Every finding on record at C C Young Memorial Home

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 5 residents (Residents #1) reviewed for reporting allegations. The facility failed to report an allegation of drug diversion to the State Survey Agency within the required 24 hours. This failure could result in continued drug diversion.The findings included: Record review of the facilities Provider Investigation Report, revealed the incident date was 06/15/2026, at 4:45 p.m. allegation of drug diversion made by LVN Aon 06/17/2026 and reported to State Survey agency 06/23/2026. Record review of Resident #1's face sheet, dated 06/18/2026, revealed a [AGE] year-old female, admitted [DATE]. Resident #1's diagnoses included Alzheimer's (a progressive, irreversible brain disorder that destroys memory and thinking skills) disease and Radiculopathy lumbar region (occurs when a nerve root in your lower back is pinched, inflamed, or compressed). Record review of Resident #1's Comprehensive MDS Assessment, dated 06/14/2026, revealed Resident #1 did not complete a brief interview for mental status as Resident #1 was rarely/never understood and that Resident #1 received scheduled pain medication regimen. Record review of Resident #1's care plan, dated 07/07/2026, revealed was at risk for alteration in comfort/pain related to lumbar radiculopathy. Goal: Maintain pain control to satisfactory level for Resident #1. Interventions: Assess for pain each shift and PRN, intervene as needed, medicate as ordered and position/reposition to decrease pain. Durning an interview on 07/07/2026 at 10:00 a.m., the Administrator that she was informed by the DON of an allegation of drug diversion on 06/17/2026 that occurred on 06/15/2026 and reported it to the State Survey Agency on 06/23/2026. The Administrator stated that when she learned of the event she started an investigation that consisted of resident assessment to ensure resident was not in pain or harmed, family, medical director and pharmacist were contacted, an audit completed by the DON and ADON with no negative findings, called the police department, drug test of staff with no negative findings, safe surveys. The Administrator stated what she had been informed of was that LVN A told the Compliance Nurse that a narcotics sheet and narcotic medication were missing. The Administrator stated through the investigation the drug diversion was discovered. The Administrator stated she reported a drug diversion to the State Survey Agency but did not understand why the allegation was changed to misappropriation of property. The Administrator stated LVN A, who reported the drug diversion, was unavailable. During an attempted telephone interview with LVN A on 07/07/2026 at 10:45 a.m., there was no answer and a voicemail message was left with no return call. During an attempt interview with Resident #1 on 07/07/2026 at 11:52 a.m., Resident #1 could not verbally communicate. During an interview on 07/07/2026 at 12:32 p.m., the Compliance Nurse revealed that on 06/17/2026 10:25 a.m., LVN A reported that on 06/15/2026 her narcotics count was fine, and then when she came into work on 06/16/2026 there were narcotics that were missing, but LVN A was not sure what medications were missing, or how many, as the count sheet was also missing, but knew Resident #1 had a PRN Hydrocodone that was no longer there. The Compliance Nurse stated that LVN A stated her medication cart did not contain many narcotics and was employed long enough to know which residents had narcotics prescribed for their use. The Compliance Nurse stated LVN A told her that she had not reported it sooner because she wanted to talk to other nurses, to see if they were aware of any medications found or if any were disposed of. The Compliance Nurse stated that she contacted ADON to ask whether she was aware of any medications that had been turned in for destruction for possible expiration, the ADON said she had not. The Compliance Nurse said she told the ADON what LVN A reported and sent LVN A to talk to the ADON. During interview on 07/07/2026 at 1:15 p.m., ADON stated that she was informed of the suspected drug diversion on 06/17/2026 from the Compliance Nurse at around 10:30 a.m. The ADON stated when she learned of the suspected drug diversion she contacted LVN A. The ADON stated that LVN A told her that she was unable to locate medications on her medication cart but did not provide her with details of the date or time that she last saw the medications. The ADON stated she instructed LVN A to recheck the medication cart and medication storage room. The ADON stated that she contacted the DON after she spoke to LVN A. The ADON stated she contacted the DON, because that was who she reports to. The ADON stated she had drug diversion training at least annually but had no experience with drug diversions prior to this event. The ADON stated she received abuse and neglect monthly in-services and stated staff had to report allegations of abuse and neglect to the Administrator immediately. The ADON stated that a drug diversion was a form of misappropriation of property and should have been reported to the administrator immediately. The ADON stated that she received reeducation on Drug Diversion, Abuse and Neglect, assisted the DON with audit of the medication carts and storage rooms, and was educated on a medication and treatment documentation and running narcotic change log that the facility implemented to ensure drug diversion would not occur again. The ADON stated there were no other medications missing and there Resident #1 had PRN narcotics on 06/16/2026. During an attempted telephone interview with LVN A on 07/08/2026 at 1:08 p.m., there was no answer and no return call back prior to exit of the facility. During interview on 07/08/2026 at 10:35 p.m., the DON stated that he was informed of an allegation of drug diversion on 06/17/2026 that occurred on 06/15/2026. The DON stated that he reported to the Administrator immediately. The DON stated that after he had informed the Administrator, he contacted the pharmacy to get a pharmacy dispense report and then conducted an audit of all med carts and med storage rooms. The DON stated that there were no other narcotics missing and Resident #1 had received an order for her PRN medications on 06/16/2026. The DON stated that abuse and neglect in-services were completed monthly and anytime there was an allegation of abuse. The DON stated the in-service instructed the staff to report misappropriation of property to the Abuse Coordinator immediately. The DON stated the allegation of drug diversion was misappropriation of property and should have been reported to the Administrator immediately. The DON stated the expectation was to follow the facility policy on reporting to the Abuse Coordinator, as they were educated. The DON stated he could not state why the staff did not report the drug diversion to the Abuse Coordinator, but once he learned of the incident, he told the Abuse Coordinator. The DON stated it was the expectation of the facility that staff would report all allegations of drug diversion to the Abuse Coordinator immediately. The DON stated that if staff reported immediately it would keep the incident isolated, ensure the safety of residents, and was a requirement. The DON stated to the action taken by the facility to address the staff's alleged failure to report missing narcotic were reeducating staff through in-service on Drug Diversion and Abuse, Neglect and Exploitation, educated on medication and treatment documentation, and the facility implemented a weekly pharmacy audit dispense report against what narcotics were on hand, and staff that handle narcotics now have to fill in the narcotics sheet as well as implemented a running narcotic log for staff to fill out each shift. The DON stated that the running narcotic log staff were to log the date, shift, count at the start of shift, count at end of shift, explain/account for if there was a difference in the count, two nurses must print their names. During an interview on 07/08/2026 at 1:44 pm., the Administrator stated that it was her responsibility to ensure all suspected allegations of misappropriation were reported to the proper authorities within the time frame. The Administrator stated that because there was no serious bodily injury the facility had 24 hours to report the allegation of suspected drug diversion. The Administrator stated that suspected drug diversions were considered misappropriation and should have been reported immediately. The Administrator stated she could not state why LVN A did not report the alleged drug diversion immediately. The Administrator stated that it was important for the staff to report immediately to limit the opportunity for additional drug diversion to occur. The Administrator stated that it was her expectations that any allegations be reported to the Administrator for investigation. The Administrator stated to the action taken by the facility to address the staff's alleged failure to report missing narcotic were reeducating staff through in-service on Drug Diversion and Abuse, Neglect and Exploitation, the facility implemented a weekly pharmacy audit dispense report against what narcotics were on hand, and staff that handle narcotics now have to fill in the narcotics sheet as well as implemented a running narcotic log for staff to fill out each shift. A record review of LVN A's witness statement, dated 06/19/2026, revealed, On Tuesday 06/16/2026 after counting narcotic (LVN A) noticed 4 blister cards missing. - (LVN A) decided first to ask nurses that had worked and search for the medications before reporting the issue. (LVN A) asked 3 nurses, looked on nurse's station, med room, nurse's cart, and on destruction boxes. No medications nor counting sheets located. Then (LVN A) reported the missing meds to the complaints officer, she sent me to the ADON. A record review of facility in-service titled, Drug Diversion, undated, revealed: Any discrepancy in the inventory of a controlled substance is to be reported to the DON as soon as possible shift or pr person responsible or person responsible for the discrepancy, and efforts made to reconcile it. If a major discrepancy or pattern of discrepancies occurs, or there is obvious criminal activity the DON is to notify the administrator and consult pharmacist immediately.The administrator and DON will be responsible to notify the local police and then immediately notify the appropriate state agency when it is determine or there is reason to believe that the drug diversion was a result of theft. A record review of facility policy titled, Abuse and Neglect Prevention Policy, dated July 2018, revealed, Identification: The facility trains all staff to immediately report injuries of unknown origin, allegation of abuse or neglect so an investigation can be initiated and appropriate notification can be made.Reporting/Response: The appointed lead investigator will contact HHSC office to make an oral or online report of the allegation or injury immediately, if the events that cause the suspicion do not result in serious bodily injury, the lead investigator will report within 24 hours.Definitions: Misappropriation of residents' property means deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a residents' belongings or money without the residents' consent.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 13 residents (Resident #67, and Resident #146) reviewed for rights. The facility failed to ensure the staff in the main dining room served Resident #67, and Resident #146, at the same time the other residents were served the lunch meal. These failures could place residents at risk of feeling like their dignity was being violated or the facility was not their home.Findings included: Record review of Resident #67's admission MDS assessment, dated 04/29/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #67 had diagnoses which included: metabolic encephalopathy (change in brain function), dementia (forgetfulness), and hypothyroidism (low thyroid production). Resident #67 had severe cognitive impairment and required assistance of one staff for activities of daily living, including eating assistance. Record review of Resident #146's admission MDS assessment, dated 01/07/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #146 had diagnoses which included: metabolic encephalopathy (change in brain function), dysphagia (swallowing difficulty), chronic kidney disease (kidneys do not fully function), and diabetes (increased sugar levels). Resident #146 had moderate cognitive impairment and required assistance of one staff for activities of daily living. Observation on 01/13/2026 beginning at 12:05 p.m. revealed the other residents at Resident #67's table were served their lunch meal at the table where she was sitting. As the other residents received their meals they began to eat. Resident #67 continued to sit at the table watching the other residents eat. There was a staff member assisting another resident to eat right next to Resident #67, as she sat there and watched. Observation on 01/13/2026 at 12:09 p.m. revealed the other residents at Resident #146's table had begun to receive their lunch meals. The staff served the entire table of residents except Resident #146. Resident #146 continued to sit at the table and watch the other residents eat their meals. Observation on 01/13/2026 at 12:22 p.m. revealed Resident #146 was served her lunch meal. Observation on 01/13/2026 at 12:28 p.m. revealed the staff serving Resident #67 her lunch meal. In an interview on 01/13/2026 with Resident #146 at 12:30 p.m. revealed that the resident could understand but could only nod yes and no. The Resident communicated that she was new here, but she had been getting her meal with the rest of the residents off and on. The Speech Therapist, sitting with the resident, stated she was working with the resident concerning her swallowing difficulty. The Speech Therapist stated she works with the resident one to two meals each day and the meals are served inconsistently to the table. Sometimes Resident #146 must wait to be served while the other residents have their meal served, and other times, she has her meal. In an interview and record review on 01/13/2026 at 12:35 p.m. Resident #67 revealed she did not want the chicken pot pie the main meal, Resident #67 stated she wanted a sandwich. Review of Resident #67's meal ticket showed the chicken pot pie marked off and the sandwich checked. Resident # 67 stated she could not recall when she had changed her mind. Resident #67 stated she did not like sitting at the table watching someone else eat their food. An interview on 01/13/2026 with Unit Manager B at 12:45 p.m. revealed that all residents at the same table should be served at one time. This prevents residents from sitting watching the other residents eat their meal. Unit Manager B stated that sometimes that does not happen because the kitchen does not serve the trays out that way. Unit Manager B stated that it is the residents' rights, and the serving line and specialty service (alternate items) need to be better coordinated to get all the residents in the dining room served appropriately. An interview on 01/13/2026 at 1:11 p.m. with the Administrator revealed the residents have a specialty menu also, that they can choose foods from, indicating this could cause a resident to have to wait for their food. The Administrator stated the staff will be trained when the meals are served in the dining room all the residents at one table should be served at the same time. In an interview on 01/14/2026 at 1:16 p.m. DON revealed when servicing meals in the dining room all tables should be served at the same time. The DON stated even if another resident joined the table later or ordered a specialty item the tray should be brought to that resident when they joined the table. It is the right of the residents to not have to sit at the table and watch someone else eat, when they have nothing to eat themselves. In an interview on 01/13/2026 at 1:45 p.m. CNA C revealed that all residents at the same table should be served their meals at the same time, but the kitchen does not send them out to the tables that way. The CNA said they can ask for the trays; the kitchen sends out the trays as they serve each ticket. The CNA stated she did not know if there was any organization to the process. CNA C stated it is the right of the residents to not have to sit and watch another resident eat, and they have been trained about that. Record review of Policy titled The Dining Experience revised dated 2023 reflected The dining experience will be person centered with the purpose of enhancing each individual's quality of life and being supportive of each individual's needs during dining. Individuals will be provided with nourishing, palatable, attractive meals that meet daily nutrition and/or special dietary needs and for preferences and are served at a safe and appetizing temperature. Procedures: . 13. individuals at the same table will be served and assisted at the same time.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. The facility failed to ensure dietary staff wore appropriate hair and beard restraint while in the kitchen.The facility failed to maintain the sanitizing solution used in the manual dishwashing process at the proper chemical concentration required for effective sanitation.These failures could place residents at risk for contamination, foodborne illness, and infection resulting in possible physical harm to residents receiving the food.Findings included:Observation of the kitchen on 01/13/2026 at 10:32 a.m. revealed the following:Observed the Director of Dining Services walking through the kitchen and interacting with staff, not wearing appropriate hair restraint over his mustache.Observed the Executive Chef walking through the kitchen, interacting with staff, and handling food trays that had food on them not wearing an appropriate hair restraint over his goatee.Observed the Porter, in the kitchen on 01/13/2026 at 10:45 a.m. complete a test of the sanitizing water he was using to clean the dishes and the test strip read zero.Observation of the kitchen revealed the following:Observed [NAME] A, in the kitchen on 01/14/2026 at 10:26 a.m. preparing pie shells not wearing appropriate hair restraint over his mustache.Observed [NAME] B, in the kitchen on 01/14/2026 at 10:32 a.m. transporting trays that had food on them to other areas of the kitchen not wearing a hair restraint appropriately, her braids were hanging out of her hairnet across her forehead.During an interview with the Director of Dining Services on 01/13/2026 at 11:43 a.m., he stated that hairnets were required to be worn in the kitchen, and that a facial hair restraint was only required if approximately one-quarter of the face was covered with hair and only for staff who were cooks or servers. He further stated that staff who were not preparing food were not required to wear facial hair restraints and acknowledged that the impact of not using appropriate hair and facial hair restraints could include contamination of food products in the kitchen.During an interview and observation with the [NAME] on 01/13/2026 at 10:45 a.m., he was asked to check the sanitizing chemicals in the water he was using to manually wash dishes. He used a test strip and compared the strip, which turned orange, to the indicator colors on the test strip container. When asked what the color of the test strip indicated, he stated it showed the temperature of the water and that the water was okay. The color indicator on the test strip container showed that orange represented zero chemical concentration in the water. During an interview with the Executive Chef on 01/13/2026 at 10:48 a.m., he was asked what the test strip indicated, and he stated that the test strip was used to measure the chemical-to-water ratio in the sanitizing solution and to determine whether the concentration of sanitizer in the water was within the acceptable range for proper dish sanitation. He explained that the orange on the test strip meant there were not enough chemicals in the water. During an interview with the Executive Chef on 01/13/2026 at 11:20 a.m., he stated that hairnets were required to cover all the hair on the head, and that facial hair restraints were only required for staff who were cooks or servers. He further stated that staff who were not preparing food were not required to wear facial hair restraints.During an interview with [NAME] A on 01/14/2026 at 10:28 a.m., [NAME] A stated that hairnets were to be worn by everyone who entered the kitchen, and that facial hair restraints were required for beards but not for mustaches. [NAME] A further stated that the impact of not wearing a hairnet could have resulted in hair getting into the food and the food being ruined for service to residents.During an interview with [NAME] B on 01/14/2026 at 10:32 a.m., [NAME] B stated that hairnets were to be worn by everyone in the kitchen, and that staff with facial hair, including mustaches, were to wear facial hair restraints over their facial hair. [NAME] B stated that the impact on residents of staff not wearing required hair or facial hair restraints could have affected residents' psychological well-being and trust in the facility and could have potentially affected the quality of care and services provided. During an interview with the Executive Chef on 01/14/2026 at 2:33 p.m., he said that he educated the kitchen staff on how to properly test chemicals when manually washing dishes and how often it needed to be completed. Record review of the facility's Food Storage Policy, dated with no month, 2023 revealed, All employees will: 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. The surveyor did not receive a facility policy addressing the required chemical concentration level for manual dishwashing.Review of the U.S. FDA Food Code 2022 reflected: 2-402 Hair Restraints 2-402.11 Effectiveness (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.

