Every finding on record at Coryell Health Rehabliving at the Meadows

Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and communicable disease and infections for 4 (Resident #35, Resident #52, Resident #84, and Resident #88) of 8 residents and 1 of 1 laundry room reviewed for infection control practices, in that: The facility failed to ensure CNA C performed hand hygiene while seated with Residents #88 and #52 during lunch and while assisting Residents #35 and #84 during the lunch meal on 02/10/2026.The facility failed to monitor and ensure laundry room practices were followed to prevent the spread of infection. in laundry room was observed unclean with thick lint clusters behind and around the dryers; staff failed to ensure the washing machine was being sanitized after washing soiled linen from a TBP room. These failures had the potential to place residents at risk for cross contamination and healthcare associated infections.Findings included: 1.During an observation of the secured memory care dining room on 02/10/2026 between 12:03 p.m. and 12:41 p.m., C.N.A C was observed assisting with the lunch meal and feeding Residents #35 and #84 without performing hand hygiene. At 12:03 p.m., C.N.A C sat at a table with Residents #52 and #88 and used a paperclip to scrape under his fingernails, push up his cuticles, and blow nail debris in the direction of the table. He performed hand hygiene, then reached into his pocket, removed a pen, wrote on his hand, and returned the pen to his pocket. He wiped crumbs from a table with his bare hand and continued picking at his fingernails. He rubbed his nose and mouth with both hands, walked down the hallway, scratched his hair, and entered the employee lounge. At 12:14 p.m., C.N.A C returned to the dining room and continued picking at his fingers. He touched Resident #35's wheelchair and clothing without performing hand hygiene. At 12:17 p.m., he touched Resident #84's plate and retrieved silverware to assist with feeding without performing hand hygiene. At 12:18 p.m., he touched Resident #84's wheelchair, straw in drink, and shirt while holding a fork and feeding the resident without performing hand hygiene. At 12:20 p.m., he rubbed his face and did not perform hand hygiene. At 12:24 p.m., he yawned into his hand, rubbed his face, touched Resident #35's plate, removed utensils, and assisted with feeding without performing hand hygiene. At 12:26 p.m., he wiped his nose with his thumb, picked up a fork to feed Resident #84, and then resumed feeding Resident #35 without performing hand hygiene. At 12:29 p.m., he touched Resident #35's wheelchair and shirt and continued feeding without performing hand hygiene. At 12:32 p.m., he touched Resident #35's bare arm and hand, touched an earring in his ear, and resumed feeding without performing hand hygiene. At 12:39 p.m., he touched Resident #84's bare hand and then fed Resident #35 without performing hand hygiene. During an interview on 02/10/2026 at 12:41 p.m., C.N.A C stated he was agency staff and had been trained in hand hygiene. He stated he knew he should wash his hands before entering a resident's room or assisting with feeding. He stated he used hand sanitizer after picking his nails and touching his face. When asked why he did not sanitize between feeding residents or after touching wheelchairs, clothing, or skin, he stated he did not think he needed to because he did not directly touch the residents' food. He apologized and stated he did not think performing nail care at the table was inappropriate because the residents had not yet been served. During an interview on 02/11/2026 at 9:24 a.m., LVN E stated she had been trained in hand hygiene and that staff were expected to perform hand hygiene anytime they touched a resident, before feeding, and before and after handling a resident's food. She stated failure to do so could cause illnesses such as MRSA, flu, or colds. During an interview on 02/11/2026 at 9:30 a.m., C.N.A D stated she had been trained in hand hygiene and sanitized her hands anytime she touched a resident, delivered a meal tray, entered or exited a room, or provided care. She stated staff were expected to sanitize before feeding, after touching a resident, and when moving between residents to prevent cross contamination which could make residents sick. During an interview on 02/11/2026 at 9:39 a.m., the ADON stated she had been trained in hand hygiene and that staff were expected to perform hand hygiene before and after assisting a resident, between passing meal trays, and after touching a resident. She stated it would not meet expectations for C.N.A C to clean underneath his fingernails at a table with residents or to fail to sanitize after touching a resident's clothing or skin before feeding. She stated that proper hand hygiene, particularly during feeding, was important due to infection control concerns and not wanting to spread germs or bacteria that can make the residents sick. During an interview on 02/11/2026 at 9:49 a.m., the DON stated she had been trained in hand hygiene and that staff were expected to sanitize between patient care tasks, when entering and exiting rooms, and between handling trays or food. She stated failure to do so could cause the spread of pathogens, which could make the residents sick. She stated it would not meet expectations for staff to perform personal nail care at a table with residents or fail to sanitize after touching a resident's body, clothing, or dining room surfaces. She stated she intended to contact the agency to request hand hygiene training before CNA C returned to the facility. During an interview on 02/12/2026 at 8:30 a.m., the ADM stated she had trained staff on proper hand hygiene and expected staff to wash hands with soap and water if visibly soiled and use hand sanitizer before and after donning gloves, providing care, touching a resident, touching their own body, or touching multiple surfaces. This was important due to infection control concerns of not wanting to spread germs, which could lead to an outbreak and make residents sick. The ADM stated C.N.A C's behavior on 02/10/2026 did not meet expectations and that she placed him on the Do not Rehire list. 2. During an observation on 02/11/26 at 02:04 p.m., in the one and only laundry room, one staff member was observed working with both clean and soiled linen. The areas around the dryers were observed unclean with lint and other items which included hangers, wood block, sock/clothing items, and what appeared to be a duster that had fallen behind the machine. Behind the dryers appeared an inch thick film of lint on the machines in addition to the items that had fallen behind the machines. An observation around the washing machines there was no observed chemical sanitizer in use or available. During an interview on 02/11/26 at 02:15 p.m. with the LA, she stated that when clothing came in from a TBP room or from anyone on any contact isolation, they arrived in yellow bags and are washed in hot water. She stated that after the items are washed the machines were not sanitized and they simply continued to wash the next residents' items. She stated she believed the machine remained clean since it used hot water. The LA stated the washing machines were only cleaned once a week with a TIDE product and not a chemical sanitizer. The LA stated there was no tracking that the facility used for cleaning to provide evidence of sanitation. She stated they did not use cleaning logs, or lint logs; they just cleaned daily. The LA stated that the housekeeping staff was in charge of cleaning the laundry room and ensuring it was kept in sanitary condition. She stated maintenance was responsible for pulling the machines forward so that lint and debris or items could be cleaned from behind it. She stated she did not know when the last time maintenance went in to pull the machines and allowed them to clean behind them. She stated it was the expectation that the laundry room remained clean and a potential negative outcome of not sanitizing the machines after contamination from TBP clothing would be cross contamination and the ability to transfer infections if the clothing is not processed correctly. During an interview on 02/11/26 at 02:18 p.m. with the HSK, she stated there was no checklist for housekeeping that monitored cleaning and sanitation practices. She stated she did not know the machines, to include the dryer, were supposed to be cleaned from behind, and she was unaware that it was maintenance who assisted. The HSK stated that what was observed with the lint and other items accumulating around the machines that day on the floor did not meet her expectations. She stated a potential negative outcome was that dust and particles could get on clean clothing and trigger residents' allergies. The HSK stated that if clothing is coming from a room that is excessively soiled or from certain precautions such as MRSA that it was the expectation that the machines are sanitized after. She stated she was not sure why staff was saying they did not sanitize the machines after clothing was washed from rooms with special precautions. She stated that could result in cross contamination. During an interview on 02/12/26 at 03:38 p.m. with the MMD, she stated it was her expectation that the laundry room be cleaned daily to maintain a sanitary environment. She stated it is the responsibility of the laundry attendants to clean the laundry room and to clean behind the dryers. She stated maintenance can assist with pulling the machines out, but the attendants must clean it. The MMD stated failure to clean and remove lint and debris buildup could cause allergies and could pose a fire risk. She stated that it was expectation that the HSK was going into the laundry room daily to do spot checks and conducting weekly full inspections. The MMD stated it was her expectation that the washing machines were sanitized daily, and that if clothing was washed from an isolation room or special precaution room it should be sanitized after that load before the next use. She stated the method used is a Fuzion Clorox based spray that should be sprayed in the machine, they should wait for the appropriate kill time to pass and then wipe down. She stated failure to sanitize the machines after exposure to clothing from an isolation or special precaution room could result in other residents getting sick. She stated after observing the images of the conditions of the laundry room they did not meet her expectations for a sanitary environment. Training documentation was requested from the MMD for in-services provided to laundry staff on the sanitizing procedures for the washing machines and maintaining a sanitary environment; the MMD stated there was no training available that had been completed with staff. During an interview on 02/12/26 at 04:02 p.m. with the ADM, she stated it was her expectation that the laundry room was cleaned daily, and as needed, when soiled. She stated a negative outcome to lint behind a dryer would be the potential for a fire. She stated it was the responsibility of the laundry attendants to ensure a clean and sanitary environment. She stated she did not believe the washing machines needed to be sanitized because it was her understanding that they were cleaned as clothing was washed with the soap and hot water. She stated she did not oversee laundry services. She stated she would need to review the policy to determine the expectations. After reviewing images taken on 02/11/26 in the laundry room, the ADM stated that it did not meet her expectations of a sanitary environment. Record review of the facility policy Handwashing/Hand Hygiene, revised October 2023, reflected that the facility considered hand hygiene the primary means to prevent the spread of healthcare associated infections and required staff to perform hand hygiene immediately before touching a resident, after touching a resident, and after touching the resident's environment. Record review of the facility's in service training titled Infection Control dated 10/24/2025 reflected staff were trained in hand hygiene, including Your 5 Moments for Hand Hygiene, which required cleaning hands before touching a patient, after touching a patient and their surroundings, and after touching any object or furniture in the patient's immediate environment. Review of the facility Laundry Dryer Safety & Laundry Area Care Policy effective 01/01/26 reflected: Purpose To ensure safe operation of laundry dryers and maintain a clean, sanitary laundry environment in order to prevent fire hazards, ensure infection control, and comply with Life Safety Code and regulatory standards. Scope This policy applies to all Environmental Services staff, laundry personnel, and any facility staff responsible for operating laundry equipment or maintaining the laundry area. Policy Statement The facility is committed to maintaining a safe and sanitary laundry operation. Dryers and laundry equipment shall be operated, maintained, and monitored in accordance with manufacturer guidelines, Life Safety Code requirements, and facility safety standards. Fire prevention, equipment maintenance, and environmental cleanliness are essential components of laundry operations. Preventative Maintenance EVS Supervisors shall coordinate with Maintenance to ensure: Dryer panels are routinely removed and cleaned. Internal lint accumulation is removed. Equipment is serviced per manufacturer recommendations. Laundry Area Environmental Care The laundry area must be maintained in a: Neat Clean Sanitary Clutter-free condition At all times. Routine Cleaning & Disinfection Laundry areas and equipment shall cleaned in the following way: Empty trash receptacles Clean horizontal surfaces Spot clean vertical surfaces Dust mop floors Damp mop floors Environmental Cleaning – Laundry Area Laundry areas must be cleaned daily and when visibly soiled, including: Sorting tables Machines Carts Floors Door handles Hampers EPA-approved disinfectants must be used.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure the kitchen dishwasher contained sanitizer. The facility failed to ensure expired items were removed from the reach in refrigerator in the dining room containing residents' beverages. (individual milk cartons with best by date of 02/08/26). The facility failed to ensure food remained off the ground in the walk-in freezer. (individual serve cups of ice cream). The facility failed to ensure CK A, CK B, and CK H properly sanitized a food thermometer before and after use when taking food temperatures for lunch service on 02/10/26. The facility failed to ensure DA wore a hairnet while in the kitchen during meal preparation for lunch service on 02/10/26. These failures could place residents who received prepared meals from the kitchen at risk for foodborne illness and cross-contamination.The findings included: During an initial tour of the kitchen and dining room on 02/10/26 at 08:27 a.m. the following was observed:In a walkthrough with the ND, he was asked to run the dishwasher to test the sanitizer. It was ran and the chemical strip returned indicating no sanitizer was being released into the dishwasher. It was then observed that the sanitizer container to the dishwasher was empty. The ND stated the sanitizer was empty and he would need to place a call to have some ordered since they did not have any more. ND was observed placing the call to order sanitizer.The walk-in freezer contained multiple single-serve vanilla ice cream cups on the floor.The reach in refrigerator contained multiple single-serve milk cartons with a best buy date of 02/08/26. During an observation on 02/10/26 at 10:34 a.m. in a follow up to the kitchen for pureed food observation, CK B was observed taking the temperature of a chicken gumbo without sanitizing the thermometer probe before use. CK B was then observed wiping the thermometer probe with a dry rag before closing it and putting it away without sanitizing it. During an observation on 02/10/26 at 11:00 a.m. in a follow up to the kitchen for pureed food observation, CK A was observed pulling a thermometer out of his pocket to take the temperature of ravioli (no sauce) that had just finished cooking. The thermometer probe was not sanitized prior to using it on the ravioli. The thermometer was then observed left opened sitting on top of the prep station countertop. CK A then pureed ravioli with Marinara sauce and after finishing the puree was observed grabbing the thermometer from the counter and taking the ravioli puree temperature without sanitizing the thermometer probe. After taking the temperature of the pureed ravioli CK A was observed wiping the thermometer probe with a dry rag taken off the prep station counter and then using it to take the temperature of a soup. During an observation on 02/10/26 at 11:52 a.m. during lunch service in the main dining room, CK H was observed wearing gloves throughout the entire service while serving residents food from the steam table. CK H was observed completing several different tasks without changing his gloves or washing his hands. CK H was observed taking food temperatures from the steam table then wiping the thermometer probe with a dry rag and not sanitizing it. CK H recorded the temperatures in a logbook, took temperatures of other food items, but did not change gloves while in contact with different surfaces. During an interview on 02/10/26 at 11:11 a.m. with CK A, he stated that he was supposed to sanitize the thermometer probe with an alcohol wipe before and after use. CK A stated there were stations around the kitchen that contained alcohol wipes, and pointed to an area near the prep station across the ovens where a small bin hung containing alcohol wipes. CK A stated that a negative outcome of not using an alcohol wipe before and after using the thermometer probe could result in cross contamination and spread of allergens. CK A stated he failed to use the wipes because he forgot and did not like carrying them around in his pockets, but did not remember to grab them from the bin when it was time to clean the thermometer probe. During an interview on 02/10/26 at 11:15 a.m. with CK B, he stated it was the expectation that the thermometer probes be sanitized before and after use. CK B stated he believed they had sanitizing wipes that could be used. He stated a negative outcome of not using alcohol wipes was cross contamination. After the interview CK B was observed asking CK A where the alcohol wipes were located. During an observation and interview on 02/10/26 at 11:17 a.m., the DA was observed entering the kitchen without a hairnet and walking through the food preparation area while food was being prepared for lunch services. DA stated that she had just started 02/09/26 and completely forgot to wear a hairnet. She stated it was the expectation that hairnets were put on before entering the kitchen and failure to do so could result in hair/ allergens getting into the food and cross contamination. During an interview on 02/10/26 at 01:42 p.m. with CK H, he stated that it was the expectation when taking food temperatures that he wiped the thermometer probe with an alcohol wipe before taking the temperature of the next food item. CK H stated he was also required to change gloves between tasks. He stated failure to do each of these food safety tasks could result in cross contamination, and residents had the potential to become ill if not done. CK H stated that the facility emphasized hand hygiene daily. During an interview on 02/12/26 at 02:12 p.m. with the ND he stated it was his expectation that expired items be removed from the refrigerator before its expiration, he stated if they expired on the 8th then it should have been removed on the 7th when referring to the expired milk cartons with the best by date of 02/08/26 that were still in the dining room reach in refrigerator on 02/10/26. He stated it was all dietary staff responsibility to ensure that it was occurring and being checked daily. He stated that it was his expectation that dishes being washed via the 3-compartment sink and the dishwasher included sanitizer, and the dishwasher should include detergent, sanitizer, and rinse aide. He stated that he expected the dishwasher staff, assigned each shift, to ensure sanitizer was always in use at the dishwasher and that it be checked 3 times a day. He stated, ultimately as the supervisor, he was in charge of ensuring all these processes were being carried out. The ND stated that a potential negative outcome of not pulling expired items from the refrigerators would be, health and safety and nutrition could be compromised. In terms of the sanitizer at the dishwasher, he stated, not using sanitizer could result in germs being present on the dishes and could endanger the health and safety of residents. The ND stated that it was his expectation that hairnets were always worn while in the kitchen, and all exposed hair should be restrained by an effective hair restraint which can include hairnet or hat. He stated food items should be stored after delivery so that they are 6 inches off the ground, and after delivery no food items should be on the ground. He stated dietary staff should be checking regularly to ensure if food items fell on the ground they were discarded and not used. He stated his expectation was that gloves were used when working with food, and changed regularly if contaminated. He stated, gloves don't replace handwashing, hands should be washed after gloves are used. He then stated his expectation for the thermometer probes was that they were sanitized before use and after each item was checked for temperature to make sure there was no cross contamination of the food. During an interview on 02/12/26 at 04:02 p.m. with the ADM, she stated that it was her expectation that if staff were in the kitchen they should have a hairnet or beard guard if required. She stated that the thermometer probe should be sanitized in between each use. She stated the procedure for gloves is that in between touching surfaces or changing duties they should be changed. She stated it was her expectation that there should not be any expired items in the refrigerator, and that they be maintained in an area where they can be credited back. When asked about sanitizer for the dishwasher, she stated she was unable to answer in that moment and would need to review the policy before answering. She stated food should not be on the floor. She stated a negative outcome of not wearing a hairnet while food was being prepared had the potential to result in hair getting in the food. She stated a negative outcome of not sanitizing the thermometer probe or changing gloves if changing tasks would be cross contamination. Review of the facility's Policy and Procedure Manual Food Safety and Sanitation policy Chapter 4: Sanitation and Infection Control 4-2 2023 reflected: Policy: All local, state, and federal standards and regulations will be followed to assure a safe and sanitary food and nutrition services department.Procedure:.2. Employeesa. All staff will be in good health, will practice good personal hygiene and will use safe food handling practices. Hair restraints are required and should cover all hair on the head.4. Food Storage (see Chapter 3: Food Production and Food Safety for Food Storage)a. Stored food is handled to prevent contamination and growth of pathogenic organisms.Perishable foods with expiration dates should be used prior to the use by date on the package.Food stored in dry storage will be placed on clean racks at least 6 inches above the floor. Review of the 2022 U.S. Food and Drug Administration Food Code revealed: 2-301.12 Cleaning Procedure. (A)Except as specified in (D) of this section, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under S 5-202.12 and Subpart 6-301. P 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES P and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P(E) After handling soiled EQUIPMENT or UTENSILS; P(F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands. P (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; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. 4-204.117 Warewashing Machines, Automatic Dispensing of Detergents and Sanitizers A WAREWASHING machine that is installed after adoption of this Code by the REGULATORY AUTHORITY, shall be equipped to: (A) .Automatically dispense detergents and SANITIZERS; Pf and (B) Incorporate a visual means to verify that detergents and SANITIZERS are delivered or a visual or audible alarm to signal if the detergents and SANITIZERS are not delivered to the respective washing and SANITIZING cycles. Pf 4-301.12 Manual Warewashing, Sink Compartment Requirements. (A)Except as specified in (C) of this section, a sink with at least three (3) compartments shall be provided for manually washing, rinsing, and SANITIZING EQUIPMENT and UTENSILS. Pf (B)Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf 1. The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and 2. The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Pf 3-304.15 Gloves, Use Limitation. (A)If used, SINGLE-USE gloves shall be used for only one task such as working with READY-TO-EAT FOOD or with raw animal FOOD, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 3-305.11 Food Storage. (A)Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (3) At least 15 cm (6 inches) above the floor.

