Every finding on record at Twin Oaks Manor

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure freezer and pantry items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illnesses. Findings included:Observation of the freezer on 06/09/26 at 10:24 AM revealed the following:1. (1) bag of breaded meat, no label or date.2. (3) bags of white meat, dated, no label.3. (1) bag of meat, dated, no label.4. (6) bags of what looked like bread, dated, no label.5. (5) frozen pies in boxes, no label or date. 6. (2) opaque brown bags, dated, no label. 7. (1) bag frozen breaded vegetables, dated, no label.8. (4) packages of meat, no label or date.9. (2) packages of what looked to be hot dogs or sausages, dated, no label. Observation of the pantry on 06/09/26 at 10:27 AM revealed the following:1. (1) bag that contained what looked like cereal, dated, no label.2. (2) large clear bags that contained individual bags of popcorn, no label or date. In an interview on 06/09/26 at 10:36 AM, the ADS stated she started as supervisor of the kitchen in September 2025 and that it was everyone's responsibility to label and date food and if this did not happen, food could go bad and residents could get sick.In an interview on 06/10/26 at 10:40 AM, [NAME] C stated she had worked at the facility for 4 years and that it was everyone's responsibility to label and date food and that not doing it could put residents at risk of getting sick and being served out-of-date food.In an interview on 06/09/26 at 10:41 AM, [NAME] A stated she had worked at the facility for 31 years and everyone who worked in the kitchen was responsible for labeling and dating food. She stated if this did not happen, residents could become sick. In an interview on 06/09/26 at 10:43 AM, [NAME] B stated it was everyone's responsibility to label and date food and if this was not happening, the kitchen could serve bad food which could make residents sick. Record review of facility policy, titled Refrigerators and Freezers dated December 2014, revealed the following information in part:7. All food shall be appropriately dated to ensure proper rotation by expiration dates.Record review of facility in service meeting held on June 11, 2026, titled, Why is it important to label and date food items in the kitchen for safety? revealed the following in part: -Food safety compliance: Labeling and dating items ensure adherence to health regulations, minimizing the risks for food borne illnesses. - Cross contamination prevention: Proper labeling and dating helps prevent confusion and clearly identifies the food type, keeping our residents safe from food allergy reactions and great potential harm.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment requirement for 1 of 1 kitchen staff (Dietary Manager) reviewed for qualifications. The facility failed to ensure the individual functioning as the Dietary Manger possessed the appropriate certification, training, and qualifications to direct the food and nutrition services department. This failure could place residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition.Findings included: Record review of ADS's undated employee file revealed she was hired into the Dietary Manager position on 08/19/25. Record review of a facility receipt dated 4/1/2026 revealed payment for the ADS's enrollment in an online Dietary Manager training course on 04/10/2026. During an interview on 06/10/26 at 10:33 AM, the ADS stated she began working in the dietary supervisor role in September 2025. The ADS stated she began online Dietary Manager certification classes in May 2026 and was currently on the first module of the course. The ADS stated she was not certified as a Dietary Manager. The ADS stated she logged onto the training course the previous evening but did not complete any course work and had been on vacation the prior week. The ADS stated the only course work she completed occurred in May. The ADS stated she felt overwhelmed with her job responsibilities and did not have sufficient time to complete both her work duties and the training course. She stated not having a certified DM in the kitchen could mean that things would not be done right, staff would not be trained correctly, and bad things could happen. During an interview on 06/10/26 at 10:40 AM, [NAME] C stated she had worked at the facility for 4 years and that they currently do not have a certified DM, but believed the ADS was taking classes to obtain that certification. She stated a negative outcome for not having a certified DM could be that things would not be done right in the kitchen, staff would not be trained properly, and things could go wrong. During an interview on 06/11/26 at 9:39 AM, the BOM stated the ADS had not completed Dietary Manager training. The BOM stated the ADM supervised the ADS and was responsible for ensuring required training was completed for non-nursing staff. She stated she was unable to identify a negative potential outcome related to the absence of a trained DM and stated that the ADM would be responsible for answering that question. In an interview on 06/11/26 at 9:44 AM, the RD stated she had provided consulting services to the facility for approximately three to four years. She stated the ADS was not a certified DM, but it was her understanding the ADS was enrolled in an online DM course but not sure how much progress had been made. The RD stated she consulted with the ADS monthly and more frequently if needed. The RD stated she believed the ADS had functioned as the Dietary Manager for approximately seven to eight months. She stated the absence of a trained DM could result in insufficient knowledge of nursing home regulations and special diets but that she had not observed any negative outcomes related to dietary services at the facility. In an interview on 06/11/26 at 10:00 AM, the ADM stated the ADS was not certified as a DM and it was ultimately his responsibility for making sure all staff were trained. He stated he believed the ADS had been functioning in the role since August or September 2025. The ADM stated he understood that they enrolled the ADS for online DM classes in April 2026. The ADM stated he would not answer the question about why there had been a long length of time between hiring the ADS and the time it took to get her signed up for classes. He stated he was not aware that she was only on her first module of the course until yesterday. The ADM stated a negative outcome for not having a trained DM could be wrong diets served to residents and possible choking issues. During an interview on 06/11/26 at 10:23 AM, the ADM stated the facility did not have a policy identifying qualifications or requirements for the Dietary Manager position. The ADM provided the surveyor with the ADS's job duties.Record review of the facility document titled, Policy and Job Duties Cont., not dated, included in part: Job Summary: The purpose of this portion is to supervise the Dietary Services with regularly scheduled consultation from a qualified dietician. The Supervisor is directly responsible to the Administrator.Nothing in the document revealed any mention of what the qualifications were for a Dietary Supervisor/Dietary Manager.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #2) of 13 residents reviewed for resident rights. Resident #2 was observed with her catheter bag not in a privacy bag for 3 days exposing her catheter bag to an open hallway and the outside environment. This failure could place residents at risk for feeling uncomfortable and disrespected leading to isolation and deterioration in general health conditions. Findings included: Record review of Resident #2's face sheet printed 6/11/26 revealed she was an [AGE] year-old female resident admitted [DATE] and readmitted on [DATE] with diagnoses to include chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), encounter for palliative (specialized medical care focused on relieving symptoms (such as pain, nausea, or shortness of breath) and the mental stress of serious illness) care, and wedge compression fracture of unspecified thoracic vertebrae (a structural collapse of the front of a bone in the mid-back). Record review of Resident #2's significant change of condition MDS assessment printed 6/11/26 and completed 4/16/26 listed Resident #2 with a BIMS of 4 indicating she was severely cognitively impaired, she had a functionality of being dependent on staff for her toileting hygiene, and she required an indwelling catheter. Record review of Resident #2's care plan printed 6/11/26 with admission date of 7/06/25 revealed the following: Focus - The resident has Indwelling Catheter: Pressure Ulcer Date Initiated: 04/18/2026 Record review of Resident #2's Order Summary Report printed 6/11/26 with Active Orders As Of: 6/11/26 revealed the following order:- 16F foley catheter to promote wound healing to pressure ulcer Verbal Active 03/19/2026 During an observation on 06/09/2026 at 10:35 AM Resident #2 was sleeping in her bed and did not wake to knocking or introduction. Resident #2 was noted to have a catheter bag hanging from the left side of her bed in view of the window to the sidewalk and street. There was no privacy bag covering the catheter bag. The window had no blinds or curtains to obstruct the view from the sidewalk into the room. During an observation on 06/09/2026 at 10:44 AM an unidentifed staff member entered Resident #2's room and place a privacy bag on the catheter bag. During an observation on 06/10/2026 at 7:02 AM Resident #2 was observed in her room sleeping in her bed. Resident #2's catheter bag could be observed from the hallway through her open doorway and was not in a privacy bag. Noted the 3 residents that resided further down the hall had passed Resident #2's room to go to the dining room for the am meal. During an observation on 06/10/2026 at 7:58 AM Resident #2 was observed in her room being assisted by a staff member with her am meal. Resident #2's catheter bag continued to hang from the foot of her bed without a privacy bag and was still in view of the hallway. [NAME] liquid could be observed in Resident #2's catheter bag. During an observation on 06/10/2026 at 9:08 AM 8 unidentified residents and two unidentified staff were noted at the end of the hall completing an activity next to Resident #2's room. Resident #2's catheter bag that was not covered for privacy could be seen from the hallway through her open door. During an observation on 06/11/2026 at 8:22 AM Resident #2 was observed in her bed sleeping and did not wake. Resident #2's catheter bag could be observed through her open door from the hallway that did not have a privacy bag. Noted 300cc's of amber liquid in the catheter bag. One resident was observed in the hallway in her wheelchair that had just passed Resident #2's room. During an observation and interview on 06/11/2026 at 8:28 AM the ADON observed Resident #2 from the hallway and reported Resident #2;s catheter bag was left uncovered and could be observed. The ADON reported the catheter bag should be in a privacy bag to maintain the resident's dignity. During an observation and interview on 06/11/2026 at 8:33 AM RN D (the charge nurse responsible for Resident #2 this shift) observed Resident #2 and reported the catheter bag should be covered for privacy. That if the catheter bag was left uncovered then the resident could have an issue with dignity even shame. RN D reported she would get it covered immediately and entered the room to complete the task. During an interview on 06/11/2026 at 10:32 AM the DON reported that the catheter bag for each resident should be covered at all times, staff should check to make sure they were covered at all times, and if the catheter bag was left uncovered it could be a dignity issue for the resident. During an interview on 06/11/2026 11:06 AM CNA E (the CNA responsible for Resident #2 this shift) reported CNA staff check the resident every two hours, and a resident's catheter should be in a privacy/black bag so it would not be in view. CNA E reported if the catheter bag was not in a privacy bag, then the resident could be embarrassed because you could see the pee. CNA E reported it could also affect other residents or families who could see the catheter bag uncovered. Record review of facility provided policy titled, Nursing Facility Requirements for Licensure and Medicaid Certification Handbook - Statement of Resident Rights revised 1/03/08, revealed the following: You have the right:6. to privacy.

