident #51, and Resident #111's rooms had the resident's bed with grab/assist bars raised on both sides of the beds and residents were resting in those beds. Observations on 01/14/2026 at 4:18 PM, revealed Resident #1, Resident #51, and Resident #111's rooms continued to have the resident's bed with grab/assist bars raised on both sides of the beds with Resident #51 and Resident #111 resting in those beds. Resident #1 was not observed in the bed on 1/14/2026 as they had discharged earlier that day and the grab/assist bars remained on the bed. In an interview with the ADON on 1/15/2026 at 10:55 AM, revealed that before grab/assist bars could be placed on a resident's bed, resident or family consent, resident assessment for appropriateness, and care planning had to happen first. The care planning was entered by the DON when the assessment triggered for it or when the interdisciplinary team met and discussed the resident's admission; when the assessment was answered yes to the question of Are bed rails/bar currently utilized by resident or indicated at this time? it also prompted the care plan entry. Care plans were the responsibility of the DON, ADON, and other members of the interdisciplinary team to review for accuracy and completeness. Interview with the ADM on 01/15/20264 at 11:15 AM, revealed that the facility required for consent, assessment, and care planning to be done before grab/assist bars could be added to a resident's bed. The expectation was for the required tasks to be completed correctly and timely. The facility conducts morning meetings with managers where they, among other topics, discuss any new admits from the previous day including what equipment was needed, any items not working properly, observations of concerns the staff noticed overnight. The staff responsible for completing care plans, RN's and other members of the interdisciplinary team, make sure the grab/assist bars are entered in the care plan and then for the ADON to review for accuracy. The ADM stated the risks to the residents by having grab/assist bars placed inappropriately on a bed varies from the resident may not have the ability to use correctly and get hurt. Interview with the DON on 01/15/2026 at 11:45 AM, revealed that consent, an assessment, and care planning are required for grab/assist bars to be placed on a resident's bed. The consent and assessment are completed by the nursing staff and should be done on admission of the resident or before any type of bars are added to the resident's bed. The assessment for appropriateness triggers the care planning portion to be completed. The DON stated that the risks to the residents that grab/assist bars could create are falls or incorrect positioning. Record review of the facility's provided policy Care Plans- Comprehensive, (Revised December 2009), revealed the policy statement An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The facility will ensure the resident has the right to participate in the development and implementation of his or her person-centered plan of care. Policy Interpretation and Implementation item #1, highlighted as Developing the Comprehensive Care Plan, states Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a person-centered comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain through establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and other factors related to effectiveness of the plan of care. Policy Interpretation and Implementation item #2, highlighted as Basis of Comprehensive Care Plan, states The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Policy Interpretation and Implementation item #3, highlighted as Purpose of Care Plan, states Each resident's comprehensive care plan is designed to:a. Incorporate identified problem areas;b. Incorporate risk factors associated with identified problems;c. Build on the resident's strengths;d. Reflect the resident's expressed wishes regarding care and treatment goals.f. Identify the professional services that are responsible for each element of care;g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels;h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; [NAME]. Reflect currently recognized standards of practice for problem areas and conditions. Policy Interpretation and Implementation item #5, highlighted as Revisions, states The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans:a. When there has been a significant change in the resident's condition;b. When the desired outcome is not met;c. When the resident has been readmitted to the facility from a hospital stay; andd. At least quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to assess the resident for appropriateness and review the risks and benefits of grab/assist bars (smaller bars used by the person in bed to reposition themselves), with the resident or resident representative and obtain informed consent prior to installation or assess for appropriateness for 4 (Resident #1, Resident #32, Resident #51, and Resident #111) of 5 residents observed and reviewed for grab/assist bars. The facility failed to have evidence of informed consent for Resident #1 and Resident #32's grab/enabler bars to be placed on the bed. The facility failed to have evidence of assessment for Resident #1, Resident #51, and Resident #111 for risk of entrapment and ability to safely use the grab/enabler bars. These failures could affect residents who used grab/assist bars at risk of the resident/responsible party not being aware of the risks, informed consent not being obtained from the resident or responsible party, and assessments not being completed for appropriateness. Findings included: Record review of Resident #1's face sheet, dated 1/14/2026, revealed resident was originally admitted on [DATE] with pertinent diagnoses of Cerebral Infarction Due to Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery (stroke that affects the right side of the brain and often results in left-sided paralysis or neglect, impulsive behavior, and facial weakness), Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (chronic condition where the body either does not produce enough insulin or cannot use insulin effectively, leading to high blood sugar levels that have damaged the kidneys' filters leading to reduced waste removal, often accompanied by high blood pressure), Paroxysmal Atrial Fibrillation (irregular heartbeat where episodes start and stop on their own, typically within seven days, though they can last shorter or longer and often become more frequent or persistent over time), Dysphagia Following Other Cerebrovascular Disease (when damage disrupts the brain's swallowing control network, leading to risks like pneumonia, malnutrition, and dehydration, with symptoms including choking or food getting stuck), Pneumonitis due To Inhalation of Food And Vomit (lung inflammation/infection from breathing foreign material like gastric contents into the airways, causing cough, fever, chest pain, and shortness of breath), Spontaneous Tension Pneumothorax (rare, life-threatening condition where air leaks into the space between the lung and chest wall from a ruptured air-filled sac on the lung's surface, forming a one-way valve that traps air, rapidly increasing pressure, collapsing the lung, and compressing the heat and major blood vessels), Acute and Chronic Respiratory Failure with Hypoxia (sudden worsening of the chronic low blood oxygen, often needing oxygen, ventilation, and treatment for breathlessness, confusion, and rapid breathing), Muscle Weakness (Generalized), Abnormal Posture, Unspecified Displaced Fracture of Second Cervical Vertebra (break in the axis bone of the neck where the fragments have shifted from their normal alignment), Subsequent Encounter for Fracture with Routine Healing, Unspecified Fracture of Upper End of Left Humerus (broken upper arm bone near the shoulder joint), and Subsequent Encounter for Fracture with Routine Healing. Review of Resident #1's MDS assessment (admission), dated 12/05/2025, revealed the resident had a BIMS score of 11 (a score of 8-12 indicates moderate cognitive impairment),was noted to not have been assessed for prior functioning: everyday activities. Resident #1 is noted to have functional limitation in range of motion with both lower extremities and used a manual wheelchair. Resident #1's mobility assessment indicated partial/moderate assistance needed for sit to lying, lying to sitting on side of bed, toileting hygiene, shower/bathe self, and upper body dressing; substantial/maximal assistance for tub/shower transfer, lower body dressing, putting on/taking off footwear, and personal hygiene; and dependent for sit to stand, chair/bed-to-chair transfer, toilet transfer, car transfer, and any walking. Record review of Resident #1's Care Plan, dated 1/14/2026 as reviewed, revealed no indication of grab/assist bar discussion of risks and benefits with Resident or responsible party. Resident #1's Care Plan has no reference to an assessment that was completed for bed rails or grab/assist bars. Review of Bed Bar/Side Rail Evaluation, dated 11/30/2025, for Resident #1 revealed no assessment for use of grab/assist bars or bed rails or any other interventions attempted, Review of electronic health records on 1/14/2026 for Resident #1 revealed no grab/assist bar consent for the 1/8 bed rails/grab/assist bars signed by the resident or resident's responsible party or noted to have verbal permission for the enabler bars. Record review of Resident #32's face sheet, dated 1/14/2026, revealed resident was originally admitted on [DATE] with diagnoses of Cerebral Infarction Due to Embolism of Left Middle Cerebral Artery (stroke that affects the left side of the brain and often results in right-sided weakness/paralysis, speech/language issues, and sensory loss), Localization-Related (Focal) (Partial) Idiopathic Epilepsy and Epileptic Syndromes with Seizures of Localized Onset, Not Intractable, Without Status Epilepticus (seizures that start in one brain area, are not drug-resistant, and do not lead to prolonged seizures), Aphasia Following Cerebral Infarction (language disorder caused by brain damage, most often in the left hemisphere, leading to difficulties with speaking, understanding, reading, or writing, though intelligence remains intact), Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side (occurs after stroke in the dominant hemisphere of the brain leading to difficulty moving the right arm, leg, and sometimes face requiring intensive rehabilitation), Apraxia Following Cerebral Infarction (neurologic condition where the brain loses the ability to plan and execute learned, purposeful movements, despite having the physical ability and desire to do so, affecting daily tasks, gestures, and speech), Dysphagia Following Cerebral Infarction (difficulty swallowing after a stroke), Other Lack of Coordination, and Aphasia (language disorder, often sudden after a stroke or head injury, that impairs speaking, understanding, reading, and writing due to brain damage). Review of Resident #32's MDS assessment (quarterly), dated 12/26/2025, revealed the resident had a BIMS score of 00 (a score of 0-7 indicates severe cognitive impairment), was noted to have a functional limited range of motion for both upper and lower extremities on one side and uses a manual wheelchair. Resident #32's assessment indicated partial/moderate assistance needed with oral hygiene; substantial/maximal assistance needed with toileting hygiene, shower/bathe self, upper and lower body dressing, roll right and left, sit to lying, and personal hygiene; and dependent with putting on/taking off footwear and tub/shower transfer. Functional mobility activities of lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and walking any distance not attempted due to medical condition or safety concern. Record review of Resident #32's Care Plan, updated 11/05/2025 as reviewed, revealed a focus area of Utilizes bed bar/assist rail while in bed to aid with turning/repositioning and transitioning into or out of bed and interventions of Assess the use of bed bars/assist rails at least quarterly and prn as appropriate, Encourage the use of the bed bar/assist rails for independence and assist resident when needed, Ensure call light is within reach, Monitor resident during rounds for proper use of bedside device. Review of Bed Bar/Side Rail Evaluation dated 11/06/2025, for Resident #32 revealed an assessment for use of grab/assist bars or bed rails initially on 4/05/2023 and most recent assessment was on 11/06/2025 with recurrent assessments in between. Review of electronic health record on 1/14/2026 for Resident #32 revealed no grab/assist bar consent for the 1/8 bed rails/grab/assist bars signed by the resident or resident's responsible party or noted to have verbal permission for the enabler bars. Record review of Resident #51's face sheet, dated 1/14/2026, revealed resident was originally admitted on [DATE] with diagnoses of Wedge Compression Fracture of First Lumbar Vertebra Subsequent Encounter for Fracture with Routine Healing (when the front part of the vertebra has collapsed forward, taking on a wedge shape, often from osteoporosis r trauma falls, causing pain, height loss, and a stooped posture); Muscle Wasting and Atrophy not Elsewhere Classified, Muscle Weakness (Generalized), Dysphagia Oropharyngeal Phase (difficulty moving food from the mouth to the esophagus leading to choking, coughing, nasal regurgitation, and a feeling of food sticking), Other Lack of Coordination, Cognitive Communication Deficit (difficulty speaking, listening, reading, or writing due to underlying thinking problems like poor memory, attention, problem-solving, or social understanding), Need For Assistance With Personal Care, Unspecified Dementia Unspecified Severity with Other Behavioral Disturbance (cognitive decline that does not fit a specific dementia type), Paroxysmal Atrial Fibrillation (irregular heartbeat where episodes start and stop on their own, typically within seven days, though they can last shorter or longer and often become more frequent or persistent over time), Heart Failure Unspecified, Neuralgia and Neuritis Unspecified (nerve pain or inflammation when the specific nerve or cause is not identified, causing sharp pain, numbness, or weakness along the nerve pathway), Unspecified Fall Subsequent Encounter. Review of Resident #51's MDS assessment (entry), dated 1/02/2026, revealed only identification information for the resident the resident as the full assessment had not been completed on 1/14/2026. Record review of Resident #51's Care Plan, dated 1/13/2026 as reviewed, revealed no indication of grab/assist bar discussion of risks and benefits with Resident or responsible party. Resident #51's Care Plan has no reference to an assessment that was completed for bed rails or enabler bars. The care plan does have a focus area of Exhibits ADL Self Care Performance Deficit, requires assistance with interventions of Bathing: requires assist x 1 staff participation; Eating: requires assist x 1 staff participation assist; Toileting: requires assist x 1 staff participation assist; Transfer: requires assist x 1 staff participation assist; Praise resident for all efforts made; Refer to OT for any change in ADL self performance. Focus area of at risk for falls with interventions of Anticipate and meet needs; Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance; Ensure a safe environment: floors even and free from spills or clutter, adequate light, bed in low position, personal items within reach. Review of Bed Bar/Side Rail Evaluation, dated 1/02/2026, for Resident #51 revealed an assessment for use of grab/assist bars or bed rails that stated No to the Current Bed Bar/Side Rail question: Are bed rails/bar currently utilized by resident or indicated at this time? Review of Informed Consent for Use of Bed Rails, undated, for Resident #51 revealed a grab/assist bar consent for the 1/8 bed rails/grab/assist bars initialed by the resident who is their own responsible party. Record review of Resident #111's face sheet, dated 1/14/2026, revealed resident was originally admitted on [DATE], with diagnoses of Malignant Neoplasm of Head, Face and Neck (cancerous tumors developing in the mouth, neck, throat, voice box, sinuses, or lymph nodes, often starting from mucous membranes presenting as non-healing sores, lumps, or voice changes), Critical Illness Myopathy (severe muscle weakness and wasting condition developing in critically ill patients), Acute Respiratory Failure with Hypoxia (life-threatening condition where the lungs cannot get enough oxygen into the blood, causing low blood oxygen and severe shortness of breath and confusion), Unspecified Osteoarthritis Unspecified Site (degenerative joint disease but specific joint or type is not documented), Acute Kidney Failure Unspecified, Syncope and Collapse (syncope is fainting or a temporary loss of consciousness due to a brief drop in blood flow to the brain, characterized by sudden limpness and quick recovery, while collapse can include syncope but also other serious events like seizures, strokes, or cardiac issues). Review of Resident #111's MDS assessment (preliminary), undated and unsigned, revealed the resident had a BIMS (Brief Interview for Mental Status; assessment of cognitive functioning that is performance-based) score of 14 (a score of 13-15 indicates intact cognition). Information on functional ability was not available on 1/14/2026 when information was reviewed. Record review of Resident #111's Care Plan, dated 1/12/2026 as reviewed, revealed no indication of grab/assist bar discussion of risks and benefits with Resident or responsible party. Resident #111's Care Plan has a focus area of at risk for falls d/t poor balance, use of psychoactive meds with interventions of Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Focus area of ADL Self Care Performance Deficit, requires assistance: limited mobility with interventions of Bathing: requires assist x 1 staff participation. Eating: requires assist x 1 staff participation assist. Toileting: requires assist x 1 staff participation assist. Transfer: requires assist x 1 staff participation assist. Praise resident for all efforts made. Allow resident time to complete tasks. Refer to OT for any change in ADL self performance. Focus area of (chronic) pain with interventions of Administer analgesia as per orders. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care. turn and reposition for comfort. Resident #111's Care Plan has no reference to an assessment that was completed for bed rails or grab/assist bars. Review of Bed Bar/Side Rail Evaluation, dated 1/07/2026, for Resident #111 revealed an assessment for use of grab/assist bars or bed rails that stated No to the Current Bed Bar/Side Rail question: Are bed rails/bar currently utilized by resident or indicated atthis time? . Review of Informed Consent for Use of Bed Rails, dated 1/08/2026, for Resident #111 revealed a grab/assist bar consent for the 1/8 bed rails/grab/assist bars signed by the resident or resident's responsible party. Observation on 01/13/2026 at 11:06 AM revealed Resident #1, Resident #32, Resident #51, and Resident #111's rooms had the resident's bed with grab/assist bars raised on both sides of the beds and residents were resting in those beds. Observation on 01/14/2026 at 4:18 PM revealed Resident #32, Resident #51, and Resident #111's rooms had the resident's bed with grab/assist bars raised on both sides of the beds and residents were resting in those beds. Resident #1 was not observed in the bed on 1/14/2026 as they had discharged earlier that day and the grab/assist bars remained on the bed. In an interview with LVN I on 1/15/2026 at 9:25 AM, revealed the facility trained staff that the policy was that before bed rails or grab/assist bars could be placed on the bed there must be a signed consent form, a discussion on risks of the grab/assist bars with resident and responsible party, the DON must approve the grab/assist bars be put on the bed, therapy needed to conduct an assessment, and either the DON or SW added the use of the grab/assist bars to the care plan. LVN I stated that the risks to the resident of grab/assist bars on the bed inappropriately would place the resident at risk for hitting their head, the bars could be considered a restraint, or for injury, skin tear, or bruising. In an interview with CNA J on 1/15/2026 at 10:04 AM, revealed that in order for grab/assist bars to be placed on a resident's bed, consent was needed from the resident or responsible party and that maintenance installed after required items were obtained. The facility required vendors to remove any full or half rails when leaving beds as only grab/assist bars were allowed in this facility. CNA J also stated that an assessment of the resident was needed for the grab/assist bars. Any CNA was to let the nurse know if a resident asked for or had the ability to use grab/assist bars. CNA J stated that the risks of grab/assist bars could have been strings from call light/overbed light getting caught and risk strangulation of the resident, the grab/assist bars could have posed a hazard for resident getting in/out of bed, entrapment of resident, resident could have hit head, or resident may have tried to get up out of the bed without assistance when they actually needed help or supervision to avoid injury. In an interview with CNA K on 1/15/2026 at 10:15 AM, CNA K stated that if a resident requested grab/assist bars they would have to talk with the nurse about the process for grab/assist bars and make sure the resident had the right bed, that the resident or family as well as the doctor needed to approve the addition of grab/assist bars, and that an assessment needed to be done. CNA K stated that the risks to a resident who was not appropriate for grab/assist bars was that the resident could have fallen and got hurt, received skin tears or bruising. In an interview on 1/15/2026 at 10:20, CNA L stated that consent from the residents or their family was required for grab/assist bars to be added to a bed and was not aware of anything else required. CNA L stated that the nurse or DON was the one who would review that any required things were obtained before grab/assist bars were placed on a bed. CNA L stated that grab/assist bars or bed rails could be considered a restraint. CNA L stated that assessments were done when a resident admitted . CNA L stated that risks of grab/assist bars to residents could range from the resident taking off the grab bar and using it to hurt others, could provide a false sense of safety and cause a fall, could worsen situation like feeling trapped, the cords (of call light or overbed light) could get wrapped up and get hurt the resident, the resident could break something (like a bone if hits the bar), or could sustain bruising. In an interview with the ADON on 1/15/2026 at 10:55 AM, revealed that before grab/assist bars could be placed on a resident's bed, resident or family consent, resident assessment for appropriateness, and care planning had to happen first. Consent was obtained when the assessment was completed showing the resident was appropriate to use the grab/assist bars; this was the responsibility of the admitting nurse. The care planning was entered by the DON when the interdisciplinary team met and discussed the resident's admission; when the assessment was answered yes to the question of Are bed rails/bar currently utilized by resident or indicated at this time? it also prompted the care plan entry. Care plans were the responsibility of the DON, ADON, and other members of the interdisciplinary team to review for accuracy and completeness. Interview with the ADM on 01/15/2026 at 11:15 AM, revealed that the facility required for consent, assessment, and care planning to be done before grab/assist bars could be added to a resident's bed. The expectation was for the required tasks to be completed correctly and timely. The facility conducts morning meetings with managers where they, among other topics, discuss any new admits from the previous day including what equipment was needed, any items not working properly, observations of concerns the staff noticed overnight. The expectation was that nursing staff complete assessments and obtain any consents required and then move to next assessment the resident needed to have completed. The staff responsible for completing care plans, RN's and other members of the interdisciplinary team, make sure the grab/assist bars are entered in the care plan and then for the ADON to review for accuracy. The ADM stated the risks to the resident by having grab/assist bars placed inappropriately on a bad varies from the resident may not have the ability to use correctly and get hurt. The timeframe for the assessment to be done was assigned to the admission nurse who works during the afternoon shift and, depending on number of admissions, charge nurses will also assist with the assessments. If there were too many new admits, the assessments would have fallen to the next shift and would have been done on next day (goal of within 24 hours of admit to have all assessments done). Interview with DON on 01/15/2026 at 11:45 AM, revealed that consent, an assessment, and care planning are required for grab/assist bars to be placed on a resident's bed. The consent and assessment are completed by the nursing staff and should be done on admission of the resident or before any type of bars are added to the resident's bed. The assessment for appropriateness triggers the care planning portion to be completed. The DON stated that the risks to the resident that grab/assist bars could create are falls or incorrect positioning. Record review of the facility's provided policy Bed Safety, (C)2001 MED-PASS, Inc. (Revised December 2007), revealed the policy statement Our facility shall strive to provide a safe sleeping environment for the resident. Policy Interpretation and Implementation item #1, highlighted as Assessment of Resident Sleeping Environment, states The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. Policy Interpretation and Implementation item #2, highlighted as Hospital Bed System Safety Review, states e. Identify additional safety measures are implemented for residents who have been identified as having a higher than usual risk for injury including bed entrapment (e.g., altered mental status, restlessness, etc.). Policy Interpretation and Implementation item #5, highlighted as Side Rail Use and Interdisciplinary Assessment, states If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. Policy Interpretation and Implementation item #6, highlighted as Consent for Use of Side Rails, states The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. Policy Interpretation and Implementation item #8, highlighted as Side Rails to Help Support Medical Needs, states Side Rails May be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. Policy Interpretation and Implementation item #9, highlighted as Risk-Benefit Assessment for Use of Side Rails, states Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with the side rails. Policy Interpretation and Implementation item #10, highlighted as Reducing Related Risks, states When using side rails for any reason, the staff shall take measures to reduce related risks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for three of six (Med Cart #1, Med Cart #2, and Med Cart #3) medication carts reviewed for storage of medication 1. LVN B left Med Cart #1 unlocked and unattended on 01/13/26. 2. Med Aide D failed to secure 5 medications before leaving Med Cart #2 unattended outside Resident #3's room on 01/13/26. 3. Med Aide E failed to ensure Med Cart #3 was free of brown and black sticky substance and brown dust particles in the compartment that had medicine cups and water cups in it on 01/14/26. These failures could place residents at risk of their medications being stolen or misused and health complications related to accidental ingestion of drugs and/or biologicals, including hospitalization. Findings included: 1.During an observation on 1/13/26 between 08:50 AM to 09:10 AM, Med Cart #1 was unlocked and unattended on the 400 hallway, the drawers was facing out into the hallway. Med Cart #1 was accessible to anyone walking by, three staff members walked by the unlocked and unattended medication cart. LVN B was observed walking towards the cart, upon reaching the cart she pushed the lock mechanism in to indicate locked position. In an interview with LVN B on 01/13/26 at 09:10 AM, revealed Med Cart #1 belonged to her, she said s it was a nurse medication cart. LVN B said Med Cart #1 contained insulins (medications that can lower blood sugars), prescription medications pills, over the counter medications, and breathing treatments inhalers containing albuterol, (a medication that causes nervousness, shakiness, throat/nasal irritation, muscle aches, and trembling). LVN B said she forgot to lock the cart when she pulled the key out of the lock. She said the lock mechanism might have opened, and she was not aware of this before walking away. LVN B stated the expectation was that the medication cart was always locked when no one was using it to prevent anyone from getting into the medication cart. 2.Record review of Resident #3's face sheet, dated 01/14/26, reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included unspecified encephalopathy (this is a brain disease that alters brain function or structure), hyperlipidemia (elevated level of lipids, like cholesterol in the blood), Type 2 diabetes (a problem in the way the body regulates and uses sugar as fuel). During a medication observation and interview on 01/13/26 at 12:40 PM, Med Aide D administered medications to Resident #3 in her room. The medications was Eliquis 5 mg tablet (blood thinner), Clopidogrel tablet 75 mg (blood thinner), Furosemide 40 mg tablet (medication used for fluid overload, Glimepiride 4 mg tablet (this medication is used to regulate/lower blood sugar), and Carvedilol 3.125 mg tablet (used to treat high blood pressure). Med Aide D popped the pills out of the bubble pack into a medication cup. She then locked the medication cart however she left the medication bubble cards with medicines on top of Med Cart #2 and went into Resident #3's room. The door to Resident #3's room was open, but Med Aide D had her back towards Med Cart #2, and the cart was not in her line of view. Two staff and a resident walked by Med Cart #2. Resident #3 dropped one of her pills and Med Aide D bent down to look for it. She did not have direct eye contact to the medications on top of Med Cart #2. Med Aide D said that she left the medications out thinking the surveyor was keeping an eye on her cart for her. She did not see the staff that had walked by the cart. She said that if medication is not in direct eye view, it should be locked inside the cart. She said that anyone could have access to the medications that were left on top of Med Cart #2. She said the risk was drug diversion or accidental ingestion by a resident. 3.Observation on 01/14/26 at 08:10 AM, revealed Med Cart #3 with two medication cup compartments, one had smaller medicine cups and the one below it had bigger medicine /water cups. Outside both compartments was brown and black sticky substance. Inside both compartments with cups facing downwards were brown dust particles inside the compartment that had medicine cups and water cups in it and a belonging bag in the bottom compartment next to the cups. The trash bag and lid to trash can underneath the medicine cup compartment had brown and black substances stuck on the medication cart. Interview with Med Aide E on 01/14/26 at 08:11 AM, he said he had cleaned Med Cart #3 yesterday (1/13/26) and he did not know who or why the person that used it overnight did not clean it. He said he did not clean it this morning before using it. He said all med aides and nurses was responsible for the cleanliness of the medication cart to prevent the risk of cross contamination and infection control. In an interview with the ADON on 01/14/26 at 09:45 AM, she said she would go and assist Med Aide E to clean the cart. She said all staff that used the medication carts was responsible for the cleaning the carts and maintaining cleanliness. She said the ADON's was responsible for monitoring that medication carts was kept clean and sanitary. She said the risk of having a dirty medication cart was cross contamination. The ADON stated she had just completed an in-service with LVN B for medication safety and that she would also do an in-service for clean, safe, and sanitary medication carts. Interview with the DON on 01/15/26 at 09:53 AM, he said they had started in-servicing the current staff and was still working on oncoming staff which included all nurses and medication aides on medication safety. He revealed names on the in-service sheet that had already completed the in-service, including the one-on-one sheet that was completed with LVN B on 01/13/26. He said all medications should not be left unattended, and the medication cart should be locked when not in use and out of sight. He said all medication carts should be kept clean for infection control. In an interview with the Administrator 01/15/26 at 1:33 PM, the administrator said that they had written up LVN B for leaving medication cart unlocked and unattended. She stated that they would in-service all the staff on different shifts regarding medication safety. She said the risk was unauthorized access to medications; medication can go missing and harm if ingested. She said the expectation was that all medication carts were kept clean for infection control. She said all nursing staff were responsible for medication safety. Record review of the facility's policy titled Storage of Medications, with a revision date of April 2007, reflected, in part, The medication cart shall be secured during medication passes ., when it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall and drawers facing the wall. The cart must be locked before the nurse enters the room . medications carts must be securely locked at all times when out of the nurses view

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 (Residents #4) of 1 resident reviewed for refrigerator in the rooms. The facility failed to place a thermometer in Residents #4's refrigerator and monitor the temperature. This failure could affect residents by placing them at risk for food-borne illnesses. Finding included: Record review of Resident # 4's face sheet, dated 01/15/26 revealed an [AGE] year old female who was admitted to the facility on [DATE] with a primary diagnosis of unspecified sequelae of Cerebral infarction (this is a condition that is not specified but started due to long term effect of stroke such as cognitive, speech issues, emotional issues, and memory loss). Her secondary diagnosis was Dementia. Record review of Resident #4's admission MDS dated [DATE] revealed a BIMS score of 8, which indicated moderate cognitive impairment and required substantial/maximal assistance with personal hygiene. A record review of Resident #4's care plan initiated on 09/24/25 revealed Resident #4 had a focus on memory judgement, decision making and thought process related to dementia. The goal was for her to communicate basic needs daily. The interventions included maintaining as much consistency as possible with environment, routines, situations, care, and caregivers. Orient and reorient to change. Observation and interview with Resident #4 on 01/13/26 at 11:28 AM, revealed Resident #4 in her room and she had family at bedside. A small refrigerator with a glass door was observed near the window. Items inside were visible via the glass door. There was no thermometer inside, and no temperature log attached to the refrigerator. Resident #4's family member said that he had just gotten the refrigerator a few weeks ago. He stated Resident #4 needed the refrigerator to store her [Soda brand] that she loved so much. He said the refrigerator had a compressor, and he had set it to 40 degrees. He said the refrigerator was built just like a regular refrigerator, just small. He said that he monitored the temperature when he was visiting Resident #4 daily by the coolness of the items. Interview with CNA F on 01/13/26 at 12:10 PM, revealed she was not aware of any residents with refrigerators. She said that maybe housekeeping was responsible for them. Interview with the Housekeeping Supervisor on 01/15/26 at 09:10 AM, revealed the nursing department was responsible for monitoring the refrigerators' temperatures in rooms and med rooms. In an interview with the DON on 01/15/26 at 09:53 AM, revealed that per the facility admission policy residents were not allowed to have refrigerators in their rooms. He said the nursing department was responsible for the refrigerators in the medication rooms, and they monitored those. He said that the risk of not monitoring refrigerators temperatures was infection control and outdated or spoiled items in the refrigerators. In an interview with the Administrator on 01/15/26 at 1:33 PM, revealed by the facility admission policy, residents were not allowed to have refrigerators in their rooms. She said that she would speak to Resident #4 and her family regarding the violation of the admission agreement, and she would start an inservice with staff. The administrator said that the facility did not have a specific policy for personal refrigerators because they were not allowed in the facility. She said it was a food safety concern and could have an impact on their health. admission packet pending from administrator as of 01/20/26 at 7:44 PM. Record review of the facility policy titled Resident Personal Food Storage revised 12/2008 revealed 7. The nursing staff is responsible for discharging perishable food on or before the use by date .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents resided and received services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #3) of fifteen reviewed for call lights. The facility failed to ensure Resident #3's call button was not broken and placed within reach.These failures could place residents at risk for needs not being met, decreased quality of life, self-worth and dignity.Findings included: Record review of Resident #3's face sheet, dated 01/14/26, reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included unspecified encephalopathy (this is a brain disease that alters brain function or structure), hyperlipidemia (elevated level of lipids, like cholesterol in the blood), and Type 2 diabetes (a problem in the way the body regulates and uses sugar as fuel). Record review of Resident #3's comprehensive MDS Assessment, dated 12/02/25 reflected no record of Resident #3's BIMS. Cognitive patterns included memory problems and severely impaired cognitive skills for daily decision making. She was always incontinent of bowels and bladder and dependent on toileting, showers, and transfers. Record review of Resident #3's care plan initiated 12/01/25 reflected the following: Focus: [Resident #3] is high risk for falls. Goal: Will be free of fall. Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observation on 01/13/26 at 10:47 AM, revealed Resident #3 was in bed, and could not communicate well. Resident #3 did not answer questions this surveyor asked about the call button. Call light was observed tied to the bed rail with the call button missing. In an interview with CNA F on 01/13/26 at 11:08 AM, she stated she last worked with Resident #3 on Friday, and the call light had been working because the resident had used it. She said that she would report it to maintenance to have it replaced right away. She said that not having a call light that worked placed the residents at risk of not having their needs met. She stated that she was international about rounding in the residents' rooms to check on them. She said it was all staff's responsibility to ensure call lights were within reach for all residents. She said it was a resident's right to be able to call for assistance when they required it. In an interview on 01/15/2026 at 9:30 AM, with the ADON revealed the CNAs are responsible for ensuring that all the call lights are within reach to each resident. It is her expectation that each CNA who provides care to the resident's place the call light within reach before they leave the room and recheck the call light through the day. A resident could have an emergency or fall and unable to call for assistance. In an interview with the DON on 01/15/26 at 09:53 AM, the DON stated that all residents should have access to their call light. He said all staff were responsible for ensuring residents' call lights were placed in their reach to ensure they could call for assistance if they needed to. The DON stated he expected staff to check for light placement throughout the day to ensure residents could call for assistance. In an interview with the maintenance person on 01/15/26 at 11:30 AM, she said that all staff had access to an electronic reporting system for all broken items. She said she was notified before 01/13/26 that Resident #3's call light was broken. She said she was made aware on 01/13/26 when CNA F informed her that call light for Resident #3 was broken, she said once she was notified (01/13/26), she replaced it right away. In an interview with the Administrator on 01/15/26 at 1:33 PM, all call light should be in good working condition and within reach. She said the call light was important for residents to call for help. She said the expectation was that all equipment's that was broken was reported immediately. Review of policy revised October 2010 for Answering Call Lights reflected The purpose of this procedure is to respond to the resident's request and needs. Be sure that the call light is plugged in at all times. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Some residents may not be able to use their call light. Be sure you check these residents frequently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviewed the facility failed to ensure appropriate care and services to prevent complications of enteral feeding for one (Resident #75) of three residents reviewed for enteral tube feeding, in that; LVN C failed to ensure Resident #75 was not flat in bed during repositioning while his enteral feeding was still connected and running. This failure placed residents with enteral feedings at risk of receiving inappropriate care and maintenance which could result in fluid overload, vomiting, aspiration (entering the airways or lungs), and hospitalization. Findings Included: Record review of Resident #75's face sheet dated 01/14/26 revealed a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included cerebral palsy (this is a congenital disorder of movement, muscle tone and posture) and gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individuals who have difficulty swallowing). Review of Resident #75's quarterly MDS dated [DATE], reflected no record of Resident #75's BIMS. Cognitive patterns included memory problems and severely impaired cognitive skills for daily decision making. Further, MDS revealed a functional status assessment that Resident #75 required extensive two-person assistance with bed mobility and was totally dependent on two-person assistance for dressing, toilet use, and personal hygiene. MDS also revealed that Resident #75 had a g-tube and obtained 51 percent or more of total calories and 501 cc of fluid through the feeding tube. Review of Resident #75's physician orders for January 2026, on 01/14/25 revealed that he had an order to elevate his head at 30-40 degrees except to allow for ADL care. Order started on 09/27/18.-Order flush g-tube with 300 cc water every 4 hours. Start date 5/14/25.-Order Pump [brand name of feeding] 40 cc/hr per g-tube for 22 hours every shift. Order start date 07/23/25. Review of Resident #75's care plans initiated on 09/27/18 reflected a focus of Resident #75 requiring a tube feeding related to difficulty swallowing (dysphagia). The goal was to make sure the insertion site was free of signs and symptoms of infection. The interventions included keeping the Head of Bed elevated (up) 30-45 degrees during feeding and thirty minutes after tube feeding. During a medication administration observation on 01/14/26 at 06:53 AM, Resident #75 was lying in bed with his eyes open. He had a g-tube which was connected to a feeding pump infusing at 40 ml/hr with 300 cc of water flushes. LVN C stated she was going to reposition the resident so that she could administer his medication. LVN C did not get help; she laid Resident #75's head of bed down without pausing or switching off the feeding pump. LVN C pulled him up the resident using the bed sheet until she reached the desired position and then raised the head up. In an interview with LVN C on 01/14/26 at 7:20 AM, she stated that she should have stopped the feeding before lowering Resident #75's head down. She said she was trained to stop feeding before repositioning. She said she had forgotten because she was nervous being watched. She said the risk of not holding the feeding when resident is laid flat is aspiration (backflow of feed entering the airways or lungs). In an interview with the DON on 01/15/26 at 09:53 AM, he said the expectation was for the nurse to pause the feeding when repositioning or providing incontinent care. He said that there was a risk of aspiration if the feeding is not held when the head of the bed is lowered. In an interview with the Administrator on 01/15/26 at 1:33 PM, the administrator said she was not a nurse; however, the expectation was that nursing staff follow the process and procedure in place for the safety of residents. She said she was told by the nurse managers that lying down a resident on feedings can cause the resident to aspire, which could harm them. Review of the facility policy, Medication Administration, revised 12/12 and facility policy titled Gastrostomy/Jejunostomy Care, revised 09/24, did not address resident in proper position with head of bed elevated to 45 degrees with enteral feeding as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Residents #16 and Resident #27) of eight residents reviewed for Respiratory Care.
1. The facility failed to ensure on 01/23/25 that Resident #16's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored in a bag and labeled when not in use.
2. The facility failed to ensure on 01/23/25 that Resident #27's breathing mask used for nebulization was stored in a bag and labeled when not in use.
These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.
Findings included:
Review of Resident #16's Face Sheet, dated 01/23/25, reflected that the resident was a [AGE] year-old male admitted on [DATE]. Resident #16 was diagnosed with metabolic encephalopathy (a brain disorder that occurs when there's an imbalance of chemicals in the blood. This imbalance can be caused by an illness or organ failure.)
Review of Resident #16's Quarterly MDS Assessment, dated 04/13/2024, reflected Resident #16 was cognitively intact with a BIMS score of 15. Resident #16's Quarterly MDS Assessment indicated that the resident had COPD .
Review of Resident #16's Comprehensive Care Plan, dated 08/02/2024, reflected Resident #16 had oxygen therapy related to COPD and one of the interventions was oxygen therapy continuous.
Review of Resident #16's Physician Order dated 01/15/25 O2: change and label water humidification and NC tubing weekly on Sunday and on 2-10 shift, every evening shift every Sunday.
Observation and interview with Resident #16 on 01/23/25 at 12:15 PM revealed the resident's NC tubing unbagged wrapped around the portable oxygen container.
In an interview with Resident #16 on 01/23/25 at 12:15 PM, he stated that he uses the portable oxygen when he was out of bed and transported to medical appointments. He stated that he used the oxygen yesterday. He stated that the oxygen concentrator and NC tubing was changed.
Review of Resident #27's Face Sheet, dated 01/24/25, reflected that resident was a [AGE] year-old female admitted on initially on 06/30/20 and 01/08/25. Resident #27's was diagnosed with Acute respiratory failure with hypercapnia, (inflammation and fluid in the lungs caused by a bacterial, viral, or fungal infection), Chronic obstructive pulmonary disease, unspecified. (Is a progressive lung disease that makes it difficult to breathe. It's caused by damage to the lungs that leads to inflammation and swelling in the airways. This inflammation narrows the airways, making it harder to move air in and out of the lungs.)
Review of Resident #27's entry MDS, dated [DATE], reflecting admission.
Review of Resident #27's baseline Care Plan dated 01/08/25 reflected O2 by NC 4L no care plan for oxygen therapy.
Review of Resident #27's Physician Order (PO), dated 01/12/25, reflected Change and label Nebulizer Mask and tubing every week on Sunday on 2-10 shift. PO dated 01/12/25 reflected Change and label water humidification and NC tubing every week on Sunday on 2-10 shift. Order dated 01/08/25 reflected O2: O2 at 4L/minute via NC continuously.
at change and label water humidification and NC tubing weekly on Sunday.
Observation and interview with Resident #27 on 01/23/25 at 12:00 PM revealed that Resident #27 was lying in her bed, awake. It was observed that she had a nasal cannula tubing and water bottle was not dated. The nebulizer machine and tubing were sitting a chair next to the bed in a bag with the mask and tubing hanging out touching the chair cushion and floor. She said she last used the nebulizer machine and tubing last night 01/23/25. She said she did not remember when the NC tubing and water was changed.
In an interview with RN L on 01/23/25 at 2:13 PM, RN L said she did not observe the NBM in the resident visitor chair with tubing hanging out of bag and touching the chair seat and floor, neither did she observe Resident #27's concentrator water bottled, and NC tubing were not dated during her resident rounds. RN L said she did not observe Resident #16's NC tubing coiled around the portable oxygen tank not dated and bagged when not in use. RN L stated the NBM and NC should not be exposed nor touching anything because it could cause cross contamination and infection. RN L said the NBM/NC should be bagged when not in use.
In an interview with the ADON on 01/23/25 at 3:01 PM, the ADON stated the breathing mask, and the nasal cannula should be bagged when the resident was not using it to prevent cross contamination and infection. She said the staff were responsible for taking off nebulizer mask should be bagged and labeled, and the NC and water bottle should be labeled. She said that the resident could not move independently to place mask on the chair. She said the expectation was for the staff to bag the breathing mask and the nasal cannula when not in use. She said she would coordinate with the DON to conduct an in-service pertaining to bagging the nasal cannula and the breathing mask when the residents were not using them. She said she would also make a round to check if the breathing masks and nasal cannula not in used were bagged.
In an interview with the DON on 01/23/25 at 3:37 PM, the DON stated the breathing mask, and the nasal cannula should be bagged when not in use to keep it clean. The DON said the proper way of storing the breathing mask and the nasal cannula was to place them inside the plastic bag when the resident was done with the breathing treatment or when the resident was not using the nasal cannula. She said if those breathing apparatus were not bagged, they were exposed, or touching surfaces that were not clean, then oxygen administration could be compromised. The DON said the staff, were responsible for monitoring the nebulizer mask and the nasal cannula to ensure they were bagged when not in use. She said the expectation was the breathing mask and the nasal cannula would be stored properly, NC labeled when administered by the nurse.
In an interview with the ADMIN on 01/23/25 at 3:43 PM, the ADMIN stated she expects all resident devices (nebulizer, NC, water bottle) ordered by MD used should be stored properly according to professional clinical standards and procedures to prevent cross contamination and potential infections. The ADMIN said she would coordinate with the DON for further monitoring and training.
Review of facility policy Oxygen Administration revised March 2004 revealed the purpose of this procedure is to provide guidelines for safe oxygen administration. After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: The date and time that the procedure was performed . the policy did not address tubing storage for safe, sanitary, and clean storage when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for one (Residents #44) of three residents reviewed for parenteral fluids.
The facility failed to ensure on 01/23/25 that Resident #44 received IV hydration per parental fluids professional standards by labeling and dating the solution at the time of administration.
This failure placed the residents at risk for infections, wrong dose, and clinical monitoring of doses.
Findings included:
Review of Resident 44's face sheet dated 01/23/25 reflected he was a [AGE] year-old male that was admitted on [DATE]. The residents DX included: Kidney Failure, Chronic Pain, Cyst (cyst is a sac-like pocket of membranous tissue that contains fluid,) on Kidney, Type 2 Diabetes mellitus (Type 2 diabetes is a condition that causes high blood sugar), Anemia (Anemia is a blood disorder that occurs when the body doesn't have enough healthy red blood cells or hemoglobin, which carries oxygen throughout the body) Unspecified, Hyperlipidemia (Hyperlipidemia is a medical condition where there are abnormally high levels of lipids, or fats, in the blood.), and he was being treated for hydration via IV from low BP on 01/23/25.
Review of Resident #44's quarterly MDS dated [DATE] reflected he had a BIMS score of 06, indicating he was severely impaired cognitively. His functional abilities reflected he required set up and clean up assistance for eating. Substantial assistance for toileting, bathing, dressing, and oral hygiene. He receives anticoagulant (helps to keep away blood clots) hypoglycemic (low blood sugar insulin) and diuretic (helps kidneys to make more urine).
Review of Resident #44's care plan dated 01/01/25 reflected CHF (a progressive heart disease) interventions .Check breath sounds and document labored breathing, encourage nutrition He has an ADL self-care performance .He was resistive to care r/t Dementia (memory loss) deficit in memory, poor judgement, poor decision making, and poor thought process. He has mood problems AEB: trouble falling asleep, Disease process CHF, chronic pain renal insufficiency r/t kidney disease intervention monitor labs, vital signs, diet, intake, changes in electrolytes and report to MD.
Review of Resident #44's MD orders dated 01/23/25 normal saline flush, intravenous solution 0.9%. monitor BP every 4 hours for X 3 days.
Review of Resident #44's dated 01/23/25 at 3:28 PM by LVN M reflected Resident alert with general weakness, Low BP, notified ISNP received orders from KUB (kidney (The kidneys are two bean-shaped organs found on the left and right sides of the body.), ureter (the ureters are tubes made of smooth muscle fibers that propel urine from the kidneys to the urinary bladder.), Bladder .A kidney, ureter, and bladder (KUB) study is an X-ray study that allows your doctor to assess the organs of your urinary and gastrointestinal systems) CBC, CMP, CXR, 2-V flu test, UA with C&S, NS 0.9 @ 75ml 1 liter N. Saline (mixture of sodium chloride. Salt water) started @ 75 ml/hr. UA (examines the visual, chemical, and microscopic properties of urine.) collected CXR and KUB completed by neighborhood x-rays.
Observation on 01/23/24 at 12:10 PM revealed Resident #44 lying in bed asleep, with the IV-line fluids connected to an IV with fluids infusing. The resident's line was on his left arm and the dressing was in place undated and saline solution bag was not dated. Resident # 44 was not interviewed as he was asleep.
Interview on 01/23/25 at 2:41 PM with LVN M revealed she received the order to administer the fluid today by ISNP. LVN M said she forgot to label the bag and dressing with name, date, order amount, and time. LVN M said she administered the IV, after receiving orders from MD. LVN M also said the risks of not labeling the saline bag communicates to other clinical staff the contents of the bag, dose for monitoring solution, and informs all nursing and clinical staff of the resident's name, prescriber, person administering, time administered, and correct dose.
Interview on 01/23/25 at 3:37 PM with the DON revealed IV lines are administered and dispensed with clinically guided protocol. She stated that the bag would need to be labeled after 24 hours. She stated the clinical staff can check the MAR for date, dose, time, and MD. Then she stated the resident name and date should be labeled by the nurse on the bag initially then more detailed after 72 hours to monitor by shift.
Review of the facility's undated policy titled Intravenous Administration of Fluids and Electrolytes . date of revision April 2009. the purpose of this procedure is to provide guidelines for the safe and aseptic administration of intravenous fluids and electrolytes for hydration. The following information should be recorded in the resident's medical record: The date and time the infusion was administered. The type of solution administered. The amount of solution administered. The route of administration. The rate of administration. The condition of the IV site before and after administration. Notification of the physician if there are any complications. Report other information in accordance with facility policy and professional standards of practice. Quote from resident stating how they tolerated the procedure. The signature and title of the person recording the data.

Based on observation, interviews, and record reviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 10 (main dining room) of 25 residents served in the facility only resident dining room reviewed for environmental conditions.
The facility staff failed to ensure on 01/23/25 the dining room trash was covered with a lid, and the vacuum cleaner was clean and stored away from residents that were dining for lunch.
This failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.
