**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, review of the clinical record, facility documentation, and policy, the facility failed to ensure that a code status was accurate and consistent in the medical record for one resident, # 10 of sixty-nine residents. The deficient practice could result in the resident not receiving care consistent with the signed advance directive.Based on resident and staff interviews, review of the clinical record, facility documentation, and policy, the facility failed to ensure that a code status was accurate and consistent in the medical record for one resident, # 10 of sixty-nine residents. The deficient practice could result in the resident not receiving care consistent with the signed advance directive. Findings include: Resident # 10 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including multiple sclerosis, local infection of the skin and subcutaneous tissue, atrial fibrillation, pressure of left heel (unstageable) osteomyelitis of vertebra, sacral and sacrococcygeal region, peripheral vascular disease, heart failure, chronic pain syndrome, iron deficiency anemia, acute kidney failure, muscle weakness, post-hemorrhagic anemia, chronic obstructive pulmonary disease, essential hypertension, arthritis, anxiety disorder, hyperlipidemia, neuromuscular dysfunction of bladder, migraine, and history of urinary calculi. The Minimum Data Set (MDS) for significant change in status dated 6/16/2025 revealed a Brief Interview of Mental Status (BIMS) score of 13, which indicated no cognitive deficits. The Patient Health Questionnaire-2 (PHQ-2) revealed a score of 00, which indicated no alteration in mood. Section E of the MDS indicated no evidence of delusions, psychosis, or behaviors, but revealed instances of the resident rejecting care. The face sheet (Kardex) on the electronic health record revealed the advance directives as do not resuscitate (DNR). A review of the miscellaneous documents in the electronic health record dated 3/3/ 2025 revealed the resident's desire for cardiopulmonary resuscitation as well as IV hydration, blood transfusions, but declined to receive nutrition by tube feeding. A review of the physician orders dated 06/26/2025 revealed the initial order for code status as full code. Additional orders included maintenance of a rectal collection bag in place at all times, low air low-air-loss mattress for skin integrity, staff to attempt care in pairs whenever staffing allows, nocturnal enteral feeds, catheter, IV, and PICC line care. Wound care orders included orders to cleanse wounds by gently dabbing, with the notation that A Cell is still in place on wound bed, change soaked gauze and then apply dry dressing on top only. Do not remove anything but gauze. Medication orders included Zosyn 4.5 gm, Pantoprazole 1 by mouth daily for GERD, Piperacillin Sodium-Tazobactam Sodium) use 4.5 gram intravenously every 8 hours for VRE in the urine and osteomyelitis until 7/11/2025, apixaban 5 mg 1 tablet by mouth 2 x /day, diltiazem HCL ER Oral Tab Extended Release 240 mg 1 tablet by mouth daily for essential hypertension, gabapentin 100 mg 1 capsule by mouth 2 times a day for neuropathy, oxycodone 5 mg 1 tablet by mouth every 4 hours as needed for pain- document result/effectiveness or non-pharmacological interventions: E-effective, N-not effective. A review of the comprehensive care plan dated 3/14/2025 revealed that the resident had an advance directive and had documentation in the medical record electing full code status initiated on 3/4/2025. The focus of the care plan revealed that the resident had an advance directive and had documentation in their medical record related to code status that indicated a desire for full code status which was initiated on 3/4/2025. The care plan included the goal that the resident wishes will be honored and maintained. Interventions to achieve the goal indicated that the resident's choice for code status would be honored. An interview conducted with Resident # 10 on June 24, 2025 at 09:50 A.M. confirmed her desire for advance directives to be full code. She confirmed that she signed advance directive documents and did not require a representative to do so. The resident stated however, that her family is aware of her decision concerning advanced directives. An interview was conducted with Staff # 88, Certified Nursing Assistant (C NA) on 6/26/25 11:39 A.M. The CNA stated that she receives information during shift-to-shift report and stated that the CNAs walk from room to room to evaluate the patients during change of shift. The C NA stated that staff know if the patient is a full code because they wear armbands that indicate their code status. Staff # 88 reported that the code status is also on the Kardex. An interview with Staff # 65, the Social Services Director was held on 6/26/25 at 09:51 A.M. This writer requested employee (#65) pull up and review the electronic health record for resident # 10. The Social Services Director identified and confirmed the discrepancy between the face sheet in the electronic health record and the resident's advance directives election. She reported that records are audited by medical records staff and the ADON and stated that when discrepancies are noted, the medical records department should have notified nursing of the discrepancy. Staff # 65 stated that if this resident were to code, facility staff would not do anything because the advance directive on the face sheet in the electronic health record indicated that the resident had elected a do-not-resuscitate status. The Social Services Director further stated that this discrepancy did not meet expectations because if the resident coded, staff would check the chart first and then call 911 and notify the family of a change in the resident's condition. When first responders arrived, they would ask to see the 'orange card' that reflects the resident's pre-hospital directive. The Social Services Director stated that the impact on the resident could be that when the staff attempted to retrieve the pre-hospital directive from the code book at the nurses' station, it would not be there, and they would not have started the resuscitation effort that was chosen by the resident. An interview was conducted with the Assistant Director