**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure the physician was consistently notified when a scheduled blood pressure medication was unavailable and not administered to one resident (#5). The sample size was 5. The deficient practice could result in residents not receiving necessary blood pressure medications. Findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris, hypertension, atrial fibrillation, presence of cardiac pacemaker and long-term use of anticoagulants. A physician order dated February 28, 2021 included for Nifedipine (antihypertensive) ER (extended release) 60 milligrams (mg) by mouth one time a day for hypertension. Review of the care plan initiated on March 1, 2021 revealed the resident had hypertension. The goal was that the resident would be free of complication related to hypertension. Interventions included to give anti-hypertensive medications as ordered. The quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 7 which indicated the resident cognition was severely impaired. Review of the November 2021 MAR (Medication Administration Record) revealed Nifedipine ER 60 mg was not given on November 2, 6, 7 and 8, 2021 and included the number '9' which meant other/see nurses notes. Review of corresponding e-MAR (electronic MAR) notes revealed the following: - November 2, 2021 stated waiting for delivery - November 6, 2021 stated out of stock, reordering - November 7, 2021 stated awaiting for delivery - November 8, 2021 stated Still not available. Will follow up with pharmacy. The progress notes were reviewed and did not reveal the medication was administered on November 2, 6, 7 and 8, 2021. The progress notes also did not reveal that a physician was notified when the medication was unavailable those days. Review of the resident blood pressure for November 2021 revealed the following blood pressure (BP) readings for the days the resident did not receive the blood pressure medication: November 2, 2021 at 9:08 a.m. BP was 164/62 November 6, 2021 at 6:21 a.m. BP was 140/74 November 7, 2021 at 6:55 a.m. BP was 150/60 November 8, 2021 at 7:03 a.m. BP was 132/68. During a medication observation conducted on November 10, 2021 at 8:53 a.m. with a Registered Nurse (RN/staff #35), the RN stated that she had not received Nifedipine ER 60 mg from the pharmacy for resident #5 and that she would check the Omnicell later. The RN was not observed to administer Nifedipine ER to the resident at that time. An interview was conducted with the RN (staff #35) on November 10, 2021 at 2:00 p.m. The RN stated that when a medication is not available, the process is to check the Omnicell Pyxis, call the pharmacy, request the medication STAT (immediately), and notify the physician. She stated normally the physician would give an order to hold the medication and administer once available. She stated she was not aware that the medication Nifedipine ER was not given and was not available on November 2, 6, 7 and 8, 2021. The RN stated that the medication should have been given and that was a long time without the medication. She stated she did not know what happened. An interview was conducted with a Licensed Practical Nurse (LPN/staff #43) on November 10, 2021 at 2:06 p.m. She stated when a medication is not available, the process is to click on number '9' in the MAR, enter a note in the MAR that the medication was not given as the medication was not available, pharmacy was called and the physician was notified. Staff #43 stated the pharmacy should be called to find out when the medication will be delivered. She stated if the delivery is late, then the physician should be notified and the physician order should be followed. The LPN stated she remembered that the medication was unavailable on November 6, 7 and 8, 2021. She stated she notified the physician on November 6, 2021 and called the pharmacy. She stated the pharmacy told her they needed to track down the order and the pharmacy asked to be called back. Staff #43 stated that she did not get a chance to call the pharmacy back and the physician had stated to make sure the resident received the medication. The LPN stated that she had passed it on to the evening shift and the evening shift had stated they will pass it on to the morning shift so that the regular nurse on the unit could take care of it. She stated on November 7 and 8, 2021 she did not get a chance and did not call the physician as she thought the physician was going to say the same thing. An interview was conducted with an LPN (staff #3) on November 12, 2021 at 10:44 a.m. He stated that when a medication is not available, it is important the resident receive the medication even if the facility has to pay for the medication. He stated the nurses need to look for the medication, if not available, call the pharmacy and notify the physician. He stated normally the physician will give an order to hold until available. The LPN stated everything needs to be documented in a progress note. The LPN stated if there is no documentation the medication was given and the physician was notified then that meant it did not happen. Staff #3 stated nurses must notify the physician when a medication is not given to a resident and document it in the progress notes. An interview was conducted with a RN (staff #10) on November 12, 2021 at 11:48 a.m. She stated if a medication is not available then the Omnicell Pyxis should be checked, pharmacy should be called immediately and the physician should be notified. She stated notification to the physician should be documented in the progress notes. An interview was conducted with the Director of Nursing (DON/staff #86) on November 12, 2021 at 2:04 p.m. The DON stated if a medication is not available, her expectation from the staff is to go to Omnicell Pyxis as many of the medications are stored in the Omnicell. She stated if the medication is not in the Omnicell then her expectation is for the staff to call the physician. The DON stated the physician usually gives an order to put the medication on hold until available. She stated if a nurse failed to give a medication, she expected the nurses to document in the e-MAR that the medication was on hold and the physician was notified. The DON stated the physician should be aware whenever the residents are not administered their medications. Staff #86 stated the facility randomly check/audit the MARs to make sure the medications were given. The facility policy titled Following Physician Orders effective April 4, 2018 stated physician's orders provide directions to the healthcare team regarding medications, procedures, treatments, therapy, diagnostic tests, and nutrition. The policy further stated the order establishes the medical necessity for the services provided. The policy stated the healthcare providers are notified by the licensed nurses if medications are held. The policy also stated that the licensed nurses should notify the healthcare provider for further directions when a medication has not been received from the pharmacy and is unavailable in the Omnicell. Further, the policy stated the licensed nurses should document on the e-MAR/TAR in PCC (Point Click Care) after administration of medication or rendering of treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, and policy review, the facility failed to report an allegation of verbal abuse for one sampled resident (#120) to the State Survey Agency and to Adult Protective Services (APS). The deficient practice could result in further allegations of resident abuse not being reported. Findings include: Resident #120 was admitted to the facility on [DATE] with diagnoses that included traumatic subarachnoid hemorrhage without loss of consciousness, unspecified occipital condyle fracture, and unspecified dementia with behavioral disturbance. Review of the admission Minimum Data Set assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance with most activities of daily living. Review of a nursing progress note dated 12/7/2019 at 08:56 revealed the resident's spouse arrived to the facility at 08:55, dragged the resident on a wheelchair from the TV room where the resident was watching holiday movies after eating breakfast into the resident's room. The spouse was yelling at the resident saying, why did you not answer your phone when I called you. The spouse took the resident into the room, slammed the door, and said with a loud voice this is where you need to stay, so that when I call you, you will answer your phone. The note included the writer