The findings included:
Observations on 01/23/25 from 12:30 p.m. to 1:00 p.m., of the facility dining room revealed the following:
-The housekeeping vacuum cleaner (blue/black) was observed with gray cotton type particles and brown powder in placed behind 4 residents waiting to be served lunch.
- The dining room trashcan was not covered with the lid on the south wall behind 3 residents waiting to be served
lunch.
In an interview on 01/23/25 at 3:05 PM., the HSKS stated housekeeping staff were responsible for cleaning the dining room after each meal and ensuring the lids were covering all trashcans. She stated the vacuum cleaner should have been stored immediately after using to locked housekeeping supply closet. HSKS said the failure could result in residents being exposed to bacteria, unsanitary dining, and potential illnesses from cross contamination. The HSKS said she would in-service all housekeeping staff on following sanitation for a safe and clean environment, immediate storage of vacuum equipment, and ensuring the trash cans were covered with a lid.
In an interview on 01/23/25 at 3:05 PM., the ADMIN stated the expectation for the facility to be clean, and sanitary, at all times, with tightly covered trash containers and the vacuum stored appropriately. The ADMIN stated if facility staff observed unsanitary concerns, she expected them to report the issue, so it could be corrected. The ADMIN stated staff would be in-serviced on facility cleanliness, dining room sanitation, and proper storage of equipment. The ADMIN stated that the trash left uncovered and vacuum cleaner placed in the dining room was unsanitary.
Record review of the facility's policy entitled Sanitation ., revised in December of 2008, read in part: 'The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects .Sanitizing of environmental surfaces must be performed with one of the following solutions: Kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure residents had the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States for 8 (Residents #6, #21, #31, #39, #50, #57, #65, and #78) of 10 residents, and 1 of 1 residents reviewed for dignity in the dining room (Resident #9).
1. Residents #6, #21, #31, #39, #50, and #57 were not asked by staff if they were interested in voting.
2. Residents # 65 and #78, interviewed in their room, reported not being asked by staff if they were interested in voting.
3.The facility failed to ensure Residents #9 had the right to a dignified existence when the staff stood over the resident while feeding the resident.
This deficient practice could affect all residents and could result in residents not being able to exercise their rights as United Stated citizens.
Findings included:
1. Record review of Resident #6's face sheet, dated 11/01/2024, revealed he was readmitted on [DATE] with an initial admission on [DATE]. Admitting diagnoses included unspecified diastolic (congestive) heart failure (heart unable to pump blood the way it should); type 2 diabetes mellitus without complications (body unable to use insulin properly); and unspecified convulsions (seizure when exact cause is unknown).
In an interview on 10/30/2024 at 10:30 a.m., Resident #6 said the staff had not asked him if he wanted to vote. Resident #6 stated he was interested in voting for the November Presidential election.
Record review of Resident #21's face sheet, dated 11/01/2024, revealed she was admitted on [DATE] with diagnoses that included cardiomegaly (enlarged heart); chronic pain syndrome (pain that may be caused by inflammation or dysfunctional nerves); and essential (primary) hypertension (high blood that is multi-factorial and doesn't have one distinct cause).
In an interview on 10/30/24 at 10:30 a.m., Resident #21 stated she wanted to vote in the November election, but no staff had asked her about voting.
Record review of Resident #31's face sheet, dated 11/01/2024, revealed she was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe); chronic atrial fibrillation (type of heart arrhythmia that causes the upper chambers if the heart to bear irregularly and quickly); and essential (primary) hypertension (high blood that is multi-factorial and doesn't have one distinct cause).
In an interview on 10/30/24 at 10:30 a.m., Resident #31 stated she was interested in voting in the upcoming election, but no staff had asked her about voting.
Record review of Resident #39's face sheet, dated 11/01/2024, revealed he was readmitted on [DATE] with an initial admission on [DATE]. Admitting diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (conditions that occur after a cerebral infarction, a type of stroke that happens when blood flow to the brain is reduced or blocked); non-traumatic intracerebral hemorrhage, unspecified (type of stroke that occurs when there's bleeding within the brain without trauma or surgery); and cerebral infarction, unspecified (serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die).
In an interview on 10/30/24 at 10:30 a.m., Resident #39 stated she was interested in voting in the upcoming election, but no staff had asked her about voting.
Record review of Resident #50's face sheet, dated 11/01/2024, revealed she was readmitted on [DATE] with diagnoses included hypopituitarism (decreased secretion of one or more of the eight hormones normally produced by the pituitary gland at the base of the brain); essential (primary) hypertension (high blood that is multi-factorial and doesn't have one distinct cause); and unspecified osteoarthritis, unspecified site (a progressive, degenerative joint disease).
In an interview on 10/30/24 at 10:30 a.m., Resident #50 stated she was interested in voting in the upcoming election, but no staff had asked her about voting.
Record review of Resident #57's face sheet, dated 11/01/2024, revealed she was readmitted on [DATE] with an initial admission on [DATE]. Admitting diagnoses included Alzheimer's Disease, unspecified (causes the brain to shrink and brain cells to eventually die); essential (primary) hypertension (high blood that is multi-factorial and doesn't have one distinct cause); and chronic kidney disease, stage 3 unspecified (a condition where the kidneys are mild to moderately damaged and are less able to filter wastes from the blood).
In an interview on 10/30/24 at 10:30 a.m., Resident #57 stated she was interested in voting in the upcoming election, but no staff had asked her about voting.
2. Record review of Resident #65's face sheet, dated 11/01/2024, revealed she was readmitted on [DATE] with an initial admission on [DATE]. Admitting diagnoses included diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified (a common complication of type 1 and type 2 diabetes); chronic obstructive pulmonary disorder with (acute) exacerbation (a sudden worsening of COPD symptoms); and essential (primary) hypertension (high blood that is multi-factorial and doesn't have one distinct cause).
In an interview on 10/30/24 at 10:30 a.m., Resident #65 stated she was interested in voting in the upcoming election, but no staff had asked her about voting.
Record review of Resident #78's face sheet, dated 11/01/2024, revealed she was admitted on [DATE] with diagnoses that included acute on chronic systolic (congestive) heart failure (occurs when the heart muscle weakens or stiffens, making it difficult to pump blood efficiently; unspecified diastolic (congestive) heart failure; essential (primary) hypertension high blood that is multi-factorial and doesn't have one distinct cause).
In an interview on 10/30/24 at 10:30 a.m., Resident #78 stated she was interested in voting in the upcoming election, but no staff had asked her about voting.
Residents #6, #21, #31, #39, #50, #57, #65, and #78 felt that their rights were ignored by not being able to vote,
In an interview on 10/31/24 at 12:15 p.m., the AD stated he did ask the residents if they wanted to vote. The residents were offered absentee voting or the option to be taken out to the polls to vote. The AD revealed that the resident's family members assisted with this voting. The AD could not provide documentation regarding residents requesting assistance with exercising their right to vote in the election.
In an interview on 10/31/24 at 02:45 p.m., the Adm revealed that residents at the facility have never been offered the opportunity to vote. The Adm stated that most of the residents do not have a current ID and the resident was not from the local area. The ADM revealed the Activity Director spoke with the residents related to voting. There was no documentation r/t offering voting in the Presidential Election. The ADM states the facility did not have a policy related to exercising resident rights to vote as united states citizens.
3. Record review of Resident #9's Face sheet, dated 10/30/2024, revealed a [AGE] year-old-female who admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, stroke affecting left non-dominant side, dysphagia (difficulty swallowing) oropharyngeal phase (this is a swallowing difficulty of food and liquids), glaucoma and cataract in both eyes (eye diseases that causes vision loss), and generalized weakness.
Record review of Resident #9's quarterly MDS, dated [DATE], revealed a BIMS score of 3, indicating severe cognitive impairment.
Record review of Resident #9's care plan initiated on 04/09/2024 and revised on 04/09/2024 with a target date of 01/01/2025, revealed Resident #9 had a risk for weight fluctuations related to changes in appetite. Interventions included monitoring weights as per facility protocol, to provide prescribed diet and to observe closely during mealtime.
Observation in the main dining room on 10/10/24 at 12:33 PM, revealed Resident #9 in a Geri chair tilted at a 45-degree angle being fed lunch. Resident #9 ate well. CNA G stood over her while feeding her.
In an interview with CNA G on 10/30/2024 at 12:44 PM, she stated she helped feed Resident #9 sometimes, the resident needed assistance eating. She stated that she had training on feeding the resident. She stated she had to explain to the resident what she was going to do, ask her to drink water, explain, make sure she swallowed small bites. She stated Resident#9 was a good eater and the resident eats everything. She stated Resident #9 was supposed to sit at a 45-degree angle while eating. She stated, I'm supposed to be sitting to feed her. CNA G stated it was important to position the resident because of aspiration. She stated she was supposed to sit down while feeding so that she can hear the residents when talking. CNA G stated the risk was it could cause the resident to feel like they were neglected, and they were not treated like a person.
In an interview with the Administrator on 10/30/2024 at 2:56 PM, she stated that she expected all direct care staff to sit down at eye level with residents while feeding them. She said it was important to take the time while feeding residents to communicate, to be kind, not heaping food on spoon, and talk with them. She said the risk to residents was concern of her dignity.
Record review of the facility policy titled, Resident Rights, revised 09/2009, reflected, read in part . Employees shall treat all residents with kindness, respect, and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:
1.Be informed about what rights and responsibilities he or she has, 2. Voice grievances and have the facility respond to those grievances 3. Residents are entitled to exercise their rights and privileges to the fullest extent possible .4. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #5) of five residents reviewed for limited range of motion or therapy services.
The facility failed to complete a quarterly Physical Therapy Reevaluation screening for Resident # 5 after completion of his physical therapy 4/27/2024.
This failure could place residents at risk for a decline in range of motion, decreased mobility, and a decline in physical capabilities.
Findings included:
Review of Resident # 5's admission Record dated 11/01/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included gastrointestinal stromal tumor of other sites (rare cancer that develops in the digestive tract walls), muscle wasting and atrophy, lack of coordination, and generalized muscle weakness. The residents were a full code, and the family was the responsible party (RP).
Review of Resident # 5's MDS assessment dated [DATE], revealed the resident admitted to the facility from the hospital. Resident # 5 had intact cognition with a BIMS score of 7. The MDS further reflected the resident needed extensive assistance for bed mobility, transfers, locomotion on and off unit, dressing, toilet use, and personal hygiene. The MDS further reflected Resident # 5 had upper and lower extremity functional limitation in range of motion and was dependent of staff.
Review of Resident #5 evaluation orders on 11/01/2024 reflected PT to evaluate and tx as indicated verbal order active 11/01/2023. PT to evaluate and tx as indicated verbal order active 03/29/2024.
The orders did not reflect a PT evaluation in August, September, or October 2024.
Review of Resident # 5's care plan revealed Resident # 5 had ADL self-care performance deficit related to intolerance. Interventions reflected PT, OT were to evaluate and treat as ordered. Date initiated 11/30/2023.
Review of Resident # 5's care plan conference plan dated 02/07/2024 revealed Resident #5 was referred for physical therapy (PT), Occupational therapy (OT), and Speech therapy (SLP). NO care conference completed after 02/07/2024.
Review of Physical Therapy Evaluation and Plan of Treatments reflected the following:
Certification period 10/19/2023 -11/17/2023- Date of service 10/30/2023, Completed 10/31/2023 Response to Tx-Response to session interventions: Patient needed encouragement for OOB activity today.
Certification period 11/01/2023-11/30/2023- Date of service 11/05/2023, Completed 11/5/2023 Response to Tx- Response to session interventions: Needs encouragement to work with therapy.
Certification period 03/29/2024-04/27/2024 - Date of service 03/29/2024, completed 03/29/24 Response to session interventions: Actively participates with skilled interventions. None of the certification periods reflected Resident #5 refused PT.
In an interview on 10/30/2024 at 10:23 AM Resident # 5 and his family stated he had not done any therapy in a long time. Family stated she had talked to the facility, and she was told that the facility had no physical therapist on site earlier this year. The family stated on several occasions the facility stated they were short staffed and could not do physical therapy for Resident #5. Family stated she did not file a grievance because she was expecting the facility to follow up with physical therapy. Resident #5 stated he had not refused to do therapy, and he would like to walk if possible. Resident #5 stated he is getting weaker.
In an interview with the Administrator on 10/30/2024 at 02:59 PM, She stated she did not know much about Resident #5's Physical Therapy, that she was unaware of any issues, and family had not said anything to her. She referred any concerns for rehabilitation to the DOR. The Administrator stated the DOR was responsible for following up on the therapy screens. She stated the risk for not getting rehabilitation services was they could lose range of motion and have a negative outcome. She stated she would reach out to the family and DOR to follow up.
In an interview on 10/31/2024 at 02:12 PM the DOR stated he had been employed since March 2024. He stated Resident #5 had just been discharged from PT services at that time. He stated reevaluations were done quarterly and he was responsible for the follow up from the therapy screen to ensure the evaluations were completed. The DOR stated he was fully staffed to complete services. The DOR stated Resident # 5 had not been re-evaluated for PT because he was refusing to do PT. When asked why so much time had elapsed from the date of the multidisciplinary care plan meeting without the evaluations being completed, the DOR stated I don't waste my time reevaluating them knowing that they refuse PT. The DOR stated Resident #5 was already bedridden when he was admitted to the facility. The DOR stated OT had just picked up Resident #5 in September. The DOR stated that Resident #5 was reevaluated for PT services after talking to the Administrator yesterday. The DOR did not state the risk for Resident #5 not being reevaluated to PT services quarterly.
Review of the facility's Specialized Rehabilitative Services H5MAPL0836 dated December 2009, reflected the following: Our facility will provide Rehabilitative Services to residents as indicated by the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 1 resident (Resident #85) whose records were reviewed for behavioral health services.
The facility failed to follow up to ensure Resident #85 received psychiatric services after a referral was made.
This failure could place residents at risk of not receiving needed mental health services and a decrease in quality of life.
Findings included:
Record review of Resident #85's admission record, dated 11/01/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, muscle weakness, morbid obesity, and cognitive communication deficit.
Record review of Resident #85's 48-hour care plan progress notes, dated 09/06/24, reflected a BIMS score of 6, indicating severe cognitive impairment.
Record review of Resident #85's physician orders dated 10/21/2024 reflected need psychiatric evaluation.
Record review of Resident #85's progress note dated 10/16/24, written by LVN F, reflected resident yelling, threatening to physically hit roommate and staff in face, confusion, aggression, agitation, unable to be redirected notified physician Dr. [Name] received new order Ativan 1 mg 1x dose administered from E-kit received consent from R.P labs -CBC, BMP, UA labs ordered in PCP.
Record review of Resident #85's progress note dated 10/17/24, written by LVN K, revealed Resident refused his meds, appears to be agitated, confused and in an unpleasant mood. Upon asked the reason for refusal, resident stated that 'I'm not happy with the life I'm living, and I would like to die.
Record review of Resident #85's progress note, dated 10/21/24, written by LVN O, revealed Resident refused to eat his dinner, asked why he is not eating; responds leave me alone. Offered snack, nutritional shake declines. Res is blood glucose 66 now, offered orange juice refused. Patient teaching completed on dangers of low BS, non-compliant. Lunch tray was in the res room, untouched. RP [Name] didn't pick up the phone, unable to leave voicemail. Daughter [Name] reached, said she is not sure if she will make it to the facility because she is preparing stuff for her schooling children. Res refused writer to assess VS. Dr. [Name] notified with new orders for psych evaluation. DON made aware.
Record review of Resident #85's progress note, dated 11/01/24, revealed SSD went to visit patient to conduct PHQ-9 assessment. When asked directly, the patient kept stating no, ma'am to feels of depression, feeling poorly about himself, and thoughts of wanting to harm himself or others. When asked about his experience with his previous roommate, patient stated that he didn't remember.