Based on observation, interview, and record review the facility failed to ensure residents who use psychotropic drugs received gradual dose reductions (unless clinically contraindicated) in an effort to discontinue those drugs for 3 (Resident #1, #2, and #7) of 5 residents reviewed for unnecessary medications. Resident #1 was on two psychotropic medications with no attempted gradual dose reductions in the past 12 months. Resident #2 was on one psychotropic medication with no attempted gradual dose reductions in the past 12 months. Resident #7 was on two psychotropic medications with no attempted gradual dose reductions in the past 12 months and one psychotropic medication with one gradual dose reduction completed since admission 5/09/2025. This failure could affect residents resulting in excessive sedation, dizziness, blurred vision, weight gain/loss, falls, feelings of isolation, and/or increased depression.Findings included: Resident #1: Record review of Resident #1 face sheet printed 6/09/26 revealed he was a [AGE] year-old male admitted to the facility originally on 1/01/2025 and readmitted on [DATE] with diagnoses to include Post traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), depression (a common, serious mental health condition characterized by persistent sadness, loss of interest in activities, and low energy, lasting at least two weeks), and anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #1's quarterly MDS assessment printed 6/10/26 was completed 4/18/26 listed Resident #1 with a BIMS of 99 indicating he was severely cognitively impaired, and he was independent with most of his activities of daily living. Record review of the care plan printed 6/11/26 with admission date of 6/05/25 for Resident #1 revealed the following: Focus - The resident uses psychotropic medications Date Initiated: 01/20/2025. Intervention - Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness for possible decrease, elimination or change of psychotropic medication. Date Initiated: 01/20/2025. Record review of Resident #1's Order Summary Report printed 6/10/26 with Active Orders As Of: 6/10/26 revealed the following order:- QUEtiapine Fumarate Tablet 25 MG Give 1 tablet by mouth at bedtime related to POST TRAUMATIC STRESS DISORDER, UNSPECIFIED (F43.10) Active 02/10/2025. (Seroquel - atypical antipsychotic) - TraZODone HCl Tablet 100 MG Give 1 tablet by mouth at bedtime for INSOMNIA related to POSTTRAUMATIC STRESS DISORDER, UNSPECIFIED (F43.10) TO BE ADMINISTERED AT BEDTIME Active 01/01/2025. (Trazadone - atypical antidepressant) Record review of the facility provided document untitled signed by LPH 6/02/2026 for Resident #1 revealed Psychoactive Drugs-Dose-Last Change: Seroquel 2.5mg qHS - 2/10/25 PTSD Trazadone 100mg HS - 1/01/25 PTSD/InsomniaDuring an observation and interview on 06/09/2026 at 10:54 AM Resident #1was in his room, in his bed under his covers with a coat over his head. Resident #1 did not respond to knocking or introduction. During an observation and interview on 06/09/2026 at 1:43 PM Resident #1 was in his room in his bed laying on top of his covers. SS H attempted to interview Resident #1. He became loud, had mumbled speech, and was unable to understand. Resident #2:Record review of Resident #2 face sheet printed 6/09/26 revealed she was an [AGE] year-old female admitted on [DATE] and readmitted [DATE] with diagnosis to include major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #2's significant change of condition MDS assessment printed 6/11/26 was completed 4/16/26 listed Resident #2 with a BIMS of 4 indicating she was severely cognitively impaired and she had a functionality of being dependent on staff for most of her activities of daily living. Record review of the care plan printed 6/11/26 with admission date of 7/06/25 for Resident #2 revealed the following: Focus - The resident is palliative care d/t failure to thrive. Date Initiated: 06/26/2025. Interventions - Offer pain medication or antianxiety medication of ordered and to keep resident comfortable. Record review of Resident #2's Order Summary Report printed 6/10/26 with Active Orders As Of: 6/10/26 revealed the following order: Zoloft Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for DEPRESSION. Active 08/19/2024. Record review of the facility provided document untitled signed by LPH 6/02/2026 for Resident #2 revealed Psychoactive Drugs-Dose-Last Change: Zoloft 50 qd - 6/20/2024 Depression During an observation on 06/09/2026 at 10:35 AM Resident #2 was asleep in her room and did not wake to knocking or introduction. Resident #7: Record review of Resident #7 face sheet printed 6/09/26 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses to include bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (a common, serious mental health condition characterized by persistent sadness, loss of interest in activities, and low energy, lasting at least two weeks). Record review of Resident #7's quarterly MDS assessment printed 6/10/26 was completed 5/23/26 listed Resident #7 with a BIMS of 15 indicating he was cognitively intact, and he required partial/moderate supervision with most of his activities of daily living. Record review of the care plan printed on 6/11/26 with admission date of 5/09/25 for Resident #7 revealed the following: Focus - The resident uses anti-anxiety medications & antidepressants r/t bipolar disorder &Anxiety. Date Initiated: 05/31/2025. Interventions - Monitor for side effects and effectiveness for possible decrease, elimination or change of psychotropic medication. Record review of Resident #7's Order Summary Report printed 6/11/26 with Active Orders As Of: 6/11/26 revealed the following order:- Paxil Oral Tablet 40 MG (Paroxetine HCl) Give 40 mg by mouth one time a day related to DEPRESSION, UNSPECIFIED (F32.A). Active 05/09/2025. (Paxil - antidepressant) - Wellbutrin XL Oral Tablet Extended Release 24 Hour 150 MG (Bupropion HCl) Give 150 mg by mouth one time a day related to BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MILD OR MODERATE SEVERITY, UNSPECIFIED (F31.30). Active 05/09/2025. (Wellbutrin - atypical antidepressant) - BusPIRone HCl Tablet 15 MG Give 1 tablet by mouth two times a day for anxiety. Active 07/09/2025 Start Date 07/09/2025. (Buspar - Anxiolytics (anti-anxiety drugs) Record review of the facility provided document untitled signed by LPH 6/02/2026 for Resident #1 revealed Psychoactive Drugs-Dose-Last Change: Paxil 40mg qd - 5/10/25 - Depression Wellbutrin CL 150mg 5/10/25 - Bipolar Buspar 15mg BID 7/09/25 - Anxiety During an observation and interview on 06/10/2026 at 12:14 PM Resident #7 was observed entering his room after completing lunch. Resident #7 was dressed well but was guarded with his conversation and did not wish to answer any questions. Resident #7 was not in any distress. During a group interview on 06/11/2026 at 11:11 AM with the DON and ADON both reported no GDRs were completed for Resident #1, #2, and #7. They DON and ADON reported that they did not want the physicians to increase doses to address behavioral issues. That as a facility they want to use alternative steps to address resident behavioral issues. They reported that they also have families that did not want the residents' medications changed. SS H attempted to explain the residents' psychotropic medications need to be addressed by the physicians to ensure they are not used improperly, and they again repeated that they have attempted in the past and often have difficulty coordinating and would prefer not risk having the residents' medications increased. This surveyor explained the reason for the GDR request three separate times, and they gave the same answer. During a telephone interview on 06/11/2026 at 11:29 AM the LPH wanted to know the residents age, medication, and diagnoses. The LPH stated that she was unaware the residents were supposed to have a GDR done. The LPH reported each resident was stable on the current medication and dose. The LPH reported the physicians were in the facility frequently but often would not document they had addressed the resident's medication concerns. The LPH stated she Could certainly start writing letter to the physicians for the medications to be addressed. Record review of facility policy titled Antipsychotic use in residents-update 04/25/2025 revealed: Procedure:7. Upon monthly review of resident medical records, the Consultant Pharmacist will make recommendations/adjustments.a. This review will also include any other psychotropic medication(s), which is due for review by the attending/psychiatrist at this time.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided with such care consistent with professional standards of practice for 1 (Resident #1) of 13 residents reviewed for respiratory care. The facility failed to change the oxygen hydration bottle for Resident #1 for 5 months. This failure could place resident at risk for complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.Findings included: Record review of Resident #1's face sheet printed 6/09/26 revealed an [AGE] year-old male resident admitted [DATE] and readmitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #1's quarterly MDS assessment printed 6/10/26 was completed 4/18/26 listed Resident #1 with a BIMS of 99 indicating he was severely cognitively impaired, he was independent with most of his activities of daily living, and he was listed for the use of oxygen therapy. Record review of Resident #1's order summary with Active Orders as of: 6/10/26 revealed the following order:- Oxygen: Oxygen at 2L per NC every shift. Active 01/01/2025. Record review of Resident #1's care plan printed 6/10/26 with date of admission 1/01/25 revealed the following: Focus The resident has COPD. Date Initiated: 01/20/2025.Interventions Have continuous supplemental oxygen via n\c as ordered. Date Initiated: 01/20/2025. During an observation on 06/09/26 at 10:54 AM Resident #1 was in his room in his bed under his covers with a coat over his head. Resident #1 was observed receiving oxygen from an oxygen concentrator next to his bed. Observed a less than 1/4 full hydration bottle attached to the oxygen concentrator. The oxygen hydration bottle was dated 12/30/25 and was milky and discolored. Resident #1 did not respond to knocking or introduction. During an observation on 06/09/26 at 1:43 PM Resident #1 was observed in his room in his bed lying on top of his covers. Resident #1's oxygen hydration bottle was dated 12/30/25. This surveyor attempted to interview Resident #1, and he became loud with speech that was unintelligible. During an observation on 06/10/26 at 07:02 AM Resident #1 was not in his room. Resident #1's oxygen hydration bottle was dated 12/30/25 During an observation and interview on 06/10/26 at 11:09 AM RN F entered Resident #1's room, checked his oxygen hydration bottle, and reported the oxygen hydration bottle was dated 12/30/25. RN F reported the night shift was supposed to check all the respiratory equipment weekly and this should have been changed. RN F reported she would change the oxygen hydration bottle immediately. RN F reported if the oxygen equipment was not changed timely and properly such as the hydration bottle then the resident was at risk for mold or bacteria which could result in a respiratory infection. During an interview on 06/11/26 at 8:40 AM the ADON reported resident's respiratory equipment such as their oxygen hydration bottle should be changed at least monthly. The ADON stated, If a hydration bottle was not changed for 5 months, it could be an issue, a sanitary issue, and the resident possibly could get an infection. During an interview on 06/11/26 at 10:33 AM the DON reported nurses should check the residents' oxygen each time they were in the resident's room or as needed. The DON reported the night shift checked the residents tubing and hydration and filters for the need to be changed or reported for repair. The DON reported staff change tubing every two weeks. The DON reported the hydration bottles are changed as needed. The DON reported if they were not changed frequently then the oxygen tubing could become occluded (blocked) or other complications can occur. The DON reported if the staff did not change a hydration bottle the resident should be ok. Record review of the facility provided policy titled Cleaning and Maintenance of Oxygen Concentrators date issued 8/24/25, revealed the following: Purpose: The purpose of this policy is to provide guidelines for the safe and effective operation of oxygen concentrator use by residents.Procedure:5. Tubing and humidifier canisters shall be replaced monthly by a charge nurse, except where more frequent replacement is specified.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 13 residents reviewed for comprehensive care plans. -The facility failed to address the use of a catheter in Resident #1's care plans. This failure could place residents at risk for not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.Findings included: Record review of Resident #1's face sheet printed 6/09/2026 revealed an [AGE] year-old male resident admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), retention of urine (the inability to completely or partially empty the bladder), history of urinary tract infections, and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland that commonly affects men as they age, often causing bothersome urinary symptoms). Record review of Resident #1's quarterly MDS assessment printed 6/10/26 was completed 4/18/26 listed Resident #1 with a BIMS of 99 indicating he was severely cognitively impaired, he was independent with most of his activities of daily living, and he had an indwelling catheter (a closed sterile system with a catheter and balloon inserted in the urinary bladder to allow for bladder drainage). Record review of Resident #1's order summary with Active Orders as of: 6/10/26 revealed the following order:- CHANGE 14FR FOLEY CATHETER MONTHLY AND PRN every shift. Active 02/25/2026.- CATHETER CARE EVERY SHIFT. Active 02/25/2026. Record review of Resident #1's care plan printed 6/10/26 with date of admission 1/01/25 revealed no care plan for the use of a catheter. During an observation on 06/09/2026 at 10:59 AM Resident #1 was in his room sleeping in his bed under his covers with his head covered. Resident #1 did not wake or react to knocking or introduction. Observed was Resident #1's catheter bag hanging from the foot of his bed in a privacy bag. During an interview on 06/11/2026 at 8:35 AM the ADON reported Resident #1 did have a catheter and has had a catheter for several months. The ADON reviewed Resident #1's chart and reported Resident #1 did not have a care plan for his catheter. When questioned if the resident should have his catheter care planned, the ADON stated, Of course. The ADON stated, If a resident does not have his catheter care planned then staff who are unfamiliar with that resident might not know he had a catheter. During an interview on 06/11/2026 at 9:53 AM MDS G reported she completes and updated the care plans when she did the MDS's. MDS G reviewed Resident #1 electronic chart and reported Resident #1 did have a catheter marked on his last MDS, but it was not addressed on his care plans. MDS G stated, It was just missed. MDS G reported if the care plan did not address the resident care such as the catheter, then the resident could be affected in a way that they can get a UTI, infection, or have increased pain. During an interview on 06/11/2026 at 10:37 AM the DON reported if a resident's care, to include such things as a catheter, was not addressed in the resident care plan then protocols could be violated such as infection control or the staff would not be able coordinate with the family during a care conference if they do not know what the resident was getting. Record review of the facility provided policy titled Care Plan Completion effective 6/10/25, revealed the following: 2. The facility will develop a Comprehensive Person-Centered Care Plan for each resident within 7 days after completion of the comprehensive assessment that includes:-Measurable objective and timeframes to meet the residents medical, nursing.needs.-Services to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.