immediately went into the resident's room and asked the resident's spouse what the problem was. The resident's spouse stated why was the resident not in the room to answer the phone when the spouse called. The resident's spouse was informed that at the time of the call, the resident was in the dining room eating breakfast. The resident's spouse removed their eye glasses and slammed them on the chair and it fell down. The resident's spouse was told that if the aggressive behavior did not stop, security would be called to remove the spouse from the premises. The note included the spouse knew the resident was a fall risk and had fallen many times. The note also included the resident's spouse immediately wheeled the resident outside with anger, the writer informed the weekend supervisor who went after them to make sure all was well. Further review of the clinical record did not reveal evidence that this allegation of abuse had been reported to the State Survey Agency or APS. In an interview conducted with a Certified Nursing Assistant (CNA/staff #72) on November 10, 2021 at 7:15 AM, the CNA stated that she has had abuse training and that if she witnessed any one being abused, she would immediately remove the resident from the area, notify the nurse, the Director of Nursing, and the police. She stated that she could not recall the resident and was not aware of this incident. In an interview conducted with a Licensed Practical Nurse (LPN/staff #43) on November 10, 2021, the LPN stated that she does not recall the resident or any incident of family yelling. She stated that she has received training on abuse. The LPN stated that if she would see any resident being abused, she would immediately intervene and ensure the safety of the resident. The LPN stated that she would then report the incident to the Director of Nursing, the Administrator and the police. During an interview conducted with a Registered Nurse (RN/staff #96) on November 10, 2021 at 9:54 AM, the RN stated that they receive abuse training annually. The RN stated that she would report an allegation of abuse to the Administrator and the Director of Nursing (DON), or the supervisor. Staff #96 stated that if no one was available, she would notify the State Agency of the allegation within 2 hours. The RN stated that she had no recollection of this incident or if the DON or the Administrator were notified. She stated that she would consider the spouse yelling at the resident to be potential verbal abuse. An interview was conducted on November 10, 2021 at 10:44 AM with the Administrator (staff #31), who stated the incident occurred prior to his arrival as Administrator. He stated there were no records of any information regarding allegations or complaints. Review of the facility policy regarding Abuse, Neglect and Exploitation effective date April 4, 2018, revealed all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property shall be reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse. Such alleged violations shall be reported to the State Survey Agency and Adult Protective Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interviews, and review of policy and procedure, the facility failed to notify one resident (#4) and the resident's representative of the transfer or discharge and the reasons for the move in writing, and send a copy of the notice to the Office of the State Long Term Care Ombudsman. The sample size was 3. The deficient practice could result in the resident/resident representative and/or the Ombudsman not being aware of the transfer and reason for transfer. Findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease with lower respiratory infection, acute and chronic respiratory failure with hypoxia, pneumonia, and heart failure. Review of a nurse progress note dated August 15, 2021 revealed the resident appeared very anxious with shortness of breath and labored respirations. Lung sounds wheezing with diminished lung sounds. Increased respirations with low oxygenation. Primary care provider responded with the recommendation to send the resident 911 to emergency room for evaluation and treatment. A physician order dated August 15, 2021 included to send the resident to the hospital for treatment and evaluation. A nurse progress note dated August 15, 2021 revealed the resident was sent to the hospital 911 per physician order for oxygen saturation 80% on 8 liters per minute. Power of Attorney notified of transfer. Review of a transfer form dated August 15, 2021 revealed that the resident representative was notified of the transfer and was aware of the clinical situation, the form included the representatives phone numbers. Review of a nurse progress note dated August 20, 2021 revealed the resident returned to the facility from the hospital. However, review of the clinical record did not reveal evidence the resident and the resident's representative were informed of the transfer to the hospital in writing. Review of the facility documentation of Ombudsman notifications of discharges did not include notification of the August 15, 2021 transfer to the hospital for resident #4. An interview was conducted on November 10, 2021 at 11:04 a.m. with a Registered Nurse (RN/staff #35). She stated that if a resident had a change of condition she would call the physician. She stated that if the physician gave orders to send the resident to the hospital she would notify the family. The RN stated that a transfer form would be filled out in the computer and a copy would go to the hospital with the resident. The RN stated that she had never shown a family member the transfer form. An interview was conducted on November 12, 2021 at 10:38 a.m. with the Director of Nursing (DON/staff #86). She stated that she spoke with social services and case management and that neither they, nor the nursing staff, provide a written transfer notice to the resident or the resident's representative when a resident is discharged to the hospital and anticipated to return to the facility. The DON stated that resident #4, resident #4's representative, and the Ombudsman did not receive a written notice of transfer of the resident's August 2021 transfer to the hospital. Review of the facility policy for Emergency Discharges dated March 31, 2021 revealed: Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will prepare a transfer form to send with the resident and notify the representative or other family member. The policy did not include the provision of written transfer information to the resident/resident representative or Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurate for one resident (#22). The sample size was 12. The deficient practice could result in inaccurate discharge tracking information. Findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included abscess of the lung with pneumonia, pleural effusion, acute respiratory failure with hypoxia, dependence on supplemental oxygen, and chest pain. A physician order dated September 25, 2021 included to discharge the resident home with home health on September 25, 2021 with all medications. Review of a progress note dated September 25, 2021 at 10:24 AM revealed the resident was discharged home with home health and all remaining medications, prescriptions, and all belongings. The note included discharge instructions were given to the resident and the resident's spouse, the resident was transported via private vehicle by the resident's spouse, and the resident was assisted to the vehicle by staff. However, review of the discharge MDS assessment dated [DATE] revealed the resident was discharged to the hospital. During an interview conducted on November 10, 2021 at 9:57 AM with the Director of Nursing (staff #86), she stated that her expectation is that all the documentation on the MDS assessment be accurate when it is completed. An interview was conducted with the MDS Registered Nurse (staff #49) on November 10, 2021 at 12:01 PM. She stated that she reviews the chart and progress notes for each resident prior to completing the MDS assessment in addition to any interviews which need to be conducted. Staff #49 stated that the Director of Nursing had just advised her that the resident was not coded correctly for discharge location. She stated that after reviewing the clinical record she realized she had entered the data incorrectly. Staff #49 further stated that the facility had no specific policy on completion of the MDS assessment that they used the RAI manual as their guide. The RAI manual instructs