Every finding on record at Ware Memorial Care Center

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 6 residents reviewed for medication administration.The facility failed to ensure LVN A stayed with Resident #1 until the medications she gave him were taken on the morning of 04/16/26.This failure could place residents at risk of harm due to not receiving necessary medications or receiving medications at the wrong time as well as taking medication that does not belong to them.Findings Included:Record review of Resident #1's admission record dated 04/16/26 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, persistent atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), essential hypertension (high blood pressure), heart failure (heart muscle fails to pump blood as it should), and edema (swelling).Record review of Resident #1's quarterly MDS assessment completed on 03/10/26 revealed a BIMS of 15 which indicated intact cognition. Section GG Functional Abilities revealed Resident #1 was dependent with all ADLs except eating and oral hygiene where he required only setup or clean-up assistance. Section N Medications revealed Resident #1 was receiving medications from the following high risk drug classes: antidepressant, anticoagulant (blood thinner), diuretic (increases urine production to remove excess water and salt from the body), opioid (pain medication), and anticonvulsant (helps prevent or control seizures).Record review of Resident #1's care plan completed 03/10/26 revealed no mention of Resident #1 self-administering his medication.Record review of Resident #1's MAR for April 2026 dated 04/16/26 revealed the following medications administered by LVN A on the morning of 04/16/26:Lasix Oral Tablet 40 MG (diuretic medication)Multiple Vitamin TabletSenna-Plus Oral Tablet 8.6-50 MG (laxative [medication to help with bowel movement if constipated] and stool softener)Spironolactone Tablet 25 MG (diuretic medication)Zoloft Oral Tablet 100 MG (antidepressant medication)Eliquis Oral Tablet 5 MG (anticoagulant medication)Gabapentin Capsule 100 MG (anticonvulsant medication)Metoprolol Tartrate Oral Tablet 100 MG (blood pressure medication)Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (opioid pain medication)During an observation and interview on 04/16/26 at 07:27 AM Resident #1 was seated with another resident at a table in the dining room. Resident #1 had a small oval orange-pink pill on the table in front of him and a small plastic medication cup on the table in front of him containing approximately eight medications. He had a lidded cup with a straw of what appeared to be coffee on the table in front of him. No staff were in sight. Resident #1 stated staff leave his medications with him for him to take on his own every day.During an observation on 04/16/26 at 07:30 AM Resident #1 was seated at the table in the dining room with medications in the plastic medication cup in front of him on the table and LVN A was standing 4-6 yards away behind her medication cart looking at her computer screen.During an interview on 04/16/26 at 07:32 AM LVN A stated she leaves Resident #1's medications with him for him to take on his own because, He takes one pill at a time and if you stand there with him, he won't take them. I stay close where I can watch. She stated a possible negative outcome of not watching Resident #1 take his medication was he could not take the medicine and if he did not take the medicine it could affect his health or he could save up the medicine.During an interview on 04/16/26 at 07:36 AM RN B stated it was never okay to leave a resident alone with their medication. She stated, Another resident could swing by, grab it (medication) and swallow.During an interview on 04/16/26 at 07:46 AM LVN C stated it was never okay to leave a resident alone with their medication. She stated residents could store their medication and take too much at once or another resident could come along and grab the medication.During an interview on 04/16/26 at 07:50 AM ADON and DON stated nurses were to stay with residents until all medications administered were taken. DON stated otherwise the nurse could not know if the resident took the medication which could lead to the resident not receiving needed treatment. She stated, I worry about them (residents) choking or residents could hoard medication.Record review of an undated page from the facility's admission packet titled Common Items Not Allowed in Nursing Home Resident's Rooms revealed the following: . MEDICATIONS: (Includes all prescription and over-the-counter drugs) NOTE: if a resident is requesting to administer his/her own medications(s), the Physician must approve the request and the Care Plan Team must evaluate whether the resident is capable of this task, and there must be specific precautions taken to prevent other residents from possible harm by inadvertently eating or drinking it.Record review of facility policy titled Drug Administration Policy and dated 01/26/17 revealed no mention of nurses remaining with residents while medications were taken.Record review of facility policy titled Pharmacy Services and dated 01/26/17 revealed no mention of nurses remaining with residents while medications were taken.Record review of undated facility form titled POC Education-Medication Administration revealed the following: . 2. Unattended Medications Nursing best practice for medication administration is to observe every resident while taking their medications to ensure they have been swallowed. Medications are never to be left unattended with a resident . Leaving medications unattended with residents places them at risk for:-intentional or unintentional medication avoidance-potential abuse of medications (stockpiling medications)-potential decline in condition due to missed medications-chokingIt is also a violation of the Nurse Practice Act which requires a nurse's direct supervision with medication dispensing and administration.I understand the information above and have had the opportunity to ask questions. I understand these responsibilities and agree to administer medications according to best practice guidelines. I understand that if I choose to leave medications unattended with a resident, I will face disciplinary action up to and including termination and jeopardize my nursing license.LVN A signed the form on 03/04/26.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 (Resident #46 and Resident #79) of 24 residents reviewed for medication administration.1. The facility failed to ensure LVN A stayed with Resident #46 until her medications were swallowed on the morning of [DATE].2. The facility failed to ensure LVN B stayed with Resident #79 until her medications were swallowed on the morning of [DATE].3. The facility failed to ensure the Southeast Hall medication cart did not contain expired eyedrops.4. The facility failed to ensure the Southwest Hall medication cart did not contain expired insulin.These failures could place residents at risk of harm due to not receiving necessary medications or receiving medications at the wrong time as well as taking medication that does not belong to them or is no longer effective due to being past expiration.Findings Included:1. Record review of Resident #46's admission record dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, rheumatoid arthritis (inflammatory disease causing painful swelling in affected areas of the body), hypothyroidism (thyroid gland does not make enough thyroid hormone resulting in fatigue, weight gain, increased blood cholesterol, sensitivity to cold, hair loss, constipation, joint pain, and puffy face), other specified depressive episodes (depressive conditions with significant symptoms and impairment that do not meet full criteria for major depressive disorder or other specific depressive disorders), hypertension (high blood pressure), gout (common and complex form of arthritis that can affect anyone. It's characterized by sudden, severe attacks of pain, swelling, redness and tenderness in one or more joints), pain in right shoulder, cognitive communication deficit, and hyperlipidemia (high cholesterol).Record review of Resident #46's annual MDS completed [DATE] revealed a BIMS score of 15 which indicated intact cognition. Section GG Functional Abilities revealed Resident #46 was independent across most ADLs except eating where she required set up or clean up assistance and bathing where she required substantial maximal assistance. Section K Swallowing Nutritional Status revealed no issues with swallowing. Section N Medications revealed she received diuretic (medication that helps remove excess fluid and salt from the blood by increasing urination) and opioid medications (pain relief medication).Record review of Resident #46's care plan dated [DATE] revealed she was at risk for aspiration or impaired swallowing related to a diagnosis of GERD (risk of stomach acid going back and forth between the mouth and stomach). The care plan did not mention self-administration of medication.Record review of Resident #46's MAR dated February 2026 revealed she received the following medications on the morning of [DATE] from LVN A:Allopurinol Tablet 100 MG Give 1 tablet by mouth one time a day for GoutAtenolol Tablet 50 MG Give 1 tablet by mouth one time a day for HTN Hold if SBP is less than or equal to 120Cholecalciferol Tablet Give 2000 unit by mouth one time a day for OA (degenerative joint disease)Folic Acid Capsule 0.8 MG Give 1 capsule by mouth one time a day for SupplementLosartan Potassium Oral Tablet 100 MG Give 1 tablet by mouth in the morning for HTNMeloxicam Tablet 15 MG Give 1 tablet by mouth one time a day for painPoly-Iron 150 Oral Capsule Give 150 mg by mouth one time a day for anemiaSenna-S Oral Tablet 806-50 MG give 2 tablet by mouth two times a day for constipationTylenol with Codeine #3 Oral Tablet 300-30 MG Give 1 tablet by mouth 4 times a day for painDuring an observation and interview on [DATE] at 09:00 AM Resident #46 was seated in her room with a plastic medication cup containing several pills in front of her on her tray table. She stated the nurse left the medication with her to take. She stated she did not know what the medications were. She stated, The nurse tells me (what the medications were), but I forget.During an interview on [DATE] at 08:17 AM Resident #46 stated it was normal for the nurse to leave her medications with her for her to take on her own. She stated LVN A trusted her to take her medications.2. Record review of Resident #79's admission record dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), hypothyroidism (Thyroid gland does not make enough thyroid hormone resulting in fatigue, weight gain, increased blood cholesterol, sensitivity to cold, hair loss, constipation, joint pain, and puffy face), pain, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and hypertension (high blood pressure).Record review of Resident #79's quarterly MDS completed on [DATE] revealed a BIMS score of 14 which indicated intact cognition. Section GG Functional Abilities revealed Resident #79 dependent across most ADLs except eating where she required set up or clean up assistance and oral care where she required supervision or touching assistance. Resident #79 was independent in moving from sitting to lying. Section K Swallowing Nutritional Status revealed no issues with swallowing. Section N Medications revealed she received anticoagulant (blood thinning medication), diuretic (medication that helps remove excess fluid and salt from the blood by increasing urination) and opioid medications (pain relief medication).Record review of Resident #79's care plan dated [DATE] revealed she was at risk of aspiration or impaired swallowing due to chronic pain related to nausea and vomiting. The care plan did not mention self-administration of medication.Record review of Resident #79's MAR dated February 2026 revealed she received the following medications from LVN B on the morning of [DATE]:Amlodipine Besylate Oral Tablet 5 MG Give 1 tablet by mouth one time a day for HTNCalcium 600+D Oral Tablet 600-5 MG MCG (Calcium Carbonate-Vitamin D) Give 1 tablet by mouth one time a day for supplementEscitalopram Oxalate Oral Tablet 10 MG Give 1 tablet by mouth one time a day for depressionLevothyroxine Sodium Tablet 100 MCG Give 1 tablet by mouth one time a day for low thyroid hormone @630 (6:30 AM) per pt requestLosartan Potassium Oral Tablet 50 MG Give 1 Tablet by mouth one time a day for HTNPantoprazole Sodium Tablet Delayed Release 40 MG Give 1 tablet by mouth one time a day for GERDApixaban Oral Tablet 5 MG Give 1 tablet by mouth two times a day for atrial fibrillationSenna S Oral Tablet 8.6-50 MG Give 3 tablet by mouth two times a day for constipationVitamin C Oral Tablet 500 MG Give 1 tablet by mouth two times a day for supplementTylenol Oral Tablet 325 MG Give 2 tablet by mouth three times a day related to painDuring an interview and observation on [DATE] at 09:11 AM Resident #79 was lying in bed on her back with head of bed slightly raised and over the bed table in front of her. There was a small medication cup with more than six pills in it and a small plastic cup full of water on her over the bed table. She stated they were her morning medications, and the nurse regularly left them with her to take on her own. 3. During an observation and interview on [DATE] at 08:50 AM of the 1-Southeast medication cart with LVN A present. Noted Genteal Eyedrops marked as opened [DATE] and marked expiration of [DATE]. LVN A stated that they were advised that eye drops were to be disposed of every 90 days, LVN A stated it used to be 30 days, but they were going through too many bottles, so it was changed to every 90 days.4. During an observation and interview on [DATE] at 09:04 AM of the 1-Southwest medication cart with LVN G present. Noted was Insulin Glargine with open date of [DATE] and expiration date of [DATE]. LVN G stated that the insulin was expired, that the resident received a dose each evening, and that the insulin should have been pulled and replaced. LVN G stated that the facility policy was that all insulins should be initialed with the date they are opened, due to expire usually in 28 days, and that each medication cart has a guide provided for each medication and its expiration. LVN G stated giving expired insulin can result in the residents having raised blood sugar which would be a negative effect. During an interview on [DATE] at 01:21 PM LVN A stated that if a resident was given a medication that was expired, then that medication could possibly be not as effective as it should be, it would have decreased effectiveness, or it could be toxic which will affect the residents negatively. LVN A stated that each medication cart has information on medication storage and provided the directions for ophthalmic medication care that her cart currently had. During an interview on [DATE] at 02:17 PM ADON D stated that the night shift should check all medication carts to ensure they are in good condition on Tuesdays and Thursdays which should have been checked the previous evening. ADON D stated all night staff will need to be retrained on how to inspect a medication cart. ADON D stated as far as any issues with the medication carts they usually do not have any problems because their staff are good about checking the carts. ADON D stated insulins should be marked when they are opened but do not need an expiration date because all the staff know when they expire in 28-30 days. ADON D stated that if a medication was given that was expired then it could have a bad effect. ADON D stated she was not familiar with the policy for the care of eye drop medications. During an interview on [DATE] at 09:01 AM the DON stated insulins should be marked with the date they are opened and the date they expire which should be 28 days and if a resident received an insulin that was expired then the insulin would have less efficacy, and the resident could have poor control of their condition. If a resident received an eye drop medication that was expired, then there could be an issue with infection control. The DON stated it was the responsibility of every nurse administering the medication to check and see if it was appropriate to administer.During an interview on [DATE] at 09:57 AM CNA M stated he had never noticed residents left with medication to take on their own. He stated nurses were responsible for administering medications.During an interview on [DATE] at 10:00 AM LVN F stated nurses or medication aides were responsible for administering medications. She stated nurses were to stay with the residents until the medications were taken. She stated it was never appropriate to leave medications with residents to take on their own. LVN F stated a possible negative outcome of leaving medications with residents was, You could have another resident wander in a take it or they could just not take it at all, or they could hold onto it and save it and take it at the wrong time.During an interview on [DATE] at 10:05 AM CNA N stated nurses were responsible for administering medications to residents. She stated she had never seen residents left with medications to take on their own. CNA N was working on Resident #79's hall at the time of the interview.During an interview on [DATE] at 10:12 AM CNA O stated nurses were responsible for administering medications to residents. She stated if medications were left with residents to take on their own, Another resident could pass by and get them (medications). She stated she had not seen residents left with medications to take on their own. CNA O was working on Resident #46's hall at the time of the interview and stated she worked all over the facility when she picked up shifts.During an interview on [DATE] at 10:14 AM LVN A stated nurses or medication aides were responsible for administering medications to residents. She stated she left medications with Resident #46 to take on her own in the morning because Resident #46 took several medications in the morning, and it made her nauseous to take all of them at the same time. LVN A stated, We are working on an order from [name of director of medicine] because Resident #46 was alert and oriented times a thousand. She stated Resident #46 was not able to identify each of her medications and what they were for, but she could identify her pain pill. LVN A stated she did not think there was a possible negative outcome for leaving medications with Resident #46. She stated, The only negative outcome is if someone came into (Resident #46's) room, saw those pills, and took them themselves.During an observation and interview on [DATE] at 10:21 AM ADON stated charge nurses were responsible for administering medications. She stated it was not okay for nurses to leave medications with residents to take on their own unless we have an order for it. She looked in the EHR for Resident #46 and Resident #79. ADON stated there was no such order for Resident #46 or Resident #79. She stated a possible negative outcome of leaving medications with residents to take on their own was maybe they just wouldn't take them (the medications).During an interview on [DATE] at 10:26 AM MDS RN stated nurses were responsible for administering medications to residents. She stated it was not appropriate to leave medications with residents to take on their own. MDS RN stated a possible negative outcome of doing so was the resident might not take their medication, or they might double up on the medication later.A call was placed to LVN B on [DATE] at 10:44 AM with no answer.During an interview on [DATE] at 11:06 AM DON stated charge nurses were responsible for administering medications to residents. She stated nurses were not supposed to leave medications with residents to take on their own. DON stated a possible negative outcome of doing so was that the resident might not take their medication. She stated, They could throw it in the trash, flush it down the toilet, or give it to their roommate.During an interview on [DATE] at 11:11 AM ADM stated nurses were responsible for administering medications to residents. She stated nurses were not to leave medications with residents to take on their own. She stated the residents could fail to take the meds (medications).A call was placed to LVN B on [DATE] at 03:02 PM with no answer.Record review of an undated page from the facility's admission packet titled Common Items Not Allowed in Nursing Home Resident's Rooms revealed the following: The following is a list of items which are either specifically controlled by codes, standards, or regulations, or have been demonstrated by this facility as having an adverse effect on the health and safety of our residents. MEDICATIONS: (Includes all prescription and over-the-counter drugs) NOTE: if a resident is requesting to administer his/her own medications(s), the Physician must approve the request and the Care Plan Team must evaluate whether the resident is capable of this task, and there must be specific precautions taken to prevent other residents from possible harm by inadvertently eating or drinking it.Record review of facility policy titled Drug Administration Policy and dated [DATE] revealed no mention of nurses remaining with residents while medications were taken.Record review of the facility provided Medication Storage Guidance provided on each medication cart Clinical Geriatrics 2025, revealed the following: Ophthalmic Products - Date when opened and discard in accordance with manufacturer's recommendations. refer to manufacturer's recommendations.Record review of the facility provided Storage Recommendations for Injectable Diabetes Medications provided on each medication cart Clinical Geriatrics 2025, revealed the following: Insulin Vial - Lantus (Glargine) - Until Expiration Date - Opened - 28 days.Record review of the Ophthalmic Medication Beyond-Use Guide provided by Health Direct Pharmacy Services (From the Centers for Medicare & Medicaid Services (CMS)) dated [DATE] revealed the following:Manufacturer - [name of manufacturer]Drug Name - Genteal Tear Sol - ModerateExpiration Date - 90 days from openingRecord review of the facility provided policy titled Drug Security Policy dated [DATE], revealed the following: Medications must be properly labeled and stored in locked medication room, cabinet, or cart.