of Nursing (ADON), Staff # 81 on 6/26/2025 at 09:17 A.M, who stated that the facility uses an intercom system to announce code arrests that occur within the facility. Staff # 81 stated that the resident's code status is available on the landing page of the electronic health record. Staff # 81 stated that the miscellaneous tab in Point Click Care (PCC), the facility's electronic health record, holds consent forms designating the resident's election for advance directives. The ADON stated that he and the Medical Records Coordinator audit advance directives through this system. The ADON stated that the audit involves reviewing advance directive orders and cross-checking them with the forms signed by the resident or the resident's representative. The ADON stated that If DNR status is elected, the orange cards (pre-hospital directives) are placed in a DNR book housed at the nurses' station. Staff # 81 stated that the code status needs to be aligned with the information that appears at the top of PCC code status. He further stated that if the resident elects a DNR status, all staff receive guidelines on their advance directive election through an orange binder or DNR binder, that keeps the orange prehospital directives for all residents who have elected DNR status, which is located at the nurses' station. When asked which the staff would review first, the ADON stated that staff would first check the electronic record to determine code status. Staff # 81 stated that finding a discrepancy between the information in the electronic health record and the consent signed by the resident would not meet his expectations. The ADON stated that the risk to the resident is that if the record was marked as DNR and the resident had elected a full code status, the resident could not get the care that they wanted. No interview was conducted with the Medical Records Coordinator as they are on planned leave and unavailable. An interview was conducted with the Director of Nursing (DON) staff # 79 on 6/26/25 at 10:06 A. M. The DON stated that in the event of a code arrest on the unit, the CNA would ask the nurse or check the code book and call for help. The DON was asked to pull up and review what code status was reflected on the resident's face sheet in PCC. It is listed as DNR. Then asked DON to pull up the resident's election for advance directives. When she did, she identified and confirmed the resident's wishes to be full code based on the signed advance directive form. She stated that this did not meet her expectations, and the risk to the resident was that if the advance directives are not clearly communicated, it could result in death. A review of Resident's Rights Regarding Treatment and Advance Directives, reviewed on 4/15/2024, revealed that it is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate and advance directive. The policy stipulated that upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure adequate supervision was provided for one resident (#204), in a public area who was exploited by assisted living staff. The deficient practice could result in residents being exploited.Findings include:The resident was admitted to the facility on [DATE] with diagnoses that included major depression, chronic kidney disease, and repeated falls.The Skilled Nursing Facility admission Agreement dated July 7, 2022 by the resident states that the facility strongly encourages residents not to keep valuables, checks, credit cards or cash sat the facility. If the resident requires anything, the facility will arrange to meet this obligation and add any cost to the resident's monthly bill. The clinical record revealed that the resident had a diagnosis for unspecified dementia dated September 7, 2022.A progress note dated September 13, 2022 revealed that the resident spoke with the Social Services Assistant (SSA/staff #65) and asked if she could keep six, $20.00 bills. The SSA reminded the resident that it would be best for her not to keep any cash, credit cards or valuable in her room or with her. On September 13, 2022, the SSA emailed the financial office and gave the resident the option to open a resident trust account and the resident wanted the trust. The SSA will follow up and assist with this. An SSA progress note dated September 14, 2022 included that a care plan meeting was held and the SSA reminded the resident not to keep valuables or money. The SSA also educated the resident on labeling personal belongings and adding them to the inventory sheet at the nurse's station. The clinical record revealed that the resident a diagnosis for bipolar disorder dated September 13, 2023. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. It also included that the resident had a diagnosis for non-Alzheimer's dementia. Review of the 5-day investigation dated January 22, 2024 revealed that the resident's checkbook ledger showed that checks were written to the assistant living caregiver (#100), who was terminated on January 25, 2024 for standard of conduct, acceptance of gifts or anything of value. Per company policy, employees are not able to accept checks from residents. The resident mentioned that she had a friend/employee at the facility that helps her with her finances and errands. The caregiver stated that she accepted $385 dollars for a phone purchased for the resident and $7000.00 for a storage unit that she said, she tore up and asked the resident to write the check directly to the storage unit. The care plan dated January 23, 2024 revealed that the resident had forgetfulness at times related to dementia. Interventions included to keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Review of the clinical record did not reveal an inventory list for personal belongings. An interview was conducted on June 24, 2025 with the Social Services Director (SSA/staff #65), who stated that nursing staff completes the inventory list for personal belongings when a resident is admitted to the facility. She stated that if the certified nursing assistant (CNA) lets her know that a resident has valuables, she talks to the resident and offers to lock it up in the safe in her office and she documents that she had the conversation with the resident in the clinical record. She stated that they discourage the residents from