Based on interview and record review, the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 5 of 8 medication carts (Medication Aide Cart and Nurse Cart for Unit 2, Medication Aide Cart and Nurse Cart for Unit 3, and Medication Aide Cart for Unit 4) reviewed for pharmacy services.The facility failed to record narcotic receipt and reconciliation documentation for the medication aide cart on unit 2, the nurse cart on unit 2, the medication aide cart on unit 3, the nurse cart on unit 3, and the medication aide cart on unit 4 during each shift change.This failure could place residents at risk of drug diversions and could result in missed medication, diminished health and well-being.Findings Include:Review of the Change of Shift Narcotic Count Sheets on the Medication Aide Cart for Unit 2 reflected missing narcotic receipt and reconciliation documentation on 02/07/2026 for the off-going night shift.Review of the Change of Shift Narcotic Count Sheets on the Nurse Cart for Unit 2 reflected missing narcotic receipt and reconciliation documentation on 02/07/2026 for the off-going night shift and on 02/08/2026 for the off-going day shift.Review of the Change of Shift Narcotic Count Sheets on the Nurse Cart for Unit 3 reflected missing narcotic receipt and reconciliation documentation on 02/01/2026 for the on-coming day shift and on-coming night shift, 02/03/2026 for the off-going night shift, and on 02/10/2026 for the on-coming and off-going day shift.Review of the Change of Shift Narcotic Count Sheets on the Medication Aide Cart for Unit 3 reflected missing narcotic receipt and reconciliation documentation on 02/03/2026 for the off-going day shift and off-going night shift.Review of the Change of Shift Narcotic Count Sheets on the Medication Aide Cart for Unit 4 reflected missing narcotic receipt and reconciliation documentation on 02/05/2026 for the off-going day shift.During an interview with LVN G on 02/11/2026 at 2:03 p.m., she stated that it was required for the off-going and on-coming staff to count the narcotic medications and sign the narcotic count sheet. She stated that a negative outcome of not consistently following the narcotic count expectations was a possibility of drug diversion.During an interview with LVN E on 02/11/2026 at 2:12 p.m., she stated that it was required for the off-going and on-coming staff to count the narcotic medications and sign the narcotic count sheet. She stated that a negative outcome of not consistently following the narcotic count expectations was a possibility of drug diversion.During an interview with MA on 02/11/2026 at 2:15 p.m., she stated that it was required for the off-going and on-coming staff to count the narcotic medications and sign the narcotic count sheet.During an interview with LVN F on 02/11/2026 at 2:22 p.m., she stated that it was required for the off-going and on-coming staff to count the narcotic medications and sign the narcotic count sheet. She stated that a negative outcome of not consistently following the narcotic count expectations was a possibility of drug diversion.During an interview with the DON on 02/12/2026 at 12:18 p.m., she stated that it was required for the off-going and on-coming staff to count the narcotic medications and sign the narcotic count sheet. She stated that a negative outcome of not consistently following the narcotic count expectations was a possibility of drug diversion. She stated that she plans on re-educating staff over this expectation. Review of the facility's Controlled Substances policy titled Dispensing and Reconciling Controlled Substances last revised on 11/2022, reflected: Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.

Based on observation, interview, and record review, the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments for 1 (medication cart #1) of 2 medication carts reviewed for pharmacy services. The facility failed to ensure that MC #1 was locked when staff were not present. This failure could place residents at risk of overdose, hospitalization, and pain. Findings included: An observation conducted on 02/04/2026 at 11:30 AM revealed MC #1 unattended and unlocked in the main lobby area. During the observation a resident was observed in the area the MC was located. An observation conducted on 02/04/2026 at 11:40AM revealed staff members walking by the unlocked MC. An interview conducted on 02/04/2026 at 12:58 PM with RN A revealed she had worked at the facility for 5 years. RN A stated she also received training on medication carts which included the 5 rights to medication administration, as well as the protocol for locking the medication carts. RN A stated that if staff walk away from the MC, they should lock it, and keep it locked at all times when not in use. RN A stated that residents could get medications inside of the MC if it was left unlocked. RN A stated it could negatively affect a resident by the potential for harm if ingested. RN A stated she had left the MC unlocked due to an oversight. An interview conducted on 02/04/2026 at 1:20 PM with LVN B revealed she had worked at the facility for almost 1 year. LVN B stated she also received training on MCs which included the process of signing narcotics and keeping the MC locked. LVN B stated if staff turned their back to the MC, not using the MC, then the MC should be locked. LVN B stated if the MC was left unlocked, then residents or other people could have access to the medications in the cart. LVN B stated that residents could potentially poison themselves if they had access to an unlocked MC. LVN B stated the nurses assigned to the MC were responsible for locking the MC. An interview conducted on 02/04/2026 at 1:45 PM with CNA C revealed she had worked at the facility for 1 year. CNA C stated that anyone assigned to the MC was responsible for ensuring the MC was locked. CNA C stated that residents could get medications and potentially get harmed if they had access to an unlocked MC. An interview conducted on 02/04/2026 at 2:38 PM with CNA D revealed she had worked at the facility for 2 years. CNA D stated that MAs and RN/LVN were responsible for ensuring the MC are locked. CNA D stated that staff should lock the MC if they saw it unlocked. CNA D stated if residents had access to the unlocked MC, the residents could potentially take the mediation and it could lead to death. An interview conducted on 02/04/2026 at 2:45 PM with the DON revealed she had worked at the facility for 2.5 years. The DON stated she had received training on RR which included the residents have the right to be free from abuse, neglect, right to privacy, and right to refuse or receive medications. The DON also received training on MC which included to keep the MC locked. The DON stated her expectation for staff was to keep the MC locked, keep the drawers facing the bedrooms, and cart should be locked if not in use. The DON stated residents could enter an unlocked MC and result in them to have access to the medications. An interview conducted on 02/04/2026 at 3:25 PM with the ADM who had worked at the facility for 2.5 years. The ADM stated her policy regarding the MC was that the MC should remain secured when someone was not pulling items in and out of it. The ADM stated her expectation would be for the MC to be locked and secured. The ADM stated that the MA or LVN/RN would be responsible for ensuring the MC was locked. The ADM also stated it could negatively affect the residents if they had access to the unlocked MC, because there would be the potential for residents to retrieve items from the cart that did not belong to them. Record Review of the facility's policy titled Security of Medication Cart dated April 2007 provided the following information: The medication cart should be secured during medication passes. The nurse must secure the medication chart during the medication pass to prevent unauthorized entry. Medication carts must be securely locked at all times when out of nurse's view. When the medication cart is not being used, it must be locked and parked at the nurses st

Based on interviews and records review the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, for one (Resident #1) of two residents reviewed for foot wounds.The facility's Agency CNA put tennis shoes on Resident #1 after being told not to put tennis shoes on Resident #1 who had a blister on the back of her left heel which later became a pressure ulcer.This failure could place residents at risk of discomfort and worsening of foot blister or wound.Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Dementia with behavioral disturbance, DM w/o complication type II Anxiety, Chronic diastolic CHF (congestive heart failure- is a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply.) Chronic obstructive pulmonary disease (Chronic obstructive pulmonary disease (COPD) is an ongoing lung condition caused by damage to the lungs), Dependence on supplemental oxygen, Age related osteoporosis, Dementia without behavioral disturbance, Generalized muscle weakness, Abnormality of gait due to impairment of balance, Benign hypertensive heart disease with congestive heart failure, Sprain of unspecified ligament of left ankle, Unspecified fall, subsequent encounter. Review of Resident #1's quarterly MDS assessment, dated [DATE], reflected a BIMS score of 06, indicating severe cognitive impairment. Section I (Active diagnosis) reflected she had Chronic Pain. Section J (Health Conditions) reflected she had been hurting within the past five days and her pain intensity of 06 on the pain scale 00-10. Section M (Skin Condition) indicated the resident was at risk of developing pressure ulcer/ injuries. Review of Resident #1's quarterly care plan, initiated [DATE] and modified on [DATE], reflected she had blister at her left heel with interventions to off load her heels with a cushion or pillow to prevent skin breakdown on her heels, change dressings as ordered. The care plan also reflected Resident #1 had LTC Pain IPOC, with outcome of pain level maintained at less than moderate. Review of the facility's wounds documentation reflected Resident #1's left heel skin issue was identified on [DATE]. Review of Resident #1's wound notes dated [DATE] completed by the Wound Care Nurse reflected: Type of Injury/ Onset: Pressure ulcer DTILocation of Wound: L HEELWound Dimension:Length: 2.5 cm Width 2.4cm Depth: cmWound Appearance: Tissue Type (estimate%) 15 % Epithelial (the epithelial tissue, primarily the epidermis, that regenerates to cover a wound surface _75 % Granulation (a type of new, pink, soft tissue that forms in the wound bed during the healing process) 10 % Slough (the dead, yellowish, or whitish tissue in a wound that can delay healing) _ % Necrotic Color (refers to the appearance of dead tissue, which is typically brown, gray, or black): pink Review of the facility's grievances revealed a grievance filed by Resident #1's family dated [DATE] and taken by the Administrator which reflected: During the course of last 60 days, a tissue injury was identified on resident's heel. Tennis shoes were not to be worn, and when [Resident #1's] family arrived, she had tennis shoes on. She feels like the communication between nursing administration and line staff should improve. She provided photos of the heel injury. Treatment in place and hospice is aware.What Action Was Taken:Daily document of [Resident #1] dx and what is going on with her on 24-hour report. Set up a care plan meeting with and hospice to ensure we are all on the same page Administrator will attend care plan meeting. Resolved by the Administrator on [DATE] Review of Resident #1's physician's order dated [DATE] reflected: WOUND CARE NURSE TO CHANGE DRSG TO LEFT HEEL ON MON & WED & FRIDAY/ BLISTER/DTI -ON MEDIAL LEFT HEEL/ CLEAN WITH VASHE/ APPLY BETADINE TO HEEL-ALLOW TO DRY/ APPLY ADAPTIC TO AREA/THEN COVER WITH TETRA NET ELASTIC DRSG / PLEASE DATE & INITIAL DRSG. USE HEEL BOOT AT ALL TIMES TO OFFLOAD PRESSURE/ USE LIDOCAINE SPRAY PRIOR TO WOUND CARE TO HELP CONTROL PAIN. Review of Resident #1's progress notes dated [DATE] reflected Resident #1 expired on [DATE]. During an interview on [DATE] at 3:00 pm Resident #1's family stated a fluid filled blister was identified on Resident #1's left heel sometimes in April of 2025. Resident #1's family stated Resident #1 was noted with tennis shoes on after it was communicated with the ADON that Resident #1 didn't need the tennis shoes due to the pressure area on Resident #1's heel. Resident #1's family stated she spoke with LVN A who stated Resident #1 was not supposed to be wearing tennis shoes. Resident #1's family stated she spoke with the CNA on duty that day and the CNA stated she did not know Resident #1 was not supposed to wear the tennis shoes. Resident #1's family stated she took the tennis shoes home. During an interview on [DATE] at 12:09 pm, the Wound Care Nurse stated Resident #1 had a pressure area to her left heel which started as a fluid filled blister and DTI. The Wound Care Nurse stated she heard in conversation that Resident #1's tennis shoes were put on her. The Wound Care Nurse stated there should have been an order for Resident #1 to wear only socks or opened back house shoes. The Wound Care Nurse stated she or the ADON were responsible to put in the order. The Wound Care Nurse stated putting tennis shoes on Resident #1's foot with a pressure area would cause discomfort. The Wound Care Nurse stated the facility had boots ordered, they were offloading Resident #1's heels and providing positioning pillows and wedges and repositioning her every 2 hours and as needed. During an interview on [DATE] at 1:12 pm, the ADON stated, when the blister had started on Resident #1's left heel, she and Resident #1's family had discussed that maybe the shoes were tight. The ADON stated she asked Resident #1's family if it was ok to a house shoe on the Resident #1 and the family agreed. The ADON stated she communicated with staff. The ADON stated 3-4 days after the discussion, an agency staff working with Resident #1 put the shoes on Resident #1 and the family was visiting and saw the shoes on the Resident #1. The ADON stated that was the only time the shoes were put on Resident #1, after that incident the shoes were not in the Resident #1's room. During an interview on [DATE] at 12:57 pm the DON stated it was discussed in a care plan meeting concerning Resident #1 not wearing her tennis shoes. The DON stated, I believe they had asked the family to take the shoes home, but the family didn't. I believe there was a missed communication with the CNAs, the charge nurse was supposed to notify the CNA. I will have to check with the ADON to find out if there was an in-service with the staff not to put the tennis shoes on Resident #1. I don't remember what the wound looked like back in June ([DATE]) but once it was agreed upon not to put the shoes on Resident #1, the staff shouldn't have put the shoe on the resident. Review of facility's in-services for the months of May, June, and [DATE] reflected no in-service regarding Resident #1 not to wear tennis shoe due to pressure areaRequested Skin and wound Care policy from the Administrator on [DATE] at 09:30 am and it was not provided.

Based on interview, and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of three residents reviewed for pain. The facility failed to assess Resident #1 pain level on [DATE] when family reported Resident #1 was hurting and needed pain medication. These failures could place residents at risk of increased pain, hospitalization, and a decreased quality of life.Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Dementia with behavioral disturbance, DM w/o complication type II, Anxiety, Chronic diastolic CHF (congestive heart failure- is a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply.), Chronic obstructive pulmonary disease (Chronic obstructive pulmonary disease (COPD) is an ongoing lung condition caused by damage to the lungs), Dependence on supplemental oxygen, Age related osteoporosis, Dementia without behavioral disturbance, Generalized muscle weakness, Abnormality of gait due to impairment of balance, Benign hypertensive heart disease with congestive heart failure, Sprain of unspecified ligament of left ankle, Unspecified fall, subsequent encounter. Review of Resident #1's quarterly MDS assessment, dated [DATE], reflected a BIMS score of 06, indicating severe cognitive impairment. Section I (Active diagnosis) reflected she had Chronic Pain. Section J (Health Conditions) reflected she had been hurting within the past five days and her pain intensity of 06 on the pain scale 00-10. (0 meaning no pain and 10 meaning worst pain) Section M (Skin Condition) indicated the resident was at risk of developing pressure ulcer/ injuries. Review of Resident #1's quarterly care plan, initiated [DATE] and modified on [DATE], reflected she had a blister on her left heel with interventions to Off load heels with cushion or pillow to prevent skin breakdown on heels, change dressings as ordered. Care plan also reflected Resident #1 had LTC Pain IPOC, with outcome of Pain Level Maintained at Less Than Moderate. Review of Resident #1's physician's orders reflected the following:Hydromorphone 1.5 mg, Oral, Liquid, every 1 hr, PRN pain, First Dose: [DATE] 12:42:00 CDT, Routine Give 1.5 ml = 1.5 mg every one (1) hours as neededFentanyl 12 mcg, Transdermal, every 72 hr, First Dose: [DATE] 6:00 pm RoutineHydromorphone-- 2 mg, Oral, Tab, QID, First Dose: [DATE] 4:00 pm Routine Per HospiceAcetaminophen 650 mg, Oral, Tab, every 4 hr, PRN fever, First Dose: [DATE] 1:26 pm Routine Give TWO (2) tablets of 325 to equal 650 mg total dose for fever Review of Resident #1's narcotic count sheet dated [DATE] reflected Resident #1 was given Hydromorphone 2 mg 2 tabs at 7:31 pm by LVN A. Review of Resident # 1's narcotic count sheet dated [DATE] reflected Resident #1 was given Hydromorphone 5mg/5ml solution at about 8:00 pm by LVN A for break through pain. During an interview on [DATE] at 3:00 pm, Resident #1's family stated Resident #1 was crying of pain at about 6:30 pm on [DATE] and the nurse stated the resident had just gotten her 6:00 pm medication and could not get pain medication until 7:00 pm. Review of Resident #1's pain assessment on [DATE] reflected the following:No actual or suspected pain (Charted at [DATE] 10:46pm)No actual or suspected pain (Charted at [DATE] 11 :42 am)There was no pain assessment noted on [DATE] at about 6:30 to 7:30 pm when Resident #1's family requested pain medication. Review of Resident #1's progress notes dated [DATE] reflected Resident #1 expired on [DATE]. During an interview on [DATE] at 09:04 am LVN A stated, she was not sure of the date but there was a day Resident #1's family requested pain medication, and she told Resident #1's family that Resident #1 had just gotten pain medication at 6:00 pm. LVN A stated Resident #1's family stated Resident #1 did not get pain medication at 6:00 pm. LVN A stated she called the medication aide to confirm, and the medication aide stated she did not give Resident #1 pain medication at 6:00 pm. LVN A stated she gave Resident #1 her pain medication within the time frame, which was an hour before or an hour after. LVN A stated she would have given Resident #1 PRN pain medication as ordered but she was out of the time frame for medication administration. LVN A stated it depends on the day, some days Resident #1's was in so much pain and on other days she was not in pain. LVN A could say how much pain Resident #1 was in on [DATE]. During an interview on [DATE] at 1:55 pm the DON stated if a resident was complaining of pain, it was the expectation of the nurse to assess the resident's pain level. The DON stated not assessing the resident's pain level, they wouldn't be able to know what medication to give the resident or how to treat them. The DON reviewed Resident #1's MAR and TAR for [DATE] and stated Resident #1 was supposed to be assessed for pain every time the nurses administered pain medication. The DON stated Resident #1's schedule Hydromorphone was schedule for 08:00 am, 12:00 noon, 4:00 pm and 8:00 pm so Resident #1 was not scheduled for pain medication at 6:00 pm. Review of facility's policy titled Pain - Clinical Protocol undated reflected: Assessment and Recognition1. The physician and staff will identify individuals who have pain or who are at risk for having pain.a. This includes reviewing known diagnoses and conditions that commonly cause pain; for example, degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without vertebral compression fractures), diabetic neuropathy, oral or dental pathology, and post-stroke syndromes.b. It also includes a review for any treatments that the resident currently is receiving for pain, including complementary and non-pharmacologic treatments.2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain.3. The staff and physician will identify the characteristics of pain such as location, intensity, frequency,pattern, and severity.a. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.4. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation, or repositioning.5. The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls.Monitoring1. The staff will reassess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain.a. Review should include frequency, duration and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities.