Based on interview, and record review the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through the means other than a postal service for 7 of 7 residents reviewed for rights to forms of communication with privacy. The facility failed to deliver mail to the resident within twenty-four hours of delivery on premises or the facility's post office box according to their policy. This failure could place residents at risk of not receiving mail in a timely manner and could result in a decline in residents' psychosocial well-being and quality of life During a confidential group interview, 5 of 7 residents stated mail was not distributed at the facility on Saturdays. 2 of 7 residents stated mail was never distributed to them. 1 of the 7 confidential residents stated mail was distributed to her whenever they felt like it. The residents stated they were unaware who was responsible for distributing mail. In an interview on 01/14/2026 at 1:30 p.m. with the Admin she stated that Life Enrichment is responsible for delivering mail. She stated that Life Enrichment also delivers mail on the weekend as well. She stated that the package deliveries usually go directly to the resident. In an interview on 01/14/2026 at 2:10 p.m. with the Life Enrichment manager revealed that her staff delivers mail within 24 hours. She stated that mail that comes in on Saturday is delivered on the following Monday. She stated that there may be a time when the mail is delivered to another of the 7 buildings on the campus. She stated it may take a while for the mail to make it to this building, but her team delivers it to the Residents as soon as they get the mail. In an interview on 01/14/2026 at 3:00 p.m. with the ADM revealed her expectation was that the Life Enrichment team was delivering mail on Saturdays. She stated she was unaware that mail was not being delivered and she would get with her staff to confirm mail was to be delivered on Saturdays as well as Monday-Friday. Record review of the facility's Mail Delivery Policy revised 07/17/2019 reflected: Policy Statement: Mail will be delivered Monday through Saturday excluding federal holidays by a member of the Life Enrichment Staff or representative. Life Enrichment Staff will ensure that all personal resident mail is delivered to the appropriate party in a timely matter (within 24 hours ). Al informal mail will be delivered directly to resident, Examples: Cards catalogues, newsletters, personal correspondence.Al formal mail will be either a) forwarded to families b) placed in the family's predetermined location c) delivered to residents who are responsible for their own finances or families agree they are able to manage this mail. Examples are bills letters from insurance companies, information from doctors.(Saturdays) weekend staff will not be responsible for forwarding mail to families or identifying and locating predetermined location. On Saturday s, all formal mail will be put under the door of the Life Enrichment Director, All informal mail will be delivered directly to residents.

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 one of four (CNA A) staff members and two of ten residents (Resident #27 and #103) reviewed for infection control procedures. CNA A failed to perform hand hygiene after direct contact with Residents #27, and #103 while serving meals in the dining room. This failure could place residents at risk for healthcare associated cross contamination and infections.Findings included: Record review of Resident #27's admission MDS assessment, dated 4/18/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #27 had diagnoses which included: Coronary Artery Disease (clogged arteries), Heart failure (weak heart), and hypertension (high blood pressure). Resident #27 was severely cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #103's admissions MDS Assessment, dated 06/25/2025, revealed an [AGE] year-old male who was readmitted to the facility on [DATE]. Resident #103 had diagnoses which included: dementia (brain disease that effects memory), hypertension (increased blood pressure), and depression (mental illness). Resident #103 moderately impaired for cognition and unable to make decisions and required one staff for assistance with activities of daily living. Observation on 01/13/2026 beginning at 12:05 p.m., revealed CNA A had entered the dining room, and did not use hand sanitizer. CNA A served a lunch tray to Resident #103, touched the table in the dining room, touched the hand and shoulder of Resident #103 and prepared the meal tray for the resident to eat the lunch. CNA A did not have gloves on. CNA A was observed not to wash her hands or use hand sanitizer, available in the serving area. Observation on 01/13/2026 beginning at 12:05 p.m., revealed CNA A was observed to serve Resident #27 a bowl of soup, stepped away, went and obtained a drink from the refrigerator for Resident #27, signed the drink out on a log next to the refrigerator and then took it to Resident #27. CNA A returned to the serving line not washing her hands or using the hand sanitizer. Further observation at 12:15 p.m. revealed CNA A served the lunch meal to Resident #27 without washing hands or using hand sanitizer. She did not complete hand hygiene before going to the next resident. Further observation revealed Unit Manger B instructing CNA A to use hand sanitizer at which time the CNA did so. In an interview on 01/13/2026 at 12:45 p.m. CNA A stated she did not complete hand hygiene after having direct contact with residents. CNA A stated she was supposed to use the hand sanitizer in between serving each tray. CNA A said she had been educated on completing hand hygiene. CNA A stated she did not sanitize her hands, because she was trying to get the lunch meal served, so the residents would be happy. An interview with the DON on 01/14/2026 at 1:16 p.m., revealed that all staff must complete hand hygiene after having contact with residents. He stated all staff were trained to wash their hands with soap and water prior to tray service, then use hand sanitizer between each tray. The DON stated if the staff do not use appropriate hygiene, they can spread germs to the residents and themselves. Record review of an in-service log dated 12/07/2025 revealed CNA A received handwashing and hand sanitizing training, to prevent the spread of infection. Further review of in-service logs revealed an in-service conducted on 01/13/2026 reflected: when passing trays in the dining room, sanitize after serving every tray. CNA A received this training after surveyor intervention. Record review of the Facility's Policy titled Handwashing/Hand Hygiene revised October 2023 reflected: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Administrative Practices to Promote Hand Hygiene 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for Hand Hygiene 1. Hand hygiene indicated: .d. after touching a resident; e. after touching the residents environment; .

