Every finding on record at Mount Olivet Home

Based on observation, interview and document review the facility failed to ensure 1 of 1 commercial can opener was kept in a clean and sanitary manner and failed to ensure dry goods removed from original packaging were stored in a manner to reduce the risk of cross-contamination. These findings had the potential to affect all 80 residents, staff, and visitors who consumed food prepared from the main production kitchen.Findings include:During initial tour with director of culinary services (DCS) on 5/11/26 at 11:10 a.m., a series of 4 white-colored plastic bins were observed in the food preparation area. The wheeled bins were on the floor and were labeled for flour, white sugar, rice and powdered sugar. The flour bin was approximately 1/3 full of white flour and a black-colored scoop was inside, partially covered with flour including the scoop's handle. The bin labeled white sugar had a yellowish-tan dry matter inside the right lateral wall. The inside front wall of the bin had red dry matter 6-7 centimeters (cm) in diameter. Also, the rims around the lids of all 4 bins were dirty with dark like dust particles. DCS verified the findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. Additionally, an [NAME] brand can opener attached to a counter was inspected. The can opener's blade was halfway covered with dry, red-colored matter.During a subsequent kitchen tour on 5/12/26 at 11:35 a.m., the can opener's blade still had dry, red-colored matter, but the red matter had been pushed upward by 0.2 cm, and a small light amber particle was noted right below the red-colored matter.During interview on 5/12/26 at 11:44 a.m., the cook (C)-A stated he used the can opener in the morning to open a can of cream of corn. The cream of corn was used for preparing today's lunch.During interview on 5/12/26 at 11:46 a.m., the DCS verified the presence of dry matter on the can opener. DCS stated the can opener should be washed every time it was used to prevent cross contamination. DCS also stated the dry bins should be cleaned inside and out, and the scoops should never be left inside the containers to prevent cross contamination and food born illnesses.Facility's policy titled Dry Storage Areas dated 2019, indicated the dry storage areas will be maintained to keep food safe and free of infestation or contamination.Facility's policy titled Sample Cleaning Schedule dated 2019, indicated the can openers should be clean after each use.

Based on observation, interview, and document review the facility failed to provide a dignified experience for 1 of 2 residents (R20) who was receiving medications. Findings include: R20's annual Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others and other behavioral symptoms. It further included diagnoses of dementia (severe with psychotic disturbance), visual hallucinations, general anxiety disorder, post-traumatic stress disorder (PTSD), and delusional disorder. R20's care area assessment (CAA) also dated 3/18/26, triggered for cognitive loss/dementia due to being unable to respond to questions on the Brief Interview for Mental Status (BIMS) assessment due to cognition and had diagnoses of Alzheimer's disease, dementia, visual hallucinations and delusional disorder. R20's care plan dated 3/12/26, indicated R20 had an alteration in mood/behavior/sleep due to diagnoses of Alzheimer's disease, dementia, generalized anxiety disorder, history of paranoia, public outburst and accusations of rape and people throwing meds down her throat. R20 could be agitated and aggressive during cares. R20's care plan included the following interventions:-Redirect and reapproach when resistive/combative. -Offer to go for a walk holding hands if wanting to leave the unit (elevator open, door to stairs/hallway) -Ok to allow resident to come to the dining room when ready. -Provide comfort items when resident is having challenges such as a snack or music- depending on where she is -Provide reassurance that needs will be met.-Calm approach During observation and interview on 5/13/26 8:30 a.m., R20 was in the dining room sitting at the table. Registered nurse (RN)-A brought her medications to administer them. RN-A attempted to pour the medications out of a small plastic medication cup into R20's mouth. R20 removed one of the medications (Divalproex) from her mouth and threw it on the floor. RN-A then attempted to pour the remaining medications in her mouth from the plastic medication cup while R20 was moving her head back and forth and attempting to pull away. In a raised voice, RN-A stated the residents name and told her she needed to take her medications. RN-A then pulled her chair back from the table and picked up the Divalproex from the floor and put it in a separate medication cup and asked R20 why she wouldn't take her medications. R20 replied because you weren't being nice. RN-A walked out of the dining room and back to the medication cart with the remaining medications she had refused to take. RN-A stated R20 would take them later and she always has a behavior when taking her morning medications. During interview on 5/13/26 at 1:41 p.m., RN-A stated if a resident refused to take their medications, they should reapproach at a later time. If they notice a pattern with medication refusals, they should try to figure out why the resident was refusing especially because there are residents who can't express themselves, so they should try everything to get them to take their medications. There are different things they can try such as putting the medication in ice cream and they should also let the rest of the team know the resident refused. During interview on 5/13/26 at 1:25 p.m., RN-B stated if a resident refused medications, they should reapproach at a later time or let another nurse know so they can try. The resident may just need a different face or a different approach and then they will take them. They also have a right to refuse so if those things don't work, then the nurse should dispose of the medication and document it. During interview on 5/14/26 at 9:40 a.m., trained medication aide (TMA)-A stated if a resident was refusing medications, they would step away and reapproach tree times, waiting in between each time. They would also notify the nurse. If the resident appeared to be upset (even if they couldn't express it/say it) she would walk away and reattempt at a later time stating you can't force them to take their medications. TMA-A further stated R20 would often refuse to take her medications but was usually able to get her to take them by offering her a banana. She also had family members that would visit almost every day, and they were able to convince her to take them. During interview on 5/14/26 at12:40 p.m. the director of nursing (DON) stated if a resident was refusing medications, she would expect the nurse to step away and reattempt later if the resident is accepting of it, stating some residents don't want the staff to reattempt. If they still refuse, then the nurse should update the provider and document the refusal. If there is a pattern of refusals the staff should try to figure out the why. The facility policy on resident's rights regarding respect, dignity, and self-determination dated 8/31/21, indicated the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Each resident will be treated with respect and dignity and be cared for in a manner that promotes maintenance of his or her quality of life, recognizing each resident's individuality regardless of diagnosis, severity of condition or payment source.

Based on observation, interview, and document review, the facility failed to ensure personal hygiene care (i.e., nail care, hair washing, showers) was provided for 1 of 1 resident (R36) reviewed for activities of daily living (ADLs) and who was dependent on staff for his care. Findings include: R36's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R36 had severe cognitive impairment, verbal behaviors, refused bathing, needed moderate assistance with toileting, and needed supervision/touching assistance to put on shoes, dress his upper body, and for personal hygiene. R36's diagnosis list indicated Alzheimer's disease, parkinsonism and high blood pressure. R36's care plan reviewed 5/11/26, indicated R36 had a potential for alteration in completion of ADLs, due to diagnosis of Parkinson's disease. Care plan's goal indicated R36 will maintain good oral hygiene with/without assistance, and will be neat, clean and odor free. The care plan directed staff to assist R36 with bathing, grooming and lower body dressing. R36's Kardex dated 5/14/26, indicated R36 needed assistance of one with bathing, grooming, and personal hygiene. A review of R36's Weekly Skin checks (completed on shower days) indicated:-on 4/7/26, R36 had a shower and was dependent on staff. -on 4/14/26, 4/21/26, and 5/5/26 R36 refused showers, nail care and shaving. R36's medical record lacked documentation about attempts to reapproach or reschedule his showers. During observation on 5/11/26 at 4:57 p.m., R36 was unable to answer questions related to bathing and personal cares. R36 had oily dull hair, overgrown facial hair and his fingernails were uneven and jagged up to 0.6 cm long. During observation on 5/12/26 at 8:30 a.m., R36's hair was full and oily, his nails were long and uneven, and his facial hair was unshaven. During observation and interview on 5/12/26 at 2:23 p.m., nursing assistant (NA)-A verified R36's dirty hair, and long nails. NA-A stated, he needs to be shaved. During interview on 5/12/26 at 3:10 p.m., registered nurse (RN)-C stated R36's behavior varied day to day and sometimes he would allow staff to help him with personal cares and other days he will not. RN-C stated he needed supervision and verbal redirection. RN-C stated he had his bear done 2-3 weeks ago. RN-C verified documentation regarding, R36 not having a shower since 4/7/26. RN-C stated usually a different NA will attempt to provide cares. RN-C added she knew sometimes he allowed staff's help. During interview on 4/13/26 at 11:34 a.m., with the director of nursing (DON) and the assistant director of nursing (ADON), they stated their expectations were for the staff to re-approach residents, then try to have a different person give the shower or try to give the shower at a different time of the day. DON and ADON stated getting showers, nail care and shaving were important for cleanness and residents' dignity. Facility's policy titled ADL Completion/Cares dated 1/11/23 indicated all staff will follow the residents' plan of care which identifies ADL assistance needed. The policy also indicated the residents have the right to have a choice and the right to refuse. If a resident refuses ADL assistance, ensure that resident is safe and reapproach. If the resident continues to refuse care, NA is to notify the nurse or manager to have them approach the resident.