Review of Resident #85's EHR did not reflect a psychiatric evaluation or progress note.
Interview on 11/01/2024 at 2:01 PM with LVN F revealed Resident #85 was a little confused, easy to redirect, and did not seem depressed. She said the resident was not on any medication for dementia and when he was really confused, they contacted the Dr. who wanted to try a low dose of Aricept. LVN F stated she thought the resident had a psychiatric evaluation. She said the SW does the referral.
Interview on 11/01/2024 at 2:33 PM with the Social Worker revealed she did not know about Resident #85's incident with the roommate and she had only been working at the facility for a month. She stated there had been instances where a patient had needed a psych eval and she would go in and see it had been done and processed. The SW said she did not know if it was the hall nurse who got the order and if the nurse went into [EHR name] and added the provider. She said she had not submitted a referral for anyone since she had been there. She stated the doctors would stop by before they see patients and ask if anyone was outstanding and verify if they were on their list to be seen. She said the risk to residents of not following up on the referral was that it increased harm to themselves or others depending on what was going on mentally. The SW called the Dr. from [provider name] who stated Resident #85 was not on her list, and it would depend on insurance, but she did not see that the resident was ever referred.
Interview on 11/01/2024 at 4:03 PM with LVN K was unsuccessful.
Interview on 11/01/24 at 3:29 PM the acting DON stated if a psych evaluation was not completed timely, the resident could harm himself, or a functional decline could happen if he was depressed. She stated at every facility, it was different but usually the SW put the order in and followed up on the referral, She stated the SW was responsible and it should be discussed in morning meetings and in the IDT meeting to make sure it did not get dropped.
Review of the facility's policy titled Referrals revised September 2005 reflected in part: social services personnel shall coordinate most resident referrals with outside agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (Resident#301) of seven residents reviewed for pharmaceutical services.
The facility failed to obtain heart rate and or pulse parameters for heart medication Digoxin 125 MCG before administering it to Resident #301 since 10/29/2024.
These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.
Findings Included:
Review of Resident #301's face sheet, dated 10/31/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were metabolic encephalopathy (this is a brain disorder caused by a chemical imbalance in the blood that affects brain function, paroxysmal atrial fibrillation (this is a heart condition that cause an irregular, often rapid heart rate that can cause poor blood flow), heart diseases, fluid overload, and high blood pressure.
Review of Resident #301's orders dated 10/31/2024, reflected Digoxin oral tablet 125 MCG. Give 1 tablet by mouth one time a day. Order active. Start date 10/29/2024 at 12:00. Order did not reflect parameter for administering medication.
Review of Resident #301's MAR reflected Resident #301 was administered Digoxin 125 MCG on 10/29/2024, 10/30/2024, and 10/31/2024. MAR did not reflect parameter for administering medication.
Review of Resident #301's transfer orders dated 10/25/2024 reflected Digoxin Oral tablet 125 MCG (digoxin). Give 1 tablet by mouth one time a day for chf hold if pulse less than 60.
Review of Resident #301 care plan on 10/31/2024 did not reflect heart medication digoxin and it did not reflect interventions or monitoring for digoxin toxicity.
During medication observation on 10/31/2024 at 11:54 AM with LVN C revealed Resident #301 lying in bed. LVN C checked her pulse on her left finger with a pulse oximeter and the reading was 108. LVN C took medication bubble pack Digoxin tablet 0.125 MG, sub for Lanoxin. Give 1 tablet by mouth 1 time daily. She took 1 pill and administered it to Resident #301.
Interview with Resident #301 on 10/31/2024 at 12:00 PM, she stated she had been taking Digoxin heart medication for a while now, but she did not know how many milligrams and she did not know the parameters for the medication. Resident #301 did not appear to have any medication related complications since being at the facility.
In an interview with LVN C on 10/31/2024 at 12:02 PM, she stated the medication had no parameters, but she would have used her nursing judgement not to administer the medication if Resident #301's heart rate was below 60. She stated if Resident #301's heart rate was lower than 60, and if it was, she would hold the medication and reach out to the doctor. LVN C stated it was the nurse's responsibility to make sure they obtained order clarification for medication. She stated the ADON was good at auditing new admissions and catching what might have been missed. She stated that all blood pressure and heart medications required parameters before administering. LVN C stated she does not know why she did not reach out to the doctor for parameters, or to the ADON or admission nurse for order clarification. She stated not having parameters could cause adverse effects to residents if given with low vitals. She stated she would check Resident #301's vitals including her blood pressure as the resident was daily full vitals check anyways [temperature, blood pressure, and pulse/heart rate].
Phone interview attempted with LVN N on 10/31/2024 at 03:20 PM, voice mail not available to leave a message.
In an interview with LVN M on 10/31/2024 at 03:32 PM she stated she was the admitting nurse however she did not admit resident #301. She stated LVN N notified her that she had called 4-5 times for orders from the sister facility that Resident #301 came from, and they had not gotten back to them. She stated Resident #301 just came to the facility with no admission/discharge paperwork. When asked what could happen to the resident if no parameters or orders were not correct? She stated it would not be a good thing. She stated we must check the heart rate, and it must be at least 60 or greater. If there was nothing to stop the nurse, she would use nursing judgement, however there should be a parameter. LVN M stated only nurses give digoxin medication. She stated to ensure accuracy, checks and balances need to be used. She stated after she finished entering orders, the ADONs came in the next day and they were supposed to lay eyes on it also.
In an interview with ADON A on 10/31/2024 at 04:14 PM, she stated LVN C notified her about the digoxin missing parameters after the medication observation, and she was able to fix the order. She stated she was out on leave and just returned and had not been able to look at the new admissions. ADON A stated it was the responsibility of the nurse doing the admission to verify orders and to ask questions if they did not understand something and even to clarify if they see the mistake. The ADON stated medications that require parameters must always have them so that they know when to hold medications and to notify the doctor. She stated not having order parameters can cause confusion and could lead to adverse medication effects.
In a phone Interview with LVN N on 11/01/2024 at 04:53 PM she stated that she was PRN at the facility, she worked on 10/28/2024 and did Resident #301's admission. She stated the facility that Resident #301 came from was having a hard time faxing over paperwork and she was unable to complete the orders. She stated she passed it on to the oncoming admission nurse LVN M to follow up. She stated she did not know why she did not document that she had issues completing the orders, but she just verbalized it to the oncoming admission nurse. LVN N stated the transport company that transported Resident #301 did not bring any paperwork and they were gone by the time she discovered the missing orders. LVN N stated she followed protocol and notified the IDT team about missing orders. She stated missing orders could delay residents from getting their medicines.
Interview with the acting DON on 11/01/2024 at 03:30 PM, she stated she expected nursing, when they received orders that required parameters, to verify them. She stated she also expected the med aide to ask nursing if medication was missing parameters. She stated she expected nursing managers to follow up on new admission to make sure orders were not missing anything. She stated a resident on digoxin should have orders for blood draw to check digoxin toxicity, they should have parameters for heart rate or pulse, and their vitals should be checked before medication administration.
Phone interview attempted with prescribing physician on 11/01/2024 at 09:28 AM, voice mail message left.
Record review of the facility's Medication Orders, revision date November 2014, read in part The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders.
1.
Each resident must be under the care of a Licensed Physician authorized to practice medicine in this state and must be seen by the Physician at least every sixty (60) days.
2.
A current list of orders must be maintained in the clinical record of each resident.
3.
Orders must be written and maintained in chronological order.
4.
Physician Orders/Progress Notes must be signed and dated every thirty (30) days. (Note: This may be changed to every sixty (60) days after the first ninety (90) days of the resident's admission, provided it is approved by the Attending Physician and the Utilization Review Committee.)
Recording Orders When recording orders for medication, specify the type, route, dosage, frequency, and strength of the medication ordered. A placebo is considered a medication and must also have specific orders.

**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 4 of 4 Residents (Resident's #33, #67, #23, and #48) observed for infection control and 1 of 4 quarters reviewed for water management.
1. The facility failed to ensure LVN E followed facility protocol while administering medication via G-tube entering for a resident on enhanced barrier precautions-EBP, Resident #33.
2. The facility failed to implement infection control and prevention, including wound care procedures and cross contamination for Resident #67 during wound care by LVN D and CNA H.
3. The facility failed to perform a water system flush quarterly.
4. The facility failed to ensure Hospice CNA Q followed facility protocol in maintaining infection control while providing a safe, sanitary environment, while preventing the development and transmission of disease and infection during provision of care for Resident #23 and Resident #48.
These failures could place residents at risk of cross contamination and infections.
Findings included:
1.Record review of Resident #33's admission Record dated 10/30/2024, revealed a [AGE] year-old female initial admission to facility on 06/24/2021 and readmitted on [DATE] with diagnoses that included unspecified sequelae of cerebral infarction (a condition that affects blood flow to your brain), left side weakness, colostomy status, (an opening into the colon from the outside of the body), and gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have a difficulty swallowing).
Record review of Resident #33's care plan initiated on 09/09/2024 and revised on 09/09/2024, revealed Resident #33 was on Enhanced Barrier Precaution at risk for infection related to medical device. The goal was to reduce the risk of infection for Resident #33. Interventions included wearing gloves and gowns during high contact activities for residents with indwelling medical devices, wounds, and colonized or infection with CDC targeted MDRO. The care plan further revealed Resident #33 had a feeding tube. Interventions included monitor, document, report to doctor as needed Infection at tube site, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. Date Initiated: 06/25/2021 Revision on: 03/08/2023. The care plan initiated 12/30/2022 with revision date 10/04/2024, revealed Resident #33 had an unavoidable pressure sore stage 4. Goal was for Resident #33 to remain free of infection through review date 01/24/2025. Interventions were to assess, record, and to monitor wound healing weekly.
During medication observation on 10/30/2024 at 08:24 AM, it was revealed that LVN E crushed medications belonging to Resident #33. Hand hygiene completed and bedside table cleaned. After putting on gloves, LVN E closed the privacy curtain, stopped Resident #33's feeding and exposed g-tube area by removing some of the covers. She started to administer medication via g-tube. LVN E did not change her gloves before starting to administer medication and she did not wear a gown.
In an interview with LVN E on 10/30/2024 at 08:50 AM, she stated that Resident #33 was on EBP, and she was supposed to wear her gown. She stated that she forgot to wear one. She stated she had been trained on EBP which was to protect residents that had medical devices from infection and to prevent carrying infection to other residents.
2. Record review of Resident #67's admission Record dated 10/30/2024, revealed a [AGE] year-old female initial admission to facility on 09/30/2024 and readmitted on [DATE] with diagnoses that included infection following surgical site procedure, right below the knee amputation, and chronic kidney diseases.
Record review of Resident #67 admission MDS dated [DATE] reflected a BIMS score of 9 out of 15 indicating moderate cognitive impairment. MDS reflected Resident #67 had a surgical wound and that she had a wound infection.
Review of Resident #67 orders dated 11/01/2024 reflected Wound Vacuum: Change wound vac dressing using green foam on Monday, Wednesday, and Friday. Location of wound: right BKA. Order active 10/24/2024.
During wound care observation and interview on 11/01/24 at 10:07 AM for by LVN D and CNA H, revealed Resident #67 in bed in her room. LVN D prepared items for wound care outside Resident #67's room on the treatment cart. LVN D cleaned bed side table and took it inside Resident #67's room. She handed CNA H a clear trash bag which CNA H filled with some blue gloves and then CNA H placed the bag on top of a COVID isolation cart as he put on his PPE. After collecting her wound care and wound vac supplies, LVN D then placed wax paper on the clean table and placed all the wound supplies on the wax paper. LVN D went to wash her hands and put on PPE. While she was completing those tasks, CNA H entered Resident #67's room and placed the contaminated trash bag on top of clean field with wound care items on the table. LVN D noticed the trash bag on top of the wound care supplies, and she took the bag off and handed it to CNA H. CNA H came around bed to the left side and placed the contaminated trash bag again on top of the wound care items. LVN D took the bag again and gave it to CNA H as he walked back to the right side of Resident #67's bed. CNA H assisted holding Resident #67's leg as LVN H removed the old wound vac and the old dressing from the wound. After removal of the dirty wound vac material, hand hygiene was completed. LVN H then opened sterile wound vac green foam and then she left the bedside and went to get a sessors to cut the form. She placed cut green foam new and dressing from the solid field. Closed it and attached wound vac plastic. LVN H with clean gloves took off soiled wound vac canister with soiled tubing and placed it in the trash bag. Without changing her gloves, LVN H touched the new canister connection and attached tubing from wound to tubing to wound vac machine. All biohazard was bagged and discarded accordingly. Bed side table cleaned, and pain reassessed. LVN D stated that she should have started over after noticing the contamination of her clean field. She stated the risk to Resident #67 was infection and contamination. CNA H stated he was not paying attention to where he had placed the bag. He stated the risk to resident #67 was cross contamination and spread of infection.
In an Interview on 11/01/24 at 04:14 PM with ADON A, she stated she was the Infection Control Preventionist. She stated that she had in-services done on hand washing, PPE, and EBP for all staff including rehab, housekeeping, nursing. She stated the expectation was that staff would take all the precautions that were posted outside the residents' doors and if they do not know to come and ask her. ADON A stated she was responsible overall, and the charge nurses were responsible for monitoring infection control on their shifts. She stated they made rounds, making sure doors were closed to rooms during patient care. She stated she went in the hallways to make sure that they had set up isolation carts and that they were following whatever precautions. She stated the wound vac was sterile and contaminating the sterile field can cause the infection to get worse. The treatment nurse would have done the in-services on wound vacs.
3. Interview on 10/31/24 05:11 PM, the VP of Facilities Management and Development stated the former Maintenance Director was here transferred to another property and the current Maintenance Director was in the position for 3 days. He stated they have a policy and procedure for Legionnaires, and they perform a water flush quarterly. He stated they set aside a 3-4-hour time frame and notify the staff of the increase temperature to hot water tanks to above 150 degrees F. He said once the temperature was reached, they release the faucet fixtures on the ends of corridors, utility, and soiled utility to allow that temp to run through it. After that process, they flushed all the pipes with temp water and reduced it back to 110 degrees, closed the faucets back up and tested the temperatures again to ensure they were in normal range. He stated housekeeping and laundry services clean under the faucets and faucet spray heads with high concentrated bleach. He said he wanted staff logging each flush and provided staff examples from other buildings. The State Surveyor requested logs for the last 4 quarters.
Interview and record review on 11/01/24 at 11:22 AM the VP of Facilities Management and Development revealed water flushes were completed on 10/10/2023, 02/05/2024, and 06/17/2024. He said they missed a quarter between Q3 and Q4. He stated the risk to residents according to the CDC, was they could get airborne particles and could get pneumonia from Legionella. He said there was an excuse why the flush was not completed and stated it was a labor shortage. He said the former Maintenance Director left for another facility which left a gap. He stated the Administrator was responsible for ensuring the flushes were completed quarterly. Record review of Water Management Plan log revealed start times, temperatures, locations, opening and closing of fixtures for 10/10/2023, 02/05/2024, and 06/17/2024 signed by Maintenance and Housekeeping Directors.
Record review of Legionella Water Management Plan, undated, reflected in part: During the Lunch Meal on a Quarterly basis (March, June, September & December), all staff and residents will be alerted to not use water in Resident's Rooms, Showers, and Nourishment Rooms.
The Maintenance Director will increase the water temperature on Hot Water Tanks serving these
areas to > 150° F. Once the tank has reached > 150° F, the Maintenance Director will turn on each faucet and showerhead to run for 5 minutes and then proceed to shut off.