bringing valuables to the facility by telling the resident that if he or she is going to stay in the facility, you don't need cash here or any valuables and she offers to call the family member to pick it up. She keeps the ATM cards of some of the residents because the cards have gone missing, but that happened years ago. The CNAs/nurses did not let her know that the resident had her checkbook and wallet, but the resident always had a little purse with her and carried it around. She acknowledged that she never had a conversation with the resident about the purse or if she had personal belongings of value in the purse that she wanted stored for safety. She reviewed the resident's documentation and stated that the inventory list for personal belongings was not there. The SSA stated that a woman from hospice came to the facility and reported to her and the Director of Nursing (DON/staff #79) that she had concerns that someone was taking advantage of the resident and suggested that the SSA and DON check the resident's room. She stated that the resident was in the hospital at this time, and they checked her room. They found jewelry, a checkbook and ledger, legal documents, and an IPAD in the resident's room. They reviewed the ledger and noted that a lot of checks were written to a man and woman. The woman was a caregiver (#100) for independent living and assisted living which are located at the same site as long-term care. She stated that the caregiver met the resident when she resided in assisted living, but the checks were written while the resident was living in long-term care, which is on the second floor, and the caregiver was charged with theft. She stated that the resident would sign out and go by herself to the first floor where there is a restaurant and bar to meet with her friends from independent and assisted living. An interview was conducted on June 24, 2025 at 10:29 a.m. with the Director of Nursing (DON/staff #79), who stated that the resident was on life support at the hospital and a man from the church (priest) came her to see if the resident had an advance directive in place. He stated that the resident told him that there was a staff member who was taking care of her finances and he was concerned. Once the caregiver was identified, she was suspended immediately from Assisted Living and an investigation was started. The DON thought that the resident and the caregiver (#100) were meeting in the open area on the first floor. She stated a team assessed the resident for risk of elopement and falls and it was determined that she was safe to goes downstairs and walk around by herself. She stated that the caregiver (#100) was arrested and charged and was terminated due to reasonable suspicion. She also stated that an admission packet is completed with the resident during admission, which includes a statement about the facility storing the resident's valuables, which the resident is required to sign. that can be stored and the resident signs the form. She stated that the checks and ledger were given to the police department. An attempt was made on June 24, 2025 at 11:29 a.m. to contact the detective in charge of the case. A second interview was conducted on June 25, 2025 at 9:00 a.m. with the (DON/staff #79), who stated that she does not have an inventory list for the resident personal belongings which is supposed to be completed when the resident is admitted . If the CNA sees anything of value, they offer to write down the valuables on the sheet and may lock it up in the Social Services safe. She stated that the resident transferred from assisted living to long-term care in 2022. The Social Services Director did see the resident with a purse along with other staff, but she is not aware of any documentation of discussing the contents of the purse or offering to store the contents. She stated that the caregiver (#100) did say that she had accepted a small amount of money for a phone for the resident and the resident was complaining that it was taking forever to get the cell phone and did not find a phone amongst the resident's belongings. An interview was conducted on June 25, 2025 at 12:11 p.m. with the Unit Coordinator/Social Services Assistant (#23), who stated that only long-term care residents are allowed to go downstairs to the first floor to the bar and restaurant area. She stated that there are residents from independent living, the memory care unit, and assisted living as well. Friends and family members are allowed to come to the first floor to visit with the residents from all the areas. She stated that a resident needs to be able to ambulate independently and must not have any cognition issues to go to the first floor alone. She stated that she knows all the residents, so would know who can go downstairs. She stated that there are currently 58 residents on this floor. She has a census, but doesn't have any documentation regarding which residents are independent and can go downstairs alone, but she is able to look up the resident's profile to see if the resident is a fall risk. However, she doesn't know which document she would look at to determine cognitive status and if a resident has a cognitive issue, the resident must be accompanied by a CNA if one is available. She also stated that she knows the residents, but not all the staff working at the nurse's station by the elevator would know about all the residents and it is possible that a resident could get by to the elevator if she was typing or on the phone, but she would still stop them. The staff down by the bar area are supposed to supervise the residents from this unit and would call if something was wrong or suspected anything, but usually just sees staff dealing with their own residents. The facility's policy, Abuse, Neglect, and Exploitation states that it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of misappropriation for one resident (#38) was reported to the State Agency within the required time frame of twenty-four hours.Findings include:Resident #38 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, cirrhosis of the liver, and acquired absence of right leg above knee.Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition.Review of the facility-reported incident, submitted to the State Agency on March 15, 2024 at 3:59PM, revealed that Resident #38 had an unknown amount of cash and a debit card in his possession on March 12, 2024 at approximately 7:30PM, which was verified by staff. The report indicated that on March 13, 2024 around 11:00AM, Resident #38 reported to the facility that the money and debit card were missing. The report indicated that staff searched for the missing items all day on March 14, 2025, and that the debit card was found on March 15, 2025, but the money was not located. There was no evidence found that this incident was reported prior to March 15, 2025 at 3:59PM, which would indicate that this alleged violation of misappropriation was not reported within the mandated time frame of twenty-four hours.Interview was conducted on June 26, 2025 at 12:57PM with a Certified Nursing Assistant (CNA/Staff #88), who stated that if a resident reported that their items or money was missing, this would have to be reported to the nurse and the social worker, who would then take over.Interview was conducted on June 26, 2025 at 1:15PM with a Licensed Practical Nurse (LPN/Staff #73), who stated that if a resident reported items missing, the staff would first look for it and then would report it to the Director of Nursing or Assistant Director of Nursing. The LPN stated that missing items are usually reported right away.Interview was conducted on June 27, 2025 at 10:39AM with the Director of Nursing (DON/Staff #79), who stated that once a resident reports items or money as missing, the staff start looking for it right away. The DON stated that the items are often located, though it may be later. The DON stated that if the item cannot be found the same day, the facility will report it as missing. The DON explained that once they deem that the items cannot be found, the facility will also start reporting to the appropriate agencies, including the State Agency, treating it as misappropriation. When asked about the facility's timeline for reporting misappropriation, the DON explained that she prefers to report all alleged violations, including misappropriation, within two hours. She clarified that she starts the time from when the facility finishes looking for the item and could not find it, which she stated could sometimes take one or two hours. When asked about Resident #38's missing funds, the DON stated that Resident #38 had several items go missing around this time, and the items were mostly quickly located. She explained that in this case, the resident had asked the staff to hold off reporting or treating the items as missing. The DON stated that this was mostly driven by the resident. The DON acknowledged that the missing funds were not reported within twenty-four hours, stating that she knew it was a little later but that she still wanted to report it. The DON also stated that the funds were eventually found one or two months later in the resident's belongings.Review of the facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revealed that it is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, to the Administrator and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes.Review of the facility policy titled, Abuse, Neglect and Exploitation, revealed that the facility should report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes, including not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and facility policies, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level I was processed for determination of need for PASRR level II for one resident (# 42). The deficient practice could result in residents not receiving the appropriate services they need.Findings include: Resident # 42 was admitted to the facility on [DATE], with diagnoses that included esophageal varices with bleeding, acute post-hemorrhagic anemia, bipolar disorder, and alcoholic cirrhosis of the liver with ascites. The admission Minimum Data Set (MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. Review of the resident's Care Plan that was initiated on 5/15/2025 included a focus that included the resident has potential for altered activity participation related to decreased mobility and weakness, with a related goal that the resident will participate in preferred group activities daily through the next review date. Interventions to reach the care plan's goals included that staff will respect the resident's preferences for enjoying independent activities and provide opportunities for resident to enjoy activities, staff will encourage resident to participate in activities of resident's choosing, and staff will assist resident to the day room/transfer resident out of bed for sensory stimulation. The care plan did not specify a focus, goals, or interventions related to antipsychotic medication.Medication order for resident # 42 included Fluphenazine 5 mg, 1 tablet by mouth every day for bipolar as evidenced by mood lability, Melatonin 3 mg, 2 tablets by mouth daily at bedtime as needed.A review of the resident's electronic health record identified that there was no level I or level II PASRR.Review of the electronic health record revealed an informed consent for psychotropic medications dated 5/3/2025, signed by the resident for the above medications. Consent was indicated for melatonin, identified as to treat inability to sleep. The resident did not indicate consent for the ordered fluphenazine.Progress note dated 5/8/2025, and signed by Certified Nurse Practitioner included diagnoses of other stimulant abuse, in remission, schizoaffective disorder, unspecified, anxiety disorder, unspecified, bipolar disorder, unspecified, and alcohol abuse, uncomplicated. The note further indicated that the resident was diagnosed with bipolar disorder, and that the diagnosis was identified ten years ago. The provider stated that the resident endorsed a longstanding psychiatric history and stated that her mental health is being managed by an outside provider. The resident endorsed ongoing auditory hallucinations that were non-distressing and episodes of racing thoughts. The provider identified no agitation, aggression, anxiety, or cognitive impairment.An interview was conducted with Staff # 65, Social Services Director, on 6/26/2025 at 09:51 A.M. Staff # 65 reported that residents arrive to the facility with