Based on observations, interviews, and record reviews the facility failed to store, prepare, and serve food in accordance with professional standards for 1 out of 1 kitchen reviewed for food safety. The facility failed to ensure foods were labeled and dated. The facility failed to ensure frozen foods were properly closed. The facility failed to ensure foods and condiments served to residents were not expired. These failures could place residents at risk of food-borne illnesses. Findings included: An initial tour of the kitchen on [DATE] at 10:45AM revealed the freezer contained the following: (1) partial 1 gallon container of Neapolitan ice cream with no date opened, (1) partial 1 gallon container of Chocolate/Vanilla swirl ice cream with no date opened, (1) 11.25oz. partial box of Texas toast garlic bread with no date opened and open to air, (1) 5lb. bag of fish sticks with no date, (2) loose corn dogs in their original box, open to air, with no date opened, (1) 40oz. package of frozen mixed vegetables with no date, (1) 32lb. bag of frozen pork chops open to air, with no date, (4) 2lb. packages of Chuckwagon corn with no date. An observation of the dry pantry on [DATE] at 11:10AM revealed the following: (4) 2lb. packages of brown sugar with no date, (1) 0.25oz. box of assorted food coloring with an expiration date of [DATE], (1) 1oz. box of unflavored gelatin with an expiration date of [DATE], (1) 12 count box of Ritz Bits individually bagged cheese crackers with no date, (3) 4.5oz. packages of egg nog mix with no date, (2) 32oz. packages of white chocolate caramel cappuccino mix with no date, (5) 32oz. packages of hot chocolate mix with no date, (2) 0.75oz bags of coffee with no date, (1) 6lb. box of traditional black tea bags with no date, (1) 5oz. bottle of Chalula hot sauce with no date opened, not refrigerated, with instructions to Refrigerate after opening, (1) partial 18oz. container of chili powder with no date, (1) 5oz. bottle soy sauce with no date, (4) 1.5lb. bags of country style grave mix with no date, (1) 25.9oz. container of ground coffee with no date, (1) 10.5oz can of Chicken and Stars condensed soup with no date. The refrigerator contained one kitchen employee's personal food, as well. An observation on [DATE] at 1:32PM of the condiments sitting on the dining room tables for resident use revealed the following: (7) partial 38oz. bottles of ketchup with the instructions to Refrigerate after opening. 3 of the bottles had a date written of them of [DATE]. 2 of the bottles had a date written on them of [DATE], and 2 of the bottles had a date written on them of [DATE]. (7) partial 14oz. bottles of yellow mustard with the instructions to Refrigerate after opening with a date written on them of [DATE], (7) partial 12oz. bottles honey with and expiration date of [DATE]. An interview with the Dietary Manager [DATE] at 09:47 AM, reflected the negative outcome of serving outdated or unrefrigerated foods and condiments to residents was they could become sick. Record Review of the undated facility policy for Food Storage revealed the following: 1. All staples are stored in sealed or tightly covered containers. 2. Food is stored to preserve flavor, nutritive value, and appearance. 3. Perishable foods are refrigerated immediately after receiving. 4. All employee's personal items should be kept away from all food items.

Based on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 (the medication room) of 3 medication storage areas reviewed for medication storage. The medication room refrigerator had medications that had been stored out of recommended storage temperatures. The facility's failure could result in a resident receiving a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes. Findings included: Record review of the medication room (the facility had one medication storage room) refrigerator log for April 2025 revealed the following documented temperatures: (-per merriam-webster.com: freezing point of water is 32 degrees Fahrenheit.) 4-01-2025 - 34 degrees Fahrenheit 4-02-2024 - 34 degrees Fahrenheit 4-03-2025 - 32 degrees Fahrenheit 4-04-2024 - 32 degrees Fahrenheit 4-09-2024 - 34 degrees Fahrenheit 4-10-2024 - 32 degrees Fahrenheit 4-12-2024 - 32 degrees Fahrenheit 4-12-2024 - 34 degrees Fahrenheit 4-17-2024 - 34 degrees Fahrenheit 4-18-2024 - 32 degrees Fahrenheit 4-19-2024 - 34 degrees Fahrenheit 4-25-2024 - 34 degrees Fahrenheit 4-26-2024 - 34 degrees Fahrenheit During an observation on 04/29/25 at 08:25 AM wit RN A present the following medications were noted in the medication room refrigerator: -Ozempic Insulin Pen x1 with instruction printed on the box Do Not Freeze. The medication was filled on 4-15-2025. -Lantus Insulin Pen x2 with instruction printed on the box store between 36 to 46 degrees. The medication was filled on 6-26-2024. During an interview on 04/29/25 at 08:29 AM RN A reported that 32 degrees was considered freezing. RN A reviewed the list of April refrigerator temperatures and noted the 5 documented temperatures at 32 degrees. When questioned if the current medications in the refrigerator had been stored at a temperature that were freezing, RN A stated, It could have frozen. RN A did not offer any further information. During an observation and interview on 04/29/25 at 01:27 PM the ADON reported that 32 degrees was considered freezing. The ADON reported that it could affect a medication if it was to freeze. The ADON checked the med room refrigerator and noted the 5 documented temperatures at 32 degrees then reviewed the box for Lantus that read store between 36 to 46 degrees and the Ozempic box that read Do Not Freeze. The ADON reported that if either of these medications had frozen then someone would have told him and as far as he knows they have never frozen. The ADON reported that freezing a medication could affect the medication and the resident receiving it but again as far as he knew they had never been frozen. During an interview on 04/30/25 at 02:47 PM the DON reported that if a medication was stored outside its recommended storage range, then that could affect that medications longevity and potency which could affect the resident's condition and treatment. The DON reported that she did not know what the temperature was that was considered freeing. Record review of the facility provided polity titled, Medication Storage effective 1-2024, revealed the following: i. Medications with storage requirement for temperature, light, or humidity controls must be stored to meet specifications for the medication.

Based on interviews and record reviews the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 1 Dietary Manager reviewed for Dietary Manager Certification. The facility failed to ensure the Dietary Manager was certified as a Dietary Manager. This failure could place residents at risk of not having their nutritional needs met and/or a decreased quality of life. Findings included: Record review of facility staff records on [DATE] at 9:41 AM, revealed the Dietary Manager's certificate expired on [DATE] . An interview with the Dietary Manager on [DATE] at 10:29 AM, reflected she was aware her certificate was expired. The Dietary Manager stated she needed to get registered to take the test for recertification, today . An interview with the Administrator on [DATE] at 10:48 AM, reflected he had been made aware the Dietary Manager's certificate was expired before today, but had a shunt replaced in his head and was unable to recall when and with whom the conversation had taken place. He stated he had spoken with the Dietary Manager, and she was registered to take the recertification test in [DATE]. The Administrator stated he was not suspending the Dietary Manager until she took the test. There was no facility policy regarding the employment of a certified Dietary Manager .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (CNA B) of 4 staff observed for infection control. -CNA B did not wash her hands while performing incontinent care for Resident #34. This deficient practice placed residents at risk of infections. Findings include: Record review of Resident #34's face sheet revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), fracture of the greater trochanter of right femur (right hip), macular degeneration (a degenerative condition affecting the central part of the retina), and hallucinations (sensory experiences that occur in the absence of an external stimulus). Record review of Resident #34's last MDS revealed an admission assessment completed on 02/10/25 with a BIMS score of 07 indicating she was severely cognitively impaired, she had a functional status of requiring partial/moderate assistance with most of her activities of daily living, and she was frequently incontinent of urine. Record review of the care plan with admitted [DATE] for Resident #34 revealed the following: Focus: Potential for impaired skin integrity d/t incontinence. - Date initiated 02/16/25 Interventions: Good pericarp after each incontinent episode. - Date initiated 02/16/25. During an observation on 04/29/25 at 09:05 AM CNA B was observed assisting with incontinent care for Resident #34. CNA B wash her hands and put on gloves then pull Resident #34's bed out from the wall so she could access Resident #34. CNA B then pulled Resident #34's covers down and assisted with removing Resident #34's used brief. CNA B pulled wipes from the wipe package to give to the primary CNA giving care, then rolled Resident #34 to her left side and place both gloved hands on Resident #34's right hip to hold her in place for the primary CNA to perform rectal care. When the primary CNA left to change her gloves and wash her hands in the bathroom, CNA B picked up the new brief with her used gloves and placed the new brief under Resident #34. CNA B then rolled Resident #34 to her back and finished placing the new brief. CNA B then replaced Resident #34's covers, replaced the bed to its original position, removed the used supplies and cleaned the area, then removed her used gloves and washed her hands. During an interview on 04/29/25 at 01:10 PM CNA B said she assisted with for Resident #34's incontinent care she said, she washed her hand, moved the bed, removed the residents covers, assisted with removing the resident used brief, then assisted with rolling the resident to her left side and using both hands on the resident to maintain the resident position during the incontinent care and then picking up the new brief putting it on the resident. When questioned if she should have removed her gloves and washed her hands before applying the new brief, CNA B shook her head no and stated no. CNA B reported that she felt like her hands were still clean and that she did not need to perform hand hygiene. CNA B reported that she had been instructed on hand hygiene by the ADON. During an interview on 04/29/25 at 01:22 PM the ADON reported that he does the hand hygiene training for the facility. The ADON reported that he expects staff to change gloves and wash hands before and after entering a resident's room and when removing the dirty portion of the care and before moving to the clean portion especially before applying the new brief. The ADON reported that if a staff member touches things such as the call light or moves the resident back and forth then they need to remove their gloves and wash their hands. The ADON reported that if the process for good hand hygiene was not followed then cross contamination would occur with the residents. During an interview on 04/29/25 at 02:43 PM the DON reported that she expects her staff to complete hand hygiene to include glove changes and handwashing with resident care upon entering the room, during the care, and when exiting the room. They should complete hand hygiene when they change a brief or their gloves get dirty. The DON reported that staff should change their gloves and wash their hands before applying a new brief. The DON reported that if a staff member does not use the correct hand hygiene process, then a resident could get an infection and cross contamination could occur. Record review of training provided for CNA B dated 04/10/25 revealed the following instructions: 9. Removed gloves after cleaning perineal area and removal of soiled incontinence product. Applied new gloves after using handrub sanitizer and applied new incontinent product. -instructions completed by the ADON Record review of the facility provided policy titled Handwashing/Hand Hygiene revised August 2019, revealed the following: Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: h. Before moving form a contaminated body sit to a clean body site during resident care.