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments inaccessible to unauthorized staff, visitors, and residents for 1 (Resident #63) of 40 residents reviewed for medication storage. The facility failed to ensure Resident #63 did not have medications stored at the bedside. This failure could place residents at risk of ingesting unprescribed medications resulting in adverse health consequences. Findings included: Review of Resident #63's face sheet revealed a [AGE] year-old woman admitted on [DATE] with diagnoses of hypertension, muscle weakness, abnormalities of gait and mobility, lack of coordination, need assistance with activities of daily living, and chronic diastolic (congestive) heart failure. Review of Resident #63's annual MDS dated [DATE] reflected she had a brief interview of mental status score of 14, indicating no cognitive impairment. Resident # 63 required supervision or moderate assistance with activities of daily living. Review of Resident #63's physician orders dated 10/02/24 reflected the following medications were not ordered for the resident; Tums Ultra 400 mg calcium (1,000 mg) chewable tablet, Nasal Spray 12 Hour 0.05 % (Oxymetazoline), Cortizone-10 1 % topical gel (Hydrocortisone), Debrox 6.5 % ear drops (Carbamide peroxide), and fiber gummies (chewable). Review of Resident #63's care plan dated 10/03/24 revealed, (Resident #63) wishes to administer some of her own medication. Resident's cognition level BIMS score of 14. Goal, (Resident #63) will successfully name medication and reason for administration within next 90 days.Obtain order for self-medication administration, .Ensure medications can be safely secured from other resident's access within room. Ensure (Resident #63) is able to demonstrate safe handling and storage. Observation on 10/02/24 at 11:45 AM revealed Resident #63 was in bed, awake, and alert. The following medications were noted on the bedside table; bottle of Xylident dry mouth, 1 tube of Hydrocortisone cream which was about half used, 1 bottle of ear wax removal, and 2 bottles of nasal spray. On the shelf wall there was a bottle of fiber chewable gummies. In an interview on 10/02/24 at 11:52 AM with Resident #63, she stated she had been in the facility for about 1 year and reported no concerns. Resident #63 stated she ordered the medications from store and self-administered the medications and at times being assisted by the staff, but she was not able to identify the staff who assisted her. Resident #63 stated she had been using the medication for a while and she did not give a specific timeline she had used the medications. She stated she always stored the medications on the bedside table and the shelf. Resident #63 stated she had not been educated on self-administration of medications. In an interview on 10/02/24 at 01:51 PM with LVN A she stated she was the charge nurse of Resident #63. LVN A stated she was not aware of the medications in the resident's room, but again stated the resident had been assessed for self-medication administration and she was looking for the record in the resident's clinical record. LVN A then stated she was going to get the document from a printer, and she did return. Later, LVN A was noted in Resident #63's room, and she stated she had gone to help the staff who was getting Resident #63 in the wheelchair. LVN A then stated she was not able to find the self-administration assessment or the orders to indicate the resident could administer her own medications. LVN A stated Resident #63 was supposed to have the orders of all the medications she was taking. LVN A stated she saw the medications in the resident's room on the bedside table and on the shelf. LVN A stated the resident was supposed to have orders of the medications and complete a self-medication administration assessment on the resident. The medications were not supposed to be in the resident's room on the bedside table or shelf, they were supposed to be stored in a safe place. Resident #63 self-administering medications without the knowledge of the facility could lead to medication interaction with the ones the resident was prescribed which could lead to side effects. In an interview on 10/02/24 at 03:53 PM with the ADON she stated she was made aware of Resident #63 having medications in her room. The ADON stated the staff were supposed to report to the charge nurse any medications noted in any resident's room. The ADON stated Resident #63 was not supposed to have medications in the room without the physician's order. The ADON stated Resident #63 had not been assessed for self-medication administration prior to the medications being noted in the room. The ADON stated she called the resident's primary care provider and obtained the orders for the medication, and she will complete the self-medication administration assessment. Resident's self-administering medications could lead to medication interactions and even overdose. In an interview on 10/02/24 at 04:20 PM with the DON he stated he had just been notified that the resident had medications in the room. The DON stated the self-medication administration assessment was being completed today and the orders for the medications would be obtained from the primary care provider. The DON stated the resident was not supposed to have medications in the room and use without the doctor's orders and staff assessment for self-medication administration. The DON stated the staff were supposed to report if there were any mediations in the resident's room to prevent medication interactions, overdose, or side effects. The facility was supposed to be aware of all the medications the resident was taking. Review of the facility policy undated and titled, Medication Storage reflected, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Review of the facility policy revised February 2021 and titled Self - Administration of Medication reflected, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.7. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. 8. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

Based on observations, interviews, and record reviews the facility failed to review the risks and benefits of bed rails and enabler pivot assist bars with the resident or resident representative and obtain informed consent prior to installation for three (Residents #81, #312, #314) of 37 resident rooms observed and reviewed for bed rails/pivot assist bars in that: The facility failed to have consents signed for the pivot assist quarter bed rails for Residents #81, #312, and #314. This failure could affect residents who used bed rails/pivot assist bars at risk of the resident/responsible party not being aware of the risk. Findings included: 1. Record review of Resident #81's face sheet, dated 08/31/2023 revealed resident was originally admitted on [DATE] and current admit on 03/23/2023 with diagnoses of Pneumonia, unspecified organism; Paroxysmal atrial fibrillation; Unspecified dementia, unspecified severity, without behavioral/psych/mood; Hypothyroidism, unspecified; Muscle weakness (generalized); Difficulty in walking, not elsewhere classified; Cognitive communication deficit; Other abnormalities of gait and mobility; Essential (primary) hypertension; Other lack of coordination; Unsteadiness on feet; Need for assistance with personal care; Unspecified lack of coordination. Per the face sheet, Resident #81's responsible party was a family member. Review of Resident #81's MDS, dated [DATE], revealed the resident had issues with forgetfulness. Resident needed assistance with all ADL care. Resident was not able to move from seated to standing position, move on and off toilet, or perform a surface-to-surface transfer without the assistance of staff. Resident used a wheelchair for mobility. Review of Medical record of Resident #81 revealed no written Physician Order for quarter bed rails (pivot assist bars) for mobility and positioning. Review of Medical Record of Resident #81 revealed no Physical Device Acknowledgement form (bed rail/pivot assist consent) for the pivot assist bars (quarter bed rails) signed by the resident's responsible party. Record review of Resident #81's Care Plan, dated 3/23/2023, revealed no indication of bed rail or pivot assist bar discussion of risks and benefits with Resident or responsible party. Observation on 08/29/2023 at 9:50 AM revealed Resident #81's room revealed the resident's bed with quarter bed rails/pivot assist bars raised on both sides of bed with call light laying on the mattress. Observation on 08/30/2023 at 02:05 PM of Resident #81's room revealed both quarter bed rails/pivot assist bars raised on resident's bed. Observation on 08/31/2023 at 08:42 AM of Resident #81's room revealed both quarter bed rails/pivot assist bars raised on resident's bed. 2. Record review of Resident #312's face sheet dated 08/31/2023 revealed resident's current admitted [DATE], initial admitted [DATE], with diagnosis of Stable burst fracture t11-t12 vertebra, subs for fracture with ro; Parkinson's disease; Unspecified fall, subsequent encounter; Hyperlipidemia, unspecified. Per face sheet, the responsible party was the resident, spouse listed as emergency contact. Record review of Resident #312's Care Plan, dated 08/31/2023, revealed resident is a fall risk and has a history of falls. Record review of Resident #312's Physician Orders reveals twice daily medication for dementia. Review of Medical record of Resident #312 revealed no written Physician Order for quarter bed rails (pivot assist bars) for mobility and positioning. Review of Medical record of Resident #312 reveals no Physical Device Acknowledgement form (bed rail/pivot assist bar consent) for the pivot assist bars (quarter bed rails) signed by the resident's responsible party. Record review of Resident #312's Care Plan, dated 08/31/2023, revealed no indication of bed rail or pivot assist bar discussion of risks and benefits with Resident or responsible party. Observation on 08/29/2023 at 09:35 AM revealed Resident #312 sitting in wheelchair in room. Resident #312's bed was equipped with quarter bed rails (pivot assist bars) that were raised. Observation on 08/30/2023 at 2:54 PM revealed Resident #312's bed observed with both quarter bed rails/pivot assist bars raised. Observation on 8/31/2023 at 10:15 AM of Resident #312's empty room revealed both quarter bed rails/pivot assist bars raised. 3. Record review of Resident #314's face sheet dated 08/31/20232 revealed resident was admitted on [DATE], with a current admitted [DATE], with diagnosis of Encephalopathy, unspecified; Sepsis, unspecified organism; Urinary tract infection, site not specified; Cerebral infarction, unspecified; Type 2 diabetes mellitus without complications; Generalized anxiety disorder; Depression, unspecified; Essential (primary) hypertension; Hyperlipidemia, unspecified; Unsteadiness on feet; Other lack of coordination; Need for assistance with personal care; Difficulty in walking, not elsewhere classified; Muscle weakness(generalized). Per the face sheet, the responsible party was the resident. Review of Medical record of Resident #314 revealed no written Physician Order for half bed rails (pivot assist bars) for mobility and positioning. Review of Medical Record of Resident #314's Care Plan, undated with updates made between 6/22/2023 and 7/27/2023, revealed there was no care plan addressing the use of bilateral half bedrails or pivot assist device on resident's bed. Review of Medical record of Resident #314 reveals no Physical Device Acknowledgement form (bed rail/pivot assist bars consent) for the pivot assist bars (half bed rails) signed by the resident's responsible party. Observation on 08/29/2023 at 10:03 AM revealed Resident #314 sitting in bed watching television with both half bedrails/pivot assist bars raised. Call light was wrapped on the bed rail. Observation on 08/30/2023 at 02:55 AM revealed Resident #314 lying her in bed sleeping with television on. Resident #314's bed was equipped with half bed rails (pivot assist bars) that were raised on each side. Observation on 8/31/2023 at 09:55 AM revealed Resident #314 in bed eating breakfast; both half side rails/pivot assist bars were raised. In an interview with Administrator on 8/31/2023 at 10:35 AM, the facility has used the pivot assist enabler bars on every bed in the facility since 2020 and had not obtained physician orders or signed consent. Administrator A maintains that the pivot assist bars are not bed rails and bases this on the manufacturer's product statement flyer and that the beds are custom. Administrator A stated the pivot assist bars can swing out to aid in standing if an individual is sitting on the edge of the bed. Administrator A, in an email dated 8/31/2023 at 11:17 AM, when asked for consents for bed rail/pivot assist bars stated however we will not have consent forms for the assistive devices as they are not side rails and therefore not required. In an interview on 08/31/2023 at 8:58 AM, DON reviewed facility process and policy for bed rail and grab bars/pivot assist bars use. DON stated the bed rails and grab bars/pivot assist devices are used for residents for positioning and comfort. DON stated that on admission residents are informed about the facility use and evaluated for extent of need for bed rails and grab bars/ pivot assist bars; Residents were also reviewed quarterly or when care is plan updated. DON stated this facility did not call them bed rails rather they called them supportive devices. DON stated that the grab bars/pivot assist bars were also used to anchor the call light cable to make sure it did not fall on ground and was more available for resident use. DON stated that when a family member or resident did not want the grab bars/pivot assist bars to be used, the facility would put them in a down position or have them removed. DON stated that electronic health records should be updated with resident evaluations for safe use of bed rails and grab bars/pivot assist bars and that staff should be reviewing and familiar with resident status in their care areas. Interview with LVN A on 8/30/23 at 1:36 PM about bed rail or grab bar/pivot assist bar use in the facility. LVN A stated she would check orders for new residents for information on need for bed rails or grab bars/pivot assist bars being used or if a change in use or position of the bars is noticed. LVN A stated that bed rails can be a hazard as a resident could be hurt by choking on a cord anchored on the rail, having limb caught in the open spaces of the bar resulting in fractures or injury. Interview with LVN B on 8/30/23 at 2:10 PM about bed rail or grab bar/pivot assist bar use in the facility. LVN B stated she checks the electronic chart of residents she was not familiar with for the reasoning for use of bed rails or grab bars/pivot assist bars. LVN B stated that bed rails or grab bars/pivot assist bars can be dangerous due to the potential of injury to a resident getting caught in the bars and because the bars may be seen as a restraint. Interview with CNA C on 8/30/23 at 1:55 PM about bed rail or grab bar/pivot assist bar use in the facility. CNA C states that she would verify with a floor nurse if she saw a change in use of bed rails or grab bars/pivot assist bars for a resident and verified what the need for the bars or change in use. CNA C stated that bed rails and grab bars/pivot assist bars can be a danger as they can be a restraint and limit mobility of a resident. Facility provided product statement flyer, undated, by [Company Name], the manufacturer of the bed rails/grab pivot assist bars in use by facility. The statement states that the product is not a bed rail but a three position pivoting assist device . and does not fulfill all the criteria indicated in CMS F604 S483.10 Euro Respect and Dignity. Facility Administrator states that as the manufacturer Product Statement is specific that these pivot assist bars are not side rails that the facility does not care plan their use, obtain consent or physician orders. Record review of the facility's provided Proper Use of Side Rails, (C)2001 [Company Name] (Revised December 2016), revealed the purpose To ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guideline item #2 states Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. General Guideline #3 states An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. General Guideline #4 states The use of side rails as an assistive device will be addressed in the resident care plan. General Guideline #5 states Consent for using restrictive devices will be obtained from resident or legal representative per facility protocol. General Guideline #7 states Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. No General Guideline item indicated need for a physician order before side rails or pivot assist bars can be used or installed.