Based on interviews and records review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1)of three residents review for medication administration.The facility failed to administer Resident 1's antibiotic on [DATE] as was ordered on [DATE].This failure could place residents at risk of ineffective therapeutic effect.Findings included:Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Dementia with behavioral disturbance, DM w/o complication type II, Anxiety, Chronic diastolic CHF (congestive heart failure- is a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply.), Chronic obstructive pulmonary disease (Chronic obstructive pulmonary disease (COPD) is an ongoing lung condition caused by damage to the lungs), Dependence on supplemental oxygen, Age related osteoporosis, Dementia without behavioral disturbance, Generalized muscle weakness, Abnormality of gait due to impairment of balance, Benign hypertensive heart disease with congestive heart failure, Sprain of unspecified ligament of left ankle, Unspecified fall, subsequent encounter. Review of Resident #1's quarterly MDS assessment, dated [DATE], reflected a BIMS score of 06, indicating severe cognitive impairment. Section I (Active diagnosis) reflected she had Chronic Pain. Section J (Health Conditions) reflected she had been hurting within the past five days and her pain intensity of 06 on the pain scale 00-10. Section M (Skin Condition) indicated the resident was at risk of developing pressure ulcer/ injuries. Review of Resident #1's physician's order dated [DATE] reflected: Cephalexin 500 mg. Oral, cap, every 12 hr (sch), Antibiotic Indication Urinary Tract Infection, first Dose: [DATE] 8:00 pm, Stop Date: [DATE] 7:59 PM, Physician Stop, Routine -do NOT crush or chew Review of Resident #1's Medication Administration Records (MAR) for the month of [DATE] reflected Resident #1's Cephalexin 500 mg. Oral, cap, every 12 hr (sch), was not given on [DATE]. Review of Resident #1's MAR for the month of [DATE] reflected Resident #1's Cephalexin 500 mg. Oral, cap, every 12 hr (sch), was given as followed:On [DATE] at 8:00 pmOn [DATE] at 1:32 pm and at 7:48 pm. On [DATE] at 7:59 am and at 7:24 pm. On [DATE] at 7:51 am and at 7:06 pmOn [DATE] at 8:26 am and at 7:10 pmOn [DATE] at 8:36 am and at 7:01 pm Review of Resident #1's progress notes for [DATE] and [DATE] reflected no documentation of Resident #1 starting an antibiotic on [DATE] or why the ABT was not given on [DATE]. Review of Resident #1's progress notes dated [DATE] written by LVN A reflected: Resident is Day 1 of 7 for start of medication: Keflex for cystitis (is a medical condition that refers to inflammation of the bladder. It is a common infection of the urinary tract, typically caused by bacteria.) Adverse reaction / Side effects: no. If yes, document adverse reaction / side effects below: Medication appears to be_, If ineffective, has PCP been notified To early to see effects resident has only had 2 doses Electronically Signed on [DATE] 01:34 pm. Review of Resident #1's progress notes dated [DATE] reflected Resident #1 expired on [DATE]. During an interview on [DATE] at 2:28 pm, the Hospice Nurse stated she was not aware of Resident #1's ABT not being in the facility or not arriving on time. The Hospice Nurse stated the facility staff were good at communicating with hospice that the medication was not in the E-kit. The Hospice Nurse stated if it was communicated with hospice that Resident #1's ABT was not available, she would have ordered the medication from the nearby pharmacy or ordered the medication to start the following day. During an interview on [DATE] at 3:00 pm Resident #1's family stated on [DATE] Resident #1 was smelling of a foul urine odor. Resident #1's family stated hospice was contacted and an ABT was ordered. Resident #1's family stated hospice confirmed the ABT was ordered, and Resident #1 was starting the ABT on [DATE]. Resident #1 family stated she called on [DATE] and spoke with LVN A and asked about Resident #1's ABT administration. Resident #1's family stated she was told by LVN A that Resident #1 did not get her morning and evening dose of ABT due to the medication not being put in the system. Resident #1's family stated LVN A stated she would put the orders in the computer system. Resident #1's family stated she did not complain to hospice, the DON, ADON or the Administrator because she couldn't process what to say. During an interview on [DATE] at 09:04 am, LVN A stated she couldn't remember the exact incident regarding Resident #1's ABT orders because it has been a while. LVN A stated they may have started Resident #1's ABT the next day or so. LVN A stated it might have been pharmacy issues. LVN A stated they could take the ABT from the e-kit, but there were lot of residents in the facility who also got medication from the e-kit and staff had to wait for the medication to be refilled in the e-kit. During an interview on [DATE] at 10:52 am the DON stated if there is an order for ABT, the nurses were expected to get it from the Cubex (e-kit). The DON stated hospice usually provided the medication once it was ordered. The DON stated, if hospice was unable to provide a medication, the facility provided it. The DON stated she did not recall an instance where Resident #1 was ordered an ABT, and she did not get the medication as ordered or the medication was not provided by hospice. Later the DON stated, she did not know why Resident #1's ABT was not given on [DATE]. The DON stated she would check and see why. The DON stated the expectation was for the nurses to give the initial dose of the ABT from the e-kit /cubex and continue as ordered. The DON stated she couldn't remember from 3 months ago, but the process was to call the pharmacy to find out why the medication was not delivered; if they can't get the medication, they order it from the local pharmacy. The DON stated is Resident #'s ABT was not given as ordered, it should have been documented in Resident #1's progress why the medication was not given, and hospice and the MD should should have been notified. The DON again stated she couldn't find where the ABT was ordered, but the initial dose was given on [DATE]. The DON stated maybe there was an error with when the medication being put in the computer system. The DON stated she couldn't tell who put the medication in the computer system, but the next dose was given on [DATE]. The DON stated not administering an ABT as ordered could have impact on the effectiveness of the medication. Review of the facility's medication errors for the months of May, June and [DATE] reflected no medication error for Resident #1. Review of the facility's policy titled Medication and Treatment Orders revised [DATE] reflected: Policy Statement Orders for medications and treatments will be consistent with principles of safe and effective order writing.Policy Interpretation and Implementation7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order.

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 for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices of cleaning the ice machine, cleaning the microwave, hand hygiene, hair restrained, and clothing sleeves not touching food items were occurring in the kitchen. 2. The facility failed to ensure temperature logs were being completed. 3. The facility failed to ensure labeling and dating of all food items in the kitchen. 4. The facility failed to ensure all items were covered and stored properly. These failures could place residents at risk of foodborne illness. Findings included: Observation on 11/25/24 at 9:10 AM of the dining room kitchen entry door revealed a sign posted stating hair restraints required upon kitchen entry, the bin on the wall that was below the posted sign that was labeled for hair nets was empty of any hair restraints. Observation on 11/25/24 at 9:13 AM of the kitchen revealed the microwave had what appeared to be dried food particles and debris stuck to the inside of the roof. Observation on 11/25/24 at 9:15 AM of the kitchen revealed the ice machine inside of the door had splotches of a black and brown substance that appeared to be mold growing on the inside of the door. Observation on 11/25/24 at 9:18 AM of the kitchen walk-in refrigerator revealed: 1. An opened bag of salad mix loosely saran wrapped dated 11/24 (unsure if this is open date or use by date) and unlabeled. 2. An opened bag of chopped onions with the opening loosely tied in a knot unlabeled and undated. 3. A storage bin with the lid unsecured and placed diagonally with loose salad mix inside unlabeled and undated. 4. A bag of shredded cheese dated 11/22 (unsure if this is open date or use by date) loosely saran wrapped and unlabeled. 5. A package of chopped ham lunchmeat loosely saran wrapped unlabeled and undated. 6. A package of turkey breast lunchmeat loosely saran wrapped unlabeled and undated. 7. A shelf full of containers of individually packaged pieces of apple pie unlabeled and undated. 8. A shelf full of containers of individually packaged pieces of pumpkin pie unlabeled and undated. 9. An opened bag of baby spinach loosely saran wrapped unlabeled and undated. 10. A bunch of cilantro saran wrapped undated and unlabeled. 11. An opened bag of salad mix dated 11/2/24 that had brown slimy pieces throughout bag. 12. A utility rack full of packages of beef patties thawing unlabeled and undated. 13. A utility rack full of turkey breasts thawing unlabeled and undated. 14. A utility rack full of hams thawing unlabeled and undated. Observation on 11/25/24 at 9:31 AM of the kitchen revealed a 55-gallon trash can in the kitchen near dish room without a lid. Observation on 11/25/24 at 9:35 AM of the kitchen walk-in freezer revealed: 1. A box that contained a opened package of sweet potato French fries unsealed with the open part of package just twisted together unlabeled and undated, an opened package of what appeared to be hush puppies undated and unlabeled, an open package of battered cauliflower bites unsealed with the package just folded over on itself undated and unlabeled, an open bag of what appeared to be frozen ravioli with a date of 11/6/24 no use by date recorded and bag was open with product falling out into box, an opened package of breaded zucchini fries unsealed with saran wrap on half of package undated and unlabeled, and an open package of what appeared to be battered onion rings wrapped in saran wrap undated and unlabeled. The box all these items were in was labeled crinkle cut French fries. 2. An opened bag of sliced okra with bag opening just folded over on itself unlabeled and undated. 3. An opened bag of whole kernel corn with the opening tied close undated and unlabeled. 4. A bag of what appeared to be frozen dinner roll dough with the bag just folded on itself unlabeled and undated. 5. An open bag of frozen chicken breast with the Ziploc seal portion of the bag wide open unlabeled and undated. 6. A saran wrapped bunch of what appeared to be chicken breasts unlabeled and undated. 7. An open bag of diced dark meat chicken unlabeled and undated. Observation on 11/25/24 at 9:40 AM of the kitchen dry storage revealed: 1. An open package of macaroni with opening loosely tied with saran wrap unlabeled and undated. 2. A row of 4 dented cans of tomato sauce stored on the canned goods rack with all the other cans not in the dented can area outside of the dry storage room. 3. An unopened case box of granola stored on the dry storage floor. Observation on 11/25/24 at 9:55 AM of the kitchen grill prep area with storage racks of bread revealed 6 packages of hot dog buns dated 9/16/24 and 2 undated packages of hoagie buns. Observation on 11/25/24 at 10:00 AM of the kitchen salad prep refrigerator revealed: 1. Three trays of individually bowled up salads undated and unlabeled. 2. Container tomato slices undated and unlabeled. 3. Container of cut up cantaloupe and honeydew melon undated and unlabeled. 4. Container of cheese slices undated and unlabeled. 5. Container of mixed fruit salad undated and unlabeled. 6. Container of cut up lemons undated and unlabeled. 7. Plates of burger salads undated and unlabeled. Observation on 11/25/24 at 10:10 AM of the back service hall corridor with kitchen entry door revealed signage posted of required hair restraints, bin labeled hair nets below signage empty of any hair restraints. Observation on 11/26/24 at 10:47 AM of the kitchen salad prep refrigerator revealed: 1. Plates of burger salads undated and unlabeled. 2. Three trays of individually bowled up salads undated and unlabeled. 3. Container of chopped onion unlabeled and undated 4. Container of chopped lettuce undated and unlabeled. Observation on 11/26/24 at 10:55 AM of the kitchen revealed Chef was only wearing a ball cap without a hair restraint under it and no beard guard. The chef had hair roughly 1 inch below the ball cap and facial hair. Chef also was wearing a long sleeve chef jacket and while panning up cooked chicken for lunch chef jacket repeatedly rubbed across cooked chicken surfaces. Observation on 11/26/24 at 10:55 AM of the kitchen revealed [NAME] had hair restraint not covering all of cooks hair. [NAME] had hair at nape of neck not covered by hair restraint. Further observation revealed [NAME] cleaning prep table from breading chicken breast, [NAME] picked up copies of recipes and threw copies into trash can and shoved papers down in trash can with ungloved hand touching trash can. [NAME] then proceeded to pick up cleaning cloth and continue cleaning prep table without washing hands. After cleaning prep table [NAME] then proceeded to wash hands. [NAME] then picked up trash from floor and discarded into trash can touching trash can without washing hands. [NAME] then wiped hands on front of clothes and went to get new cleaning cloths for prep table area. [NAME] then rinsed out dirty mixing bowl and then proceeded to wash hands. [NAME] then used the new cleaning cloths she had just put on prep table area as potholders to take cooked chicken from oven. [NAME] then threw trash away again touched trash can and did not wash hands just put on gloves and proceeded to start cutting up cooked chicken. Interview attempted on 11/27/24 at 1:00 PM with the Dietary Director but unsuccessful as Dietary Director was on vacation at time of survey. Interview on 11/27/24 at 1:13 PM with the Chef revealed Chef stated hair restraints including hair nets and beard guards were to be always worn while in the kitchen. The Chef stated that even while wearing a ball cap a hair net was to be worn under the ball cap if employee has hair. The Chef stated shirt sleeves were to be rolled up if they extend past the wrist so they will not come in contact with food. The Chef stated hair contamination and clothing sleeves touching food could be a physical and biological contamination. The Chef stated these types of contaminations could negatively affect residents by being cross contamination. Interview on 11/27/24 at 1:22 PM with the ADD revealed ADD stated hair restraints were to be worn by all staff in the kitchen and all hair was to be covered. The ADD stated ball caps can be worn but staff must have a hair restraint on under the ball cap. The ADD stated beard guards were to be worn for all facial hair. The ADD stated it can negatively affect residents if hair gets into the food because it would be a turn off to the resident and they would lose their appetite and possibly lose weight. The ADD stated it was the Dietary Director responsibility to ensure hair restraints were being worn. The ADD stated long sleeves were to be pulled up or rolled up to prevent them from getting into the food. The ADD stated if the clothing sleeves got into food this could negatively affect residents by being cross contamination. The ADD stated it was the Dietary Director responsibility to ensure staff clothing is not contaminating food products. The ADD stated staff were supposed to wash and sanitize their hands after discarding trash before their next activity. The ADD stated if staff did not perform hand hygiene correctly this could negatively affect residents by germs and residents getting sick. The ADD stated it was the Dietary Director responsibility to ensure staff were performing hand hygiene correctly. The ADD stated all food items in the kitchen were to be labeled and dated. The ADD stated everything was dated upon receipt and when opened /prepared and at that time also with a discard date. The ADD stated if items were not labeled and dated then this could negatively affect residents by them getting spoiled food and getting sick. The ADD stated it was the Chefs responsibility to ensure proper labeling and dating practices are occurring. The ADD stated food temperature logs were to be completed daily at every meal. The ADD stated if temperatures were not being taken and recorded then this could potentially negatively affect residents by foods being in the temperature danger zone and residents getting sick. The ADD stated it was their responsibility to ensure food temperature logs were completed daily at each meal. Interview on 11/27/24 at 1:36 PM with the [NAME] revealed [NAME] stated hair restraints were to be worn by all staff in the kitchen. The [NAME] stated all hair was to be covered by the hair restraint. The [NAME] stated it could negatively affect residents if hair got into the food by being a choking hazard. The [NAME] stated all food items were to be labeled and dated upon receipt and when open and at that time with a discard date. The [NAME] stated if food items were not labeled and dated this could negatively affect residents by bacteria growth and spoilage and make them sick. The [NAME] stated hygiene was to be performed after throwing away trash and touching the trash can before moving to the next task. The [NAME] stated if hand hygiene was not performed then this could negatively affect residents by there could be contamination and could make residents sick. The [NAME] stated food temperature logs were to be completed daily prior to the meal being served. The [NAME] stated by food temperatures not being taken then this could negatively affect residents by bacteria growth and sickness. Interview on 11/27/24 at 2:20 PM with the ADM revealed ADM stated it was their expectation that all food products were labeled and dated per policy. The ADM stated it was their expectation that sanitation practices were followed according to policy and guidelines. The ADM stated it was their expectation that hand hygiene practices were being followed according to policy and guidelines as that was the facilities biggest fight against infection. The ADM stated it was their expectation that temperature logs were being completed according to policy and guidelines. The ADM stated it was their expectation that hair restraints were being worn according to policy and guidelines. The ADM stated if labeling and dating, sanitation practices, hand hygiene, temperature logs, and hair restraints practices were not occurring then this could negatively affect residents by the residents could potentially receive spoiled food and get sick. The ADM stated it was the Dietary Director responsibility to ensure these practices were occurring. Record review of food temperature logs reflected 11/1/24 breakfast and lunch food temperatures not recorded, 11/7/24 lunch food temperatures not recorded, 11/11/24 lunch food temperatures not recorded, 11/18/24 dinner food temperatures not recorded, 11/19/24 dinner food temperatures not recorded, 11/21/24 lunch food temperatures not recorded, 11/24/25 lunch food temperatures not recorded, and 11/25/24 lunch food temperatures not recorded. Food temperature logs reviewed for 26 days with 8 meals temperatures not being recorded. Record review of ice machine cleaning and sanitizing log reflected the last time recorded for the ice machine to have been cleaned was 9/18/24. No documentation of cleaning to have occurred for October or November Record review of the food storage policy undated reflected under heading policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Under heading procedure: 6. Food items will be stored on shelves, with heavier and bulkier items stored on lower shelves. 7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. a. old stock is always used first (first in - first out method or FIFO). The person designated to manage stock should be trained to rotate it properly. b. Food should be dated as it is placed on the shelves if required by state regulation. c. Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat TCS food should be consumed, sold or discarded. d. Food will be stored and handled to maintain the integrity of the packaging until ready for use. Food stored in bins may be removed from its original packaging. 8. Plastic containers with tight fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated. 10. Food should be stored a minimum of 6 inches above the floor, 18 inches from the ceiling and 2 inches from the wall with adequate space on all sides of stored items to permit ventilation. Racks and other storage surfaces should be clean and protected from splashes, overhead pipes or other contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.). 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2022 Federal Food Code. (Also see policy on Use of Leftovers later in this chapter.) Check state regulations as some states may allow shorter time frames for the use of leftovers. 13. Refrigerated food storage: f. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded. 14. Frozen Foods: c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their use by dates or discarded. Record review of the Food Safety and Sanitation policy undated reflected under heading policy: All local, state, and federal standards and regulations will be followed to assure a safe and sanitary food and nutrition services department. Under heading procedure: 2. Employees c. Employees are required to have their hair styled so that it does not touch the collar, and to wear clean aprons, clothes, and closed toe shoes. o Hair restraints are required and should cover all hair on the head. o [NAME] nets are required when facial hair is visible. d. Employees will wash their hands just before they start to work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds or dirty dishes, and touching face, hair, other people or surfaces or items with potential for contamination. 3. Food Purchasing e. Bulging or leaking cans, cans with severe dents on the seams or broken containers of food will not be used. 4. Food Storage a. Stored food is handled to prevent contamination and growth of pathogenic organisms. Leftovers are used within 72 hours (or discarded). Note: 2022 Federal Food Code guidelines allow 7 days for food safety with the day of preparation counted as day 1 of the 7 days and then food is discarded. Check local and state regulations and if different from the Federal Food Code, determine which regulation should be followed. Perishable foods with expiration dates should be used prior to the use by date on the package. Perishable ingredients should be refrigerated when they are not being used. All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered and dated when stored. When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. Canned and dry foods without expiration dates should be used within six months of delivery or according to the manufacturer's guidelines. Record review of the General Hazard Analysis Critical Control Points Guidelines for Food Safety policy undated reflected under heading policy: Food and nutrition services staff will be educated and supervised on all hazard analysis critical control points {HACCP) information and procedures. A good training program and the proper systems and tools will help to assure a successful HACCP/Food Safety program. Under heading procedure: Educate and monitor food and nutrition services staff on the following: 1. Hand Washing Train staff to wash hands prior to working with food, after using the restroom or soiling hands in any way. 2. The Time-Temperature Connection a. Limit the time that food is in the temperature danger zone (TDZ). b. The TDZ: Food must be held at greater than 135 For less than 41 F. c. Limit the time that food is in the TDZ to no more than 4 hours combined total for all preparation (thawing, preparation, cooling and re-heating). This includes hot foods, cold foods and foods stored at room temperature being prepared for consumption (such as fresh fruits or hermetically sealed ready to eat foods stored at room temperature). 4. Prevent Cross Contamination and Employee Contamination a. Preparation: Avoid the TDZ, prevent cross contamination and employee contamination. b. Cooking: Final internal temperatures as noted earlier. c. Hot holding: greater than 135 F, cover and stir often. d. Cooling: Safe cooling to less than 41 F within 4 hours, or to 70 F in 2 hours and from 70 F to 41 Fin 4 hours (not to exceed 6 hours). e. If food drops less than 135 F, reheat to 165 F for minimum of 15 seconds. 7. Food Temperatures for Meal Service a. Check to be sure the staff takes food temperatures correctly and records temperatures. 11. Receiving a. Take food temperatures upon receiving. Be sure the vendors have refrigerated trucks that are clean and in good repair. b. Label and date foods and put foods away promptly. c. Check temperatures upon delivery and reject any damaged goods: cans dented on the seams, refrigerator or freezer foods at improper temperatures, damaged boxes of dry goods that expose the foods, etc.