Based on observation, interview and record review the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored food was properly labeled and dated. This failure could put place Residents at risk for foodborne illness. Findings Included: Observation of refrigerator one on 3/12/ 24 at 10:58 am revealed 1 container of launchable for staff with no label or date. Observation of refrigerator one on 3/12/24 at 11:08 am revealed 1 tray of individual boxes of vanilla shake milk with no label or date. Observation of refrigerator one on 3/12/24 at 11:08 am revealed 1 bag of parsley with no label or date. Observation of freezer two on 3/12 at 11:15 am revealed 3 packages of ground beef with no date. Observation of freezer three on 3/12/24 at 11:15 am revealed 1 container of chocolate ice cream with no date. Observation of refrigerator two on 3/12/24 at 11:15 am revealed 1 bag of sliced oranges with no label or date. Observation of refrigerator two on 3/12/24 at 11:18 am revealed 1 small lunch tray in a plastic bag with no label or date. Observation of refrigerator three on 3/12/24 at 11:18 am revealed 1 small lunch tray in a plastic bag with no label or date. Interview on 3/14/2024 at 8:43 am with the DM, said that all kitchen staff are responsible for safe food storage per their policy. The DM stated that a negative outcome for not practicing food storage would be contamination and residents could get sick. Interview with FSA 1 on 3/14/24 at 8:46 am she said that all kitchen staff are to follow facility policy and procedure for food storage. She stated that a negative outcome would be that residents could get sick. Interview with Cook 1 on 3/14/24 at 8:47 am she said that all kitchen staff are responsible for food storage. She said a negative outcome would be that residents could get sick. An interview with FSA 2 on 3/14/24 at 8:49 am she said that all kitchen staff are responsible for food storage. She said a negative outcome would be residents could get sick. An interview with FSA 3 on 3/14/24 at 8:51 am she said that all kitchen staff are responsible for food storage. She said a negative outcome would be residents could get sick. Record Review of in-service dated 3/12/20 at 2: 30 PM, training contained proper labeling and storage. In- service indicated that all food is to be labeled and dated.

Based on observations, interviews, and record reviews the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail for 3 (Resident #8, Resident #16, and Resident #17) and failed to obtain informed consent prior to installation of bedrails for 1 (Resident #31) of 12 residents reviewed for bedrails. 1. Resident #8 had a bedrail on her bed which was placed there on her admission to the facility without prior attempts at appropriate alternatives. 2. Resident #16 had a bedrail on his bed which was placed there on his admission to the facility without prior attempts at appropriate alternatives. 3. Resident #17 had a bedrail on her bed which was placed there on her admission to the facility without prior attempts at appropriate alternatives. 4. Resident #31 had bedrails on his bed despite a consent for bedrails in his paper chart that indicated they were not being used. These failures could place residents in danger of entrapment or injury. Findings Included: 1. Record review of Resident #8's admission record dated 10/04/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and long-term use of insulin (a hormone that helps cells use glucose from food for energy and keeps blood sugar levels stable). Record review of Resident #8's quarterly MDS, completed on 01/15/24 revealed a BIMS of 13 which indicated intact cognition. Section GG of the MDS revealed Resident #8 had impairment on one side of her upper extremities and that she used a cane or a crutch. Section GG further revealed Resident #8 was independent across all ADLs needing only set up and clean up assistance with eating. Section I of the MDS revealed Resident #8 had a diagnosis of traumatic brain dysfunction. Section P of the MDS did not list bedrails as restraints for Resident #8. Record review of Resident #8's care plan dated 01/15/24 revealed no mention of bedrails. Record review of Resident #8's Consent for Use of Side Rails revealed a signature by Resident #8's representative dated 10/03/23. Page one of the form noted in part, It is the policy of this facility to use side rail(s) only after assessment and care planning deem it appropriate to treat the resident's medical symptoms and assist the resident in attaining or maintaining his or her highest practicable physical and psychosocial well-being, and other methods or interventions are inadequate. In all instances the least restrictive device, which is effective, will be used. Record review of Resident #8's Evaluation for Use of Side Rails revealed resident and family requested side rails for security and safety and that Resident #8 was on an antidepressant which would require increased safety measures. This evaluation was not signed or dated. Page 2 of the evaluation stated Resident would be reevaluated on a quarterly basis. Record review of Resident #8's physician's orders dated February 2024 revealed and order for an antidepressant with a start date of 10/03/23 and no order for bedrails. During an observation and interview on 03/12/24 Resident #8 was seated in her recliner next to her bed. Her bed was against the wall on the right side and had a bedrail in the upright position at the top of the left side. She stated she had had the bedrail since she was admitted to the facility, and she used it to get into and out of bed. During an observation on 03/13/24 at 08:15 AM Resident #8 was seated in her recliner watching TV. The bedrail on the left side at the top of her bed was in the upright position. During an observation on 03/13/24 at 02:19 PM Resident #8 was asleep in her recliner and the bedrail on the left side at the top of her bed was in the upright position. During an observation on 03/14/24 at 09:36 AM Resident #8 was asleep in her recliner and the bedrail on the left side at the top of her bed was in the upright position. 2. Record review of Resident #16's admission record dated 07/20/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, osteoarthritis (degenerative joint disease) and fracture of left acetabulum (concave surface of the pelvis). Record review of Resident #16's quarterly MDS with a completion date of 01/18/24 revealed a BIMS of 8 which indicated moderately impaired cognition. Section GG of the MDS revealed Resident #16 used a walker to ambulate. Section GG further indicated Resident #16 needed partial/moderate to substantial/maximal assistance across all ADLs except for eating, oral hygiene, chair to bed transfer, walking and toileting where he needed set up help or supervision. Section P of the MDS did not list bedrails as restraints for Resident #16. Record review of Resident #16's care plan dated 01/18/24 revealed Resident #16 used bedrails as enablers for safety and mobility. Record review of Resident #16's physician's orders dated February 2024 revealed an order for bedrails dated 07/19/24. Record review of form Evaluation for use of Side Rails revealed Resident #16's family requested side rails. The form is unsigned and undated but page one has Resident #16's name and the name of his physician on the bottom. Page two is blank. Record review of for Consent for use of Side Rails was signed and dated 07/17/23 by Resident #16's primary physician. Page one of the form noted in part, It is the policy of this facility to use side rail(s) only after assessment and care planning deem it appropriate to treat the resident's medical symptoms and assist the resident in attaining or maintaining his or her highest practicable physical and psychosocial well-being, and other methods or interventions are inadequate. In all instances the least restrictive device, which is effective, will be used. During an observation and interview on 03/12/24 at 12:34 PM Resident #16 was seated in his recliner. His bed was made, and a bedrail was in the upright position on the top, left side of his bed. Resident #16 stated he used the bedrail to get into and out of his bed. The right side of Resident #16's bed was against the wall. During an observation and interview on 03/13/24 at 08:14 AM Resident #16 was seated in his recliner and asked for his call light which was clipped to the bedrail on his bed. The bedrail was on the top, left side of his bed and was in the upright position. During an observation on 03/14/24 at 11:11 AM Resident #16 was seated in his recliner. His bed was made and the bedrail on the top, left side of his bed was in the upright position. 3. Record review of Resident #17's admission record dated 11/04/19 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, high blood pressure, pain, and weakness. Record review of Resident #17's quarterly MDS with a completion date of 02/03/24 revealed a BIMS of 99 which indicated Resident #17 was unable to complete the BIMS. Staff assessment of her cognitive ability moted a memory problem with short and long-term memory and moderately impaired cognition in regards to daily decision making. Section GG of the MDS revealed Resident #17 had bilateral impairment to her lower extremities and was dependent on staff or needed substantial to maximal assistance across all ADLs except eating where she required setup/clean-up help and oral hygiene where she required partial/moderate assistance. Section P of the MDS did not note use of bedrails as restraints. Record review of Resident #17's care plan dated 02/05/24 revealed Resident #17 had the potential to fall due to weakness and a history of falling prior to admission to the facility. The care plan also revealed Resident #17 used bedrails as enablers and for safety. Resident #17 was noted to be disoriented to time and place in her care plan. Record review of Resident #17's physician's orders dated February 2024 revealed an order for bedrails with a start date of 10/29/19. Record review of Resident #17's paper chart revealed one Evaluation for Use of Side Rails dated 10/29/19. Page two of the form indicated Resident #17 would be reevaluated yearly. Record review of Resident #17's paper chart revealed a second Evaluation for Use of Side Rails dated 07/18/20. Page two of this form indicated Resident #17 would be reevaluated yearly. The paper chart did not reveal any other evaluations. Record review of Resident #17's Consent for Use of Side Rails revealed one form dated 10/29/19 which indicated Resident #17 would use bedrails for safety and as an enabler. The form was signed by Resident #17's family member. Page one of the form noted in part, It is the policy of this facility to use side rail(s) only after assessment and care planning deem it appropriate to treat the resident's medical symptoms and assist the resident in attaining or maintaining his or her highest practicable physical and psychosocial well-being, and other methods or interventions are inadequate. In all instances the least restrictive device, which is effective, will be used. During an observation on 03/12/24 at 12:17 PM Resident #17 was in her bed under a blanket with her eyes closed. A bedrail was on the top, right side of her bed in the upright position. The left side of Resident #17's bed was against the wall. During an observation on 03/13/24 at 08:09 AM Resident #17 was lying in bed under a blanket with her eyes closed. A bedrail was on the top, right side of her bed in the upright position. During an observation on 03/13/24 at 02:17 AM Resident #17 was lying in bed under a blanket with her eyes closed. A bedrail was on the top, right side of her bed in the upright position. During an observation on 03/14/24 at 09:41 AM Resident #17 was lying in bed under a blanket with her eyes closed. A bedrail was on the top, right side of her bed in the upright position. 4. Record review of Resident #31's admission record dated 11/24/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, centrilobular emphysema (long-term, progressive lung disease), alcoholic cirrhosis of liver (impaired liver function caused by the formation of scar tissue), anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), weakness, and malignant neoplasm of esophagus (cancer of the esophagus). Record review of Resident #31's quarterly MDS with a completion date of 02/05/24 revealed a BIMS of 6 which indicated severely impaired cognition. Section GG of the MDS revealed Resident #31 needed partial/moderate to substantial/maximal assistance across all ADLs except eating and oral hygiene where he needed setup or clean up assistance only. Section J of the MDS indicated Resident #31 had had 2 or more falls since admission to the facility. Section N of the MDS indicated Resident #31 was taking antipsychotic, antianxiety, and opioid medications. Section P of the MDS did not list bedrails as restraints for Resident #31. Record review of Resident #31's care plan dated 02/05/24 revealed Resident #31 needed assistance with ADLs due to weakness, limited range of motion, and tiring easily. The care plan revealed Resident #31 used bedrails as enablers, safety, and mobility. The care plan noted that Resident #31 took antianxiety and antipsychotic medications as well as opioids. Record review of Resident #31's Consent for Use of Side Rails revealed a blank form with No written across the middle of page one and Does not use Bed rails written across the bottom of page 2. The form was undated and unsigned though it did have Resident #31's name printed on the bottom of page 1. Page one of the form noted in part, It is the policy of this facility to use side rail(s) only after assessment and care planning deem it appropriate to treat the resident's medical symptoms and assist the resident in attaining or maintaining his or her highest practicable physical and psychosocial well-being, and other methods or interventions are inadequate. In all instances the least restrictive device, which is effective, will be