to review the clinical record including the discharge orders for documentation of discharge location and code the corresponding 2-digit code. The manual included the assessment must accurately reflect the resident's status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility document, staff interviews, and facility policy and procedures, the facility failed to provide an ongoing resident centered activities program based on the comprehensive assessment, care plan, and resident's preferences for one of two sampled residents (#220). The deficient practice could result in residents not participating in activities which could impact their mental and social well-being. Findings include: Resident #220 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, urinary tract infection, and acute kidney failure. Review of the clinical record revealed a physician order dated July 19, 2021 that the resident may participate in activities as tolerated. A review of the Optimum Life Program admission Data Collection form dated July 20, 2021 revealed the resident's short-term memory and long-term memory was OK and that the resident's preferences for activities included cards/other games, arts/crafts, exercise sports, trips/shopping/outings, TV/movies, and hobbies. Also included was that the resident's current participation in activities was active and the resident's preferred time for engagement in the programs and activities was morning. Continued review of the Optimum Life Program admission Data Collection form dated July 20, 2021 revealed that while in the facility it was very important to the resident to be around animals such as pets, keep up with the news, go outside to get fresh air when the weather is good, and do favorite activities. Included was that it was also somewhat important for the resident to do things with groups of people, and not very important to listen to music and have books, newspapers, and magazines to read. Further review of the Optimum Life Program admission Data Collection form dated July 20, 2021 revealed the resident would be suited for four 1:1 in room activities of choice such as hydration, pet therapy, 10-minute massages, and popcorn. Review of the care plan initiated on July 20, 2021 revealed the resident was dependent on staff for activities, cognitive stimulation, and social interaction. The goal was that the resident would maintain involvement in cognitive stimulation and social activities as desired. Interventions included for all staff to converse with the resident while providing care; encourage the resident's family to maintain ongoing involvement via telephone, in person, etc. in order to enhance the resident's quality of life; introduce the resident to residents with similar background and interests, and encourage/facilitate interaction; invite the resident to scheduled activities; thank the resident for attendance at activity function; when the resident chooses not to participate in organized activities, encourage the resident to turn on the television; music in room to provide sensory stimulation; and the resident needs assistance/escort to activity functions. However, review of the progress notes dated July 19, 2021 through July 26, 2021 did not reveal evidence that activities had being offered or declined by the resident. Review of the discharge Minimum Data Set assessment dated [DATE] revealed the resident was discharged return not anticipated on July 26, 2021 to another nursing home. Review of a facility document signed by the Director of Nursing (DON/staff #86) included activities now may be held in a group setting with a handwritten date 4/4-10/2021. An interview was conducted on November 9, 2021 at 1:03 p.m. with the Activities Coordinator (staff #56), who stated that she completes the Optimum Life Program admission Data Collection assessment when a resident is admitted . She said the assessment includes the activities a resident likes to do and that she tries to offer these activities to the resident. During the interview, staff #56 reviewed her documentation regarding activity participation and stated that she did not have any documentation to show the resident participated in any activities, was offered activities, or that the resident declined to participate. Then the Activities Coordinator stated that the residents were not allowed to meet in groups in July 2021, so she gave the nurse activities to pass out to the residents, so they would have something to do in their rooms, but that she never checked to see if the activities were offered to the residents. Staff #56 stated that she met with the residents a lot and these visits occurred through a closed window. Staff #56 stated that she would knock on the window, and make a funny face to let residents know that someone was there. She stated that she did not enter the residents' rooms because of COVID. On November 9, 2021, an interview was conducted at 2:40 p.m. with the DON (staff #86), who stated that the Activities Coordinator completes an assessment when a resident is admitted and initiates a care plan based on the resident's cognition and interests. The DON stated that if a one-to-one is needed in order for the resident to participate in activities, she expects it to be provided. The DON stated that in July 2021, the facility was only accepting residents who had been vaccinated, so isolation would not have been required and all residents could leave their rooms for group activities. Staff #86 stated that it is her expectation that the Activities Coordinator or the nurses would come to her if a resident is not participating in activities so they could try to determine why the resident is not participating. She also said that the Activities Coordinator should have progress notes to show that the resident participated in activities. A review of the facility's policy regarding activities dated April 4, 2018 stated residents shall have the right to choose the types of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility. As much as possible, the facility will provide activities, social events, and schedules that are compatible with the residents' interests, physical and mental assessment, and overall plan of care. Staff will document the reasons for any limitations in the resident's medical record. The policy also stated that activities will be scheduled periodically during the day, as well as during evenings, weekends, and holidays. The facility's policy, Quality of Life-Dignity, dated April 4, 2018 stated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be assisted in attending the activities of their choice, including activities outside the community.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and review of policy and procedures, the facility failed to ensure one sampled resident (#320) received treatment and care in accordance with professional standards of practice related to the application of Thrombo-Embolus Deterrent (TED) hose as ordered. The census was 39. The deficient practice could result in a lack of proper care being provided to residents. Findings include: Resident #320 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF), bradycardia, pneumonia, personal history of venous thrombosis and embolism, and peripheral vascular disease (PVD). The admission Minimum Data Set (MDS) assessment dated [DATE] included the resident scored 14 on the Brief Interview for Mental Status (BIMS) indicating the resident did not have cognitive deficits. The assessment also included the resident required the assistance of one person for dressing. A physician order dated November 4, 2021 included the resident was to have Thrombo-Embolus Deterrent (TED) hose on in the AM for edema and off at bedtime. Review of the care plan (undated) revealed the resident had an activities of daily living self-care performance. Interventions included the physician had ordered TED hose and the resident needed assistance to put on the TED hose every morning and to remove them at bedtime. The Treatment Administration Record (TAR) for November 2021 included the TED hose were applied November 4, 2021 on the day shift and continued to be applied every day shift through November 10, 2021 as ordered. Additionally, the TAR revealed the TED hose were removed on the night shift November 4 through 9, 2021. On November 8, 2021 at 12:12 PM, resident #320 was observed sitting in a wheelchair. The resident's lower extremities were resting on the wheelchair foot pedals, the resident's feet were edematous, and no TED hose were