a level I PASRR, and that she creates a new level I document if they stay at the facility for 30 days or more. The Social Services Director states that she uses a 'bible' based on the facility census and keeps a calendar to manage the 30-day follow-up requirement. The Social Service Director stated that the company changed hands last November and has received no new tax identification number, and stated that without this number, she is unable to provide a level II referral to the state as required; however, she creates the documents and maintains them in files secured in her office. Staff # 65 states that she has raised the issue with the Facility Director and the Director of Nursing. Staff # 65 was asked to pull up the electronic health record for resident # 42 to locate and identify the level I PASRR. Upon her review of the resident's electronic health record, she stated that she could not find the document. Staff # 65 stated that this did not meet her expectation since admissions should have downloaded and further stated, We have been having some problems with that. When asked about the risk to the resident if PASRRs are not completed, she stated that they may not receive needed care or services.An interview with staff # 57 Facility Director was conducted on 6/26/25 at 13:50 P.M. The Facility Director stated that he was aware of the issue regarding the state tax ID and related National Provider Identifier (NPI) number. The Facility Director stated that he has been in frequent communication with his corporate office, the facility legal team and the Social Services Director to resolve the issue. The Facility Director further stated that the issue has a negative impact on facility revenue as due to the delay in obtaining the new tax identification and NPI numbers, he is unable to bill for Arizona Health Care Cost Containment System (AHCCCS) care. The Facility Director stated that the issue does not meet his expectations, but identified the barrier to resolution as outside of his influence.Email records provided by the facility, identified as INC0058578 to the Arizona Health Care Cost Containment System (AHCCCS) Provider Support system, dated 5/16/25, indicated that the facility Social Services Director (Staff # 65) contacted them to request assistance in creating a user account. The specific help inquiry stated I cannot create an account as my company went through change of ownership. We do not have a new AHCCCCS ID or Tax ID. The attached response from Customer Support, AHCCCCS stated, We're showing that your account has not been updated and you will not be able to do so until you have the new AHCCCS credentials.A level I PASRR obtained from the facility and generated from the hospital dated 6/26/2025, signed by, a Registered Nurse Case Manager (RNCM) indicated no indication for level II screening.A level II PASRR obtained from the facility, generated by the Social Services Director (Staff # 65) dated 5/7/2025, indicated referral for level II PASRR determination for mental illness (MI) only.A review of the facility administrative manual, # 5005.3 Preadmission Screening and Resident Review (PASRR) Policy revised 11/30/2023 noted guidelines for initial admissions from general acute care hospital using the Department of Health's PASRR online system to complete the PASRR process prior to discharging an individual to a SNF regardless of payor source. The policy further addresses PASRR documentation, stipulating that a copy of the level I screening and determination must be kept in the resident's current medical chart to allow access for Medi-Cal field office verification. Licensing and Certification monitoring, and Centers for Medicare & Medicaid Services (CMS) verification. The policy also states that PASRR documentation will be included in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure appropriate infection control measures were implemented and followed for one resident (# 44) related to tube feeding. The deficient practice could result in a spread of preventable illness to residents and staff.Findings include:Resident # 44 was readmitted to the facility on [DATE], with diagnoses that included hydrocephalus, hyperosmolality and hypernatremia, epilepsy, history of benign neoplasm of the brain, presence of cerebrospinal fluid drainage device, dysphagia, muscle weakness, diabetes insipidus, presence of cardiac pacemaker, hypothyroidism, gastrostomy, bilious vomiting, acute kidney failure, altered mental status, other post-procedural endocrine and metabolic complications and disorders, unspecified abdominal pain, autoimmune thyroiditis, hyperlipidemia and urinary incontinence. Review of resident #44's care plan revealed a focus, initiated 4/16/2025, that stated the resident is at nutritional risk and required tube feeding related to dysphagia. Interventions in place for this focus included the use of enhanced barrier precautions. Review of physician orders revealed a physician's order dated 3/8/2025, which indicated that Enhanced Barrier Precautions (EBP) were in place. The order indicated that Personal Protective Equipment (PPE) was required for high resident contact care activities, related to having a feeding tube, and specifically specified that a gown and gloves are required when assisting with device care or use, including central line, urinary catheter, or feeding tube.