Based on observation, interview and record review, the facility to ensure interventions were implemented for 2 of 2 residents (R83, R5) and a root cause analysis was completed for 1 of 2 residents (R5) after a fall. This lead to actual harm for both R83 and R5 when R83 fell and sustained a right hip fracture that required hospitalization and surgery and when R5 fell and sustained a right clavicle fracture that required hospitalization . In addition, the facility failed ensure an elopement risk assessment was completed for 1 of 1 residents (R79) who had attempted to elope and failed to provide monitoring for 1 of 1 residents (R47) who had complaints of coughing during meals. Findings include: R83 R83's quarterly Minimum Data Set (MDS) dated [DATE], indicated R83 had severe cognitive impairment and diagnoses of Alzheimer's Disease and osteoporosis (disease that causes weak bones). R83 required moderate assistance with toileting and supervision or touching assist when walking at least 10 feet and was at risk for falls. R83'S nursing progress note dated 10/4/24 at 9:26 a.m., indicated R83 had an unwitnessed fall at 7:30 a.m. The root cause was R83 slid out of bed onto the floor when trying to get out of bed. The intervention implemented was a perimeter mattress. R83's fall risk management dated 10/4/24, indicated R83 had slid out of bed. R83 was found with one sock on and one barefoot. R83 had impaired memory and was confused. A predisposing factor to the fall was improper footwear. R83's interdisciplinary (IDT) note dated 10/4/24 at 1:35 p.m., indicated R83 slid off the side of her bed onto the floor. Mattress was changed to perimeter and staff to assist R83 to place gripper sock on at bedtime as R83 allows. R83's care plan was reviewed and updated. R83's care plan revised 10/4/24, lacked indication the gripper socks at bedtime was initiated after this fall. R83's electronic medical record (EMR) lacked indication R83 had refused or took off the gripper socks at bedtime. R83's nursing progress note dated 10/30/24 at 7:23 a.m., indicated R83 was found on the floor at 1:00 a.m. The note identified the root cause was R83 slipped out of bed and was wearing slippery socks. R83 had severe pain to their right hip and was sent to the hospital. R83's fall risk management dated 10/30/24, indicated R83 was found on the floor next to their bed. R83 had severe pain and was guarding their right hip. R83 was sent to the emergency room for evaluation. R83's IDT note dated 10/30/24 at 10:30 a.m., indicated R83 sustained a fall while transferring out of bed. R83 was sent to the emergency room for evaluation. R83's emergency room provider note dated 10/30/24 at 3:54 a.m., indicated R83 was transferring out of their bed and slipped on their socks. R83 sustained a right femur fracture and required surgical intervention. R83's discharge physical therapy note dated 12/11/24, indicated R83 required assist of one and supervision for all mobility. R83's discharge occupational therapy note dated 12/11/24, indicated R83 required supervision for toileting, peri-cares and clothing management and directed R83 to have assistance with nursing. R83's fall Care Area Assessment (CAA) dated 12/18/24, indicated R83 recently had a right hip hemiarthroplasty (partial right hip replacement) due to a fall with fracture and had continued impaired mobility. Staff were to walk with resident with gait belt and wheelchair to activities and dining. R83's falls assessment dated [DATE], indicated R83 had impaired mobility and used a walker and wheelchair for ambulation. R83's care plan revised on 4/24/25, indicated R83 was at risk for falling due to cognitive impairment, history of falls, weakness and recent hip surgery. Interventions included to keep call light in reach, perimeter mattress, keep walker at bedside when resting, and ensure R83 has proper footwear. R83's care plan further indicated R83 required assistance with mobility due to hip surgery. Interventions included ambulation with supervision/touch assist. Walking in hallway to and from meals required staff assist of 1, gait belt, and a wheelchair to follow. R83's Kardex as of 4/29/25, directed staff R83 required supervision/touch and use of 2 wheeled walker for ambulation and walk resident in hallway with wheelchair to follow with meals. R83 also required supervision with toileting with assist of one. During an observation on 4/28/25 at 4:59 p.m., R83 was standing in the doorway shouting for help. R83 had no walker and one pant leg was pulled up to their knee and the other one was on the floor. R83 was yelling for someone to help them. Registered nurse (RN)-F was seated at the computer across from R83's room and stated I will be there in a minute without looking up from the computer. R83 then said what nobody around to help? RN-F then stood, saw the situation, and got up to assist R83. During an observation on 4/29/25 at 9:03 a.m., R83 was seated in the television area. At 9:36 a.m., activity aide (AA) asked R83 if they wanted to go for a walk in the hallway. AA walked R83 down to the dining room and then back, past the television room towards the birds. AA walked R83 without the transfer belt or a wheelchair behind them. About halfway down to the birds, R83 stated they needed to use the bathroom. AA turned back to go into R83's room and stopped at the bathroom door. At the bathroom door, R83 told AA to stay out. AA closed R83's bathroom door and room door when exiting. At 8:58 a.m., AA told nursing assistant (NA)-B, who was sitting at the desk across from R83's room charting, R83 was in the bathroom. NA-B continued charting and at 10:12 a.m., got up and walked down the hallway towards the dining room and returned at 10:14 a.m., knocked and entered R83's room. R83 was now in bed. R83's walker was in the bathroom and R83 had walked back to bed. NA-B stated oh, she must have already went back to bed. When interviewed at 4/29/25 at 10:16 a.m., NA-B stated the Kardex let staff know what kind of assistance residents need. NA-B further said, the nurses will report off who was at risk of falling and stated R83 was a fall risk. R83 was unsteady at times and was confused and still thinks she is independent. NA-B verified R83 required staff to be in with her for the bathroom, but often R83 doesn't want anyone in. NA-B stated usually, they stood right outside the door and listened. When R83 got up or the toilet flushed, then would enter and assist but had not done that this time. NA-verified R83 required a walker for ambulation and walked without it back to their bed. NA-further stated using a wheelchair behind them was more of a therapy thing, and it was an option if R83 was feeling weak. When interviewed on 4/29/25 at 10:28 a.m., AA stated they check with staff and the NA's to know how much an assistance a resident needed. AA further stated as you work with the residents- usually get to know them. When interviewed at 4/29/25 at 10:33 a.m., RN-E sated when a resident falls, an assessment of the resident is completed. Once the resident was deemed ok, a risk management report was completed. The report walks through the situation and what the root cause was and there should be an intervention placed. Nurse managers will put any new interventions in the Kardex and care plan. RN-E verified R83 was a fall risk and further stated R83 transferred independently and used a walker to ambulate. R83 doesn't always use the wheelchair, but maybe for longer distances. RN-E stated if there were any changes in mobility assistance or devices, therapy was usually involved. When interviewed on 4/29/25 at 12:38 p.m., the Director of Therapy (DOT) stated R83 discharged from therapy when they signed up for hospice on 12/11/24. At the time of discharge, R83 was transferring with assistance of one person and ambulating with assist of one with a two wheeled walker. Walking directions to follow with a wheelchair was from therapy and verified that was communicated to nursing on 11/18/24. Nursing could evaluate and change the mobility status if no longer needing the wheelchair or transfer belt. When interviewed on 4/29/25 at 1:43 p.m., RN-B stated when a fall happens, the resident was assessed for injuries and questions asked as to what happened. The nurse will complete a fall risk management report and this was where the root cause of the fall would be listed and any interventions needed. Any nurse can update the care plan or Kardex, however typically the nurse manager would complete. The IDT reviews the fall and will ensue any interventions added were appropriate and ensure the care plan was updated. RN-B verified R83's care plan had not included gripper socks at bedtime. RN-B expected that intervention to be included on the care plan and Kardex so staff were aware of it. Furthermore, RN-B verified R83's care plan and Kardex directed staff to use a walker, transfer belt and a wheelchair to follow for mobility to the dining room. RN-B expected staff to follow those directions. When interviewed on 4/29/25 at 2:52 p.m., the Director of Nursing (DON) expected staff to assess the resident, complete a risk management form to start the fall investigation, contact family, provider. The risk management form asks about the description of what happened, immediate actions, environment, and any pre-disposing factors. If the nurse knew what the root cause of the fall was, that would also be added. Then IDT meets and reviews the fall. The nurse will implement the immediate intervention, and IDT will determine if that is enough or if more investigation or interventions were needed. The nurse managers are then responsible to implement the interventions into the Kardex and care plan. DON expected R83's identified interventions for a perimeter mattress and gripper socks to be implemented and would need to review these. DON further expected staff to follow the interventions on the care plan and Kardex for mobility. If there were changes, therapy or nursing would evaluate and then update the interventions. A follow up interview at 4/30/25 at 8:51 a.m., the DON stated R83 never had the gripper socks implemented after the fall on 10/4/24. DON stated discussion with staff on the unit, R83 would not keep them on and always took them off and therefore not implemented. DON verified there was no documentation to support this. 42586 R5 R5's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), orthostatic hypotension, and a history of falls. It further indicated impairment on bilateral lower extremities (LE), independent with toileting and mobility, was occasionally incontinent of urine and always continent of bowel. Shortness of breath (SOB) when laying flat, had a fall within the last 2-6 months prior to admission/entry or reentry, and received an antidepressant and diuretic on a routine basis. R5's Care Area Assessment (CAA) triggered for falls from the MDS (11/27/25) for the following reasons: -new admit -advanced age -history of falls -impaired mobility (uses a wheelchair and was able to self-transfer with walker) -COPD with oxygen use as needed (PRN), CHF, bilateral (both sides) LE edema, morbid obesity, chronic pain, Benign Prostatic Hyperplasia (BPH) with occasional urinary incontinence, hypertension (HTN), atrial fibrillation (A-fib), depression, insomnia, restless leg syndrome (RLS), and cerebral aneurysm, non-ruptured. -medications (that may contribute to falls) Trazadone, Cymbalta, and Bumex. He hasn't had had any falls since entry/admission. Proceed to the plan of care that resident will remain safe in environment with interventions in place as evidenced by no falls during the quarter. R5's Care plan indicated R5 was at risk for falls related to medical diagnoses and history of falls prior to admission. admitted following transitional care unit (TCU) stay for strengthening following two falls on 12/27/24 (scalp laceration) and 12/30/24 (left clavicle fracture). Spasmodic torticollis. Bilateral lower extremities (BLE) edema with ready wraps daily. All staff to observe and identify for possible hazards in environment to prevent avoidable accidents/falls. It further indicated the following interventions along with the dates they were developed and implemented: -Call light within reach of resident when in room (11/27/24) -Encourage resident to call for assist with transfers and ambulation (1/31/25) -Ensure that resident has proper and non slip footwear (11/27/24) -Need to assist with evacuation in case of emergency (11/27/24) -Offer pharmacological and non-pharmacological interventions for pain when noted (11/27/24) -Physical therapy (PT)/Occupational therapy (OT) referral as needed/ordered (11/27/24) R5's progress note dated 12/27/2024, indicated R5 had an unwitnessed fall at 3:45 a.m. He slid off the commode and struck his head on the floor which resulted in a 6 centimeter (cm) laceration on the left side of his head. He was sent to the ER. R5's progress note lacked indication of a root cause analysis indicating how the fall may have occurred. R5's fall risk management dated 12/27/24, indicated R5 was found lying on his left side in his bathroom beside the commode with a 6 centimeter (cm) long laceration to the left side of his head. He was sent to the ER via non-emergency ambulance. Decreased range of motion (ROM) and gait imbalance were predisposing factors. R5's interdisciplinary team (IDT) note dated 12/30/2024, indicated resident reported that he lost his balance and fell while in the bathroom. Resident was at risk for falls due to impaired gait. Physical Therapy (PT) to evaluate and treat resident due to fall. Care plan reviewed. R5's care plan dated 11/27/24, lacked any new interventions following his fall on 12/27/24, in which he sustained a head laceration, went to the hospital, and received 7 staples in his head. During interview on 4/29/25 at 9:49 a.m., the director of therapy: (DOT) stated they had received a referral for R5 on 11/22/24 for PT. He was enrolled in PT from 12/4/24-12/31/24. The DOT further stated R5 was referred (for PT and OT) after a fall on 12/30/24, and was discharged to the Care View side for increased care on 12/31/24. R5's PT progress note dated 12/27/24, indicated R5 had seen progress since start of care (SOC) with reducing bilateral edema. Resident had a fall this morning and sustained a laceration to the head, returned from ER the same day. After education on wraps, resident continued to refuse wraps. Will continue current plan of therapy (POT) for manual lymph drainage and working on strengthening to reduce risk of falls. Resident in agreement. Today hold on exercise due to recent fall and fatigue/headache and hold on manual due to redness noted bilateral and nursing confirmation that patient appears to have cellulitis bilateral. R5's progress notes dated 12/30/24, indicated R5 had an unwitnessed fall at 4:15 p.m. The resident was found on the bathroom floor on his back with his left side against the wall. He was sent to the emergency room (ER) for evaluation. R5 was soaking wet and appeared like he used the toilet before and the floor was wet with urine. The root cause of the fall was R5 was unstable and the new intervention put in place was for him to start PT/OT. R5's risk management dated 12/30/24, indicated R5 was found on the bathroom floor on his back. He had extreme left shoulder/upper neck pain and was sent to the hospital. A wet floor, decreased ROM, gait imbalance, and previous falls were listed as predisposing factors. R5's after visit summary dated 12/30/24, indicated R5 had a fractured left clavicle (collarbone) as a result of a fall and was treated in the ER. R5's IDT note dated 12/31/2024, indicated resident reported that he fell asleep in the chair in his bathroom and fell . Resident has been re-educated to lie down in bed whenever he's tired to prevent falls/injuries. Resident will be transferred to Care View (CV)-TCU for rehab due to fracture of left clavicle. During interview on 4/29/25 at 8:58 a.m., licensed practical nurse (LPN)-A stated when a fall occured, nurses were responsible for trying to figure out why the fall happened and putting in an immediate intervention. Then the nurse managers were responsible for putting in follow up interventions in order to prevent another fall. During interview on 4/29/25 12:46 p.m. the nurse manager registered nurse (RN)-A stated when a fall occurred, the nurses were responsible for filling out an official fall progress note indicating what happened, and putting in an immediate intervention. Then the nurse managers were responsible for coming up with a root cause analysis (RCA). RN-A further stated there should be a new intervention put into place after each fall in order to determine what interventions are working or if there was anything else they could be doing to prevent the fall. RN-A also verified there wasn't a root cause analysis or any new interventions following R5's fall on 12/27/24. RN-A was unable to answer as to how the facility was able to determine whether R5 was safe to transfer and toilet himself following the fall. During interview on 4/30/25 at 10:40 a.m., the director of nursing (DON) stated there was no documentation that a RCA for R5's fall on 12/27/24 had been completed or that a new intervention had been added. This was important in order to prevent another fall. The facility's policy regarding falls dated 1/24/23, indicated the purpose of the policy was to identify and monitor residents at high risk for falls, minimize the incidence and potential for injury from falls, and ensure that proper assessment, intervention and documentation of incidents are completed. It further indicated all incidents should be assessed for the root cause and care plan modified if possible to prevent further incidents. R79 R79's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses including dementia, intellectual disabilities, and epilepsy. It further indicated R79 was independent with most activities of daily living (ADL) and mobility. R79's medical record lacked documentation an elopement risk assessment had been completed. During interview on 4/29/25 at 12:46 p.m. the nurse manager registered nurse (RN)-A stated they don't fill out elopement risk assessments for residents on the 2nd and 4th floors because they are able to come and go independently. RN-A stated they determine whether a resident can leave the facility independently or not upon admission and by asking the resident's responsible party. During interview on 4/30/25 at 9:02 a.m. the receptionist (RC) who sits at the front desk by the entrance door stated if a resident tried to leave the facility by themselves she would look in the book of photos at her desk that contained pictures of residents who were not able to safely leave the facility by themselves and would not unlock the door to let them out. She would then try to redirect them and call the nurse. The receptionist showed the surveyor the book of photos and there was a picture of R79 in the book. R79's progress note dated 4/27/25, indicated resident attempted to leave the facility without family, was stopped by the receptionist, and educated. During interview on 4/30/25 at 8:37 a.m licensed practical nurse (LPN)-A stated they do not fill out elopement assessments on the 4th floor but if a resident tried to elope, then they would complete one, notify the provider, family member, and supervisor. The surveyor showed LPN-A the progress note from 4/27/25 for R79 and she stated there should've been an elopement risk assessment filled out for R79 and notifications should have been made. During interview on 4/30/25 at 10:40 a.m., the DON stated elopement risk assessments were built into their admission data base, but R79's was not filled out and was unable to find any elopement risk assessments for him and there should have been . A facility policy regarding wandering and elopement dated 11/2022, indicated on admission, each resident will be assessed for elopement risk via completion of Admission Database Assessment. 46885 R47 R47's annual MDS dated [DATE], indicated R47 did not have signs or symptoms of a swallowing disorder, did not have coughing or choking during meals or when swallowing medications. R47's Optional State Assessment (OSA) dated 4/8/25, indicated intact cognition, did not reject cares, was independent with bed mobility, transfers, eating, and required supervision support with eating. R47's quarterly MDS dated [DATE], indicated intact cognition, did not have physical or verbal behaviors, did not reject care, had anxiety, depression, and mild cognitive impairment, was independent with ambulation, had coughing or choking during meals or when swallowing medications, was not on a therapeutic diet, mechanically altered diet, and did not have parenteral, IV feeding, or a feeding tube. R47's Medical Diagnosis form indicated R47 had the following diagnoses: mild cognitive impairment, major depressive disorder, other anxiety disorders, gastro-esophageal reflux disease (GERD) (a digestive disorder where stomach acid flows back up into the esophagus) without esophagitis, and disease of digestive system unspecified. R47's Physician's Orders form indicated the following orders: 12/9/19, regular diet, regular texture, and thin liquids consistency. 9/14/22, omeprazole (a medication that reduces the amount of acid your stomach makes) delayed release give 20 milligrams (MG) by mouth. R47's care plan dated 1/15/25, indicated R47 had a history of verbal aggression towards staff and other residents and did not like anyone sitting in her dining room chair and placed notes on the chair to remind other residents not to sit in her chair and because other residents ignored her request, preferred to eat in her room. R47's care plan revised 2/3/25, indicated R47 could feed herself independently and required as needed set up assist. R47's care plan revised on 4/30/25, indicated R47 had an altered nutrition and hydration status due to GERD, depression, anxiety and reported occasional discomfort with swallowing and declined speech therapy at this time. Further, R47 continued to express preferences to eat in her room and was educated on the risks and benefits of eating in the room versus the main dining room and verbalized understanding. Interventions included a regular diet, regular texture, thin liquids, notify dietary professional of changes in oral intake, weight, chew/swallowing, abnormal labs and skin integrity, and the dietician was to follow up as needed. R47's Kardex dated 4/30/25, indicated R47 had a regular diet, regular texture, and thin liquids. Further, R47 ate independently with as needed setup assistance. The Kardex lacked information R47 had difficulty swallowing or that R47 required any supervision. R47's physician progress note dated 4/4/25, indicated R47 had a history of GERD and diverticulitis, had no cough, was known to be lactose intolerant, and had been taking her meals in her room lately. R47's dietitian progress notes dated 4/8/25 at 8:12 a.m., indicated R47 ate in her room, had moved tables a few times due to not liking who was sitting with her. Further, R47 noticed when swallowing, sometimes things went down the wrong way, mostly with liquids and reported it was not painful, but more uncomfortable and reported food went down the wrong way and R47 coughed for it to come back up. The dietician explained speech therapy (ST) and R47 did not feel she needed ST and the note indicated to monitor for dysphagia (difficulty swallowing) signs and symptoms, gastrointestinal issues, and weight changes and the dietician would monitor R47's feeding ability and chewing and swallowing ability to provide further interventions as warranted. The note lacked information R47's provider was updated, or whether safety was assessed due to R47 eating in her room. R47's Nutrition Assessment form dated 1/21/25, indicated R47 ate in her room, was on a regular diet, regular textures with thin liquids, occasionally required set up help and did not have any chewing or swallowing difficulties. The note further indicated the dietician would continue to monitor R47's nutritional status including weight trends, meal intakes, labs, gastrointestinal status, feeding ability, and chewing and swallowing ability to provide further interventions as warranted. R47's Nutrition Assessment form dated 4/8/25, indicated R47 was on a regular diet, had regular textures with thin liquids, ate in her room and occasionally required set up help, had coughing or choking during meals or when swallowing medications. The form indicated R47 reported noticed when swallowing, liquids went down the wrong way and reported it was not painful, but more uncomfortable. R47 reported food went down the wrong way and R47 coughed for it to come back up and speech therapy was explained to R47 who did not feel she needed speech therapy and R47 would watch and see if it was needed in the future. Further, no nutritional interventions were in place. A heading, Goals/Recommendations, indicated to monitor for dysphagia signs and symptoms, gastrointestinal issues, and weight changes. During interview and observation on 4/29/25 at 12:33 p.m., R47 was in her room and stated she had not yet had lunch. During interview and observation on 4/29/25 at 1:01 p.m., nursing assistant (NA)-C brought R47's meal tray into her room and stated R47 was having a turkey Swiss wrap for lunch per R47's request. During observation on 4/30/25 at 12:26 p.m., R47 was in her room and stated lunch was served between 12:00 p.m., and 12:30 p.m., downstairs and then food was plated and brought up to rooms. R47 wanted her door closed. During observation on 4/30/25 at 12:21 p.m., a paper sign was located at the nursing station that directed staff regarding meals to ask residents their choice of meals before each meal and indicate the meal choice on the meal ticket. When serving check that the meal tray has condiments, utensils, and other items for the resident and check to make sure all food items are accessible and with in reach of the resident and ask the resident if there was anything else needed before leaving the room. Return to the resident's room shortly after tray pass to make sure they have everything they need, check to make sure all tray items are accessible and within reach and offer refills on drinks, re-warm or replace food as needed and at the end of the meal return to the resident's room to check if they are done eating collect the tray and return to the culinary cart. During observation on 4/30/25 at 12:51 p.m., the meal cart was observed coming down the hallway. During interview and observation on 4/30/25 at 12:52 p.m., NA-C stated R47 was going to have chicken salad and knocked on R47's door and introduced herself. NA-C stated they looked at the Kardex to know what cares a resident required and if a resident refused, staff reapproached and the nurse would try and document refusals. NA-C stated a nurse would have to answer what to do if a resident had trouble swallowing and stated therapy worked with residents and did not know whether residents should eat in their rooms if they had difficulty swallowing. NA-C stated R47 was independent and did not complaint of difficulty swallowing and stated her Kardex did not indicate R47 required monitoring with meals. During interview on 4/30/25 at 1:07 p.m., licensed practical nurse (LPN)-A stated they used the care plan to know what cares a resident required and if a resident refused would document. LPN-A stated if a resident reported difficulty swallowing would assess the resident, call the nurse practitioner or the doctor and residents would have speech therapy. LPN-A stated they first had to assess and then call the provider and if they received an order would fax it to the therapy department and further would add to the care plan and Kardex. LPN-A stated residents could not eat in their room if they had a swallowing problem and did not do a risk versus benefits form and added they couldn't force residents, but at the same time they encouraged them. LPN-A stated R47 did not have difficulty swallowing, was alert and oriented, and used to eat in the dining room but somebody sat in her spot and chose not to go down. LPN-A viewed R47's Kardex and verified it lacked information R47 had difficulty swallowing. LPN-A stated she hadn't heard R47 had difficulty swallowing and stated if R47 had difficulty, they had to assess and could not eat in her room. LPN-A viewed R47's nutrition assessment and verified R47 had coughing or choking during meals and stated if the physician was updated, it was documented in the progress notes and added it would be important for nursing to know if R47 had difficulty swallowing because they had to monitor her and was not monitored eating in her room. During interview on 4/30/25 at 1:27 p.m., RN-D stated they would document if a resident had difficulty swallowing and wanted to eat in their rooms the risk versus benefits and would order speech therapy to evaluate and treat and offer a recommendation. If the resident declined speech therapy (ST), ST would document the attempted evaluation and the nurse would update the doctor and stated ST had a waiver if ST saw a resident and the resident declined recommendations. RN-D stated it was a resident's preference if they wanted to eat in their room would tell them the risks versus the benefits of eating in the room and stated R47 did not have difficulty swallowing and had not exhibited the symptoms or reported any symptoms of trouble swallowing. RN-D viewed R47's nutrition assessment and stated he could have the dietician amend the note because he was not aware of any swallowing problems and would follow up with the dietician along with R47 and stated the dietician should have mentioned R47 had difficulty swallowing. RN-D later documented a progress note on 4/30/25 at 1:54 p.m., that indicated the progress note was a follow up note to the dietitian progress note dated 4/8/25 at 8:12 a.m., R47 reported occasional discomfort with swallowing and did not want a speech evaluation, but would let RN-D know if symptoms worsened. R47 continued to express preferences to eat in her room, was educated on risks and benefits of eating in the room versus in the main dining room, and R47's family and primary care provider were updated. Further, the note indicated the care plan was reviewed and updated. During interview on 4/30/25 at 1:39 p.m., dietician (D)-J stated if a resident reported difficulty swallowing would talk to the nurse manager and get ST in place and if the resident didn't want ST, would still follow up with the nurse manager to find a solution. During interview on 4/30/25 at 2:41 p.m., RN-D brought D-I to the conference room. D-I stated RN-D had updated D-I regarding inquiries on R47's swallowing. D-I stated she asked if a resident had difficulty swallowing on every assessment and R47 mentioned she noticed it happened and brought up ST because R47 stated sometimes things went down the wrong way and expected staff monitor R47 and watch for foods and fluids going down the wrong way. When asked how resident would be monitored for choking when eating in her room, D-I stated that could happen and they encouraged everyone to eat in the dining room and R47 preferred to eat in her room. D-I stated she would document if a risk versus benefits was completed and stated she did not discuss with R47 the risks versus benefits of eating in her room and stated she discussed what ST could help with and expected monitoring to be on the care plan and Kardex and verified information was not on the Kardex and stated it would be im [TRUNCATED]