used. Record review of Resident #31's physician's orders dated February 2024 revealed he had an order for an antianxiety medication twice a day as well as PRN with an order start date of 11/12/23. Resident #31 also had an order for an antipsychotic medication once a day at bedtime with a start date of 10/27/23. The orders did not mention bedrails. During an observation on 03/12/24 at 11:48 AM Resident #31 was seated in his recliner next to his bed. His bed was made and had bilateral bedrails on the top in the upright position. When asked if he used the bedrails resident #31 glanced at his bed but did not answer the question. During an observation on 03/12/24 at 12:21 AM Resident #31 was seated in his recliner with his eyes closed. His bed was made and had bilateral bedrails on the top in the upright position. During an observation on 03/13/24 at 08:25 AM Resident #31 was reclined in his recliner with his feet propped up on his w/c in front of him and a blanket over his lap. His eyes were closed. His bed was made and had bilateral bedrails on the top in the upright position. During an observation on 03/13/24 at 02:18 PM Resident #31 was seated in his recliner with his eyes closed. His bed was made and had bilateral bedrails on the top in the upright position. During an observation on 03/14/24 at 09:35 AM Resident #31 was seated in his recliner with his eyes closed. His bed was made and had bilateral bedrails on the top in the upright position. During an interview on 03/13/24 at 01:47 PM ADON stated the charge nurses did bedrail consents and evaluations on admission. She said she did not know if they did them regularly or just at admission. ADON stated the evaluations and consents were kept in the paper charts. When asked if less restrictive options were tried before bedrails were used ADON said, We have them when they come in. Most of our residents are able to make their own decisions but most of the time it is the family that asks for them (bedrails). When asked for a possible negative outcome of installing bedrails before trying less restrictive options or doing an evaluation and getting a signed consent, ADON said, We haven't had any here, but I know in [name of another town] somebody got their head caught in the bedrail. She stated possible alternatives to bedrails would be a low bed and a fall mat. During an interview on 03/14/24 at 08:58 AM RN G stated the nurses were responsible for doing bedrail consents and evaluations. He stated they were done on admission and if the resident had a significant change in condition. RN G stated the consents and evaluations were kept in the paper charts. He stated the families of residents often request bedrails for enablers. RN G stated the facility gets physician orders for the residents who use bedrails. He stated a possible negative outcome of installing bedrail prior to attempting less restrictive options or doing an evaluation and getting a signed consent was a resident could get their hand or head caught in the bedrail. During an interview on 03/14/24 at 09:38 AM RN G stated Resident #31 usually sleeps in his bed. The DON was unavailable during the survey and the ADM was unavailable during the last two days of the survey. Therefore, they were not interviewed regarding this failure. Record review of facility policy titled, Bed Safety and dated December 2007 revealed the following: . 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 8. Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified.

Based on observation, interview, and record review the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 1 (Resident #14) of 12 residents reviewed for accuracy of assessment. Resident #14 was coded as having a diagnosis of cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture), when he did not, in fact, have cerebral palsy. This failure could lead to residents receiving unnecessary care. Findings Included: Record review of Resident #14's admission record dated 03/03/22 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included but were not limited to major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), generalized anxiety disorder (inability to control constant worrying), muscle spasm (when a muscle involuntarily and forcibly contracts), myopia (near sighted), and presbyopia (gradual loss of your eyes' ability to focus on nearby objects).The admission record did not mention cerebral palsy. Record review of Resident #14's EHR diagnoses tab revealed no mention of cerebral palsy. Record review of Resident #14's physician's orders dated February 2024 revealed no orders related to cerebral palsy. Record review of Resident #14's care plan dated 02/04/24 revealed no mention of cerebral palsy. Record review of Resident #14's quarterly MDS with a completion date of 02/04/24 revealed a BIMS of 99 which indicated severe cognitive impairment or that Resident #14 refused to answer the questions and was therefore unable to complete the BIMS. The staff assessment for mental status revealed Resident #14's short-term and long-term memory were okay. Resident #14's cognitive skills for daily decision making were coded as Modified Independent-some difficulty in new situations only. Section I of the MDS revealed Resident #14 had a diagnosis of cerebral palsy. Section Z of the MDS revealed MDS RN's signature on 02/04/24 in the space verifying assessment completion. During an observation and interview on 03/14/24 at 09:24 AM ADON stated she did not think Resident #14 had cerebral palsy. She said, Let me look right here and turned to her computer. ADON opened Resident #14's EHR and looked under the diagnosis tab. She read off Resident #14's diagnoses and said, He has cerebral infarction but not cerebral palsy. During an observation and interview on 03/14/24 at 09:33 AM Resident #14 was sitting in a chair facing his bed and working on a puzzle on a foam board covered in newspaper that was sitting on his bed. When asked if he had cerebral palsy he laughed and shook his head. During an interview on 03/14/24 at 10:53 ADON stated a possible negative outcome of an inaccurate MDS as pertains to diagnoses was, The resident could be given wrong medication or not receive the right treatment. In the case of Resident #14 she stated, There is a big difference between cerebral infarction and cerebral palsy. During an interview on 03/14/24 at 10:56 AM MDS RN stated she was responsible for completing MDS assessments. She stated she used the RAI as her policy when working on MDS assessments. She stated Resident #14 did not have cerebral palsy. She said, He doesn't have it. It must have been a typo or an error on my part. MDS RN stated she could not think of a negative outcome of having an inaccurate MDS as pertained to diagnoses. The DON was unavailable during the survey and the ADM was unavailable during the last two days of the survey. Therefore, they were not interviewed regarding this failure. Record review of a facility policy titled Comprehensive Assessment and the Care Delivery Process dated December 2016 revealed in part: . 2. Assessment and information collection includes (WHAT, WHERE, and WHEN?). The objective of the information collection (assessment) phase is to obtain, organize, and subsequently analyze information about a patient. Record review of a facility policy titled Certifying accuracy of the Resident Assessment and dated December 2009 revealed in part: . All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 (RAI) Version 1.18.11 dated October 2023 revealed in part: . SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseased that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #8 and Resident #14) of 12 residents reviewed for comprehensive person-centered care plans. 1. Resident #8 had a bedrail installed on her bed, but her care plan did not address use of bedrails. 2. Resident #14 was care planned to have supervision during smoking and to have staff keep his cigarettes and lighter, but he was allowed to smoke unsupervised and to have his cigarettes and lighter in his possession. These failures could lead to residents being injured due to not receiving needed care and/or supervision. Findings included: 1. Record review of Resident #8's admission record dated 10/04/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and long-term use of insulin (a hormone that helps cells use glucose from food for energy and keeps blood sugar levels stable). Record review of Resident #8's quarterly MDS, completed on 01/15/24 revealed a BIMS of 13 which indicated intact cognition. Section GG of the MDS revealed Resident #8 had impairment on one side of her upper extremities and that she used a cane or a crutch. Section GG further revealed Resident #8 was independent across all ADLs needing only set up and clean up assistance with eating. Section I of the MDS revealed Resident #8 had a diagnosis of traumatic brain dysfunction. Section P of the MDS did not list bedrails as restraints for Resident #8. Record review of Resident #8's care plan dated 01/15/24 revealed no mention of bedrails. Record review of Resident #8's Consent for Use of Side Rails revealed a signature by Resident #8's representative dated 10/03/23. Record review of Resident #8's Evaluation for Use of Side Rails revealed resident and family requested side rails for security and safety and that Resident #8 was on an antidepressant which would require increased safety measures. This evaluation was not signed or dated. Record review of Resident #8's physician's orders dated February 2024 revealed and order for an antidepressant with a start date of 10/03/23 and no order for bedrails. During an observation and interview on 03/12/24 Resident #8 was seated in her recliner next to her bed. Her bed was against the wall on the right side and had a bedrail in the upright position at the top of the left side. She stated she had had the bedrail since she was admitted to the facility, and she used it to get into and out of bed. During an observation on 03/13/24 at 08:15 AM Resident #8 was seated in her recliner watching TV. The bedrail on the left side at the top of her bed was in the upright position. During an observation on 03/13/24 at 02:19 PM Resident #8 was asleep in her recliner and the bedrail on the left side at the top of her bed was in the upright position. During an observation on 03/14/24 at 09:36 AM Resident #8 was asleep in her recliner and the bedrail on the left side at the top of her bed was in the upright position. During an interview on 03/14/24 at 08:58 AM RN G stated a possible negative outcome of a care plan not addressing the use of bedrails was negligence and patient injury. RN G stated that if a resident was using bedrails they would usually get an order for them. During an interview on 03/14/24 at 09:24 AM ADON stated there could be a possible negative outcome of a care plan not mentioning the use of bedrails. She stated, Depends on the resident. We're kinda out of compliance. We need an order for bedrails. During an interview on 03/14/24 at 10:56 PM MDS RN stated if bedrails are ordered it is usually in the care plan. 2. Record review of Resident #14's admission record dated 03/03/22 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included but were not limited to major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), generalized anxiety disorder (inability to control constant worrying), muscle spasm (when a muscle involuntarily and forcibly contracts), myopia (near sighted), and presbyopia (gradual loss of eyes' ability to focus on nearby objects). Record review of Resident #14's quarterly MDS with a completion date of 02/04/24 revealed a BIMS of 99 which indicated severe cognitive impairment or that Resident #14 refused to answer the questions and was therefore unable to complete the BIMS. The staff assessment for mental status revealed Resident #14's short-term and long-term memory were okay. Resident #14's cognitive skills for daily decision making were coded as Modified Independent-some difficulty in new situations only. Section GG of the MDS revealed Resident #14 had impairment to upper and lower extremities on one side and used a cane or crutch. Section GG further revealed Resident #14 was independent or needed partial to moderate assistance across all ADLs. Section I of the MDS revealed Resident #14 had diagnoses of stroke, hemiplegia or hemiparesis (partial paralysis), seizure disorder or epilepsy, anxiety, and depression. Record review of Resident #14's care plan dated 02/04/24 revealed Resident #14 had a diagnosis of cerebral infarction and resultant short-term memory deficit. The care plan stated Resident #14 smokes. A goal for Resident #14 regarding smoking was that he would continue to understand he could smoke on the patio with supervision. The approaches for this goal included Resident #14's smoking materials would be kept at the nurse's station for his to request. Resident was to smoke in view of staff according to the care plan. In addition, staff were to ensure he was compliant with smoking outside with staff supervision. Another area of the care plan noted, Go with resident when he wants to go outside to smoke. During an interview on 03/12/24 at 02:18 PM ADM stated they only had one smoker in the building and that was Resident #14. ADM stated they did not have designated smoking times. During an observation and interview on 03/12/24 at 04:08 PM Resident #14 was lying on his back on his bed. Next to his bed near his head was a nightstand and on the nightstand was a plastic basket with three cigarette lighters in it. He stated he keeps his cigarettes and lighters in his room or on his person. He stated he does not give them to staff at any point. Resident #14 said he goes to smoke whenever he wants to and he does not take staff with him. During an observation on 03/13/24 at 10:24 AM Resident #14 exited the facility into the patio area at the end of Hall D. He was not accompanied by any staff. He was carrying his cane but not using it. During an observation on 03/13/24 