Maintenance Director will lower the water temperature on the Hot Water Tanks to < 120° F and
after cooling down, he will check a faucet to ensure not> 110° F.
Staff and Residents will be informed when it is safe to again use the hot water.
Housekeeping will be asked to clean all faucets and showerheads with a chlorine (bleach) solution
following the flushing.
4. Record review of Resident #23's face sheet dated 11/01/2024, revealed she was readmitted to facility on 01/24/2024 with an initial admission of 12/14/2022. Admitting diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; type 2 diabetes mellitus without complications; and cerebral infarction, unspecified.
Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed R#23 was assessed and had a Cognitive BIMS summary score of 99, which indicated severely impaired cognition-decisions, poor; cues/supervision required. Total dependence on staff on eating, locomotion, personal hygiene, bathing, and toilet use. R#23 is a one-to-two-person physical assist in transferring.
Record review of Resident #48's face sheet dated 11/01/2024 revealed she was readmitted to facility on 02/14/2024 with an initial admission of 07/01/2021. Admitting diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; type 2 diabetes mellitus with other diabetic ophthalmic complications; and essential (primary) hypertension.
Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed R#48 was assessed and had a Cognitive BIMS summary score of 05/15, which indicated severely impaired cognition-decisions, poor; cues/supervision required. Total dependence on staff on eating, locomotion, personal hygiene, bathing, and toilet use. R#48 is a one-to-two-person physical assist in transferring.
In an observation on 10/30/2024 at 10:45 AM, Hospice CNA Q placed soiled linen in a bag belonging to Resident #23 on Resident #48's bed. Resident #23 and Resident #48 were both in their beds. This failure would cause contamination and the spread of infection from Resident #23 to Resident #48.
Interview on 10/30/2024 at 11:00 AM, DON revealed that the hospice agencies were expected to train their staff on infection control. The hospice agencies are to follow the same infection guidelines that are required in the nursing facility.
Interview on 10/30/2024 at 3:30 p.m. the Administrator revealed she expected the hospice agency to follow the same regulations as the facility r/t infection control. The ADM revealed that she was not aware the facility has been given the trainings provided to hospice staff. The ADM states she will have the DON and ADONs review infection control practices with the hospice agency. The ADM's goal is to have the ADONs take over monitoring the Hospice staff while they were in the facility. If the infection control guidelines are not followed this failure could place all residents at risk for cross-contamination and infections,
Interview on 11/08/2024 at 11:17 a.m. with Hospice Supervisor revealed she was aware of the incident with CNA Q related to infection control that occurred on 10/30/2024. The Hospice Supervisor stated that the agency would retrain the employee at the facility and review the checklist for re-orientation to assist the employee with corrections from the mistake made. The Hospice Supervisor would follow-up with the facility ADM and the facility DON.
Record review of facility policy titled Handwashing/Hand Hygiene revised June 2010 reflected in part: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .
Record review of facility policy titled Policies and Practices - Infection Control revised August 2007 reflected in part: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . I. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that the resident's medical record included documentation that indicated the resident or resident's representative were provided education regarding the benefits and potential side effects of influenza immunization; and that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal for 1 of 6 (Resident #299) residents reviewed for immunizations.
The facility failed to offer Resident #299 an influenza immunization.
This failure could place residents at risk of harm, by contracting and spreading influenza.
Findings included:
Record review of Resident #299's admission Record, dated 11/01/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of malignant neoplasm of unspecified part of unspecified adrenal gland.
Record review of Resident #299's BIMS assessment, dated 10/19/2024 revealed a score of 15, indicating intact cognition.
Record review on 10/31/24 of Resident #299's EHR reflected refused and not eligible under immunizations for influenza.
Record review of Resident #299's informed consent for influenza vaccination, e-signed by Resident #299 on 10/21/2024, indicated she wanted the influenza vaccine.
Interview on 10/30/2024 at 10:30AM, Resident #299 stated she did not have any complaints except she had not had the flu shot yet. Resident #299 stated she got to the facility around 10/16/2024. She stated she thought the vaccine would be good to have since she had lung cancer. She stated staff did not ask her if she wanted the flu or pneumonia vaccine.
Interview on 10/31/2024 at 3:32 PM, LVN M stated flu and pneumonia immunizations were offered, and she asked residents at admission if they had one already. She stated they should have a consent and the ADON kept up with all the consents. LVN M stated even if she got the consent the ADONs would administer them. She said she did not remember asking Resident #299 if she wanted the flu vaccine. She stated the risk for not providing immunizations was the resident would be more susceptible to the flu.
Interview on 10/31/2024 at 4:00 PM, ADON A stated all residents were offered the flu, pneumonia, and COVID vaccine. She said the concierge usually did the paperwork and had the resident sign the consent. She said they had 72 hours to get with the family or resident, then she would confirm those answers. She said some residents would tell the concierge no and when she went back to ask the resident again, they would say yes. She said she usually goes back to check the consents. ADON A said Resident #299 did not ask her for the flu vaccine.
Interview on 10/31/2024 at 4:32 PM, CNA H stated he did the admission packet with the residents or family members. He stated if the resident was able to sign, they would E-sign the consent forms. He stated he did not remember asking Resident #299 because he did so many. He stated if a resident marked yes on a vaccine consent form he would relay the message.
Interview on 11/01/24 at 3:29 PM, the acting DON stated residents were to receive vaccines within the first few days of admission. She said if residents were not offered a vaccine, they could get sick.
Review of the facility's policy titled Influenza Vaccine revised August 2016, reflected in part: All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives) .1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medical contraindicated, or the resident or employee has already been immunized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 of 2 residents (Resident #9 and Resident #298) reviewed for ADL care.
The facility failed to ensure Resident #9, and Resident #298 were provided nail care as needed.
These failures could place residents at risk of not receiving services and a decreased quality of life.
Findings included:
Record review of Resident #9's admission Record, dated 10/30/2024, revealed a [AGE] year-old-female who admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, and other paralytic syndrome (paralysis or weakness) following nontraumatic subarachnoid hemorrhage (brain bleed) affecting left non-dominant side .
Record review of Resident #9's quarterly MDS, dated [DATE], revealed a BIMS score of 3, indicating severe cognitive impairment.
Record review of Resident #9's care plan initiated on 07/28/2021, and revised on 10/30/2024 revealed Resident #9 had inappropriate behavior; Resistive to treatment/care related to: Cognitive impairment Dx: Dementia, depression: Refused labs and refused to
have nails trimmed. Interventions included document care being resisted, if resident refuses care, leave resident and return in 5-10 minutes.
Record review of Resident #298's admission Record, dated 11/01/2024, revealed an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included sepsis, muscle weakness, and malignant neoplasm of rectum (rectal cancer).
Record review of Resident #298's admission MDS, dated [DATE], revealed a BIMS score of 99, indicating the resident was not able to complete the interview.
Record review of Resident #298's care plan, initiated on 09/20/2024 revealed Resident #298 exhibited ADL Self Care Performance Deficit, required assistance: limited mobility. Interventions included provide assistance with eating, dressing, bathing, toileting and grooming as needed.
Observation on 10/30/24 at 12:40 PM, revealed Resident #9 was seated in a Geri chair in the dining room eating lunch. Resident #9's left arm was covered. All of Resident #9's nails on the left hand appeared long, thick, yellowish-brown, and sharp. Resident #9 was not interviewable.
Interview on 10/30/24 at 02:57 PM, the Administrator stated charge nurses were responsible to make sure the aides were taking care of resident nails. She stated if a patient refused, the aides should tell their charge nurse, the charge nurses should tell their ADONs, and the refusal should be care planned. She said if nails were too long it would not allow a person to do everything they want and inhibited them to be able to use the ends of their fingers.
Observation on 10/31/2024 at 1:42 PM, revealed Resident #9 was in her room lying in bed. Resident #9's nails on her left hand appeared the same as 10/30/24. The nails were long, thick, yellowish-brown, curled, and sharp. ADON B held a disposable ruler next to Resident #9's nails while the state surveyors observed. Resident #9's thumb nail measured approximately 1.75 cm past the nail bed, the index fingernail measured approximately 1.0 cm past the nail bed, the middle fingernail measured approximately 2.0 cm past the nail bed, the ring fingernail measured approximately 3.0 cm past the nail bed, and the pinky fingernail measured 1.5 cm past the nail bed.
Interview on 10/31/2024 at 1:42 PM, ADON B stated last week she asked the Social Worker to call the podiatrist. ADON B stated the podiatrist came last Friday (10/25/2024) and he was going to cut her nails and toenails. She stated she did not look at Resident #9's nails when he was done. ADON B said the Podiatrist told the SW the resident was resistant and pulling back her hand. ADON B stated she forgot to follow up and staff were doing nail care on everyone. She said the Weekend Supervisor was responsible to make sure resident nails were cut. ADON B stated normally the CNA's cut nails, but the nurse would do it because Resident #9 was diabetic. She said the risk would be the resident could cut their skin, and infection if she scratches.
Interview on 11/01/2024 at 9:53 AM, Resident #298 was lying in bed. Resident #298 stated he received a shower the day before yesterday, and they washed his hair, but he wanted his nails cut. Resident #298's fingernails appeared to have a yellow substance underneath and some appeared to have jagged edges.
Interview on 11/01/2024 at 1:55 PM CNA P stated resident nail care was done after showers, were supposed to be checked that they were clean, and if nails needed to be cut, they would just cut them.
Interview on 11/01/24 at 02:26 PM the SW stated she contacted the podiatrist for Resident #9 on 10/24/24 by text and asked for Resident #9 to be seen.
Interview on 11/01/24 at 11:11 AM the Podiatrist stated the facility had called him about Resident #9 and he had seen the resident 6 weeks ago to do her toenails. He stated that when he got a call to come back due to family request, he stated that he took more off her toes. He stated that the facility might have been confused because had they told him to cut her fingernails, he would
have said No sorry, I can't do fingernails. He stated his scope of practice was feet, not fingernails.
Interview on 11/01/2024 at 4:41 PM, CNA L stated she did not do nail care. She stated when giving showers she would use a towel to wash hands and nails. CNA L stated she would tell her nurse if a resident's nails were long. She said if a resident's nails were left long, they could hurt themselves or have germs.
Observation and interview on 11/01/2024 at 4:45 PM, LVN I used a disposable ruler to measure Resident #298's fingernails. Resident #298's nails on both hands measured between 0.5 to 0.75 cm past the nail bed. LVN I removed Resident #298's socks from both feet and the toenails appeared to be yellow, and some appeared to be curling downwards. The fourth toenail on Resident's right foot appeared to have a dried red/black substance underneath the nail and surrounding skin, and the nail was sticking straight up at a 90-degree angle. LVN I measured Resident #298's toenails on both feet which measured between 0.5 to 1.0 cm past the nail bed. LVN I stated he cuts nails upon request, especially ones for diabetes. He stated Resident #298 was not diabetic. LVN I stated he did not notice any issues with Resident #298's nails and the resident had not verbalized any complaints. LVN I stated the fourth toenail was infected and he would ask with the wound nurse about it. He said he would have to clarify with ADON A if Resident #298 should be referred to podiatry. LVN I stated he would raise concerns with the family if they wanted treatment and he stated he does not know how to follow up on the podiatry list. He stated the risk to the resident would be skin integrity, scratches that lead to other skin issues, could be infection control, and could be pain especially if they rub on the fabric.
Interview on 11/01/2024 at 3:29 PM, the DON stated the CNA's can clean and file resident nails and the nurses were to trim if the resident was diabetic. She stated all ADL care should be documented. The DON stated nurses were to monitor that nail care was done. She said the risk was residents could get sick.
Review of the facility's policy titled Care of Fingernails/Toenails, dated April 2007, reflected in part:
The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .
1.
Nail care includes daily cleaning and regular trimming.
2.
Proper nail care can aid in the prevention of skin problems around the nail bed.
3.
Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments.
4.
Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations of abuse were reported to Health and Human for one (Resident #1) of 12 residents reviewed for abuse and neglect reporting.
The facility failed to report an allegation of abuse when a grievance was filed by a family member on behalf of Resident #1 on 04/04/24 that a staff member (identity unknown) yelled at the resident, told her to go back to sleep, and called her stupid.
This failure could place residents at risk of being abused or neglected and lack of oversight by a state agency.
Findings included:
Review of Resident #1's face sheet reflected a [AGE] year-old female, admitted on [DATE], and having diagnoses of dementia, cardiac pacemaker, insomnia, and an anxiety disorder. A family member was her responsible party.
Review of Resident #1's Quarterly MDS assessment, dated 06/14/24, reflected she was rarely able to understand others, or be understood by others, and had long and short-term memory problems, and severely impaired decision-making ability. The document indicated no problems with sleeping. Resident #1 used a wheelchair, and was able to eat with set-up assistance, but required substantial/ maximal assistance (helper does more than half of the effort) with toileting, bathing, dressing, and hygiene. She was always incontinent of bowel and bladder.
Review of Resident #1's care plans, dated 03/23/22, reflected care plans for antidepressant medication, falls, communication problems, impaired visual function, ADL self-care performance deficits, and incontinence.
Review of Resident #1's care plan, dated 09/14/22, reflected she was on melatonin (a supplement to help with sleep) therapy, secondary to inability to fall asleep.
Review of a facility Grievance/Complaint Report form, dated 04/04/24, reflected a grievance received by the ADON for Resident #1, from Resident #1's family member. The hand-written document reflected, Nurse Aide came into the resident's room at 3AM, yelled at the resident to go back to sleep, and called her stupid. The form reflected that the Aide was terminated/disciplined. The grievance was noted to be resolved by the RP (family member) requested to have video monitoring in the room. The document reflected that the resident and/or representative were notified in writing and with a phone conversation. The document was signed by the Social Worker.
An interview on 06/28/24 at 11:22 AM with the Administrator revealed her looking at the grievance form for Resident #1. She said the family did not report abuse, they reported a customer service violation, and it did not rise to the level of abuse and did not need to be reported. She said it was very poor customer service, the family and resident did not feel it was abuse, and they terminated the staff member.
An interview on 06/28/24 at 12:10 PM with CNA D revealed verbal abuse would be things like yelling or raising your voice to a resident or calling someone names. She said calling someone stupid would definitely be abuse.
An interview on 06/28/24 at 12:13 PM with CNA E revealed verbal abuse would be raising your voice, calling bad names, or cussing at a resident, and that calling a resident stupid would be abuse.
An interview on 06/28/24 at 12:15 PM with LVN C revealed it would be considered verbal abuse if someone yelled or said profanity at a resident or called the resident names. She said calling a resident stupid would be abuse.
An interview on 06/28/24 at 12:20 PM with CNA F revealed verbal abuse would be when someone talked bad to a resident. She said talking bad to them would be things like yelling, telling the resident you were not going to take care of them, or calling them bad names. She said calling them stupid would be abusive.
An observation and interview on 06/28/24 at 12:36 PM with Resident #1 revealed her to be in her room, rolling herself in her wheelchair. She was neatly dressed, and said she was doing very well. When asked how the staff treated her, she said Oh, they are lovely! When asked if anyone had ever treated her badly, she said I don't think so.
An interview on 06/28/24 at 2:22 PM with the DON revealed she thought a grievance in which a staff member allegedly yelled or called someone stupid would be reported. She said any allegation would be reported to the Administrator, and it would be investigated further. She said she only vaguely remembered the grievance, and that the family member and the resident were interviewed, and the staff member suspended. She said it did not take away from the fact it was abuse if the resident did not feel abused.