Based on observation, interview, and document review, the facility failed to ensure food items were labeled and dated, three of three kitchenettes were not properly cleaned per facility policy and cleaning log manual. This had the potential to affect all residents whom consumed beverages from the kitchenettes. During the initial observation of kitchenette on 2nd floor on 4/28/25 at 2:04 p.m., there was one filled frozen dixie cup no name or label in freezer, and one 20-ounce bottle of Gatorade one third opened no name or label in refrigerator. The ice/water machine had white flaky substance on back by dispenser. Folgers coffee machine had scant amount of brown tinged dried brown liquid on bottom of grate. Observed on 4/28/25 at 2:14 p.m., dietary aide-A verified refrigerator/freezer temperatures and documented findings on the log, removed labeled and covered food items from refrigerator, did not observe cleaning of any machines. Interview on 4/28/25 at 2:25 p.m. with NAR -A, confirmed the observation of the machines. They stated all items are to be labeled and dated in refrigerator and freezer. The machines should be clean and should not have water drippings and stains on them. During observation of kitchenette on 2nd floor on 4/30/25 at 7:42 a.m., all food and beverages labeled in refrigerator and freezer. Folgers coffee machine had scant amount of brown tinged dried brown liquid on bottom of grate. The ice/water machine had white flaky substance on back by dispenser. Interview with NAR-C confirmed findings, stated the machines should not have any liquid in the grates or water scales on ice/water machine. During the initial observation of kitchenette on 3rd floor on 4/28/25 at 2:18 p.m., on top of refrigerator there was one uncovered, no name or label cupcake in bowl and a wrapped Resees Peanut Butter Cups candy, no name or label. The ice/water machine had white flaky substance on the back of machine, where the dispenser is located and standing water under the grate. The juice machine had black substance in the corners of machine where juice is dispensed and grate. Interview on 4/28/25 at 2:30 p.m., NAR-B verified observation and stated the machines should be clean and all food and beverages need to be covered, dated and labeled. During observation of kitchenette on 3rd floor on 4/30/25 at 8:13 a.m., no food on top on refrigerator, no unlabeled or uncovered food or beverages in refrigerator or freezer. The ice/water machine had white flaky streaks on back side of machine where the dispenser is located. The juice machine has a black substance in corners where juice is dispensed and grate. Interview on 4/30/25 at 9:10 a.m., assistant culinary director confirmed observation. They stated the culinary staff is responsible for the cleaning of every beverage machine, refrigerators/ freezers, and microwaves in every kitchenette. There is a schedule and sign off sheet for cleaning tasks in a logbook in main kitchen area. During initial observation of kitchenette on 4th floor on 4/28/25 at 2:37 p.m., Folgers coffee machine had standing brown liquid with dark brown flakes under grate. The ice/water machine had white flaking streaks, where the dispenser is located. Interview on 4/28/25 at 2:40 p.m., LPN-B, confirmed the observation and stated the machines are supposed to be cleaned. They did not know which department was responsible for the cleaning. Interview on 4/28/25 at 2:45 p.m., housekeeping -A stated housekeeping department was responsible for the kitchenette space, not the machines. During observation of kitchenette on 4th floor on 4/30/25 at 9:12 a.m., Folgers coffee machine had standing brown liquid under grate, ice/water machine had white flaky substance streaked on the back of machine where dispenser is located. Interview with on 4/30/25 at 9:24a.m., NAR-D confirmed observation. They stated the machines should be cleaned because they can pass germs or illness onto residents. During an interview on 4/29/25 at 9:39 a.m., culinary director stated the culinary staff oversees cleaning refrigerator/freezers and verify the food and beverages are covered and labeled properly. All the beverage machines, microwaves and countertops are to be cleaned by culinary staff. A sign off log is located in main kitchen for the schedule and completion of cleaning in kitchenettes. The policy and procedure manual, Cleaning Instructions: Coffee, Beverage, Juice, Frozen Yogurt, or Ice cream Machines, stated coffee makers, urns, juice machines, frozen yogurt and/or ice machines will be cleaned thoroughly.

Based on interview and document review, the facility failed to ensure identified triggers were documented in the comprehensive care plan and individualized trauma-informed approaches were utilized for 2 of 2 residents (R14, R77) who had a history of trauma. Findings include: R14 R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and reported diagnoses of anxiety, depression, bipolar disorder (a mental disorder characterized by episodes of extreme elevated mood, or mania, and depression), and post traumatic stress disorder (PTSD, a psychiatric disorder that some people who have experienced or witnessed distressing or life-threatening event(s) may develop). Per a trauma informed care/vulnerabilities assessment dated [DATE], R14 indicated she had experienced trauma that was so frightening, horrible, tragic, or upsetting she had a hard time not thinking about it. The assessment identified her traumatic experiences and reported she was physically, sexually, and emotionally abused. Raped by an older male relative. Furthermore, the assessment identified she felt angry, sad, isolated, alone, shameful, irritable, and moody because of the experience(s). The assessment identified potential triggers that could cause such feelings to escalate, including being touched, loud noises, not having input/control, someone coming up behind me scares me. I'm disturbed by yelling/swearing [sic] Afternoon and evening are more difficult times for me [sic] Anniversaries - 3/30 (death of mother) and divorce (7/2). Furthermore, the assessment listed activities she identified might help her feel better when she as having a hard time, including listening to Christian music, reading, sitting by the office or nurse, talking, walking, having her hand held, physical exercise, writing, participating in activities, breathing exercises, and lying down. R14's care plan dated 3/25/25 identified her potential for abuse and neglect due to her history PTSD. The care plan directed staff to observe for changes in her mood and behavior, indicated she did not wish to discuss her trauma with her sister and reported she was close with her friend with whom she discussed all issues with. The care plan lacked documentation of triggers that may re-traumatize her and lacked resident-specific interventions to mitigate the risk of re-traumatization. R14's Kardex dated 4/29/25, was reviewed and lacked identification of triggers and resident-specific interventions to mitigate the risk of re-traumatization. During interview on 4/30/25 at 1:41 p.m., nursing assistant (NA)-H verified familiarity with R14's care. NA-H stated if a resident had a specific behavior or trigger, it would be identified on staff's PointOfCare (POC) charting. NA-H was unable to identify trauma-related triggers. During interview on 4/30/25 at 2:27 p.m., R14 could not recall if staff had asked her about things that set me off, but stated there had been no instances of re-traumatization in the facility. However, she stated, I have bipolar disorder and PTSD, I said something to the director of nursing about they [staff] need to learn how to deal with people who have mental health problems. R14 stated there were times she asked NAs to get a nurse for her treatments and she felt staff responded by scolding her and it bothered her and gives me anxiety. During interview on 4/30/25 at 4:16 p.m., NA-I stated R14 did not have much patience and wanted everything right away. NA-I stated she had a lot of anxiety and a lot of worry. NA-I stated if staff were able to get her everything set up right away, then she was okay. NA-I was unable to identify any trauma-related triggers for R14 but stated if she had any or behaviors, they would be on the care sheet. During interview on 4/30/25 at 5:17 p.m., registered nurse (RN)-A expected a resident's trauma and vulnerabilities to be identified on their care plan. RN-A reviewed R14's care plan and confirmed her trauma and trauma-related triggers were not documented on her care plan. RN-A stated, I don't see anything listed, and indicated it would be important for NAs to identify what her triggers were. R77 R77's quarterly Minimum Data Set (MDS) dated [DATE], indicated he had unclear speech that was slurred or mumbled and was unable to complete the cognitive assessment interview. The MDS indicated he was severely impaired in his daily life decision making and had both short- and long-term memory problems. The MDS reported he had no hallucinations or delusions, displayed physical and verbal behaviors 1-3 during the lookback period, rejected care 1-3 days during the lookback period and had wandering behavior. The MDS indicated he took antipsychotic and antidepressant medications and identified diagnoses including Alzheimer's disease (a progressive brain condition that affects thinking, memory, and behavior), aphasia (a language disorder caused by injury to the brain), depression, post traumatic stress disorder (PTSD, a psychiatric disorder that some people who have experienced or witnessed distressing or life-threatening event(s) may develop), chronic pain, and psychotic disorder (a mental condition characterized by abnormal perceptions and loss of contact with reality). The MDS reported R77 required extensive assistance with two staff for toileting and grooming cares but was independent with ambulation. A trauma informed care/vulnerabilities assessment dated [DATE], indicated he had an experience so upsetting he had a hard time not thinking about it and reported his step mom [sic] expressed that resident had been sexually assaulted as a child. The assessment reported, resident may resist bathing because of this trauma. Furthermore, the assessment identified he had severe cognitive impairment and identified his wandering behavior, and his communication limitations made him susceptible to abuse by others or increased his risk of abuse to himself or others. An undated order summary reviewed 4/29/25 at 2:06 p.m., included the following orders: - citalopram hydrobromide oral tablet, Give 10 milligrams (mg) by mouth one time a day for depression, dated 4/14/25. - Risperdal oral tablet, Give 1mg by mouth one time a day for psychotic disorder, dated 3/24/25. - Risperdal oral tablet, Give 0.5mg by mouth at bedtime for psychotic disorder, dated 4/10/24. R77's care plan last revised 4/19/25, identified he had a potential for abuse and neglect from himself or others related to his memory impairment and his diagnoses of dementia and depression and directed staff to be mindful of residents [sic] hx [sic, history] of trauma but lacked documentation of potential triggers that may re-traumatize him. The care plan identified he was sexually abused as a child, and indicated he had an alteration in his mood and behavior due to his PTSD. The care plan directed staff to follow American Clinic of Psychiatry (ACP)'s recommended interventions, including having 1-2 staff approach him for cares (cares in pairs), offer him his preferred food or drink or something soft/texture for him to hold, approach him slowly and greet him by name, introduce self and inform him of the cares to be performed and move him to a quiet, less-stimulating environment. The care plan did not identify a preference for male versus female caregivers. R77's Kardex dated 4/29/25, directed staff to be mindful of his history of trauma but lacked documentation of potential triggers that may re-traumatize him. The Kardex included behavioral interventions including have 1-2 staff approach him for cares (cares in pairs), offer him his preferred food or drink or something soft/texture for him to hold, approach him slowly and greet him by name, introduce self and inform him of the cares to be performed and move him to a quiet, less-stimulating environment. The Kardex did not identify a preference for male versus female caregivers. An ACP progress note dated 4/8/25, indicated under the treatment recommendations care team should be aware that R77's history of childhood sexual abuse could impact his emotional/behavioral responses. The progress note indicated it was possible his resistance and behavioral responses could be related to his trauma history. An ACP progress note dated 12/23/24, indicated the provider interviewed floor staff for updates. The progress note revealed a nursing assistant (NA) reported R77 can become aggressive during cares, and responds better to male caregivers and is typically less aggressive. With female caregivers, he benefits from cares in pairs. Under the treatment recommendations/plan, the progress note indicated staff were encouraged to continue with care planning trauma hx [sic, history] and behaviors/preferences and identified he responded well to male caregivers and benefited from cares in pairs with female caregivers. Per provider progress note dated 4/1/25, nursing staff reported R77 was combative with cares and had a very long unkempt beard and long hair that he wouldn't let staff wash and comb. The progress note indicated he wouldn't allow staff to perform peri-cares, incontinence cares, and displayed aggressive behaviors. The progress note revealed he was taking risperidone (antipsychotic medication) 0.75mg in the morning and 0.5mg in the evening and it was increased in 3/2025 due to combative with cares. An email correspondence dated 4/1/25 with the subject line orders faxed fyi, indicated R77 was becoming more agitated, and his risperidone was increased and an order to start an antidepressant medication was provided. During interview on 4/30/25 at 10:23 a.m., social services (SS)-A verified completing the mood and behavior assessments and building up that section of the care plan. Additionally, SS-A reported being responsible for reviewing ACP progress notes and transcribing the recommendations into the care plan. SS-A stated behavioral interventions were reviewed during interdisciplinary team (IDT) meetings and occasionally at care conferences if a resident's family or representative(s) asked how they were doing with a behavior. SS-A expected staff to utilize non-pharmacologic interventions prior to implementing or adjusting psychotropic medications and stated, I would hope that's what they're doing. During interview on 4/30/25 at 11:08 a.m., NA-F stated resident-specific behaviors were identified on the Kardex and were reported in daily huddles. NA-F stated staff were expected to document resident behaviors in PointOfCare (POC) charting and report them to the nurse, however, stated NAs could not document details or interventions attempted NA-F was not able to identify R77's trauma-related triggers, but stated he could sometimes get really strong and grab tight. NA-F reported talking to him in a calm manner, offering him chips, leaving him be and re-approaching and singing to him were effective interventions for him when he became resistive to cares and aggressive. NA-F stated when staff re-approach for cares, we go with two people. NA-F stated if staff were not paying attention to him during cares, he could go off and hit you. Per interview on 4/30/25 at 11:35 a.m., NP-E expected staff to be aware of a resident's trauma history and utilize non-pharmacologic interventions prior to implementing or adjusting psychotropic medications. NP-E stated a root cause analysis of a resident's behaviors would be helpful information before adding or adjusting a psychotropic medication. NP-E indicated assessing baseline symptoms, diagnoses, and history would be helpful to review for a resident residing on a memory care unit because they may be unable to articulate their preferences for cares. NP-E confirmed seeing R77 and agreed with the medication changes made prior to their encounter. NP-E stated the goal was to reach a therapeutic dose of his citalopram and gradually taper him off the risperidone. NP-E reviewed the ACP note dated 12/23/24 and expected staff to have attempted the interventions recommended but stated, it was my understanding he was quite aggressive with cares; it wasn't just being resistive. NP-E did not believe there was evidence of oversedation or chemical restraint with the increased dose of risperidone. Per interview on 4/30/25 at 1:32 p.m., NA-G reported, I go all over the facility to every floor. NA-G stated resident information could be located on their [Kardex] care card posted inside their closet. NA-G stated this would include resident-specific behaviors, triggers, and interventions. During re-interview on 4/30/25 at 1:58 p.m., SS-A verified responsibility for completing R77's trauma assessment and indicated triggers and interventions should be on the care plan and the Kardex. SS-A stated this information was also passed along via word of mouth, so staff knew about it right away. SS-A stated it was of high importance staff were aware of potential triggers so they could try and avoid re-traumatizing residents with PTSD. SS-A reviewed R77's Kardex and confirmed it lacked documentation of potential triggers. SS-A confirmed staff should be aware of his potential triggers and stated the Kardex doesn't say what it is. During interview on 4/30/25 at 3:37 p.m., licensed practical nurse (LPN)-C walked into R77's room and showed the surveyor the Kardex care card was located inside the closet doors and stated resident preferences and activities of daily living (ADL) support requirements were located on the Kardex. LPN-C stated everything staff needed to know for R77 was located on the Kardex. LPN-C was not able to identify his trauma or related triggers. LPN-C stated he got along with regular staff well but did not believe there was a preference for male or female caregivers. Per interview on 4/30/25 at 4:01 p.m. with registered nurse (RN)-B, a resident's care plan would be the first place to look for their trauma or related triggers. During interview on 4/30/25 at 4:11 p.m., NA-E was unable to identify trauma-related triggers for R77. NA-E stated he sometimes refused cares but holding his hand and offering him a snack of chips were often effective interventions. NA-E was not aware of a male or female caregiver preference for R77, but stated when he refused cares, we need two staff. Per interview on 4/30/25 at 4:21 p.m., medical doctor (MD)-F stated it was not possible to determine why R77 was having behaviors because he was aphasic, so he can't articulate his thoughts, and when he became reactive during personal cares, MD-F indicated it would be difficult to determine if it was due to anxiety or delusions. MD-F expected staff to attempt non-pharmacologic interventions before moving to medications and believed the recommendations from ACP progress notes should be available for staff to utilize. MD-F stated knowing about his past trauma and triggers could have changed staff's approach towards his cares, but MD-F could not determine if it would have changed the outcome. MD-F believed staff were utilizing recommended interventions they were aware of, including re-approaching with different staff members. MD-F was supportive of the medication changes and stated prior to adjusting medications, we review progress notes, ACP notes, we interview staff and residents if we're able. Sometimes we'll talk to families if that's appropriate. We don't just start or increase psychotropics because of staff reports. Per interview on 4/30/25 at 5:30 p.m., the director of nursing (DON) expected the care plan and Kardex to be updated with anything staff should be aware of regarding a resident's trauma assessment. The DON stated social services completed the trauma assessments and care plans and was usually responsible for reviewing ACP progress notes and ensuring recommendations/interventions were transcribed and updated on the care plan. The DON indicated not having this information available to staff risked not knowing how to care for a resident if they were triggered or re-traumatized. The DON stated it could have been beneficial for staff to be aware of R77's potential triggers and all interventions recommended by ACP in theory. Per interview on 4/30/25 at 6:10 p.m., NP-D stated because of R77's aphasia, we don't know what exactly is going through his head and we can't determine what his thought process is. NP-D stated the goal of care was to decrease the level of anxiety surrounding his agitated behaviors. NP-D confirmed awareness of his trauma history and stated, he hasn't spoken, right? So, it's all from a third party, and indicated he was estranged from his family for [AGE] years. NP-D was not totally convinced what could have triggered his behaviors, however, believed staff were doing what they can and doing a good job with him. NP-D believed staff had familiarity with him and his history and believed, despite being unaware of his potential triggers and ACP recommended interventions related to male and female caregivers, staff had exhausted all non-pharmacologic interventions. NP-D stated it would not be feasible to have a male provide cares all the time and maybe that wouldn't have made a difference. We can't tell that because he can't tell us. During interview on 5/2/25 at 12:04 p.m., licensed social worker and ACP clinical intern (LSW)-G confirmed working with R77. LSW-G explained PTSD generally as, a re-experiencing of trauma, a flashback of something that occurred to them. LSW-G stated this re-experiencing of a traumatic event may present differently for everyone, but someone could be escalated and fearful with big movements. Furthermore, LSW-G explained a person could be very emotional, distraught, or they could be completely frozen and fearful, even dissociate. LSW-G stated someone who was aphasic and had PTSD, like R77, could express being triggered through being resistive and combative or aggressive with cares. LSW-G indicated the recommendation for him was to gain more information by paying attention to his body language, his reactions both during approach and during cares, because a thorough root cause analysis of behavior monitoring could identify patterns which may help both behavior and medication management. LSW-G stated, we want to see staff trialing all non-pharmaceutical interventions before medications. LSW-G stated his trauma most definitely could be impacting his interactions with staff because, in those moments when there are cares being performed, it might have reminded him of something in the past. LSW-G stated having a better understanding of his trauma and triggers could have mitigated re-traumatization. LSW-G believed thorough behavior monitoring and utilizing all recommended interventions may have altered the need for medication changes, however, did not believe there was harm and stated, I do believe R77 is safe and the care he receives is safe. Per facility policy titled Psychotropic [psychoactive] Drugs reviewed 4/21/25, psychopharmacologic drugs may be used only after non-pharmaceutical approaches have been attempted and failed to sufficiently modify a resident's maladaptive behavior, mental status or mood. The policy identified antipsychotics and antidepressants as psychotropic drugs. An undated facility policy titled Trauma Informed Care and Culturally Competent Care indicated its purpose was to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The policy directed staff the develop an individualized care plan that would address past trauma and identify and decrease exposure to triggers that may re-traumatize the resident as well as to incorporate language needs, culture, cultural preferences, normal and values (for example, food preparation and choices; clothing preferences such as covering hair or exposed skin; physical contact or provision of care by a person of the opposite sex; or culture etiquette, such as avoiding eye contact or not raising the voice). Furthermore, the policy directed staff to recognize the relationship between past trauma and current health concerns.