at 10:27 AM Resident #14 was seated on a patio chair outside the facility alone smoking a cigarette. During an observation and interview on 03/13/24 at 10:30 AM Resident #14 was seated in a patio chair outside the facility smoking a cigarette which he held in his right hand. He had his right leg crossed over his left leg at the knee. He allowed the ash on his cigarette to get so long that it fell to the ground brushing the inside of his left pants leg. This happened twice during the observation. Resident #14 stated he had been smoking at this facility for [AGE] years and staff rarely smoked with him or sat with him while he smoked. During an interview on 03/13/24 at 01:47 PM ADON stated she did not know if Resident #14 kept his cigarettes and lighter in his room or if he checked them in with staff. She said someone was usually out there smoking with [first name of Resident #14]. She said, I don't believe he has ever burned himself, but he fell going out to smoke one time. ADON stated a possible negative outcome of allowing Resident #14 to keep his lighter and cigarettes in his room despite his care plan saying they need to be checked in with staff was he could catch the building on fire. She said of Resident #14 smoking unsupervised, One of his hands, he has had a stroke so I don't know if he could even light one (cigarette) on his own. When asked what the facility smoking policy said about residents keeping their cigarettes and lighters in their rooms, ADON stated, I don't think they are supposed to have them. When asked what the facility admission packet said about residents keeping their cigarettes and lighters in their rooms she said, Other than them doing a smoking assessment, I don't know. During an interview on 03/14/24 at 08:58 AM RN G stated he was unsure who was responsible for safe smoking assessments. He stated he thought MDS RN was responsible for safe smoking assessments. He stated he did not know how often safe smoking assessments were done or where they were kept. RN G stated residents were not allowed to keep cigarettes and lighters in their rooms. He said a possible negative outcome of Resident #14 having his cigarettes and lighter in his room was patient burns and fires being set. He said a possible negative outcome of not following a care plan regarding smoking was negligence and putting patient at risk for burns. He said the facility policy stated residents were not allowed to keep their cigarettes and lighters in their rooms. During an interview on 03/14/24 at 09:24 AM ADON stated a possible negative outcome of not following a care plan regarding smoking was, Somebody could get burned or catch on fire. During an interview on 03/14/24 at 10:56 AM MDS RN said of the facility's smoking policy, We all know the policy. It says if they can handle their smoking material they can smoke outside. During an interview on 03/14/24 at 01:26 PM MDS RN stated she does not do safe smoking assessments. She stated she just reviews and updates care plans. She said of Resident #14, He is still able to handle his smoking stuff. When asked if she was basing that decision on a smoking assessment she stated, I don't know if they do an assessment per se. I just review his care plan. The DON was unavailable during the survey and the ADM was unavailable during the last two days of the survey. Therefore, they were not interviewed regarding this failure. Record review of facility policy titled, Care Area Assessments and dated May 2011 revealed the following: . d. Make decisions about the care plan: (1) Determine whether the problem(s) need intervention; . (4) Establish which items need further assessment or additional review.e. Document interventions on the care plan: . (2) Include recommendations for monitoring and follow-up timeframes. Record review of facility policy titled, Care Planning - Interdisciplinary Team and dated September 2013 revealed the following: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Record review of facility policy titled, Care Plans, Comprehensive Person-Centered and dated December of 2016 revealed the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The care planning process will: . b. include an assessment of the resident's strengths and needs; . 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; . g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. Record review of facility policy titled, Goals and Objectives, Care Plans and dated April 2009 revealed the following: Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Record review of facility policy titled, Using the Care Plan and dated August 2006 revealed the following: The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident.

Based on observations, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 (Resident #14 and Resident #31) of 12 residents reviewed for accidents and hazards. Resident #14 was allowed to keep his lighter and cigarettes in his room and on his person and to smoke unsupervised. Resident #31 was allowed to keep his lighter and cigarettes in his room and he smoked in his room on at least one occasion. These failures could lead to residents being burned or starting a fire in the facility. Findings Included: 1. Record review of Resident #14's admission record dated 03/03/22 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included but were not limited to major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), generalized anxiety disorder (inability to control constant worrying), muscle spasm (when a muscle involuntarily and forcibly contracts), myopia (near sighted), and presbyopia (gradual loss of your eyes' ability to focus on nearby objects). Record review of Resident #14's care plan dated 02/04/24 revealed Resident #14 had a diagnosis of cerebral infarction and resultant short-term memory deficit. The care plan stated Resident #14 smokes. A goal for Resident #14 regarding smoking was that he would continue to understand he could smoke on the patio with supervision. The approaches for this goal included Resident #14's smoking materials would be kept at the nurse's station for his to request. Resident was to smoke in view of staff according to the care plan. In addition, staff were to ensure he was compliant with smoking outside with staff supervision. Another area of the care plan noted, Go with resident when he wants to go outside to smoke. Record review of Resident #14's quarterly MDS with a completion date of 02/04/24 revealed a BIMS of 99 which indicated severe cognitive impairment or that Resident #14 refused to answer the questions and was therefore unable to complete the BIMS. The staff assessment for mental status revealed Resident #14's short-term and long-term memory were okay. Resident #14's cognitive skills for daily decision making were coded as Modified Independent-some difficulty in new situations only. Section GG of the MDS revealed Resident #14 had impairment to upper and lower extremities on one side and used a cane or crutch. Section GG further revealed Resident #14 was independent or needed partial to moderate assistance across all ADLs. Section I of the MDS revealed Resident #14 had diagnoses of stroke, hemiplegia or hemiparesis, seizure disorder or epilepsy, anxiety, and depression. Record review of a letter from Resident #14's primary physician dated 09/20/18 revealed the following: . Mr. [First and Last Name of Resident #14] is a resident of [Name of Facility] in [Name of City and State]. He is placed there due to an inability to care for himself at home. Medically he has multiple neurological issues that preclude him from performing his ADLs and increase risk to himself and others should he be allowed to return to a self-care setting. Record review of a form titled Consent and Release for Smoking and signed on 02/24/17 by Resident #14 and his responsible party revealed Resident #14 acknowledged he was acting against medical advice by smoking, consented to and agreed to abide by the facility policy, and agreed to hold the facility harmless for any accidents, injuries, or events resulting from smoking or any violation of the smoking policy. During an interview on 03/12/24 at 02:18 PM ADM stated they only had one smoker in the building and that was Resident #14. ADM stated they did not have designated smoking times. During an observation and interview on 03/12/24 at 04:08 PM Resident #14 was lying on his back on his bed. Next to his bed near his head was a nightstand and on the nightstand was a plastic basket with three cigarette lighters in it. At the foot of Resident #14's bed two tables were set up and on the tables were stacks of puzzles glued together and separated by sheets of newspaper. On top of one of the stacks of puzzles was a stack of puzzle boxes some open and others closed. Resident #14 got up and began to show off the puzzles on his wall and a few of those on top of the stacks. He stated he keeps his cigarettes and lighters in his room or on his person. He stated he does not give them to staff at any point. Resident #14 said he goes to smoke whenever he wants to, and he does not take staff with him. During an observation on 03/13/24 at 10:24 AM Resident #14 exited the facility into the patio area at the end of Hall D. He was not accompanied by any staff. He was carrying his cane but not using it. During an observation on 03/13/24 at 10:27 AM Resident #14 was seated on a patio chair outside the facility alone smoking a cigarette. During an observation and interview on 03/13/24 at 10:30 AM Resident #14 was seated in a patio chair outside the facility smoking a cigarette which he held in his right hand. He had his right leg crossed over his left leg at the knee. He allowed the ash on his cigarette to get so long that it fell to the ground brushing the inside of his left pants leg. This happened twice during the observation. Resident #14 stated he had been smoking at this facility for [AGE] years and staff rarely smoked with him or sat with him while he smoked. During an interview on 03/13/24 at 01:47 PM ADON stated she did not know if Resident #14 kept his cigarettes and lighter in his room or if he checked them in with staff. She said someone was usually out there smoking with [first name of Resident #14]. She said of Resident #14, I don't believe he has ever burned himself, but he fell going out to smoke one time. ADON stated a possible negative outcome of allowing Resident #14 to keep his lighter and cigarettes in his room despite his care plan saying they need to be checked in with staff was he could catch the building on fire. She stated staff have tried to clean up the piles of puzzles in Resident #14's room but he does not allow them to do so. She said of Resident #14 smoking unsupervised, One of his hands, he has had a stroke so I don't know if he could even light one (cigarette) on his own. When asked what the facility smoking policy said about residents keeping their cigarettes and lighters in their rooms, ADON stated, I don't think they are supposed to have them. When asked what the facility admission packet said about residents keeping their cigarettes and lighters in their rooms she said, Other than them doing a smoking assessment, I don't know. During an interview on 03/14/24 at 08:43 AM ADON stated DON would not be coming to the facility for the day and she did not think ADM would be coming back either. During an interview on 03/14/24 at 08:58 AM RN G stated he was unsure who was responsible for safe smoking assessments. He stated he thought MDS RN was responsible for safe smoking assessments. He stated he did not know how often safe smoking assessments were done or where they were kept. RN G stated residents were not allowed to keep cigarettes and lighters in their rooms. He said a possible negative outcome of Resident #14 having his cigarettes and lighter in his room was patient burns and fires being set. He said a possible negative outcome of not following a care plan regarding smoking was negligence and putting patient at risk for burns. He said the facility policy stated residents were not allowed to keep their cigarettes and lighters in their rooms. During an interview on 03/14/24 at 09:24 AM ADON stated a possible negative outcome of not following a care plan regarding smoking was, Somebody could get burned or catch on fire. During an interview on 03/14/24 at 10:56 AM MDS RN said of the facility's smoking policy, We all know the policy. It says if they can handle their smoking material they can smoke outside. During an interview on 03/14/24 at 01:26 PM MDS RN stated she does not do safe smoking assessments. She stated she just reviews and updates care plans. She said of Resident #14, He is still able to handle his smoking stuff. When asked if she based that decision on a smoking assessment she stated, I don't know if they do an assessment per se. I just review his care plan. During an interview on 03/14/24 at 01:28 PM ADON was asked for a copy of Resident #14's safe smoking assessment. She stated, I will look and see if I can find one. 2. Record review of Resident #31's admission record dated 11/24/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, centrilobular emphysema (long-term, progressive lung disease), alcoholic cirrhosis of liver (impaired liver function caused by the formation of scar tissue), anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), weakness, and malignant neoplasm of esophagus (cancer of the esophogus). Record review of Resident #31's quarterly MDS with a completion date of 02/05/24 revealed a BIMS of 6 which indicated severely impaired cognition. Section GG of the MDS revealed Resident #31 needed partial/moderate to substantial/maximal assistance across all ADLs except eating and oral hygiene where he needed setup or clean up assistance only. Section J of the MDS indicated Resident #31 had had 2 or more falls since admission to the facility. Section N of the MDS indicated Resident #31 was taking antipsychotic, antianxiety, and opioid medications. Record review of Resident #31's care plan