Based on Interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by having an indication for use of 5 (Residents #39, 72, 146, 69, and 70) of 5 residents reviewed. The facility failed to have adequate indications for routine medications for Residents #39,72,146,69, and 70. This failure could potentially affect all residents that receive routine medications from receiving unnecessary medications. Findings included: Record review of Resident # 39 face sheet dated 11/26/2024 reflected an [AGE] year-old female admitted [DATE] with diagnoses that included Coronary Artery Disease (a type of heart disease involving the reduction of blood flow to the cardiac muscle due to a build-up of plaque in the arteries of the heart.), Hypertension ( a long-term medical condition in which the blood pressure in the arteries is persistently elevated), Diabetes Mellitus ( a chronic condition that happens when you have a persistently high blood sugar levels affecting your body to use insulin properly) Hyperlipidemia ( abnormally high levels of any or all lipids in the blood) Cerebrovascular Accident ( an event involving an interruption of blood flow or bleeding in a region of the brain), Vascular dementia ( a type of dementia caused by brain damage from impaired blood flow), gastro-esophageal reflux disease without esophagitis ( is a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach without inflammation of the esophagus), Anxiety disorder ( a disorder characterized by excessive anxiety), Depression ( a mood disorder that causes feeling of sadness that won't go away) and Unspecified osteoarthritis ( a degenerative joint disease that can affect the many tissues of the joint,). Record review of Resident # 39's Annual MDS dated [DATE] reflected BIMS score of 5 which indicated severe cognitive impairment. Record review of Resident # 39 Physician orders dated 11/26/2024 reflected the following medications with no indication for use. Divalproex sodium (Depakote Sprinkles) 125 mg, oral, BID. Ordered 9/22/23. Lorazepam (Ativan) 0.5 mg, oral, tab daily. Ordered 8/26/2024. Amlodipine 10 mg, oral, tab, daily. Ordered 8/30/2024. Review of Resident # 72's Face sheet dated 11/26/2024 reflected a [AGE] year-old female admitted [DATE] with diagnoses of unspecified dementia ( a loss of cognitive functioning that interferes with daily life and activities ), Type 2 diabetes mellitus with diabetic polyneuropathy( a chronic condition that happens when you have a persistently high blood sugar levels affection you bodies use of insulin with nerve damage), Chronic kidney disease ( a long term kidney disease in which there is a gradual loss of kidney function), unspecified osteoarthritis ( a degenerative joint disease that can affect the many tissues of the joint,), Depression ( a mood disorder that causes feeling of sadness that won't go away), Hypertensive heart disease ( a group of medical problems that can happen when you have unmanaged high blood pressure for a long time), and Anxiety disorder ( a disorder characterized by excessive anxiety). Record review of Resident # 72's Quarterly MDS dated [DATE] reflected BIMS score of 7 that indicated severe cognitive impairment. Record review of Resident # 72's physician orders dated 11/26/2024 reflected the following medications with no indication for use. Atorvastatin 40 mg, 1 tab, oral every evening. Written 6/12/2023. Carvedilol 6.25 mg 1-tab, oral bid Give one tablet by mouth twice daily***hold (do not give medication) if SBP less than 100 or DBP less than 60 and HR less than 55*** ordered written 6/12/23. Omeprazole 20 mg, oral, cap-dr, daily, ***Do Not Crush**** written 6/12/2023. Gabapentin 600 mg, oral, TID written 6/21/2023. Methocarbamol 750 mg, Oral, TID Give two (2) 750 mg tablets to equal 1500 mg by mouth three times daily written 6/21/23. Ferrous Sulfate 325mg, Oral, Daily, ***Do Not Crush*** written 6/23/23. Ergocalciferol 2,000 units, oral, cap, daily, written 8/18/23. Insulin Glargine (Lantus) 45 units, subcutaneous, soln, every night at bedtime. Written 10/12/23. Insulin aspart (NovoLog FlexPen) 3 units, Subcutaneous, soln, TID (AC) written 10/16/23. Insulin aspart (NovoLog Medium sliding scale) Sliding scale, subcutaneous injection, TID with meals. Moderate sliding scale insulin. To be taken If accucheck <60 for alert patient give sweet snack and notify provider. If accucheck < 60 for patients unable to take by mouth give 1-amp D50.Order 6/20/2024. Divalproex sodium (Depakote Sprinkles) 250 mg, Oral, BID written 10/21/24. Record review of Resident # 146's face sheet dated 11/26/2024 reflected an [AGE] year-old male admitted [DATE] with diagnoses that included Dementia in other diseases classified elsewhere (a loss of cognitive functioning that interferes with daily life and activities), Coronary Artery Disease ( (a type of heart disease involving the reduction of blood flow to the cardiac muscle due to a build-up of plaque in the arteries of the heart.) Hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated) Renal Insufficiency (poor functioning kidneys) and Hyperlipidemia (abnormally high levels of any or all lipids in the blood). Review of Resident # 146's quarterly MDS dated [DATE] reflected a BIMS score of 9 which indicated a moderate cognitive impairment. Review of Resident # 146's Physician orders dated 11/26/2024 reflected the following medication ordered with no indication of use. Allopurinol 50 mg = 0.5 tab, oral, tab, daily at home patient was taking medication with the following details: comments give half a tablet to equal 50 mg tab. Written 2/27/2024. Famotidine 20 mg = 1 tab, oral, tab, BID. Written 2/27/2024. Losartan 75 mg= 1.5 tab, oral, tab, daily at home, patient was taking medication with the following details: Comments: give one and a half tablets to equal 75 mg dose written 2/27/2024 Rosuvastatin 10 mg, oral, cap, every night at bedtime. Written 2/27/24, Sertraline 100 mg, oral, tab, daily written 3/4/2024. Aspirin 81 mg, oral, tab-DR, daily, written 7/17/2024. Buspirone 10 mg, oral, tab, daily. Written 10/14/2024. Record review of Resident # 69's Face Sheet dated 11/26/2024 reflected a [AGE] year old male admitted on [DATE] with the diagnoses that included Dementia in other diseases classified elsewhere (a loss of cognitive functioning that interferes with daily life and activities ), Gastroesophageal reflux disease ( is a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach without inflammation of the esophagus), Hyperlipidemia (abnormally high levels of any or all lipids in the blood), Diabetes mellitus type 2 ( a chronic condition that happens when you have a persistently high blood sugar levels affecting your body to use insulin properly), and Alzheimer's disease ( a disease that can cause trouble concentrating and thinking, especially about abstract concepts such a numbers) Review of Resident # 69's admission MDS dated [DATE] revealed a BIMS score of 8 which indicated moderate cognitive impairment. Review of Resident # 69's physician orders dated 11/26/2024 reflected the following medication had no indication for use. Ascorbic Acid 1,000 mg = 1 tab, oral, tab, daily written 10/18/2024. Aspirin 81 mg, oral, Tab-DR, daily, written 10/18/2024. Atorvastatin 40 mg = 1 tab, every evening. Written 10/18/2024. Calcium-vitamin D (Calcium 500 + D) 1 tab, chewed, tab-chew, BID. Written 10/18/2024. Cholecalciferol (Vitamin D3) 25 mcg= 1 tab, oral, tab, daily. Written 10/19/2024. Cranberry 1 tab, oral, tab, daily. Give 500 mcg tab. Written 10/19/2024. Cyanocobalamin 500 mcg=1 tab, oral, tab, daily. Written 10/19/2024. Donepezil 10 mg= 1 tab, oral, tab, daily. Written 10/19/2024. Famotidine 40 mg = 1 tab, oral, tab, every evening. Written 10/19/2024. Ferrous Sulfate 325 mg, oral, Tab-DR, Daily, give with food/snack. Written 10/19/2024. Metformin 500 mg, oral, Tab-ER, every evening, give with food/snack Written 10/19/2024. Multivitamin (Vitamin B Complex 100) 1 tab, oral, tab, daily. Written 10/19/2024. Melatonin (Advanced Sleep Melatonin) 10 mg, oral, every night at bedtime. Written 10/23/2024. Memantine 10 mg, oral, tab, BID. Written 10/24/2024. Tamsulosin 0.4 mg, oral, every evening for 2 weeks start date 11/13/2024, stop date 11/27/2024. Monitor and document resident urinary symptoms. Written 11/13/2024. Review of Resident # 70's Face sheet dated 11/26/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses, Bipolar Disorder ( a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks), Dementia with anxiety ( a long term disorder causing personality changes and impaired memory, reasoning and social function with anxiety) Osteoporosis ( s systemic skeletal disorder characterized by low bone mass) and Hyperlipidemia (abnormally high levels of any or all lipids in the blood). Review of Resident # 70's Quarterly MDS dated [DATE] revealed resident was unable to participate in BIMS score testing, A staff assessment for Mental status was conducted revealed the resident is severely impaired with cognitive skills for daily decision making. Review of Resident # 70's Physician orders dated 11/26/2024 reflected the following medication have no indication for use. Atorvastatin 10 mg= 1 tab, oral, tab, daily. Written 6/22/2023. Calcium-vitamin D (Calcium 550 +D) 2 tab, oral, daily, give two 500 mg tablets to equal 1000 mg dose. Written 7/5/2023. Oxcarbazepine (Trileptal) 450 mg, oral, tab, BID. Written 5/2/2024. Paroxetine (Paxil) 60 mg, oral, tab, every night at bedtime. Written 10/1/2024. Cyanocobalamin (Vitamin B12), 1,000 mcg, oral, tab, daily. Written 10/16/2024. Buspirone 30 mg, oral, tab, BID. Written 11/19/2024. Interview with the DON on 11/26/2024 at 10:30 am stated that the facility was aware of the issue and was working with the company that does the EMR to fix the issue. She stated she audits the resident's chart but sometimes the indications do not save to the physician order. She stated the program they used for EMR was made for the hospital and there were no regulation at the hospital that required an indication for medication. They were working with the company to address the issue, but it is a slow process. She demonstrated that when indications were added they did not always save. She stated that this could put the residents at risk for overmedication due to duplicate of treatment. Interview with the Pharmacy consultant via phone on 11/26/2024 at 2:15 pm she stated that she was aware of the limitations of the program for the indications and had been focusing on the PRN and psychotropic medications so that they were at least compliant with that regulation. She had offered to meet with the company that owns the EMR to come up with a solution but had not heard back about it. She stated that the residents could be at risk for duplicate treatment for the same illness if not corrected. Interview with the ADM on 11/26/2024 at 3:30 pm she stated that she was aware of the indications not always showing up on the physician orders and was working with her corporate lead and the EHR company to find a solution. She stated she had been aware since the last survey and they were trying to address the issue with weekly audits and that the medical director was aware of the issue. She stated the hospital did not have the same requirements as the Skilled facility and the program was developed for the acute care setting. She stated she felt they were doing their best to keep the residents safe but there was always a risk when giving resident care. Record review of the policy titled Medication orders revised November 2014 read Recording orders 1. Medication orders- When recording orders for medications, specify the type, route, dosage, frequency and strength of the medication.