observed on the resident's lower extremities. Another observation was conducted of the resident on November 8, 2021 at 2:15 PM. The resident was not wearing TED hose as ordered. During an observation conducted of the resident on November 9, 2021 at 12:13 PM, the resident was observed with no TED on and the resident's lower legs were edematous. On November 10, 2021 at 11:08 AM, an interview was conducted with the resident. The resident was observed dressed and in a wheelchair. A white pair of TED hose were observed lying on the resident's bed. When asked about the TED hose, the resident stated it was the first time she had ever seen them and that staff had never put them on her before. The resident stated she had not refused the TED hose because she had never seen them and that if staff asked, she would allow staff to apply the TED hose. Resident #320 stated that she would like to see the staff try to apply the TED hose now because her feet are very swollen and it would be difficult to apply due to the size of her feet and ankles. An interview was conducted on November 10, 2021 at 11:15 AM with a Licensed Practical Nurse (LPN/staff#33). The LPN stated that an intervention for lower extremity edema would include to encourage the elevation of the legs, apply TED hose in the morning and remove them at bed time. The nurse explained that TED hose is a form of compression that increase circulation and decrease edema in a resident's legs. Additionally, she stated that application or removal of TED hose will be documented in the TAR. The LPN stated that if a resident refuses cares then they will retry and assess why the resident refused. The LPN stated that if the resident does not want to wear the TED hose after 3 attempts in a row then they will notify the physician and document all refusals in the resident's record. The nurse stated that a risk factor for not wearing TED hose with lower extremity edema is that the resident's legs or feet will continue to increase in size and there would be a decrease in cardiac circulation throughout the resident's body. After reviewing the TAR, the LPN stated that on November 10, 2021 the TAR indicated the TED hose was applied. The LPN stated that resident #320 is alert and oriented and that the resident required TED hose for her lower leg edema. The nurse stated that resident #320 had refused to have the TED hose applied to her legs today and that this was the first time the resident had refused to wear them for her. The LPN stated that she forgot to document the resident's refusal. Staff #33 further stated that on November 9, 2021, the nurse had removed the resident TED hose after lunch but did not document the occurrence of the removal. An interview was conducted on November 10, 2021 at 11:30 AM with a Certified Nursing Assistant (CNA/staff #38). The CNA stated that she is familiar with resident #320 care needs and that the resident is alert and oriented but is sometimes a little forgetful first thing in the morning. The CNA stated that this resident does have edema in her feet and that the staff have to apply the TED hose in the morning and that the night staff will remove the TED hose when the resident goes to bed. The CNA stated that on November 8, 2021 she was assigned to work with resident #320 and that she was going to go get resident #320 a new pair of TED hose that would fit the resident's legs better. Staff #38 stated that she got busy and forgot to bring the TED hose to the resident. Staff #38 stated that she left her shift that day and never brought resident #320 a pair of TED hose. Additionally, the CNA stated that the TED hose was not brought to the resident until today (November 10, 2021). She stated the resident did not want them on and refused them. After informing the CNA the resident had stated that she would not refuse having the TED hose applied by staff because her feet were so swollen, the CNA stated that the TED hose had not been on the resident and that she would go and apply the TED hose at this time. An interview was conducted with the Director of Nursing (DON/staff #86) on November 10, 2021 at 11:51 AM. The DON stated that TED hose requires a physician's order and the standard application of TED hose is on in the morning and off at bedtime. The DON stated that the nurses should document in the TAR when the TED hose are applied and removed. Further, she stated that if a resident refused any cares that refusal should be documented in the clinical record. The DON reviewed resident #320 TAR and stated that the nursing documentation indicated that the TED hose were applied that morning, November 10, 2021 at 6:00 AM, by the floor nurse. Further, the DON stated that if the resident was not wearing the TED hose then the documentation in the resident record should indicate that. Additionally, the DON stated there should be documentation if the resident wanted the TED hose removed or if the resident refused to have the TED hose applied. The DON stated that if the resident is not wearing the TED hose and the TAR indicates that they were applied, then that would not meet her expectation for application, removal, or refusal of TED hose. The facility's policy for Following Physician Orders dated April 4, 2018 stated a physician's orders provide directions to the healthcare team regarding medications, procedures, treatments, therapy, diagnostic tests, and nutrition. The order establishes the medical necessity for the services provided. Licensed nurses are to carry out healthcare provider orders as written per their scope of practice. Licensed nurses after administration of medication or rendering of treatment, will document on the electronic Medication Administration Record (MAR)/TAR in Point Click Care (PCC). The facility's policy titled Activities of Daily Living (ADL) Care Documentation dated April 4, 2018 stated it is the expectation that the activities of daily living (ADL) care outlined in the resident's care plan will be delivered to the resident as scheduled. ADL care which has been rendered will be documented in the resident's medical record. Activities of Daily Living (ADL) performed will be rendered as per the care plan and resident preferences. Explain all procedures to the resident before completing each task. ADL care will be rendered as care planned and encouraging resident involvement. ADL care that is not performed during a shift shall be reported to the charge nurse on duty of that shift and to the incoming associates of the next shift. It should also be entered into the medical record. ADL care that is not performed whether because of resident declination or other circumstance should be documented in the resident's record along with the reason the ADL care was not performed by the nurse/designee. Repetitive refusal or declination of ADL care should be reported to the charge nurse, nurse, or designee and then appropriately communicated to the resident's responsible party and/or physician/healthcare provider as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical review, staff interviews, and facility policy and procedures, the facility failed to ensure thorough pain management was consistently provided to one sampled resident (#2). The census was 39. The deficient practice could result in residents' pain not being addressed. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and Thyrotoxicosis. Review of the care plan initiated on April 6, 2016 stated the resident has the potential for chronic pain related to PVD, osteoarthritis and a history of right ankle fracture. The goals were that the resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain, and would not have an interruption in normal activities. Interventions included to administer analgesia as per orders, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions, and review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Review of the Order Listing Report revealed a physician order dated September 16, 2020 for MAPAP 325 milligrams tablet give 2 tablets orally every 4 hours as needed (prn) for pain 1-10. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 5 indicating the resident had severe cognitive impairment. The assessment included the resident had not been on a scheduled pain medication regimen and had not received prn pain medication during the 5 days lookback period. Review of the Medication Administration Record (MAR) dated October 2021 revealed that the resident's pain level was assessed at a 3/10 on October 7, 4/10 on October 8, and 4/10 on October 30, 2021. Further review of the MAR for October 2021 revealed that MAPAP 325 mg tablet give 2 tablets orally every 4 hours as needed for pain 1-10 was not administered on October 7, 8, or 30, 2021. Progress notes dates October 7, 8, and 30, 2021 did not reveal that pain medication was offered, administered, or declined by the resident. An interview was conducted on November 12, 2021 at 1:33 p.m. with a licensed practical nurse (LPN/staff #3). During the interview, he reviewed the MAR for October 2021 and stated that the resident's pain was assessed at 3/10 on October 7, 4/10 on October 8, and 4/10 on October 30, 2021. He also identified an order for MAPAP 325 mg tablet give 2 tablets orally every 4 hours as needed for pain 1-10 and stated that he would have offered the pain medication to the resident. The LPN stated that according to the MAR, the pain medication was not offered. Then, he referred to the progress notes and stated there was no documentation on the 7th or the 8th or the 30th indicating the pain medication was offered or that the resident declined the mediation. The LPN continued to review the clinical record and stated that the pain medication was not offered or given and if the medication was not offered, the resident may have continued to have pain. The Director of Nursing (DON/staff #86) was interviewed on November 12, 2021 at 1:43 p.m. She stated that the nurses assess each resident for pain daily and it is documented on the MAR. The DON stated pain medication orders include a pain scale and that she expects the staff to administer pain medication as per the pain scale and to document that it was administered on the MAR. The DON stated that she and the LPN (staff #3) are responsible for reviewing the MAR to make sure documentation is complete. Staff #86 stated if pain was assessed and no medication was administered, she would review the progress notes to see if the resident declined the pain medication. Review of the facility's policy regarding medication administration revised January 1, 2013 stated to document medication administration for example when medications are refused on the appropriate forms. The facility's policy, Administering Pain Medications, dated March 31, 2020 stated the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: -Assessing the potential for pain; -Recognizing the presence of pain; -Identifying the characteristics of pain; -Addressing the underlying causes of the pain; -Developing and implementing approaches to pain management; -Identifying and using specific strategies for different levels and sources of pain; -Monitoring for the effectiveness of interventions; and -Modifying approaches as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for two of five sampled residents (#6 and #15). The medication error rate was 6.67%. The facility census was 39 residents. The deficient practice could result in additional medication errors. Findings include: -Resident #6 was admitted to the facility on [DATE] with diagnoses that included hypertensive chronic kidney disease, peripheral vascular disease (PVD) and osteoarthritis. Review of the physician's order revealed an order dated [DATE] for Aspirin 81 milligram (mg) tablet by mouth one time a day every Wednesday and Saturday for PVD (peripheral vascular disease). During a medication administration observation conducted on [DATE] at 8:44 a.m., a RN (Registered Nurse/staff #35) was observed to administer one tablet of Aspirin Enteric Coated (EC) 81 mg to resident #6 instead of one tablet of Aspirin 81 mg. -Resident #15 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease with heart failure, hypothyroidism and hyperlipidemia. Review of the physician's order revealed an order dated [DATE] for Cholecalciferol tablet 25 microgram (mcg)/1000 units two tablets by mouth one time a day for Vitamin D deficiency. During a medication administration observation conducted on [DATE] at 9:01 a.m., staff #35 was observed to pour one tablet of Vitamin D instead of two tablets in the medication cup. The RN was observed to pour a total of nine tablets. Staff #35 was asked to count the total medication poured following the preparation of medication for resident #15. The RN counted and stated there were nine tablets in the medication cup. The nurse then administered the medications to resident #15. Following the administration of medications to resident #15, staff #35 was asked to count how many tablets the staff was supposed to administer the resident. Staff #35 looked at the MAR (Medication Administration Record), counted and stated she was supposed to give a total of ten tablets. She then stated that maybe she miscounted before as she knew she gave the resident everything. The RN stated that she would let the DON (Director of Nursing) and the physician know. An interview was conducted with a Licensed Practical Nurse (LPN/staff #43) on [DATE] at 12:10 p.m. She stated that her medication cart contained Aspirin 81 mg EC, 81 mg chewable, 325 mg EC and 325 mg regular. She stated if the physician order stated Aspirin 81 mg, she would clarify whether it is chewable or EC with the physician. She stated the facility just have two kind of Aspirin 81 mg, EC and chewable. An interview was conducted with a RN (staff #96) on [DATE] at 12:48 p.m. She stated the facility had Aspirin 81 mg chewable, 81 mg standard, 81 mg EC, 325mg standard, 325 mg EC. She stated if a resident had an order for Aspirin 81 mg, she would call the physician to clarify if it is chewable or EC. She stated the medication cannot be given before the clarification. A second interview was conducted with staff #35 on [DATE] at 1:30 p.m. She stated she had Aspirin 81 mg chewable and EC. She stated if the physician wants the resident to receive chewable then the order will specify chewable. She stated when the resident admits from hospital, the hospital specifies which kind of Aspirin. She then stated if the order stated Aspirin 81 mg then Aspirin 81 mg EC can be given as the order specifically does not state chewable. An interview was conducted with the DON (staff #86) on [DATE] at 2:04 p.m. The DON stated her expectation is for the nurses to compare the medication with the MAR, and ensure the medication is correct, is the correct dose, and is not expired. She stated the medication ordered and what is on hand should match. She stated if the order is for Aspirin 81 mg and the order did not say EC then the medication should be of regular route. The DON stated if Aspirin EC is given then the order should state Aspirin EC. She stated if the order is Aspirin 81 mg then regular Aspirin should be administered. She stated if Aspirin 81 mg regular is not available then her expectation is for the nurses to go to central supply, as central supply has the medications. The DON stated nurses should not be giving Aspirin 81 mg EC if the order did not specify EC. She stated staff #35 informed her about resident #15, who was supposed to receive two tablets of Vitamin D. She stated she was informed and the physician was informed. Review of the facility policy titled, General Dose Preparation and Medication Administration revised [DATE] revealed prior to administration of medication, facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. The policy further stated that the facility staff should confirm that the MAR reflects the most recent medication order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure a scheduled blood pressure medication was consistently administered to one resident (#5). The sample size was 5. The deficient practice could result in medications not being administered to residents. Findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris, hypertension, atrial fibrillation, presence of cardiac pacemaker and long-term use of anticoagulants. During a medication administration observation conducted on November 10, 2021 at 8:53 a.m. with a Registered Nurse (RN/staff #35), the RN stated that she had not received Nifedipine (antihypertensive) ER (extended release) tablet from the pharmacy for resident #5. At 8:56 a.m., staff #35 asked a Licensed Practical Nurse (LPN/staff #3) to look for the medication in the Omnicell Pyxis. On November 10, 2021 around 9:12 a.m., staff #3 informed staff #35 that the Omnicell pyxis did not carry the medication Nifedipine ER and he informed the physician. He stated the physician gave an order to hold the medication and give the medication once it arrives from the pharmacy. He stated he called the pharmacy to send the medication STAT (immediately). He informed staff #35 that he would add the orders to hold the medication and give the medication once it arrived. A review of the physician orders revealed an order dated February 28, 2021 for Nifedipine ER 60 milligrams (mg) by mouth one time a day for hypertension. Review of the November 2021 MAR (Medication Administration Record) revealed Nifedipine ER 60 mg was not given on November 2, 6, 7, 8 and 10, 2021. The MAR and was marked 9 for November 2, 6, 7, and 8, 2021 which meant other/see nurses notes and marked 5 which meant hold/see nurses notes for November 10, 2021. The MAR revealed the medication was on hold on November 11, 2021. The MAR also revealed the medication was administered on November 1, 3, 4, 5, and 9, 2021. Review of the corresponding e-MAR (electronic MAR) notes revealed the following; - November 2, 2021 stated waiting for delivery - November 6, 2021 stated out of stock, reordering - November 7, 2021 stated awaiting for delivery - November 8, 2021 stated Still not available. Will follow up with pharmacy - November 10, 2021 stated hold, see progress note. A review of the resident blood pressure (BP) for November 2021 revealed the following on the days the resident was not administered Nifedipine: November 2, 2021 at 9:08 a.m. BP was 164/62 November 6, 2021 at 6:21 a.m. BP was 140/74 November 7, 2021 at 6:55 a.m. BP was 150/60 November 8, 2021 at 7:03 a.m. BP was 132/68 November 10, 2021 at 7:07 a.m. BP was 150/78 November 11, 2021 at 7:09 a.m. BP was 164/60 The progress notes were reviewed and did not reveal the medication was given on November 2, 6, 7 and 8, 2021. The progress note dated November 10, 2021 stated resident's #5 medication Nifedipine was not available, the physician was notified and gave an order to hold the medication until available. Review of the medication delivery shipment summary sheet from the pharmacy for October 2021 and November 2021 for Nifedipine ER 60 mg for resident #5 revealed the facility received thirty tablets of Nifedipine ER 60 mg for resident #5 on October 22, 2021. The summary also included the facility received seven tablets of Nifedipine ER 60 mg for resident #5 on November 10, 2021. Further review of the progress notes did not reveal that the medication was given on November 10 and 11 after the medication became available. An interview was conducted with staff #35 on November 10, 2021 at 2:00 p.m. The RN stated that she believed she gave resident #5 last tablet of Nifedipine ER the day before and forgot to reorder it from the pharmacy. She stated she remembered there was one last tablet left the day before. The RN stated when a medication is not available, the process is to check the Omnicell Pyxis, call pharmacy and request the medication STAT, and notify the physician. The RN stated that she was unaware the medication was not available and not given on November 2, 6, 7, and 8, 2021. Staff #35 stated that was a long time without the medication and that the medication should have been given. In an interview conducted with an LPN (staff #43) on November 10, 2021 at 2:06 p.m., the LPN stated when a medication is not available, the process is to click on number '9' in the MAR, enter a note in the MAR that the medication was not given as the medication was not available, that pharmacy was called and the physician was notified. She stated pharmacy should be called to find out when the medication will be delivered. She stated if the delivery was late then the physician should be notified and the physician direction should be followed. The LPN stated sometimes they have to request the medication STAT so that the medication is delivered within 2 hours. She stated if the medication did not arrive during her shift then she would pass it on to the oncoming shift. The LPN stated she remembered that the medication was unavailable on November 6, 7 and 8, 2021. She stated she notified the physician on November 6, 2021 and called the pharmacy. She stated the pharmacy told her they needed to track down the order and the pharmacy asked to be called back. Staff #43 stated that she did not get a chance to call the pharmacy back and the physician stated to make sure the resident received the medication. She stated she had passed it on to the evening shift and the evening shift had stated they would pass it on to the morning shift so that the regular nurse on the unit could take care of it. The LPN stated she did not usually work on the unit and she waited for the regular nurse on the unit to communicate with the pharmacy. An interview was conducted with another LPN (staff #3) on November 12, 2021 at 10:44 a.m., who stated that he did wound care and assisted the nurses on the unit. He stated the pyxis did not have Nifedipine ER so he spoke with the physician and requested the medication STAT from the pharmacy. He stated depending on the pharmacy the medication should be available within 4 hours when the medication is ordered STAT. He stated he assumed the nurses gave the medication once the medication was available. He stated when a medication is not available, it is important the resident receive the medication even if the facility has to pay for the medication. The LPN stated the medication should have been given on November 10 and 11, 2021 if the medication arrived November 10, 2021. The LPN stated if the pharmacy was not able to deliver the medication then the process is to let the DON (Director of Nursing) know so that the residents received the medication they need. He stated if the pharmacy did not deliver the medication, the nurses should follow up to see what happened. An interview was conducted with an Omnicell Pharmacy representative (staff #129) on November 12, 2021 at 11:04 a.m. She stated that the medication Nifedipine ER for resident #5 was ordered on November 10, 2021 and a seven-day supply was filled on November 10, 2021. She stated the medication was sent out on the noon run. Staff #129 stated that before the November 10, 2021 order, the medication was ordered on October 22, 2021 and a thirty-day supply was filled. She stated there was no information that the medication was reordered between October 22, 2021 to November 10, 2021. An interview was conducted with a RN (staff #10) on November 12, 2021 at 11:48 a.m. She checked the medication Nifedipine on the cart and stated 7 pills were dispensed on November 10, 2021. She stated medications are ordered through PCC (Point Click Care). She stated if a medication is not available then the Omnicell Pyxis is checked, pharmacy is called immediately, and the physician is notified. She stated she will then follow the physician direction regarding holding the medication or skipping the dose. The RN stated if the pharmacy is late to deliver the medication then the staff should call the pharmacy and follow up and if the medication did not arrive till next day, staff should notify the physician. An interview was conducted with the Director of Nursing (DON/staff #86) on November 12, 2021 at 2:04 p.m. She stated if a medication is not available, her expectation from the staff is to go to Omnicell pyxis as many of the medications are stored in Omnicell. She stated if the medication is not in the Omnicell then her expectation is for the staff to call the physician. She stated the physician usually gives an order to put the medication on hold until available. She stated the nurses should call the pharmacy as soon as possible. She stated sometimes the pharmacy states the resident have an insurance issue. In that case she stated the nurses should notify her even if it is on a weekend. The DON stated she usually tells the nurses to tell the pharmacy that the facility will pay and the pharmacy usually sends a seven-day supply. The DON stated the facility do not want the resident to go without their scheduled medications so the facility will pay for the medication. Staff #86 stated if a nurse failed to give a medication, she expects the nurses to document it in the e-MAR. Staff #86 stated the facility randomly check the MAR to make sure the medications were given. She stated she and staff #3 does random checks, that the MAR is audited randomly. The facility policy titled Following Physician Orders effective April 4, 2018 stated physician's orders provide directions to the healthcare team regarding medications, procedures, treatments, therapy, diagnostic tests, and nutrition. The policy further stated the order establishes the medical necessity for the services provided. The policy stated that if medication has not been received from the pharmacy, the licensed nurse will check the Omnicell for available medications. The policy stated if not available in the Omnicell, the Healthcare Provider will be notified for further directions and the pharmacy will also be notified for medication availability. The policy stated the licensed nurses should document on the e-MAR/TAR in PCC (Point Click Care) after administration of medication or rendering of treatment.