Based on observation, interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 4 (Resident #1, #2, #28, and #40) of 24 residents reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #1, #2, and #40 for the use of restraints on their MDS assessments. -The facility failed to accurately assess Resident #28 for the use of CPAP therapy on his MDS assessment. This failure to accurately assess a resident could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Findings include: Resident #1 Record review of Resident #1's face sheet printed 02/10/26 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include heart failure (a chronic condition in which the heart dose not pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), pain, and diabetes (a chronic condition that affects the way the body processes blood sugar (glucose). Record review of Resident #1's last MDS was a quarterly assessment completed 01/10/26 listing her with a BIMS score of 11 indicating she was moderately cognitively impaired, she had a functionality of being independent with lying to sitting at the side to the bed and Section P0100 - Physical Restraints Resident #1 was listed for using bed rails. Record review of Resident #1's care plan with admission date of 07/03/23 revealed the following: Focus:-Resident uses side rails for positioning. - Date initiated 07/21/2024.Intervention:-12/03/2024 Side rails in use for positioning. Record review of the clinical record for Resident #1 revealed an Order Summary Report with active orders as of 02/10/26 with the following order:- Side rails in use for positioning - Start Date: 12/04/2024. During an observation and interview on 02/10/2026 at 09:27 AM Resident #1 did not have any bedrails up but Resident #1 did report staff put them down during the day and up at night so she can use them to get in and out of bed and to move around in bed. Resident #2 Record review of Resident #2's face sheet printed 02/10/26 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include discitis, unspecified of the lumbosacral region (a uncommon, painful condition characterized by inflammation and infection of the intervertebral disc between the lumbar vertebrae and the sacrum, often causing severe lower back pain), Osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), and altered mental status. Record review of Resident #2's last MDS was an annual assessment completed 12/06/25 listing her with a BIMS score of 15 indicating she was cognitively intact, she had a functionality of requiring partial/moderate assistance with lying to sitting at the side to the bed and Section P0100 - Physical Restraints Resident #2 was listed for using bedrails. Record review of Resident #2's care plan with admission date of 11/29/23 revealed the following: Focus:-Resident uses side rails for positioning. - Date initiated 07/21/2024. Record review of the clinical record for Resident #2 revealed an Order Summary Report with active orders as of 02/10/26 with the following order:-Bilateral side rails for self-positioning in bed and for transfers in and out of bed. - Start date of 1/28/2026. During an observation and interview on 02/10/2026 at 11:18 AM Resident #2 had her quarter bed rails in use. Resident #2 stated she used them to assist her getting in and out of bed and moving around in bed. Resident #28 Record review of Resident #28's face sheet printed 02/12/26 revealed he was a [AGE] year-old male resident admitted to the facility originally on 01/16/23 and readmitted on [DATE] with diagnoses to include heart failure (a chronic condition in which the heart dose not pump blood as well as it should), dementia (a group of thinking and social symptoms that interfere with daily functioning), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), Parkinson's (a disorder of the central nervous system that affects movements to include tremors), and dysphagia (difficulty or discomfort in swallowing). Record review of Resident #28's last MDS was an annual assessment completed 12/24/25 listing him with a BIMS score of 12 indicating he was moderately cognitively impaired, he had a functionality of requiring partial/moderate assistance for most of his activities of daily living, and Section O - Special Treatments, Procedures, and Programs: Resident #28 was listed in Section G1. Non-invasive Mechanical Ventilator (BiPAP/CPAP) as not having it On admission or While a Resident. Record review of Resident #28's care plan with admission date of 12/17/24 revealed the following: Focus:-Resident uses CPAP at night. - Date initiated 12/17/24. Record review of the clinical record for Resident #28 revealed an Order Summary Report with active orders as of 02/12/26 with the following order:-C-PAP QHS at bedtime. - Start date 12/17/2024. During an observation on 02/10/2026 at 08:40 AM noted in Resident #28's room there was a CPAP machine on the bedside dresser with tubing and mask present. During an interview on 02/10/2026 at 11:17 AM Resident #28 stated he has used his CPAP for years and staff help him with all his needs and care of his CPAP. Resident #28's family member entered the room and reported Resident #28 had used CPAP therapy for 15 years. Resident #40 Record review of Resident #40's face sheet printed 02/10/26 revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include Alzheimer's (a progressive disease that destroys memory and other important mental functions), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), and congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should). Record review of Resident #40's last MDS was a quarterly assessment completed 11/01/25 listing him with a BIMS score of 15 indicating he was cognitively intact, he had a functionality of requiring substantial/maximal assistance with lying to sitting on the side of the bed, and Section P0100 - Physical Restraints Resident #30 was listed for using bed rails. Record review of Resident #40's care plan with admission date of 03/12/14 revealed the following: Focus:-Resident uses a bed rail for mobility. - Date initiated 12/04/24. Record review of the clinical record for Resident #40 revealed an Order Summary Report with active orders as of 02/10/26 with the following order:- Bed rails for mobility. - Start Date: 12/04/24. During an interview on 02/10/2026 at 11:13 AM Resident #40 stated he liked his bed rails and stated, State better not get them taken away. Resident #40 stated they (his bed rails) are a benefit to him; they help him reposition, especially when staff are changing his brief, it helps him move from left to right. During an interview on 02/10/2026 at 2:40 PM the MDS Coordinator with the DON present stated she had been the MDS Coordinator for 4 months and she was currently in training. The MDS Coordinator reviewed Resident #1's last MDS assessment and verified Resident #1 was marked as having restraints for the use of her bed rails. The MDS Coordinator stated, That was my fault. When I first started, I thought when they had bed rails it was supposed to be marked in this section. I will get this corrected today. The MDS coordinator stated this was the case with Residents #2, #28 (with his CPAP therapy), and #40 also and she would get each MDS corrected as soon as possible. The MDS Coordinator stated an incorrect MDS assessment that does not accurately reflect the resident's status could affect the residents negatively and could affect the facility's reimbursement. The DON stated none of the residents had bed rails for the purpose of restricting their movements and therefore they should not be considered restraints. During an interview on 02/12/2026 at 8:56 AM the DON stated if the MDS assessment was not completed correctly then it would be an inaccurate reflection of the resident's condition and could affect reimbursement. The DON did not feel this would affect residents' care as long as the rest of the residents' records such as orders and care plans addressed the residents' issues. During an interview on 02/12/2026 at 8:47 AM the MDS coordinator stated the facility used the RAI manual to complete all MDS assessments. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023 revealed the following: SECTION P: RESTRAINTS AND ALARMS Enter Codes in BoxesUsed in Bed-A. Bed rail-B. Trunk restraint-C. Limb restraint-D. Other SECTION O: SPECIAL TREATMENTS, PROCEDURES, ANDPROGRAMS Coding Instructions for Column b. While a ResidentCheck all treatments, procedures, and programs that the resident received or performed afteradmission/entry or reentry to the facility and within the last 14 days. If no treatments,procedures or programs were received by, performed on, or participated in by the residentwithin the last 14 days or since admission/entry or reentry, check Z, None of the above. O0110C1, Oxygen therapyCode continuous or intermittent oxygen administered via mask, cannula, etc., delivered to aresident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive AirwayPressure/Continuous Positive Airway Pressure (BiPAP/CPAP) here. Do not code hyperbaricoxygen for wound therapy in this item. This item may be coded if the resident places or removestheir own oxygen mask, cannula.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 2 kitchens when they failed to: Ensure kitchen staff used proper hand washing and sanitation procedures when handling food. Ensure kitchen staff and other employees wore hair restraints and beard coverings while in the kitchen. This failure could cause decreased meal satisfaction and decreased meal consumption due to using unsanitary practices in the facility's kitchen and could affect all residents in the facility that receive meals from the facility kitchen. Findings included: In an observation and interview of the kitchen food prep activities on 2/10/26 at 8:50 am, [NAME] I was observed in the kitchen with his beard cover under his chin and not covering his moustache. He stated he had been aware it should have been covering the moustache and just forgot to pull the face covering up over his moustache. He stated food borne illness would be a consequence of not having the proper covering. In an observation of the kitchen prep area on 2/10/26 at 8:52 am, the MM was observed in the kitchen with no beard cover. A repairman from outside the facility was in the kitchen with no hairnet or beard cover laying on the floor in the middle of the kitchen repairing the kitchen equipment.In an observation and interview on 2/10/26 at 9:00 am [NAME] K was observed in the back of the kitchen putting up groceries from the truck delivery. [NAME] K did not have a beard cover on his face. [NAME] K stated he had just forgotten to put it on. He stated he had been trained to wear a beard cover while in the kitchen and food borne illness would be a consequence. In an observation on 2/10/26 at 10:40 am, [NAME] I was observed in the kitchen with his moustache uncovered. In an observation and interview on 2/10/26 at 11:02 am, [NAME] L was observed touching various kitchen surfaces and the puree blender with her gloved hands. [NAME] L then walked across the kitchen to a pan of rolls on a rack and picked up a handful of rolls in her gloved hands. [NAME] L then walked back to the blender and put the rolls into the blender. [NAME] L tore rolls up with her gloved hands and began to puree. [NAME] L stated she had not been aware she had touched other surfaces before touching the rolls. She stated she should have changed her gloves. In an observation on 2/10/26 at 11:22 am [NAME] I was observed touching various kitchen surfaces with his gloved hands. [NAME] I then picked up a pan of rolls from a rolling rack and placed the pan on the prep counter. [NAME] I picked up rolls with his gloved hands and broke them into sections and placed the rolls into several serving pans. [NAME] I filled up a serving pan then touched the pan to move it. [NAME] I then picked up more rolls and placed the rolls into other serving pans. In an observation on 2/10/26 at 12:07 pm [NAME] J was observed touching various kitchen surfaces with gloved hands. [NAME] J opened the oven, pulled out a pan of rolls, picked a roll up with his gloved hand and checked for doneness by touching the roll. [NAME] J then put the roll back on the tray and returned the pan of rolls to the oven. In an observation and interview on 2/10/26 at 12:07 pm [NAME] I was observed serving the lunch meal. [NAME] I touched various kitchen surfaces with his gloved hands, picked up a plate, used serving utensils to plate food then picked up a roll with his gloved hand and placed the roll on the plate. [NAME] I stated he had been aware he touched the roll with his hands and should not have done that. He stated he had been trained in the kitchen duties and had been aware he needed to use tongs to plate rolls. He stated he had been using the tongs but had just forgotten to use the tongs for that roll. He stated food borne illness would be a possible consequence to the residents. In an interview on 2/11/26 at 9:40 am, the DM stated beard covers and hair restraints should always be worn even by the maintenance and other visitors. She stated moustaches should always be covered. The DM stated tongs should always be used when serving bread and when preparing food. She stated food should not be touched with hands that had touched other surfaces. She stated she was new and had not had any in-services with the kitchen staff but would schedule them. The DM stated the consequences of not washing hands and changing gloves would be cross contamination. In an interview on 2/12/26 at 9:30 am, the MM was asked about not having a beard cover on his face when in the kitchen on 2/10/26 at 10:40 am. He denied he did not have a beard cover on his face on 2/10 26 and stated if he had been repairing the ice machine that day, he did have a beard cover on. He stated he always wore a beard cover when in the kitchen. In an interview on 2/12/26 at 9:40 am, the RD stated she had been told about the issues in the kitchen during the survey. She stated she expected all staff and visitors to have effective hair and beard covers while in the kitchen. She stated she expected hand washing and glove changes when changing tasks and for staff to use tongs when handling food. She stated she had not had any recent in-services with the staff but had been told the DM had scheduled an upcoming training for handwashing, hair restraints and general cleanliness in the kitchen. She stated the DM had been recently hired and seemed to have some good ideas about how to run the kitchen. She stated the issues in the kitchen could cause food borne illness as well as meal dissatisfaction in the residents. In an interview on 2/12/26 at 10:00 am the DM stated he had a current Dietary Managers certificate but did not supervise the DM. He stated he had been on the clinical side dealing with admission paperwork and did not go in the kitchen very often. He stated he had not been in charge of training the DM in kitchen duties. He stated he had been aware of the issues in the kitchen and would make sure staff were retrained. He stated of the issues with touching food with contaminated hands that he expected all staff to always follow the handwashing guidelines and to use tongs with serving bread. He stated he expected all staff to wear beard covers and hair restraints at all times and for the beard covers to completely cover the facial hair. He stated all issues in the kitchen would cause issues of food borne illness for the residents. Record Review of the facility's policies titled Handwashing Policy with a date of 1/11/19, documented: ' It is the policy of this facility that hand washing be regarded as the single most important means of preventing the spread of infections. Record Review of the facility's policies titled Traffic in Food Service Areas with a date of 1/16/17, documented: ' Traffic of non-food employees will be kept to a minimum. Any employee entering the food service area must wear appropriate hair restraint. The traffic of non-service food personnel through the food preparation and utensil areas is prohibited. Record Review of the USDA Food Code, dated 2017, documented:Hair Restraints2-402.11 Effectiveness. (A) FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; Record Review of the USDA Food Code, dated 2017, documented: 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room. (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS. (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD, (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands.

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 (Resident #11) of 4 residents observed for infection control. -LVN E did not perform hand hygiene properly while performing wound care for Resident #11. This deficient practice has the potential to affect residents by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene. Findings included: Record review of Resident #11's admission record dated 02/12/2026 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to included Parkinson's (a disorder of the central nervous system that affects movements to include tremors), dementia (a group of thinking and social symptoms that interfere with daily functioning), Osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), and repeated falls. Record review of Resident #11's clinical record revealed his last MDS was a significant change of condition completed 11/28/2025 listing him with a BIMS score of 12 indicating he was moderately cognitively impaired, he had a functionality of being dependent on staff for most of his ADL's and he had one stage 2 pressure ulcer. Record review of Resident #11's Order Summary Report with Active Orders as of 02/12/2026 revealed the following order:- Wound care to coccyx wound. Clean with wound cleanser and pat dry. Apply Collagen to wound bed and cover with Allevyn gentle border dressing every day shifr for wound healing. Active 12/16/2025. Record review of Resident #11's care plan with admission date of 08/26/2025 revealed the following: Focus:- Resident has impaired skin integrity. Revised on 10/29/2025. Intervention:-Wound care to coccyx wound . Date initiated: 12/18/2025. During an observation on 02/11/2026 at 10:03 AM of wound care LVN E (with LVN F assisting) cleaned Resident #11's wound with two wet 4x4's, dried the wound with a dry 4x4, removed her gloves, did not perform hand hygiene, then placed new gloves, applied collagen to the wound bed, and covered the wound with a dry dressing. LVN E then removed her gloves and performed hand hygiene. During an interview on 02/11/2026 at 10:17 AM LVN E stated, I should have probably used hand sanitizer or washed my hands when I went from the dirty to the clean portion of the wound care. LVN E reported by not performing hand hygiene at the correct time the resident was placed at risk for infection. LVN E reported the staff are currently trained by the DON on hand hygiene. During an interview on 02/11/2026 at 10:20 AM LVN F reported that hand hygiene should have been performed between the dirty and clean portion of the wound care and if proper hand hygiene was not completed then the resident can develop an infection. During an interview on 02/12/2026 at 8:58 AM the DON reported she expects staff to perform hand hygiene to include removing gloves, washing hands, and placing new gloves at multiple times of care to include the dirty to clean portion of wound care, catheter care, and incontinent care. The DON reported if hand hygiene was not completed correctly the resident could be placed at risk for infection and staff could spread infection from one room to another. During an interview on 02/12/2026 at 9:20 AM the DON reported they do an annual training on hand hygiene, and the last training was 4/2025. Record review of the facility provided training titled, 2025 Annual Competency Topics - Competency Checks: Hand Hygiene undated revealed the following:LVN E passed her competency. Record review of the facility provided policy titled, Infection Control Program dated 09/18/2023, revealed the following: Policy: The facility will establish and maintain and Infection Control Program.Objectives of the Infection Control Program are: 2. Maintain a safe, sanitary, and comfortable environment. B. Components of the Infection Control Program include: m. Hand washing. Record review of the facility provided policy titled, Handwashing Policy dated 01/11/2019, revealed the following: Policy - It is the policy of this facility that hand washing be regarded as the single most important means of preventing the spread of infections. Record review of the facility provided policy titled Perineal Care effective 05/11/2022, revealed the following: Important Points - Always perform hand hygiene before and after glove use.

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 1-Northwest Hall medication cart) of 10 medication storage areas reviewed for medication storage. -The 1-Northwest Hall medication cart has loose medication pills. The facility's failure could result in a resident receiving medications that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes.Findings included: During an observation on 02/11/2026 at 08:44 AM of the 1-Northwest medication cart with LVN E present. Noted two loose pills identified by the LVN E as Levothyroxine and Atorvastatin. During an interview on 02/11/2026 at 1:24 PM LVN E reported loose medication in a medication cart can result in a resident missing a dose of medication, they could run out of the medication early and the insurance might not refill it. This could affect the residents if they do not receive the dose of medication they need. During an interview on 02/11/2026 at 2:17 PM ADON D reported that the night shift should check all medication carts to ensure they are in good condition to include no loose pills on Tuesdays and Thursdays which should have been checked the previous evening. ADON D reported all night staff will need to be retrained on how to inspect a medication cart. ADON D reported as far as any issues with the medication carts they usually do not have any problems because their staff are good about checking the carts. During an interview on 02/12/2026 at 9:01 AM the DON reported the night shift should review all medication carts for loose or expired medications, but they often get busy and cannot get to that duty. The DON reported loose pills in a medication cart should not be an issue if there are 1-2 loose pills. If there were 5-6 then the residents could incur increased expenses. The DON reported there was a chance that the pill could get stuck in the foil when the nurse expressed the medication from the blister pack but that was an unlikely occurrence. The DON reported it was the responsibility of every nurse administering the medication to check and see if it was appropriate to administer. Record review of the facility provided policy titled Drug Security Policy dated 01/30/2017, revealed the following: Medications must be properly labeled and stored in locked medication room, cabinet, or cart.

Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #55) of 25 residents reviewed for advanced directives.Resident #55's DNR form lacked a dated notarial acknowledgment and therefore was not fully executed.This failure could place residents at risk of receiving medical treatment inconsistent with their or their legal representative's expressed wishes.Findings included:Record review of Resident #55's face sheet dated [DATE] revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses including but not limited to unspecified atrial fibrillation(irregular heart rhythm), drug induce subacute dyskinesia(movement disorder related to side effects of medications), peripheral vascular disease (narrowed arteries/reduce blood flow to limbs) and hypertension(high blood pressure). Resident #55 was identified as a DNR in the Advance Directive section.Record review of Resident #55's quarterly MDS Assessment was completed on [DATE]. In section C0500 the BIMS Summary Score was blank. In section C1000- Cognitive Skills for Daily Decision Making reflected Resident #55 was severely impaired.Record review of Resident #55's care plan revised on [DATE] included the following:Focus/intervention:Advanced Directives: Do not administer CPR if heart stops and/or breathing stops (initiated [DATE]).Record review of Resident #55's active physician orders as of [DATE] revealed the following order:DNR (Do not resuscitate) dated [DATE].Record review of the clinical record for Resident #55 revealed a DNR signed by the Resident's Representative and physician dated [DATE]. Under the Two Witnesses section: the document contained the notary's signature/seal and printed name; however, there was no date indicating when the notary completed the form.An attempted telephone call on [DATE] at 3:06 PM to Resident #55's family representative was unsuccessful.During an interview on [DATE] at 2:22 PM, the DON reviewed Resident #55's DNR and stated it was not correct due to the missing notary date. The DON stated the SW was responsible for ensuring DNRs were accurate and acknowledged the potential outcome would be the facility would be legally in trouble because the facility would not be following the resident's wishes. During an interview on [DATE] at 3:01 PM the SW stated she was responsible for verifying the DNRs were correct. Upon reviewing the DNR document, the SW acknowledged the document lacked a notary date and stated she mistook the notary commission expiration date as the date signed. The SW did not give a negative outcome for not having a completed/accurate DNR.During an interview on [DATE] at 9:38 AM, RN C stated she worked on the hall where Resident #55 resided. After reviewing Resident #55's DNR, she stated the document would be considered null and void because it did not have the date the notary signed. RN C stated that because the DNR was not completed correctly, she would have to initiate resuscitation, which would be against the resident or their representative's wishes. RN C further stated she believed it was the social worker's responsibility to ensure DNRs were completed correctly.Record review of a blank OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES revealed the following: The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional.Record review of facility policy Advance Directives dated [DATE] reflected the following: The facility recognizes the right of each individual to make choices and decisions regarding his/her treatment, including the right to withdraw or withhold life sustaining treatment.