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 promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for eight (Resident #3, Resident #11, Resident #15, Resident #16, Resident #30, Resident #31, Resident #38, and Resident #66) of twenty residents reviewed for rights, in that: The facility failed to ensure Resident # 3, Resident #11, Resident #15, Resident #16, Resident # 30, Resident # 31, Resident # 38, and Resident #66 were assisted with feeding in a dignified manner. These failures put residents at risk of experiencing humiliation, degradation, and a decreased quality of life. The findings included: Record review of Resident # 3 Comprehensive MDS dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of non-Alzheimer's dementia with psychosis, glaucoma, cataracts, congestive heart failure, and asthma. Resident # 3 did not have a BIMS score recorded. Resident # 3 had it documented that she was dependent upon staff for all her ADL's including eating. Record review of Resident # 3 care plan reflected under nutritional status dated 9/27/24 outcome listed as nutritional intake meets needs with interventions of evaluate eating limitations, diet ordered regular/pureed/thin liquids ADL function dated 11/26/24 outcome listed as functions at optimal level with ADL's with interventions of assist resident with meals, provide assistance to support level of need. Record review of Resident # 66 quarterly MDS dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia with other behavioral disturbances, chronic kidney disease stage 2, pain, age related osteoporosis. Resident # 66 did not have a BIMS score recorded. Resident # 66 had it documented that she needed supervision and touching assistance with eating. Record review of Resident # 66 care plan reflected under nutritional status dated 10/7/24 outcome listed as nutritional intake meets needs with interventions of evaluate eating limitations, diet ordered vegetarian/mech soft/thin liquids, cut food into small bite size pieces. ADL function dated 11/26/24 outcome listed as functions at optimal level with ADL's with interventions of assist resident with meals, provide assistance to support level of need. Observation on 11/25/24 at 12:30 PM of Resident # 3 in dining room seated at a table with Resident # 66 being assisted with her lunch meal by 1 staff member assisting to fed both residents. Resident # 66 was seated on the left and Resident # 3 was seated on the right with the staff member seated at the end of the table. The staff member proceeded to use her left hand to feed Resident # 66 and her right hand to feed Resident # 3. The staff member did not turn her body towards either resident when feeding them or check to see if they were enjoying their meal. Resident # 3 and Resident # 66 are both non-interviewable residents. Residents appeared not to have an issue with their tablemate sitting across from them being fed. Record review of Resident # 11 quarterly MDS dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia with other behavioral disturbances, anxiety disorder, protein-calorie malnutrition, cerebral aneurysm, and osteoarthritis. Resident # 11 did not have a BIMS score recorded. Resident # 11 had it documented that she had it documented that she was dependent upon staff for all her ADL's including eating. Record review of Resident # 11 care plan reflected under nutritional status dated 9/27/24 outcome listed as nutritional intake meets needs with interventions of evaluate eating limitations, diet ordered regular/pureed/thin liquids. ADL function dated 11/26/24 outcome listed as functions at optimal level with ADL's with interventions of assist resident with meals, provide assistance to support level of need. Record review of Resident # 16 quarterly MDS dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, chronic kidney disease stage 3, Parkinson, chronic pain, and anxiety disorder. Resident # 16 did not have a BIMS score recorded. Resident # 16 had it documented that she was dependent upon staff for all her ADL's including eating. Record review of Resident # 16 care plan reflected under nutritional status dated 9/27/24 outcome listed as nutritional intake meets needs with interventions of evaluate eating limitations, diet ordered consistent carbs/pureed/thin liquids. Aspiration precautions-oral feeding dated 1/13/24 outcome listed as oral feeding without aspiration, pureed diet, swallowing disorder, respiratory symptoms with interventions of evaluate for coughing when eating and drinking, evaluate for regurgitation with oral intake, evaluate for hoarseness and gurgling, use cueing and redirection and quiet room, provide liquids small controlled amounts, no straws while drinking, position food in mouth per SLP directions, use multiple swallow technique, clear pocketing from cheek, alternate solids and liquids, allow extra swallow time, and use chin tuck technique for swallows. ADL function dated 11/26/24 outcome listed as functions at optimal level with ADL's with interventions of assist resident with meals, provide assistance to support level of need. Observation on 11/25/24 at 12:33 PM of Resident # 11 in dining room seated at a table with Resident # 16 being assisted with her lunch meal by 1 staff member assisting to fed both residents. Resident # 11 was seated on the left and Resident # 16 was seated on the right with the staff member seated at the end of the table. The staff member proceeded to use her left hand to feed Resident # 11 and her right hand to feed Resident # 16. The staff member did not turn her body towards either resident when feeding them or check to see if they were enjoying their meal. The staff member did not follow the interventions in Resident # 16 care plan listed under her aspirations interventions. Resident # 11 and Resident # 16 are both non-interviewable residents. Residents appeared not to have an issue with their tablemate sitting across from them being fed. Record review of Resident # 31 quarterly MDS dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, chronic obstructive pulmonary disease, chronic pain syndrome, osteoarthritis, rheumatoid arthritis, and major depressive disorder. Resident # 31 did not have a BIMS score recorded. Resident # 31 had it documented that she was substantial/maximal assistance from staff for eating. Record review of Resident # 31 care plan under nutritional status dated 9/27/24 outcome listed as nutritional intake meets needs with interventions of evaluate eating limitations, diet ordered regular/pureed/thin liquids. ADL function dated 11/26/24 outcome listed as functions at optimal level with ADL's with interventions of assist resident with meals, provide assistance to support level of need. Record review of Resident # 38 quarterly MDS dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of vascular dementia, cerebral infarction, dysphasia, congestive heart failure, muscle weakness, abnormalities of gait and mobility, acute kidney failure, and chronic kidney disease stage 3. Resident # 38 did not have a BIMS score recorded. Resident # 38 had it documented that they required supervision or touching assistance from staff for eating. Record review of Resident # 38 care plan under nutritional status dated 10/18/24 outcome listed as nutritional intake meets needs with interventions of evaluate eating limitations, diet ordered regular/mech soft/thin liquids, give 2 Cal supplement for weight loss with each meal. Aspirations precautions-oral feeding dated 1/8/24 outcome oral feeding without aspiration, swallowing disorder, respiratory symptoms with interventions of evaluate for coughing when eating and drinking, evaluate for regurgitation with oral intake, evaluate for hoarseness and gurgling, use cueing and redirection and quiet room, auscultate breath sounds with evaluation, use cueing and redirection and quiet room, provide liquids small controlled amounts, no straws while drinking, position food in mouth per SLP directions, use multiple swallow technique, clear pocketing from cheek, alternate solids and liquids, allow extra swallow time, and use chin tuck technique for swallows. ADL function dated 11/26/24 outcome listed as functions at optimal level with ADL's with interventions of assist resident with meals, provide assistance to support level of need. Observation on 11/25/24 at 12:36 PM of Resident # 31 in dining room seated at a table with Resident # 38 being assisted with her lunch meal by 1 staff member assisting to fed both residents. Resident # 31 was seated on the left and Resident # 38 was seated on the right with the staff member seated at the end of the table. The staff member proceeded to use her left hand to feed Resident # 31 and her right hand to feed Resident # 38. The staff member did not turn her body towards either resident when feeding them or check to see if they were enjoying their meal. The staff member did not follow the interventions in Resident # 38 care plan listed under her aspirations interventions. Resident # 31 and Resident # 38 are both non-interviewable residents. Residents appeared not to have a issue with their tablemate sitting across from them being fed. Record review of Resident # 30 quarterly MDS dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, cerebral infarction, anxiety disorder, and gastro-esophageal reflux disease. Resident # 30 did not have a BIMS score recorded. Resident # 30 had it documented that they required supervision or touching assistance from staff for eating. Record review of Resident # 30 care plan under nutritional status dated 9/27/24 outcome listed as nutritional intake meets needs with interventions of evaluate eating limitations, diet ordered regular/no salt on tray/regular texture/thin liquids. ADL function dated 11/26/24 outcome listed as functions at optimal level with ADL's with interventions of assist resident with meals, provide assistance to support level of need. Record review of Resident # 15 Comprehensive MDS dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, epilepsy, osteoarthritis, osteoporosis, dysphasia, and gastro-esophageal reflux disease. Resident # 15 had a BIMS score of 6 indicating severe cognitive impairment. Resident # 15 had it documented that they required supervision or touching assistance from staff for eating. Record review of Resident # 15 care plan under nutritional status dated 10/7/24 outcome listed as nutritional intake meets needs with interventions of evaluate eating limitations, diet ordered regular/mech soft/thin liquids. ADL function dated 11/26/24 outcome listed as functions at optimal level with ADL's with interventions of assist resident with meals, provide assistance to support level of need. Observation on 11/25/24 at 12:40 PM of Resident # 30 in dining room seated at a table with Resident # 15 being assisted with her lunch meal by 1 staff member assisting to fed both residents. Resident # 30 was seated on the left and Resident # 15 was seated on the right with the staff member seated at the end of the table. The staff member proceeded to use her left hand to feed Resident # 30 and her right hand to feed Resident # 15. The staff member did not turn her body towards either resident when feeding them or check to see if they were enjoying their meal. Resident # 30 and Resident # 15 are both non-interviewable residents. Residents appeared not to have an issue with their tablemate sitting across from them being fed. In an interview on 11/27/24 at 1:53 PM with LVN A revealed LVN A stated All staff members help with feeding during all meals, and it depends on which shift duties. She will do lunch or both breakfast and lunch, some staff do lunch and dinner, but it depends how many staff they have on that shift. If she is on shift, she will help with all meals and there is always a nurse in there before the meal starts and after the last person finishes their meal. She feels like it is manageable to feed two residents' at once. She can concentrate on feeding both residents one at a time while making sure they are clean during feeding. She doesn't have any concerns with feeding two residents at once. She doesn't remember the policy and what it says with assisted feeding, and she is not sure how many residents they are able to feed at once, but she can check. She thinks 1:2 assistance feeding is doable; she thinks what could make it better is feeding resident's and eating with them to make it more community based. They are not rushing the resident's and doesn't see a dignity or safety issue. She sees the facility as it is a community-based setting. There are not any cross-contamination issues during feeding, and they don't feed both at a time with each hand or giving the resident each other's food accidentally. In an interview on 11/27/24 at 2:00 PM with CNA C revealed CNA C stated one staff member for every 2 residents who need to be fed unless the resident won't eat for that staff member then another staff member comes to help and try and get the resident who is not eating to eat. CNA C stated they do not feel there is a safety issue because the staff member sits facing the two residents so they can watch for any swallowing issues and a nurse is always present in the dining room. CNA C stated they did not feel feeding two residents at the same time was a dignity issue because all of the residents who need to be fed are seated together on one side of the dining room and they are all encouraged to eat equally. CNA C stated that it appeared to them that the residents to not mind having a table mate who is also being fed. In an interview on 11/27/24 at 2:10 PM with LVN B revealed LVN B stated one staff member feeds two residents and the staff members have a rotation as to which meal and what day they feed residents. LVN B stated they do not feel there is a resident safety issue since the staff member sits facing the residents and can see if they have swallowing problems. LVN B stated they do not feel that feeding two residents at a time is a dignity issue since all the residents who need to be fed are seated at tables next to each other and all encouraged to eat together from all the staff. In an interview on 11/27/24 at 2:20 PM with ADM revealed the ADM stated for residents who need meal assistance it is their expectation that 1 CNA to every 2 residents is acceptable parameters. ADM stated she did not feel having 1 staff member feed 2 residents at the same time was a dignity issue since the staff communicate and engage with the residents and even though eating is an ADL it is not the same as receiving a shower or toileting. ADM cited CNA training curriculum from 3/12 and HHSC module 5 feeding assistant training dated 12/22 saying both of which stated adequate staff with feeding. Record review of assistance with meals policy undated reflected under policy statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Under heading policy interpretation and implementation Dining room Residents: All residents will be encouraged to eat in the dining room. 2. Facility staff will serve resident trays and will help residents who require assistance with eating. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals. b. keeping interactions with other staff to a minimum while assisting residents with meals. c. avoiding the use of labels when referring to residents (e.g., feeders); and d. avoiding the use of bibs or clothing protectors instead of napkins, unless requested by the resident.

Based on interview and record review, the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for one (Resident #1) of six residents reviewed for developing and implementing abuse and neglect policies, in that: Facility staff failed to report to the Administrator, who was the Abuse Prevention Coordinator, potential incidents of abuse that occurred on 4/23/2024 when: 1. RN B was allegedly heard making a derogatory statement about Resident #1 to CNA A. 2. RN B was allegedly heard making a derogatory statement about Resident #1 to CSM C. 3. RN-B was allegedly heard making a derogatory statement about Resident #1 in front of CSM D This failure placed residents at risk of abuse, neglect, or exploitation. Findings included: Review of Resident #1 undated face sheet reflected an [AGE] year-old female with an unknown admitted with diagnoses that included: Diabetes mellitus Type II (blood sugar disorder), Hypertension (high blood pressure), Hyperlipidemia (high cholesterol) Congestive Heart Failure (chronic condition in which the heart doesn't pump blood correctly) Mild Asthma, Generalized Anxiety Disorder, Chronic Pain Syndrome, Disorder of the Connective Tissue (inflammation of connective tissue like collagen and elastin), and Osteoarthritis . (Degeneration of joint cartilage) Review of Resident #1's Quarterly MDS assessment dated [DATE]., reflected Resident had a BIMS score of 15 suggesting Resident # 1 had no cognitive impairments. Review of Resident #1's care plan dated 5/6/2024 reflected a plan of LTC Falls with outcome: free from falls and interventions including: low bed, ensure glasses worn, evaluate room for clutter, use of assistive devices, adequate room lighting, call light tin reach and non -slip footwear. During an interview on 5/2/2024 at 1:30 pm, CNA -A stated they were at work on 4/23/2024 and they received a call from another CNA that Resident #1 had an unwitnessed fall , and their help was needed. On their way to that hall, CNA - A stated they encountered RN-B in the hall and RN-B stated that Resident #1 had fallen. CNA-A asked RN-B if they were sending Resident #1 out to the hospital and RN-B stated no it was a boy who cried wolf scenario. CNA-A stated at the time they did not think RN-B's derogatory comment about Resident #1 was abuse so they did not report it. CNA-A stated they had received training on abuse and neglect and was able to identify the Administrator as the Abuse Coordinator. CNA-A stated later after talking with Resident #1 they called and spoke to the ADON and told her what RN-B has said to them about Resident #1 crying wolf about the fall. During an interview on 5/2/2024 at 2:43 pm, RN-B stated she had been at work on 4/23/2024 when Resident #1 sustained an unwitnessed fall. She stated she assessed the resident and had not seen any injuries but Resident #1 wanted to be sent to the ER, so she had gone back to the nurse's desk to start the process. She stated Resident #1 has Generalized Anxiety Disorder and can be hyper-sensitive. She stated she never told Resident #1 that she would not send her out to the ER. She also stated that she had not said anything to anyone about the resident being overly dramatic or crying wolf. She stated when she provided information at the nurse's station at shift change she did not say Resident #1 was faking it or being overly dramatic. She stated she did not remember that she said anything to CNA-A in the hall about the fall. RN-B stated Resident #1 had a history of making false accusations and has had frequent somatic complaints. She said, the thought entered my mind that she had not fallen because the resident could not tell me how she got to sitting on the floor by her recliner. She stated Resident #1 had made accusations in the past that are not quite accurate from my viewpoint. RN-B She stated she had received training on ANE and how to recognize and report ANE. She stated they are supposed to report all ANE to the Abuse Coordinator who is the AD. RN-B denied any ANE of Resident #1. During an interview on 5/2/2024 at 3:49 pm, the ADON stated she had received a call from CNA-A after Resident #1 had fallen. She stated nothing was reported to her as abuse or neglect, there was just a concern that RN-B was not going to send Resident to ER. She stated she received no statements from staff stating RN-B stated Resident #1 was faking her fall or crying wolf. She stated if she had, she would have reported it to the Administrator. During an interview on 5/2/2024 at 4:13 pm, the AD stated she was aware of the fall incident with Resident #1 on 4/23/2024. She stated staff thought RN-B wasn't going to send Resident #1 out, but that staff didn't understand protocol for sending a resident to the ER. She stated she had no concerns about ANE and no concerns with how the incident was handled. During an interview on 5/3/2024 at 1:57 pm, CSM-C stated they were at work on 4/23/2024 and had been sitting at the nurse's station at shift change and heard CNA staff come up to the desk and tell RN-B that Resident #1 had fallen. RN-B stated that Resident #1 was faking it and CSM-C heard RN B say She's always crying wolf, there's nothing wrong with her, she didn't hit her head and I'm not sending her out.' CSM-C stated Resident #1 is the type of resident that will say things sometimes that staff think are not true. During another interview on 5/5/2024 at 1:36pm, CSM-C stated they had received training on abuse and neglect and was able to identify the AD as the person to report any ANE. CSM-C stated that it did not cross my mind that it might be abuse, referring to what she heard RN-B had said on 4/23/2024 and that RN-B wasn't being malicious about it, that's how they talk about Resident #1. During an interview on 5/3/2024 at 2:19 pm, CSM-D stated they had been working on 4/23/2024 and was at the nurse's desk about 5:15 pm. RN-B told her that Resident #1 had fallen and you know she's faking it, she did one of her fake falls,. CSM - D asked if Resident #1 had hit her head and RN-B stated, she says she did. CSM-D asked RN-B if she was going to send Resident #1 out and RN-B said no. CSM-D stated later that evening the DON called them and asked what happened at the nurse's desk earlier that day and CSM-D stated they told the DON that RN-B told me that Resident #1 fake fell and that she wasn't sending her to the ER. During another interview on 5/3/2024 at 4:09 pm, CSM-D stated at the time they did not think what RN-B said was abuse or neglect but looking back now they think that it was , and they should have reported it to the AD who is the abuse coordinator. CSM-D stated, I wanted to get out of the situation because of RN-B's attitude at the time. I know that's wrong, and I have been beating myself up over it. She stated the facility policy stated any concerns with ANE are to be reported to the abuse coordinator who is the administrator. During an interview on 5/3/2024 at 4:59 pm, the DON stated she was aware of the fall incident with Resident #1 and that staff thought RN-B was not going to send Resident #1 out to the ER. She stated she does not recall any staff telling her that RN-B said it was a fake fall or that Resident #1 was crying wolf., I'm not saying they didn't, I don't recall, I don't remember; not to my recollection. She stated there was no reason to believe that there was any abuse or neglect going on by RN-B. She stated the events were reported to the AD in the morning meeting the next day on 4/24/24 and there was nothing reported in the morning meeting about RN-B refusing to send Resident #1 out to the ER. She stated she did have an informal discussion with RN-B on 4/24/24 at the nurse's station face to face to remind her if a resident wants to be sent out we have to send them out. Review of undated facility policy Prevention and Reporting of Suspected Resident Abuse and Neglect reflected: This facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. This facility has implemented the following processes in an effort to provide residents and staff a comfortable and safe environment. The Administrator and Director of Nursing are responsible for the implementation and ongoing monitoring of abuse policies and procedures. Implementation and ongoing monitoring consist of the following policies: Screening, Training, Prevention, Identification, Protection, Investigation and Reporting .4. B. Any person with the knowledge or suspicion of suspected violations must report, immediately, without fear of reprisal. Notification will be to the Unit Charge Nurse (UCN) for the resident involved. The UCN is identified as responsible for initiating the reporting process and will notify the Director of Nursing and/or Administrator.

Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 2( Hall E treatment cart , Wound care) of 9 medication/treatment carts reviewed for medication storage in that: Treatment Cart #1 was left unattended and unlocked at the nurse's station on 9/25/23 and 9/26/23. Wound care cart #2 was left unlocked outside of a resident room This failure could allow residents, unsupervised access to prescription and over the counter medications. Findings Include: Observation on 9/25/2023 at 10:21am revealed, Hall E treatment cart was unsupervised and unlocked at the nurse's station.RN A was sitting out of eyesight of the cart at the nurse's station, . Review of the contents of the cart revealed glucometer supplies, insulin pens, insulin syringes, some over the counter medication, prescription ointments and treatment, secured locked box. Treatment cart secured at 10:22 am by RN A Interview on 09/25/2023 at 10:25 am with RN A, she said she was the nurse assigned to E hall, and she stated she was responsible for the treatment cart. She stated she was not aware the cart was unlocked and does not remember how long ago she used it. She stated that if a resident was able to access some of the supplies or medications on the cart, potential harm could come to the resident for unauthorized use med medications. Interview on 09/25/2023 at 10:30 am with the IDON, she stated that the nurses were responsible for the treatment cart on their assigned halls. Treatment carts were considered medication carts and fall under the same policy. Medication and treatment carts were to be locked when not in use. Potential harm to the residents was access to unauthorized medication and treatments. Observation on 9/25/2023 at 11:00 am revealed, the Wound care cart was unsupervised and unlocked in front of a resident room on Hall B. The I DON was in the hall and noticed the cart was unlocked and secured it at 11:01 am. The cart was removed from the floor by the IDON. Cart contained prescription creams, dressing supplies, antiseptic wipes and several pair of scissors. Interview on 9/25/2023 at 11:15 am with wound care nurse, she stated she was aware that the cart was supposed to be locked, but the lock was broken and should be in this week. She stated that she placed a work order for repair of the lack a week ago and replacement has been ordered. She stated that she has removed most of the medications and creams. She stated that with most of the medication and creams off the cart there was not a potential danger. She stated she was not aware of a policy that stated it should not be used since most of the supplies were in her office. Interview on 09/25/203 at 11:20 am, the IDON stated that she was not aware the lock was broken, it should have been reported to her and the cart should have been taken out of service. She stated even with minimal medication on the cart there was still a potential risk to residents from the equipment and over the counter creams on the cart. Observation and interview on 9/26/2023 at 11:32 am revealed the E hall treatment cart was at nurses' station unsupervised and unlocked. RN B stated he was unaware the cart was unlocked and stated he last used it at about 9:30 am. Cart secured at 11:35 am By RN B. Interview on 9/26/2023 at 11:35 am with RN B, he stated he was an agency nurse and had been oriented to the facility medication cart policy. He stated he knew that medication and treatment carts should be locked when not in use. He stated he simply forgot to lock it. He said that he felt there was a potential danger for the resident to get something they don't need with the cart opened. Interview on 9/26/2023 at 11:50 am with the ADON, he stated that medication and treatment carts were to be locked when not in use. He stated that agency nurses were oriented to facility policies. He stated that residents were at risk for potential harm with access to unauthorized medications. Interview on 9/28/2023 at 11:00 am with the ADM, she stated her expectation was that the nursing staff treat all carts with medications on it as a medication cart and the policy states they were to be locked with not in use or eyesight. She stated that residents can have access to medication on an unlocked cart and that could be potential harm. Record Review of the policy storage of medications dated November 2020. 6. Compartments (including but not limited to, draws, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on interview, observation and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 4 of 6 residents (Resident #35, #16, #43, #210) reviewed for ventilator orders. The facility failed to label and date O2 tubing and water concentrator bottles weekly, per physician's orders, for Resident #35, #16, #43, #210. This failure could result in residents receiving incorrect or inadequate ventilator support and could result in a decline in health. Findings include: Review of Resident #35's MDS dated [DATE] reflected a [AGE] year-old female who was admitted on [DATE] with diagnoses of Chronic Kidney Disease (loss of kidney function), A-Fib (irregular, rapid heart rhythm), Hypothyroidism (decreased production of thyroid hormones), Dehydration, CHF (heart disease that causes SoB), Dementia and Hyperlipidemia (elevated lipid levels). Review of Resident #35's Significant Change in Status MDS dated [DATE] reflected no coding for oxygen. Resident #35 had a BIMS score of 3. Review of Resident #35's Comprehensive Care Plan, dated 07/15/23, reflected the following: - Monitor oxygen saturation level related to supplemental oxygen use as ordered by provider. Review of Resident #35's consolidated physician's orders reflected the following: - 09/18/23 21:00:00 CDT, Monday, CHANGE Oxygen Tubing and Water every Monday night *** Ensure to Date and Inital *** During an observation on 09/25/23, around 11:00 AM, Resident #35 was observed in her room connected to an Oxygen concentrator. The connected tubing was dated 09/08/23 and the water concentrator bottle was dated 09/23/23. Review of Resident #16's MDS reflected an [AGE] year-old female who was admitted on [DATE] with diagnoses of Cerebral Infarction (stroke), GERD (reflux), COPD (lung disease causing obstructed airflow from the lungs), Anemia (red blood cell deficiency), Cardiac Arrhythmia (abnormal heart rhythm), Presence of Cardiac Pacemaker and Osteoarthritis. Resident #16 had a BIMS of 6 and Section O reflected the use of oxygen therapy. Review of Resident #16's Care Plan, initiated 08/30/2023, reflected the following: - Intervention: Evaluate Effectiveness of O2 and Respiratory Review of Resident #16's consolidated physician's orders reflected the following: - 09/18/23: Monday, CHANGE Oxygen Tubing and Water every Monday night *** Ensure to Date and Initial *** - 09/18/23: Oxygen Therapy TAR, BID, 1, Nasal Cannula, PRN, Apply 1 L via Nasal Cannula PRN for SoB or sats less than 90% During an observation on 09/25/23, around 11:00 AM, Resident #16's room was observed with an Oxygen concentrator at her bedside. The connected tubing was dated 09/08/23 and the water concentrator bottle was dated 09/10/23. Review of Resident #43's Quarterly MDS dated [DATE] reflected an [AGE] year-old female who was admitted on [DATE] with diagnoses of CHF (heart disease that causes SoB), A-Fib (irregular, rapid heart rhythm), Cognitive Impairment, and Hemiplegia Affecting Right Dominant Side. Resident #43's BIMS was not documented and Section O of the MDS reflected the use of oxygen. Review of Resident #43's Comprehensive Care Plan, dated 07/19/23, reflected the following: - Monitor respiratory status related to supplemental oxygen therapy resident non-compliance Review of Resident #43's consolidated physician's orders reflected the following: - 09/24/23: Sunday, CHANGE Nebulizer Setup every Sunday night *** Ensure to Date and Initial *** - 09/18/23: Monday, CHANGE Oxygen Tubing and Water every Monday night *** Ensure to Date and Initial *** - 06/27/23: Oxygen Therapy TAR, BID, 3, Nasal Cannula, 366 days; Continuous Supplemental Oxygen Therapy via Nasal Cannula @ 3.5 LPM - 07/23/23: Oxygen Check TAR, every week, change resident oxygen tubing and cannister once weekly Observation of Resident #43's room on 09/25/23, around 11:00 AM, revealed the presence of an oxygen concentrator. The connected tubing and water concentrator bottle were both undated. A nasal cannula was observed on the ground next to the oxygen concentrator. Observation on 09/25/23 at 3:03 PM revealed Resident #43 in her room and was connected to the oxygen concentrator, with the nasal cannula inserted into their nose. The tubing remained undated. Observation of Resident #43's room on 09/26/23 at 10:11 AM revealed the presence of an oxygen concentrator. The connected tubing was dated 09/08/23 and the water concentrator bottle was undated. The resident was not connected to the concentrator, but the nasal cannula was observed on the floor. An observation on 09/27/23 of Resident #43 revealed she was sitting in her room in her recliner chair, reading a book. Oxygen concentrator was in her room. Nasal cannula was observed positioned on the oxygen machine. During an observation and interview on 09/27/23 at 11:42 AM, Resident #43 revealed she can place her nasal cannula in her nose on her own. She stated, I guess I should put this on. Resident was observed grabbing her nasal cannula and appropriately placing it on her nose. She stated when she leaves her room, she can remove the cannula herself. Review of Resident #210's MDS dated [DATE] reflected an [AGE] year-old female who was admitted on [DATE] with diagnoses of CHF (heart disease that causes SoB), Chronic A-Fib (irregular, rapid heart rhythm), HTN (high blood pressure), Osteoarthritis, Obstructive Sleep Apnea (stopping breathing during sleep), Dementia, and Anxiety. Resident #210 had a BIMS score of 8 and oxygen was not coded in the MDS. Review of Resident #210's Comprehensive Care Plan, dated 07/19/23, reflected the following: - Encourage resident to keep nasal cannula in place for supplemental oxygen therapy related to non compliance. Review of Resident #210's consolidated physician's orders reflected the following: - 09/18/23: Monday, CHANGE Oxygen Tubing and Water every Monday night *** Ensure to Date and Initial *** - 09/19/23: Oxygen Therapy TAR, Daily, 2, Nasal Cannula, PRN, Apply 2L of o2 via Nasal Cannula as needed for SoB or saturation level (stats) less than 90% During an observation on 09/25/23 at 11:05 AM, Resident #210 was observed in bed, with O2 Concentrator on and nasal cannula was in the resident's nose. The connected tubing was undated. During an interview on 09/27/23 at 11:45 AM, LVN A stated the nurses have been trained and were responsible for changing and ensuring the tubing on oxygen concentrators weekly and are up to date. She stated there were residents at the facility who may remove their nasal cannulas on their own, but they provide education on infection control for those residents who were capable to do so. LVN A stated the risks of not changing the tubing weekly could pose the risk of infection. Interview on 09/27/23 at 2:14 PM with LVN B revealed nurses were responsible for changing the tubing on oxygen concentrators. She stated when they were changed, the tubing should have a label with the date it was changed; she stated the water bottle should also be labeled and dated. She stated this information (orders) can be found on the computer; with the new software, the facility has begun to put orders to change the tubing and bottle weekly. During an interview on 09/28/23 at 10:00 AM, the DON stated the expectation for changing oxygen tubing was that it should be changed at least every (7) days to avoid complications including infection to the resident. She stated this should be reflected in residents MAR. During an interview on 09/28/23 at approximately 12:00 PM, the ADM stated regarding labeling and dating oxygen tubes and water concentrator bottles, she would expect staff to follow their policy. She stated the risks of not ensuring oxygen concentrator equipment was not labeled and dated per physician's orders was that there is a risk of infection which could cause harm to the resident. Review of a facility policy titled Oxygen Administration, last revised October 2021, reflected the following: Purpose: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration

Based on observation, interview and record review, the facility failed to ensure residents receive food that accommodates their preferences for 1 out of 1 resident (Resident #206) reviewed for food and nutrition services. The facility failed to complete required documentation to ensure Resident #206 was served a regular texture diet based on her preference and assessment. This failure could place residents at risks for a diminished quality of life. Findings include: Review of the electronic health records revealed Resident #206 was a 95 y/o female who was admitted on [DATE]. Review of an MDS dated [DATE] revealed Resident #206 had a BIMS score of 13. Review of a Baseline Care Plan dated 09/20/23 revealed Resident #206 had diagnoses of Hypertension (high blood pressure), Anemia, Diabetes, Respiratory Failure and Pneumonia, and reflected the following information: - Dietary Goal: Maintain 5% of admission weight - Intervention: No salt, puree texture and thin liquids; will endorse likes and dislikes; provide supplements as needed. Review of a Nutrition Note for Resident #206, completed by the RD, dated 09/25/23 reflected: - Nutrition Goal: Maintain stable wright, good PO (by mouth) intake with no difficulty chewing or swallowing; maintain healthy skin - Interventions: Continue with Boost with meals - Comments: Reports good appetite, no difficulty chewing or swallowing; Resident was on baby food, resident did not like baby food, referred to SLP and now on regular texture. - Diet Orders: Diet Order, 09/25/23, 13:12:00, No salt tray, Regular texture, Thin liquids During an interview on 09/25/23 at 2:50 PM, Resident #206 stated she doesn't like baby food, that she has teeth and can chew her food. During an observation on 09/26/23, Resident #206 was observed eating lunch, the food had been pureed. During an interview on 09/27/23 at 11:55 AM, Resident #206 stated she had not received her lunch yet. She stated for breakfast, she was served solid foods which consisted of eggs, a sausage patty and oatmeal. Observation on 09/27/23 at 1:15 PM revealed Resident #206 had been served solid food which consisted of spaghetti, mashed potatoes, a dinner roll, and pudding. During an interview 09/27/23 at 1:15 PM, Resident #206 stated she was initially served pureed food for lunch, and she told staff she did not want to eat the food. She stated they returned with solid foods, reiterating that she was not a baby and that she has teeth. Review of Resident #206's meal ticket reflected that it was dated 09/25/23 and puree diet texture was highlighted. Review of the menu on the ticket reflected meal options were all noted to be puree options. Review of the ticket reflected that puree had been scribbled through and regular texture was now circled. The puree notation in front of the spaghetti, vegetables and bread was scribble through. During an interview on 09/27/23 at 11:42 AM, LVN A stated a resident may be admitted with puree diets due to their admitting orders. She stated new admissions were assessed during their first meal at the facility, and subsequently assigned an appropriate diet texture. She stated if a resident prefers a different texture, they can communicate that to the nurse who would complete and submit required documentation to reflect this request and relay this information to the doctor for an order for the change. She stated once the order was received, this should be communicated to dietary, and the changes should be reflected in the system and on the resident's meal ticket. During an interview on 09/27/23 at 2:05 PM, the DM revealed if a resident had a change to their diet order, an Order Communication Form was completed/updated by the nurses and sent to the dietary department; this change could also be communicated via e-mail. The DM stated the dietary department had not received any communication forms on 09/25/23 and they had not received an e-mail regarding Resident #206's diet order change. The DM stated normally, changes to diet orders should be honored on the residents next meal if the forms or changes were communicated by 7:30 PM the previous night. During an interview on 09/27/23 at 2:14 PM, LVN B stated changes to a resident diet order was submitted via S-BAR Communication Form, which was given to the ADON. The ADON would contact the Physician and the physician would send an order. She stated Resident #206 has an order for puree diet and this change has already been communicated to the ND due to Resident #206 receiving a puree diet for lunch (on 09/27/23) instead of regular texture diet. She stated an S-BAR nor Order Communication Form was not completed as of today (09/27/23), which was when she relayed the discrepancy to ND. She stated Resident #206 likely received a puree diet due to her being sick upon admission. She stated a risk of a resident not having their preferences honored was depression. During an interview on 09/27/23 at 4:05 PM, the ND revealed he was informed about Resident #206's request for a new diet order on 09/27/23. He stated on 09/25/23, he did not receive a verbal report or Order Communication Form with notice that her diet order was changed. He stated he received a form on 09/27/23. During an interview on 09/28/23 at 8:44 AM, RN C revealed he was covering as ADON while their actual ADON was on leave. He stated when there was a diet order change, an SBAR form was submitted to the dietary department. He stated on Monday, the doctor visited Resident #206 during shift change. He stated the nurse working was an agency nurse (LVN D), and this was when a change was made to her diet order. He stated a communication form should have been submitted on 09/25/23, but he could not locate the completed form. He further stated the form was submitted on 09/27/23. During an interview on 09/28/23 at 9:00 AM, the RD stated that when there was a diet order change, the nurse would receive the order from the doctor and [the nurse would] relay the change to the food service department via a(n) [unspecified] form. She stated she assessed Resident #206 when she communicated that she didn't like the texture of her food. She stated this information was relayed to the SLP and they received the order from the physician for this change. She stated she would expect that this change would have been made by 09/28/23 as the order was received 09/25/23. She stated it was important to honor these changes as it was the resident's choice. During an interview on 09/28/23 at 10:00 AM, the DON stated yesterday (09/27/23), she met with the ND and reviewed the communication form used to reflect changes to resident diet orders. She stated she has started to in-service staff on the form and instructions for completion. The DON stated all changes should be reflected on the sheet, signed by the nurse, and taken to the dietary department. She stated the risks could be that if a resident fails a swallow study and needs a new diet texture, they could choke if inappropriately served. She stated regarding honoring resident preferences, this could be a quality of life issue as the facility has a duty to issue a homelike environment which included being respectful of residents choices. During an interview on 09/28/23 at 10:15 AM, LVN D stated he was not sure rather or not he worked on Monday. He stated he works on night shift on E-halls. He stated he was familiar with Resident #206 but was unsure of what diet texture she usually receives because she has had her meals by the time he arrives for work. He stated he did not put in an order for a changed diet texture for her. He stated the process was that if a new order was received, they can go into the system and input dietary orders. He stated then, there was a form completed by the nurse and filled out and given to the kitchen. During an interview on 09/28/23 at 11:33 AM, the SLP stated Resident #206 was admitted to the facility about a week ago with Puree diet texture. She stated on Monday, she was informed that the resident had requested a diet change. The SLP stated she evaluated Resident #206 for the three textures and found that she was safely consumed foods with the regular texture, adding that she had no history of swallowing issues. Following this assessment, the SLP stated she went into their charting software to input the order for the diet change. She stated in this situation, nurses were responsible for ensuring [residents] are getting the correct diet. Dietary should receive the order and it should be printed on the residents' meal ticket. She stated that nurses should double check that this change is reflected on the meal ticket. She stated previously, a communication form would be completed by the nurse, but due to changes to their charting software, she was unsure if these forms still existed. She stated when a resident was evaluated early in the morning, she would expect that the change to have been made by dinner; if evaluated the resident in the evening, she would expect the change to be made by the next morning. She stated risks of not honoring a diet change order was that the resident would receive the wrong diet texture which may be important if they had swallowing issues. Review of a policy titled Interdepartmental Notification of Diet (Including Changes and Reports), last revised October 2017, reflected: 1. When a resident is admitted or has a diet change, the nurse shall ensure that the food and nutrition services department receive a written or electronic notice of the diet order. 2. The food and nutrition services department will be notified verbally if the diet change occurs before a scheduled meal, or if the circumstances indicate that the written or electronic procedure will not be adequate to ensure service at the next meal. Review of a policy titled Resident Food Preferences, revised July 2017, reflected: 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. The dietitian and nursing staff, assisted by the physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences. 6. If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with. Review of an in-service dated 09/28/23 titled Dietary Communication Form, completed by the DON, reflected: - Use this form when you receive dietary orders and any changes - This will need to be signed by the nurse receiving the order - Take to Dietary Dept.

Based on observation, interview and record review, the facility failed to respect the residents' rights to personal privacy of medical record on 1 (Resident # 213) of 1resident reviewed for privacy in that: CMA A failed to lock the screen on a computer used for documenting residents' medications. This failure could place residents at risk of personal information being exposed to unauthorized persons, loss of dignity and low esteem. Findings include Review of Resident # 213's face sheet dated 09/28/2023 revealed an [AGE] year-old male admitted on [DATE] with diagnoses that include Pneumonia (Infection of the lung), Kidney failure (the kidney lose the ability to remove waste and balance fluids) Atrial Fibrillation (an irregular often rapid heart rate) and Fecal impaction (Harden stool that is stuck in the lower colon). Review of Resident # 213 MDS dated [DATE] revealed a Brief Interview for Mental status score of 14 (13 to 15 points indicates cognitive intactness). Observation on 09/27/2023 at 8:07 am while walking down hall A, revealed a medication cart with computer open with Resident # 213's medical information including date of birth and medical diagnoses. 2 staff members walked by, and one noticed screen was open and logged out of program. MA A returned to the cart at 8:10 am. Interview on 9/27/2023 at 8:10 am with MA A, she stated that with the new program she was unaware of a way to lock the screen without logging out and if you close the computer, it also logs you out. Interview with the DON on 9/27/2023 at 2:00 pm revealed her expectation was that when a staff member leaves a computer, they either close the program or the computer to protect the resident's privacy. She stated that as much traffic there was up and down the halls the resident was a risk for harm due to someone unauthorized finding out a medical diagnosis or even attempting to steal their identity. Interview with the ADM on 9/28/2023 at 11:00 am, stated that her expectation was that the staff always maintain HIPPA when conducting care and that includes but not limited to securing the medical record when you walk away from it. She stated that risk to the resident was potential harm as this practice can put the resident at risk for identity theft. Reviewed document Resident rights that speaks to confidentiality and was signed by all staff upon employment.