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that the resident had a feeding tube while a resident. The MDS revealed that the resident received 51% or more of her total calories through tube feeding, and averaged 501cc per day or more of fluids by IV or tube feeding.Observation of medication administration through the patient's gastrostomy tube was conducted on 6/25/2025 at 08:09 A.M. with a Licensed Vocational Nurse (Staff # 41). Prior to discontinuing the tube feeding at the ordered hour and administering the medications, the LVN gathered and prepared all required materials and performed hand hygiene. The LVN then donned gloves, but no gown. The LVN discontinued the tube feeding, flushed the tube and administered crushed and liquid medications through the tube without issue. The LVN flushed the tube again following the medication administration, removed gloves and performed hand hygiene prior to administering ordered oral medication. The entire medication process was conducted by the LVN without the use of a gown. An interview was conducted with Certified Nursing Assistant (CNA), Staff # 88 who stated that staff know which residents require Enhanced Barrier Precautions (EBP) by the sign that is hung outside their door. The LVN reported that she receives information during shift-to-shift report and stated that they walk from room-to-room to evaluate the patients. Staff # 88 identified the risk of not using EBP as spreading infections. An interview was conducted on 6/26/2025 at 09:17 A. M. with the Assistant Director of Nursing, (Staff # 81), who reported that staff are advised of the need for EBP by signs outside of the resident's room. The ADON reported that bins for Personal Protective Equipment (PPE) are stored in the hallway with receptacles in the room for use when discarding PPE. Staff # 81 stated that staff are to gown and glove when providing care to residents who require EBP and that staff receive training on EBP upon hire and at monthly staff meetings. The ADON stated that care provided without donning a gown would not meet expectations, as the risk to residents and staff would be that it is not up to facility standard. An interview was conducted with the Director of Nursing (Staff # 79) on 6/26/2025 at 10:06 A. M., who stated that she would expect EBP to be used when providing care for any residents with feeding tubes, urinary catheters, or wounds. She also stated that a gown and gloves should be used anytime a staff is providing advanced care to a resident on EBP. The DON states that EBP practices are overseen by periodic audits and reinforced by required training. Training is provided to agency and facility staff upon hire to the facility and annually. The DON stated that the risk of not following EBP would be the potential spread of infection to staff and residents. Review of the Routine Cleaning and Disinfection Policy, reviewed on 1/5/2025, revealed that transmission-based precautions refer to actions (precautions) that are based upon the means of transmission (airborne, contact or droplet) in order to prevent or control infections. The policy further states that staff will look for precautions signage prior to entering resident's room and use standard precautions, including appropriate personal protective equipment, for all rooms, unless transmission-based precautions are identified. The policy revealed that staff are to adhere to transmission-based precautions as indicated on precaution signs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide continence and shower care according to professional standards for one resident (#102). The deficient practice could result in skin breakdown.Findings Include:-Resident (#102) was admitted to the facility on [DATE] with diagnoses that included a urinary tract infection, multiple sclerosis, and anxiety disorder. The hospital summary dated September 15, 2022 included that the resident had an open area on buttocks with measurements: length: 4 mm, width 3 mm, and depth 0.A wound care weekly observation dated September 16, 2022 revealed left buttock with moisture associated skin damage (MASD). Measurements were length 4 mm, width 3 mm and depth 0. An order dated September 16, 2022 and discontinued on September 18, 2022 revealed cleanse left buttocks with NSS- pat dry - apply Xeroform - cover with bordered gauze every night shift for wound care. An order dated September 18, 2022 and discontinued October 6, 2022 revealed cleanse left buttocks with NSS- pat dry - apply Xeroform - cover with bordered gauze every night shift for wound care and every 1 hours as needed for wound care. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. It also included that the resident had moisture associated skin damage (MASD)A skin assessment dated [DATE] revealed an open area to the left buttock, and redness to the groin. There were no measurements included. The order dated September 24, 2022 and discontinued October 6, 2022 revealed complete skin observation (Form in PCC) check skin & sign shower Sheet every evening shift every Wed, Sat for shower. A skin observation form dated September 27, 2022 revealed that the resident received a bed bath with skin intact and no concerns. The care plan dated September 30, 2022 revealed the resident has potential impairment to skin integrity related to decreased mobility, bowel and bladder incontinence, left buttock MASD, status post left ankle fracture, status post left hip fracture, status post left distal hip fracture, resistant with cares, makes personal choice not to allow staff to move left leg and to not turn off back. Interventions included to apply moisture barrier as needed, observe skin condition on a weekly basis, and provide incontinence care as needed . Wash, rinse, and pat dry peri area. A skin assessment dated [DATE] revealed no new skin issues. Review of the Medication Administration Record (MAR) dated September 2022 revealed that skin observations and nightly wound care were completed. Review of the ADL Toileting task sheet (urine task sheet) dated September 2022 revealed:-15 times the activity did not occur-8 times there was no documentation-0 refusalsReview of the bowel task sheet dated September 2022 revealed:-9 times there was no documentation-0 refusalsReview of the ADL Toileting task sheet (urine task sheet) dated October 2022 revealed:-7 times the activity did not occur-2 times the resident was not available-0 refusalsReview of the bowel task sheet dated October 2022 revealed:-7 times the activity did not occur-2 times the resident was not available-0 refusalsNote that paper shower forms were requested and not provided. An interview was conducted on June 27, 2025 at 1:23 p.m. with the Director of Nursing (DON/staff #79), who stated that the resident was admitted to the facility on [DATE] and discharged on October 6, 2022. She stated that the MDS dated [DATE] revealed that the resident required two plus assistance with transfers and toileting, but assumed that the resident was not using the toilet. She stated that the staff are supposed to complete the task sheets every shift, so there should be documentation three times a day. She reviewed the task sheet for bowel care dated September 