dated 02/05/24 revealed Resident #31 needed assistance with ADLs due to weakness, limited range of motion, and tiring easily. The care plan revealed Resident 31 was a smoker and would be assessed for mental and physical abilities to manage smoking materials. Staff were to assist Resident #31 to the smoking area and monitor and intervene for factors causing smoking related injuries. The care plan stated Resident #31 may smoke in view of nursing staff. The care plan noted that Resident #31 took antianxiety and antipsychotic medications as well as opioids. Record review of Resident #31's paper chart did not reveal any nurses' notes regarding Resident #31 smoking in his room. Record review of Resident #31's EHR under the notes tab did not reveal any notes regarding Resident #31 smoking in his room. Record review of Resident #31's physician's orders dated February 2024 revealed he had an order for an antianxiety medication twice a day as well as PRN with an order start date of 11/12/23. Resident #31 also had an order for an antipsychotic medication once a day at bedtime with a start date of 10/27/23. Record review of a form titled Consent and Release for Smoking and signed on 10/27/23 by Resident #31's responsible party revealed Resident #31 acknowledged he was acting against medical advice by smoking, consented to and agreed to abide by the facility policy, and agreed to hold the facility harmless for any accidents, injuries, or events resulting from smoking or any violation of the smoking policy. During an interview on 03/12/24 at 07:04 PM Resident #31's family member stated he does smoke but not as much as he used to due to the facility taking his cigarettes and lighter away. She stated Resident #31 was caught smoking in his room in the facility twice and she told staff to take his cigarettes and lighter away. She stated she has not purchased him any more cigarettes and she did not think he was smoking very often now. She stated she did not remember exactly when Resident #31 was caught smoking in his room, but she thinks it was within the first few months of his admission. During an interview on 03/13/24 at 01:47 PM ADON stated nurses do the safe smoking assessments on admission. She stated she does not know if safe smoking assessments are done other than at admission. She stated a possible negative outcome of not doing safe smoking assessments periodically was, If there was some kind of a decline, they could burn themselves. ADON stated she was working for the facility at the time Resident #31 smoked in the facility, but she was not at the facility that day. She stated the incident should be documented in Resident #31's paper chart in the nurses' notes. She stated Resident #31's smoking materials were at the nurses' station, but she thought he had quit smoking. During an interview on 03/14/24 at 08:58 AM RN G stated he was not in the building when Resident #31 smoked in his room, but he did see Resident #31's cigarettes and lighter in his room during the time that he was providing care. He could not remember the date that he saw the lighter and cigarettes. During an interview on 03/14/24 at 10:56 AM MDS RN stated she was in the facility when Resident #31 smoked in his room. She said, His reasoning was it was too cold outside. During an interview on 03/14/24 at 01:26 PM MDS RN said of Resident #31, He quit (smoking) thank God! During an interview on 03/14/24 at 01:28 PM ADON was asked for a copy of Resident #31's safe smoking assessment. She said, I'll see if I can find one. During an observation and interview on 03/14/24 at 01:39 PM BOM displayed a checklist from the admission packet for smoker to acknowledge the smoking policy and a blank Consent and Release for Smoking form and asked if they were the safe smoking assessments. When it was explained to her what a safe smoking assessment was, she stated maybe MDS RN did those. When she was told that MDS RN had already stated she did not do them, BOM said, I guess we don't do that. The DON was unavailable during the survey and the ADM was unavailable during the last two days of the survey. Therefore, they were not interviewed regarding this failure. Copies of Resident #14 and Resident #31's safe smoking assessments were never provided. Record review of information from the facility admission packet titled [Name of Facility]-Admission Information ITEMS NEEDED FOR CHECK IN revealed the following: . 14. Do not keep pocket knife, sharp objects or items labeled, 'Keep our [sic] of reach of children' . Online image review of cigarette lighters in packaging revealed a note across the bottom stating, Keep away from children. Record review of information from the facility admission packet titled, Authorization and Certification of Policies revealed the following: . SMOKING. I understand the following smoking policy: The [name of facility] had adopted a NO SMOKING in any other place than the designated area for the Residents. Residents will e allowed to smoke under the supervision in the designated area. All Resident smoking paraphernalia will be distributed by nursing staff and will be kept locked up at the nurses station. NO SMOKING will be allowed by visitors or employees in the building. The form had an area for a resident to initial out beside the policy in a box that said yes or a box that said no. The last page of the form had a place for signature and date by the resident, responsible party, and facility representative. Record review of information from the facility admission packet titled, Operation Policy revealed the following: . SMOKING. Flammable liquids, smoking tobacco, lighters, matches, etc. cannot be kept or stored in the resident's room or in their possession without supervision due to fire and safety regulations. Residents will be allowed to smoke only under supervision in the designated area. Record review of information from the facility admission packet titled, General Information revealed the following: . SMOKING AREA This facility is a smoke free environment. Residents must only smoke in the smoking designated area and with supervision. Smoking is prohibited in all resident rooms. Record review of facility policy titled, Care Plans, Comprehensive Person-Centered and dated December of 2016 revealed the following: . 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; . g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. Record review of facility policy titled Smoking Policy - Residents and dated July 2017 revealed the following: This facility shall establish and maintain safe resident smoking practices. 6. The resident will be evaluated on admission to determine if he or she is a smoker or no-smoker. If a smoker, the evaluation will include: a. Current level of tobacco consumption; b. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. Desire to quit smoking, if a current smoker; and d. Ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 7. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 11. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of staff member, family member, visitor or volunteer worker at all times while smoking.

Based on interview and record review the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days for 1 (Resident #31) of 12 residents reviewed for PRN orders for psychotropic drugs. Resident #31 had an order for a PRN antianxiety medication with a start date of 11/12/23. This failure could place residents at risk of being overmedicated or receiving unnecessary medications. Findings Included: Record review of Resident #31's admission record dated 11/24/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, centrilobular emphysema (long-term, progressive lung disease), alcoholic cirrhosis of liver (impaired liver function caused by the formation of scar tissue), anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), weakness, and malignant neoplasm of esophagus (cancer of the esophagus). Record review of Resident #31's quarterly MDS with a completion date of 02/05/24 revealed a BIMS of 6 which indicated severely impaired cognition. Section N of the MDS indicated Resident #31 was taking antipsychotic, antianxiety, and opioid medications. Record review of Resident #31's care plan dated 02/05/24 revealed Resident #31 took antianxiety and antipsychotic medications. One of the approaches regarding this medication was for staff to evaluate effectiveness and side effects of medications for possible decrease/elimination or change of psychotropic drugs. Record review of Resident #31's physician's orders dated February 2024 revealed he had an order for an antianxiety medication twice a day as well as PRN. Both orders had a start date of 11/12/23 and both orders were for the same medication. Record review of Resident #31's EHR under the notes tab revealed a note by LVN H on 02/08/24 at 10:59 AM. The note revealed Resident #31 had been refusing his antianxiety medication very frequently in the morning and in the evening despite nurses attempting several times to administer. The note stated the physician was contacted and told the nurse to change the standing order for the antianxiety medication to PRN every 12 hours. During an interview on 03/13/24 at 01:47 AM ADON stated she thought PRN orders for psychotropic meds were good for 90 days. When she was reminded about the State Operations Manual saying they were good for 14 days she said, Oh, I did know that! When asked why Resident #31 had a PRN order for an antianxiety medication from November still active she said he was anxious about coming to the facility and about trouble swallowing due to his cancer. During an interview on 03/14/24 at 08:43 AM ADON stated she was working on all of the PRN orders to ensure no others were out of date. During an interview on 03/14/24 at 08:58 AM RN G stated PRN orders for psychotropic medications could only be active for two weeks. RN G stated there was not a negative outcome for Resident #31 if he is not using it. I mean if he was using it: dependency. During an interview on 03/14/24 at 09:24 AM ADON stated a possible negative outcome of PRN orders for psychotropic medications extending past two weeks was Someone being given a medication they don't need. Maybe they could become addicted. I am going not do an in-service with all of our nurses to put a stop date on PRN orders. The DON was unavailable during the survey and the ADM was unavailable during the last two days of the survey. Therefore, they were not interviewed regarding this failure. Record review of facility policy titled Antipsychotic Medication Use revealed the following: . 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.

Based on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 3 Medication Carts (Medication Cart #1 and Medication Cart #2) observed. 4 opened bottles of medications without open dates and 1 expired medication found on A-Hall Medication Cart #1. 5 opened bottles of medications without open dates and 2 expired medications found on B and D Halls Medication Cart #2. The facility's failure could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level. Findings include: Observation on 3/12/24 at10:48AM of A-Hall Medication Cart #1 with MA D revealed multidose bottles, one bottle of each medication; Pepcid, Senna Plus, Simethicone, and [NAME]-Vision without open dates. Expired 1 bottle of Milk of Magnesia date 9/23. An observation on 3/12/24 at 1102AM of B and D-Halls Medication Cart #2 with MA E revealed multidose bottles, one bottle of each medication; Melatonin, Iron Tablets, Buffered Salt Replacement, Simethicone, and Vitamin C wthout open dates. Expired 1 bottle of Geri-Tussin Oral Solution (Guaifenesin) dated 2/24 and expired 1 bottle Milk of Magnesia dated 9/23. Interview on 3/12/24 at 1120AM MA D was asked what a negative outcome would be for giving medications from bottles without open dates and expired medications. She stated, Either get a bad reaction or upset stomach. Interview on 3/12/24 at 1125AM MA E was asked what a negative outcome would be for giving medications from bottles without open dates and expired medications. She stated, Medication can get old and not be helpful or make someone sick. Interview on 3/12/24 at 248PM LVN F Charge Nurse stated, Open dates are on most of the bottles of medications because some of the nurses or medication aides write them on. It's not our policy to have to write open dates on the bottles. We only need the expiration dates on the bottles. She stated, The expired medications could make them sick or not get the full strength. Not putting open dates on the bottles might cause the same thing to happen. Interview on 3/13/24 1017AM the ADON stated, giving medications without an open date or expired medication could make somebody sick. The ADON stated, I don't think so, but it should be. When asked if labeling multidose bottles was policy. Record review of the facility's Storage of Medications Policy revised April 2019 * indicated: The facility stores all drugs and biologicals in a safe secure, and orderly manner. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Record review of the facility's Labeling of Medication Container policy revised April 2019 * indicated: 4. Labels for stock medications include all necessary information d. Appropriate accessory and cautionary statements. Facility Letter to Resident and Family Members about Omnicare Pharmacy in Admission Packet * indicated: '(facility) must define uniform standards for labeling, packaging, storing, processing, and administering of drugs. The uniform standards are essential in assuring that all residents are protected from medication errors.' According to web site Drugs.com (https://www.drugs.com/article/drug-expiration-dates) accessed on * indicated: Once the container of medication is opened after production, that expiration date is no longer guaranteed. According to the manufacturer, the stability of a drug cannot be guaranteed once the original bottle is opened. Heat, humidity, light, and other storage factors can affect stability.