Based on interview and document review, the facility failed to develop and implement a comprehensive care plan to include identified trauma-related triggers and individualized trauma-informed care approaches for 2 of 2 residents (R14, R77) who had a history of trauma. Findings include: R14 R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and reported diagnoses of anxiety, depression, bipolar disorder (a mental disorder characterized by episodes of extreme elevated mood, or mania, and depression), and post traumatic stress disorder (PTSD, a psychiatric disorder that some people who have experienced or witnessed distressing or life-threatening event(s) may develop). Per a trauma informed care/vulnerabilities assessment dated [DATE], R14 indicated she had experienced trauma that was so frightening, horrible, tragic, or upsetting she had a hard time not thinking about it. The assessment identified her traumatic experiences and reported she was physically, sexually, and emotionally abused. Raped by an older male relative. Furthermore, the assessment identified she felt angry, sad, isolated, alone, shameful, irritable, and moody because of the experience(s). The assessment identified potential triggers that could cause such feelings to escalate, including being touched, loud noises, not having input/control, someone coming up behind me scares me. I'm disturbed by yelling/swearing [sic] Afternoon and evening are more difficult times for me [sic] Anniversaries - 3/30 (death of mother) and divorce (7/2). Furthermore, the assessment listed activities she identified might help her feel better when she as having a hard time, including listening to Christian music, reading, sitting by the office or nurse, talking, walking, having her hand held, physical exercise, writing, participating in activities, breathing exercises, and lying down. R14's care plan dated 3/25/25, identified her potential for abuse and neglect due to her history PTSD. The care plan directed staff to observe for changes in her mood and behavior, indicated she did not wish to discuss her trauma with her sister and reported she was close with her friend with whom she discussed all issues with. The care plan lacked documentation of triggers that may re-traumatize her and lacked resident-specific interventions to mitigate the risk of re-traumatization. R14's Kardex dated 4/29/25, was reviewed and lacked identification of triggers and resident-specific interventions to mitigate the risk of re-traumatization. During interview on 4/30/25 at 2:27 p.m., R14 could not recall if staff had asked her about things that set me off, but stated there had been no instances of re-traumatization in the facility. However, she stated, I have bipolar disorder and PTSD, I said something to the director of nursing about they [staff] need to learn how to deal with people who have mental health problems. R14 stated there were times she asked NAs to get a nurse for her treatments and she felt staff responded by scolding her and it bothered her and gives me anxiety. During interview on 4/30/25 at 5:17 p.m., registered nurse (RN)-A expected a resident's trauma and vulnerabilities to be identified on their care plan. RN-A reviewed R14's care plan and confirmed her trauma and trauma-related triggers were not documented on her care plan. RN-A stated, I don't see anything listed, and indicated it would be important for NAs to identify what her triggers were. R77 R77's quarterly Minimum Data Set (MDS) dated [DATE], indicated he had unclear speech that was slurred or mumbled and was unable to complete the cognitive assessment interview. The MDS indicated he was severely impaired in his daily life decision making and had both short- and long-term memory problems. The MDS reported diagnoses including Alzheimer's disease (a progressive brain condition that affects thinking, memory, and behavior), aphasia (a language disorder caused by injury to the brain), depression, post traumatic stress disorder (PTSD, a psychiatric disorder that some people who have experienced or witnessed distressing or life-threatening event(s) may develop), chronic pain, and psychotic disorder (a mental condition characterized by abnormal perceptions and loss of contact with reality). A trauma informed care/vulnerabilities assessment dated [DATE], indicated he had an experience so upsetting he had a hard time not thinking about it and reported his step mom [sic] expressed that resident had been sexually assaulted as a child. The assessment reported, resident may resist bathing because of this trauma. Furthermore, the assessment identified he had severe cognitive impairment and identified his wandering behavior, and his communication limitations made him susceptible to abuse by others or increased his risk of abuse to himself or others. R77's care plan last revised 4/19/24, identified he had a potential for abuse and neglect from himself or others related to his memory impairment and his diagnoses of dementia and depression and directed staff to be mindful of residents [sic] hx [sic, history] of trauma but lacked documentation of potential triggers that may re-traumatize him. The care plan identified he was sexually abused as a child, and indicated he had an alteration in his mood and behavior due to his PTSD. The care plan directed staff to follow American Clinic of Psychiatry (ACP)'s recommended interventions, including having 1-2 staff approach him for cares (cares in pairs), offer him his preferred food or drink or something soft/texture for him to hold, approach him slowly and greet him by name, introduce self and inform him of the cares to be performed and move him to a quiet, less-stimulating environment. The care plan did not identify a preference for male versus female caregivers. R77's Kardex dated 4/29/25, directed staff to be mindful of his history of trauma but lacked documentation of potential triggers that may re-traumatize him. The Kardex included behavioral interventions including have 1-2 staff approach him for cares (cares in pairs), offer him his preferred food or drink or something soft/texture for him to hold, approach him slowly and greet him by name, introduce self and inform him of the cares to be performed and move him to a quiet, less-stimulating environment. The Kardex did not identify a preference for male versus female caregivers. An ACP progress note dated 4/8/25, indicated under the treatment recommendations care team should be aware that R77's history of childhood sexual abuse could impact his emotional/behavioral responses. The progress note indicated it was possible his resistance and behavioral responses could be related to his trauma history. An ACP progress note dated 12/23/24, indicated the provider interviewed floor staff for updates. The progress note revealed a nursing assistant (NA) reported R77 can become aggressive during cares, and responds better to male caregivers and is typically less aggressive. With female caregivers, he benefits from cares in pairs. Under the treatment recommendations/plan, the progress note indicated staff were encouraged to continue with care planning trauma hx [sic, history] and behaviors/preferences and identified he responded well to male caregivers and benefited from cares in pairs with female caregivers. During interview on 4/30/25 at 10:23 a.m., social services (SS)-A verified completing the mood and behavior assessments and building up that section of the care plan. Additionally, SS-A reported being responsible for reviewing ACP progress notes and transcribing the recommendations into the care plan. SS-A stated behavioral interventions were reviewed during interdisciplinary team (IDT) meetings and occasionally at care conferences if a resident's family or representative(s) asked how they were doing with a behavior. SS-A expected staff to utilize non-pharmacologic interventions prior to implementing or adjusting psychotropic medications and stated, I would hope that's what they're doing. During interview on 4/30/25 at 11:08 a.m., NA-F stated resident-specific behaviors were identified on the Kardex and were reported in daily huddles. NA-F was not able to identify R77's trauma-related triggers, but stated he could sometimes get really strong and grab tight. NA-F stated when staff re-approach for cares, we go with two people. NA-F stated if staff were not paying attention to him during cares, he could go off and hit you. NA-F reported talking to him in a calm manner, offering him chips, leaving him be and re-approaching, and singing to him were effective interventions for him when he became resistive to cares and aggressive. Per interview on 4/30/25 at 1:32 p.m., NA-G reported, I go all over the facility to every floor. NA-G stated resident information could be located on their [Kardex] care card posted inside their closet. NA-G stated this would include resident-specific behaviors, triggers, and interventions. During re-interview on 4/30/25 at 1:58 p.m., SS-A verified responsibility for completing R77's trauma assessment and indicated triggers and interventions should be on the care plan and the Kardex. SS-A stated this information was also passed along via word of mouth, so staff knew about it right away. SS-A stated it was of high importance staff were aware of potential triggers so they could try and avoid re-traumatizing residents with PTSD. SS-A reviewed R77's Kardex and confirmed it lacked documentation of potential triggers. SS-A confirmed staff should be aware of his potential triggers and stated the Kardex doesn't say what it is. During interview on 4/30/25 at 3:37 p.m., licensed practical nurse (LPN)-C walked into R77's room and showed the surveyor the Kardex care card was located inside the closet doors and stated resident preferences and activities of daily living (ADL) support requirements were located on the Kardex. LPN-C stated everything staff needed to know for R77 was located on the Kardex. Per interview on 4/30/25 at 4:01 p.m., with registered nurse (RN)-B, a resident's care plan would be the first place to look for their trauma or related triggers. Per interview on 4/30/25 at 5:30 p.m., the director of nursing (DON) expected the care plan and Kardex to be updated with anything staff should be aware of regarding a resident's trauma assessment. The DON stated social services completed the trauma assessments and care plans and was usually responsible for reviewing ACP progress notes and ensuring recommendations/interventions were transcribed and updated on the care plan. The DON indicated not having this information available to staff risked not knowing how to care for a resident if they were triggered or re-traumatized. During interview on 5/2/25 at 12:04 p.m., licensed social worker and ACP clinical intern (LSW)-G confirmed working with R77. LSW-G indicated the recommendation for him was to gain more information by paying attention to his body language, his reactions both during approach and during cares, because a thorough root cause analysis of behavior monitoring could identify patterns which may help both behavior and medication management. LSW-G stated his trauma most definitely could be impacting his interactions with staff because, in those moments when there are cares being performed, it might have reminded him of something in the past. LSW-G stated having a better understanding of his trauma and triggers could have mitigated re-traumatization. An undated facility policy titled Trauma Informed Care and Culturally Competent Care indicated its purpose was to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The policy directed staff the develop an individualized care plan that would address past trauma and identify and decrease exposure to triggers that may re-traumatize the resident as well as to incorporate language needs, culture, cultural preferences, normal and values (for example, food preparation and choices; clothing preferences such as covering hair or exposed skin; physical contact or provision of care by a person of the opposite sex; or culture etiquette, such as avoiding eye contact or not raising the voice). Furthermore, the policy directed staff to recognize the relationship between past trauma and current health concerns.