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 one (CMA D) of two staff observed during medication pass reviewed for infection control. 1. CMA D failed to disinfect the blood pressure cuff in between use with Resident #1 and Resident #91. These failures could affect all residents by causing cross contamination and placing them at risk for exposure to a contagious disease, infection, and possible hospitalization . Findings included: 1. Record review of Resident #1 face sheet dated 8/31/23.admitted to the facility at 8/19/23 with diagnosis of urinary tract infection, and hypertension (high blood pressure). Observation on 8/30/23 at 8:15AM with CMA D revealed him going into Resident #1 room to take his blood pressure. He placed the blood pressure machine on the bed while receiving a reading. Once CMA D was done, he came out of the room. Placed the blood pressure machine back on his cart without sanitizing the cuff. He then Sanitized his hands to prepare Residents #1 medication. Once he finished given the medication, he washed his hands to prepare to go to the next resident room. Record review of Resident #91 dated 8/31/23 admitted [DATE] with diagnosis of hypertension (high blood pressure), depressive episodes, and muscle weakness. Observation on 8/30/23 at 8:27AM with CMA D went to Resident #91 room and took the non-sanitized blood pressure cuff in the room to take his blood pressure. After that CMA D sanitized his hands to prepare Residents #91's medications and placed the non-sanitized blood pressure cuff on the medication cart. Interview on 8/30/23 at 8:35AM revealed CMA D had been trained to sanitize multi-use devices such as the blood pressure cuff right after using it on a resident and in between residents. He stated they have wipes that were supposed to be used but he forgot to use them. Interview on 8/30/23 at 2:23PM with the Administrator revealed when dealing with multi use devices she expected her staff to disinfect and clean in between residents. The Administrator revealed the risk of not doing so could lead to the spread of infection. She also stated they do infection control once a month and every couple of weeks go around to watch medication passes to make sure staff are following the appropriate protocol. Record Review dated September 2022 of Cleaning and disinfection of resident-care items and equipment policy revealed, Reusable items are cleaned and disinfected or sterilized between residents (eg. Stethoscopes, durable medical equipment Reusable resident care equipment is decontaminated and or sterilized between resident according to manufacturer's instructions. 48329