Based on interview and record review the facility failed to, within 7 days after completing a resident's assessment, encode the following information for each resident in the facility: A subset of items upon a resident's transfer, reentry, discharge, and death for 3 (Resident #49, Resident #53, and Resident #60) of 21 residents reviewed for assessments.1. The facility failed to encode a death in facility assessment for Resident #49 within 7 days of his death in the facility on [DATE].2. The facility failed to encode a discharge assessment for Resident #53 within 7 days of his discharge on [DATE].3. The facility failed to encode a death in facility assessment for Resident #60 within 7 days of her death in the facility on [DATE].These failures could place residents at risk of inaccurate medical records.Findings Included:1. Record review of Resident #49's admission record dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included heart disease (a range of conditions that affect the heart) and kidney disease. He was receiving hospice services. He died in the facility on [DATE].Record review of Resident #49's EHR under the MDS tab revealed he did not have a death in facility MDS assessment completed. The last MDS listed in the EHR was a significant change assessment with an ARD of [DATE]. Record review of this significant change assessment revealed a BIMS of 6 which indicated severely impaired cognition.Record review of Resident #49's progress notes revealed his hospice nurse pronounced him dead on [DATE] at 08:56 PM and his body was released to the funeral home the same day at 10:40 PM.Record review of Resident #49's discharge summary revealed he was deceased and discharged to the funeral home on [DATE]. The section labelled Brief History revealed the following: admitted for long term care [DATE]. Decline in condition due to CHF. Hospice admit [DATE]. deceased [DATE].2. Record review of Resident #53's admission record dated [DATE] revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), fracture of left clavicle (broken collar bone), prostate cancer and bone cancer. Resident #53 was discharged on [DATE] to an acute care hospital.Record review of Resident #53's admission MDS completed on [DATE] revealed a BIMS score of 15 which indicated intact cognition. Section GG Functional Abilities revealed he needed assistance across all ADLs. Section N Medications revealed he was receiving opioid (pain) medication.Record review of Resident #53's EHR under the MDS tab revealed he did not have a discharge MDS assessment completed. The last MDS listed in the EHR was an Entry MDS dated [DATE].Record review of Resident #53's care plan initiated on [DATE] revealed no mention of discharge plans.Record review of Resident #53's miscellaneous tab in the EHR revealed no discharge summary.Record review of Resident #53's progress notes revealed Resident #53 was taken by family members to the veteran's hospital and admitted for therapy on [DATE] at 09:00 AM.3. Record review of Resident #60's admission record dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). She was receiving hospice services. She died in the facility on [DATE].Record review of Resident #60's EHR under the MDS tab revealed she did not have a death in facility MDS assessment completed. The last MDS listed in the EHR was a significant change assessment with an ARD of [DATE].Record review of Resident #60's progress notes revealed she died on [DATE] at 08:32 PM and her body was released to the mortuary at 09:10 PM.Record review of Resident #60's discharge summary revealed she was deceased and discharged to the mortuary on [DATE]. The section titled Brief History revealed the following: Resident had confusion pleasantly confused and started to decline during the weakend (sic) [DATE]. Hospice was notified also [family member]During an interview on [DATE] at 10:21 AM ADON stated she and MDS RN were responsible for completing discharge MDS assessments. She stated she did not think there was a negative outcome for a resident if a discharge MDS was not completed timely. She stated, We will eventually get them done. Just sometimes we get behind.During an interview on [DATE] at 10:26 AM MDS RN stated she was responsible for completing discharge MDS assessments. She stated ADON was helping and training her. She stated she used the RAI as her policy when completing MDS assessments. She stated according to the RAI a discharge MDS was to be completed within 14 days of discharge. She stated a possible negative outcome of not completing discharge MDS assessments timely was, If they (the discharge resident) come back in, we would have the same information, and it might not be accurate.During an interview on [DATE] at 11:06 AM DON stated MDS RN and ADON were responsible for completing discharge MDS assessments. She stated she did not think a resident would be negatively impacted if a discharge MDS was not completed timely. DON stated, My perspective of MDS is that if there is a negative outcome it would be a facility issue, fines, reimbursement, something like that.During an interview on [DATE] at 11:11 AM ADM stated MDS RN was responsible for completing discharge MDS assessments. She stated discharge planning was more important and had more potential to negatively impact a resident than did completing a discharge MDS timely.Record review of facility policy titled, Resident Assessment and dated [DATE] revealed the following: . The facility will complete the MDS assessment in accordance with the RAI manual as may be amended from time to time.Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated [DATE] revealed the following: . the following situations warrant a Discharge assessment. Resident is admitted to a hospital or other care setting (regardless of whether the nursing home discharges or formally closes the record) . Discharge Reporting MDS assessments and tracking records that include a select number of items from the MDS used to track residents and gather important quality data at transition points, such as when . they leave a nursing home . Discharge reporting includes. OBRA Discharge assessments, . and Death in Facility tracking record.

Based on observation, interview and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #1) of nine residents reviewed for pressure ulcers. The facility failed to: A. Ensure Resident #1 who was admitted to the facility without a pressure ulcer did not develop an unstageable pressure ulcer with eschar (a layer of dead skin tissue that forms over a wound) on her coccyx within two weeks of admission. B. Failed to notify the wound care nurse of the ulcer. C. Failed to accurately document Resident #1's skin conditions which caused delayed care for the ulcer. D. Failed to document descriptions of the pressure ulcer which put the resident at risk of worsening pressure ulcer due to not accurately documenting Resident #1's skin conditions. These failures resulted in an Immediate Jeopardy (IJ) situation on 02/20/2025. While the IJ was removed on 02/24/2025, the facility remained out of compliance at a severity level of no actual harm with the potential for more harm than minimal harm that is not Immediate Jeopardy. These failures placed the residents at risk for worsening pressure ulcers, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood), severe pain or death. Finding Include: Record Review of Resident #1's face sheet revealed Resident #1 to be a [AGE] year-old female admitted to the facility for rehabilitation services on 01/27/2025 with a diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other functions), anxiety, chronic pain, high blood pressure, and muscle weakness. Resident #1 had gone to a physician appt on 2/10/25 and was admitted to the hospital for open reduction and removal of femoral component of total hip arthroplasty without allograft. An unstageable pressure ulcer with eschar and tunneling was found upon admission to the hospital on 2/10/25. Resident #1 returned to the facility from the hospital on 2/19/25. An Admission MDS dated [DATE] documented Resident #1 had a BIMS score of 4 out of 15 which indicated cognition was severely impaired. Section H Bladder and Bowel documented resident was always incontinent of bladder and frequently incontinent of bowel. Section M Skin Conditions documented there were no pressure ulcer based on clinical assessment and formal assessment of Braden. An MDS assessment dated [DATE] documented in Section M- 00300 Resident #1 had an unstageable -Slough and Eschar. The MDS further revealed Resident #1 to be totally dependent on staff for ADL care and required two-person assistance with transfer, bed mobility, incontinent care and personal hygiene. Resident #1 was not admitted to the facility with pressure ulcers and was noted to be at risk for development of skin issues. A Baseline Care Plan, used for new admissions, dated 1/27/25 and completed 1/28/25 documented Resident #1 was incontinent, at risk for pain and required assistance with ADL's. Skin conditions were addressed as: Patient skin will remain intact. Document any skin issues in PCC. For pressure related wounds document location, length width and depth. Describe wound in detail, including peri wound. Record Review of the physician orders for 1/1/25 through 1/31/25 documented no orders for wound care for buttocks or weekly skin assessments. Skin tears to shins were addressed. Record Review of the physician orders for 2/1/25 through 2/28/25 documented Licensed Nurse to perform weekly skin assessments every day shift every Friday. Start Date: 2/21/25. Coccyx pressure wound, apply wound cleanser, and pat dry, apply Medi honey to wound bed, then apply Allevyn foam dressing (adhesive dressing for absorption and management of wounds). Every shift for Pressure Ulcer 2/9/25. Facility treatment nurse to evaluate wound on sacral area and treat as needed. Every shift Start date 2/19/25. Record Review of the January 2025 TAR dated 1/1/25 through 1/31/25 TAR documented there were no orders for weekly skin assessments or treatment for a coccyx pressure ulcer. Record Review of the February 2025 TAR dated 2/1/25 through 2/28/25 TAR documented there were no orders for weekly skin assessments or treatment for a coccyx pressure ulcer from 2/1/25 to 2/8/25. Record Review of the facility nurses' notes for Resident #1 revealed no skin assessments had been done since admission. Record Review of the Hospital records for Resident #1 documented Resident #1 was admitted to the hospital on 2/10/25 for hypotension, left anterior hip dislocation and was noted to have an unstageable pressure injury to the coccyx. Nurses' hospital note stated wound was present upon admission. Wound care was provided on 2/11/25 and was documented as: Wound Treatment Summary Braden Scale Score: 12; Unstageable pressure Injury: Coccyx assessed on 2/11/25 as dark colored superior portion suspect deep tissue unstageable pressure. Wound bed assessment stated area to coccyx noted to have moist, yellow tan adherent slough to 100 percent of wound bed. State of healing: inflammatory stage. Surrounding Skin Assessment: clean dry blanchable red. Dressing Drainage Description: Serosanguineous. Wound Width- 1.5 cm, Wound surface 5.55cm. 2 Debridement: Autolytic; Mechanical. In an interview on 02/18/2025 at 9:30 am Resident #1's RP, who was a nurse, stated Resident #1 had developed an unstageable pressure ulcer on her coccyx since being admitted to the facility. Resident #1s RP stated she had taken Resident #1 to a Dr appointment on 2/10/25 and Resident #1 had been sent to the hospital as the procedure could not be done in the office. Upon admission to the hospital, Resident #1 was found to have an unstageable pressure ulcer on her coccyx. Resident #1's RP stated she saw the ulcer at the hospital on 2/10/25. She stated it was unstageable with eschar and was pretty large. She stated the eschar was thick yellow and the hospital had to work to get all the eschar off. She stated the pressure ulcer had to have been there before the resident went to the hospital that day. She stated the facility never told her about the pressure ulcer. She stated she called the facility and had spoken to the ADM and the DON. The RP stated, Of course they did not want to admit the facility did not do what they were supposed to, but they tried to tell me it started in the emergency room . The RP stated the pressure ulcer was too bad to have started in the emergency room . She stated the hospital put the Thera honey on the wound and could only uncover half of the ulcer. She stated the pressure ulcer had tunneled. The RP stated the Risk Manager (RM) called and said he was very sorry about the pressure ulcer and that Resident #1's treatment did not meet there standard of care. She stated the RM said the pressure ulcer would be investigated and steps would be taken to ensure they got to the bottom of the issue. In an observation and interview on 2/18/25 at 1:10 pm Resident #1 was observed in bed. Resident #1 was talking to people who were not in the room and was not able to be interviewed. In an observation and interview on 02/18/2025 at 1:15 pm, the Hospital RN (RN A) stated she had been taking care of Resident #1 on this date. RN A stated Resident #1 had a pressure ulcer upon admission to the hospital that was necrotic and tunnelling. She stated Resident #1 had to have had the sore for quite some time for it to be tunneling. She stated there was MRSA (a type of staph bacteria resistant to many antibiotics) in the wound. RN A reviewed the hospital records and notes from admission and stated the hospital noted Resident #1 had the pressure ulcer upon admission to the hospital. She showed the computer screen of the pressure ulcer, the admission notes, and the wound measurements. She stated since Resident #1 was still in the hospital, medical records would not print medical records. A picture of the pressure ulcer and the measurements on admission were printed. Review of the picture of the pressure ulcer on the hospital computer screen revealed a large open wound on the coccyx. In an interview on 02/19/2025 at 8:30 am, the ADM stated she had been aware Resident #1 had gone to the hospital and stated the facility did not know she had a pressure ulcer until the family stated the hospital showed it to them. She stated that was why it was not reported. In an interview on 2/19/25 at 9:50 am, the DON stated the only Braden assessments (most commonly used assessment for risk of pressure ulcers) for Resident #1 were done on admission 1/27/25 and on 2/3/25. She stated Resident #1 did not have pressure ulcers on those dates. She stated Resident #1 should have been turned and repositioned every 2 hours while she was in the facility. She stated turning and repositioning were standard orders. She stated she did not know if Resident #1 had been turned and repositioned or not. She stated it was not something that was documented. In an interview on 2/19/25 at 10:40 am, RN B stated she had not been aware Resident #1 had a Stage 4 pressure ulcer while she was at the facility. She stated she had done an assessment on Resident #1 when she was admitted . She stated Resident #1 did not have a pressure ulcer upon admission and only had a small red spot on her bottom. She stated no one had informed her of the worsening spot. She stated she did not find out it was an unstageable pressure ulcer until she had been admitted to the hospital on 2/10/25. She stated the normal procedure would be a CNA or nurse informed her she needed to see a resident for a wound. She stated the nurses knew Resident #1 had a pressure ulcer, but the nurses had not let her know. RN B stated she had found a nurses note that a nurse documented a pressure ulcer on 2/8/25. She stated of the note that the nurse documented she had notified her of the pressure ulcer. RN B stated she had not been notified of the pressure ulcer. She stated no one in the facility had verbally told her about the sore until 2/10/25 when the family had called the ADM. When asked if the pressure ulcer could have developed in the emergency room in one day, she stated, No it could not have. She stated there had not been weekly skin assessments done by the nurses for Resident #1 and the skin assessments from the CNA's doing incontinent care had been done incorrectly or were not done at all. She stated the consequences of not having a skin assessment weekly would be missing skin issues causing further skin issues. She stated she had done training with the nurses and the CNAs. She stated the consequences of not finding a pressure ulcer would be poor care, worsening pressure ulcers and medical complications for the resident. In an interview on 2/19/25 at 11:00 am, the Risk Manager (RM) stated he was aware there was an issue with the Resident #1 as the RP had called him. He stated the RP discussed the pressure ulcer. He stated she told him a pressure was found in the emergency room and no one at the facility had told her about it. He stated she was a nurse and was a very reasonable person to him. Then the ADM and the DON called her. The RM stated Maybe we should have seen it. Maybe we should have had better documentation on the skin. I told the RP we do not like unavoidable pressure ulcers. He stated he could not tell the RP if it was avoidable or not. He stated It's on my radar now. As far as the pressure ulcer in the facility that was not documented, I am going to let the ADM and the DON deal with that. They run the building. Not me. I look at trends. In an interview on 2/19/25 at 11:27 am, the ADM stated We did not know about the pressure ulcer. No one laid eyes on it here. We do not know when it started. Whoever the nurses were that were supposed to be doing the weekly skin assessments did not do it or did not check the right box. In an interview on 2/19/25 at 12:10 pm, the DON stated she found a nurses note about the sore, but the nurses had not followed up on it. She stated she did not know when she found the note. She stated RN B, had not been notified about the sore. The DON stated all nurses were supposed to have done weekly skin assessments, but they had not done it. She stated the CNAs had not checked the correct boxes for the toileting either. She stated there were no measurements done for Resident #1's wound. In a follow-up interview on 02/19/2025 at 3:55 pm,, the DON stated she did not find the paperwork that confirmed Resident #1 had been turned and repositioned every 2 hours. The DON stated a complete skin assessment was not completed for Resident #1 upon admission. The DON stated she did not have any paperwork for toileting. In an interview on 2/20/25 at 10: 37 am, LVN C stated she had not found any weekly skin assessments for Resident #1. She stated she had not found any documentation on turning and repositioning Resident #1 but stated it was standard care and they usually did not have orders for turning. She stated she had not been aware Resident#1 had a pressure ulcer until the 9th of February. Regarding the skin issues, she stated the CNAs looked at skin when they change the residents and when the residents were showered. She stated the CNAs were good about notifying the LVNS about any red spots, changes in skin, bruises, and sores. She stated after a sore was found then the LVN would assess the sore or spot and report to the RN house supervisor or the DON. She stated she would also call or tell the wound care nurse. In an interview on 2/20/25 at 1:45 pm, RN D stated she had seen a note from RN E that stated Resident #1 had a pressure ulcer on 2/8/25. RN D stated she had done a return anticipated to the facility MDS after Resident #1 went to the hospital on 2/10/25. She stated the progress note stated RN E called the on-call Nurse practitioner and got orders for treatment. RN D stated this prompted her to ask RN B about the pressure ulcer. She stated RN B told her she had no idea Resident #1 had a wound. RN D stated she logged into the hospital records and found information on the pressure ulcer from the hospital records. RN D stated the pressure ulcer had been unstageable due to sloth. She stated the usual procedure for wounds would be the nurses would tell RN B about the pressure ulcers which prompted RN B to assess and treat. She stated the nurse's notes did not have specific documentation about the pressure ulcer in the nurses' notes as to size condition and treatment which is why she logged into the hospital records. She stated Resident #1 had returned to the facility on [DATE]. In an interview on 2/20/25 at 2:05 pm, RN F stated Resident #1 would not stay in bed and was always wanting up from the bed. RN F stated she was only in bed for naps and at night. She ate in the dining room and sat in the lobby with the other residents. RN F stated Resident #1 would try to get up on her own without calling for assistance. She stated she found out about the pressure ulcer on 2/8/25 when another RN pointed it out to her. RN F stated the pressure ulcer was not that bad and was not that big. She stated the aides were good about saying something about skin issues. She stated she did not know if the wound care nurse knew about it and she had not notified her. In an interview on 2/20/25 at 2:30 pm, CNA G stated she had taken care of Resident #1 while she was in the facility. She stated she had only seen a red spot-on Resident #1 when she did incontinent care and she put barrier cream on it. She stated there were no open sores that she saw. She stated all the CNAs were to alert the Charge Nurse of any skin issues they see during incontinent care. She stated the CNAs were to mark the Skin Observation Task on PCC after incontinent care as to what they saw. She stated sometimes the documentation would not be accurate. In an interview on 2/22/25 at 9:20 am RN H stated she was the Weekend House Supervisor and stated she saw Resident #1 when a night nurse asked her to evaluate the sore on Resident #1's coccyx. She stated it was a Stage 2 with slough on 2/9/25. RN H stated the nurses were just doing a topical cream up to that point. She stated she did not know if the wound care nurse had seen the wound before this date, and she stated she left an email for the wound care nurse. She stated the CNAs document the skin issues and are to let the nurses know about any skin issues they see. The nurses report to the house supervisors who pass on the information to the DON. She stated the consequences of not charting correctly would be some form of disciplinary action. She stated the consequences to the resident of not properly assessing skin issues would be not being properly assessed or treated and would result in a pressure ulcer. In a follow-up interview on 2/19/25 at 3:55 PM, the DON stated she did not find the paperwork that confirmed Resident #1 had the pressure ulcers upon admission. The DON stated a complete skin assessment had not been completed for Resident #1 upon admission. In an interview on 2/19/25 at 4:30 pm, LVN E stated she had seen the pressure ulcer on Resident #1's coccyx on the 8th and had left a message for RN B. She stated she had not followed up with RN B to make sure she knew about the sore. She stated she did not measure the wound. LVN E stated the wound was a large open area. She stated she called the NP on duty and had gotten orders to apply a triad (a paste for light to moderate skin breakdown after incontinence). In an interview on 2/22/25 at 4:30 pm, LVN I stated Resident #1's sore had been reported on the 2/9/25 by the night nurse. LVN I stated the night nurse had called the Nurse Practioner for orders. LVN I stated she had not known Resident #1's bottom was red or that she had a pressure ulcer before that day. LVN I stated the bottom had been red but was not open the week before and the CNAs had been putting barrier cream on her. She stated she had left a message for RN B but had not followed up further. In an interview on 2/22/25 at 10:00 am PA stated she is the facility physicians 's PA. She stated she had not seen Resident #1 before she had gone to the hospital. She stated she was not aware Resident #1 had a pressure ulcer before she went to the hospital. She stated Resident #1 had a big pressure ulcer now on her spine. She stated the facility had a wound care nurse that treated the wounds in the facility. She stated she could give no further information on the matter. Record review of Resident #1's facility nursing notes revealed on 1/27/25 at 8:00 pm an admission note stated blanchable redness to bilateral buttocks, no open areas noted. Nurses Note on 2/6/25 documented area to buttocks other skin issue redness/wound was present upon admission. Skin has not been evaluated. Nurses note on 2/8/25 documented Resident #1 had pressure ulcer to coccyx. Triad applied to open area. Nurses note dated 2/8/25 documented redness present at admission. Nurses note dated 2/8/25 at 8:30 pm documented Resident had developed a pressure ulcer to coccyx which appeared to be worsening. Wound cleanser and triad had been used for the past 2 days. On call FNP was contacted about using Medi honey (a wound dressing that reduces bacteria and inflammation in wounds) and dressing on pressure wound. Record Review of the physician orders for 1/1/2025 through 1/31/25 documented no orders for wound care for buttocks. Record Review of the physician orders for 2/1/25 through 2/28/25 documented: Licensed Nurse to perform weekly skin assessments every day shift every Friday. Start Date: 2/21/25. Coccyx pressure wound, apply wound cleanser, and pat dry, apply Medi honey to wound bed, then apply a dressing. Every shift for Pressure Ulcer 2/9/25. Facility treatment nurse to evaluate wound on sacral area and treat as needed. Every shift, Start date 2/19/25. Record Review of the facility Treatment Administration Record titled CNA tasks report for Resident #1 documented: 1/27/25 at 2:25 pm documented none of the above observed. 1/27/25 at 11:29 pm redness and discoloration 1/28/25 at 9:58 am documented none of the above observed. 1/28/25 at 9:11 pm documented none of the above observed. 1/29/25 at 8:41 am none of the above observed. 1/29/25 at 7:55 pm documented none of the above observed. 1/30/25 at 9:37 am documented none of the above observed. 1/30/25 at 9:16 pm documented red area 1/31/25 at 8;25 am documented none of the above observed. 2/1/25 1:54 am documented Not applicable 2/1/25 10:03 am none of the above observed. 2/2/25 2:19 am documented none of the above observed. 2/2/25 7:52 am documented none of the above observed. 2/3/25 1:55 am documented a red area. 2/3/25 8:47 am documented none of the above observed. 2/3/25 7:15 pm documented none of the above observed. 2/4/24 5:44 pm documented a red area discoloration and open area. 2/4/25 9:36 pm documented none of the above observed. 2/5/25 9;43 am documented none of the above observed. 2/5/25 7:17 pm not applicable 2/6/25 9:03 am not applicable 2/6/25 8:40 pm documented a red area. 2/7/25 8:28 am documented none of the above observed. 2/7/25 9:02 pm documented red area 2/8/25 8:43 am documented discoloration 2/8/25 at 7:15 pm documented a red area. 2/9/25 7:59 am documented none of the above observed. 2/10/25 3:45 am documented a red area. 2/10/25 10:10 am documented none of the above observed. 2/10/25 at 9:45 pm documented resident not available Record Review of Resident #1's Hospital record dated 2/10/25 documented Resident#1 had been admitted to the hospital for 2/10/25 for hypotension, left anterior hip dislocation and noted to have an unstageable pressure injury to the coccyx. Nurses' hospital note stated wound was present upon admission. Wound care was provided on 2/11/25 and was documented as: Wound Treatment Summary Braden Scale Score: 12; Unstageable pressure Injury Coccyx assessed on 2/11/25 as dark colored superior portion suspect deep tissue unstageable pressure. Wound bed assessment stated area to coccyx noted to have moist, yellow tan adherent slough to 100 percent of wound bed. State of healing: inflammatory stage. Surrounding Skin Assessment: clean dry blanchable red. Dressing Drainage Description: Serosanguineous. Wound Width- 1.5 cm, Wound surface 5.55cm. 2 Debridement: Autolytic; Mechanical. Record Review of Resident #1's admission nurses note on 1/27/25 revealed for skin integrity Resident #1 had normal skin with the only skin issues noted as skin warm and dry with surgical incision 13 cm with striker zip dressing in place. No signs or systems of infection, blanchable redness to bilateral buttocks no open areas noted: left shin skin tear 4 cm with steri-strip, right shin skin tear 8 cm in width. Record review of the facility policy titled Skin Care and Prevention dated 2/17/23 revealed Every effort will be made by the facility to ensure that every resident that moves into the facility without a pressure injury does not develop a pressure injury unless the individuals clinical condition demonstrates the pressure injury was unavoidable. The facility will also ensure that necessary treatment is provided to promote healing, prevent infection, and prevent new sores from developing. Record Review of the facility policy titled Wound Care and Pressure Injury Treatment dated 4/16/24 revealed The facility will ensure that necessary treatment is provided to promote healing, prevent infection and prevent new sores from developing. Record Review of the facility policy titled Protocol: Prevention is the Key to Wound Care dated 2/23/23 revealed Prevention is the key to Wound Care. Complete a Braden scale upon admission, weekly, or with any change in condition including new wound. A resident with a BRADEN score of less than 15 will be considered at risk for pressure and breakdown. An Immediate Jeopardy was identified on 02/20/25 at 4:10 pm. The Administrator was notified of the Immediate Jeopardy on 02/20/2025 at 4:10 pm and the IJ template was provided. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted by the Administrator on 2/21/25 at 3:38 pm and is as follows: Plan of Removal for I J 2/20/2025 Corrective Action: All residents in the building will receive a head-to-toe skin assessment observed by a member of the Nurse Management Team, to be completed 2/21/2025. Any area of concerns will be addressed with pressure prevention interventions and/or orders will be obtained and implemented immediately by the charge nurse. Beginning on 2/21/2025, all new admissions/readmissions to Skilled Nursing or Long-Term Care will receive a head to toes skin assessment, while a member of the Nurse Management Team is present to observe. When any area of concern is noted, pressure prevention interventions and/or orders will be obtained and implemented immediately by the charge nurse. When a change in skin condition is identifies by a CNA during route care or peri care/bathing the change will be reported to the charge nurse, who will ensure pressure prevention interventions and/or orders will be obtained and implemented immediately. Identification of Others: All residents have the potential to be affected by this alleged deficient practice. Systemic Changes: Staff education will be provided to all nurses for proper skin assessments, wound care prevention, treatment protocols, documentation by exception, and importance of communication of resident concerns, to completed on 2/21/2025 or before next shift worked. CNA's will be educated related to Skin Integrity and Wounds, beginning 2/21/2025. All CNA's will receive education prior to next scheduled shift. Monitoring to Sustain Compliance: A member of the Nurse Management Team will continue to be present to observe head to toe skin assessments for new admissions/readmissions to Skilled Nursing or Long-Term Care, for a minimum of 30 days, to be completed on 3/31/2025. Head to toe skin assessments will be monitored by a member of the Nurse Management Team randomly for an additional 30 days, to be completed on 4/30/2025. The Wound Care Nurse or designee will continue to monitor to ensure that skin care preventative interventions are in place, treatments are performed, and skin is monitored for changes in condition. In a facility monitoring visit on 2/22/25 from 8:45 am to 11:30 am the following interviews were conducted to verify the facility completion of the plan of removal were conducted. The House Supervisor was interviewed and stated all the staff were in the process of being in serviced on documentation and assessing residents' skin during incontinent care, The ADM stated the skin assessments were completed but she had only in serviced 27 CNAs and nurses. She stated she had at least 60 more employees left to in-service. 13 CNAs were interviewed and stated they had been in serviced on pressure ulcers and documentation. 4 LVNS and a Nurse Supervisor were interviewed. All stated they had been in serviced on pressure ulcers and documentation. All staff interviewed could demonstrate compliance with facility policy and inservice recommendations. The ADM stated she would not complete the interviews until Monday 2/24/25. Record Reviews of the resident skin assessments did not reveal any further pressure ulcers not already being treated. In a facility monitoring visit of the night shift on 2/23/25 from 5:00 pm to 6:45 pm the following interviews were conducted to verify the facility completion of the plan of removal were conducted. The ADM stated the in servicing of staff would be completed on 2/24/25. 11 CNAs were interviewed and stated they had been in serviced on pressure ulcers and documentation. 5 LVNS were interviewed. All stated they had been in serviced on pressure ulcers and documentation. All staff interviewed could demonstrate compliance with facility policy and inservice recommendations. In a facility monitoring visit on 2/24/25 from 9:00 am to 10:50 am, the following interviews were conducted to verify the facility completion of the plan of removal were conducted. The ADM stated the in-services were completed with the exception of 4 staff who were either out of town or on FMLA. 14 CNAs and 8 LVNS were interviewed, and all stated they had been in serviced on pressure ulcers and documentation. All staff interviewed could demonstrate compliance with facility policy and inservice recommendations. The IJ was lifted on 2/24/25 at 10:50 am.While the IJ was removed on 02/24/2025, the facility remained out of compliance at a severity level of no actual harm with the potential for more harm than minimal harm that is not Immediate Jeopardy.