An interview on 06/28/24 at 3:11 PM with the Administrator revealed yelling or name calling in some situations would constitute abuse. She said it would depend on factors like tone, and loudness. She said it was presented by the family member as a customer service issue, and that the staff member had been rude. She said she did not remember who the terminated staff member was and would have to contact their Human Resources person and send the information later. She said it was important to report allegations of abuse, because residents had a right to live in their homes free from issues of mistreatment. She maintained that the circumstances in the grievance were not abuse.
Review of a typed statement dated 07/01/24, and signed by the Administrator, reflected the Administrator had interviewed the ADON about the 04/04/24 grievance, and the information on the grievance was not what the ADON had written. The statement reflected that the ADON had not been able to identify a staff member, and the family member had only said that the aide told the resident to go back to bed. She stated the ADON did an in-service on 04/04/24 regarding staff speaking professionally and with a clear voice and being respectful at all times. The statement reflected that the Social Worker said the family member told her about the information on the grievance, and that she was the one who documented that the staff member was terminated, because she thought that was the conclusion, but that was an error. The Administrator's statement reflected that the termination of a staff member documented by the Social Worker was incorrect, as no staff member had been identified, and that the Social Worker had misunderstood and combined two grievances.
Review of a typed statement, dated 07/01/24, and signed by the ADON reflected the ADON had found a note slipped under her door to call the family member of Resident #1, and when she did the family member informed her that a staff member had told Resident #1 to go back to sleep in a loud tone. The family member was not able to tell the ADON a time or date, or identity of the staff member, so the ADON informed the family member that she would do a general in-service on proper tone of voice and the family member thanked her and had no further questions.
Review of a typed statement, dated 07/01/24, and signed by the Social Worker, reflected she had documented that the employee had been terminated in error on the 04/04/24 grievance, and this conclusion had been made in error, because she misunderstood the issue.
Review of the Abuse Prevention Program policy, Revised December 2016, reflected: Policy Statement:
Our residents have the right to be free from abuse, ( .). This includes but is not limited to freedom from ( .) involuntary seclusion, verbal, mental, sexual or physical abuse ( .). Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: I. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff; other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. ( .) J . Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. ( .) 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interviews, 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 one of three (Resident #2) residents reviewed for pharmacy services.
The facility failed to ensure that documentation of narcotic medications signed out on the narcotic count sheet were consistent with documentation of narcotic medications administered to Resident #2 as reflected on his MAR.
Narcotic count sheets for Resident #2 one showed more doses of oxycodone signed out on Resident #2's narcotic count sheet than what was documented as administered on his MAR on 05/16/24, 05/28/24, and 05/30/24.
These failures could place residents at risk for medication errors, potentially leading to overdose of narcotic pain medications, or diversion of narcotic pain medications.
Findings included:
Review of Resident #2's admission Record, dated 06/28/24, reflected he was a [AGE] year-old made, admitted to the facility on [DATE], with diagnoses of infection of his right knee prosthesis, arthritis, legal blindness, and muscle spasms. The document reflected Resident #2's discharge to the hospital on [DATE].
Review of Resident #2's 05/18/24 admission MDS reflected a BIMS score of zero. Resident #2 was able to understand others and to be understood by others. He had verbal behavioral symptoms directed toward others every day of the seven-day lookback period, which did significantly interfere with his care. The MDS reflected Resident #2's one-sided impairment of both upper and lower extremities, and that he used a wheelchair. Resident #2 received scheduled pain medications, non-pharmaceutical interventions for pain, and received PRN pain medications or was offered and declined them. Resident #2's MDS pain assessment indicated he frequently experienced pain, which had frequently limited his participation in rehab therapy. His pain occasionally interfered with his sleep and limited his day-to-day activities. He rated his pain over the past five days of the assessment period as a seven out of ten. Resident #2 had a knee replacement which had an infection or inflammatory reaction at the location of the prosthesis.
Review of Resident #2's MAR for May of 24 reflected the following:
- oxyCODONE HCl Oral Tablet 10 MG (Oxycodone HCl)-Give 1 tablet by mouth every 4 hours as needed for pain -Start Date- 05/15/24 [9:45 AM] -D/C Date- 06/19/24 [1:01 PM]
The document reflected the resident was administered the following:
-05/16/24- Oxycodone was administered to Resident #2 twice, at 8:47 AM, and 12:49 PM.
-05/28/24- Oxycodone was administered to Resident #2 four times, at 3:15 AM, 8:49 AM, 12:44 PM, and 4:22 PM.
-05/30/24- Oxycodone was administered to Resident #2 three times, at 7:00 AM, 11:00 AM, and 3:40 PM.
Review of Resident #2's Narcotic Record (count sheet) for 10 MG oxycodone HCl tablets for 05/14/24 through 05/17/24 reflected the following:
-05/16/24- one tablet was signed out five times, at each of the following times: 12:00 AM, 4:00 AM, 8:47 AM, 12:49 PM, and 4:XX PM (X numbers are illegible.)
Review of Resident #2's Narcotic Record (count sheet) for 10 MG oxycodone HCl tablets for 05/18/24 through 06/01/24 reflected the following:
-05/28/24- one tablet was signed out five times, at each of the following times: 3:20 AM, 8:45 AM, 12:45 PM, 4:00 PM, and 9:00 PM.
-05/30/24- one tablet was signed out five times, at each of the following times: 2:12 AM, 7:00 AM, 11:00 AM, 3:00 PM, and 7:00 PM.
An interview on 06/27/24 at 3:57 PM with LVN A revealed it was standard practice to document in both the EMR and on the narcotic count sheet. The narcotic sheet was filled out when the pill was dispensed, so the time on the electronic MAR might not match up exactly, but that was the live time (the medication was administered.) She said they documented in two places because the count sheet was where the amount of medication removed by the staff member was tracked. She said it was important to document in the electronic MAR as well, because if the resident asked for pain medication, and the nurse only checked the electronic clinical record for the last time it was given, before providing the medication, the resident could end up getting too much narcotic. She said Resident #2 was very hard and demanding about his medications, and other care, and often would say he wanted one thing, and when you went to give it to him, he would want another. She felt the documentation in the MAR was probably just overlooked at the time due to the staff having to deal with his behavior.
An interview on 05/28/24 at 11:00 AM with RN B revealed the procedure for controlled medications was to document the quantity dispensed, and date and time and signature. She said they also documented in the MAR and the progress notes. She said the narcotic count sheet was for keeping track of how much of the controlled substance was given. She said if it was not documented in the MAR that the medication was given, they would need to follow up to see why the medication was not given, or it would be a medication error. She said it was important to document in both places, to keep track of the medication, and so nobody overdosed on their narcotics.
An interview on 05/28/24 at 11:15 AM with LVN C revealed it was important to document in both the MAR, and on the narcotic count sheet, because if someone only looked in the MAR to see what a resident had been given and a dose was not documented there, they could accidentally give them an overdose of the medications, and the narcotic count sheet was where they kept track of how much medication had been removed from the bottle.
An interview on 05/28/24 at 2:22 PM with the DON revealed they went by the five rights of medication administration (right patient, drug, time, dose, and route) and she expected staff to correctly document the medications. She said narcotic pain medications should be documented in the MAR, and signed off on the log, because not doing so could cause possible problems. She said not documenting could throw off the medication count, and cause medication errors. She said in the worst case, they would have to look into possible drug diversion.
Review of the facility policy for Controlled Substances, dated 2001, revised December 2012, reflected instructions for the receipt and dispensing of controlled medications, including the narcotic count sheets, but did not address documentation in the electronic MAR.
Review of the facility policy for Charting and Documentation, dated 2001, revised July 2017, reflected: Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. ( .) Policy Interpretation and Implementation: 1. Documentation in the medical record may be electronic, manual or a combination. 2.
The following information is to be documented in the resident medical record: ( .)b. Medications administered; ( .)

**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, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure specialized services or specialized rehabilitative services the nursing facility was provided as a result of PASARR recommendations for one (Resident #1) of one resident reviewed for PASRR.
The facility failed to order a standing board for Resident #1 based on PASRR assessment for specialized services as stated in the care plan.
This failure could affect residents by preventing them from receiving specialized services as care-planned which could contribute to a decline in quality of life, physical, mental, and psychosocial well-being .
Findings include:
Record review of Resident #1's face sheet, dated 11/03/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizoaffective disorder, depressive type, unspecified intellectual disabilities, and cognitive communication deficit.
Record review of Resident #1's care plan, revised 8/22/23, reflected he was evaluated for PASRR for services for a standing board service for DD (Muscle wasting and atrophy). Interventions included: Obtain a soft padded standing board specialized equipment recommended by Physical therapy, to help resident stand longer with minimal pain against his lower legs against the standing board.
Record review of Resident #1's annual MDS assessment, dated 9/10/23, reflected Resident #1 was wheelchair dependent. He could communicate some words or could finish thoughts if prompted or given time in making daily decisions. Resident #1 required partial/moderate assistance - helper did less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort assistance with ADL care. He was considered by the state PASRR evaluation.
Record review of Resident #1's service plan with IDT with the Rehabilitation Director, Social Worker, MDS Coordinator, LAR, and Speech/Language/Cognitive therapies was held on 6/01/23 reflected an outcome of meeting was skilled service: To prevent decline in function, improve attention/concentration, and enhance cognitive skills to enhance residents' quality of life by improving ability to participate in functional activities of choice and a new electric wheelchair with a reclining high back.
Record review of Resident #1's IDT meeting with LAR on 8/13/23 reflected a soft standing board was recommended by Director of Rehabilitation (DOR) for Resident #1 to achieve a better outcome in his standing during therapies by using a soft padded standing board. 73 days after the IDT meeting and PASRR approval, Resident #1 had not received the soft standing board paid by PASRR (MCD).
In an observation and interview on 11/02/23 at 11:50 a.m. revealed Resident #1 was in an electric wheelchair going to the gym. He said he did not know if he got the standing board. He revealed he liked to go to the gym. No standing board was observed.
Interview with the DOR on 11/02/23 at 11:55 AM, revealed the PASRR assessment was done when a change or a decline was identified. He reported he suggested a personal soft standing board and was awaiting the PASRR advocate to get back to him. On 09/2023 he sent an email to the MDS Coordinator (that over saw the PASRR services) but had not gotten a response from her, so no standing board was ordered. He reported because MDS Coordinator had retired and 3 other staff were filled that role of the MDS Coordinator, she may not have seen his emails to follow up. He reported he was unsure who was responsible for ordering equipment but stated he would call, if he was given a response from the PASRR advocate, the company the facility used to do custom measurements for specialized equipment, to come out to take the measurements for Resident #1's soft standing board. The DOR revealed the delay caused the resident delay in receiving specialized service .
Interview with MDS Coordinator on11/02/23 at 12:28 PM revealed she was retired and only came into the office once a week until the facility could fully hire a new MDS Coordinator. She revealed when she was not in the office someone from the cooperate office covered once a month and on other times, staff from business development covered that role. She reported she would make sure the DOR obtained the standing board for Resident # 1. She stated the delay caused the resident a delay in receiving PASRR service .
Interview with the ADM on 11/02/23 at 5:24 PM revealed she was not aware Resident #1 needed a standing board. She reported the MDS Coordinator screeded the residents for PASRR until she retired at the end of September beginning of October 2023.She revealed a new person was starting on Monday, 11/06/23, in the role of MDS Coordinator. She said in the meantime, 3 staff members were overseeing the PASRR. She said PASRR assessments were done when a change or a decline was identified. The ADM revealed her expectation was to follow through with PASRR recommendations and/or any other assessed needs. The ADM revealed any type of risk could come from a delay in services such immobility, mobility could not improve, risk of injury by not having equipment, and poor progression. She revealed the PASRR process was to screen the resident, obtain a recommendation if applicable, set up a meeting with PASRR advocate, notify via phone call, then the company would come in to take measurements for specialized equipment and/ or wheelchairs, and then the paperwork would be sent to the facility for an order to be placed .
Record review of the facility's, undated, policy, PASRR Clinical policy, reflected, .The MDS/PPS Nurse/DON and/or designee will initiate delivery of specialized services within 30 days of the date SS added to the plan

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for one (Resident #1) of one resident reviewed for PASRR services.
The facility failed to order a standing board for Resident #1 based on PASRR assessment for specialized services.
This failure could place residents at risk of not receiving specialized PASRR services which could contribute to a decline in quality of life, physical, mental, and psychosocial well-being .
Findings include:
Record review of Resident #1's face sheet, dated 11/03/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizoaffective disorder, depressive type, unspecified intellectual disabilities, and cognitive communication deficit.
Record review of Resident #1's care plan, revised 8/22/23, reflected he was evaluated for PASRR for services for a standing board service for DD (Muscle wasting and atrophy). Interventions included: Obtain a soft padded standing board specialized equipment recommended by Physical therapy, to help resident stand longer with minimal pain against his lower legs against the standing board.
Record review of Resident #1's annual MDS assessment, dated 9/10/23, reflected Resident #1 was wheelchair dependent. He could communicate some words or could finish thoughts if prompted or given time in making daily decisions. Resident #1 required partial/moderate assistance - helper did less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort assistance with ADL care. He was considered by the state PASRR evaluation.
Record review of Resident #1's service plan with IDT with the Rehabilitation Director, Social Worker, MDS Coordinator, LAR, and Speech/Language/Cognitive therapies was held on 6/01/23 reflected an outcome of meeting was skilled service: To prevent decline in function, improve attention/concentration, and enhance cognitive skills to enhance residents' quality of life by improving ability to participate in functional activities of choice and a new electric wheelchair with a reclining high back.
Record review of Resident #1's IDT meeting with LAR on 8/13/23 reflected a soft standing board was recommended by Director of Rehabilitation (DOR) for Resident #1 to achieve a better outcome in his standing during therapies by using a soft padded standing board. 73 days after the IDT meeting and PASRR approval, Resident #1 had not received the soft standing board paid by PASRR (MCD).
In an observation and interview on 11/02/23 at 11:50 a.m. revealed Resident #1 was in an electric wheelchair going to the gym. He said he did not know if he got the standing board. He revealed he liked to go to the gym. No standing board was observed.
Interview with the DOR on 11/02/23 at 11:55 AM, revealed the PASRR assessment was done when a change or a decline was identified. He reported he suggested a personal soft standing board and was awaiting the PASRR advocate to get back to him. On 09/2023 he sent an email to the MDS Coordinator (that over saw the PASRR services) but had not gotten a response from her, so no standing board was ordered. He reported because MDS Coordinator had retired and 3 other staff were filled that role of the MDS Coordinator, she may not have seen his emails to follow up. He reported he was unsure who was responsible for ordering equipment but stated he would call, if he was given a response from the PASRR advocate, the company the facility used to do custom measurements for specialized equipment, to come out to take the measurements for Resident #1's soft standing board. The DOR revealed the delay caused the resident delay in receiving specialized service .
Interview with MDS Coordinator on11/02/23 at 12:28 PM revealed she was retired and only came into the office once a week until the facility could fully hire a new MDS Coordinator. She revealed when she was not in the office someone from the cooperate office covered once a month and on other times, staff from business development covered that role. She reported she would make sure the DOR obtained the standing board for Resident # 1. She stated the delay caused the resident a delay in receiving PASRR service .