Based on observation, interview and record review, the facility failed to ensure that 3 of 10 residents (Resident # 2, Resident #3, Resident #4) reviewed for pressure ulcers and wounds received the necessary treatment and services, consistent with professional standards of practice, to provide wound healing. 1) The facility failed to implement interventions of providing wound care as needed on Resident #2's left heel. 2) The facility failed to ensure Resident #4's sacral wound was covered with a dressing. 3) The facility failed to implement wound care on 08/25/23 for Resident #3's right great toe. These failures could place residents with pressure ulcers and wounds at risk for worsening of pressure injuries and wounds. Findings included: 1) Record review of Resident #2's MDS assessment dated [DATE], reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's diagnoses included Unspecified fracture of left femur, unspecified fall, essential (primary) hypertension, peripheral vascular disease, pain in left hand, lack of coordination, muscle weakness, unsteadiness on feet, difficulty walking, pain in left hip. The resident's health conditions included repair of fractures of the pelvis, hip, leg, knee, or ankle. The resident skin conditions include 3 unstageable deep tissue injury. The resident had a BIMS score of 14, indicating the resident is cognitively intact. She required limited assistance of one person with ADL's and was incontinent of both bowel and bladder. She had limited mobility in one lower extremity and required the assistance of one person with transfers to her walker. Record review of Resident #2's Skin Evaluation Form dated 08/22/23 reflected the resident had a unstageable pressure injury to the left heel of the foot. The size of the pressure injury included a length (L) x 3.6cm width (W) x 3.6cm and depth (D) x 0.4cm. The wound was described 40% granulation (new connective tissue), and 30% necrotic (dead tissue), 30% slough (a form of dead tissue) with Tissue type 4 necrotic/eschar and serosanguineous (pink/brown) drainage. Record review of Resident #2's Care Plan dated 08/03/23 reflected she had unstageable pressure wound to the left heel and will show signs of healing by the next review date. The care plan stated, treatment as follows: clean with ns, pat dry, apply calcium alginate with AG, cover with dry dressing every Tuesday and Friday and PRN if becomes soiled/dislodged. Review of Resident #2's Physician's Orders dated 08/04/23 and 08/16/23 (respectively) revealed wound care orders for the following; 1. Start Date: 08/04/23 wound care- twice a week cleanse unstageable pressure wound to left heel with NS, pat dry, apply calcium alginate with Ag, cover with dry dressing 2 times a week on Tuesday and Friday and PRN if becomes soiled/dislodged. 2. Start Date: 08/16/23 PRN wound care- as needed cleanse unstageable pressure wound to left heel with NS, pat dry, apply calcium alginate with Ag, cover with dry dressing 2 times a week on Tuesday and Friday and PRN if becomes soiled/dislodged Review of Resident #2's electronic Treatment Administration Record (eTAR) and eTAR Notes, dated August 2023 revealed when the wound care treatment was performed the nurse would indicate this with her initials. According to the eTAR wound care start date was 08/04/23 and was provided on 08/18/23, 08/22/23, and 8/25/23 for the left heel. When the procedure was not performed an X would take the place of the nurses' initials. The as needed wound care order was not listed on the eTAR until the day of surveyor entry on 08/26/23. The eTAR revealed 08/26/23 was the only day Resident #2 had received as needed wound care. Review of nurse's notes revealed Resident #2 did not refuse wound care in August 2023. Interview on 08/26/23 at 12:18 PM with the Resident #2 family member revealed the Resident #2 only spoke Spanish. The Family member stated Resident #2 had been at the facility for 3 weeks. The Family member stated the resident was getting wound care on the left heel and there was a large blister that had been drained by the wound care doctor. She stated the resident had walked a lot which caused the heel to drain to the point of Resident #2's sheets would often get changed. The Family member stated wound care was provided only upon request. The Family member stated Initially the staff would do the resident's wound care often and the wound was getting worse because it was a open wound. The Family member stated Resident #2's left heel drained so much the facility had left a small kit in the resident's room for the family to change the dressing. The Family member stated she had changed the resident dressing last night. Record review revealed Resident #2 had muscle tissue debridement performed by surgical excision of devitalized subcutaneous muscle on 08/15/23. Observation on 08/26/23 at approximately 12:30 PM revealed Resident #2 had no date on the left heel dressing. Observation revealed the family member had removed Resident #2's dressing because the bottom of the dressing was saturated with pink/brown fluid. The family member had check the bag of supplies given to her by Resident #2's left heel pressure ulcers had shown the top two layers of the skin was absent and draining clear fluid towards the bottom of the heel, and black necrotic (dead) tissue on top. The pressure ulcer was approximately (L)3cm x (W)3cm x (D) 0.5cm. Interview on 08/26/23 at 1:17 PM with Wound Care Nurse revealed Resident #2 was to receive wound care for her left heel twice weekly on Tuesdays and Fridays and as needed if the dressing become dislodged. She stated she would be responsible for Resident #2's scheduled dressing changes and the floor nurses were responsible for as needed and weekend dressing changes. She stated the left heel was unstable (there may been [NAME]/ dead tissue, but you need to see the bed to accurately stage it). She stated family was not allowed to provide wound care to residents because it can delay healing and she was not aware that family was providing wound care for Resident #2. The Wound Care Nurse stated she did complete in-services on wound care in the last month. Interview on 08/26/23 at 1:56 PM with LVN A revealed Resident #2's left foot has an unstageable ulcer with the bottom edges open with drainage. He stated the family was usually good at keeping up with the wound care. He stated the family was not supposed to provide wound care because the resident would pose the risk of infection. LVN A stated he had completed in-services on wound care in the last month. Interview on 08/27/23 at 3:57 PM with the Wound Care Physician revealed Resident #2 was admitted with a left heel pressure ulcer. She stated Resident #2 was seen on 08/08/23, 08/15/23, and 08/22/23 was admitted with a deep tissue injury ulcer of the left heel and was a blood blister which meant the wound was at a muscular level. She stated the wound on the left heel was unstageable (will be at the muscular or the bone level). She stated unstageable was somewhere between stage 3 or 4. The Wound Care Physician stated the Left heel was at the 50% slough and granulation Unstageable. She stated the dressing changes was on Tuesday and Friday and prn if dislodged. She stated she was not aware that family was providing wound care and given supplies to complete the intervention. The Wound Care Physician stated Resident #2's left heel was to be always covered because it had sanguineous drainage coming from the wound. She stated the risks of the family members performing wound care for Resident #2 could cause an infection and delayed wound healing. Interview on 08/27/23 at 6:38 PM with the DON (Director of Nursing) revealed Resident #2 was being treated for wound care on the left heel. He stated the family was not allowed to provide wound care to Resident #2. He stated he was not aware that family was providing wound care to Resident #2. The DON stated, the nurses are the only employees allowed to do wound care for the residents. He stated the treatment nurse was responsible for wounds during the week and the floor nurses were responsible for wound care on the weekends. He stated the wounds were supposed to be covered all times. The DON stated the risks of allowing a family member provide dressing changes could delay healing. 2) Record review of Resident #3's MDS assessment dated [DATE], reflected she was an [AGE] year-old male, who had a current admitted to the facility on [DATE]. The resident's diagnoses included presence of left artificial hip joint, post covid-19, anemia, fall, peripheral vascular disease, cutaneous abscess of the right limb, chronic kidney disease, heart failure, presence of cardiac pacemaker, sinus syndrome, and need for assistance with personal care. The resident had a BIMS score of 15, he was cognitively intact. He required limited assistance of one person with ADL's and was incontinent of both bowel and bladder. He had limited mobility in the lower extremities and required partial/ moderate assistance. Record review of Resident #3's Care Plan dated 07/27/23 revealed he had peripheral vascular disease- right 1st metacarpal joint and treatment should be followed per doctor orders. Review of Resident #3's Physician's Orders dated 07/10/23 and 07/19/23 (respectively) revealed wound care orders for the following. 1. Start Date: 08/02/23 wound care- once daily cleanse right 1st metatarsal joint with normal saline, pat dry, apply Santyl, apply derma blue foam, cover with dry dressing 3 times on Monday, Wednesday, and Friday and as needed if became dislodge. 2. Start Date: 08/02/23 PRN wound care- cleanse right 1st metatarsal joint with normal saline, pat dry, apply Santyl, apply derma blue foam, cover with dry dressing 3 times on Monday, Wednesday, and Friday and as needed if became dislodge. Review of Resident #3's electronic Treatment Administration Record (eTAR) and eTAR Notes, dated August 2023 revealed when the wound care treatment was performed the nurse would indicate this with her initials. According to the eTAR wound care start date was 08/02/23 and was provided on the right 1st metatarsal joint. The eTAR revealed wound care had not been completed on 08/25/23. Review of nurse's notes revealed Resident #3 did not refuse wound care in August 2023. Observation on 08/26/23 at 9:13 PM with the Wound Care Nurse revealed Resident #3's dressing on his right 1st metatarsal joint was dated for 8/24. The wound dressing appeared to look old and the edges were pulled up. She had cleaned the wound with normal saline and had applied a dressing dated for 8/27. The wound had shown signs of healing with approximated edges, skin around the wound was yellow and pink. Interview on 08/26/23 at 1:17 PM with the Wound Care Nurse revealed Resident #3's Right toe dressing was to be changed three times a week on Monday, Wednesday, and Friday. She stated Resident #3 should have had wound care done on 08/25/23 and because the wound dressing was labeled 08/24/23 then wound care was not done on the 08/25/23 as ordered. Wound Care Nurse stated she was responsible for providing wound care Monday- Friday and floor nurses was responsible Saturday and Sunday and in her absence during the week. Wound Care Nurse did confirm she was at work on 8/25/23. She stated the risk were delayed wound healing. The Wound Care Nurse stated she had received an Inservice on medication administration in the last month. Interview on 08/27/23 at 3:57 PM with the Wound Care Physician revealed Resident #3 was seen on 08/08/23, 08/15/23, and 08/22/23. She stated, Resident #3 has a right 1st metatarsal joint wound due to peripheral vascular disease. Order for ointment Monday, Wednesday, and Friday and prn if the dressings dislodged or soiled. The Wound Care Physician stated the risks of not receiving wound care on ordered days would delay wound healing. Interview on 08/27/23 at approximately 6:38 PM with DON (Director of Nursing) revealed Resident #3 was seen for wound care. He stated the resident was ordered to receive wound care on right 1st metatarsal joint on Mondays, Wednesdays, Friday, and as needed when dressing had become dislodged. He stated the expectation for staff was to use the correct date for dressing every time the dressing was changed. The DON stated the date was applied to a wound dressing was to ensure wound care had been provided for that day. He stated the nurses were responsible for ensuring the dressing change was completed. He stated the risks of not performing wound care for the resident as ordered could lead to delayed wound healing. The DON stated the staff had received an Inservice on wound care in the last month. Interview on 08/27/23 at approximately 6:45 PM with the Administrator revealed she had spoken with the Wound Care Nurse and 08/25/23 was a missed date on eTAR for Resident #3. Interview on 08/27/23 at approximately 6:46 PM with the DON revealed missed dates that were not documented on the eTAR would put Resident #3 at risk for delayed healing. 3) Record review of Resident #4's MDS assessment dated [DATE], reflected she was an [AGE] year-old female, who had a current admitted to the facility on [DATE]. The resident's diagnoses included benign neoplasm, history of venous thrombosis, type 2 diabetes, depression, hypothyroidism, hyperlipidemia, aortic valve stenosis, and anxiety disorder. The resident had a BIMS score of 6, indicating severe cognitive impairment. She had required extensive assistance of one person with ADL's and was incontinent of both bowel and bladder. Record review of Resident #4's Care Plan dated 07/27/23 revealed she had a potential for skin breakdown due to: cognitive deficit, urinary in continence, and bowel incontinence. Staff were to minimize exposure to moisture and assist with toileting or provide incontinence care. Review of Resident #4's Physician's Orders dated 08/22/23 revealed wound care orders for the following; 1. Start Date: 08/22/23 wound care- once daily cleanse right upper buttocks with NS, pat dry, apply collagen powder, cover with dry dressing daily and as needed if became soiled/dislodge. 2. Start Date: 08/02/23 as needed wound care- as needed cleanse right upper buttocks with NS, pat dry, apply collagen powder, cover with dry dressing daily and as needed if became soiled/dislodge. Review of Resident #4's electronic Treatment Administration Record (eTAR) and eTAR Notes, dated August 2023 revealed when the wound care treatment was performed the nurse would indicate this with her initials. According to the eTAR wound care start date was 08/22/23 and was provided on the right upper buttocks. The eTAR revealed as needed wound care had not been added or completed on 08/27/23. Review of nurse's notes revealed Resident #4 did not refuse wound care in August 2023. Interview and observation on 08/27/23 at 9:42 AM with Resident #4 stated she was in pain on her bottom. The Wound Care Nurse had asked Resident #4 if she wanted pain medication. The resident had refused at that time, but as the nurse was turning the resident the resident yelled ouch, ouch and stated she was in pain on her bottom, and she could not be turned no further. The resident requested her pain medications. The Wound care nurse stopped and informed the floor nurse resident need for pain medication. Observation on 08/27/23 at 9:53 AM of Wound Care Nurse and CNA C revealed Resident #4 tolerated the body turn but complained of pain on her bottom. Resident #4 was given pain medication. There were no dressing on the resident's right upper buttocks. The nursed had opened the brief to look for the dressing, but there were no dressing in the brief or on the resident's bed. The Wound was open and red with underlying tissue exposed at approximately (L) 2cm x (W) 3cm. The resident had asked, is that what hurt so bad and Wound Care Nurse responded by saying, you have an open sore on your bottom. The Wound Care Nurse and CNA C had proceeded to provide incontinent care to the resident because her brief was wet. Interview on 08/27/23 at 10:13 AM with LVN B revealed she must clean Resident #4 very often because of how Resident #4 would slide down in her chair and incontinent care causes dressings to become dislodged. LVN B stated the last time she had provided wound care was 08/26/23 after it had gotten dislodge, but she did not have documentation of the time. The nurse stated she did not chart the prn wound changes because she just does not. However, she said the last charted wound change was for 08/26/23 at 9:42 AM. She stated Resident #4's wound was located on her coccyx area in between the glutes at the top with redness around the open with jagged edges. She stated the resident had voiced and exhibited pain regarding her wound. She stated when she gets the wound cleaned, she voices that she is in pain and will say ouch. She stated she was not aware of the resident wound being uncovered. LVN B stated the wound was not supposed to be uncovered, it was to always remain covered. She stated the resident was to receive daily and prn when dressing dislodge. The cna will let the nurse know when the dressing dislodges. She stated if Resident #4 wound was not covered, the risk had posed infection and delay of wound healing. She stated the last skin assessment on the resident was yesterday 08/26/23 and she does not recall the last time the resident was seen by a physician. She stated the wound looks the same as it did when wound care first had begun. She stated whenever staff would inform her of an uncovered wound she would immediately to clean and cover the area. She stated the resident had not voiced that she was not receiving wound care or that her wound was not covered. She stated she had received in services on wound care in the last month. Interview on 08/27/23 at approximately 10:30 AM with CNA C revealed she was caring for Resident #4. She stated Resident #4 had wounds on the right side below the coccyx area. She stated Wound Care Nurse or LVN B provide wound care. She stated the wound was supposed to be always covered. She stated she had noticed this morning around 8 am the dressing was missing, and it was not inside the resident brief at that time. CNA C stated she did not know how long Resident #4's dressing had been uncovered. She stated she did not inform LVN B immediately about the wound being uncovered because breakfast trays were already being passed. CNA C stated she was rushing to get Resident #4 up and dressed and to the dining area. She stated she would inform LVN B once she had brought the resident to her room. She stated when Resident #4's wound was uncovered or soiled, she was supposed to notify LVN B immediately after. CNA C stated she had completed in services on wound as it related to providing incontinent care. She stated the risks for leaving a wound uncovered could cause an infection. Interview on 08/27/23 at 10:55 AM with the Wound Care Nurse revealed the wound care physician would come on Tuesday and she rounds with her. She stated Resident #4 was seen by the wound care physician. She stated Resident #4 had moisture associated skin damage. She stated it was typically diagnosed for residents with incontinent or residents with yeast folds. She stated the wound was located on the upper buttocks but was not a pressure wound because it was moisture associated. She stated the wound was located on the right upper buttocks. She stated the wound was painful for the resident during the time of wound care that was performed. She stated the resident had not experienced pain from her wound prior to today. She stated the resident received wound care daily. She stated the resident can verbalize needs but has moments of confusion. She stated she completes wound care during the week for Resident #4 and the floor nurses would complete wound care on the weekends. She stated the resident's wound was not covered when she went to perform wound care. She stated the resident's wound was to be covered due to daily wound care and she was supposed to have a dressing on her wound. She stated if the dressing had become dislodged a new dressing was supposed to be applied. She stated she did not know the approximate dimensions but said her wound was better. She stated if the CNA saw the residents dressing was off Resident #4 right upper buttocks, the nurse should have been notified to place a dressing on the wound. She stated there was a risk of infection because the wound was open and could deteriorate. She stated the wound had minimal redness. She stated the minimal redness could also be from her having an open wound. Interview on 08/27/23 at approximately 3:57 PM with the Wound Care Physician revealed Resident #4 was seen on 8/15/23. She stated Resident #4 wound was not a pressure ulcer because the wound was not on a bony prominence. She stated Resident #4 had an upper right buttock wound due to moisture skin damage. Right buttocks orders were daily and as needed. She stated when the dressing had dislodged the dressing needed to get replaced. Wound Care Physician stated the risk of leaving open wounds uncovered would delay wound healing. Interview on 08/27/23 at approximately 6:38 PM with the DON (Director of Nursing) revealed Resident #4 had a wound on the upper right buttocks. He stated the wound was to be covered with dry dressing. The DON stated the orders stated the resident wound was to remain covered with dry dressing daily prn or if it gets dislodged. He stated Resident #4 was at risk for delayed wound healing if the wound was not covered. He stated Wound Care Nurse was responsible for Resident #4 wound care during the week and the floor nurse was responsible for wound care on the weekend. He stated the expectation of staff was to notify the nurse immediately when they see a wound was not covered or dressed. The DON stated the staff had received an Inservice on wound care in the last month. Review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol policy dated April 2018 reflected, The physical will help staff characterize the likelihood of wound healing based on review of pertinent factors' for example: Healing or Prevention Likely: The resident's underlying physical condition, prognosis, personal goals, and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic .