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 7 out of 8 resident snack refrigerators located in the residents dining rooms, reviewed for kitchen sanitation. 1. The facility failed to ensure food items were properly stored, labeled, and dated. 2. The facility failed to ensure refrigerators were free of expired foods, non-food items and staff items. 3. The facility failed to ensure cleanliness was maintained in the refrigerators. These failures could place residents who ate food served by the kitchen, and stored food in the resident refrigerators were at risk of food-borne illness. Findings include: North Side First Floor In an observation and interview on [DATE] at 8:25 am of the initial tour of the lower-level resident dining room on the North side called the North First Floor Dining there were 2 refrigerators in the dining room. The refrigerators were stainless steel and had freezers on the bottom portion of the refrigerator. There were no postings on the refrigerators and no cleaning sheets. Residents in the dining room eating breakfast and staff in the dining room assisting residents confirmed the refrigerators were for resident foods. In an observation on [DATE] at 8:36 am, of the resident refrigerators located on the North side Lower-Level Dining called the North First Floor Dining room the following was observed: In the freezer: 1. A Michelina frozen dinner, no residents name, no label or date. 2. A Thai Curry Chicken frozen dinner, no resident name, no label or date. 3. Frozen spicy beef dinner, no resident name, open to air, no label or date with an expiration date of [DATE]. 4. Assorted ice cream bars loose in the freezer, no label or date, no resident name, not in original box. 5. A Ziplock baggie with one breaded meat patty, no label or date, no resident name, not in original package. 6. Food spills and food crumbs were observed in the bottom of the freezer bin. South Side Second Floor In an observation and interview on [DATE] at 8:55 am of the initial tour of the upper -level resident dining room on the South side titled South Second Floor Dining there were 2 refrigerators in the dining room. The refrigerators were stainless steel and had freezers on the bottom portion of the refrigerator. There were no postings on the refrigerators and no cleaning sheets. Residents and staff in the dining room area confirmed the refrigerators were for resident foods. In an observation on [DATE] at 9:55 am of the resident refrigerators located on the South Second Floor Dining room the following was observed: In the refrigerator: 1. A sandwich, partially wrapped in torn foil with holes in the foil, no label or date, no resident name. 2. A slice of pumpkin pie no label or date, no resident name, not in original container. 3. A plastic grocery bag containing a bag of green fruit and a banana and empty plastic storage bowls, no resident name, no label or date. 4. A yeti soft sided lunch cooler, no label or date, no resident name. 5. A glass of thickened liquid, no resident name, no label or date 6. A plastic storage container that appeared to hold a noodle substance, no label or date, no resident name, a foul smell coming from the container. 7. A Dairy Queen cup of frozen blizzard type ice cream laying on its side in the bottom of the freezer, , no resident name, no lid or covering for the top of the blizzard, no date. South First Floor In an observation on [DATE] at 11:30 am, of the resident refrigerators located on the South First Floor Dining room the following was observed: 1. 1 red plastic container with fruit salad, no label or date, no resident name 2. A piece of cheesecake, no resident name, dated [DATE]. 3. There were crumbs on the shelves and food spills in the refrigerator. 4. An individual fruit salad in a cup from the kitchen, no label or date, no resident name. 5. In the freezer there was a package with one corn on the cobb, open to air, no label or date. There were crumbs and food spills in the bottom of the freezer. South Second Floor In an Observation and Interview on [DATE] at 9:15 am, of the South Second Floor refrigerator, DA J stated the resident refrigerators were for resident use only and staff were supposed to use the employee refrigerators in the breakroom. She stated she thought staff had used the resident refrigerators for their personal foods. She stated she did not know who was responsible for maintaining the refrigerators but thought it was housekeeping or nursing services. DA J stated of the half-wrapped sandwich wrapped in foil, that it should have a label, date and be covered completely. She stated she would throw it out. DAJ also took the pumpkin pie with no label or date and a bottle of Gatorade out of the refrigerator and threw them away. In an observation on [DATE] at 9:25 am of the South Second Floor refrigerator there was a cup of thickened liquid from the kitchen, no label or date, no resident name. The Dairy Queen Blizzard type ice cream was in the bottom of the freezer, on its side, no covering, no label or date, no resident name. North First Floor In an observation on [DATE] at 11:30 am of the North First Floor resident refrigerator the following was observed: 1. A package of opened partially used blood worms in the freezer with an expiration date of ,d+[DATE]. The package stated Not for Human Consumption. 2. A breaded meat patty in a Ziplock bag, no resident name, no label or date. 3. The refrigerator and freezer had food spills and crumbs on the shelves. South Second Floor In an observation on [DATE] at 2:10 pm, of the resident refrigerators located on the South Second Floor Dining room the refrigerator contained a glass of thickened liquid, no label or date, no resident name, and the Dairy Queen cup of ice cream, open to air, no label or date, no resident name lying on its side in the bottom of the freezer. North Second Floor In an observation on [DATE] at 3:07 pm of the resident refrigerators located on the North Second Floor Dining room the following was observed: In the refrigerator: 1. A package of turkey breast, no label or date, no resident name. 2. A bowl of fruit from a deli grocery store, no label or date, no resident name. 3. A plastic grocery bag containing a piece of pie dated ,d+[DATE], no resident name. 4. A frozen pizza, no resident name, no label or date. 5. A plastic storage container that appeared to hold a noodle substance, no label or date, no resident name, a foul smell coming from the container. In an observation on [DATE] at 2:00 pm, of the facility break room for employees revealed a black refrigerator in the locked breakroom that was labeled for staff use. In an interview on [DATE] at 3:15 pm, the ADM stated she believed the staff were using the resident refrigerators on the units. She stated the nursing staff were not supposed to use the resident refrigerators. She stated everything must be labeled, dated, and have the residents name on the food item. She stated if the food item did not have a name or date on it, it should be thrown out. The ADM stated the kitchen is responsible for cleaning the refrigerators. She stated the consequences of not labeling and dating foods would be foodborne illness. In an interview on [DATE] at 8:30 am the AD stated she had only one refrigerator used for activities, and it was locked all the time. She stated the residents know the refrigerators in the dining areas were for their use. She stated she thought housekeeping was in charge of cleaning the refrigerators but was not sure who was responsible to clean them. She confirmed all the other refrigerators on the ding area units were the resident refrigerators and were not supposed to be used by staff. In an interview on [DATE] at 8:35 am LVN I stated the refrigerators on the units were the resident refrigerators and were not for staff use. She stated there was a refrigerator in the employee breakroom for employees to use. She stated she was not sure who was responsible for cleaning the refrigerators but stated the cooks stock the refrigerators with snacks and juices for the residents' snacks and residents put food in the refrigerators for eating later. She stated when a resident puts food in the refrigerator the nursing staff were supposed assist the resident to label and date the food. She stated all foods should have the residents name and the date the food was put in the refrigerator. She stated a consequence of unlabeled, undated foods and expired foods would be a food borne illness. She stated she was not aware of the current condition of the refrigerator where food was uncovered or unlabeled and undated. In an interview and observation on [DATE] at 9:20 am Dietary Manager F stated the housekeepers clean the resident refrigerators on the units. He stated he was aware nursing staff frequently puts their foods in the resident refrigerators but were not supposed to. When told there were expired foods, foods were not labeled and dated, there were dirt, food spills and food crumbs he stated he was not aware of that. He stated the consequences of not keeping food refrigerators in order were food borne illness. He stated he was trained by the dietician in all areas of the kitchen, and he trained his staff in all aspects of the kitchen duties. He stated he had no cleaning sheets for the resident refrigerators. He stated he had no policies for the resident refrigerators. In an interview and observation on [DATE] at 9:40 am Housekeeper E stated the housekeepers do not clean the resident refrigerators on the unit. She stated she has never been told to clean the resident refrigerators. She stated the housekeepers do clean the staff refrigerator and pointed to the black refrigerator in the breakroom that the staff use. She stated she has never been told by her supervisor to clean the resident refrigerators. In an interview and observation on [DATE] at 9:40 am Housekeeper E stated the housekeepers do not clean the resident refrigerators on the unit. She stated the resident refrigerators were for resident foods only. She stated she did not know who was supposed to clean the resident refrigerators. She confirmed the black refrigerator in the break room was for employees. In an interview and observation on [DATE] at 9:48 am Housekeeping Supervisor F stated the housekeepers do not clean the resident refrigerators on the units. She stated the housekeepers have never been told to clean the resident's refrigerators. She stated no one had ever told her to clean the refrigerator but thought the kitchen was supposed to clean the refrigerators. She stated there was a problem with not labeling or dating foods and not putting resident's names on the food. She stated there was one activity refrigerator which is always locked, and she assumed the activity personnel clean that one. She stated she had no policies for cleaning. She stated residents could get food borne illnesses from expired and unlabeled undated foods. She stated the one refrigerator that is locked is the AD refrigerator for resident activities. She confirmed none of the refrigerators were labeled as to being the resident refrigerators, but everyone knew the refrigerators were for residents to use. In an interview on [DATE] at 8;30 am, the DM was asked for policies regarding such topics as resident refrigerators, discarding foods from the resident refrigerators, refrigerators on the units, employee food, labeling and dating, in and out procedures for storing foods, cleaning resident refrigerators in the dining room, policies for staff and residents for resident refrigerators. The DM stated he would look for these policies. In an interview on [DATE] at 9:20 am, the DM stated he could not locate any policies for the resident refrigerators. In an interview on [DATE] at 10:36 am, the ADM stated she did not have any policies for the resident refrigerators. In an interview on [DATE] at 2:09 pm, CNA G stated the CNAs are supposed to use the black refrigerator in the employee break room for their food storage. She stated she had been told not to use the refrigerators on the units as they are for the resident's food. She stated she had known of staff who had used the resident refrigerators for their personal food. She stated she had never been told the CNAs were responsible for cleaning the resident refrigerators. She stated she thought the kitchen staff were responsible to clean the resident refrigerators. She stated she had been told to label and date foods they put in the resident refrigerators. She stated both refrigerators on the east and west were resident refrigerators. Record review of the facility policy titled, Special Meal Arrangements and Guest Tray Policies, dated [DATE], revealed the following documentation, . Food may be brought to the facility by family and visitors. The facility is responsible for storing food brought in by family or visitors in a way that is separate and distinguishable from facility food. The facility is responsible for helping family and visitors understand safe food handling practices. Facility staff must use safe food handling practices. Record review of the facility policy titled Eating /Drinking in Food Service Areas , dated [DATE], revealed the following documentation, . The Food Service manager will encourage the use of employee break rooms for staff use. Record review of the facility policy titled Cleaning and Sanitation of Food Service Areas and Equipment dated [DATE], revealed the following documentation, . The Food Service Department will clean and sanitize the food service area and any equipment used daily and weekly by following the daily and weekly cleaning schedule provided by the Food Service Manager. The facility will follow proper cleaning procedures on all equipment used. Record review of the facility policy titled Food Storage, Food Safety in Display and Service , dated [DATE], revealed the following documentation, . While being stored, served . food shall be protected from potential contamination, including dust, insects, unclean equipment and utensils, unnecessary handling, coughs, and sneezes, Food will be stored in a clean covered container when not in use or preparation.

Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 residents (Resident #31, Resident #82, and Resident #240) reviewed for Medicare/Medicaid coverage. 1. The facility failed to ensure Resident #31, Resident #82, and Resident #240 were given a NOMNC (a notice that indicates when care is set to end from a home health agency, skilled nursing facility, comprehensive outpatient rehabilitation facility, or hospice) with information on how to appeal the decision when residents were discharged from skilled services prior to covered days being exhausted. 2. The facility failed to ensure Resident #31, Resident #82, and Resident #240 were given a SNF ABN (document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. These failures could place residents at risk of not being aware of their right to appeal the decision to end Medicare coverage for skilled services and/or changes to provided services. Findings Included: Record review of Resident #31's admission record dated 12/04/24 revealed an [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on 11/20/24 to an assisted living facility. She had diagnoses that included, but were not limited to, unspecified sequalae of unspecified cerebrovascular disease (the resultant symptoms of stroke, transient ischemic attack, aneurysm, or vascular malformation), chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), heart failure (heart muscle fails to pump blood as it should), and dysphagia (difficulty in swallowing). Resident #31's primary payer was Private Pay, and her second payer was Medicare A coinsurance from insurance. She was admitted from an acute care hospital, and her admission type was listed as short term. Record review of Resident #31's Admission MDS completed on 10/24/24 revealed the following: Section A: Resident #31's most recent Medicare stay started on 10/15/24. Section C: Resident #31 had a BIMS of 11 which indicated moderately impaired cognition. Section I: Resident #31's primary medical condition was Stroke. Record review of Resident #31's care plan revealed an initiation date of 10/31/24. The care plan noted Resident #31's normal social routine had been disrupted by admission to the SNU and she required assistance from staff with ADLs due to CVA. Resident #31 was at risk for injuries related to impaired balance and was to receive of skilled occupational and physical therapy five times a week for 30 days. Attempted interview on 12/05/24 at 09:11 AM, a voicemail message was left for Resident #31. The call was not returned. Attempted interview on 12/05/24 at 09:13 AM, a voicemail message was left for Resident #31's family member. The call was not returned. Record review of Resident #31's SNF Beneficiary Review form revealed Resident #31's Medicare Part A start date of 10/15/24 and the last covered day of Medicare Part A service was 11/15/24. In answer to the question How was the Medicare Part A Service Termination/Discharge determined? the IP checked the box for Other and added a handwritten note which reflected, Resident met Part A stay then moved to [name of assisted living facility] on 11/25/24. There were no answers to the following questions on the form: 1. Was a SNF ABN, Form CMS-10055 provided to the resident? 2. Was a NOMNC, Form CMS 10123 provided to the resident? Record review of Resident #82's admission record dated 12/04/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, other symptoms and signs involving the musculoskeletal system (affecting muscles, bones, joints and connective tissue), unspecified fall, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and muscle weakness. He was admitted from an acute care hospital and his admission type was Short Term. Resident #82 had Medicare Part A and B coverage and his primary payer was listed as Private Pay. Record review of Resident #82's Admission MDS completed on 11/11/24 revealed the following: Section A: Resident #82's most recent Medicare stay started on 10/31/24. Section C: Resident #82 had a BIMS of 15 which indicated intact cognition. Section I: Resident #82's primary medical condition was Medically Complex Conditions. Record review of Resident #82's care plan revealed an initiation date of 11/18/24. The care plan noted Resident #82's normal social routine had been disrupted by admission to the SNU and he required assistance from staff with ADLs due to his diagnoses. Resident #82 was at risk for injuries related to impaired balance and weakness and was to receive skilled occupational and physical therapy five times a week for 30 days. Record review of Resident #82's SNF Beneficiary Review form revealed Resident #82's Medicare Part A start date of 10/31/24 and the last covered day of Medicare Part A service was 11/27/24. In answer to the question How was the Medicare Part A Service Termination/Discharge determined? the IP checked the box for Other and added a handwritten note which reflected, Respite on 11/27/24 Respite still in the facility. Resident no longer making progress in SNU. The plan was to transition him to our LTC. There were no answers to the following questions on the form: 1. Was a SNF ABN, Form CMS-10055 provided to the resident? . 2. Was a NOMNC, Form CMS 10123 provided to the resident? During an interview on 12/05/24 at 08:57 AM the IP stated Resident #82 came into the facility on respite and was hesitant to give the facility his financial information to get Medicaid Pending in progress. She did not have an answer when asked if he would have wanted to appeal the decision to end his skilled care. During an interview on 12/05/24 at 09:21 AM Resident #82's family member stated the facility did not inform her or Resident #82 of the right to appeal the decision to end his skilled care. She stated private pay since skilled care ended, This $274.00 a day is gonna break us. We will be in the poor house. Record review of Resident #240's admission record dated 12/04/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, nondisplaced fracture of medial condyle of left tibia (broken left lower leg), osteoarthritis of knee (degenerative joint disease), acute chronic diastolic heart failure (heart muscle fails to pump blood as it should), and muscle weakness. Resident #240 was admitted from an acute care hospital and her primary payer was Private Pay. Her second payer was Medicare A coinsurance from insurance. Her admission type was Short Term. Record review of Resident #240's discharge MDS [her Admission MDS was requested from facility but was not provided] completed on 11/14/24 revealed the following: Section A: The MDS was a SNF Part A Discharge Assessment. Resident #240's most recent Medicare-covered stay started on 10/17/24 and ended on 11/08/24. Section C: Resident #240 had a BIMS of 11 which indicated moderately impaired cognition. Record review of Resident #240's care plan revealed an initiation date of 11/04/24. The care plan noted Resident #240's normal social routine had been disrupted by admission to the SNU and she required assistance from staff with ADLs due to her diagnoses. Resident #240 was at risk for injuries related to impaired balance and weakness and was to receive skilled occupational therapy five times a week for 360 days and physical therapy five times a week for 30 days. Record review of Resident #240's SNF Beneficiary Review form revealed Resident #240's Medicare Part A start date of 10/17/24 and the last covered day of Medicare Part A service was 11/08/24. In answer to the question How was the Medicare Part A Service Termination/Discharge determined? the IP checked the box for Other and added a handwritten note which reflected, Resident transitioned to LTC room [room number of Resident #240] (private pay) met part A stay then transitioned to our LTC. There were no answers to the following questions on the form: 1. Was a SNF ABN, Form CMS-10055 provided to the resident? . 2. Was a NOMNC, Form CMS 10123 provided to the resident? During an interview on 12/05/24 at 09:14 AM Resident #240's family member stated a facility staff member (he could not remember which one) told him he could appeal the decision to end Resident #240's skilled care but it would only extend care for 2-3 more days and there were a lot of hoops to jump through. He stated because of the 2-3-day extension and because he was receiving cancer treatments and his wife was in the hospital for a hip replacement he decided not to appeal. He stated, There is no doubt she (Resident #240) should have had longer (skilled care). Because she's 97 and they don't respond as fast (to treatment). We were just at a place were filling out forms was not an option, especially for just a few more days of services. During an interview on 12/05/24 at 08:57 AM the IP stated she was responsible for issuing NOMNCs and SNF ABN notices to residents. She stated she had not had to do any SNF ABN notices in the facility. She stated the facility became licensed for SNF in September of 2023. The IP stated she had not received any training on NOMNCs or SNF ABNs, but she worked closely with the Social Worker who was in charge of them at her last facility, so she was familiar with the process. When asked why Resident #31, Resident #82, and Resident #240 did not receive either notice she stated they did not need the notices because they transitioned to a lower level of care due to not needing skilled care any longer. The IP stated the three residents would not have needed to appeal the decisions to lower their care as it was a team decision made during team meetings so they would not have wanted to appeal. The IP stated none of the three residents exhausted their 100 days of skilled care but they could not receive skilled care for 100 days if they did not need it. During an interview on 12/05/24 at 08:57 AM the DON stated she was only partially familiar with NOMNCS and SNF ABNs. She stated, We get them for issues with insurance. If (the resident is) not progressing with goals, we get the information to discharge them from services. I know there is an appeal process. We give them (the residents) a heads up (that services are ending). The DON stated residents were told that they could appeal and if their benefits ran out before the appeal was approved, they would be responsible for the cost of care. She stated a possible negative outcome for residents not receiving the NOMNC and SNF ABN was they could miss out on more services. During an interview on 12/05/24 at 08:59 AM the ADM stated she did not know anything about NOMNCs or SNF ABNs. She stated the IP was responsible for both. During an interview on 12/05/24 at 10:36 AM the ADM stated the facility did not have policies addressing NOMNCs or SNF ABNs. She said, I looked high and low, and didn't find any.

Based on observation, interview and record review, the facility failed to ensure residents had the right to be informed in advance if the risks and benefits of proposed care, or treatment and treatment alternatives or treatment options and to chose the alternative or options he or she prefers for 5 of 19 residents (Resident #13, #15, #47, #70, and #75) and 5 residents interviewed during an anonymous interview reviewed for self-determination. The facility failed to ensure Resident #13, #15, #47, #70, and #75 and 5 anonymous residents received requested bedrails for 10 days or more after requested by the resident or family. This failure could cause residents to feel uncomfortable and disrespected leading to feeling of anxiety, anger, isolation, and deterioration in general health conditions. Findings include: Resident #13 Record review of Resident #13's clinical record revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), Alzheimer's (a progressive disease that destroys memory and other important mental functions), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), osteoarthritis(a type of arthritis that occurs when flexible tissue at the ends of bones wears down), chronic respiratory failure(a long-term condition that occurs when the body's respiratory system can't exchange oxygen and carbon dioxide properly), and muscle weakness (a lack of muscle strength). Record review of Resident #13's last MDS revealed a quarterly assessment completed on 9-1-2024 with a BIMS of 15 indicating he was cognitively intact, and he had a functionality of requiring substantial/maximal assistance with chair/bed-to-chair transfers and rolling left and right. Record review of the care plan with admitted [DATE] for Resident #13 revealed the following: Problem: [Resident #13] requires assistance from staff with performance of daily living and functional abilities related to HTN (hypertension-a condition in which the force of the blood against the artery walls is too high), DM (diabetes-a chronic condition that affects the way the body processes blood sugar (glucose), HLD (hyperlipidemia-a condition in which there are high levels of fat particles in the blood), Seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), and Intellectual Disabilities. - Revision on 12-7-2023 Interventions: [Resident #13] may use 1/2 rails for mobility, positioning, and comfort. - Revision 7-17-2023. Record review of Resident #13's Order Summary Report with Active Orders as of 12-5-2024 revealed no physician orders for side rails. During an interview on 12-03-2024 at 09:44 AM Resident #13 reported that he was very upset that his bedrails were removed. Resident #13 reported that he used his bedrails for everything, to include getting in and out of bed, moving around in bed, and making sure he stayed safe. Resident #13 reported that he was told state told the facility they had to be removed and he did not appreciate that. Resident #13 wanted it corrected immediately and the bedrails returned. Resident #13 reported that he requested his bedrails be returned the day they were removed. Resident #13 reported that he has talked with multiple staff about getting bedrails back and on several different occasions and that he was going to a care plan meeting at 10:00 AM this day and was going to bring it up again. Resident #15 Record review of Resident #15's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include CHF (a chronic condition in which the heart dose not pump blood as well as it should), morbid obesity (a disorder involving excessive body fat that increase the risk of health problems), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), polyneuropathy (malfunction of many peripheral nerves throughout the body), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), PVD (a circulatory condition in which narrowed blood vessels recue blood flow to the limbs), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record review of Resident #15's last MDS revealed a quarterly assessment completed on 11-5-2024 with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of being dependent with chair/bed-to-chair transfers and partial/moderate assistance with rolling left and right. Record review of the care plan with admitted [DATE] for Resident #15 revealed the following: Problem: [Resident #15] requires assistance from staff with performance of daily living and functional abilities related to CHF (congestive heart failure-a chronic condition in which the heart dose not pump blood as well as it should), AFIB (atrial fibrillation-an irregular, often rapid heart rate that commonly causes poor blood flow), HTN (hypertension-a condition in which the force of the blood against the artery walls is too high), OA (Osteoarthritis-a type of arthritis that occurs when flexible tissue at the ends of bones wears down), COPD chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), Epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and weakness. - Revision on 7-30-2024 Interventions: [Resident #15] may use 1/2 rails for mobility, positioning, and comfort. - Revision 8-2-2024. Record review of Resident #15's Order Summary Report with Active Orders as of 12-5-2024 revealed the following physician's order: May use side rails for comfort and to aid in positioning and mobility . Order dated 08-29-2024. During an interview on 12-03-24 at 09:37 AM Resident #15 was in her room in her wheelchair. Resident #15 reported that her bedrails had been recently removed and she would like them back. Resident #15 reported that she had reported this to staff the day the bedrails were removed and a couple of times since then but she had not received any response other than to report that state told the facility they could not have bedrails. Resident #15 reported she uses the bedrails to get in and out of bed safely. Resident #47 Record review of Resident #47's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), CAD (damage or disease in the hearts major blood vessels), chronic pain(persistent pain that can last years), macular degeneration (a degenerative condition affecting the central part of the retina), history of falls, and weakness. (a lack of muscle strength). Record review of Resident #47's last MDS revealed an annual assessment completed on 11-11-2024 with a BIMS of 13 indicating she was cognitively intact, and she had a functionality of requiring partial/moderate assistance with chair/bed-to-chair transfers. and rolling left and right. Record review of the care plan with admitted [DATE] for Resident #47 revealed there were no care plans related to the use of bedrails. Record review of Resident #47's Order Summary Report with Active Orders as of 12-5-2024 revealed no physician orders for side rails. During an interview on 12-3-2024 at 09:04 AM Resident #47 was in her room in her wheelchair. Resident #47's bed was made with her bedrails under her bed. This surveyor attempted to move them and noted that they were securely locked in place. Resident #47 reported that she was currently [AGE] years old, had been in the facility for several years and that she has always used bedrails but the facility removed them and she wants them back. Resident #47 reported that the facility had locked her bedrails down. Resident #47 reported that she told the facility staff that she wanted her bedrails back, but they told her that state would not allow them, and she could not have her bedrails back. Resident #47 reported that she requested her bedrails be returned the day they were removed and several times since. Resident #70 Record review of Resident #70's clinical record revealed an [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include Alzheimer's (a progressive disease that destroys memory and other important mental functions), muscle weakness (a lack of muscle strength), pain, fracture for femur (thigh bone), history of falling, and peripheral vascular disease (blood circulation disorder) Record review of Resident #70's last MDS revealed a quarterly assessment completed on 11-6-2024 with a BIMS of 4 indicating he was severely cognitively impaired, and he had a functionality of being dependent on staff for chair/bed-to-chair transfers and rolling left and right. Record review of the care plan with admitted [DATE] for Resident #70 revealed the following: Problem: [Resident #70] uses side rail for positioning. - Revision on 7-05-2024 Record review of Resident #70's Order Summary Report with Active Orders as of 12-4-2024 revealed no physician orders for side rails. During an interview on 12-3-2024 at 09:59 AM FM H reported that the care and facility had been good except for one issue. The facility removed Resident #70's bedrails approximately 2 weeks ago and told FM H that state would not let them have bedrails for Resident #70 to use. FM H reported that Resident #70 was a tall/big man and used his bedrails all the time to reposition and transfer in and out of bed. FM H reported that since they have removed the bedrails and tied them down Resident #70 has been unable to access them. FM H reported that she requested Resident #70's bedrails be returned the day they were removed. This surveyor did note that Resident #70 did have his bedrails on his bed, they were under the bed and locked in place with zip ties. The bedrails could not be moved. Resident #75 Record review of Resident #75's clinical record revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include rheumatoid arthritis(autoimmune inflammation of the joints), osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes or deficiency of calcium of vitamin D), pain in right shoulder, muscle wasting(the loss of muscle mass and strength due to disease, injury, or lack of use), unsteadiness on feet, and history of fractures. Record review of Resident #75's last MDS revealed a quarterly assessment completed on 9-1-2024 with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of requiring supervision or touching assistance with chair/bed-to-chair transfers and setup or clean-up assistance with rolling left and right. Record review of the care plan with admitted [DATE] for Resident #75 revealed the following: Problem: [Resident #75] uses side rail for position, mobility, and comfort. - Revision on 7-21-2024 Record review of Resident #75's Order Summary Report with Active Orders as of 12-5-2024 revealed no physician orders for side rails. During an interview on 12-3-2024 at 08:54 AM Resident #75 was noted in her room sitting in her recliner. She reported no issues with the facility other that they had removed her bedrails and she would like them back so she would be steadier with her transfers and she could move around in bed. Resident #75 reported that she requested the bedrails be returned the day the facility locked them down. During an anonymous interview with 5 residents on 12-4-2024 at 10:35 AM revealed all 5 residents reported that they were upset their bedrails were removed. One resident reported that the aides made her turn every two hours when in bed and that it hurts now because they had to push and pull her, and she had nothing that she could hold on to so she could assist them with turning or moving. Another resident stated he was mad about the bedrails and that they were still on the bed but underneath the bead and locked where he could not get them up. During an interview on 12-4-2024 at 01:40 PM the DON reported that the bedrails for residents had been used for mobility and positioning, that they (the DON and Managers) went through the facility on 9-22-2024 and zip tied all the bedrails down so resident would not be able to use them. The plan was to reassess each resident to see if they needed and could use the bedrails, obtain new consents and new orders for the bedrails, and add the bedrails to the resident's care plans. The DON reported that she herself and the managers would redo the evaluations and they did one on 12-3-2024 and planned to redo one today 12-4-2024. The DON reported that she has received multiple resident reports that they want the bedrails returned. The DON reported that she has 4-6 residents on each unit that have reported they want their bedrails back (this will be a total of 16-24 residents who have requested the return of their bedrails). The DON reported that they have notified all families by mail of the change in policy but did not say if they have discussed the policy with the residents. During an interview on 12-05-2024 at 08:21 AM the Administrator reported that during last year's survey the facility was cited for a bedrail deficiency, that her nurse managers, DON, general management, and herself decided to rewrite the bedrail policy. The Administrator had the management nursing staff evaluate each resident to determine who had bedrails and found out that all but 9 residents had some type of bedrail, so they decided to remove all the bedrails and restart to determine which residents really needed them. The Administrator reported that they sent a letter to the families of the residents who could not respond and provided the letter to residents who were oriented on 11-19-2024 and removed all the bedrails on 11-22-2024. The Administrator reported that each resident would be reevaluated and if they qualified, they would get their bedrails back and if they did not qualify but wanted something for mobility then they would get a U-Bar which was a small rail that is less than 1/8th the length of the resident's bed. The Administrator reported that they planned to completely phase out the bedrails and replace them with the U-Bar's unless ordered by physical therapy. The Administrator reported that the intent was to evaluate and replace all the bed rails this week but state had taken the time of the management nursing staff and they have been unable to address the bedrail situation. The Administrator reported that as of 12-5-2024 the facility had evaluated 5-6 residents for bedrails. The Administrator reported that they were aware of 20 resident who either the family or resident had specifically requested the bedrails be put back in place and that with the current residents that have been evaluated they have approximately 15 of those Residents left. The Administrator reported that she feels the residents do have the right to participate in their care and make decisions about their care. The administrator reported that she feels 10 days, or more is not too much time to wait to make sure that they address this issue with the bedrails correctly. The Administrator stated, We have 4 nurse managers that could do this in one day if they needed to but currently, they have other things that are taking up their time. We had plans to do them this week, but state walked in. During an interview on 12-05-2024 at 01:07 PM the Administrator reported they had completed 8 more resident evaluations for the use of bedrails, and she expected they would complete the other 7 by the end of the day to have all 20 residents who requested the return of the bedrails evaluated. The Administrator stated, two weeks is a little too long to wait to get something done but we just have had too many distractions. Record review of the facility provided Resident Rights undated, provided as part of the facility's admission process to each resident revealed the following: Residents of Texas nursing facilities have all the rights .granted by the Constitution and laws of the stated and the United States. They have the right to be free of . and reprisal exercising these rights as a citizen of the United States. Freedom of Choice You have the right to: -make your own choices regarding personal affairs, care, benefits, and services. Record review of the policy provided by the Administrator on 12-5-2024 at 08:41 AM revealed the following: Texas Administrative Code Resident Rights Fee Choice (3) participate in planning care and treatment or changes in care and treatment, to the extent practicable.