2022 and stated that there were no refusals documented and there was no documentation for 9 shifts indicating the task did not occur. She reviewed the bladder task sheet dated September 2022 and stated that there were no refusals documented, no documentation for 8 shifts, and 15 times the activity did not occur. Then she stated that the residents are supposed to receive a shower twice a week and reviewed the bathing task sheets for September 2022 and stated that the resident received two showers from September 15 through September 30, 2022. She stated that there are risks to not being changed or showered regularly: UTI, skin issues, shearing, yeast infections, and pressure ulcers. An interview was conducted on June 27, 2025 at 1:54 p.m. with a certified nursing assistant (CNA/staff #89), who stated that she received training on continence care and showers. She stated that continence care and showers are documented in the electronic record and showers are provided twice a week. She stated that showers are also documented on a paper form. She stated that if the resident refuses continence care and/or showers, she documents the refusal in the electronic record. She also documents the refusal on the paper shower forms along with skin issues and if the resident is not getting a shower, there is a risk of skin breakdown, odor and rashes. She stated that continence care is provided every two hours or as needed and the risk of not providing care is not smelling fresh, UTI, and an open sore. The facility policy, Incontinence Policy states that all residents that are incontinent will receive appropriate treatment and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure weekly skin assessments were provided for one resident (#21) of three sampled residents, as ordered by the physician and failed to ensure that physician orders for one resident (# 28) for diagnostic testing were addressed in a timely manner following an unwitnessed fall. The deficient practice could lead to an injury being missed and a delay in care being provided to the resident and result in skin impairments developing or worsening without staff intervention.Findings include: -Regarding Resident #28 Resident # 28 was initially admitted on [DATE], discharged on 1/12/2025 and readmitted following a change of condition on 1/16/2025 with diagnoses that included acute on chronic diastolic (congestive) heart failure, type II diabetes mellitus with hyperglycemia and chronic kidney disease, adjustment disorder with depressed mood, unspecified, mood disorder, patient’s non-compliance with other medical treatment and regimen, history of falling, personal history of (healed) traumatic fracture, acute pain due to trauma. A quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive deficits. The Patient Health Questionnaire-9 (PHQ-9) revealed a score of 3, which indicated mild mood depression. Section E of the MDS revealed no hallucinations, delusions, behavioral symptoms towards self or others, rejection of care, or wandering. Section GG of the MDS revealed that the resident required substantial/maximal assistance in the ability to roll from lying on the back to the left and right side, and return to lying on the bed, and was dependent in sitting to lying, chair to bed, or bed to chair transfers. Section J of the MDS revealed that the resident experienced frequent pain that required scheduled and PRN medications, with the worst pain rated at 7 out of 10 on the pain scale. A physician orders last reviewed 6/15/15 revealed: orders for a wheelchair cushion to protect skin integrity and mobility, bed against the wall to increase living space and ease of ambulation, catheter care, anti-anxiety monitoring every shift and daily, pain and psychiatric services evaluations. A review of the comprehensive care plan dated 4/9/2025 revealed: Risk of injuries related to falls due to history of falls, MS, medications, and patient choice to have an air overlay mattress. The care plan specified that the resident is at risk for injuries from falls related to weakness, decreased balance, limited movement/ range of motion of the right lower extremity, history of falls, MS, medications, and the patient's choice to have an Air Overlay Mattress. The care plan revealed that the resident had an unwitnessed fall on 1/9/2025 with minor injury and that an x-ray report dated 1/12/2025 showed a displaced intertrochanteric femoral fracture with no hip dislocation. Interventions included to ensure that resident’s call light was in reach and to provide prompt response to requests for assistance, place resident’s bed against the wall to increase living space and functionality of the room, encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility, encourage resident to wear appropriate footwear when mobilizing in wheelchair, fall mat at bedside and lab monitoring that included urinalysis, macroscopic with reflex to culture, urine culture, complete blood count with differential and platelet, comprehensive metabolic panel, hemoglobin A1c with eAG/Ammonia and B-type Natriuretic Peptide. A progress notes labeled “late entry” authored by the facility administrator dated 1/9/2025 at 3:45 A.M. stated, According to the Staff Nurse: Patient was found on the floor, on the side of the bed, sitting on his bottom, knees slightly bent. Small skin tear to the front of his left hand and the big toenail is loose and bloody; this writer provided first aid. The patient was put back in bed using Hoyer lift, neuro checks in progress, bed moved against the wall for safety precautions, and floor mat beneath bed, call light within reach. Resident refused to go to the hospital for further evaluation, c/o hip pain, prn Percocet administered. The resident stated that he slid out of bed. Neuro check, put back in bed using Hoyer and two other staff for assistance, skin assessment, first aid done on right big toenail and skin tear on left hand, contacted provider and DON. A eINTERACT SBAR Summary for Providers note dated 1/9/2025 at 04:14 A.M. indicating Primary Care Provider's Feedback following contact by the facility revealed: that the Primary Care Provider responded with the following feedback: A. Recommendations: Follow up with wound nurse for further treatment. Bed in lowest position. PRN Percocet