Observations conducted of the dining room for hall 400: -On November 8, 2021 at 12:25 p.m., the Licensed Practical Nurse (LPN/staff #43) from hall 400 brought a resident into the dining room, placed the resident at the table and locked the wheelchair. Staff #43 then went to assist another resident. The LPN touched the resident on the shoulder, sat down at that residents table, touched the table cloth and one resident's silverware. The LPN was not observed to perform hand hygiene. -On November 9, 2021 at 1:15 p.m. during the lunch service, a Certified Nursing Assistant (CNA/staff #71) was observed to move from table to table delivering plates and beverages in the dining room. The CNA assisted residents in cutting food, touched silverware for several residents including two residents who subsequently used the same utensils. The CNA was not observed to perform hand hygiene. Following these observations, staff #71 left the dining room to deliver room trays. Staff #71 was observed to deliver a room meal tray from the dining room to a resident on hall 400, returned to the dining room, retrieved another room meal tray from the dining room and leave the dining room again without performing hand hygiene. -On November 10, 2021 at 7:52 a.m., staff #71 was observed to stir oatmeal for a resident and immediately afterwards stir the oatmeal served to another resident. Each time staff #71 used the spoon belonging to the resident which was then used by the resident. There was no hand hygiene observed. Staff #71 also handed both residents their coffee cups immediately afterwards with no observed hand hygiene. At 7:54 a.m., staff #71 got up from the table where she was assisting the two residents, turned on the light switch across the room, immediately came back to the residents' table and touched both residents' coffee cups without having performed any hand hygiene. At 8:26 a.m., staff #71 was observed to cut food for both residents using the individual resident silverware. The residents then used their respective silverware. No hand hygiene was observed before or between cutting the two residents' food. -On November 10, 2021 at 8:05 a.m., the Registered Nurse (RN/staff #35) from hall 400 was assisting a resident with eating, the RN got up, left the table and went to assist another resident. Staff #35 touched this resident on the back while talking and then returned to further assist the first resident with eating. Staff #35 touched the silverware of the first resident and assisted the resident in wiping her mouth. The RN was not observed to perform hand hygiene during these interactions. On November 10, 2021 at 9:02 a.m., an interview was conducted with the director of nursing (DON/ staff #86) and the administrator (staff #31) The DON stated that the expectation of their staff was to perform hand hygiene as appropriate. The DON stated that there is alcohol-based gel in the dining room for their use and staff are expected to use it between residents, even when cutting food for different residents at the same table. She stated that the staff have been taught often about appropriate hand hygiene, as there are many in-services on the topic. The administrator stated that anytime a staff members hands are contaminated the staff is to perform hand hygiene. On November 10, 2021 at 9:20 a.m., an interview was conducted with the CNA (staff #71), who stated that the process for serving food and helping in the dining room included using hand sanitizer. She stated that there is no sink to wash their hands within that area. The CNA stated that the process for serving food is that staff use hand sanitizer and then pick up the tray and take it to a resident's room. She stated that if a tray is brought to a resident room, staff should perform hand hygiene when coming out of the room. Staff #71 stated that there is also hand sanitizer at the entry to the dining room that can be used if the sanitizer outside the resident's room is not used. Staff #71 went on to state that if the resident eats in the dining room, after hand sanitizing, staff would bring a plate from the kitchen area and place it in front of resident in on the table, staff would then cut up the resident's food if needed. She stated that hand sanitizing between residents was supposed to be done. She stated hand sanitizer is on the wall in a dispenser and she has some in her pocket. The CNA stated that hand sanitizer is used if they touch a resident or mask. Staff #71 stated that she thought she used the hand sanitizer outside the dining after the room trays were delivered at lunch on November 9, 2021 but really did not clearly remember. Staff #71 stated that she had not been using hand sanitizing between residents regularly as was her normal process. In regards to the last two lunches and the breakfast today, she stated that she knew that she did not perform hand hygiene as taught, that she had forgotten to hand sanitize the last few meal services between assisting different residents and after turning on the light switch that morning. She stated that forgetting to perform hand hygiene could result in passing germs between residents and her germs to the residents as well. Review of the facility policy titled Handwashing/Hand Hygiene (April 4, 2018) revealed that all associates shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other associates, residents and visitors. The policy further stated that use of an alcohol-based hand rub containing at least 62% alcohol or soap should be used before and after direct contact with residents, before and after handling food, and before and after assisting a resident with meals. Review of the facility policy prevention and control of COVID-19 (revised July 2020) revealed that standard precautions are used during the care of any resident. The standard precautions included performing hand hygiene. Hand hygiene is performed by washing with soap and water or using alcohol-based hand rubs. Supplies for hand hygiene are to be available throughout the building. Based on observations, staff interviews, facility documentation, and review of policies and procedures, the facility failed to ensure that two staff members (#22 and #73) completed COVID-19 screening prior to or at the beginning of their shift, and the facility failed to ensure that staff performed appropriate hand hygiene during meal service. The census was 39. The deficient practice could result in the spread of infection. Findings include: Regarding staff COVID-19 screening: -Review of the time sheet for staff #22, a server, from October 25, 2021 through November 7, 2021 revealed that the staff member worked October 25, 26, 27, and 31, 2021; and November 1, 2, 3, 4, and 7, 2021. Review of the COVID-19 screening forms provided by the facility revealed COVID-19 screening by the staff member on October 27, 2021. On request, the facility was able to provide COVID-19 screening forms for staff #22 for November 2 and 7, 2021. However, there was no evidence that the staff member was screened for COVID-19 prior to or at the beginning of the shift worked on October 25, 26, or 31, 2021; or on November 1, 3, or 4, 2021. -Review of the time sheet for staff #73, housekeeper, from October 25, 2021 through November 7, 2021 revealed that the staff member worked October 25, 26, 29 and 30, 2021; and November 5, 6, and 7, 2021. Review of the COVID-19 screening forms provided by the facility revealed COVID-19 screening by the staff member on October 25, 26, and 30, 2021. On request, the facility was able to provide COVID-19 screening forms for staff #73 for November 5-7, 2021. However, there was no evidence that the staff member was screened for COVID-19 prior to or at the beginning of the shift worked on October 29, 2021. An interview was conducted on November 10, 2021 at 10:31 a.m. with a Certified Nursing Assistant (CNA/staff #9). She stated that when she reports for work she reads the screening form, check's off the questions and signs the form which means she understood the information. She stated that she checks her temperature, goes