Based on observation, interview, and document review, the facility failed to ensure wound care orders were followed and implemented for 1 of 3 residents (R27) reviewed for skin conditions. Findings include: R27's annual Minimum Data Set (MDS) dated [DATE], indicated R27 had intact cognition, did not have impairment with range of motion, used a walker, was independent with toileting hygiene, personal hygiene, transfers, and ambulation, and required substantial assistance with showering and bathing. Further, R27 was not on a toileting program, occasionally was incontinent of urine and was always continent of bowels, was not at risk for pressure ulcers and did not have other skin problems including moisture associated skin damage (MASD). R27's Medical Diagnosis form indicated the following diagnoses: retention of urine, muscle weakness, osteoarthritis, and history of falling. R27's care plan dated 3/13/25, indicated R27 had a potential for alteration in skin integrity due to urinary incontinence, skin was intact and R27's goal was to have no breakdown throughout the stay at the facility. Interventions included, daily skin observation with cares, report new or worsening concerns to the nurse immediately, treatment as ordered and observe for changes and report concerns to the physician or nurse practitioner, (NP) as warranted, weekly skin inspection by the licensed nurse. Implement appropriate interventions and update the physician or NP as warranted for worsening or new issues. R27's toileting and continence care plan dated 3/13/25, indicated R27 was independent with toileting and would remain continent of his bowel and bladder. R27's care plan was reviewed and lacked interventions for covering cushions with a cloth pillow case to assist in wicking away moisture. R27's Kardex printed 4/29/25, indicated R27 was independent with toileting, ambulation, bed mobility and used a two wheeled walker. R27's Kardex lacked interventions for covering cushions with a cloth pillow case to assist in wicking away moisture. R27's Kardex printed 4/30/25, was later updated to include an intervention to make sure any cushions/pads underneath R27 were covered with cloth/pillow case to assist with wicking away moisture. R27's physician's orders form indicated the following orders: 4/8/25, IHSS wound NP to evaluate and treat wound to left buttock. 4/24/25, treatment to left buttock, soak with warm, wet compress to gently remove previously applied topicals and or debris (do not rub or scrub to remove). Allow the area to dry for a minute before applying a new thin layer of Calmoseptine. Do not cover with a dressing! Adhesives will rip peeling skin. Topicals and soaking will help to soften and debride dry skin. R27's orders were reviewed and lacked orders to ensure cushions and pads were covered with a cloth pillow case to assist with wicking away moisture. R27's nurse practitioner (NP)-C's wound progress note dated 4/16/25, indicated under a heading, Wound Description, indicated R27 had moisture associated skin damage (MASD) to the left medial buttocks and had a previously applied bordered silicone adhesive foam dressing and evidence of previous application of Calmoseptine to the underlying surrounding skin. Under a heading, Procedure Note, indicated Cavilon Advance skin protectant was applied and R27 was at risk for recurrence due to ongoing dry, peeling skin. Further, under the heading, Wound Care Plan, indicated to soak with warm, wet compress to gently remove previously applied topicals, effluent and or debris (Do not rub or scrub to remove), allow the area to dry for about a minute before applying a new thin layer of dimethicone-based topical or petrolatum based topical ie Vaseline or critic aid clear. Do not cover with dressing, adhesives will rip peeling skin and can cause additional trauma, which is not helpful to his healing. Topicals and soaking will help to soften and autolytically debride dry, peeling skin. R27's NP-C's wound progress note dated 4/23/25, indicated under a heading, Wound Description, indicated R27 had MASD to bilateral medial buttocks and a previously applied bordered silicone adhesive foam dressing was in place, along with evidence of previous application of Calmoseptine to the underlying and surrounding skin. Under a heading, Plan, indicated recurrence with increased overall affected area, likely secondary to trapping of moisture between topicals and bordered silicone adhesive foam dressing as well as R27 sitting on a cushion without fabric, increasing humidity and decreasing the ability for moisture to wick away when sitting for long periods of time. Under a heading, Wound Care Plan, indicated to make sure any cushions and pads underneath R27 are covered with a cloth pillow case to assist with wicking away moisture and soak with warm, wet compress to gently remove previously applied topicals, effluent and or debris (don not rub or scrub to remove) allow the area to dry for about a minute before applying a new thin layer of dimethicone based topical or petrolatum based topical for example, Vaseline or Critic-Aid Clear. Do not cover with a dressing-adhesives will rip peeling skin and can cause additional trauma, which is not helpful to healing. R27's nursing progress notes dated 4/21/25 at 2:45 p.m., indicated R27 had a bath and the excoriated areas on R27's buttocks were cleaned and a dressing was applied. R27's Weekly Skin Check form dated 3/31/25, indicated skin was clean, dry, and intact. R27's Weekly Skin Check form in progress dated 4/7/25, lacked information whether R27's skin was intact. R27's Weekly Skin Check form dated 4/21/25, indicated R27 had a bath and the excoriated buttocks were cleaned and a dressing was applied. During interview on 4/28/25 between 2:32 p.m., and 2:43 p.m., R27 stated he had a rash on his bottom for 6 months and the doctor told staff not to put a patch on and the nurse put a patch on two places and it was just getting worse. R27 further stated staff didn't apply cream on his bottom and further stated he was on his own and wanted staff to tell him the area was getting better. R27 was sitting in a recliner with a cushion under him. During observation on 4/29/25 at 8:24 a.m., R27 had a black cushion in his recliner and there was no pillow case located on top of the cushion as directed in the NP note. During interview and observation on 4/29/25 between 8:38 a.m., and 8:44 a.m., nursing assistant (NA)-C stated they looked at the Kardex on the computer every a.m., to know what cares a resident required. NA-C stated they had care sheets, but did not carry one on her. NA-C stated if a resident refused, it was documented in the computer and the nurse is updated. Further NA-C stated R27 was independent and sometimes needed help applying stockings otherwise did not need anything, did not refuse cares, was alert and oriented and a reliable historian. At 8:44 a.m., NA-C viewed R27's cushion in the chair and verified there was no pillow case and R27 stated he did not have one. NA-C stated she would have to ask the manager whether R27 required a pillowcase over cushions. During interview on 4/29/25 at 8:46 a.m., NA-G stated R27 did not want to exercise because he had a rash on his bottom. During interview on 4/29/25 at 8:47 a.m., trained medication aide (TMA)-A stated they applied lotions or creams such as Voltaren gel and Calmoseptine if there was an order, and stated if a resident refused, would let the charge nurse know and the charge nurse would talk with the resident and if they still refused would document the reason. TMA-A stated the charge nurse looked at skin on shower days and stated R27 had a cream that went on his bottom, he did by himself and somedays would call the charge nurse. During interview on 4/29/25 at 8:55 a.m., registered nurse (RN)-D stated he worked at the facility since 2008 and staff looked at the Kardex and on the care plan and if a resident refused, staff reapproached, tried different interventions and if continues to refuse would be documented in a progress note for any staff who can document in the progress note. RN-D stated R27 was followed by a wound doctor on Wednesdays. RN-D viewed R27's cushion and verified there was no cloth or pillowcase on the cushion and applied a cloth that was under the cushion. During interview on 4/29/25 at 9:16 a.m., licensed practical nurse (LPN)-A stated R27 had dry skin and saw the wound doctor on Wednesdays. During interview on 4/29/25 at 9:27 a.m., LPN-A went into R27's room and R27 had a cushion sitting on top of a folded wheelchair with no pillow case and LPN-A stated R27 had not been using the wheelchair. LPN-A washed R27's buttocks with a warm wash rag and the area appeared to have previously applied Calmoseptine located on the buttocks. The area appeared dried over and no angry redness observed. During interview on 4/30/25 at 7:41 a.m., NP-C stated R27 had a sweaty bottom and when moisture sits there, can cause skin breakdown and interventions were in place to keep things dry and stated R27's bottom was getting better and verified staff were using dressings and it was an education process, staff want to apply foam which adds moisture and stated she hoped the intervention of the pillow case over the cushion was careplanned and would check with RN-A. NP-C further stated, R27's MASD wasn't due to incontinence, but due to being sweaty and not having that moisture wick away from him because R27 was ambulatory and continent. During interview on 4/30/25 at 7:51 a.m., RN-D stated it would be important to have the intervention of the pillowcase on top of the cushion on the Kardex and care plan in order for the aide to know and verified the intervention was not on the care plan or the aide Kardex. During interview on 4/30/25 at 8:46 a.m., the director of nursing (DON) stated she expected orders to be followed, careplanned or placed on the Kardex and expected staff to be aware of the interventions. A policy, Skin Integrity Management Policy, dated 8/27/24, indicated it was the facility policy to properly identify, assess, and monitor residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers/injures; to implement preventative measures; and to provide appropriate treatment modalities for pressure ulcers/injuries according to industry standards of care. Further, the policy directed staff to care plan interventions according to the resident assessment and or individual risk factors identified.

Based on interview and document review, the facility failed to collaborate with hospice for the development, implementation, and revision of the coordinated plan of care for 1 of 1 residents (R34) reviewed for hospice services. Findings include: R34's significant change Minimum Data Set (MDS) dated [DATE], indicated she had severely impaired cognition and received hospice care. The MDS identified diagnoses of Alzheimer's disease (a progressive brain condition that affects thinking, memory, and behavior), non-Alzheimer's dementia (symptoms characterized by problems with memory, thinking, and behavior), depression, and anxiety. R34's care plan revised 4/7/25, identified she was on hospice care related to her Alzheimer's dementia diagnosis and directed staff to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were met. R34's hospice plan of care dated 4/4/25, identified coordination of care between the facility, hospice team, and her and her children was a goal of care. The hospice plan of care indicated staff met with her family and reviewed hospice services and philosophy and they are in agreement with both. The plan of care reported paperwork was signed and placed in the chart. A care conference report dated 1/22/25, indicated the R34 was not present during the meeting however her family was invited and present for the care conference. The summary of care conference indicated her decline was discussed and hospice option was reviewed. The summary indicated her family was very interested and would be reviewed further when family returned from out of town. A review of R34's electronic health record (EHR) on 4/28/25 at 3:12 p.m. revealed a lack of documentation of a care conference since 1/22/25. Per interview on 4/28/25 at 3:29 p.m. with family member (FM)-A, staff reported there would be a meeting after R34 signed onto hospice care, but FM-A stated there had not been a care conference since before February when the unit's previous manager left. FM-A stated, we haven't sat down to talk with her team in several months now. FM-A expressed concern and stated without having a primary person, I just feel like I don't know what's going on. I really don't think they are collaborating with hospice. During interview on 4/30/25 at 9:34 a.m., hospice registered nurse (RN)-C confirmed familiarity with R34's hospice care and services. Hospice RN-C stated a resident should have a care conference within the first 30 days of them admitting to hospice. Hospice RN-C verified R34 admitted to hospice on 3/26/25 and stated, I don't see we've had a care conference yet. Hospice RN-C confirmed the last care conference for R34 was in January 2025 and did not see one scheduled for the upcoming week. Hospice RN-C reported the facility was responsible for arranging the care conference and inviting the hospice team, resident and family or representatives and other healthcare providers. During interview on 4/30/25 at 10:10 a.m., social services (SS)-A verified responsibility for coordinating care conferences between the facility, hospice team and resident and families/representatives. SS-A stated care conferences should take place within 21 days of a resident's admission to hospice. SS-A confirmed R34 did not have a care conference after her admission to hospice when she should have and verified the deficient practice. Per interview on 4/30/25 at 3:50 p.m., RN-B indicated SS coordinated care conferences between the facility, hospice team and resident and families/representatives. Per interview on 4/30/25 at 5:23 p.m. with the director of nursing (DON), care conferences were expected to be held at least within 21 days of a resident's admission to hospice. A facility policy titled Care Conferences revised 1/8/21, indicated the frequency of care conferences followed the MDS schedule and included significant change MDS's. The policy identified the social worker would set the date for the care conference in conjunction with the MDS dates and invite the resident and family and interdisciplinary team (IDT). A Hospice Services Agreement dated 7/8/14, indicated hospice and the facility would work together to care for the same patient. The agreement indicated the facility agrees that family involvement is desirable in caring for patients in the hospice program. The agreement included a facility policy titled Hospice at Mount [NAME] Home / Mount [NAME] Careview Home dated 7/2012, which indicated care would be coordinated between facility staff and hospice staff.

Based on observation, interview, and record review the facility failed to ensure proper sanitization of dishware used for meal prep and resident service when the high temperature sanitizing dishwasher was not reaching adequate wash and rinse temperatures. This had the potential to impact all 92 residents who reside in the facility. Findings include: Ecolab EC-66HH specifications sheet dated 2012, indicated the dishwasher operating temperatures for high temp wash was 160 degrees F. The operating temperature for sanitizing rinse was 180 degrees F. A facility document titled Culinary Services Dish Washer Temperature Log dated 6/2024, indicated logged final rinse temperatures hit 180 degrees F one time from 6/1/24-6/26/24. An observation on 6/26/24 at 7:46 a.m., dietary aide (DA)-A started to wash breakfast prep dishes. The dishwasher was from Ecolab. There were two temp gauges one for wash and one for rinse. On the wash temp dial was a small sticker stated wash temp 150 and on the other temp dial was a small sticker stated final rinse temp 180. The first rack of pans went through. An electronic thermostat connected to the dishwasher indicated the wash temp was 145 degrees F and the rinse was 175 degrees F. At 7:56 a.m., the alarm was sounding on the electronic thermostat indicating low rinse temperatures, however the alarm was not acknowledged by DA-A. DA-A then moved a second rack through of cups and bowls and the alarm was no longer sounding. At 7:59 a.m., the electronic thermostat again went on this time indicating a low wash temp of 140.1 degrees F. DA-A did not acknowledge the alarm and continued to prepare dishes to move through the dishwasher. When interviewed on 6/26/24 at 8:03 a.m., DA-A stated he was not aware the alarm was going off and didn't monitor the temperatures when washing dishes. DA-A stated other issues come up when items get stuck inside the dishwasher, then it gets cleaned out. DA-A further stated he made sure the soap was filled. DA-A was not sure what the wash and rinse temperatures needed to be. When interviewed on 6/26/24 at 8:10 a.m., the Culinary Director (CD) verified the alarm and reset it and verified the low temperature readings. A temperature puck was obtained and placed through the dishwasher. The puck indicated the wash temperature was 142 degrees F and the rinse was now 200 degrees F. CD verified the dishwasher used heat for sanitizing dishes and verified the temperatures gauges indicated wash needed to be 150 degrees F and rinse 180 degrees F. The CD wasn't sure why the temperatures were not reaching what they should be. CD further stated Ecolab was here almost weekly to service and calibrate the dishwasher. When the facility temperature logs were reviewed, CD acknowledged rinse temperatures documented below 180 degrees. CD stated the first thing in the morning, the cooks do a test of dishwasher temps to ensure the temperatures are high enough. The temperatures were then written on the log. CD further stated if there was an issue with the temperatures not reaching 150 degrees F for wash and 180 degrees F for rinse and expected staff to notify a supervisor or himself for follow up. When interviewed on 6/26/24 at 10:53 a.m., Ecolab representative stated technicians come out monthly for maintenance and noted the last time the facility called with an issue was on 5/20/24 and some valves were replaced at that time. When interviewed on 6/26/24 at 11:54 a.m., the assistant administrator expected dishwasher temperatures to be monitored to ensure sanitization was occurring. If found not to be running at the required temperatures, the CD should be notifying maintenance or Ecolab for assistance and to determine if alternative measures such as paper plate use was needed. A facility policy titled Dish Machine Temperature Log dated 1/2000, directed staff to monitor and record dish machine temperatures to ensure proper sanitization of dishes. Furthermore, the policy directed the dietary manager to spot check the logs and ensure staff monitoring and appropriate temperatures maintained. A facility policy titled Sanitation of Dishes Manual Washing dated 1/2000, directed staff to when using a mechanical dish machine using hot water to sanitize temperatures must be at or above 180 degrees F.