Based on observation, interview, and record review; the facility failed to store a controlled drug subject to abuse properly for 1 (the Rehabilitation and Long-Term Care medication room) of 8 medication storage areas reviewed for medication storage. The Rehabilitation and Long-Term Care medication room had a Schedule III narcotic stored improperly in the refrigerator. The facility's failure to ensure medications were stored properly could result in medication diversion leading to a resident not receiving ordered treatment affecting the resident's treatment and care leading to deterioration in their health. Findings included: During an observation on 12-4-2024 at 08:19 AM of the Rehabilitation and Long-Term Care medication room storage refrigerator revealed a container with Buprenorphine (a schedule III narcotic) 0.25mg (3 tablets present in the package) that were on the refrigerator shelf. The narcotic was not stored in the locked box provided on the refrigerator door. During an interview on 12-4-2024 at 08:32 AM LVN C reported that storing a narcotic in the refrigerator and not in a locked box could be a big issue. LVN C stated that any nurse could access the narcotic and the facility would not know since there was no log for the narcotic when it was in the refrigerator and not being used. LVN C reported that it would affect the residents care negatively because the medication would not be available to provide for the resident's treatment. During an interview on 12-4-2024 at 01:51 PM the DON reported that a refrigerated narcotic was supposed to be stored in a refrigerator in a locked box to comply with the double lock system. The DON reported that they have had a problem with not having a key to the lock box in the refrigerator in the medication room and she feels that someone put the narcotic in the refrigerator and probably forgot about it. The DON reported that they have called maintenance and it is supposed to be fixed today. The DON reported that leaving a narcotic medication stored incorrectly can result in that medication being stolen. 12-4-2024 at 2:49 PM requested policy for medication storage from Administrator with no response. 12-5-2024 at 08:19 AM reviewed provided policies and noted no policy for medication storage, requested from DON. 12-5-2024 at 1:10 PM requested policy for medication storage from Administrator with no response. Record review on 12-5-2024 at 09:28 AM of facility policy manual noted at 1-North Unit nurses station revealed no policy for medication/narcotic storage.

Based on observation, interview, and record review; the facility failed to provide pharmaceutical services that included the accurate acquiring and dispensing of all drugs and biologicals to meet the needs of each resident for 1 (Resident #75) of 19 residents reviewed for medication therapy and 2 (the Rehabilitation and Long-Term Care medication room and the 1-North medication room) of 8 medication storage areas reviewed for medication storage. -LVN B left the morning medications with Resident #75 unattended and did not verify if Resident #75 took the AM medications. -the Rehabilitation and Long-Term Care medication room had an expired OTC medication. -the 1-North medication room had an expired OTC medication. The facility's failure to ensure medications were dispensed in accordance with currently accepted professional principles which could result in a resident receiving or not receiving the correct medication therapy that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes. Findings include: Record review of Resident #75's clinical record revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include rheumatoid arthritis (autoimmune inflammation of the joints), osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes or deficiency of calcium of vitamin D), pain in right shoulder, muscle wasting (the loss of muscle mass and strength due to disease, injury, or lack of use), unsteadiness on feet, depressive episodes (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and traumatic hemorrhage of the cerebrum (bleeding in the brain tissue that occurs after a head injury). Record review of Resident #75's last MDS revealed a quarterly assessment completed on [DATE] with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of requiring supervision or touching assistance with most of her activities of daily living. Record review of the care plan with admitted [DATE] for Resident #75 revealed the following: Problem: [Resident #75] is at risk of aspiration, swallowing, and pain related to the medical diagnoses of GERD. Revision on: [DATE] -There was no care plan for self-administration of medications. Record review of Resident #75's Medication Administration Report revealed 12 p.o. medications were administered at 08:00 AM the morning of [DATE] to Resident #75 by LVN B. During an observation and interview on [DATE] at 08:54 AM revealed Resident #75 was noted in her room sitting in her recliner with her bedside table in front of her. Resident #75 was watching her TV and had finished her breakfast. On her bedside table was a medication cup with her morning pills. Noted ,d+[DATE] pills were present. Resident #75 reported that she was slow to swallow her pills because she often gets choked so they just leave them for me. During an interview on [DATE] at 11:31 AM LVN B reported that Resident #75 would often eat her meals in the dining room and sometimes eat them in her room. Either way, Resident #75 would often take a bite then take one of her pills. Resident #75 would usually take between ,d+[DATE] minutes to take her medications and due to that and the fact that Resident #75 was pretty much with it LVN B felt that Resident #75 was safe to take her medications independently. LVN B stated, I don't feel uncomfortable leaving her pills with her. LVN B reported that they have only one resident on Resident #75's hallway that wandered and that Resident #75 leaves her door shut and the resident that wanders would not enter a room when the door was shut. LVN B reported that she did not feel there would be any negative outcomes from letting Resident #75 take her medications independently and unsupervised. During an interview on [DATE] at 01:51 PM the DON reported that a nurse was expected take medications to a resident, make sure the resident took those medications, then document what medications were taken and when. The DON reported that a nurse leaving medications in a resident's room unattended was an issue. The DON reported the nurse would not know if that resident had taken those medications and if that resident was receiving the treatment the Resident was supposed to get. The DON reported that if that was to occur then the residents care could be affected in several ways especially if the resident intended for the medication did not take the medication or another resident were to get ahold of it. During an observation on [DATE] at 08:19 AM of the Rehabilitation and Long-Term Care medication room extra stock storage area of OTC medications available for use with LVN C revealed an unopened bottle of CertaVite that expired ,d+[DATE]. During an interview on [DATE] at 08:31 AM LVN C reported that an expired medication was an issue due to a staff member could administer the expired medication to a resident and the medication would not be as affective affecting the residents care and health. During an observation on [DATE] at 08:47 AM of the 1-North medication room extra stock storage area of OTC medications available for use with LVN D, noted was an unopened bottle of Meclizine that expired ,d+[DATE]. During an interview on [DATE] at 08:49 AM LVN D reported that using an expired medication can affect the way a medication acts and the way a resident reacts to that medication. LVN D reported that giving an expired medication would negatively affect a resident because they would not be receiving ordered treatment. During an interview on [DATE] at 01:51 PM the DON reported that nurses should check all medications for expirations and if the medication is expired then it should be disposed of properly. The DON reported that it was the floor nurses' job to check medications for expiration. The DON reported that giving an expired medication to a resident can result in it not being effective and the resident not receiving the needed care and treatment. Record Review of the facility provided policy titled Drug Administration Policy dated [DATE], revealed the following: Policy: Except for self-administration, drugs and biologicals are administer in accordance with physicians' orders only by the following: a. Physicians b. Licensed nursing personnel c. Medication aides; or d. Student nurse, student medication aides, or graduate nurses who are directly supervised by a licensed nurse . [DATE] at 2:49 PM requested policy for mediation storage from Administrator with no response. [DATE] at 08:19 AM reviewed provided policies and noted no policy for medication storage, requested from DON. [DATE] at 1:10 PM requested policy for medication storage from Administrator with no response. Record review on [DATE] at 09:28 AM of facility policy manual noted at 1-North Unit nurses station revealed no policy for medication/narcotic storage.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 2 (Resident #6 and Resident #79) of 5 residents reviewed for respiratory care. The facility failed to change nebulizer tubing for Resident #6 for 4 months. The facility failed to change nebulizer tubing for Resident #79 for 6 months. This failure could affect residents on respiratory therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition. Findings include: Resident #6 Record review of Resident #6's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), chronic bronchitis(productive cough for more than 3 months occurring within a span of 2 years), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), macular degeneration(a degenerative condition affecting the central part of the retina), and dependent on supplemental oxygen. Record review of Resident #6's clinical record revealed her last MDS was a quarterly completed 10-10-2024 listing her with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of requiring partial/moderate assistance with most of her activities of daily living. Record review of Resident #6's Order Summary Report with Active Orders as of 12-5-2024 revealed the following order: -Albuterol Sulfate Inhalation Nebulization Solution -1 vial inhale every 6 hours as needed for SOB four times daily as needed. - Start date 7-3-2024 -no orders were noted for respiratory equipment care to include the changing of tubing to masks. Record review of Resident #6's clinical record revealed a care plan with the admitted [DATE], last review date of 10-23-2024 revealed the following: Focus: Resident has impaired breathing and impaired oxygen absorption related to her medical diagnosis of COPD/Asthma. - Date initiated 1-3-2024. Revision 4-22-2024 Procedure: 7-3-2024 - Albuterol Sulfate Inhalation Nebulization Solution . 1 vial inhale orally every 6 hours as needed of for SOB 4 times daily as needed. - Initiation Date 7-24-2024. -No procedures were listed with care of any respiratory equipment to include changing of the nebulizer tubing or masks. During an observation on 12-03-2024 at 08:37 AM revealed Resident #6 was not in her room. There was an O2 concentrator next to the bed with water/hydration bottle dated 11-1-2024, no date on the O2 tubing or cannula. A nebulizer was on the bed with tubing dated 8-1-2024 and no date on nebulizer mask. The tubing appeared cloudy and the mask appeared to have small particles on the inside of the mask. There was no date on the nebulizer mask. During an observation and interview on 12-03-2024 at 09:16 AM Resident #6 was in her room in her wheelchair wearing her O2 at 2L/min via her nasal cannula. Resident #6's nebulizer was wrapped in a bag on her bedside dresser. Resident #6 reported that the staff have provided all her respiratory care to include her tubing, cannula, and mask changes and that she had no particular concerns. Resident #79 Record review of Resident #79's clinical record revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include obstructive sleep apnea (a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort), allergic rhinitis (a common condition that occurs when the immune system overreacts to allergens), dementia (a group of thinking and social symptoms that interferes with daily functioning), traumatic brain injury(an injury to the brain cause by an external force, such as a blow to the head or an object piercing the skull), anxiety (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dependence on other enabling machines and devices (such as a nebulizer and respiratory equipment). Record review of Resident #79's clinical record revealed his last MDS was an annual completed 11-9-2024 listing him with a BIMS of 10 indicating he was moderately cognitively impaired, and he had a functionality of being dependent on staff for assistance with most of his activities of daily living. Record review of Resident #79's Order Summary Report with Active Orders as of 12-5-2024 revealed the following order: -Albuterol Sulfate Inhalation Nebulization Solution -1 vial inhale orally via nebulizer every 8 hours as needed for cough. - Start date 3-16-2024 -no orders were noted for respiratory equipment care to include the changing of tubing to masks. Record review of Resident #79's clinical record revealed a care plan with the admitted [DATE], last review date of 5-22-2024 revealed the following: Focus: Resident has impaired breathing and impaired oxygen absorption. - Revision on 5-22-2024. Procedure: -No procedures were listed with care of any respiratory equipment to include changing of the nebulizer tubing or masks. During an observation on 12-03-24 at 09:25 AM Resident #79 was in his room sitting in his chair. When questioned he did not respond. Noted was a nebulizer on Resident #79's bedside dresser. The tubing on the nebulizer machine was dated 6-1-2024. The nebulizer tubing appeared cloudy with some discoloration and the mask was noted to have some small particles on the inner surface. There was no date on the nebulizer mask. During an observation and interview on 12-0424 at 11:34 AM this surveyor observed LVN B checked Resident #79's nebulizer tubing and found that the tubing had been removed with no replacement provided and then checked Resident #6's nebulizer tubing and found it dated 12-3-2024. When presented with the photo of Resident #6's tubing with it dated 8-1-2024 LVN B reported that the tubing was supposed to be changed each month according to the facility policy and that with Resident #6's tubing being left for 4 months and Resident #79's tubing being left for 6 months was too long and that not changing the tubing could place a resident at risk for infection especially respiratory infection and that would affect the residents health. During an interview on 12-04-2024 at 01:47 PM the DON reported that the policy for oxygen/nebulizer/respiratory equipment care was that they were changed monthly and assessed nightly. The secondary equipment such as tubing, cannula, and mask were changed monthly and checked nightly for defects or damage. The DON reported that if a nebulizer tubing that was left for 4 month or even 6 months was a problem, that they should be replaced monthly. The DON reported that if they were not replaced then the resident was placed at higher risk for infection and exposure to bacteria. During an interview on 12-5-2024 at 01:44 PM the Administrator reported that the facility did not have a policy that specifically listed when respiratory equipment care would be provided, just that it would be provided. Record review of the facility provided policy titled Respiratory Equipment Maintenance dated 12-27-2016, revealed the following: Policy: Respiratory maintenance will be performed in a standardized manner. Equipment will be changed out consistently to ensure clean, properly maintained equipment.

Based on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 19 residents (Resident #1) reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #1 who was listed for having a urinary catheter on her 9-3-2024 quarterly MDS. This failure to accurately assess a resident could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Finding include: Record review of Resident #1's face sheet printed 12-5-2024 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include cerebrovascular disease (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), Lupus (an illness that occurs when the immune system attacks health tissue and organs), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #1's quarterly MDS assessment started 9-3-2024 and completed 9-16-2024 revealed she had a BIMS of 7 indicating she was severely cognitively impaired, and she had a functionality of being dependent on staff for most of her adl's and activities. Record review of Section H, Bladder and Bowel, H0100 Appliances-Resident #1 was marked as having an Indwelling Catheter. Record review of Resident #1's Order Summary Report with active orders from 11-10-2022 to 12-5-2024 revealed no orders for an indwelling catheter or for indwelling catheter care. Record review of Resident #1's care plan with admitted [DATE] with last revision on 9-16-2024 revealed no care plans for an indwelling catheter or indwelling catheter care. During an observation on 12-3-2024 at 08:56 AM revealed Resident #1 was in her bed with a pillow under her right arm for positioning. Resident #1 was unable to respond to questions appropriately. Resident #1 was noted to not not have an indwelling catheter present. During an interview on 12-4-2024 at 01:15 PM MDS Coordinator A verified that Resident #1 did not have and has not had an indwelling catheter. MDS Coordinator A reviewed the 9-3-2023 Quarterly MDS for Resident #1 and reported that it was marked as Resident #1 having an indwelling catheter and that the MDS was marked incorrectly. MDS Coordinator A stated, I think someone marked it by accident. MDS Coordinator A then checked Resident #1's chart, orders, and care plans, MDS Coordinator A found no information that Resident #1 had a catheter. MDS Coordinator A reported that if a MDS was marked incorrectly the facility could lose money and the residents could be affected in that that way (they may not receive some services or supplies because the facility could not afford it) and it could be considered fraud if a staff member was marking the MDS with information on purpose. MDS Coordinator A reported that the facility used the RAI manual to complete all MDS's. During an interview on 12-4-2024 at 01:49 PM the DON reported that an MDS should accurately reflect a resident's condition and that if the MDS did not reflect the residents condition it was a problem and could affect reimbursement, billing, and could be considered fraud. Record review of the facility provided policy titled MDS Assessment Policy dated 8-29-2017, revealed the following: Policy: The assessment will accurately reflect the resident's current status at the time of the assessment. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023 revealed the following: SECTION H: BLADDER AND BOWEL H0100: Appliances Steps for Assessment 1. Examine the resident to note the presence of any urinary or bowel appliances. 2. Review the medical record, including bladder and bowel records, for documentation of current or past use of urinary or bowel appliances. Coding Instructions Check next to each appliance that was used at any time in the past 7 days. Select none of the above if none of the appliances A-D were used in the past 7 days. o H0100A, indwelling catheter (including suprapubic catheter and nephrostomy tube)