to the nurse station, tells the nurse her temperature, and gives the nurse the screening form. The CNA stated that if she had an elevated temperature and/or signs or symptoms of COVID-19, she must not report to work and immediately leave the facility and would need to get tested for COVID-19. An interview was conducted on November 10, 2021 at 11:04 a.m. with a Registered Nurse (RN/staff #35). She stated that staff fill out a screening form and get their temperature checked before entering the facility for work. The RN stated that the form is given to the night supervisor for review and if the staff member has an elevated temperature or any signs/symptoms indicated on the form, they would be sent home. An interview was conducted on November 12, 2021 at 8:26 a.m. with a staff #73, who stated that before working, she would be screened for COVID-19 at the facility entrance. She stated that if her temperature was elevated she would be sent home and would have to get a COVID-19 test. An interview was conducted on November 12, 2021 at 2:51 p.m. with the Director of Nursing (DON/staff #86). She stated that all staff had to enter for work at the main/emergency entrance and had to be screened for COVID-19 and get their temperature taken before they enter further into the building. She stated that she was unable to provide evidence of screening for staff #22 and staff #73 for all of the days requested. She stated that staff did not meet her expectation and should not be working in the building if they were not first screened. The DON stated that the risk of not being screened for COVID-19, is that staff may have an elevated temperature and/or signs and symptoms of infection and would be working with/around residents and staff. Review of the facility policy for Prevention and Control of COVID-19 dated July 17, 2020 revealed: The facility follows current Centers for Disease Control and Prevention (CDC) guidelines and recommendations for the prevention and control of COVID-19. Under Healthcare Workers, upon entering the facility, included: The Director of Clinical Services/or Nursing designee will perform taking temperature, observe handwashing, and will conduct COVID-19: Screening checklist form. Review of the facility policy on Long Term Care facility testing requirements for staff and residents dated September 13, 2021 included: It is the goal to prevent COVID-19 from entering the facility, detecting cases quickly and stopping transmission. Swift identification of confirmed COVID-19 cases allows the facility to take immediate action to remove exposure risks to the facility staff and residents. Under Testing Frequency: The facility will continue to screen all staff, residents, and other visitors. Regardless of the frequency of testing being performed or the facility's COVID-19 status, the facility will continue to screen staff each shift with temperature taking daily on all persons entering the facility. Review of the facility COVID-19 screening checklist for visitors and staff revealed: All individuals (staff, other health care workers, family, visitors, government officials etc.) entering this building must be asked the following questions and have their temperature taken. The form included 6 question: 1. Have you washed your hands or used alcohol-based hand rub (ABHR) on entry? 2. Have you have any of the following respirator symptoms? (list provided) If yes to any, restrict them from entering the building. 3A. Check temperature and enter results/fever present? 3B. For staff and health care providers/Have you worked in any facilities or locations with recognized COVID-19 cases? If yes and have worked with a person(s) with confirmed COVID-19, required to wear PPE including mask, gloves, gown before any contact with residents. 4. You are allowed entry to this building and remember to wash your hands or use ABHR throughout your time in the building, and do not shake hands, touch, or hug individuals during your visit. 5. Have you traveled internationally or to any other areas identified by CDC as hot spots/cluster with in the last 14 days? and 6. Have you been around or exposed to anyone else or within your family or community with signs or symptoms of respiratory illness or provided care for anyone with respiratory illness? If you answered yes to question 5 and/or 6, see the Director of Nursing for further instruction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, staff interview, policy review, the Centers for Disease Control and Prevention (CDC) guidance, and the Centers for Medicare and Medicaid Services (CMS) Interim Final Rule, the facility failed to ensure three residents (#2, #9, and #10), their representatives, and families were informed of new COVID-19 cases occurring in the facility within the required time frame. The deficient practice would result in residents, their representatives and families not being aware of new COVID-19 cases and the actions implemented to reduce the risk of transmission. The census was 39. Findings include: Review of documentation provided by the facility included the five most recent confirmed COVID-19 cases in the facility were staff members. Two cases on January 22, 2021, one case on January 26, 2021, one case on February 2, 2021, and one case on February 16, 2021. -Resident #2 was admitted to the facility on [DATE]. Review of the resident's progress notes did not reveal documentation that the resident, resident representative, and/or family were notified of the positive COVID-19 cases identified by the facility in January and February 2021. The facility did not provide further requested documentation of notifications for resident #2 for the months of January and February 2021. -Resident #9 admitted to the facility on [DATE]. Review of the resident's progress notes did not reveal documentation that the resident, resident representative, and/or family were notified of the positive COVID-19 case identified by the facility in January and February 2021. The facility did not provide further requested documentation of notifications for resident #9 for the months of January and February 2021. -Resident #10 had an admission to the facility on December 4, 2020 with a discharge on [DATE]. Review of the resident's progress notes for that stay did not reveal documentation that the resident, resident representative, and/or family were notified of the positive COVID-19 case identified by the facility on January 22, 2021. The facility did not provide further requested documentation of notifications for resident #10. An interview was conducted on November 12, 2021 at 2:51 p.m. with the Director of Nursing (DON/staff #86). She stated that the staff notifies residents, families, and representatives of identified COVID-19 cases of residents and/or staff via phone and that the notifications are documented in the residents' clinical record. She acknowledged that she did not provide the requested documentation of notification of COVID-19 cases in the building for residents #2, #9, and #10 for the cases identified in January and February 2021. The DON stated that she understood that, if no further information was provided, the facility did not provide documentation that selected residents/representatives were notified of new COVID-19 cases in the building by 5 p.m. the next day after a case was identified. She stated that her expectation was that notifications would be done as required by CMS. Review of the facility policy for Prevention and Control of COVID-19 dated July 17, 2020 revealed: The facility follows current Centers for Disease Control and Prevention (CDC) guidelines and recommendations for the prevention and control of COVID-19. The CDC Interim Infection Prevention and Control recommendations to prevent SARS-CoV-2 spread in nursing homes, dated September 10, 2021 stated notify healthcare providers (HCP), residents, and families promptly about identification of SARS-CoV-2 in the facility. Maintain ongoing, frequent communication with HCP (healthcare personnel), residents, and families with updates on the situation and facility actions. Review of CMS Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes dated May 6, 2020 stated to inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. This information must (i) Not include personally identifiable information; (ii) Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; and (iii) Include any cumulative updates for residents, their representatives, and families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other.