Based on observation, interview, and document review, the facility failed to ensure insulin was to be administered to the correct resident and failed to ensure appropriate medication receiving procedures were followed for 1 of 3 residents (R18) observed for insulin administration. Additionally, the facility failed to provide pharmaceutical services to meet each resident's needs which included receiving the correct resident's medications and disposing of a discharged resident's medications. This had the potential to affect all who residents who received insulin residing in the facility. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had moderate cognitive impairment and diagnoses of heart failure, renal failure, diabetes mellitus, and dementia. R18's order summary report dated 6/27/24, directed staff to subcutaneously inject R18 with 5 units of insulin aspart solution 100 unit/mL with meals for diabetes and hold if blood sugar less than 120. During observation on 6/26/24 at 8:45 a.m., RN-D prepared insulin aspart 100 units/mL for R18. The insulin pen contained a label which read a different resident's name (RSG) and listed a different facility's name (STNH). RN-D entered R18's room with insulin pen and alcohol wipe and verified the name and facility on the label, which was not the name of the resident they prepared the insulin for, and stated they did not know about the label, but the medication was the one which R18 was ordered. RN-D proceeded to ask R18 where they wanted their insulin injection and went to turn on the resident's lights so they could see better. When asked again about the insulin label, RN-D stated the insulin came from the pharmacy with the label and labels should have the medication name, expiration date, and date opened. RN-D called licensed practical nurse (LPN)-A from another floor, and LPN-A arrived and verified the label identified RSG from STNH, and the insulin pen was not for R18. LPN-A stated there were more insulin pens in the second-floor refrigerator and brought RN-D to the refrigerator in the medication room. RN-D did not find insulin for R18. During observation and interview on 6/26/24 at 9:22 a.m., LPN-C viewed the insulin pen, and RN-D stated R18 did not have any insulin right now. LPN-C asked if RN-D had called the pharmacy and checked the second-floor refrigerator and medication cart. LPN-C stated the insulin pen was opened the day prior, and resident most likely moved from another nursing facility with the insulin. LPN-C instructed to give the insulin pen until done. RN-D proceeded to R18's room with medication, and trained medication assistant (TMA)-E stopped RN-D and grabbed insulin pen and gave to LPN-C again. LPN-C verified the label identified RSG from STNH. LPN-C instructed RN-D to call the pharmacy. During subsequent interview on 6/26/24 at 9:33 a.m., RN-D stated medication labels should have resident name, medication dose, route of administration, and time of administration. Nurses were to call the supervisor and pharmacy if medication labels were incorrect and not give the medication. RN-D stated residents could have possible side effects if received incorrect medication. During subsequent interview at 6/26/24 9:43 a.m., LPN-C stated medication labels should have correct name, medication, and dosage. LPN-C stated there was a risk for medication error and the risk depended on what the medication was. During interview on 6/26/24 at 10:18 a.m., RN-D stated they signed for medication when delivered by the pharmacy and kept intake record. RN-D stated when they needed medication delivered from the pharmacy, they placed the medication refill sticker or wrote in the information on a form they faxed to the pharmacy. The receipts and medication refill requests were kept in a binder and when reviewed showed a refill request for R18's insulin aspart pen 100 unit/mL dated 12/22/23. During interview on 6/26/24 at 10:33 a.m., RN-B stated medications were sent to the floor the resident resided on. Nursing verified medication and then put away. Staff called the pharmacy to see what happened if they received someone's medications who were not on their floor. During interview on 6/26/24 at 11:12 a.m., LPN-C stated staff ensured medication received from the pharmacy was in the resident orders and medication was for the right resident. During interview on 6/26/24 at 12:32 p.m., LPN-A stated medication needed to have the right resident, medication, dose, time, and route to be given. LPN-A stated they were not to give insulin to a resident which had a different resident name and would have to find the insulin pen labeled for R18. LPN-A stated they would give the medication to the manager and contact the pharmacy about the different resident's name and facility. LPN-A stated there was a risk of giving the wrong medication or dose which could cause side effects. During interview on 6/26/24 at 1:25 p.m., LPN-C stated the pharmacy delivered medication to the second floor and the charge nurse checked off the medications and brought the medications to the third-floor nurse. Nurses checked pharmacy receipts when medications delivered and received from pharmacy. During interview on 6/26/24 at 2:17 p.m., pharmaceutical manager (PM) stated medications were labeled at the pharmacy, which included medication and concentration. A second pharmacist verified medications, and then medications were toted. Medications were scanned and placed into delivery bag, and any subsequent scans would block it and not allow medication into tote. Packing slips were associated with the delivery bags and stapled into the bag and listed residents and medications associated with the scanned barcode. Delivery drivers picked up the bags and took to the facility. PM expected nursing home staff to verify the medications as soon as possible. PM stated R18's last insulin pen was done on 5/24/24, and pharmacy had been sending out consistent deliveries so had no reason to think resident was out of insulin. During interview on 6/27/24 at 8:57 a.m., director of nursing (DON) expected staff to follow the six rights of medication administration and three checks before administering medication. DON expected staff to check medications were correct when pharmacy delivered them. DON stated there was a risk of giving the wrong medication to the wrong resident. During interview on 6/27/24 at 11:03 a.m., consulting pharmacist (CP) expected staff to follow the three-check process when administering medication. CP stated there could be risk of medication error and from there depended on what the medication error was and what medication was given versus what was ordered. CP reviewed medication errors for the facility and gave input as able and did not see trends in medication errors. The facility provided packing slip dated 5/24/24, indicated insulin aspart pen 100 unit/mL for R18 with instructions to deliver to the second floor. The facility's policy and procedure Medication Administration Protocol revised 5/25/22, directed staff to complete three checks before administering a medication and to give the medication according to the specifics of the medication, which included right resident, route, dose, medication, time and documentation. The facility's policy and procedure Medication Ordering and Receiving from Pharmacy: Ordering and Receiving Non-Controlled Medications from the Dispensing Pharmacy dated 4/1/19, directed licensed nurses to verify each medication against the pharmacy supplied packing slip. Staff were to verify medications received and directions for use with the medication order form and promptly report discrepancies and omissions to the issuing pharmacy and the charge nurse and/or supervisor. 49617 Medication Storage and Labeling Findings include: R291's admission Minimum Data Set (MDS) dated [DATE], indicated he had diagnoses of diabetes and took insulin injections. R291's order summary report for active orders as of 5/1/24 included the following orders: - insulin glargine (Lantus Solostar) subcutaneous solution pen-injector 100 units/milliliter (mL), Inject 62 unit subcutaneously at bedtime for diabetes dated 10/23/23. R291's order summary report for active orders as of 4/1/24 included the following orders: - semaglutide (Ozempic) subcutaneous solution pen-injector 8 milligrams (mg)/3mL, Inject 2mg subcutaneously one time a day every Friday for diabetes dated 10/23/23. R291's care plan last revised 11/8/23, indicated he had altered health maintenance related to his diagnosis of type 2 diabetes and identified interventions included administering insulin as ordered. A progress note dated 5/21/24, indicated R291 had discharged from the facility after needing a higher level of care. A drug disposition record for R291 was reviewed with the following record: Name of Drug Prescription (Rx) # Amount Date in Hazardous Waste Box Carvedilol 1040986 9 1/30/24 Icosapent 1040990 4 1/30/24 Escitalopram 1040986 9 1/30/24 Primidone 2050782 7 3/4/24 R291's electronic health record (EHR) lacked a discharge drug disposition form. During observation on 6/26/24 at 10:21 a.m., the second-floor medication storage room was reviewed. There was a locked refrigerator with unopened insulin pen-injectors and a locked medication cart with opened insulin pen-injectors. In the refrigerator, there were two unopened Lantus Solostar insulin glargine pen-injectors with a prescription label and R291's name on them. In the medication cart, there was an Ozempic box with a prescription label and R291's name on it. Inside the box was a semaglutide pen-injector and a label with an open date of 4/26/24. The prescription label stated to discard the medication 56 days after opening. During interview on 6/26/24 at 10:54 a.m., registered nurse (RN)-B stated R291 had recently discharged from the facility. RN-B stated when a resident discharged , the normal process was to clear their medications out of the medication cart and storage room and follow the medication destruction procedure. RN-B stated there was a primary nurse manager responsible for this process. RN-B stated because R291 was private pay and the facility was still in contact with his family, they were keeping his medications in case the family wanted to collect them. RN-B stated if his family wanted to take a medication past the discard date on the label, such as the Ozempic pen-injector, education would be provided on the risks. RN-B stated there was not a routine auditing process of medication storage rooms or carts. RN-B stated, this is an ongoing process staff were expected to do during administration. RN-B expected staff to review expirations dates during medication administration and if staff found expired medications, they were expected to follow the facility's medication destruction procedure. During interview on 6/26/24 at 11:07 a.m., licensed practical nurse (LPN)-A stated when a resident discharged , a medication disposition form was filled out and their medications were put into the medication destruction box in the medication storage room. LPN-A stated a manager was responsible for destroying the medications. LPN-A stated they did not keep medications for residents who discharged and their return was not anticipated because they would most likely expire and they would not have anything to do with those medications. During interview on 6/26/24 at 12:46 a.m., the consultant pharmacist stated there were no pharmacy audits of the facility's medication storage rooms or medication carts. During interview on 6/26/24 at 3:32 p.m., the director of nursing (DON) stated during a discharge, two nurses were expected to sign off on medications being destroyed on a disposition form. The DON stated this process was expected to be done as soon as possible to reduce the risk of error and save space. The DON stated this process applied to injectable medications, such as insulin. The DON stated it would not be appropriate to keep a discharged resident's medications with current residents' medications. Furthermore, the DON did not endorse providing medications to the resident or family after discharge. The DON stated it would have been more appropriate to give the unopened medications back to the pharmacy for billing purposes. A request for R291's discharge medication disposition was requested but not received. A facility policy titled Destruction of Non-controlled Drugs dated 8/9/19, stated its purpose was to safely dispose of medications that were discontinued, expired or resident was discharged . The policy indicated any medication that could be returned to pharmacy for credit would be returned. Additionally, the policy indicated all other medications that were unable to be returned and needed to be disposed of were to be itemized on the Drug Disposition Record and placed in the chart. This included the name of the drug, the prescription number, the amount, and what was done with the medication, for example, disposed into the hazardous waste box, sent with the resident, or returned to the pharmacy. Finally, the signatures of two nurses or a nurse and trained medication aide (TMA). The policy guided staff on how to dispose of medications that were not controlled in the Medsafe.

Based on observation, interview and document review, the facility failed to ensure insulin pens were labeled in accordance with professional standards for 2 of 3 residents observed during insulin administration. Furthermore, the facility failed to ensure insulin pen-injectors were stored in a locked compartment. This had the potential to affect all 31 residents residing on the locked memory care unit. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had moderate cognitive impairment and diagnoses of heart failure, renal failure, diabetes mellitus, and dementia. R18's order summary report dated 6/27/24, directed staff to subcutaneously inject R18 with 5 units of insulin aspart solution 100 unit/mL with meals for diabetes and hold if blood sugar less than 120. R53's quarterly MDS dated [DATE], indicated R53 had intact cognition and diagnoses of diabetes mellitus and dementia. R53's order summary report dated 6/27/24, directed staff to subcutaneously inject R53 with 6 units of Lantus SoloStar Solution pen-injector 100 unit/mL one time a day for diabetes. During observation on 6/26/24 at 7:22 a.m., registered nurse (RN)-D got out a caddy basket which contained which contained items such as a glucometer, lancets, alcohol wipes, test strips, and insulin pens. The caddy basket was in the lower drawer behind the nursing station which the nurse did not have to unlock to get to. RN-D completed blood sugar checks and returned the caddy basket to the drawer which was closed and unlocked. During observation on 6/26/24 at 8:34 a.m., RN-D did not have to unlock the door to get behind the nursing station or the drawer which had the caddy basket with insulin pens. RN-D prepared Lantus SoloStar for R53. The insulin pen stated Lantus and contained a sticker which covered up concentration information. The sticker contained information such as resident name, date of birth, and provider and did not reference the order for administration. During observation on 6/26/24 at 8:45 a.m., RN-D prepared insulin aspart 100 units/mL for R18. The insulin pen contained a label which read a different resident's name (RSG) and listed a different facility's name (STNH). RN-D entered R18's room with insulin pen and alcohol wipe and verified the name and facility on the label, which was not the name of the resident they prepared the insulin for, and stated they did not know about the label, but the medication was the one which R18 was ordered. RN-D proceeded to ask R18 where they wanted their insulin injection and went to turn on the resident's lights so they could see better. When asked again about the insulin label, RN-D stated the insulin came from the pharmacy with the label and labels should have the medication name, expiration date, and date opened. RN-D called licensed practical nurse (LPN)-A from another floor, and LPN-A arrived and verified the label identified RSG from STNH, and the insulin pen was not for R18. LPN-A stated there were more insulin pens in the second-floor refrigerator and brought RN-D to the refrigerator in the medication room. RN-D did not find insulin for R18. During observation and interview on 6/26/24 at 9:22 a.m., LPN-C viewed the insulin pen, and RN-D stated R18 did not have any insulin right now. LPN-C asked if RN-D had called the pharmacy and checked the second-floor refrigerator and medication cart. LPN-C stated the insulin pen was opened the day prior, and resident most likely moved from another nursing facility with the insulin. LPN-C instructed to give the insulin pen until done. RN-D proceeded to R18's room with medication, and trained medication assistant (TMA)-E stopped RN-D and grabbed insulin pen and gave to LPN-C again. LPN-C verified the label identified RSG from STNH. LPN-C instructed RN-D to call the pharmacy. During subsequent interview at 9:33 a.m., RN-D stated medication labels should have resident name, medication dose, route of administration, and time of administration. Nurses were to call the supervisor and pharmacy if medication labels were incorrect and not give the medication. RN-D verified R53's insulin concentration was covered by the facility's label, and the facility's label did not have the order directions such as prescribed dose. RN-D stated residents could have possible side effects if received incorrect medication. During subsequent interview at 9:43 a.m., LPN-C stated medication labels should have correct name, medication, and dosage. LPN-C stated there was a risk for medication error and the risk depended on what the medication was. During interview on 6/26/24 at 10:18 a.m., RN-D stated they did not think the swinging door of the nursing station locked, and the TMA had the key to the unlocked drawer where the caddy basket with insulin pens were kept. During interview on 6/26/24 at 12:32 p.m., LPN-A stated insulin should be labeled with the right patient, medication, dose, time, and route. Nursing should not give insulin with incorrect medication labels and find one with the correct information. Incorrect labels on medication put residents at risk of getting the wrong medication or wrong dose and have possible side effects. LPN-A stated they would give the medication to the manager and contact pharmacy if the medication label was incorrect or had the incorrect facility name. LPN-A stated medication labels should not cover the dose and concentration of medication and should not be placed over medication information. LPN-A stated they would take the label off and place a new one if a medication label covered medication information, since they needed to see the amount of medication they were giving. During follow-up interview on 6/26/24 at 1:20 p.m., LPN-C stated medications came labeled from the pharmacy and would have to peel back a label and check the medication information if the label was covering it. LPN-C stated the facility had their own labels which they used for doctor appointments, visit notes, and consent forms. LPN-C verified R53's insulin pen label was the facility's made label and covered medication information and did not specify order information. LPN-C stated the half-door of the nursing station was busted and the drawer which contained the insulin pens could lock but the TMA with the key was on break. LPN-C stated there was a risk of someone getting the insulin pens who should not if they were not locked up, and noted the nurse was currently at the nursing station. During interview on 6/27/24 at 8:57 a.m., director of nursing (DON) expected staff to check medication labels were correct when following the six rights of medication administration and three checks before administering medication. DON expected staff to check medications were labeled correctly when pharmacy delivered them. DON expected medication labels would not cover medication dose and other pertinent information which needed to be seen to see what administering. DON expected medication labels to have resident name, date of birth, dose, times of administration and medication order. DON expected staff to write order on label if grabbing from chart or can call pharmacy and have them send a label. There was a risk of residents getting the wrong dose or medication or medication at incorrect times which could lead to adverse effects if medication labels were incorrect or if labels covered medication information. DON expected insulin pens to be locked up. DON stated somebody could take medication and could use on wrong person or other incorrect use if not locked. During interview on 6/27/24 at 11:03 a.m., consulting pharmacist (CP) stated insulin pens would come in boxes which had labels with full information such as resident name, provider name, directions, etc. CP stated boxes with full information did not need to be kept with insulin pen and was okay for insulin pens to have general information, such as resident name, facility name, prescription number, and opened date, and staff could refer to the electronic medication administration record for full medication directions. CP stated there could be risk of medication error and from there depended on what the medication error was and what medication was given versus what was ordered. A facility policy titled Medication Storage in the Facility dated 4/1/19, indicated medications and biologicals were to be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply was only to be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. All medications dispensed by the pharmacy were stored in the container with the pharmacy label, but the policy did not specify what information was on the pharmacy label. Furthermore, the policy indicated medication storage containers are monitored on a regular basis by the facility on a regular basis by the facility and corrective action taken if problems identified. 49617 Findings include: During continuous observation on 6/27/24 between 7:41 a.m. and 8:18 a.m., a plastic caddy was observed in the nurse's station in an opened and unlocked drawer. There were no staff nearby and the swinging half door was open and unlocked. There were four insulin pen injectors, lancets, blood glucose test strips, gauze, and alcohol wipe pads. There was a box of safety needles for the insulin pen-injectors in the drawer next to the caddy. At 7:41 a.m., licensed practical nurse (LPN)-C stated this was the normal spot to keep insulin pens and stated both the door and drawer could be locked. LPN-C walked away from the nurse's station without securing the insulin pens. At 7:46 a.m., registered nurse (RN)-C stated, we keep the supply kit here. RN-C stated there was only one supply room and there was not one on that unit. RN-C walked back and forth between the nurse's station and various resident rooms between 7:52 a.m. and 8:12 a.m. The plastic caddy containing the insulin pens remained unlocked. At 8:12 a.m., the half door was closed but unlocked and the drawer with the caddy was closed but unlocked. Between 7:41 a.m. and 8:18 a.m., five residents walked past the unattended nurse's station. At 8:18 a.m., the plastic caddy remained unchanged and unlocked. No residents or staff were nearby. During interview on 6/24/24, the director of nursing (DON) stated insulin pens were considered medications and should be locked up because someone could take them and use them on the wrong person. A facility policy titled Medication Storage in the Facility dated 4/1/19, indicated medications and biologicals were to be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply was only to be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. All medications dispensed by the pharmacy were stored in the container with the pharmacy label, but the policy did not specify what information was on the pharmacy label. Furthermore, the policy indicated medication storage containers are monitored on a regular basis by the facility on a regular basis by the facility and corrective action taken if problems identified.