Interview with the ADM on 11/02/23 at 5:24 PM revealed she was not aware Resident #1 needed a standing board. She reported the MDS Coordinator screeded the residents for PASRR until she retired at the end of September beginning of October 2023.She revealed a new person was starting on Monday, 11/06/23, in the role of MDS Coordinator. She said in the meantime, 3 staff members were overseeing the PASRR. She said PASRR assessments were done when a change or a decline was identified. The ADM revealed her expectation was to follow through with PASRR recommendations and/or any other assessed needs. The ADM revealed any type of risk could come from a delay in services such immobility, mobility could not improve, risk of injury by not having equipment, and poor progression. She revealed the PASRR process was to screen the resident, obtain a recommendation if applicable, set up a meeting with PASRR advocate, notify via phone call, then the company would come in to take measurements for specialized equipment and/ or wheelchairs, and then the paperwork would be sent to the facility for an order to be placed .
Record review of the facility's, undated, policy, PASRR Clinical policy, reflected, .The MDS/PPS Nurse/DON and/or designee will initiate delivery of specialized services within 30 days of the date SS added to the plan

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of three residents (Resident # 1) reviewed for pressure ulcers.
1. The facility failed to ensure Resident #1 received wound care for her:
- right heel, on 08/26/23, 08/27/23 and 08/28/23;
- left iliac crest on 08/26/23, 08/27/23, 08/28/23; and
- sacrum on 08/26/23, 08/27/23, 08/28/23, and 08/29/23.
2. LVN A failed to enter wound care orders in the MAR when Resident #1 was admitted to the facility on [DATE].
These failures could place residents at risk for worsening of existing pressure ulcers and skin sores or development of new pressure ulcers or skin sores.
Findings included:
Record review of Resident #1's face sheet dated 09/14/23, revealed Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses of multiple sclerosis (a chronic disease of the central nervous system), essential hypertension (high blood pressure), pressure ulcer of sacral region Stage 3, and an unstageable pressure ulcer of the right heel. Resident #1 discharged home on [DATE] against medical advice.
Record review of Resident #1's orders, dated 08/28/23, revealed Resident #1 had the following active wound care orders:
- Location of wound: Sacrum every, day shift for Wound Treatment order: Cleanse with normal saline, Apply Calcium Alginate, Santyl, Border Gauze and as needed for Wound Healing Treatment order: Cleanse with normal saline, Apply Calcium Alginate, Santyl, Border Gauze and as needed Treatment order: Apply Collagen Sheet with Hydrocolloid Dressing. This order had a start date of 08/29/23.
- Location of wound: Left Iliac Crest every day shift Treatment order: Apply Xeroform with Island Border Gauze. and as needed Treatment order: Apply Xeroform and Island Border Gauze. This order had a start date of 08/29/23.
- Apply skin prep to right heel. one time a day. This order had a start date of 08/29/23.
Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had no BIMS score because Resident #1 is rarely/never understood. Section M Skin Conditions of the MDS revealed Resident #1 had one Stage 3 pressure ulcer that was present upon admission or re-entry and had an unstageable deep tissue injury that was present upon admission. She needed pressure ulcer/injury care and a pressure reducing device for her bed.
Record review of Resident #1's August 2023 MAR and TAR, obtained 09/13/23, revealed no documentation which indicated wound care was done for Resident #1's Stage 3 pressure ulcer to her sacrum, on 08/26/23, 08/27/23, 08/28/23 and 08/29/23, iliac crest on 08/26/23, 08/27/23 and 08/28/23 and her right heel 08/26/23 and 08/27/23 and 08/28/23.
Record review of the wound specialist notes, dated 08/30/23, revealed Resident #1 had a Stage 3 pressure wound to the sacrum which was full thickness wound size (length x width x diameter): 4.0 x 7.0 x 0.2 cm. The treatment was alginate calcium apply once daily for 30 days; Santyl apply once daily for 30 days. Secondary dressing(s) gauze island with border apply once daily for 30 days. Unstageable deep tissue injury of the right heel partial thickness measuring (length x width x diameter): 4.0 x 7.0 x [diameter] not measurable; admitted to facility with wound dressing treatment plan betadine apply once daily for 30 days.
Record review of Resident #1's care plan, dated 09/13/23, revealed the following problem area: [Resident #1] has pressure injury to Sacrum with potential for further skin breakdown rule out: immobility, impaired mobility, incontinence, and unstageable deep tissue injury pressure injury to right heel, with potential for further skin breakdown rule out: immobility, impaired mobility. The intervention was: Administer treatment as ordered and monitor for effectiveness.
Interview on 09/14/23 at 8:13 a.m. with LVN A, who was the Treatment Nurse/Wound Care Nurse, revealed she did the initial assessment of Resident #1 with a corporate nurse who was orienting her on 08/25/23, since she was newly hired. LVN A revealed Resident #1 admitted with pressure ulcers on the sacrum, a skin tear on the iliac crest, and a deep tissue injury on the right heel. LVN A stated she cleansed the wounds and applied a clean dressing on 08/25/23. She stated she did not know what happened, the orders were omitted, and she did not document on the TAR after completion of the wound care. LVN A stated on admission after the skin assessment she wrote a wound care consult, and she did not know how they forgot to put the orders in the MAR for the other nurses to be aware the resident had wounds. LVN A stated when she was not available to do wound care, the floor (charge) nurses were responsible for wound care treatment . LVN A stated Resident #1 was admitted on a Friday and when she came back on Monday, she did not check to ensure wound care was being provided. LVN A stated Resident #1 was supposed to receive daily wound care. LVN A revealed Resident #1 received wound care on 08/29/2,3 and she did not take the measurements since the wound care doctor was scheduled to come on 08/30/23; although she was supposed to document the measurements upon admission, so that she could know when the wound worsened. She could not tell whether the wounds had worsened. She stated failure to get orders and failure to perform wound care could lead to the wound getting infected.
Interview on 09/14/23 at 8:50 a.m. with the DON revealed it was the charge nurse's responsibility to admit new residents, perform skin assessments, and notify the Wound Care Nurse if a resident was admitted with wounds. The DON stated she expected the Wound Care Nurse to assess Resident #1 and put treatment orders in the TAR. The DON revealed it was the responsibility of the Wound Care Nurse to ensure wound care was being done for Resident #1. The DON revealed she left early on 08/25/23, and she had not realized Resident #1's wound care was not being documented on the TAR until on 08/29/23 when the treatment orders were received, and when the the HHSC surveyor started to inquire about the resident's wound care. The DON stated she was responsible for monitoring to ensure wound care was being provided to residents by both nurses and the treatment nurse. The DON stated failure of her staff to perform wound care could lead to infection and worsening of the wounds. The DON stated she completed in-services on 08/24/23 regarding MARs, TARs, assessments, wound assessments, and notification. She stated when the Wound Care Nurse was not at the facility the charge nurses were responsible for the wound treatment for their allocated halls.
Interview on 09/14/23 at 12:00 p.m. with LVN C revealed she was the one who admitted Resident #1 on 08/25/23. LVN C revealed Resident #1 had pressure ulcers on her sacrum, a skin tear on her iliac crest, and a deep tissue injury on her right heel. LVN C stated on 08/25/23 she removed the old dressing and applied a new dressing and notified the Wound Care Nurse for an assessment and got the wound care orders from the doctor as per the facility's protocol that indicated if a resident was admitted while the Treatment Nurse was in the facility it was her responsibility to assess the wounds and enter treatment orders. LVN C stated she worked with Resident #1 on 08/28/23 and 08/29/23, and she did not perform wound care for Resident #1, because the Wound Care Nurse was responsible for administering treatment. LVN C stated when the Treatment Nurse was off the charge nurses were responsible for the wound care on their halls.
Interview on 09/14/23 at 12:44 p.m. with RN B revealed he worked with Resident #1 on 08/26/23 and 08/27/23, and he could not recall whether Resident #1 had wound care orders. RN B stated he only worked double weekend, and he declined to reveal whether he was responsible for performing wound care on weekends. The resident was discharged home against medical advice on 09/01/23.
Record review of the facility's in-services revealed the facility offered training on MAR, TAR wound care, and assessment to their staff on 08/24/23.
Record review of the facility's current Pressure Ulcer/Skin Breakdown-Clinical Protocol policy revised March 2014, reflected:
Assessment and recognition
1 .nurse shall describe and document/report the following.
a.
Full assessment of pressure sore including location, Stage, length, width, and depth
b.
D. Current treatments including support surfaces
.3. The staff will examine the skin of a new admission for ulceration or alterations in skin.
Treatment /Management
1.The physician will authorize pertinent orders related to wound care treatments including wound cleansing and debridement, dressing and application of topical agent if indicated for type of skin.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.
1. The facility failed to ensure food items and clean dishes were kept away from contaminants and an unsanitary environment.
2. The facility failed to ensure the ice machine was clean and sanitary.
These failures could place residents at risk for food contamination and food-borne illness.
Findings included:
An observation of the kitchen on 09/12/23 at09:02 AM revealed three preparation tables had rust and debris that included dust and old food particles on the undershelves, where uncovered containers of clean cooking utensils and materials were stored. Observation also revealed the kitchen had one operating ice machine that was used for the residents, and it contained a buildup of black and brown substances on the interior lining of the machine, near the ice.
Interview on 09/12/23 at 10:48 AM with Dietary Aide D revealed she worked at the facility for 4 years. She stated all kitchen staff were trained and in-serviced on kitchen sanitation at least once a month. She stated it was the responsibility of all kitchen staff to maintain the cleanliness and sanitation of the kitchen. She stated the daily and general cleaning of the kitchen included sweeping, mopping, washing dishes, wiping down the preparation counters, equipment, and steam tables, organizing refrigerator/freezer and dry food pantry, and wiping down the walls. She stated there were no separate deep cleaning tasks or days because they were trained to deep clean on all tasks daily. Dietary Aide D stated it was maintenance's responsibility to clean things such as the ceilings, vents, and ice machine. Dietary Aide D stated she recalled wiping down the outside of the machine about a month ago, but it was not a part of her regular cleaning tasks. She stated the rust and debris had been on the undershelves of the preparation table for months and management was aware of it. She stated the risk of having an unsanitary kitchen could place the residents at risk of getting sick from cross-contamination.
Interview on 09/13/23 at 9:45 AM with the Dietary Manager revealed he had worked at the facility since December 2022 and was working on improving kitchen operations. He stated it was reported to management the preparation tables were rusted and needed to be replaced. The Dietary Manager stated he thought the tables had already been ordered about a month ago by the previous maintenance director; however, they were not. He could not state if management was following up on the order.
Interview on 09/14/23 at 2:15 PM with the Dietary Manager revealed all staff were trained on kitchen sanitation monthly. He stated the dietician also did a monthly sanitation audit of the kitchen. The Dietary Manager stated kitchen staff had sign-off sheets for all completed daily cleaning tasks. He stated the daily cleaning was split between the cooks and the dietary aides, and they all had assigned tasks. The Dietary Manager stated general and deep cleaning were all the same because the kitchen staff deep cleaned daily. He stated maintenance was ultimately responsible for emptying and cleaning out the ice machine at least once a month; however, he would wipe down the outside and interior parts that could be reached without completely breaking it down when he noticed it was dirty. He stated he would tell the kitchen staff to wipe down the ice machine as needed also. The Dietary Manager stated having rusty preparation tables and an unsanitary ice machine could cause cross-contamination and place the residents at risk for food-borne illness.
Interview on 09/14/23 at 2:38 PM with the Administrator revealed it was her expectation for all kitchen equipment to be clean and in working order. She stated it was maintenance's responsibility to clean the ice machines and order new kitchen equipment when needed. The Administrator stated the previous maintenance director was recently terminated and before leaving he had not followed through on ordering new preparation tables for the kitchen. She was unaware of the last time the previous maintenance director had cleaned the ice machine in the kitchen. There was no cleaning log for the ice machine provided. The Administrator stated there was a second ice machine in the nourishment room that was out of order and not used but had just been replaced with a brand new one. She stated new preparation tables would be ordered for the kitchen.
Interview on 09/14/23 at 3:38 PM with the Maintenance Director revealed he had only worked at the facility for one month and was still learning all his responsibilities. He stated he had just been informed it was his responsibility to deep clean the ice machines once a month, and kitchen staff were responsible for doing a weekly check to clean areas accessible to them and inform him of any major issues. He stated the Administrator informed him it was also his responsibility to order and replace kitchen equipment as needed.
Record review of the facility's Clean Schedules, dated for July 2023, August 2023, and September 2023, revealed it was current and all tasks, which included cleaning worktables, were signed off. Cleaning the ice machine was not listed on the schedules.
Record review of the facility's sanitation audit report, dated 07/27/23 and 08/22/23, revealed all major and minor equipment in the kitchen was clean.
Record review of the facility's training reports for kitchen staff, dated for July 2023, August 2023, and September 2023, revealed all current kitchen staff had received trainings including cross-contamination, cleaning and sanitation, and infection control.
Record review of the facility's current Equipment policy, revised September 2017, reflected the following:
Policy Statement: All food service equipment will be clean, sanitary, and in proper working order.
Procedures:
1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials.
2. All staff will be trained in the cleaning and maintenance of all equipment
Record review of the Federal Drug Administration Food Code, dated 2017, section titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils reflected: .(A) equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris

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 17 resident rooms (Resident #71's room) reviewed for infection control.
The facility failed to dispose of used push-button lancet (finger-prick needle), blood testing strips (used to obtain a fingerstick blood sugar), one used alcohol wipe, 0.09% sodium chloride injection and one IV catheter (used to provide access to administer IV fluids) in Resident #71's room.
This failure could place residents at risk of exposure to communicable diseases and infections.
Findings included:
Observation and interview on 09/12/23 at 11:42 AM of Resident #71's room, there was a green and orange push-button lancet, one used blood testing strip, one used alcohol wipe, 0.09% sodium chloride injection and one IV catheter on the resident's dresser located next to Resident #71 bed. Resident #71 was not in the room. Resident #71 had a roommate, Resident #54, who stated Resident #71 was sent to the hospital either Saturday or Sunday evening and had not returned yet.
Observation and interview on 09/12/23 at 11:49 AM, LVN E stated she was the nurse assigned to 400 Hall. She stated Resident #71 discharged to the hospital on Saturday (09/09/23) and had not returned yet. LVN E and the HHSC surveyor entered Resident #71's room, LVN E observed the blood testing strip, push button lancet, alcohol wipe, IV catheter and chloride injection. LVN E stated the facility did not use those items. She stated the paramedics might had left them behind. LVN E was observed to don gloves and dispose of the items in the sharps container located on her medication cart. LVN E stated she was not the nurse on Saturday; however, it was the responsibility of the nurses and CNAs to ensure the room was clean. LVN E stated housekeeping cleaned the rooms; however, they did not touch sharps items. LVN E stated the risk of leaving used sharps items in the rooms would be infection control.
Interview on 09/14/23 at 3:19 PM, CNA F stated he worked on Saturday (09/09/23) and was assigned to 400 Hall. CNA F stated Resident #71 went out to the hospital Saturday evening. He stated he was not assigned to Resident #71's room; however, if a resident was sent out to the hospital the staff assigned to the room would go back and clean the room. He stated the nurses or med tech would dispose of any used sharp items. He stated the risk of leaving used sharp items in resident rooms may cause someone to find them and poke themselves.
Interview on 09/14/23 at 3:49 PM, the DON stated LVN E informed her the paramedics left sharp items in Resident #71's room on Saturday (09/09/23). She stated her expectation was for staff to return to the room, clean, and dispose of any used sharp items. The DON stated the risk of leaving sharp items was that it could be infection control and the risk of the roommate touching the times.
Record review of the facility Waste Disposal policy, revised August 2008, reflected the following: All infectious and regulated waste shall be handled and disposed of in a safe and appropriate manner. C. Immediately after use, sharps shall be disposed of in closable, puncture resistant, disposable container that are leak- proof on the sides and bottom and are labeled or color-coded.