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 primary kitchen where all facility food is prepared. 1. The facility failed to ensure food items were covered, labelled, and dated. 2. The facility failed to ensure food items were kept away from airborne contaminants. 3. The facility failed to ensure raw food items were stored on the lowest shelf. These failures could place 84 of 86 residents, who receive food from the kitchen, at risk for food contamination and foodborne illness. Findings included: Observation on 08/01/2022 at 10:19am revealed fuzzy dust clumps on the door frame and automatic door closer on both doors leading into the kitchen. Dust and fuzz clumps were also observed in the kitchen, on the utensil rack hanging over the food preparation area. A dried yellow substance was observed inside the bottom of the double door refrigerator adjacent to the food prep area. The vents on top of the refrigerator were coated with grease and dust. An interview on 08/01/2022 at 10:25am with the Director of Dining Services revealed kitchen staff were responsible for ensuring the kitchen and equipment are clean and free of any dust and grease buildup. When asked about a cleaning schedule, he said he would ask the Soux Chef. He said it is the kitchen staff's responsibility to ensure all equipment is cleaned regularly and free of any type of contaminant that may get into food. He said any buildup of dust and fuzz could become dislodged and end up in food which could place all residents who receive food from the kitchen at risk of foodbourne illness. An observation on 08/01/2022 at 10:55am revealed five trays of raw Tilapia fish on a portable rack in the walk-in cooler. The fish was not covered, labeled, or dated. Another portable rack contained a tray of five plates each containing three scoops of prepared food, none were labeled or dated. A third portable rack contained a tray of raw Bavarian sausages on top of a tray of cooked chicken. A metal insert containing raw breakfast sausages was observed on a stationary rack without a label or date. An interview on 08/01/2022 at 11:05am with the Sous Chef revealed the prepared plates were mechanical soft meals consisting of fish, potatoes, and broccoli. He said he believed the mechanical soft meals were prepared 07/31/2022 for service on 08/01/2022 but could not be sure when they were prepared. He said he was not sure when the Tilapia was placed on the trays in the walk-in cooler. He said the prepared meal plates should be labeled and dated. He stated the Tilapia should be covered, labeled, and dated to ensure it is good and staff know how old the food is. When asked why the raw sausages were above the cooked chicken on the portable rack, he said he was not sure but would ask the cook about it. He said raw meat should always be stored on the lowest shelf to prevent the posisbility of foodbourne illness. He left the walk-in cooler and returned to say the cook told him the sausages were cooked and could be stored above the cooked chicken. When asked what he thought, he said he was going to check the box to see if the sausages were cooked. When asked what he was going to do with the undated / labeled food items, he said he was going to cook them immediately. In an interview on 08/01/2022 at 11:15am the Director of Dining Services stated there was no need to check the box, the sausages stored on the portable rack above the cooked chicken were raw and should be stored on the bottom shelf rather than over the cooked chicken. He said all food should be properly stored to prevent any contamination or foodborne illness. He said this includes covering, dating, and labeling all food. He said the raw tilapia, prepared mechanical soft meals, sausages, and cooked chicken needed to be discarded because it was not stored appropriately and poses a risk of foodborne illness to all residents eating food from the kitchen. He said he would in-service the Sous Chef and staff immediately. An interview on 08/03/2022 at 8:15am with the Administrator revealed her expectation is that all food coming from the kitchen be stored and prepared in a way that prevents any risk of foodborne illness to residents. She said kitchen staff are responsible for ensuring the kitchen and equiptment are kept clean and sanitary. A record review revealed 26 kitchen staff were in-serviced 08/01/2022 on cross contamination and food safety by the Director of Dining Services. The Sous Chef and Cook were not listed on the sign in sheet for the in-service. A record review of the facility's Cleaning and Sanitizing policy dated 02/01/2022 revealed the purpose of the policy is to prevent foodborne illness by ensuring that all food and non-food contact surfaces are properly cleaned and sanitized to reduce dangerous pathogens to safe levels.all culinary staff are responsible .Sous Chef will preform random walk throughs and records to ensure proper cleaning and sanitizing is taking place. A record review of the facility's Cross Contamination policy dated 02/01/2022 revealed .all foods shall be stored in clean covered containers in a manner to avoid the contamination of food . raw animal foods shall be stored on the lowest shelves .staff will discard food visually observed as contaminated . A record review of the facility's First In / First Out policy dated 02/01/2022 revealed .a food rotation system is essential for storing food to prevent foodborne illness . follow label by use dates . A record review on 08/4/2022 at 12:00 pm of FDA Food Code dated 2017 section: 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TO-EAT FOOD such as fruits and vegetables, (b) Cooked READY-TO-EAT FOOD; 3-305.14 Food Preparation revealed: During preparation, unpackaged FOOD shall be protected from environmental sources of contamination; 4-601.11 Equipment, Food-Contact Surfaces, Nonfood- Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. 4-602.13 Nonfood-Contact Surfaces. Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

Based on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for one (Vista 8 Nurse Medication Cart) of eight medication carts observed for Pharmaceutical Services, in that: LVN A did not continue to count, maintain, or periodically reconcile three medication blister packs of a controlled drug ([MEDICATION(S)] - a schedule II narcotic pain reliever) that remained on the Vista 8 medication cart after Resident #1's discharge from the facility on [DATE]. This failure risks possible drug diversion due to controlled medications accessible to staff after a resident's discharge from the facility. The findings were: Resident #1's closed clinical records indicated the resident was a [AGE] year-old admitted to the facility on [DATE] to Vista 8 - Room 802. Resident #1 had medically complex conditions and diagnoses, including Muscle Weakness (Generalized); Unsteadiness on Feet; Difficulty in Walking, Not Elsewhere Class; Need for Assistance with Personal Care; And Dysphagia, Oral Phase. An MDS assessment dated [DATE] indicated the resident had a BIMS score of 09, which indicate a moderately impaired cognition per staff assessment. The MDS pain assessment indicated Resident #1 received a scheduled and PRN pain medication regimen for occasional pain intensity rated ,d+[DATE] using a numerical rating scale. Resident #1's baseline care plan showed a Left AKA (Above the Knee Amputation) and [CONDITION(S)]/gangrene (dead tissue caused by an infection or lack of blood flow). The baseline care plan interventions included: Physical and Occupational Therapy to strengthen the right lower extremity and body for safe transferring; the bed in a low position; frequent rounding; and call light within reach as fall prevention interventions. High-risk medications identified included [CONDITION(S)], anticoagulant, and pain medication - [MEDICATION(S)]. Record review of Resident#1's Physician's orders dated [DATE] revealed the admitting nurse, RN C, transcribed an order for [MEDICATION(S)] 5 mg tablet [generic] - 0.5 tablet by mouth every 4 hours as needed for Pain. The pharmacy delivered Rx# 099, 84 halved tabs, on [DATE]. Record review of Resident#1's Controlled Drug Receipt/Record/Disposition Form dated [DATE] indicated [MEDICATION(S)] 5 mg 1 tablet was last administered on [DATE] @ 2350 (11:50 PM). The facility failed to provide a copy of Resident #1's PRN (as needed) Medication Administration Record (MAR) for [DATE] upon request by the surveyor. The [DATE] MAR received by the facility only listed scheduled medications and did not show [MEDICATION(S)] 5mg tablets prescribed on a PRN basis, which is requested by the resident as needed for Pain. During an observation on [DATE] at 9:53 AM with LVN A of the Vista 8 nurse medication cart, three medication blister packs wrapped with the matching Controlled Drug Receipt/Record/Disposition Form were discovered in the bottom of the narcotic drawer, separate from other controlled medications. The medication label on the medication blister packs displayed Resident #1's name and reflected Rx# 099 - #1 of 3 (8 half tablets), #2 of 3 (30 half tablets), and #3 of 3 (24 half tablets) with #16 punched out - there were a total of 62 halved tablets. During an interview on [DATE] at 9:53 AM, LVN A said that she wrapped the matching Controlled Drug Receipt/Record/Disposition Form around the three medication blister packs and placed them in the bottom of the drawer about a week ago after learning that Resident #1 had discharged . LVN A could not recall how she learned of the discharge; she thought maybe on the electronic health record (EHR) dashboard. LVN A did not know how long the resident was gone from the facility. LVN A stated the compliance nurse would come through and collect any controlled medications remaining after a resident discharge. LVN A said she had not counted the pills since she placed them at the bottom of the drawer. LVN A stated the risk of not removing the controlled drugs from the medication cart per policy; could forget about the medications, or someone could steal them. During an interview on [DATE] at 10:24 AM, ADON B indicated she generally made daily rounds to ensure expired or unused (after a resident discharge) controlled medications were counted, removed from the medication carts, and delivered to the DON for drug destruction. ADON B said the process of removing drugs was no later than three days after a resident was transferred to the hospital (in case of the resident returns). When asked about Resident #1, ADON B was unsure of the discharge date , then later said it was [DATE]. ADON B denied knowledge of unused narcotics still on the cart. She stated she had not conducted rounds recently to remove controlled medications. She noted the compliance officer had collected controlled medications in the past; however, have informed nurses scheduled on the Vista 8 Unit to notify her to remove drugs from the medication cart. ADON B said the nurses had received training to count pills and do reconciliation. ADON B said the count was supposed to be done for each controlled medication on each shift, including discontinued and unused drugs for discharged residents until removed. On [DATE] at 10:47 AM, ADON B accompanied the surveyor to the Vista 8 Nurse Medication Cart, where the discovered medications remained. ADON B told LVN A that she is to give all unused medications after a resident discharge, including controlled drugs, to ADON B as soon as possible. ADON B and LVN A verified the count of the three medication blister packs of [MEDICATION(S)]. ADON B made a new entry on the Controlled Drug Receipt/Record/Disposition Form with the date, circled the total number of pills, and both nurses signed alongside the count. ADON B stated that she would generally lock controlled drugs in a desk drawer in her office or take them to the DON if not busy but would take them to DON now. The DON met ADON B and the surveyor at her office on the 5th floor. The DON unlocked the door to gain entrance into her office. ADON B and DON confirmed the count of the three medication blister packs of [MEDICATION(S)], and the DON unlocked a cabinet to store the medications. During an interview on [DATE] at 10:56 AM, the DON stated there was no risk for not logging receipt of the medications right away, why would I need to log the medications in right away when we both signed, and we know I received them? When asked what the system was to account for the receipt of all controlled drugs and to prevent drug diversion, it was at that time that the DON logged in the medications brought by the ADON B onto a Drug Destruction Inventory List. The DON stated she is responsible for the control of medication for disposal and must schedule an hour or two on Fridays just to log in medications because she does not always have time. The DON said if she didn't log in the medications upon receipt, liquid medications could spill on them, or a pill could pop out of the blister pack. The DON stated the purpose of the Drug Destruction Inventory List is to account for all controlled medication for destruction. The DON said if a prescription were not on the Drug Destruction Inventory List, the pharmacist, nor anyone else, would know of the medicine, and if it were not on the log, it could go unnoticed or stolen. In an interview on [DATE] at 5:26 PM, the Administrator said the nurses should know to remove discharged residents and discontinued medications from their medication carts. The Administrator said nurses were in-serviced by the DON and ADONs (ADON B - Vista 8 and ADON D - Vista 5, Vista 7) on drug diversion and proper protocols for counting narcotics, destroying narcotics, and managing medication carts on [DATE] to prevent drug diversion or accidental exposure. Controlled medications are given to the DON to log and secure for destruction. Review of the facility's Discontinued Medications, Med Pass policy revised [DATE] stated, in part, the following: Discontinued medication must be destroyed or returned . following established procedures. Review of the facility's Drug Diversion policy dated [DATE] stated, in part, the following: Controlled substances in Schedules II, III, and IV are subject to special handling, storage, disposal, and record-keeping requirements. The Director of Nursing is responsible for the control of such drugs. A physical inventory of these medications will be made at the change of each nursing shift. A review of the facility's Discarding and Destroying Medications, Med Pass policy revised in [DATE] stated, in part, the following: Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident.

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of one vial of [MEDICATION(S)] (TB) PPD serum in the medication room in that: A vial of TB serum was opened but not dated in the medication room. This deficient practice could place staff and residents who receive the TB serum at risk and result in diminished effectiveness. The findings were: Observation on 05/26/2021 at 9:50 a.m. of the medication room revealed a vial of TB PPD serum was opened and had been used and was not dated or initialed. Interview on 05/26/21 at 9:50 a.m. LVN B confirmed the vial was open and the rubber seal breached and was not dated or initialed . She said the vial shoud have been labeled, she didn't say the why risk. Interview on 05/26/21 at 11:20 a.m. the DON revealed that labeling of medications followed manufacturer instructions unless otherwise specifically indicated. When asked what should be done when a vial of TB PPD serum was opened, she said the staff who opened the vial should write the open date. She stated nurses were trained by the DON on the process. She said the ADON was responsible to check the medication carts and the medication rooms for expiration and labeling of medication. When asked what the risk would be when the PPD vial not having the open date, she said it would place resident at risk of receiving PPD with diminished effectiveness. Review of Mantoux [MEDICATION(S)] Skin Test DVD Facilitator Guide (cdc.gov ) (undated) on 05/28/2021 revealed, When you open a new vial, write the date and your initials on the label to indicate when the vial was opened and who opened it .look at the vial label to make sure the vial contains the [MEDICATION(S)] that you want to use, including the [MEDICATION(S)] unit strength. The label should indicate the expiration date. If it's been open more than 30 days or the expiration date has passed, the vial should be thrown away and a new vial used. 05/26/21 at 11:20 a.m. requested the policy for PPD. Not received

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering and securing of medications for 1 (Med Aid Cart 7th Floor North) of 6 medication carts reviewed for pharmacy services. The facility failed to ensure prompt identification of potential diversion of controlled medications when RN A did not report a damaged blister pack of [MEDICATION(S)] TAB 2mg ( Opoid-controlled medication). This failure could place residents at risk result in the loss or diversion of their controlled medications which could result in a delay in medication administration and medical complications. Findings Included: An observation on 05/26/21 at 10:35 a.m. revealed the blister pack for Resident#243 [MEDICATION(S)] TAB 2mg (controlled medication) had 1 blister pack pill area seal broken and was taped over with the pill still in the blister Review on 05/26/21 at 10:35 a.m. of the controlled medication count sheet for Resident#243 [MEDICATION(S)] TAB 2mg reflected that the count was accurate (27 Pills) when compared to the medications in the drawer. Twenty seven pills were in the pack In an interview on 05/26/21 10: 35 a.m. RN A stated she was unaware when the blister pack seal became broken and she was not aware who taped over it. When asked if taping over the broken seal was the normal procedure she stated no, the medication was supposed to be discarded if opened. When she was asked what the risk could be if medication were taped over, she said it could be a potential diversion of the controlled medication. In an interview on 05/26/21 11:20 p.m. with the Director of Nursing (DON), when asked what should be done if a blister pack medication seal was broken, the DON said that the medication should be discarded. When asked what should be done if the medication was a narcotic, the DON said, Ttwo nurses need to discard and sign off the medication. The DON said it would not be acceptable to tape over a blister pack seal that was opened to prevent potential of drug diversion. She said that the nurses were responsible to chech the medication for for taped over blister during the count. Review of the facility's policy titled Storage of Medications, revised April 2019 did not adress the proceure of blester pack taped over.