Based on interview and record review, the facility failed to maintain complete, accurate, readily accessible, and systemically organized records for 1 (Resident #1) of 8 residents reviewed for medical records. The facility failed to document the fall risk evaluation for Resident #1's history of falls within the last 90 days. This failure could place all residents at risk of not receiving appropriate care through inadequate documentation possibly resulting in deterioration in condition, exacerbation of disease process, and increased risk of harm or injury. Finding include: Record review of Resident #1's medical record revealed an [AGE] year-old-female admitted to the facility on [DATE]. Resident #1's current diagnoses include muscle weakness, history of falling, insomnia, unspecified dementia, unspecified severity, with other behavioral disturbance, hallucination, long term use of anticoagulants. Resident #1's last MDS, dated [DATE] was a quarterly with a BIMS of 13 indicating Resident #1 is cognitively intact. Resident #1 had a functionality of total dependency with mobility tasks while needing partial/moderate assistance with other self-care areas. Further record review of Resident #1's nurse's notes (NN) revealed that a fall risk evaluation dated 01/08/2024 stated the resident slid out of her raising lift recliner that resulted in a bruise to the left hip, no other injury noted. Fall Risk evaluation noted 1-2 falls in past 3 months. Record review of a NN note dated 02/16/2024 stated that Resident #1 was trying to toilet herself and slid from the bed, no injury s/t this fall, fall risk evaluation stated no Hx of falls in the last 3 months. Record review of a NN note dated 03/16/2024 stated that Resident #1 had a fall when she rolled out of her bed, resident hit her head on the floor, laceration to forehead and transfer to ER was performed. Fall risk evaluation stated no Hx of falls in the last 3 months. Record review of a NN note dated 03/17/2024 stated that Resident #1 received 3 stitches at local ER, no other injury noted. Record review of Resident 1's care plan reveals that resident is at risk for falls s/t to Resident 1's in ability to transfer alone. Observation and interview on 04/02/2024 at 11:11am with Resident #1 was on TBP for COVID, Resident #1 was lying in bed in a green night gown under her blankets. The left side of Resident #1's face was slightly bruised with bruising in different stages of healing. Resident did have a laceration to the left side of her forehead and was healing stages, no signs of infection present at site. Resident #1 was able to recall the night that she fell . She stated that she was lying in bed watching a ball game and was close to the edge of the bed. She stated that she went to push herself further back into the bed and just toppled right off the side of the bed. Resident #1 stated that staff came quickly to assist her and sent her to the ER very quickly since she hit her head and was bleeding a lot. No further concerns were voiced by Resident #1. Interview on 04/02/2024 at 12:49pm DON was asked why Resident #1's fall assessments after her falls in February and March indicated that the resident has had no falls in the last 3 months, when in fact she had. DON stated that she would get the nurse's contact information that performed those evaluations for the resident in question. Interview on 04/02/2024 at 1:55pm LVN A stated that she just didn't recall that the resident had fallen in January and that the assessment was made in error. LVN A stated that a negative outcome of not filling out the assessment correctly would be that there just isn't the right documentation for it. Interview on 04/02/2024 at 2:58pm LVN B stated that this was the first time in this building that she was filling out the assessment. LVN B was asked what a negative outcome would be with not filling out the assessment correctly. LVN B stated The next person that looked it up will have the incorrect information as well. Interview on 04/02/2024 at 4:31pm DON stated that a negative outcome to not having the correct documentation on a fall risk evaluation is that the next team member to come in would not have accurate information. Record review of facility provided policy titled Electronic Health Record, dated 06/07/2023, revealed the following: The purpose of the E.H.R. is to provide a basis for planning resident care as well as documenting the provision of such care and the outcomes relating to the evaluation, treatment, and changes in condition noted. Indiscriminate use of addenda, amendments, corrections, or deletions must be avoided. All reasonable attempts must be made by facility staff to assure documentation is accurate and complete prior to signing and saving the entries in the E.H.R. This facility recognizes the requirements of clinical providers to edit electronic health information in ta functional manner and protect the integrity of the E.H.R. simultaneously. In order to accommodate the needed functions, it is essential to define some terms.

Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure stored food was properly labeled, dated, and stored. These failures placed all residents who ate food served by the kitchen at risk of food-borne illness. Findings included: An observation of the facility walk-in cooler on 10/23/23 at 8:07AM revealed: 2 watermelons, no date received. 1 Food Service box of head of Romaine lettuce; open to air; no date. 2 8-count packages of pancakes; no label; no date. 1 6-count box of thawed pork tenderloin; no label; no date. 2 boxes, 24-count each, blueberry muffins, no label; no date. 3 thawed briskets; no label; no date. 2 13-ounce bottles of mint flavoring; no date. An observation of the dry pantry on 10/23/23 at 8:33AM revealed: 3 red potatoes laying on the floor of the pantry. 1 50-pound box of red potatoes; sitting on floor; open; no date. 1 50-pound box of white potatoes; sitting on floor; open; no date. 3 12-count packages of hot dog buns, expiration date 9/29/23. 2 12-count packages of hot dog buns, expiration date 10/17/23. An observation of the freezer on 10/23/23 at 8:51AM revealed: 7 1/2 Food Service bags of French fries, no date. 1 Food Service bag of tater tots; open to air; no date. 1 box 12-count frozen fudge bar treats; no date. 1 Food Service bag of cauliflower bites; open to air; no date. In an interview on 10/23/23 at 9:18AM, the Dietary Supervisor stated all food should be labeled and dated; there should be no bags of fresh or frozen food, open to air. The DS stated foods should be labeled and dated as soon as they come in or are taken out of their box. The DS stated all kitchen staff know they should secure foods and/or date foods when storing. The DS stated that residents could become sick if these standards are not followed. Record review of the facility's policy entitled Food Storage, Food Safety in Display and Service Policy with a revised date of 1/16/17, documented: The receiving date is written on the top of all food cases or containers. All food in its original containers, will have the expiration date written on it. Record review of the USDA food Code dated 2022, revealed, in part: 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakable recognize, such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3-202.15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.

Based on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail for 7 (Residents #4, #6, #10, #17, #19, #23, and #61) of 18 residents reviewed for bed rails. The facility placed bed rails on the beds of Residents #4, #6, #10, #17, #19, #23, and #61 on the day the residents were admitted without attempting other interventions first. This failure could place residents at risk of entrapment or injury due to bed rails. Finding included: Record review of Resident #4's face sheet dated 10/24/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), hypertensive heart disease (heart problems that occur because of high blood pressure), and chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #4's care plan dated 09/13/23 revealed a focus area indicating Resident #4 was at risk for impaired skin integrity. One of the interventions related to this focus area was the use of side rails for positioning/support and/or comfort. This intervention had an initiation date of 09/01/23. The care plan revealed a second focus area which stated, [Resident #4] requires assistance from staff with performance of daily living . One of the interventions related to this focus area was, [Resident #4] may use 1/2 rails for positioning, mobility and/or comfort. Record review of Resident #4's Admission MDS completed on 09/12/23 revealed a BIMS of 13 which indicated intact cognition. Section G of the MDS revealed Resident #4 required extensive assistance by one to two staff members across all ADLs. Record review of Resident #4's active orders dated 10/24/23 revealed no order for side rails. Record review of Resident #4's, Informed Consent for use of Side Rail revealed in part: The interdisciplinary Team along with your physician has determined that a side rail is appropriate. The facility has assessed and determined that side rails will promote bed mobility and independence or individual resident has stated a preference to have side rails in place. The form contained a graph with alternatives to bed rails that had been Attempted but Failed or were Considered Inappropriate. Low bed, frequent staff monitoring, assisted toileting, and reminders to use call light had been checked as Attempted but Failed. Resident #4's name and room number were listed at the top of page one. Page two of the form contained two signature lines. The first stated The RISKS and BENEFITS of side rails have been explained to me. I understand and I consent to the use of side rails. This signature line was signed by Resident #4's POA and dated 08/31/23. The second signature line stated, This Informed Consent for use of Side Rails was read to the legal representative with understanding and verbal consent for use of side rails given. This signature line had a place for the nurse to sign and indicate who gave consent on what date at what time. This line was unsigned. Record review of Resident #4's Bed Rail Assessment revealed Resident #4 was non-ambulatory, had displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed, had difficulty with balance or poor trunk control, and expressed a desire to have Side Rails/Assist Bar for safety and/or comfort. This form was signed by Resident #4's POA and an RN from the facility and dated 08/31/23. Record review of Resident #6's face sheet dated 10/25/23 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, fracture of neck, fracture of arm, fracture of leg, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), and senile degeneration of the brain (a state of mental, emotional, and social deterioration resulting primarily from degeneration of the brain in old age). Record review of Resident #6's care plan dated 10/04/23 revealed a focus area of [Resident #6] requires assistance from staff with performance of daily living related to self care deficit . One of the interventions related to this focus area was, [Resident #6] may use 1/2 rails for mobility, positioning, and comfort. This intervention had an initiation date of 03/14/23. The care plan revealed another focus area of [Resident #6] is at risk for impaired skin integrity related to impaired mobility . One of the interventions related to this focus area was, Side rails for positioning/support and/or comfort. This intervention had an initiation date of 03/14/23. Record review of Resident #6's quarterly MDS completed on 10/04/23 revealed a BIMS of 3 which indicated severely impaired cognition. Section GG of the MDS revealed Resident #6 was dependent across all ADLs except for eating where she required partial to moderate assistance. Record review of Resident #6's active orders dated 10/25/23 revealed an order for Side rails in use for positioning, mobility and/or comfort. The order date was 03/13/23. Record review of Resident #6's, Informed Consent for use of Side Rail revealed in part: The interdisciplinary Team along with your physician has determined that a side rail is appropriate. The facility has assessed and determined that side rails will promote bed mobility and independence or individual resident has stated a preference to have side rails in place. The form contained a graph with alternatives to bed rails that had been Attempted but Failed or were Considered Inappropriate. The options of low bed, frequent staff monitoring, assisted toileting, and reminders to use call light had been checked as Attempted but Failed. Resident #6's name and room number were listed at the top of page one. Page two of the form contained two signature lines. The first stated The RISKS and BENEFITS of side rails have been explained to me. I understand and I consent to the use of side rails. This signature line was blank. The second signature line stated, This Informed Consent for use of Side Rails was read to the legal representative with understanding and verbal consent for use of side rails given by [Resident #6's POA] date 03/13/23 time 1100 [11 AM] This signature line had a place for the nurse to sign and was signed by a facility nurse. Record review of Resident #6's Bed Rail Assessment revealed Resident #6 was non-ambulatory, had fluctuation in her level of consciousness, had a history of fall, displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed, had difficulty with balance or poor trunk control, and expressed a desire to have Side Rails/Assist Bar for safety and/or comfort. This form was signed by Resident #6's POA and an LVN from the facility and dated 03/13/23. Record review of Resident #10's face sheet dated 10/24/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, generalized osteoarthritis (degenerative joint disease), hypertension (high blood pressure), and repeated falls. Record review of Resident #10's care plan dated 09/13/23 revealed a focus area indicating Resident #10 was at risk for impaired skin integrity. One of the interventions related to this focus area was the use of side rails for positioning/support and/or comfort. The care plan revealed a second focus area which stated, [Resident #10] requires assistance from staff with performance of daily living . One of the interventions related to this focus area was, [Resident #10] may use 1/2 rails for mobility, positioning, and comfort. Record review of Resident #10's Significant Change MDS completed on 09/11/23 revealed a BIMS of 12 which indicated moderately impaired cognition. Section G of the MDS revealed Resident #10 required extensive assistance by one staff member for bed mobility, transfer, locomotion on unit, locomotion off unit, dressing, and toilet use. Resident #10 required supervision by one staff member for walking in her room, walking in the corridor, eating, and personal hygiene. Record review of Resident #10's active orders dated 10/24/23 revealed an order for Side rails for positioning, comfort and mobility with an order date of 11/16/22. Record review of Resident #10's, Informed Consent for use of Side Rail revealed in part: The interdisciplinary Team along with your physician has determined that a side rail is appropriate. The facility has assessed and determined that side rails will promote bed mobility and independence or individual resident has stated a preference to have side rails in place. The form contained a graph with alternatives to bed rails that had been Attempted but Failed or were Considered Inappropriate. No options were checked on the form. Resident #10's name and room number were listed at the top of page one. Page two of the form contained two signature lines. The first stated The RISKS and BENEFITS of side rails have been explained to me. I understand and I consent to the use of side rails. This signature line was signed by Resident #10 and dated 01/28/20. The second signature line stated, This Informed Consent for use of Side Rails was read to the legal representative with understanding and verbal consent for use of side rails given. This signature line had a place for the nurse to sign and indicate who gave consent on what date at what time. This line contained only the nurse's signature and was dated 01/28/20. Record review of Resident #10's Bed Rail Assessment revealed Resident #10 was non-ambulatory, had a fluctuating level of consciousness, had alteration in safety awareness due to cognitive decline, had a history of falls, had difficulty with balance or poor trunk control, and expressed a desire to have Side Rails/Assist Bar for safety and/or comfort. This form was signed by Resident #10's family member and an RN from the facility and dated 09/06/23. Record review of Resident #17's face sheet dated 10/24/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, paraplegia (impairment in motor or sensory function of the lower extremities), hypertension (high blood pressure), and age-related physical debility. Record review of Resident #17's care plan dated 10/17/23 revealed a focus area indicating Resident #17 required assistance from staff with Functional Abilities and performance of daily living related to . limited mobility. One of the interventions related to this focus area was, [Resident #17] may use 1/2 rails for mobility, positioning, and comfort. Record review of Resident #17's Quarterly MDS completed on 07/17/23 revealed a BIMS of 99 which indicated severely impaired cognition. Section G of the MDS revealed Resident #17 required extensive assistance by one to two staff members for bed mobility, locomotion, dressing, and personal hygiene. She was totally dependent on two staff members for transfer and toilet use and required set up help only for eating. Record review of Resident #17's active orders dated 10/24/23 revealed an order of, Side rails in use for positioning, mobility and/or comfort with an order date of 11/22/22. Record review of Resident #17's, Informed Consent for use of Side Rail revealed in part: The interdisciplinary Team along with your physician has determined that a side rail is appropriate. The facility has assessed and determined that side rails will promote bed mobility and independence or individual resident has stated a preference to have side rails in place. The form contained a graph with alternatives to bed rails that had been Attempted but Failed or were Considered Inappropriate. Low bed, frequent staff monitoring, assisted toileting, and reminders to use call light had been checked as Attempted but Failed. Resident #17's name and room number were listed at the top of page one. Page two of the form contained two signature lines. The first stated The RISKS and BENEFITS of side rails have been explained to me. I understand and I consent to the use of side rails. This signature line was signed by Resident #17's family member and dated 04/05/21. The second signature line stated, This Informed Consent for use of Side Rails was read to the legal representative with understanding and verbal consent for use of side rails given. This signature line had a place for the nurse to sign and indicate Resident #17's family member gave consent on 04/05/21 at 16:30 [04:30 PM]. This line was signed by a nurse. Record review of Resident #17's Bed Rail Assessment revealed Resident #17 was non-ambulatory, had fluctuation of consciousness, had alteration in safety awareness due to cognitive decline, had displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed, had difficulty with balance or poor trunk control, was visually challenged, and expressed a desire to have Side Rails/Assist Bar for safety and/or comfort. This form was signed by Resident #17 and an LVN from the facility and dated 10/08/23. Record review of Resident #19's face sheet dated 10/24/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), hypertension (high blood pressure), and generalized muscle weakness. Record review of Resident #19's care plan dated 10/11/23 revealed a focus area of [Resident #19] is at risk for impaired skin integrity related to limited mobility. One of the interventions related to this focus area was, Side rails for positioning/support and/or comfort. A second focus area revealed, [Resident #19] requires assistance from staff with performance of daily living . One of the interventions for this focus area was, [Resident #19] may use 1/2 rails for mobility, positioning, and comfort. Record review of Resident #19's Quarterly MDS completed on 10/10/23 revealed a BIMS of 15 which indicated intact cognition. Section GG of the MDS revealed Resident #19 was independent across all ADLs except for upper body dressing where she required partial assistance. Section P of the MDS coded Resident #19's bed rail as a restraint used less than daily. Record review of Resident #19's active orders dated 10/24/23 revealed an order of, Side rails in use for positioning, mobility and/or comfort with a date of 11/23/22. Record review of Resident #19's, Informed Consent for use of Side Rail revealed in part: The interdisciplinary Team along with your physician has determined that a side rail is appropriate. The facility has assessed and determined that side rails will promote bed mobility and independence or individual resident has stated a preference to have side rails in place. The form contained a graph with alternatives to bed rails that had been Attempted but Failed or were Considered Inappropriate. The options of low bed, frequent staff monitoring, assisted toileting, assistive device at bedside and reminders to use call light had been checked as Attempted but Failed. The option floor mats had been checked as Considered Inappropriate. Resident #19's name and room number were listed at the top of page one. Page two of the form contained two signature lines. The first stated The RISKS and BENEFITS of side rails have been explained to me. I understand and I consent to the use of side rails. This signature line was signed by Resident #19's POA and dated 03/31/22. The second signature line stated, This Informed Consent for use of Side Rails was read to the legal representative with understanding and verbal consent for use of side rails given. This signature line had a place for the nurse to sign and indicate who gave consent on what date at what time. This line was signed by a nurse and dated 03/31/23. Record review of Resident #19's Bed Rail Assessment revealed Resident #19 had expressed a desire to have Side Rails/Assist Bar for safety and/or comfort. This form was signed by Resident #19 and an LVN from the facility and dated 10/03/23. Record review of Resident #23's face sheet dated 10/24/23 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, psoriatic arthritis mutilans (an inflammatory illness that results in stiff joints, joint pain, and ultimately bone loss), Raynaud's syndrome (a medical condition that affects the small arteries in your fingers and toes causing a reduction in blood flow), age-related cognitive decline, and venous insufficiency (condition in which the flow of blood through the veins is blocked, causing blood to pool in the legs). Record review of Resident #23's care plan dated 08/08/23 revealed a focus area of, [Resident #23] requires assistance from staff with performance of daily living . One of the interventions related to this focus area was,[Resident #23] may use 1/2 rails for mobility, positioning, and comfort. Record review of Resident #23's Quarterly MDS completed on 08/07/23 revealed a BIMS of 15 which indicated intact cognition. Section G of the MDS revealed Resident #23 required extensive assistance by one to two staff members across all ADLs except for eating where she required set up help and supervision only. Record review of Resident #23's active orders dated 10/24/23 revealed an order of, Side rails in use for positioning, mobility and/or comfort. The order was dated 11/22/22. Record review of Resident #23's, Informed Consent for use of Side Rail revealed in part: The interdisciplinary Team along with your physician has determined that a side rail is appropriate. The facility has assessed and determined that side rails will promote bed mobility and independence or individual resident has stated a preference to have side rails in place. The form contained a graph with alternatives to bed rails that had been Attempted but Failed or were Considered Inappropriate. The options of low bed, frequent staff monitoring, and reminders to use call light had been checked as Attempted but Failed. Resident #23's name and room number were listed at the top of page one. Page two of the form contained two signature lines. The first stated The RISKS and BENEFITS of side rails have been explained to me. I understand and I consent to the use of side rails. This signature line was signed by Resident #23's family member and dated 07/14/20. The second signature line stated, This Informed Consent for use of Side Rails was read to the legal representative with understanding and verbal consent for use of side rails given. This signature line had a place for the nurse to sign and indicate who gave consent on what date at what time. This line was signed by a nurse and dated 07/14/20. Record review of Resident #23's Comprehensive Assessment revealed Resident #23 requested side rails and preferred for the rails to be raised when she was in bed. Record review of Resident #61's face sheet dated 10/24/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), paroxysmal atrial fibrillation (irregular heartbeat), congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), hypertension (high blood pressure) and a history of falling. Record review of Resident #61's care plan dated 10/17/23 revealed a focus area which stated, [Resident #61] requires assistance from staff with performance of daily living . One of the interventions related to this focus area was, [Resident #61] may use 1/2 rails for mobility, positioning, and comfort. This intervention had an initiation date of 01/04/23. The care plan revealed another focus area of, [Resident #61] needs routine licensed services . One of the interventions related to this focus area stated, Requires side rails for mobility and comfort. A third focus area revealed, [Resident #61] is at risk for impaired skin integrity related to impaired mobility and incontinence. One of the interventions related to this focus area was, Side rails for positioning/support and/or comfort. Record review of Resident #61's Quarterly MDS completed on 10/17/23 revealed Resident #61 had moderately impaired cognitive skills for daily decision making and a short and long-term memory problem. Section GG of the MDS revealed Resident #61 was dependent on staff for toileting, bathing, lower body dressing, putting on and taking off footwear, personal hygiene, transfers, and bed mobility. Resident #61 needed partial assistance for oral hygiene and upper body dressing and was independent in eating. Section P of the MDS coded Resident #61's bed rail as a restraint used less than daily. Record review of Resident #61's active orders dated 10/24/23 revealed and order for side rails for mobility, positioning, and comfort with an order date of 01/03/23. Record review of Resident #61's, Informed Consent for use of Side Rail revealed in part: The interdisciplinary Team along with your physician has determined that a side rail is appropriate. The facility has assessed and determined that side rails will promote bed mobility and independence or individual resident has stated a preference to have side rails in place. The form contained a graph with alternatives to bed rails that had been Attempted but Failed or were Considered Inappropriate. Low bed, frequent staff monitoring, assisted toileting, and reminders to use call light had been checked as Attempted but Failed. Resident #61's name and room number were listed at the top of page one. Page two of the form contained two signature lines. The first stated The RISKS and BENEFITS of side rails have been explained to me. I understand and I consent to the use of side rails. This signature line was illegibly signed and dated 01/03/23. The second signature line stated, This Informed Consent for use of Side Rails was read to the legal representative with understanding and verbal consent for use of side rails given. This signature line had a place for the nurse to sign and indicate who gave consent on what date at what time. This line was signed by a facility nurse and the areas for who gave consent and what day at what time contained the same nurse's name, 01/03/23, and 11:30 a.m. respectively. Record review of Resident #61's Bed Rail Assessment revealed Resident #61 was non-ambulatory, had fluctuation in level of consciousness, had alteration in safety awareness due to cognitive decline, displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed, and expressed a desire to have Side Rails/Assist Bar for safety and/or comfort. This form was signed by Resident #61's family member and an LVN from the facility and dated 10/12/23. During an observation on 10/23/23 at 09:04 AM Resident #6's bed had bed rails up on both sides of the top half of the bed. During an observation on 10/23/23 at 09:24 AM Resident #23's bed had bed rails up on both sides of the top half of the bed. During an observation on 10/23/23 at 11:12 AM Resident #4 was in bed with bed rails up on both sides of the top half of her bed. During an observation and interview on 10/23/23 at 12:38 PM Resident #19 was in her room sitting in her w/c next to her bed. She had bed rails up on both sides of the top half of her bed. She stated she used the bed rails to position herself in bed. During an observation and interview on 10/23/23 at 02:24 PM Resident #6 was laying in her bed on her back under a blanket. The bed was in the lowest position and fall mats were on either side of the bed. Bed rails were up on both sides of the top of the bed. When asked if she used her bed rails, Resident #6 stated, That's my bed. When asked again if she used her bed rails, Resident #6 said, You can have it. During an observation on 10/23/23 at 02:35 PM Resident #61 was in her bed with bed at lowest position and bed rails up on both sides of the top of her bed. When asked if she would be able to put the bed rails down if she needed to she said she could if she had the strength to do it but she did not feel like she had the strength at that time. During an observation and interview on 10/23/23 at 02:43 PM Resident # 10 was lying in bed with bed rails up on both sides of the bed. Resident #10 stated she loved the bed rails because they helped her to feel secure. During an observation on 10/24/23 at 09:43 AM Resident #6 was lying in bed. Bed was in lowest position and bed rails were up on both sides of the top half of the bed. During an observation on 10/24/23 at 09:46 AM Resident #19 was asleep in her bed with bed rails up on both sides of the top half of the bed. During an observation on 10/24/23 at 11:08 AM Resident #17 was receiving catheter care in her bed with bed rails upright on both sides of the top half of the bed. Resident #17 used the rails to help herself turn from side to side. During an observation on 10/24/23 at 11:40 AM Resident #17 was seated in her w/c next to her bed. Bed rails were up on both sides of the top half of the bed. During an observation and interview on 10/25/23 at 08:14 AM Resident #19 was sitting in her w/c next to her made bed. The bed rail on the right side of her bed was still up but the left side was down. Resident #19 stated she used her bed rails every day and she was able to move them up and down as desired. She said, In fact, this morning I put that one down [gesturing to the left side bed rail]. During an observation on 10/25/23 at 08:16 AM Resident #17 was asleep in her bed and bed rails were up on both sides of the top half of her bed. During an interview on 10/25/23 at 09:38 AM LVN A stated she had worked for the facility for [AGE] years. She stated nurses were responsible for filling out bed rail consent forms if we either get a new resident or they have the criteria for bed rails. When asked how the interventions on the consent form were attempted but failed the same day the resident was admitted she said, I guess there is no way we tried them unless the family said they were tried. She stated if any of the interventions in the Attempted but Failed section of the consent form were checked it was because the family said they had been tried. During an interview on 10/25/23 at 09:42 AM LVN C stated she had worked for the company for [AGE] years. She said bed rail consent forms were filled out by the nurses on admission. When asked about the Attempted but Failed section of the form she said, I don't usually put that on there. I usually explain the pros and cons and of the bed rails. I don't put anything in that section. During an interview on 10/25/23 at 09:42 AM LVN B stated she had worked for the company for 9 years. She said bed rail consents were filled out by the nurses on admission. She stated residents often wanted bed rails as enablers. During an interview on 10/25/23 at 09:47 AM LVN G stated she had worked for the facility for two years. She said nurses were responsible for filling out the bed rail consents when residents were admitted . She said, I usually put that they [residents] requested them [bed rails] on the consent form. During an interview on 10/25/23 at 09:47 AM LVN M stated she had worked for the facility for one year. She said nurses were responsible for filling out the bed rail consents upon admission. She said, A lot of them [residents] request them for safety. During an interview on 10/25/23 at 09:51 AM DON stated she knew about some of the residents having physical restraints coded in the MDS for bedrails. She stated, I was just talking to MDS RN about that because we use them as enablers and back up coordinator thinks you have to code them as restraints. DON stated nurses were responsible for getting bed rail consents filled out. She said, Usually we do it on admission. We visit with the resident and family and ask them when they come in and we get the initial assessment from them and go from there. When asked what the consent form meant when it stated an intervention was Attempted but Failed DON stated, I think during that initial day is when they will try those things it is probably not enough time depending on your view point. When asked how multiple interventions could be attempted but fail on the same day a resident is admitted to the facility, DON stated, I guess that is what we get from the resident or their family member during admission interview. When asked for possible negative outcomes for not attempting other interventions before using bed rails DON stated, Well, you are not using the least restrictive option, I guess. You are not trying something else instead of going to what may be your last resort. During an interview on 10/25/23 at 10:26 AM LVN G was asked if she knew what the facility policy on bed rails stated. She responded, Um .no. During an interview on 10/25/23 at 10:28 AM LVN B was asked if she knew what the facility policy on bed rails stated. She responded, About bed rails in what way? When reminded that the first line of the policy stated bed rails would not be available to residents upon admission she stated, Oh yeah, they [bed rails] are tied down with straps until the resident's family signs [the bed rail consent form] and then we can cut them [the straps]. During an interview on 10/25/23 at 10:33 AM DON was asked if the facility's nurses had received training on the facility's bed rail policy. She stated, You know, I'm not sure. I mean we discuss it, but I don't know if I've ever brought the policy out. I mean, it [a copy of the policy] is in each unit. Record review of facility policy titled Protocol: Side Rails and dated 01/16/19 revealed in part: On admission to [name of facility] side rails will not be available. Alternatives will be utilized and documented. (See informed consent for alternative suggestions.) Charge Nurse will: Document alternative interventions used by facility Assess resident for the use of side rails . If assessment shows side rail use is appropriate for resident to improve mobility or meet their preference, Charge Nurse will: Educate resident or if applicable, the resident's representative the risks and benefits of side rail use using informed consent . Complete informed consent . Obtain physician order for use of side rails .