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 33 residents observed for sanitation and COVID protocols. The facility did not follow infection control policies related to hand hygiene and source control for COVID- 19 transmission-based precautions for residents that were COVID- 19 positive. This failure could place residents at risk for infections, contamination, physical decline, and mental decline. Findings included: An interview on 12/11/23 at 12:17 PM, ADM revealed 7 residents are currently COVID-19 positive and all staff are to wear masks. An observation on 12/11/23 at 11:57 AM revealed DA C not wearing a mask at serving window in dining room. At 11:59 AM, observed DC C staff putting on a mask. An observation on 12/11/23 at 12:47 PM revealed Resident #4 with a blue gown hanging outside resident's door with gloves, masks, sanitizer, thermometer, blood pressure cuff, and pulse ox on bedside table outside of the resident's room. No signs of infection control precautions on door . An observation on 12/11/23 at 1:00 PM revealed DA C not wearing a mask in the kitchen. An observation on 12/11/23 at 1:10 PM revealed LA A delivering clean laundry that was uncovered to the first room on the locked unit. An observation on 12/11/23 at 1:31 PM revealed DA C continuing to not wear masks. An observation on 12/11/23 at 3:15 PM revealed LVN B exiting Resident #1's room, take off gown, throw it in the trash can, and did not practice hand hygiene after disposing of PPE. An interview and observation on 12/11/13 at 1:45 PM, revealed DA C was not wearing a mask when exiting the kitchen or during the interview. DA C was in the main area of the facility for the interview. DA C stated, I should put on a mask but oh well. DA C indicated that administration staff had not made everyone aware that they needed to wear masks because COVID positive residents just happened yesterday. DA C stated she wore her mask all day and then went home. DA C stated that no one had said anything to her that morning and she had returned from being off work. DA C stated a negative outcome of not following infection control protocols could be bringing it (illness) into them (residents) and it can spread. An interview on 12/11/23 at 1:52 PM with LVN B stated that all departments were notified of wearing masks in the facility. LVN B stated ADON was always training on infection control. LVN B stated that when the first positive was confirmed on 12/8/23, all staff had to wear masks. LVN B stated that a negative outcome could be the infection spreading like wildfire. An interview on 12/11/23 at 3:09 PM, CNA D stated infection control protocol was done right after first COVID positive patient was confirmed. CNA D stated that all staff were to wear masks and to wear all PPE with COVID positive residents. CNA D indicated that a negative outcome of not following infection control policies could be the spread of more infection. An interview on 12/11/23 at 3:18 PM, RN E and LVN B revealed that Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were COVID-19 positive. LVN B stated the isolation period was 5 days. LVN B stated all residents have isolated except for Resident #2 who was encouraged to go back in room. LVN B and RN E stated that precaution signs were required on doors of residents that were COVID-19 positive as well as all precautions were to be in place. An interview on 12/11/23 at 3:37 PM with ADON (ICP) and ADM revealed that all staff, regardless of department must wear masks as it was the policy. ADON stated all precautions were to be on doors of residents who were COVID-19 positive. ADON was advised two signs for donning and doffing PPE were observed on doors for Resident #1 and Resident #3. ADON and ADM stated they would take care of this immediately. ADM stated he did not know the policy verbatim of residents staying in their rooms however, the staff continues to encourage the best staff could. ADM stated when the first positive resident was confirmed on 12/8/23, stations for transmission- based precautions were placed by rooms . ADON stated a call was made to the oncoming nurse and staff was verbally informed of masks requirement in the facility. ADM stated a negative outcome of not following infection control policies would be a widespread infection. ADON stated a negative outcome would be continued infections with the older population. Record review of a policy named Droplet Precautions, dated 2007, revealed staff are to wear masks within 3 feet of the resident. Record review of an in-service titled Infection Control dated 10/25/23, line 4) Handwashing! And competencies will be conducted. Record review of the CDC Recommended routine infection prevention and control (ICP) practices during the COVID-19 pandemic, dated 5/8/23 , revealed that visual alerts should be posted (e.g. signs, posters) at the entrance and strategic places about IPC recommendations for when to use source control and practice hand hygiene. Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission if any of the following three criteria are met: 1) a positive viral test for SARS-CoV-2. Record review of the NIOSH policy for Donning and Doffing PPE: Proper Wearing, Removal and Disposal, dated 10/3/22, stated to always wash hands with soap and water before wearing and after removal of PPE.

Based on observation, interview, and record review, the facility failed to promote care for a resident in a manner and in an environment that maintained or enhanced each resident's dignity for one resident of 5 residents (Resident #1) reviewed for resident's rights related to dignity. Resident #1 was not permitted to finish her dessert during meal time for lunch. This failure could cause residents to feel uncomfortable and disrespected. Findings include: Record review of Resident #1's clinical record with admitted [DATE] revealed she is a [AGE] year-old female resident admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's quarterly MDS completed on 8/17/2022 revealed a BIMS score of 99 indicating resident was unable to complete Brief Interview for Mental Status and functional status of limited one-person assistance with eating and two or more-person assist with transfer, toilet use, personal hygiene, and walk in room and corridor. During an observation on 12/7/2022 at 12:20 PM in the Alzheimer's unit, Resident #1 was sitting in the dining room eating the remaining portion of brownie as part of her lunch meal. CNA-in-training B came toward Resident #1, pushed the resident's hands away from the bowl of brownie, and started moving the dining table away from the resident when she was still trying to reach for the bowl of brownie with a silver utensil. Observed CNA-in-training B at a standing position, grabbed the utensil and quickly stuffed a small piece of brownie into Resident #1's mouth. Then CNA-in-training B continued moving the dining table a little further away from Resident #1, and moved the resident's chair from facing the dining table towards facing the staff. Then CNA-in-training B held both Resident #1's hands and quickly pulled the resident to a stand-up position without letting the resident finish chewing or finish her brownie. CNA-in-training B started to ambulate with the resident in the direction towards the nurse's station. During an attempted interview on 12/7/22 at 12:25 PM with Resident #1, she did not acknowledge the surveyor's presence nor respond. Observed Resident #1's remaining brownie was placed in a small white Styrofoam bowl with a silver utensil pinned into the brownie. During an interview on 12/7/22 at 1:05 PM the DON reported, Resident #1 cannot use silverware. Resident #1 will eat whatever is placed in front of her using her hands. Resident #1 can eat finger-food with her hands. Resident #1's dignity would have been violated if she was not permitted to finish her meal. During an interview on 12/7/22 at 1:18 PM the ADM reported, CNA-in-training B should not be rushing Resident #1. If CNA-in-training B has rushed Resident #1, I would tell CNA-in-training B to slow down. Resident #1's dignity would have been violated if she was not permitted to finish her meal. During an interview on 12/7/22 at 1:35 PM the Ombudsman for the facility reported that she was not aware of anything at the facility as it was first time assigned to her. During an interview on 12/7/22 at 4:00 PM with CNA-in-training B reported, The food was on the table, not the plate. There was one piece of brownie in the plate and two pieces out on the table. I fed Resident #1 one piece of brownie using a fork and placed the fork back in the plate. Resident #1 tried to go under the table because she always get nervous. I tried to take Resident #1 out of the table. Resident #1 was not allowed to touch the fork because it can hurt her. I left Resident #1 to sit a bit so I can assist my co-worker with another resident. When I came back to Resident #1, she was trying to touch the fork. It was a little piece of brownie left in Resident #1's plate. I cannot say that not permitting Resident #1 to finish her meal would violated Resident #1's dignity. Record review of facility provided policy revealed in the admission packet titled, Statement of Resident Rights with revision number 02-9, effective date of July 1, 2002, and printed on 1/3/2008, revealed the following: You have a right to: (1) all care necessary for you to have the highest possible level of health; and (4) be treated with courtesy, consideration, and respect. Record review of facility provided policy revealed in the admission packet titled, Rights of the Elderly, Chapter 936, House Bill number 1726, Section 1, Title 6, Human Resources Code, is amended by adding Chapter 102 to read as follows: Chapter 102. Rights of the Elderly Section 102.003 Rights of the Elderly (e) revealed: An elderly individual should be treated with respect, consideration, and recognition of the individual's dignity and individuality. An elderly individual receives personal care and private treatment.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections of 2 of 4 staff members (NA A, NA B) reviewed for infection control practices. NA A was not wearing her mask while sitting at the nurse's station and not practicing social distancing while Resident #1 and Resident #2 were walking the hallways. NA B was bent over Resident #4 with her mask below her nose and mouth talking to him during the lunch meal pass. Resident #4 was not wearing a mask. These failures have the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings include: During an observation on 01/26/2022 at 11:10 AM, NA A was observed in the locked unit for Residents diagnosed with Dementia and Alzheimer's Disease, sitting at the nurse's station without a mask. NA B was observed with her mask below her mouth and nose sitting in a chair at the nurse's station. Resident #1 and Resident #2 were walking within 3-4 feet of NA A and NA B and the residents were not wearing masks. NA B immediately pulled her mask up when she saw the surveyor and walked to assist a resident. NA A did not have a mask nearby and had to search for a mask. In an interview on 01/26/2022 at 11:13 AM with NA A, when she was approached, NA A responded, sorry when asked about the ramifications of not wearing her mask, she again, responded sorry and walked off. In an interview on 01/26/2022 at 11:15 AM, the DON confirmed staff are supplied with PPE including masks and her expectations, regarding staff wearing their masks, were to wear their masks at all times, except when eating or drinking. She continued by saying not wearing a mask while in the facility and caring for residents was a big no, no and she also stated the staff could possibly carry and spread infections to the residents. The DON stated her ADON is constantly conducting impromptu training with the staff if he sees the staff not following the infection control protocols. The DON stated that today was NA B's first day and she was supposed to be watching videos and NA A had completed all her competencies regarding infection control. During an observation on 01/26/2022 at 11:30 AM, NA B was observed leaning over Resident #4 with her mask lowered below her chin, exposing her nose and mouth, and talking to Resident #4, who was not wearing a mask. They were face to face with approximately 6-8 inches of space from each other. In an interview on 01/26/2022 at 11:34 AM, NA B was asked why she had lowered her mask, and she responded, I don't know and then confirmed, by exposing her nose and mouth to the residents, she could expose them to an illness. In an interview on 01/26/2022 at 3:00 PM, the DON stated with regard to staff wearing their masks, she referred to the COVID Response Plan, version 4.1, dated 12/31/2021, for guidance and there was no specific facility policy. Record review of the facility's Infection Control Log, dated 01/26/2022, revealed there were 7 residents who tested positive for COVID from 01/14/2022 to 01/25/2022. Record review of the facility's Staff list, dated 12/22/2022, revealed 6 staff tested positive for COVID from 01/13/2022 to 01/16/2022, with 5 of the 6 staff involved in direct care of the residents as a nurse or nurse aide.