Based on observation, interview, and record review, the facility failed to store, distribute, and serve food in accordance with professional standards for food safety in two (5th floor and 6th floor) of the facility's kitchens. 1.Dietary Aide B failed to wear an effective hair restraint in the kitchen. 2.Dietary Aide A failed to ensure she did not store her personal items with the facility's clean dietary utensils. 3.The facility failed to ensure trash receptacles were covered while not in use. These failures could affect residents by placing them at risk for food-borne illness and cross contamination. Findings included: 1.Observation on 01/14/20 at 10:13 a.m. of the 5th floor kitchen revealed Dietary Aide B was dumping and emptying trash cans. Dietary Aide B was not wearing a hair restraint and his beard restraint did not cover his mustache. Dietary Aide B had a short mustache and a short haircut. Observation on 01/14/20 at 10:28 a.m. of the 6th floor kitchen revealed Dietary Aide B was dumping and emptying trash cans. Dietary Aide B was not wearing a hair restraint and his beard restraint did not cover his mustache. Dietary Aide B had a short mustache and a short haircut. Interview on 01/14/20 at 11:44 a.m. with Dietary Aide B revealed he was supposesd to wear a hair net at all times while in the kitchen. He stated the hair net had to cover all his hair, including his beard/mustache. He stated his mustache was not covered because he got hot from going and up down the stairs and his hairnet gave him a headache. Review of the facility's Dress Guidelines for Food Service Management and Clinical Nutrition Staff policy, revised (MONTH) 2020, reflected .Procedures: Hair restraints are worn by all when in the kitchen . Review of the facility's Uniform Dress Code policy, revised (MONTH) 2020, reflected .Associates Working with Food. Wear the approved hair restraint when on duty .Restrain all facial hair with a beard net/restraint . The US Food and Drug Administration's Food Code (YEAR) reflected, Hair Restraints 2-402.11 Effectiveness .Food employees shall wear hair restraints such as hats, hair covering or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles . 2.Observation on 01/14/20 at 10:24 a.m. of the 6th floor kitchen revealed a cell phone, personal silver cup, and a coat hanging on a storage rack that contained clean eating utensils and lid covers. Interview on 01/14/20 at 10:26 a.m. with Dietary Aide A revealed the personal items belonged to her and were supposed to be stored on the second floor in her locker. She stated she stored her items on the clean dish rack because she was in the 6th floor kitchen most of the time and she did not have to keep going up and down the elevators. The US Food and Drug Administration Food Code (YEAR) reflected, 6-305.11Designation. (A) Dressing rooms or dressing areas shall be designated if EMPLOYEES routinely change their clothes in the establishment. (B) Lockers or other suitable facilities shall be provided for theorderly storage of EMPLOYEES' clothing and other possessions. Review of the facility's Associate Security Policies for Department policy, revised (MONTH) (YEAR), reflected Policies: Jackets, sweaters, handbags, cellphones and other personal items are to be stored in appropriate locations as defined by management. These items must not be stored in food production or service areas . 3.Observation on 01/14/20 at 10:22 a.m. of the 6th floor kitchen revealed a trash can that was uncovered while not in use. The trash can was half full with trash. There were no staff present in the kitchen at that time. Interview on 01/14/20at 10:26 a.m. with Dietary Aide A revealed trash cans had to have a lid on them when they were not in use. She stated she had left out of the kitchen to put up some dishes. The US Food and Drug Administration Food Code (YEAR) reflected, 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; . Review of the facility's Solid Waste Disposal policy, revised (MONTH) 2020, reflected Policies .During periods of constant use in food production, food service and dish room areas, garbage cans may remain uncovered if the local jurisdiction allows this practice . Interview on 01/14/20 at 2:43 p.m. with the Dietary Manager/Dietitian revealed all hair must be restrained while producing food or anytime staff walked inside the kitchen for food safety. She stated staff personal items should be stored in their lockers to prevent cross contamination and safety in general. She stated no personal items should be stored on storage racks in the kitchen. She stated trash cans should be covered while not in use and for safety and sanitation.

Based on observation, interview and record review, the facility failed to ensure that a resident maintains acceptable parameters of nutritional status for one (Resident #6) of three residents reviewed for excessive weight loss. The facility failed to implement interventions to address Resident #6's 5% significant weight loss or to prevent further weight loss. This failure could affect two residents who received tube feedings by placing them at risk for inadequate nutrition and unplanned weight loss. Findings included: Resident #6's undated face sheet reflected the resident was an [AGE] year-old female initially admitted on [DATE]. The October 2017 monthly physician's orders [REDACTED]. Review of a medical POA form dated 06/08/15 reflected the resident's husband was designated as the POA and the resident's daughter was the alternate agent. Resident #6 was observed on 10/17/17 at 10:25 a.m. sitting in a wheelchair in the activity area. During the observation ADON A described the resident as being cognitively impaired, dependent on staff for all activities of daily living, and received all nutrition via a gastric feeding tube (a tube inserted through the abdomen that delivers nutrition). Physician's monthly orders and treatment records dated October 2017 reflected Resident #6 was receiving one half of an 8 ounce pack of Real Food Blends bolus four times a day and one full pack of Real Food Blends at 46 cubic centimeters an hour continuously at night from 8:00 p.m. to 7:00 a.m. Real Food Blends - a pre-packaged pureed food meal that is fed via a feeding tube. Review of Resident #6's weight records for the past six months revealed the resident's weight on 08/08/17 was 78.5 pounds and was trending up from the previous month's (July 2017) weight of 77.2 pounds. The weight records reflected the resident's weight on 09/02/17 was 74.5 pounds representing a 5% significant weight loss over one month from 08/08/17 to 09/02/17. The residen'ts most recetn MDS was dated 10/06/17 and reflected the resident was 60 inches (five feet) tall and weighed 74 pounds. Review of Resident #6's care plans initiated 04/20/17 and dated reviewed on 10/06/17 reflected the problem of high risk for nutritional deficit was addressed. Goals included weight loss less than two pounds over the next month and reducing the resident's risk of weight loss. Interventions included nutritional assessments, weighing the resident and reporting weight loss to the physician, dietician and responsible party. Review of the RD's nutritional assessment and notes dated 09/18/17 reflected Resident #6 was receiving less than optimal nutrition evidenced by a significant weight loss over one month. The RD notes reflected a recommendation to increase the resident's feeding regimen to 3.5 packs or 4 packs of Real Foods Blend daily to better meet the resident's needs by providing more calories and protein. Review of the RD notes dated 09/22/17 revealed the DON had communicated with the resident's daughter and the daughter had declined to make any changes to the resident's feeding regimen. During an interview with the DON on 10/18/17 at 3:38 p.m. she stated she was aware nurses were concerned about Resident #6's weight loss and the daughter's refusal to allow changes in the feeding to provide more calories and nutrition. The DON further stated the resident's husband had given the daughter full authority to make medical decisions for the resident. When queried about what was planned to address the resident's weight loss, the DON stated, We plan to take care of her as best as we can week by week. The DON stated the consequences of significant weight loss had been explained to the resident's daughter. She further stated the physician was aware of the weight loss and had also explained the importance of increasing the resident's calories and protein to the daughter. The Administrator was present during the interview with the DON on 10/18/17 at 3:38 p.m., and stated a book on best practices had been ordered in an effort to convince Resident #6's daughter to allow the facility to adjust the feeding to provide more nutrition. Prior to exit on 10/19/17 no evidence was provided of when the book was ordered or when it was expected to arrive. An interview with the RD on 10/18/17 at 4:35 p.m. revealed she had communicated her concerns and recommendations to Resident #6's daughter regarding the resident not receiving enough calories to meet her needs. On 10/19/17 at 8:20 a.m. the DON stated she and the Administrator had contacted Resident #6's daughter and informed her of their plans to follow the clinical teams recommendations regarding improving the resident's nutritional status and preventing further weight loss. She stated the resident's physician was involved and ultimately the resident's daughter agreed to allow the resident to receive additional nutrition. Observation on 10/19/17 at 9:45 a.m. revealed LVN F and CNA G obtained Resident #6's weight which was 74.7 pounds. Review of the RD nutritional notes and assessments dated 10/19/17 revealed Resident #6's calorie and protein needs were re-estimated. The RD recommended adding a supplement (MCT oil - medium-chain triglyceride) to the resident's tube feeding formula to increase calories, protein and to better meet the resident's needs. A physician's telephone order dated 10/19/17 reflected one table spoon of MCT oil was to be added to the resident's nightly tube feeding for seven days. If the oil was tolerated two tablespoons would be added to the nightly tube feeding. An interview with Resident #6's primary physician on 10/19/17 at 10:45 a.m. revealed she was aware of the resident's weight loss and agreed with the RD's recommendations. She stated the resident's daughter argued, complained and dictated the resident's care to include selecting the Real Food Blends formula. The physician stated she had explained to the resident's daughter the risk for skin breakdown, and further weight loss was not in the best interest of the resident. The physician further stated she had previously informed the facility's Administrator and DON that if the resident's family did not allow the facility to meet the resident's needs, the resident should not reside in the facility. However, the facility was unwilling to issue a notice of discharge and the daughter continued to refuse to allow any changes to the resident's feeding. An interview with the DON on 10/19/17 at 2:40 p.m. revealed she did not participate in the facility's weekly Nutrition Alert Committee meetings because she had another meeting scheduled. She stated the RD and ADONs participated in the meetings. An interview with the RD on 10/19/17 at 3:10 p.m. revealed there was no documented discussions or plans related to Resident #6's weight loss or nutritional status from the Nutrition Alert Committee meetings. The facility's weight loss prevention and intervention program policy/procedure dated revised September 2014 was provided by the RD on 10/19/17 and identified as current. The policy/procedure reflected when weight loss was identified the Nurse Manager and Dietitian would document notes and proposed interventions during the Nutrition Alert Committee meeting. The policy/procedure further reflected appropriate intervention would be implemented and the resident would be discussed weekly until goals were achieved. Form CMS-672, Resident Census and Conditions of Residents, signed by the DON on 10/17/17 reflected two residents received tube feedings.

Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for one (Resident #10) of one resident reviewed for respiratory care. LVN D failed to check Resident #10's pulse, respirations, and assess lung sounds before and after nebulizer treatment administration. This failure could affect one resident who received nebulizer treatment in the hallway LVN D was assigned by placing them at risk for not receiving the proper assessment to ensure resident was free of respiratory distress. Findings included: Review of clinical records of Resident #10 on 10/19/17 reflected he was a [AGE] year-old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident # 10's physician's orders [REDACTED]. Observation on 10/18/17 at 9:45 a.m. of LVN D administering medication via nebulizer treatment to Resident #10 revealed LVN D put the medication inhalation solution into the face mask and then applied the face mask on the resident. LVN D then turned on the nebulizer machine and stated to resident that the medication administration would take about 10 to 15 minutes and she would be back. LVN D did not take resident's pulse, respirations, assess oxygen saturation level, or assess lung sounds prior to administering the inhalation medication. Observation on 10/18/17 at 10:00 a.m. revealed LVN D going in to Resident #10's room and he was in the bathroom with the nebulizer mask off and sitting on bedside table with machine still running. LVN D shut off the machine and when the resident came out of bathroom and sat in chair beside the bed LVN D checked resident's radial pulse, and respirations and then checked oxygen saturation via a pulse oximeter machine. LVN D did not assess the lung sounds of Resident #10. In an interview with the DON on 10/19/17 at 8:20 a.m. she stated the expectation when nurses are administering an inhalation medication via nebulizer treatment they are to do an assessment of lung sounds, check respirations, pulse, and oxygen saturation level via pulse oximeter before and after administering the medication to monitor for effectiveness and condition of the resident. She stated it was best nursing practice and they did have a policy and procedure. In an interview with LVN D on 10/19/17 at 10:50 a.m. she stated she was aware that she should have done a respiratory assessment of Resident #10 before and after administration of his inhalation medications but she forgot to do so. She stated she was told they were going to put a reminder on the Medication Administration Record [REDACTED]. In an interview with ADON E on 10/19/17 at 11:00 a.m. she stated the nurses were expected to do a respiratory assessment before and after administration of an inhalation medication. She stated LVN D should have assessed Resident #10's lung sounds via auscultation, respirations, pulse, and oxygen saturation via pulse oximeter. She stated there was only one resident (Resident # 10) that was receiving inhalation medication in the hallway LVN D was assigned. Review of the facility's policy Administering Medications through a Nebulizer dated September 2017 provided by the DON on 10/19/17 at 8:20 a.m. reflected: 6. Obtain baseline pulse, respiratory rate and lung sounds. 20. Obtain post-treatment pulse, respiratory rate and lung sounds. The following information should be recorded in the resident's medical record. 4. Pulse, respiratory rate and lung sounds before and after the treatment. Review of Perry & Potter, Clinical Nursing Skills & Techniques 6th edition pages 676 & 677 reflected: Using small -volume nebulizers, definition: Small volume nebulizers provide medications in an aerosolized form that can be inhaled by the client into the [MEDICATION NAME] tree and possibly into the bloodstream through the alveoli and as a result, systemic effects from the medications may occur. Assessment: 4. Assess pulse, respirations, breath sounds before beginning treatment. Establishes a baseline for comparison during and after treatment. ADON E stated on 10/19/17 at 11:00 a.m. that Resident #10 was the only resident receiving inhalation medication in the hallway where LVN D was assigned.

Based on observation and interviews, the facility failed to maintain patient care equipment in safe operating condition for one (first floor, LPE 1) of three Automatic External Defibrillator's (AED). The facility failed to monitor the AED equipment to ensure that it was operational. These failures could affect the four residents on the first floor (LPE1) who were full code, by placing them at risk for not having an operational AED in the event of an emergency. Findings included: Observation on 10/18/17 at 2:00 p.m. at the first floor nurses station (LPE1) revealed the AED when turned on reflected the battery was low. In an interview with LVN A on 10/18/17 at 2:00 p.m. she stated that she did not know how to charge or change the AED battery. She stated they do not check or monitor the AED equipment. She stated she was the charge nurse on the first floor (LPE1). In an interview with LVN B on 10/18/17 at 2:00 p.m. she stated that she did not know how to charge or change the AED battery. She stated they do not check or monitor the AED equipment. In an interview with LVN C on 10/18/17 at 2:00 p.m. she stated she did not know how to charge or change the AED battery. She stated they do not check or monitor the AED equipment. In an interview with RN D on 10/18/17 at 2:15 p.m. she stated she did not know how to charge or change the AED battery. She stated they do not check or monitor the AED equipment. In an interview with the Administrator on 10/18/17 at 2:50 p.m. he stated they had to replace the AED on the first floor and they were checking all the AED's in the building. He stated there were three AED's in the facility, one on each floor. In an interview with the DON on 10/19/17 at 8:10 a.m. she stated they had to replace the battery on the first floor (LPE1) AED due to it was a 5 year battery per the manufacture and it was at the end of the battery life. She stated they had checked all three AED's. She stated they had not been monitoring or checking the AED's. She stated they have implemented a process to check and monitor the AED's per the manufacture guidelines. She stated the manufactures guidelines of monitoring was in their policy and procedure. Review of the facility's policy AED (Automatic External Defibrillator) dated October 2017 and provided by the DON on 10/19/17 at 8:10 a.m. reflected: 2. The program coordinator/designee shall ensure that all issues relating to training, such as scheduling of basic and periodic reviews and record keeping is managed on a continuing basis. 3. The program coordinator/designee will assure that all equipment stock levels are maintained and/or ordered and readiness checks and record maintenance are done. F. Quality Maintenance Program 1. Daily: Nursing personnel completing checks will initial the monitoring form. If abnormalities are detected, remove the AED machine from the storage area and report abnormalities to the DON immediately. 3. Monthly: Twice a month, on the 1st and the 15th, nursing personnel will open the AED lid and wait for the AED to indicate status. 5. Annually: Check the integrity of the pads and circuitry. The Administrator revealed there were four residents on the first floor (LPE1) that were full code status.

Based on observation, interview and record review, it was determined the facility failed to ensure the most recent survey results were readily available for examination by residents and the public. The binders housing the survey results were not easily accessible to residents and the public. This failure could affect the 36 residents, family members, and visitors to the facility in that without ready access to the facility's compliance history, informed decisions were hindered. Findings included: 1) On 09/16/14 at 12:49 PM, a posting area was observed outside of Lawther Pointe West, the building which housed all the certified beds. One of the postings reflected survey results were available in the first floor Administrative offices. On 09/18/14 at 12:56 PM, the Receptionist for the first floor administrative offices was asked where the survey results were located. The receptionist answered she did not know. On 09/18/14 at 1:16 PM, the DON was asked where the survey results were located. The DON stated they were in the Administrator's office. The DON and the surveyor then walked to the Administrator's office; however, the Administrator was not present. The DON then called the Administrator who informed the DON that the survey results were by the receptionist. The DON and surveyor then went to the receptionist who stated she knew where the results were now because she asked the Administrator. At that point, the Receptionist pulled out a notebook which was behind the reception counter top and said here it is. The notebook's contents were not discernable from the counter-top. The content of the notebook was reviewed and had results from previous surveys. The Receptionist and the DON then stated the reception area closed at 5:00 PM each day and a locking window was pulled down to enclose the area where the notebook was kept. On 09/18/14 at 1:28 PM, the DON stated she was also informed by the Administrator that the survey results were also contained in notebooks at each nursing station and confirmed access would be available if one asked for the results. 2) Form CMS-672, Resident Census and Conditions of Residents, signed and dated 09/16/14 by the MDS Coordinator, reflected 36 residents (in certified beds)resided at the facility. .

Based on interview and record review, the facility failed to ensure one (Resident #6) of six residents reviewed for care plans had updated care plans using the results of the assessments to develop and/or revise the resident's comprehensive plan of care. 1) Resident #6 had no updated comprehensive care plan on file since 07/16/13. 2) Resident #1 had no care plan meeting/conference since 12/10/13. This failure affected one (Resident #6) resident and placed 72 additional residents are risk for not having their needs identified and addressed. Findings included: 1) Review of Resident #6's clinical record revealed a [AGE] year-old female who was originally admitted on [DATE], and re-admitted on [DATE]. Review of an MDS assessment, dated 09/07/13, revealed Resident #6's active [DIAGNOSES REDACTED]. There were no current MDS assessments available for review. The MDS also reflected Resident #6's functional status with ADLs as extensive assistance, Two+ (plus) persons physical assist with transfers, bed mobility, dressing, and toilet use. Resident #6's MDS functional range of motion reflected impairment on one side of her upper and lower extremity. Review of an MDS assessment (CAA Worksheet), dated 09/07/13, reflected Resident #6's assessment triggered Cognitive Loss/Dementia, Communication, ADL Functional/Rehabilitation Potential, Urinary Incontinence, Falls, Nutritional Status, Dehydration/Fluid Maintenance and Pressure Ulcer. Review of Resident #6's clinical record revealed a one page comprehensive care plan dated 07/16/13. The care plan only addressed Resident #6's skin tear to her right lower extremity. There was no other care plan on file. Review of a Care Plan Meeting form, dated 12/10/13, reflected Resident #6 had a care plan meeting where her responsible party did not attend. There were no new changes listed. Review of a report provided by the ADM on 04/02/14 at 5: 50 PM, reflected a list of all the residents on the first floor level, who were all private pay residents. The report reflected a pencil written, scheduled Care Plan dates. It reflected Resident #6 to have a Care Plan meeting on 12/10/13, 03/11/14, 06/10/14, 09/09/14 and 12/09/14. The ADM stated it was a plan in place on ensure Care Plans were conducted timely. 2) Interview with ADON E on 04/02/14 at 5:10 PM, revealed Care Plans are completed every 90 days and/or upon significant change of condition. She stated once a care plan meeting is completed, an updated care plan should be in a resident's file that same day. Interview with ADON D on 04/02/14 at 6:27 PM, revealed both ADONs are responsible for developing, revising and updating care plans for all the residents. He added Care Plans are usually updated on the same day after each care plan meeting with the resident's family. In a later interview with ADON E on 04/02/14 at 7:01 PM, she revealed Resident #6's scheduled Care Plan Meeting should have been on 03/11/14. She stated there were issues setting up a convenient time with Resident #6's responsible party. ADON E said she was awaiting for Resident #6's responsible party to inform her of a convenient time when a Care Plan Meeting could be conducted. Entrance conference with the ADM on 04/03/14 at 11:10 AM, revealed the facility census was 73.

Based on interview and record review, the facility failed to assess each resident using the quarterly review instrument specified by the state and approved by CMS at least every three months for one (Resident #6 ) of six residents reviewed for assessments. Resident #6's most current MDS assessment was an annual assessment dated [DATE]. There were no other MDS assessments completed on the resident's clinical record. The failure to complete timely quarterly assessments affected one resident and placed 72 residents at risk for not being properly assessed, which could lead to changes in the resident's health status not being identified and provided with the care and services needed, which could result in a further decline. Findings included: 1) Review of Resident #6's entire clinical record revealed she was a [AGE] year-old female, who was originally admitted on [DATE], and had a re-entry date of 08/27/11. Review of an MDS assessment, dated 09/07/13, revealed Resident #6's active [DIAGNOSES REDACTED]. The MDS assessment also reflected Resident #6's functional status with ADLs as Extensive assistance, Two+ (plus) persons physical assist with transfers, bed mobility, dressing, and toilet use. The functional range of motion reflected an impairment on one side of resident#6 upper and lower extremity. Review of a Care Plan Meeting form, dated 12/10/13, reflected Resident #6 had a care plan meeting, and the responsible party did not attend. There were no new changes listed. 2) Interview with the Administrator on 04/03/14 at 5:26 PM, revealed MDS Staff Coordinator A is responsible for completing MDS assessments for residents whose payer source is Medicaid and Private pay. The ADM stated MDS Staff Coordinator A is a part-time employee who worked on some evenings and weekends. The Administrator stated even though Resident #6 was a private pay resident, her MDS assessments should have been current. The ADM stated MDS Staff Coordinator A had been attempting to catch up with completing all MDS assessments. MDS Staff Coordinator A was not present at the facility on this date. Interview with the DON on 04/03/14 at 6:24 PM, revealed even though Resident #6 was a private paying resident, her MDS assessment should still be completed just as other residents, whose payer sources were Medicare or Medicaid. Entrance conference with the ADM on 04/03/14 at 11:10 AM, revealed the facility census was 73.