Based on interview and record review the facility failed to ensure each residents drug regimen was free from unnecessary drugs by having an indication for use for 3 (Residents #40,19 and 38) of 3 residents reviewed for unecessary drugs. The facility failed to have adequate indications for routine medications for Residents #40, 19 and 38. This failure could potentially affect all residents that receive routine medications from receiving unnecessary medications. Findings include Review of Resident # 40's face sheet dated 07/14/2023 revealed an [AGE] year-old female admitted on [DATE]. Her diagnoses included hypertension (elevated blood pressure), septicemia( infection of the blood stream), wound infection (infection to open wound), hyperlipidemia( High level of fat particles in the blood), thyroid disorder( disfunction of thyroid), and non-Alzheimer's dementia ( a group of thinking and social symptoms that interfere with daily function not related to Alzheimer's). Review of Resident # 40's MDS dated [DATE] revealed a BIMS score of 4 (0-7 indicates severe cognitive impairment). Review of Resident # 40's Physician's orders revealed the following medications with no indications for use : Ascorbic Acid 500 mg 1-tab po BID Calcium -vitamin D (Calcium500+D) 1-tab po daily Cholecalciferol 25 mcg po daily Levothyroxine 100 Mcg po daily Melatonin-pyridoxine 1 tab every night at bedtime MiraLAX 17 g po daily K-Tab 10 mEq po daily Pravastatin 20 mg I tab po every night at bedtime Senna 8.6 mg 1-tab po daily Zinc Sulfate 50 mg po daily Arginaide 1 packet po daily Prostat 30 ml po daily Aspirin 81 mg po daily Remeron 15 mg po every night at bedtime Review of Resident # 40's Medication administration record dated 9/28/2023 revealed the following medications where received by the resident. Ascorbic Acid 500 mg 1-tab po BID Calcium -vitamin D (Calcium500+D) 1-tab po daily Cholecalciferol 25 mcg po daily Levothyroxine 100 Mcg po daily Melatonin-pyridoxine 1 tab every night at bedtime MiraLAX 17 g po daily K-Tab 10 mEq po daily Pravastatin 20 mg I tab po every night at bedtime Senna 8.6 mg 1-tab po daily Zinc Sulfate 50 mg po daily Arginaide 1 packet po daily Prostat 30 ml po daily Aspirin 81 mg po daily Remeron 15 mg po every night at bedtime Review of Resident # 19's face sheet dated 5/26/2023 revealed an [AGE] year-old male with diagnoses that included Clostridium difficile colitis( inflammation of the colon caused by the bacteria Difficile), essential hypertension ( elevated blood pressure), acute myocardial infarction( heart attack), chronic obstructive pulmonary disease( a group of lung diseases that block air flow and make it difficult to breath), Dementia( group of thinking and social symptom that interfere with daily function), history of traumatic brain injury( brain dysfunction caused by an outside force), and psychotic disturbance( a mental disorder characterized by a disconnection from reality). Review of Resident # 19's MDS revealed a BIMS score of 03 (0-7 indicated severe cognitive impairment). Review of Resident # 19's Physician's orders revealed the following medications with no indications for use: Eliquis 5 mg 1 tab BID Vitamin D3 2,000 units po daily Cardizem LA 180 mg po daily (hold parameters in place) Nexium 20 mg tab 1 po daily Tramadol 50 mg 1 tab bid Potassium Chloride 20 [NAME] tab- ER po bid Florastor 250 mg cap po daily Review of Resident # 19's Medication Administration record dated 9/28/2023 indicated the resident received the following medications. Eliquis 5 mg 1 tab BID Vitamin D3 2,000 units po daily Cardizem LA 180 mg po daily (hold parameters in place) Nexium 20 mg tab 1 po daily Tramadol 50 mg 1 tab bid Potassium Chloride 20 [NAME] tab- ER po bid Florastor 250 mg cap po daily Review of Resident # 38's face sheet dated 9/28/23 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included obstructive sleep apnea ( intermittent airflow blockage during sleep), Major depressive disorder ( persistently low of depressed mood causing significate disruption in daily life), gastroesophageal reflux disease( a digestive disease in which stomach acid irritates the food pipe lining), Diabetes Mellitus, type 2 ( a chronic condition is which the body processes blood sugar) atrial fibrillation( an irregular usually fast heart rate), and chronic kidney disease( a condition where the kidney had trouble filtering the blood) Review of Resident # 38's MDS shows a BIMS score of 09 (8-12 suggest moderate cognitive impairment). Review of Resident # 38's Physician's orders revealed the following medications with no indication for use. Fluoxetine 20 mg 1 tab daily Entresto 24 mg-26 mg 1-tab po bid Vitamin D3 2000 mg daily po Jardiance 10 mg 1-tab po daily Zetia 10mg 1-tab po daily Ferrous Sulfate 325 mg 1-tab po tid Flonase 50 mcg spray 2 sprays into each nostril daily Furosemide 20 mg 1-tab po daily Gabapentin 200 mg po 1 cap daily Levothyroxine 50 mcg 1-tab po daily Metoprolol Succinate ER 25 mg I tab po daily (parameter in place with no indication for use) Crestor 10 mg 1-tab po daily Humalog 10 units subcutaneous injection with meals and bedtime Pantoprazole 40 mg 1-tab po daily Voltarin 1 app topical bid Aspirin 81 mg 1 daily po Levemir 24 units subcutaneous bid with meals Review of Resident # 38's Medication Administration Record dated 9/28/2023 indicated that the resident received the following medications Fluoxetine 20 mg 1 tab daily Entresto 24 mg-26 mg 1-tab po bid Vitamin D3 2000 mg daily po Jardiance 10 mg 1-tab po daily Zetia 10mg 1-tab po daily Ferrous Sulfate 325 mg 1-tab po tid Flonase 50 mcg spray 2 sprays into each nostril daily Furosemide 20 mg 1-tab po daily Gabapentin 200 mg po 1 cap daily Levothyroxine 50 mcg 1-tab po daily Metoprolol Succinate ER 25 mg I tab po daily (parameter in place with no indication for use) Crestor 10 mg 1-tab po daily Humalog 10 units subcutaneous injection with meals and bedtime Pantoprazole 40 mg 1-tab po daily Voltarin 1 app topical bid Aspirin 81 mg 1 daily po Levemir 24 units subcutaneous bid with meals Interview with the DON on 9/27/2023 at 5:30 pm, she said she was not aware that there were medications without a diagnosis that indicated what they were for. She stated she just started and have not had a chance to look at anything. She stated there was a potential harm to the resident as they may not be being treated for all their disease processes. Interview with the ADM on 9/28/2023 at 11:00 am, she stated that she was under the impression that indication for the medication was part of the physician order and she was not sure how it could have been missed by so many practitioners that review the charts. She stated that she saw a significate potential for harm to the residents who might not get the correct treatment needed. Attempted to contact Pharm on 9/28/2023 at 10:00 am and 11:30 am, no answer and no return phone call . Record review of the policy titled Medication and treatment orders undated read orders for medications must include a. name and strength of the drug b. number of doses, start and stop date, and/or specific duration of therapy; c. dosage and frequency of administration d. Route of administration E. Clinical condition or symptoms for which the medication is prescribed.

Based on interview, and record review, the facility failed to implement their written policies and procedures for reporting all allegations involving abuse, neglect, and injuries of unknown source in accordance with the state law for 1 of 1 resident (Resident #1) reviewed for abuse and neglect The facility failed to provide evidence that an allegation of abuse was reported to law enforcement officials immediately. The facility reported the allegation of abuse on 08/20/23. This failure could place the census of 99 residents at risk for abuse and neglect. Findings included: Review of the facility policy titled Abuse. Neglect, Exploitation or Misappropriation - Reporting and Investigating, last revised September 2022, reflected the suspicion of abuse must be immediately reported to law enforcement agencies. Review of Resident #1's electronic health record , indicated Resident #1 was [AGE] years old and admitted on [DATE] with diagnoses that included Macular degeneration (eye disease), insomnia, GERD (reflux), HTN (high blood pressure), depression, hallucinations, and Dementia without behavioral disturbance. Review of Resident #1's MDS dated [DATE] indicated Resident #1 had a BIMS of 5 . Resident #1's MDS indicated she utilized a wheelchair for mobility and required limited, one-person, physical assist for ADL's. Review of the provider investigation report dated 08/20/23 indicated an allegation of abuse was reported to the state agency on 08/20/23 regarding Resident #1. The investigation outlined an allegation of verbal Resident Abuse towards Resident #1 by an agency nurse. It was noted on the investigation report that police were not notified . The report concluded that the allegation investigation, which involved in-services, resident safety polls and witness statements, of abuse was unsubstantiated. Review of an in-service titled Abuse and Neglect dated 08/2023 was conducted, as well as review of in-services titled Abuse and Neglect, Resident Rights, Ethics and Dementia dated 08/29/23. During an interview on 09/08/23 at 3:56 PM, the DON stated she was unsure if the previous, now resigned, administrator s ubmitted a police report for the allegation of abuse against Resident #1. The DON stated she does not know why the incident was not reported to the police. She stated this would have been the responsibility of the administrator, at the time the allegation was received, to report the allegation to police. She identified the administrator as the Abuse Coordinator. The CMS 672 dated 09/08/23 indicated 99 residents resided in the facility.

Based on observation, interview, and record review the facility failed to ensure 1 of 5 (Resident #1) sampled Residents was treated with dignity, respect and adhere to HIPPA laws. CNA A took a photograph of Resident #1 lying in bed with her gown up and adult brief exposed. This failure could affect all Residents in the facility and could result in Residents not being treated with dignity and respect. The findings were: Record review of Resident #1's Admission face sheet dated (3/22/2023) revealed an admitted [DATE] with Esophageal obstruction (obstruction of the esophagus), Fracture of unspecified part of neck of left femur ( a type of high hip fracture of the thigh bone(femur), age-related osteoporosis w/o current pathological fracture( a disorder characterized by reduced bone mass that could increase fractured bones), psychophysiological insomnia (heightened arousal and learned sleep preventing associations that result in a complaint of insomnia). Record review of Resident #1's care plan (5/14/2019) revealed Resident # 1 required extensive assistance to complete ADL's and mobility tasks. Resident # 1 requires extensive assistance with x1 with bed mobility, change to sit to stand, and to transfer. Record review of Resident #1's MDS (3/8/2023) revealed a Brief Interview for Mental Status (BIMS) score of 99 (Resident was unable to complete the interview). Further review revealed Resident #1 required extensive assistance with bed mobility, transfer, and personal hygiene. During an observation on 3/21/2023 at 4:00pm of photo taken by CNA A, provided by ADM, reflected Resident # 1 lying on side with gown up and adult brief exposed, Resident # 1 did not appear to be facing into the pillow of the bed. Resident # 1 appeared to be laying on side, pillow was observed in picture above Resident # 1 head not on top of head. Review of written statement dated 3/7/2023 by CNA D, reflected she laid the Resident #1 down in bed on her right side at approx. 8:00pm. Stated Resident # 1 was laid on her side because she was going to come back to get her up for her shower. Stated when she left Resident # 1 she was lying in bed covered with a blanket because Resident # 1 indicated that she was cold. CNA D reported that CNA A came in the breakroom showing pictures of Resident # 1, she stated she thought that was against HIPPA laws, so she called in a report. In a phone interview on 3/21/2023 at 2:00pm CNA A, stated she was walking down the hall and heard the Resident moaning. She stated when she went into the room, she found Resident # 1 lying face down on her bed with both arms underneath. She stated the Resident did have a blanket however, it was down over her lower legs not covering her adult brief. She stated she called for immediate assistance and LVN A assisted her repositioning Resident #1 in her bed. CNA A stated she took the picture of Resident #1 because she wanted to find out who had placed the Resident in that position. CNA A stated she showed the picture to some people in the breakroom, to another nurse, and another staff going down the hall before she sent the picture to the DON. CNA A stated she did not want anyone to think she had placed Resident #1 in bed that way. In an interview on 3/21/2023 at 2:30pm with CNA B stated she was sitting in the breakroom with others when CNA A came in and showed the picture of Resident #1, she stated CNA A stated, this is how I found Resident # 1 and ask if she placed Resident#1 in the bed and left her like that way. CNA B stated she did not work on that hall and did not place Resident #1 in her bed. CNA B stated she then showed the picture to another staff who was also sitting in the breakroom. In a phone interview on 3/21/2023 at 6:30pm with CNA C, stated she was walking down the hall and CNA A showed her the picture of Resident #1. She stated CNA A stated, this is how I found Resident # 1. She stated she really doesn't know why she showed her the picture because she knows that she was not working on that hall. In an interview with on 3/21/2023 at 3:00pm the DON stated when she learned of the picture from CNA A, she stated CNA A sent her a copy of the picture of Resident # 1. She stated the picture reflected Resident # 1 lying in bed on her side, she states Resident # 1 face did not appear to be face down in the pillow and the pillow was at the top of the bed in the picture that she saw. The DON stated she was not aware if CNA A showed the picture to others but heard from other staff interviewed that she might have. The DON stated she advised CNA A that it was against the facility policy to take pictures of the Residents. She stated she advised CNA A that she needed to delete that picture from her cell phone. She stated all staff were in-serviced on abuse/neglect and Resident rights. The DON stated it was not reported because she was not aware that the staff had showed the photo to others. She stated at the time she thought she had been the only person who had seen the photo. She stated she advised her that it was against the facility policy, and that she could get fired for taking any type of pictures of the Residents. She stated she gave a verbal warning to the staff and will be completing a written warning once she returned to work on March 24, 2023, she stated she also will be in-serviced over photos or Residents and HIPPA laws. She stated all staff have been in-serviced over abuse/neglect, Resident rights, and positioning and transferring. The DON stated she did not think it was malicious, the Resident was not identifiable in the picture, however explained that pictures cannot be taken of the Residents. The DON stated this was an isolated incident. Records review on 3/21/2023 at 3:30pm on staff personnel file, did not reflect any written documentation of the verbal warning to staff . In an interview on 3/21/2023 at 4:45pm the ADM, stated she received the picture from the DON. She stated she advised the DON that she needed speak with CNA A about taking pictures of the Residents because it is against their policy for pictures to be taken of the Residents. The ADM stated the DON did a verbal warning to CNA A and stated all staff were in-serviced on abuse/neglect and Resident's rights. The ADM stated this was an isolated incident. She stated when she spoke with the DON about it, they were not aware that the pictures had been shown to others. She stated the staff is a good staff who just made a mistake and felt that she took the picture to show other staff what not to do. She stated they took the information in-serviced the staff over transferring/ positioning of Residents, abuse/neglect and resident rights. Reviewed Resident Right's policy dated 11/2021 reflected: The Resident has a right to be treated with dignity, courtesy, consideration, and respect. Reviewed Abuse/Neglect policy dated 10/14/2022 reflected: Protecting Resident Privacy and Prohibiting Mental abuse related to photographs and audio/video recording by nursing home staff. Taking photographs of a Resident without the Residents, or designated representatives, written consent is a violation of the Resident's right to privacy and confidentiality. Taking unauthorized photographs of Residents in any state of dress or undress using any type of equipment (e.g., smart phone and other electronic devices) is a violation of a Resident's right to privacy and confidentiality.

Based on observation, interview and record review the facility failed to ensure all drugs and biological medications were not past their expiration dates and had readable labels were labeled in accordance with professional principles for 1 of 4 medication aide carts (C-Hall medication cart) reviewed and also failed to ensure that drugs and biologicals used in the facility were secured properly for 1 of 4 nurse medication carts (E-Hall nurse medication cart) reviewed for label/store drug. The facility failed to ensure expired and/or discontinued medications were removed from the medication carts, and that all medication on the cart had readable labels. The facility further failed to ensure medication carts were not left unlocked and unsupervised. This failure could place residents at risk of not receiving the intended therapeutic benefits of their medications and could place all residents at risk for possible drug diversion. Findings include: Observation on 07/21/2022 at 3:00 PM revealed the facility's C-Hall medication cart with a bottle of cetirizine hydrochloride 10 mg expired on 06/2022. Further observation of the medication cart revealed a bottle of Benadryl 25 mg with a handwritten open date of 12/16/2021. The expiration date on the bottle was unreadable. The C-Hall medication cart also contained a bottle of melatonin 1mg with a label with no readable open date or readable expiration date. In an interview on 07/21/2022 at 3:05 PM MA B stated it was the responsibility of the medication aide to ensure medications on the cart are not expired. She stated she did not notice the medication cetirizine hydrochloride was expired or that the labels on the benadryl and melatonin were not readable. MA B stated the medication bottles should be checked when the medication is administered. MA B stated one resident was receiving the cetirizine hydrochloride daily. MA B further stated no residents had current orders for benadryl or melatonin. Observation on 07/21/2022 at 3:32 PM revealed an unlocked nurse medication cart on E-Hall in the hall next to the nurses station with drawers facing the patient hall where residents could access them. In an interview on 07/21/2022 at 3:39 PM LVN C stated the cart was open and should be locked. She stated she did not leave it open that the other LVN working on the unit did, but she was not currently on the unit. LVN C stated the cart should be locked to ensure no one is able to get into the cart and remove medications. In an interview on 07/21/2022 at 3:50 PM the DON stated the medication carts should be locked at all times to prevent unauthorized removal of medications from the carts and to protect the residents. The DON further stated that all medications on the carts should have readable labels and carts should be checked by the medication aides during the medication pass to ensure no expired medications are on the carts to ensure residents are not receiving expired medications to might have altered therapeutic effects. Review of the facility's policy Storage of medications dated 11/2020 reflected The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments .Only persons authorized to prepare and administer medications have access to the locked medications. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling .discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 8 residents (Resident #31 and #34) reviewed for nutrition. -The facility failed to provide Resident #31 with physician ordered nutrition supplement with her meals and fortified cereal with her breakfast. -The facility failed to provide Resident #34 with physician ordered nutrition supplement. These failures could place residents at risk for decreased nutritional status, decline in health, serious illness or hospitalization . Findings included: Review of Resident #31's face sheet dated 07/21/2022 revealed Resident #31 was an [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of history of a hip fracture, major depressive disorder, high blood pressure and dementia (disorder that causes impairments in thinking, memory and behavior). Review of Resident #31's annual MDS assessment dated [DATE] revealed Resident #31 had a BIMS score of zero to indicate severely impaired cognition. Resident #31 required extensive assistance by two or more people for ADL's and supervision with one-person physical assist for eating. Resident #31 did not require a therapeutic or mechanically altered diet. Review of Resident #31's care plan dated 10/23/2019 revealed Resident #31 at risk for weight loss and interventions included diet order of regular diet, mechanically soft texture as needed and offer house supplement as needed and document amount taken. Review of Resident #31's physician orders dated 03/16/2021 revealed Resident #31 to have a regular diet, regular texture and thin liquids with fortified cereal. Resident #31 ordered [LIQUID SHAKE SUPPLEMENT] as a supplement for weight stabilization. An observation on 07/20/2022 at 1:00 PM revealed Resident #31 did not have the nutrition supplement ordered at meals with her tray food. Review of Resident #31's meal ticket dated 07/20/2022 for lunch time meal revealed Resident #31 had [SUPPLEMENT NAME] ordered and health shakes at every meal. Review of Resident #34's face sheet dated 07/21/2022 revealed Resident #34 to be an [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of chronic obstructive pulmonary disease, high blood pressure, dementia and history of a traumatic brain injury (injury to the brain caused by an external force). Review of Resident #34's admission MDS assessment dated [DATE] revealed Resident #34 to have a BIMS score 6 to indicate severely impaired cognition. Resident #34 required extensive assistance by two or more people with ADL's. Resident #34 had no swallowing issues and did not require a therapeutic or mechanically altered diet. Review of Resident #34's care plan (undated) revealed Resident #34 had the potential for weight loss with interventions to include the dietitian following up at least quarterly, determine food preferences, monitor food intake and allow ample time to consume meals. Review of Resident #34's physician order dated 06/07/2022 revealed Resident #34 was ordered health shakes twice daily with meals for weight stabilization. An observation on 07/20/2022 at 1:03 PM revealed Resident #34 did not have a health shake with his meal. Review of Resident #34's meal ticket revealed Resident #34 was ordered a mighty shake. In an interview on 07/20/2022 at 1:05 PM, CNA A stated she did not know why Resident #31 did not have his health shake. She said she would get him one. She stated Resident #34 received her [SUPPLEMENT NAME] from the medication aide with her medications. She said she would get her a health shake to go with her meal. She said the meal ticket was unclear for Resident #31 because Resident #31 did not receive [SUPPLEMENT NAME] with her meals. She said Resident #31's ticket needed to be revised. In an observation on 07/20/2022 at 1:10 PM, Resident #34 received his health shake from CNA A and drank 100% of it. In a follow-up observation on 07/21/2022 at 7:40 AM, Resident #31 was not observed to have fortified cereal with her breakfast . Review of Resident #31's meal ticket dated 07/21/2022 for breakfast revealed Resident #31 had fortified cereal ordered as part of her breakfast. In an interview on 07/21/2022 at 7:45 AM CNA D stated Resident #31 did not eat the fortified cereal and they did not give it to her. She said Resident #31's meal ticket needed to be updated. She said she did not know why her meal ticket was not updated and the nurses notified the kitchen staff of changes needed to resident meal tickets. In an interview on 07/21/2022 at 10:07 AM, NTR DIR said when a resident had a changed or new diet order a nurse input the order into the resident's EMR and then completed a diet order communication change form. He said once the kitchen staff received the diet order communication change form, he or one of the assistant dietary managers will make the change to the resident's meal ticket information. He said he had not received any dietary changes for Resident #31 or Resident #34. He said what was on the resident's meal ticket was what should be on their tray. He said even if the resident was known to not eat fortified cereal, it should still be offered until it is discontinued from the meal ticket. He stated health shakes or mighty shakes should be brought with the meal as designated on the meal ticket from the kitchen. In an interview on 07/21/2022 at 10:20 AM, the ADON stated Resident #34 should have had his health shake with his meal and she did not know why staff did not serve it to him. She said the fortified cereal for Resident #31 needed to be discontinued if she did not want to eat it. She said she would reach out to the doctor for further orders for Resident #31. She stated the charge nurse should be checking each resident's meal ticket compared with the tray to ensure the resident received all of their food and supplements as ordered. She stated residents who did not receive their health shakes or supplements would be at risk for weight loss. In an interview on 07/21/2022 at 3:47 PM, the DON stated the resident's food on their tray should match their meal ticket and their meal ticket should match their physician orders. She said even if a resident was known to not eat the fortified cereal it should be offered or discontinued. She said she would check all resident physician orders with meal tickets on the locked unit to ensure consistency with what residents received on their trays. Review of Resident #31's Nutrition Update/Quarterly Review dated 05/27/2022 revealed Resident #31 required a regular diet with regular portions and [NUTRITION SUPPLEMENT] with medications. No additional supplement was noted for Resident #31. Review of Resident #34's Nutrition Update/Quarterly Review dated 05/27/2022 revealed Resident #34 required a regular diet with no documented nutrition supplement recommended. Review of Diet orders policy (undated) revealed the purpose of the policy was to ensure residents and patients are given an accurate meal. The policy noted physicians will be notified of the available diets in the facility and diets will be offered as ordered by the physician. The dietetics professional will be notified of any special diets not listed on the menu. Resident response to special and modified diets will be evaluated and ineffective or inappropriate diets (including texture modifications) will be referred to the physician for discontinuation or change to a more appropriate diet.