Based on observation, interview, and document review, the facility failed to accommodate resident preference and assist in maintaining and/or achieving independent functioning for 3 of 3 residents (R16, R60, R61) reviewed who expressed a desire to open the windows in their rooms as they wished. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], indicated R16 was cognitively intact, had diagnoses of depression, macular degeneration (an age-related eye condition that affects vision,) heart failure, and kidney failure, and was independent with transfers and ambulation. R16's annual MDS 7/19/23, indicated R16's daily preferences were not assessed. R16's care plan dated 9/24/21, included R16 was legally blind and used a walker for mobility. During observation and interview on 6/24/24 at 12:54 p.m., R16 was seated in a chair in their room which had two crank-out style windows without cranks. R16 stated the facility took all the window cranks off because the state directed them to do so, and stated, I resent that! R16 further stated they would not be able to get over the ledge to fall or jump out because the window was too high. During interview on 6/25/24 at 10:56 a.m., nursing assistant (NA)-A stated some of the residents could have their windows open, including R16, but they had to ask staff to open them. NA-A walked to R16's room and confirmed there were no cranks on the windows. R16 was seated in their chair and stated the staff had to call maintenance to find a crank to open it, appeared to become frustrated, and stated it was crazy R16 couldn't open the windows themselves. During interview on 6/25/24 at 11:02 a.m., NA-B stated if a resident wanted their window(s) opened they asked staff, and the staff would crack them open. They indicated there was one crank handle on the floor for all the crank-style windows which was usually kept in a drawer at the nurse's desk. Trained medication aide (TMA)-B was seated at the desk, opened the drawers, and was unable to locate the window crank. During interview on 6/25/24 at 11:06 trained medication aide (TMA)-A looked around the desk area and in the medication cart and stated someone must have used it and left it in a room, and they were unsure how many crank handles there were. They indicated residents could have their windows open a certain distance if they prefer, but the only person who asked to have their window open was a resident in a room with a sliding window. At 11:10 a.m., TMA-A called maintenance to try to get a crank to be able to open resident crank-style windows. During interview on 6/25/24 at 11:23 a.m., registered nurse (RN)-A stated sliding windows were recently altered to make sure they only opened four inches, and they removed the cranks from the crank-style windows to prevent residents from opening them farther than four inches and kept the cranks somewhere. RN-A stated the floor was stuffy and four inches was not very far and not even worth it, however they were instructed by leadership to limit the opening size to prevent anyone from jumping out. RN-A stated R16 was not at risk of jumping or falling out of the window and should be able to have it opened. During interview on 6/26/24 at 11:02 a.m., RN-A stated a resident asked them to open a window that morning because it was going to be a nice day. RN-A confirmed it could only be opened four inches, which did not allow any airflow. They stated the facility did not complete any individualized assessments to determine if each resident was cognitively and physically able to open and close the windows themselves. 44647 R60's annual Minimum Data Set (MDS) dated [DATE], indicated R60 as cognitively intact and had diagnoses of diabetes, anxiety, and depression. Furthermore, R60's MDS indicated it was very important for R60 to have fresh air or to be outside. R60's care conference summary dated 6/11/24, indicated R60 had complaint of inability to fully open windows in room. Staff explained to R60 windows can only be cracked open per regulations. During observation and interview on 6/24/24 at 1:07 p.m., R60 was sitting in their room in a wheelchair. R60 stated the facility just changes things when they want to and can no longer have the window open all the way due to a state code. R60's window was a slide open window and was open approximately 6 inches. On the slider track was a black stopper that was screwed in and prevented the window from being opened any further. R60 further stated it was frustrating and they really liked to have the window open for fresh air. R60 stated he understood the rule for some residents who were confused, but not for those who were independent. R61's quarterly MDS dated [DATE], indicated R61 was cognitively intact and had diagnoses of heart disease and depression. During observation and interview on 6/25/24 at 11:00 a.m., R61 was sitting in her wheelchair in her room. R61 was frustrated and stated could not open their window all the way R61's slider window had a black stopper on the track to prevent the window from opening further than approximately 6 inches. When interviewed on 6/25/24 at 11:13 a.m., nursing assistant (NA)-C stated resident can have windows open if they wanted to. NA-C wasn't aware of any concerns with windows not being opened or not opening al the way. NA-C entered R61's room and verified the black stoppers in R61's windows. R61 stated to NA-C why can't they be open .it's not like I'm going to jump out! NA-C stated hadn't noticed the stoppers in place before. During interview with the assistant administrator (AA) and director of nursing (DON) on 6/2624 at 8:20 a.m., AA stated the facility hired a consultant to conduct a mock survey, identified the windows as a safety risk, and suggested they restrict any opening to four inches for the sliding windows, and remove the handles from the crank out windows to prevent residents from opening them and jumping or falling out of them. DON stated the facility wished to maintain resident autonomy and independence as much as possible and allow residents to make their own choices based upon diagnoses and cognition. The Resident Rights on Respect, Dignity, and Self-Determination Policy dated 8/31/21, indicated the facility respects and promotes the resident's right to self-determination thought support of resident choice, including, but not limited to, the right to choose activities, schedules, health care, and providers consistent with their interests, assessments, plan of care, and preferences and the right to make choices about aspects of their lives in the facility.

Based on observation, interview and record review the facility failed to ensure an electric lift chair was assessed for safe use for 1 of 1 residents (R11) reviewed for positioning. R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 had cognitive impairment and diagnoses of osteoporosis (disease causing weak bones), spinal stenosis (narrowing of the spinal column) and dementia. Furthermore, R11's MDS indicated R11 required partial to moderate assist from sit to stand and used a walker for mobility. R11's physical device data assessment dated [DATE], indicated R11 was not assessed for safe use of an electric lift chair. R11's care plan dated 5/7/24, indicated R11 required staff assistance as needed for transfers. R11's care plan lacked indication R11 used an electric lift chair or required assistance with use. R11's Kardex dated 6/25/24, lacked indication R11 used an electric lift chair or required assistance with use. R11's provider and nursing orders reviewed 6/24/24, lacked indication R11 used an electric lift chair. R11's physical therapy (PT) note dated 3/14/24, indicated R11 stood from raised recliner with stand by assist (standing near resident to maintain safety during task being performed). R11's assessment for safe use of electric lift recliner was requested however was not received. R11's medical record lacked indication R11 had been assessed for safe use of an electric lift chair. An observation on 6/24/24 at 12:35 p.m., R11 was seated in the lift recliner and was eating lunch. R11's tray table was in front of her with lunch on it. On the right arm of the chair was the remote for the lift chair. The lift recliner was lifted and R11 was tilted forward while seated in the chair. R11 stated why do I need to sit up like this .why can't I go back? Furthermore, R11 wasn't sure how to get the chair back down. When interviewed on 6/26/24 at 9:32 a.m., trained medication assistant (TMA)-C stated electric lift chairs were recommended by PT. If the chair was needed, the manager would be notified to obtain a lift chair. TMA-C stated R11 had worked with therapy and used a electric lift chair independently. TMA-C further stated R11 had some confusion at times but did not require help with the electric chair. When interviewed on 6/26/24 at 9:35 a.m., licensed practical nurse (LPN)-A stated PT assessed residents for safe use of an electric lift chair. LPN-A stated there were no assessments completed by nursing for safe use of electric lift chairs on a routine basis and if there was an issue PT would be notified. LPN-A stated R11 did not have an electric lift chair and verified there was no provider order for one. LPN-A further stated R11 would need staff to help with a lift chair because R11 was confused sometimes. LPN-A verified the electric lift chair in R11's room and stated the chair was one brought by family. LPN-A stated R11 should have an assessment to make sure the chair was used safely. LPN-A was not sure how long R11 had the chair. When interviewed on 6/24/24 at 9:46 p.m., registered nurse (RN)-B stated physical device data assessments were not normally completed for electric lift chairs. RN-B further stated device assessments were for grab bars and code alerts. When interviewed on 6/26/24 at 1:16 p.m., the Director of Nursing (DON) stated electric lift chairs were not always PT driven and sometimes residents come from home with them and have already been using them. DON verified electric lift chairs were included on the physical device data assessments and if the electric chair was in use by a resident an assessment was needed. The DON further stated residents with cognitive impairments should be assessed to ensure continued safe use of the chair. A facility policy titled Physical Device Procedure dated 3/16/16, directed staff to assess the use of a physical device upon admission, annually, and with a significant change and will be reviewed quarterly for continued use. Furthermore, the policy directed staff to ensure a provider order was in place and documentation of the device was included on the care plan.

Based on observation, interview, and document review, the facility failed to implement resident-specific non-pharmacological interventions to address pain according to the resident's goals and preferences for 1 of 1 residents (R15) reviewed for pain. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], included they were moderately cognitively impaired, had diagnoses of rheumatoid arthritis, osteoarthritis, depression, and psychotic disorder, and was independent with ambulation. R15 received scheduled pain medications, did not receive PRN (as needed) medications, and did not receive non-pharmacological interventions for pain. R15 indicated they had frequent pain in the previous five days and rated it at a level four on a 1-10 scale. R15's pain Care Area Assessment (CAA) dated 2/13/24, included R15 has frequent/chronic bilateral knee pain with the pain intensity of 4 with contributory factors including a diagnosis of arthritis and low back pain. They received acetaminophen (a drug used to treat mild or moderate pain) three times per day, methotrexate (for pain related to rheumatoid arthritis) weekly, prednisone (to decrease inflammation) every other day, and Voltaren (a gel applied to skin to relieve arthritis pain) daily and PRN. The assessment indicated no PRN medications were used. R15 had severe cognitive impairment and had a goal to be as comfortable as possible. R15's care plan revised 3/7/24, included R15 had an alteration in comfort related to diagnoses of osteoarthritis, osteoporosis, autonomic neuropathy, history of right femur fracture, rheumatoid arthritis, and low back pain, received scheduled pain medication orally and topically, and had PRN topical medication available. The care plan included the following interventions: *Alter environment for comfort. *Provide comfortable room temperature or remove/add blanket or sweater as needed. *Meds (medications) as ordered *Monitor effectiveness of new or changed interventions using EHR (electronic health record) documentation *Observe for verbal and non-verbal signs of pain and update provider as needed. *Pain assessment quarterly and as needed. The care plan lacked resident-centric, non-pharmacological approaches to address R16's pain. R15's Pain assessment dated [DATE], included R15 frequently had moderate pain in the previous five days in both knees and right hip, received scheduled pain medications, did not receive PRN medications, and had no non-pharmacological interventions. The assessment indicated R15 reported bilateral knee pain related to longstanding diagnosis of arthritis as well as right hip pain, and received acetaminophen, Voltaren, methotrexate, and prednisone. The assessment included R15 was frequently noted walking in hallways and frequently reports pain with doing so. Advised to stop walking if experiencing pain. States she does not want to be on any more meds for pain. Care plan reviewed. R15's Order Summary Report dated 6/26/24, included: *Acetaminophen 1000 mg (milligrams) three times per day for pain *Methotrexate Sodium 2.5 mg, give 5 tablets once every Monday related to rheumatoid arthritis *Prednisone 2.5 mg once every other day, and 5 mg once on opposite days related to rheumatoid arthritis *Voltaren Gel, 1%, apply 4 grams topically to bilateral knees daily, and as needed for pain The report lacked orders for non-pharmacological pain interventions. During interview on 6/24/24 at 1:38 p.m., R15 was seated on the side of their bed, appeared to be in distress as evidenced by facial grimacing, and stated, I ache, my knees are bad. My knees are so sore. They lifted their pant legs to expose their knees, which appeared slightly swollen. R15 indicated staff did not offer ice packs or other interventions to help with pain. During interview on 6/25/24 at 9:19 a.m., trained medication aide (TMA)-B stated if a resident asked for pain medication, they asked the resident about their pain level and gave medications. They indicated R15 had acetaminophen PRN but no other interventions for pain. During interview on 6/25/24 at 10:56 a.m., nursing assistant (NA)-A stated R15 often asked for pain pills and NA-A would inform the nurse. They indicated they did not use any non-pharmacological interventions for R15's pain. During interview on 6/25/24 at 11:23 a.m., registered nurse (RN)-A stated R15 had chronic pain and had a pain assessment completed quarterly which indicated they had knee and hand pain, but not every day. They reviewed R15's medical record and confirmed R15 had pain medications and was advised by staff to stop walking if they had pain, however no non-pharmacological interventions were in place or identified on the care plan to address R15's pain. They indicated it was important to try alternatives to limit the medications needed, and it allowed anyone to assist the resident, not just licensed nurses. During interview on 6/26/24 at 8:18 a.m., director of nursing (DON) stated if a resident expressed pain, they expected the nurse to assess the resident, try non-pharmacological interventions first, and if not helpful, see if any pain medications were available. They stated they did not want to jump right to medications unless they had to since medications could have side effects and potentially cause other issues. The Pain Management Program policy dated 5/2018, indicated in collaboration with the resident and/or representative and interdisciplinary team, a goal for pain management will be established and a multidisciplinary care plan written. This will include both pharmacological and non-pharmacological interventions.

Based on interview and record review the facility failed to ensure nonpharmacological interventions were utilized before use of an as needed (PRN) antipsychotic medication and failed to ensure PRN antipsychotic medication was ordered for 14-day use for 1 of 1 residents (R9) reviewed for PRN antipsychotic medication use. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 was cognitively intact and had diagnoses of anxiety disorder and bipolar disorder (mood disorder). Furthermore, R9 had exhibited no behaviors and routinely took an antipsychotic medication (medication used to treat mental/mood disorders). R9's provider order dated 6/4/24, indicated R9 required Seroquel 12.5 milligrams (mg) (antipsychotic medication used to treat mental/mood disorders) for every 12 hours PRN anxiety/bipolar disorder. This order had no end date. R9's medication administration record (MAR) and treatment administration record (TAR) dated 6/4/2024, indicated R9 did not require behavior interventions as no behaviors were exhibited. However, at 8:07 p.m., R9 received Seroquel 12.5mg PRN. R9's MAR/TAR dated 6/5/2024, indicated R9 did not require behavior interventions as no behaviors were exhibited. However, at 5:46 p.m., R9 received Seroquel 12.5mg PRN. R9's nursing progress note dated 6/4/24 at 8:07 p.m., indicated R9 received 12.5mg of Seroquel PRN. R9's progress note lacked behaviors exhibited by R9/reasoning why R9 was administered the PRN Seroquel and indication nonpharmacological interventions were attempted prior to R9 receiving the PRN Seroquel. R9's nursing progress note dated 6/5/24 at 5:46 p.m., indicated R9 received Seroquel 12.5mg PRN as R9 requested the medication. R9's progress note lacked indication nonpharmacological interventions were attempted prior to R9 receiving the PRN Seroquel. R9's care plan dated 6/24/24, indicated R9 can have issues with anxiety and trauma history and will have scattered thoughts during times of anxiety. Interventions included encouragement of calming activities such as latch hook, phone calls with family, and quiet time. Further interventions include facilitating time with husband, reminiscing about family, and one to one interaction. R9's care plan further indicated R9 received Seroquel for psychotic disorder and directed staff to observe and document behaviors and use the minimum effective dose of medications per policy. When interviewed on 6/25/24 at 11:26 a.m., licensed practical nurse (LPN)- B stated when a resident was having behaviors or feeling anxious, staff would try to redirect the resident and determine what was happening or why they felt anxious. Interventions to try were included in the resident's care plan and sometimes the orders. LPN-B further stated if there were behaviors exhibited, nurses would use document the behaviors and what interventions were done. LPN-B stated some residents have PRN medications to help and stated other interventions should be used before giving a PRN medication. LPN-B stated R9 didn't always follow directions for safety and sometimes yells and screams. LPN-B further stated R9 could be redirected at times and liked to talk about family. LPN-B verified R9's PRN Seroquel order and stated R9 sees an outside provider and medication orders change often. LPN-B verified R9's order did not have a stop date and stated sometimes PRN orders have a stop date and sometimes they did not, and it depended on what the provider wanted. LPN-B verified there was no documentation of behaviors R9 was having or nonpharmacological interventions in place during the times R9 received PRN Seroquel. LPN-B further stated if R9 asked for the medication, then it was given. When interviewed on 3/25/24 at 3:16 p.m., registered nurse (RN)-B stated staff were expected to attempt nonpharmacological interventions before giving a PRN medication. Staff also need to document resident behaviors and the nonpharmacological interventions provided before giving the PRN medication. RN-B verified R9's PRN Seroquel did not have an end date. RN-B stated antipsychotic medications could be ordered for longer durations with provider documentation and R9 had a follow up appointment in the upcoming weeks. RN-B verified R9's medical record did not have behaviors or nonpharmacological interventions documented and further stated residents can ask for PRN medications and staff can always offer PRN medications to help residents. When interviewed on 6/25/24 at 3:16 p.m., the consulting pharmacist (CP) stated PRN antipsycotic medications had to be limited to 14 days and should be ordered with a stop date. Furthermore, the CP expected nursing to help manage PRN use of antipsycotic medications and ensure the end date was there. When interviewed on 6/26/24 at 1:16 p.m., the Director of Nursing (DON) expected nurses to be aware of the 14-day end date for antipsychotic medications and if an order was provided without an end date the provider should be notified to adjust. DON further stated staff were expected to document behaviors and nonpharmacological interventions attempted prior to giving a PRN medication, even if a resident requested the PRN medication. This was important to ensure PRN medications were given when needed. A facility policy titled Psychotropic Drugs revised 10/2020, directed staff to consider the behaviors or mood of the resident which maybe met by recognizing and responding with interventions to eliminate the need for the drug. Furthermore, the policy directed PRN antipsychotic medications must be ordered for no longer than 14 days. The provider then must do a face-to-face visit and provide documentation to extend for additional 14 day periods.