Based on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of the residents needs and preferences for 1 of 18 residents (Resident #23) reviewed for accommodation of needs. Resident #23's call light was not within her reach. The call light's cord was wrapped around the bed rail and was placed at the top of the bed rail out of reach and sight of resident. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life. Findings included: Record review of Resident #23's face sheet , dated 10/24/2023, revealed an [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, psoriatic arthritis (swollen joints), venous insufficiency (swelling due to blood flow in legs), age-related osteoporosis (weak bones), age related cognitive decline and systemic sclerosis (stiff skin and organs). Record review of Resident #23's quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated Resident #23 was cognitively intact. Resident #23 required extensive two-person staff assistance with bed mobility and dressing, total two-person staff dependence with transferring and toilet use and with impairment to upper and lower extremity with regard to range of motion. Record review of Resident #23's care plan, dated 02/16/23, revealed, in part, Resident #23 is at risk for injuries from falling related to impaired mobility .Be sure her call light is within reach . find out why Resident #23 Is attempting to get up and proactively place items of interest in reach . Resident #23 has impaired vision .place frequently used items within reach . During an observation and interview on 10/24/2023 beginning at 9:13 AM, Resident #23 was lying in her bed, resident stated she did not feel well and that she felt a little congested. Observation of call light on resident's right side of bed wrapped around the bed rail above the resident's head, out of reach of resident. LVN A was in the hall near resident's room. Once LVN A was in the resident's room an observation occurred of LVN A moving the call light in a lower position on the bed rail. LVN A stated that the negative outcome for a resident not being able to reach their call light would be that a resident may soil themselves or not get the help they need. During an observation and interview on 10/23/23 beginning at 9:34 AM, Resident #23 was lying in her bed, her blanket was off her legs, and she appeared agitated. Resident #23 stated that she had been trying to reach her call light so she could call for assistance but hasn't been able to reach it. Resident #23 continued to try to reach her call light but was not able to reach it due to her limited range of motion and where the call light was located. The location of the call light was on the resident's right side of bed on a bed rail, the call light's cord was wrapped around the bed rail and was placed at the top of the bed rail out of reach and sight of resident. During an interview on 10/24/2023 at 2:49 PM, DON stated that the facility does not have a policy regarding call lights. During an interview on 10/25/2023 at 9:26 AM, CNA E stated that when she makes the resident's bed, she puts both bed rails down and lays the call light on the bed. CNA E stated that she believes it was the night staff that attaches the call light to the bed rails. CNA E stated the negative outcome for a resident not being able to reach their call light would be that they would not be able to call for assistance. During an interview on 10/25/2023 at 9:49 AM, LVN B stated that she puts the call light in reach of her residents, LVN B stated that a negative outcome of not putting the call light in reach would that a resident could fall. During an interview on 10/25/2023 at 9:50 AM LVN C stated that she puts the call light where the resident requests it to be, sometimes it is on the bed rail, blanket, or clothes. LVN C stated that the negative outcome for a resident not being able to reach the call light would be that the resident may try to get up and get hurt. During an interview on 10/25/2023 at 10:52 AM, Resident #23 stated that her call light placement has always been a problem. During the exit conference on 10/25/2023 at 1:15 PM, ADM asked about the potential reasonable accommodations cite, Surveyor stated that on two occasions she observed a resident not being able to see or reach her call light. Administrator referred to resident by name and indicated that she has always had issues with her call light.

Based on observation, interview, and record review, the facility failed to ensure that the residents environment remained as free from accident hazards as was possible; and that each resident received adequate supervision to prevent accident hazards for one resident (Resident #1) of 7 residents observed for accident hazards. -CNA A transferred Resident #1 in an unsafe manner resulting in a small skin tear and a large bruise to her left lower leg. This failure could affect all the residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, subdural hematomas, and feeling of isolation. Findings include: Record review of the clinical record for Resident #1 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include senile degeneration of the brain (a decreased in the ability to think, concentrate, or remember), heart failure (a condition in which the heart dose not pump blood as well as it should), dementia (a group of thinking and social symptoms that interferes with daily functioning), CAD (damage or disease in the hearts major blood vessels), malnutrition (lack of proper nutrition), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), pain, falls, and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record review of Resident #1's last MDS was a quarterly completed 5-23-2023 listing her with a BIMS of 10 indicating she was moderately cognitively impaired, and she had a functionality of requiring one-to-two-person assistance with activities of daily living. Resident #1 was listed and requiring two+ persons physical assist with: B. Transfer - how resident moves between surfaces including to or from: bed, chair wheelchair, standing position. Record review of Resident #1's clinical record revealed active orders as of 10-6-2023 with the following order: Stand-up lift for all transfers every shift. Order date - 5-6-2023 Record review of Resident #1's clinical record revealed a care plan with the following: admitted : 10-7-2019 Focus: ADL's Intervention: Stand-up lift for all transfers. Date initiated - 5-24-2023. Record review of facility provided record titled Clinical Tasks revealed the following: Resident #1 Date initiated: 10-7-2019. Last Revision Date: 10-5-2023 Standard Task: ADL - Transferring Instructions: Stand up lift with all transfers Position: Certified Nursing Aide -Per interview completed on 10-6-2023 at 1:40 PM with the DON who verified that this is in the task assignment area in the computer system that is to be reviewed by each CNA assigned to the resident prior to providing care. Record review of the facility provided Progress Note received 10-6-2023 revealed the following: Resident #1 Type: Incident Note Effective Date: 8-1-2023 Department: Nursing Position: LVN (Per interview with the DON this LVN was on vacation and unavailable), Note Text: Left outer lower leg bumped wheelchair during transfer. 1.5cm x 1.5cm skin tear with skin flap intake noted .Resident nor CNA noticed injury occurred at that time. Resident #1 Type: Skin/Wound Note Effective Date: 9-13-2023 Department: Nursing Noted Text: Called to elder room. Old skin tear re-opened and started bleeding, add 3 steri strips, large dark purple bruise noted on leg. During an interview on 10-6-2023 at 09:06 AM LVN B (the nurse responsible for Resident #1 today) reported that Resident #1 did have an injury to her left lower leg that LVN B did not witness when it occurred but heard that a staff member injured her during a transfer. LVN B reported that she has worked with Resident #1 for 4 years, and was very familiar with her care, Resident #1 was currently on hospice, and was expected for her health to deteriorate. LVN B verified that Resident #1 did have a large bruise and small skin tear to her left leg that LVN B offered to show to this surveyor. During an observation and interview completed on 10-6-2023 at 09:14 AM Resident #1 was in her room in her recliner with her feet elevated on a cushion. Resident #1 was noted to have a large dark purple bruise to her left shin approximately 5 inches by 3.5 inches and a small dry skin tear to her upper left shin that had two steri strips that were in the process of pealing. There was no noted drainage on the dressing when removed by LVN B. LVN B confirmed that Resident #1 did not have a fracture or any other injury. Resident #1 stated Another person dropped me, and I should have bopped her one. Resident #1 then went back before LVN B could complete rewrapping her leg and this surveyor could complete the interview. During an interview on 10-6-2023 at 10:08 AM the DON reported that Resident #1 was not dropped by a staff member, that they were transferring her from her wheelchair to her bed and Resident #1 bumped her leg. The DON verified that she had a report for the incident and that she would provide this surveyor with a copy. During an interview complete by phone on 10-6-2023 at 12:44 PM CNA A reported that she was the CNA that transferred Resident #1 on 8-1-2023, that she transferred Resident #1 by herself, that she had not worked with Resident #1 in a while and did not realize how weak Resident #1 had become. CNA A reported that the facility had enough staff that shift and she thought that Resident #1 was strong enough to assist with the transfer. CNA A reported that Resident #1 used to be fairly independent and could use her legs. CNA A reported that during the transfer Resident #1's knee buckled resulting in her bumping the bedrail. CNA A reported that Resident #1 had a small skin tear that CNA A immediately reported to the nurse (CNA A could not remember the nurses name) who assessed the wound, wrote the report, and that the bruise did not appear until the next day. CNA A reported that Resident #1 never fell , just bumped her left leg. When asked if she was aware that Resident #1 had orders and a care plan to be transferred by Standing Lift CNA A stated, I didn't realize that. She has always been able to stand, that is my bad. CNA A verified that she had been trained on the use of a Standing Lift. During an interview on 10-6-2023 at 1:40 PM the DON reported when a person is ordered to a Standing Lift that it is automatically considered a two-person lift when addressed on the MDS. The DON verified that Resident #1 was a Standing Lift resident and that a Standing Lift should always be used. The DON reported that CNA A should have checked the computer system first which gives instructions on how a resident is supposed to be transferred. The DON checked the point click care system for Resident #1 and under the Task assignments for the CNA (which CNA A has access to) found that Resident #1 was assigned to be a Standing Lift assist with all transfers. The DON reported that she believed CNA A got into a hurry, assumed she knew what she was doing because CNA A has worked that unit in the past, and then completed the transfer on Resident #1 incorrectly. The DON stated that transferring a resident incorrectly can result in somebody getting hurt. The DON verified that CNA A had been trained on the Standing Lift system when CNA A was hired. During an interview on 10-6-2023 at 3:03 PM the Administrator reported that a staff member not following the care plans or orders was a problem and that the facility has a policy that the staff are to follow care plans and orders. The Administrator reported that if staff do not follow care plans or order, then a resident can get injured. The Administrator reported that CNA A would be educated on where to look for the proper transfer to be used on a resident in the resident's chart/computer system or to ask the charge nurse prior to providing care and that the education will be provided in writing. The Administrator reported that if this situation happens again then CNA A will be terminated. Record review revealed the following: BCS Competency: Lift-Standing/Full Body -Competency completed by CNA A on 2-15-2023 and 4-20-2023. Record review of facility provided policy titled Resident Rights undated, revealed the following: Source: Nursing Facility Requirements for Licensure and Medicaid Certification Dignity and Respect: You have the right to- -live in safe, decent, and clean conditions