Based on interview and record review, the facility failed to review and revise the comprehensive care plan for one (1) of 6 residents (Resident #1) reviewed for falls that included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment:: Resident #1's current care plan (dated [DATE]) did not list new approaches after a fall on [DATE] to prevent future falls with injury. Resident #1's fall on [DATE] resulted in fractures to her right nasal bone, anterior wall of the right maxillary sinus and a [MEDICAL CONDITION] process of C6 (vertebrae at the base of the neck). Resident #1 died in the facility on [DATE]. This was determined to be Past Non-Compliance at Immediate Jeopardy (IJ) due to the facility having implemented actions that corrected the Non-Compliance prior to the beginning of the investigation. This deficient practice of failing to revise a care plan with interventions to prevent falls could affect 5 additional residents identified at fall risk. Findings include: Review of the Face Sheet in Resident #1's closed record revealed the following Diagnoses: [REDACTED]. Resident #1 was [AGE] years old with an admission date of [DATE] to the facility. Review of a Minimum Data Set (MDS), an assessment dated [DATE] revealed that Resident #1 was a fall risk. Review of Incident/Accident Report for Resident #1 revealed the following: [DATE] "Heard bed alarm from patient room across hall and Medication Aide call for help. Resident laying on floor on right side. VS (vital signs) and neuro checks started. Assessed, c/o (complains of) pain and response upon palpation of right hip and left lower rib area. No bruising, swelling or drainage noted. Resident jumps, guards, and yells at palpation of right hip and left rib area. Send to ER (emergency room for evaluation). Resident returned from ER at 2300 (11:00 PM) no fractures. ,[DATE] Notifying Doctor for UA (urinary analysis) for falls. Continue use of TABS Alarm (The Pull-Tab Alarm features a pull-string that attaches magnetically to the alarm with a garment clip to the resident.) When the resident attempts to rise out of their chair or bed the pull-string magnet is pulled away from the alarm this causes the alarm to sound, alerting the caregiver), monitor closely. Review of a laboratory report for Resident #1 dated [DATE] revealed no urinary tract infection. Review of Incident/Accident Report for Resident #1 revealed the following: [DATE] "At 1900 (7:00 PM) this nurse heard a loud thump and someone crying, found Resident #1 lying face down on floor with head stuck in the legs of the Hoyer Lift (the Hoyer Lift was in the hallway next to resident's room), unable to get resident free, also needed to immobilize resident's head, resident was crying and blood was visible, attempted to cushion head with a towel between head and metal legs of Hoyer. Cause of this occurrence: Resident got up oob (out of bed), disconnected TAB alarm from herself. Alarm was found on bed still connected, and never alarmed. Assess and sent to ER for evaluation. Resident returned to facility. Fractures of C6, right maxillary sinus and right nasal bone. C collar to stay in place at all times for 6 weeks. Medicate for pain PRN. " 1) Review of Resident #1's Care Plan dated [DATE] revealed the following: [DATE] Problem: Potential for Falls due to Dementia Goal: I will have no injuries due to falls for the next 90 days. I will not have any falls over the next 90 days Approach: 1) Encourage resident to ask staff for assist. 2) Educate resident in the use of the call light. 3) Encourage use of the call light. 4) Call light within reach. 5) Provide adequate lighting day and night. 6) Keep environment free of clutter. 7) Encourage resident to use walker at all times. 8) Encourage non-skid shoes 9) Anticipate needs and respond promptly. 10) [DATE] [MEDICATION NAME] (pain medication) ,[DATE] mg (milligrams) 1 PO (by mouth) Q (every) 6 hours PRN (as needed) pain 11) Main mode of transportation is by w/c (wheelchair). 12) Ambulates for short distances with limited assist of 1 using gait belt. 13. [DATE] move resident to RM C6A due to family request in an attempt to reduce falls. Resident #1's Care Plan was not updated to reflect the resident's fall on [DATE] and the Care Plan did not reflect the use of a tab alarm to alert the staff that Resident #1 was getting out of bed.The Care Plan did not reflect closer monitoring or supervision by the nursing staff. During an interview on [DATE] at 1:30 PM, the Assistant Director of Nurses (ADON) stated that she had not updated Resident #1's Care Plan to reflect the fall on [DATE]. She stated that the facility decided to continue with the tab alarms and to monitor Resident #1 closely. She stated that after Resident #1's fall on [DATE] the Care Plan was updated and all Care Plan's had been be updated to reflect resident's falls. During an interview on [DATE] at 1:45 PM, Resident #1's Primary Care Physician (PCP) stated that he was out of town when Resident #1 fell on [DATE], but he was called by the Justice of the Peace (JP) on [DATE] when Resident #1 died in the facility. He stated that he told the JP that the fall could have contributed to Resident #1's death. The PCP stated that Resident #1 had a sick sinus rhythm (low heart rate) and the family did not wish a pacemaker so Hospice became involved in her care. The PCP stated that Resident #1 had severe [MEDICAL CONDITION] and had a very long history of falls with fractures before she had entered the facility. The nursing home has always notified me of any concerns with Resident #1. He stated that after her fall ([DATE]) she quit eating and continued to decline. During an interview on [DATE] at 10:05 AM, the ADON stated that Resident #1's door was left open at all times so staff could visualize her in the bed when they walked by. She stated that the staff performed checks on Resident #1 every two hours. She stated that she should have updated Resident #1's care plan. Review of a facility policy with a revised date of [DATE], titled "Accidents and Incidents" did not contain a provision for updating the residents care plan after a fall. It was determined these failures placed Resident #1 in an Immediate Jeopardy situation [DATE] through [DATE]. The facility took the following actions to correct the Non-Compliance on [DATE]. During an interview on [DATE] at 10:05 AM, the Director of Nurses stated that the facility would start documenting when they had tried all approaches to prevent falls and to update care plans. The facility completed CMS 672 form revealed a census of 77.

Based on interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and to provide supervision for one (1) of 6 residents (Resident #1) reviewed for falls. Resident #1 climbed out of bed on [DATE] and fell on a Hoyer lift (mechanical device to lift a resident from a chair or bed) that had been left in an alcove by Resident #1's door. Resident #1 received fractures to her right nasal bone, anterior wall of the right maxillary sinus and a fracture of the spinous process of C6 (vertebrae at the base of the neck). Resident #1 was treated in the emergency room and returned to the facility, and died in the facility on [DATE]. This was determined to be Past Non-Compliance at Immediate Jeopardy (IJ) due to the facility having implemented actions that corrected the Non-Compliance prior to the beginning of the investigation. This deficient practice could affect an additional 5 residents identified at fall risk. Findings include: Review of the Face Sheet in Resident #1's closed record revealed the following Diagnoses: [REDACTED]. Resident #1 was [AGE] years old with an admission date of [DATE] to the facility. Review of Incident/Accident Reports for Resident #1 revealed the following: [DATE] "Heard bed alarm from patient room across hall and Medication Aide call for help. Resident laying on floor on right side. VS (vital signs) and neuro checks started. Assessed, c/o (complains of) pain and response upon palpation of right hip and left lower rib area. No bruising, swelling or drainage noted. Resident jumps, guards, and yells at palpation of right hip and left rib area. Send to ER (emergency room for evaluation). Resident returned from ER at 2300 (11:00 PM) no fractures. ,[DATE] Notifying Doctor for UA (urinary analysis) for falls. Continue use of TABS Alarm (The Pull-Tab Alarm features a pull-string that attaches magnetically to the alarm with garment clip to the resident. When the resident attempts to rise out of their chair or bed the pull-string magnet is pulled away from the alarm this causes the alarm to sound, alerting the caregiver. The Tab Alarm should be attached to the resident's clothing in a way that is not assessable to the resident), monitor closely." Review of a laboratory report for Resident #1 dated [DATE] revealed no urinary tract infection. [DATE] "At 1900 (7:00 PM) this nurse heard a loud thump and someone crying, found Resident #1 lying face down on floor with head stuck in the legs of the Hoyer lift, (stored in the hallway next to resident's room) unable to get resident free, also needed to immobilize resident ' s head, resident was crying and blood was visible, attempted to cushion head with a towel between head and metal legs of Hoyer. Cause of this occurrence: Resident got up oob (out of bed), disconnected TAB alarm from herself. Alarm was found on bed still connected, and never alarmed. Assess and sent to ER for evaluation. Resident returned to facility. Fractures of C6, right maxillary sinus and right nasal bone. C-collar to stay in place at all times for 6 weeks. Medicate for pain PRN." Review of a facility Minimum Data Set (MDS), an assessment dated [DATE] revealed that Resident #1 was a fall risk. Review of Resident #1's Care Plan dated [DATE] revealed the following: [DATE] Problem: Potential for Falls due to Dementia Goal: I will have no injuries due to falls for the next 90 days. I will not have any falls over the next 90 days Approach: 1) Encourage resident to ask staff for assist. 2) Educate resident in the use of the call light. 3) Encourage use of the call light. 4) Call light within reach. 5) Provide adequate lighting day and night. 6) Keep environment free of clutter. 7) Encourage resident to use walker at all times. 8) Encourage non-skid shoes 9) Anticipate needs and respond promptly. 10) [DATE] Vicodin (pain medication) ,[DATE] mg (milligrams) 1 PO (by mouth) Q (every) 6 hours PRN (as needed) pain 11) Main mode of transportation is by w/c (wheelchair). 12) Ambulates for short distances with limited assist of 1 using gait belt. 13. [DATE] move resident to RM C6A due to family request in an attempt to reduce falls. Resident #1's Care Plan was not updated to reflect the resident's fall on [DATE] and the Care Plan did not reflect the use of a tab alarm to alert the staff that Resident #1 was getting out of bed. The Care Plan did not reflect closer monitoring and supervision by the nursing staff. During an interview on [DATE] at 10:05 AM, the Director of Nurses (DON) stated that Resident #1 fell into the Hoyer lift after climbing out of bed and walking into the hallway. She stated that the Hoyer lift was in an alcove in front of an unused shower room in the hallway on the secure unit. She stated that the facility immediately in-serviced all staff on [DATE] that Hoyer lifts were to be placed in the unused shower room when the Hoyer lifts were not being used to transfer residents. The DON stated that Resident #1 had been declining since she was hospitalized in [DATE] for a decreased pulse rate and placed on Hospice (end of life care) at that time. She stated that Resident #1 fell on [DATE] and was treated and released from the emergency room at the hospital and Resident #1 died in the facility on [DATE]. The DON stated that the facility would start documenting when they had tried all approaches to prevent falls. During an interview on [DATE] at 1:45 PM, Resident #1's Primary Care Physician (PCP) stated that he was out of town when Resident #1 fell on [DATE], but he was called by the Justice of the Peace (JP) on [DATE] when Resident #1 died in the facility. He stated that he told the JP that the fall could have contributed to Resident #1's death. The PCP stated that Resident #1 had a sick sinus rhythm (low heart rate) and the family did not wish a pacemaker so Hospice became involved in her care. The PCP stated that Resident #1 had severe osteoporosis and had a very long history of falls with fractures before she had entered the facility. The nursing home has always notified me of any concerns with Resident #1. He stated that after her fall ([DATE]) she quit eating and continued to decline. During an interview on [DATE] at 10:00 AM, the DON stated that every time any staff walked down the hall on the secure unit the staff were to check on Resident #1. She stated, "Nursing staff discussed Resident #1's fall on [DATE] and did not think she had a pattern of getting out of bed. We visited with the aides on the unit and did not think we needed to change anything. We did not document our discussions." During an interview on [DATE] at 11:00 AM, Certified Nurse Aide (CNA) B stated that she put Resident #1 to bed and she and CNA C went to take out the trash. She stated that when they passed Resident #1's door the resident was in the bed and she could see the alarm was attached. She stated the nurse that was passing medications was half way down the hall. CNA B stated that they had used the Hoyer lift approximately 15 minutes before and had placed it in the alcove by Resident #1's door. She stated that they were summoned back in the building to help with Resident #1. CNA B stated that Resident #1 was lying in the floor with her head on the feet of the Hoyer lift and blood was on the floor. She stated that Resident #1's alarm was still clipped to the bed. and her heel protectors were on the bed. During an interview on [DATE] at 10:35 AM, Licensed Vocational Nurse (LVN) D stated that she had been passing medications down the hall from Resident #1's room and had her back to the room. She stated that the door to Resident #1's room was left open to help staff check on her. She stated that the Hoyer lift was in the small alcove in the hallway by Resident #1's room. During an interview on [DATE] at 10:48 AM, CNA C stated that they had placed Resident #1 in the bed with the alarm (garment clip) attached to her gown and the bed. She stated they were outside for about 5 minutes emptying trash when they were told Resident #1 had fallen. She stated that the Hoyer Lift was in the hallway in front of the shower room and next to Resident #1's room. She stated that they are now to place the hoyer lift in the unused shower room not in the hallway. During an interview on [DATE] at 11:22 AM, LVN E stated that she heard a thud and saw Resident #1 lying on the floor with her head on the metal legs of the Hoyer Lift. She stated that the alarm did not sound and was later found still attached to the bed. LVN E stated that the door to Resident #1's room was left open because she was a fall risk and staff could see her when they were in the hallway. She stated that Resident #1 had been physically declining and had been on Hospice care. LVN E stated that she notified the family and Resident #1 was sent to the emergency room . Review of Resident #1's hospital radiology report dated [DATE] at 9:15 PM revealed the following: Impression: 1. Minimally displaced fracture of the spinous process of C6. 2. Comminuted, depressed fracture of the anterior wall the right maxillary sinus and mildly displaced right nasal bone fracture. Review of Resident #1's hospital radiology report dated [DATE] at 10:20 PM revealed the following: Impression: 1. No acute intracranial abnormality. 2. Comminuted displaced fracture of the anterior wall of the right maxillary sinus. 3. Right frontal scalp hematoma. Review of a facility in-service dated [DATE] revealed all staff had been in-serviced on where to store the Hoyer Lift when not in use. It was determined these failures placed Resident #1 in an Immediate Jeopardy situation [DATE] through [DATE]. The facility took the following actions to correct the Non-Compliance on [DATE]. Observations on [DATE] from 9:15 AM to [DATE] at 12:30 PM revealed no Hoyer Lift or other hazards in the facility hallways. During interviews on [DATE] between 12:05 PM and 12:30 PM, staff stated that the Hoyer Lift was to be stored in the unused shower room when not in use. Review of Incident/Accident logs for May-July, 2012 did not reveal any accidents related to hazards other than Resident #1's fall on [DATE]. The facility completed CMS 672 form revealed a census of 77.