Based on observation, interview, and document review, the facility failed to ensure hand hygiene and glove change occurred between dirty and clean tasks and a shared glucometer (blood glucose meter) was disinfected between 3 of 3 residents (R53, R18, R28) observed during blood sugar checks. Findings include: R53's order summary report dated 6/27/24, directed staff to check R53's blood glucose at 7:00 a.m. and 5:00 p.m. every other day and 11:00 a.m. and 8:00 p.m. the opposite days. R18's order summary report dated 6/27/24, directed to staff to check R18's blood glucose before meals and at bedtime. R28's physician's orders, directed staff to check R28's blood glucose before meals and at bedtime with revised date of 3/21/24. During observation on 6/26/24 at 7:23 a.m., RN-D entered R53's room with a caddy basket which contained items such as a glucometer, lancets, alcohol wipes, test strips, and insulin pens. RN-D completed hand hygiene and donned gloves. RN-D wiped R53's finger with an alcohol wipe and pricked R53's finger with a lancet. RN-D squeezed blood from R53's finger but little came out, and RN stated the blood sample was not enough. RN-D used the same gloves to grab an alcohol wipe from the group of wipes in the caddy basket and wiped another one of R53's fingers. RN-D grabbed another lancet from the group of lancets in the caddy basket and pricked R53's finger. RN-D grabbed a test strip from the test strip bottle, still with the same gloves, and placed in glucometer to get a blood sugar reading. RN-D stated there was an error message and grabbed another test strip out of the bottle with the same gloves and placed the test strip into the glucometer and got a reading of 185. RN-D placed the glucometer back in the caddy, took gloves off, and wrote 185 on nurse sheet. RN-D performed hand hygiene at nursing station and donned gloves and brought caddy basket to R18. RN-D used alcohol wipe to wipe R18's finger, grabbed test strip from bottle and put in glucometer, used lancet to obtain blood sample and reading of 145. RN-D placed glucometer back in caddy basket next to the lancets, doffed gloves, wrote blood sugar down on paper, and performed hand hygiene at nursing station. RN-D approached R28 and donned gloves. RN-D took test strip out of bottle and placed into glucometer, opened alcohol wipe, and wiped R28's finger, pricked R28's finger with lancet and squeezed finger for blood sample. RN-D placed test strip to blood to obtain reading, but the glucometer showed an error message. RN-D removed the test strip and threw into garbage, used the same gloves to grab alcohol wipe from stack in caddy basket, took test strip out of bottle and placed in glucometer, wiped R18's finger with alcohol swab, took lancet from the stack of multiple in the caddy basket, pricked R18's finger and obtained blood sugar reading of 157. RN-D wiped R18's finger with gauze square and threw away gauze square when doffing gloves. RN-D took pen to write on paper, placed paper in caddy basket, and washed hands with soap and water. RN-D returned the caddy basket to the nursing station and took the paper from the caddy basket and placed onto the nursing station. During interview on 6/26/24 at 7:52 a.m., RN-D stated they disinfected the glucometer at night to ensure it was ready for use in the morning. RN-D stated the morning shift was too busy to disinfect the glucometer, so it would be disinfected again by the evening or night shift. Then RN-D stated the glucometer would be disinfected between the morning and lunch rounds of blood sugar checks. RN-D verified they had not disinfected the glucometer between residents and would be good to do for infection prevention. RN-D stated they performed hand hygiene before and after cares, between glove changes, and after touching dirty items and before touching clean items. RN-D verified they had touched clean items with dirty gloves and hands and should have performed hand hygiene before touching their pen and getting clean items from the test strip bottle and caddy basket. RN-D stated there was a risk of infecting other residents when the same materials were used for multiple residents. During interview on 6/26/24 at 9:46 a.m., licensed practical nurse (LPN)-C stated shared glucometers should be disinfected after every single use. LPN-C stated there was a risk of spreading germs when blood glucometers were not disinfected between resident use. LPN-C stated hand hygiene should be performed before a procedure, after a task like toileting, and before touching clean products. LPN-C stated hand hygiene and glove change should have been performed after trying to obtain blood sample and before getting clean materials from caddy basket to try to obtain blood sugar reading again. LPN-C stated there was a risk of cross contamination with lack of hand hygiene and glove change. On 6/26/24 at 4:17 p.m., both infection preventionists (IP-E and IP-F) were interviewed. IP-E expected Sani clothe wipes to be used to disinfect shared glucometers after every use. IP-F stated there could be drops of blood near machine, and IP-E stated the risk to the residents would probably be small but not zero. During interview on 6/27/24 at 8:55 a.m., director of nursing (DON) stated glucometers should be disinfected between residents with Sani wipes. The risk of not disinfecting shared glucometers were contamination and risk for infection. DON expected staff to doff gloves, perform hand hygiene, and don clean gloves before grabbing clean supplies from the caddy basket. There was risk of infection and cross contamination of germs when not changing gloves and performing hand hygiene when needed. The facility's policy and procedure Infection Control- Handwashing revised 7/8/21, directed staff to complete hand hygiene after situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood or body fluids, secretions, or excretions. The policy indicated gloves should be worn when contact with blood and all body fluids, secretions, and excretions, and hands should be washed even when gloves were worn. The facility's policy and procedure Blood Glucose Testing and Glucometer Cleaning- Continuous Glucose Monitoring revised 5/22/24, directed staff to clean and disinfect the glucometer between each resident.

Based on observation, interview, and document review, the facility failed to assess the resident for risk of entrapment, review risks and benefits of bed rails with the resident or their representative, and obtain informed consent for 1 of 2 residents (R50) reviewed who had bed rails on their beds. Findings include: R50's quarterly Minimum Data Set (MDS) dated [DATE], included R50 was moderately impaired cognition, had a diagnosis of dementia, and was independent with bed mobility and transfers. The MDS indicated bed rails were not used. R50's medical record lacked assessment, consent, care plan, and physician orders for bed rail use. On 8/7/23 at 1:53 p.m., R50 was sitting in the recliner in their room and grab bars to each side of their bed were observed. R50 stated they used the grab bars to get into bed and to prevent them from falling out of bed. During interview on 8/9/23 at 1:21 p.m., nursing assistant (NA)-A stated R50 used the grab bars to get out of bed and R50 moved around the bed by themself. During interview on 8/9/23 at 1:44 p.m., registered nurse (RN-A) stated nursing needed to assess residents, provide education, and obtain consent for residents' use of grab bars. RN-A stated these steps were followed to ensure residents knew how to use grab bars safely. During interview on 8/10/23 at 8:23 a.m., licensed practical nurse (LPN)-A stated residents who used grab bars needed an assessment to make sure they needed them and a consent for use. LPN-A reviewed R50's medical record and confirmed it did not contain evidence of grab bar use in their orders, care plan, Physical Device Data Collection assessment, or consent. The facility's policy Physical Device Procedure dated 3/16/16, defined physical restraints as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The policy indicated a Physical Device Data Collection Tool will be completed on admission, annually and significant change for residents utilizing a physical device or with the initiation of a physical device to ensure the safety of the resident.

Based on observation, interview and document review, the facility failed to ensure staff treated residents in a respectful manner when requesting incontinence products and requesting tray service for 1 of 9 residents (R1) reviewed for dignity. In addition, 5 of 9 residents (R2, R3, R4, R5, R6) voiced ongoing concerns regarding undignified treatment by staff. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility investigation report dated 8/2/21, identified R1 had concerns about how they were treated by staff when they requested incontinent products and tray service in their room. Nursing assistant (NA)-A had screamed at R1. NA-A was counseled, re-educated on resident rights and customer service and would no longer be working with R1. A care audit was conducted and no issues were identified; however, the facility did not identify education was provided to all staff on treating residents with dignity and respect. R1's care plan revised 8/6/21, identified R1 had anxiety and depression. Interventions included therapy, approach resident with a calm, gentle and position approach, needs will be promptly met promptly, provide reassurance when answering requests, listening to problems. During interview on 8/12/21, at 8:42 a.m. family (FM)-A identified on 8/1/21, R1 called and reported she did not want to go down to the cafeteria for dinner due to a flare-up of her hemorrhoids and being too uncomfortable for her to go to cafeteria. Nursing assistant (NA)-A brought R1 the meal she requested but did not treat R1 with dignity as she placed the meal down and abruptly walked out of the room in a rough manner. There have been times she didn't get dinner at all when a room tray was requested, this time she asked twice. During interview on 8/12/21, at 9:42 a.m. NA-A stated on 8/1/21, R1 put on their call light and NA-A went into R1's room. R1 told NA-A she needed briefs and panty liners and the sizes R1 needed. NA-A didn't see her size and told R1 they didn't have any products in her size. Later, R1 asked the TMA to get the pads and the TMA went over to the TCU and got R1's size. The TMA gave NA-A the pads and NA-A brought the pads to R1 and R1 thanked NA-A. Fu 8/1/21, R1 refused to go to dining room because of hemorrhoids and requested a tray for supper. Usually residents couldn't have a meal tray unless they were sick. NA-A brought R1 soup and sandwich as R1 requested. NA-A reported giving the meal to R1 and leaving the room. Later that evening, the TMA approached NA-A and stated that R1 was upset because NA-A walked away from R1 without saying anything. NA-A verified that she went back into R1's room after the altercation and stated, I gave you everything you asked for today why are you complaining?. The NA-A denied raising her voice and did not know why R1 was scared of her. The NA-A reported the facility sent her for an in-service in the office and sent NA-A home for 1 or 2 days, NA-A uncertain if suspension was 1 or 2 days. The NA-A reported training was online, and the subject was about how to speak with residents. The NA-A denied facility refraining NA-A from working with R1. The NA-A has not seen R1 since the incident. During interview on 8/12/21, at 1:50 p.m. TMA stated on 8/1/21, she was called into R1's room and R1 was upset about her briefs and pads, the TMA went to the TCU and got the correct briefs and pads. The TMA let NA-A know where to get pads if there not any on the unit and had NA-A deliver the products. The TMA reported she was never in R1's room at the same time as NA-A, therefore did not hear any of the communication between the two parties. When interviewed on 8/12/21, at 10:04 a.m. R1 stated on 8/1/21, she asked for a dinner tray in her room due to having a horrible hemorrhoid flare-up. NA-A told R1, We aren't supposed to do that unless you are really sick R1 replied, I can't go down with these painful hemorrhoids. R1 stated all nursing assistants treated you poorly when asked for anything out of the ordinary. R1 stated NA-A was yelling about the situation and R1 told NA-A she could hear her; she didn't need to yell. NA-A argued and acted wild, flipping her hands in the air. R1 told NA-A she was going to report this, and NA-A responded NA-A would tell everyone R1 was lying. The NA-A wrote a note to the administrator and called her son immediately after being yelled at. R1 reported having never been treated that poorly, stating other staff has been short from time to time, but not like that. R1 reported being scared a night later, as someone knocked on her door late in the night. R1 reported she laid in bed like she was frozen in bed hoping it wasn't the NA-A. R1 did not answer door, whoever knocked went away and R1 laid awake the rest of the night in fear. R2's quarterly MDS dated [DATE], identified R2 had intact cognition. When interviewed on 8/13/21, at 10:21 a.m. R2 reported I could write a book, I just stopped complaining around here, nothing gets done. R2 reported staff are often untimely and rude. R2 stated that there is not an option to eat in room when you are ill. Stated she was so ill one day she could not lift her head off the pillow and her stomach was rolling. She stated she was told she had to go to dining room and reported not eating that night. R2 reported staff come and go as they please, I have even had conversation with staff when I am on the toilet. R2 reported one NA, R2 did not know names, she identified NA to be an African-American female she has yellow/gold hair that looks like pieces of tiny cauliflower with rubber bands. This NA was heard yelling across the hall about a week ago at R1. R2 states she has not had conversation with R1 about this situation. R2 also reported an NA described as tall skinny African American female, who doesn't work often, but when she does her voice can be heard down the hall. R2 reports feeling safe, just not treated with respect. R3's quarterly MDS dated [DATE], identified R3 had intact cognition. During interview interview on 8/12/21 at 9:42 a.m. R3 reported that when she asks for a meal in your room there is no option to do that. R4's quarterly MDS dated [DATE], identified R4 had intact cognition. During interview on 8/12/21, at 10:42 a.m. R4 stated some staff were friendly and others were rude and short. R4 has a condition which makes me move often. and gets awkward glances from staff. It made R4 feel like the staff did not like her and staff has used a rough tone of voice. R4 could not identify names of any of the staff, stating staff doesn't let you know their names or wear name badges. R4 reported feeling safe at facility. R5's quarterly MDS dated [DATE], identified R5 had moderate cognitive impairment. During interview on 8/12/21, at 11:03 a.m. R5 stated staff have been abrupt; some staff are chatty and talk about their personal lives with R5, while other do their job and leave without saying anything. Further, sometimes it's not what staff says, but how they say it. Once when R5 was ill R5 had to almost beg for a meal tray and had to request a tray from a nurse when the nursing assistant refused. R6's quarterly MDS dated [DATE], identified R6 had intact cognition. When interviewed on 8/12/21, at 11:15 am R6 stated she resided at the facility for a long time, in the last 2 years, staff were quite rude on occasions. R6 gave examples of staff rushing her cares, having to ask more than once for a request, and staff not knocking on door or announcing their presence. Further, Staff makes me feel bad about myself because I can't go as quickly as I used because I am almost blind, and they don't understand to not move things in my room. During observation of the noon meal on 8/12/21, at 11:17 a.m. no room trays were requested by residents. During interview on 8/12/21, at 12:06 p.m. assistant director of nursing (ADON) stated each floor has closets with incontinent products and each floor's stock varies due to resident needs. On 8/1/21, the day R1 was upset, the TMA had to go to the transitional care until to find the correct size for R1. The housekeeping department stocks the closets on each unit weekly and going forward housekeeping has been informed to keep R1's size on the unit. On 8/1/21, after NA-A found out R1 was upset about her treatment the evening of 8/1/21. NA-A went back into R1's room and told R1 that she had done everything asked of her. The ADON commented which wasn't necessary. NA-A was suspended during the facility investigation and NA-A was given training on how to communicate effectively with residents; however, did not educate all staff on dignity related concerns. The ADON verified NA-A would not be working on the same floor as R1 and had updated family and R1. During interview on 8/12/21, at 12:12 p.m. director or nursing (DON) reported staff were encouraged to go to the cafeteria for all meals. The DON agreed R1 did have a medical condition on 8/1/21, and received her meal in her room. The facility encourages the cafeteria dining for socialization, exercise, and being part of a family centered meal. If a resident is ill the nurse makes the final decision for the resident to eat in the room. The nursing assistants should be in communication with the nurses and meal tray requests and not make the decision on their own. A facility policy on dignity was requested and not received. The facility policy Room Trays for [NAME] Residents dated 2/18/11, indicated residents requesting to have a meal in their rooms will be checked on by the charge nurse and/or TMA to determine the necessity of their request. Staff would make an effort to encourage residents to eat the dining room including offering escort services as needed. Special circumstances may include illness, nausea, vomiting, diarrhea, upper respiratory or influenza symptoms, having appointments and may require an early or late tray, surgical procedures, active decline, psychiatric illnesses determined by the interdisciplinary team.

Based on observation, interview and document review, the facility failed to ensure supervision for 2 of 2 residents (R4, R37) who were observed to have medications left unsupervised on the dining room table without an order to self-administer medications. Findings include: During medication administration observation on 6/10/19, at 5:13 p.m. with trained medication aide (TMA)-B, R37's [MEDICATION NAME] (a cholesterol medication) was placed next to her plate while she was seated in the 1st floor dining room. R37 was left unsupervised with her medication next to her for approximately 10 minutes when she took her medication off the table, put it in her pocket and left the dining area. During medication administration observation on 6/10/19, at 5:28 p.m. with TMA-B, R4's [MEDICATION NAME] (a blood pressure medication), Tylenol (a pain medication) and Cranberry Plus (a supplement) was placed next to her in 1st floor dining room. TMA-B then went to another room to assist with meal trays. R4 was left unsupervised by facility staff for approximately 10 minutes. R4 left her medications sitting on the table and went to another part of the dining room to talk to another resident during that time. R37 stated on 6/10/19, at 5:40 p.m. she had put her [MEDICATION NAME] in her pocket and staff usually did not watch her take it as she likes to take it later at night. She was unaware if she had a self-administration of medication assessment (SAM) for [MEDICATION NAME]. TMA-B stated on 6/10/19, at 5:49 p.m. he did not know if R37 had a SAM assessment for [MEDICATION NAME] and he had not observed her taking the pill before he left the room. TMA-B also stated he did not know if R4 had a SAM assessment and he left the pills at her table, left the dining room where R4 was sitting and was not supervised by any facility staff after he left. During record review on 6/11/19, at 11:40 a.m. R4 had a SAM assessment for multiple medications but not for her [MEDICATION NAME]. R37 had a SAM assessment completed on 2/14/14, with direction to not allow R37 to self-administer her medications. The interim director of nursing (IDON) stated on 6/12/19, an order from a physician would have to be obtained for a resident to self-administer their medications and it would be put on the care plan if it was determined a resident was able to self-administer their medications. IDON also confirmed there was not a SAM assessment for R37's [MEDICATION NAME] or R4's medications and those medications should have been in the line of sight of the staff member administering them at all times. The facility's Self Administration of Medication policy dated 9/1/94, and last revised 4/5/15, included: nursing to complete a Self-Administration of Medication Data Collection for self-administration of medication if/when the resident had indicated a desire to do so or when staff identifies the need for the resident to be assessed. The assessment must indicate that the resident is competent and safe to proceed with self-administration of medications before proceeding. Nursing will request an order from the medical doctor or nurse practitioner for resident to self-administer the desired medications, which may be one or all ordered medications.