for pain management. B: New Testing Orders - other - none at this time. C. New Intervention Orders - Other -None at this time. A review of records provided by the facility revealed that an order for two-view left hip and 2-view left pelvis x-rays was ordered on 1/9/2025 at 11:47 A. M. via telephone. The order was labeled as having a normal urgency rating. A review of records provided by the facility, dated 1/10/2025 at 03:59 P.M., revealed that Registered Nurse (RN/Staff # 35) contacted the mobile imaging company to inquire about a pending ordered x-ray and was advised, “Yes, we do have that patient on file.” The imaging was noted to be still pending. A review of records provided by the facility revealed that a urinalysis was collected on 1/11/2025 at 05:30 A. M. and received at the lab on 1/11/2025 at 12:55 P.M. A review of records provided by the facility dated 1/11/2025 at 11:11 A.M. revealed a progress note written by Licensed Practical Nurse (Staff # 8), which revealed that the resident had a significantly altered mental status with an inability to administer medications due to safety risk. The nurse practitioner was notified. A progress dated 1/11/2025 at 03:04 P.M. revealed that provider orders were received that included an infusion of normal saline at 50 mL/per hour for a total of 500 mL and Rocephin 1 gram IV daily for 10 days. IV insertion was recorded at 02:00 P.M., and staff were awaiting the arrival of antibiotics from the pharmacy. A review of records provided by the facility, dated 1/11/2025 at 03:32 P.M. revealed that the Director of Nursing (DON), (Staff #79), was advised by staff that imaging had not yet been completed. The DON contacted the mobile imaging company, which advised that they planned to come later that day. The note further included information from the resident who stated, “I am not having any more pain than I normally have in my hips. That’s normal for me, so hard to tell if it's worse or not.” A review of records provided by the facility dated 1/12/2025 at 03:01 A.M. revealed a progress note written by Licensed Practical Nurse (LPN), (Staff # 84) that indicated the patient had altered mental status, and exhibited some confusion, but was cooperative with care. The same LPN noted at 04:39 A.M. that the resident complained of hip pain. A review of records provided by the facility, dated 1/12/2025 at 06:09 P.M. revealed a progress note written by Licensed Practical Nurse (Staff # 8) which revealed that the resident had a slightly improved altered mental status and was able to follow commands and answer questions appropriately. The LPN noted that the resident still had complaints of hip pain, and the x-ray was done. Staff # 8 reported that the facility was awaiting imaging results. A review of records provided by the facility revealed that urinalysis results were reported on 1/12/2025 at 07:49 A.M, which indicated a final urine culture result of Mixed gram-positive and gram-negative flora > 1000,000CFU/mL. The comments indicated that there were multiple organisms present resembling urogenital flora; therefore, no further work-up was indicated. A review of records provided by the facility dated 1/12/2025 at 07:15 P.M. revealed a progress note written by Licensed Practical Nurse (Staff # 8), which revealed that x-ray results came back indicating a broken femur. The resident was transported to an acute care hospital. The notes indicate that the resident’s son was notified of the transfer. A undated facility interdisciplinary team (IDT) Fall Committee attended by the DON, ADON, Facility Director, Medical Director, nursing representative and rehabilitation representative identified the root cause of the fall as the resident was rolling himself in bed utilizing the mobility bars and reaching rope when he slid off the bed onto the floor on the left side of his bed. The resident was recently placed on an air mattress due to a regressing pressure wound. Risk versus benefit was weighed with the wound surgeon and physician team prior to placement of the air mattress. The resident reportedly was not compliant with weight shifting and relieving pressure by getting from the wheelchair to bed throughout the day. Fall committee interventions included moving the bed against the wall to increase living space and functionality of the room, a fall mat at bedside, removal of air mattress with replacement by foam surround low-air loss mattress, Physical Therapy services, Occupational Therapy evaluation, and consideration of restorative nursing evaluation post-therapy. An interview was conducted with a Certified Nursing Assistant (CAN/Staff # 88), on 6/26/2025 at 11:39 A.M. The CNA reported that if a resident fell while she was on duty, she would help the resident and notify the nurse. She stated that she received training on safe patient handling techniques when she was hired. An interview was conducted with Resident (# 28) on 6/26/25 at 11:15 A.M. The resident stated that he remembered the incident and reported that his right leg does not work well and that his body tends to 'scootch' to the left. He stated that he used ropes attached to his bed to turn himself. He reported that he was turning to his left side, and the air mattress on top of the bed mattress slipped, and he fell over the side of the bed. The resident stated that when he fell, he landed between the wall and the bed and could not get up. Resident # 28 stated that when he fell, he could not reach the call light and spent some time on the floor before he received help. The resident reported that he was able to reach the remote to the television and increased the volume, which alerted staff that he needed help. The resident stated that when staff responded, they used the Hoyer lift to get him back into bed. Resident # 28 states that the orthopedic surgeon explained that there is no way to be sure if the fall caused the fracture or if the return to the bed in the lift was a contributing factor. The resident reported that he had significant pain following the fall that was increased from his baseline discomfort related to Multiple Sclerosis. Resident # 28 stated that his family was not notified of his injury until he called his sister to advise her of the injury and continuing pain. The resident reported that his sister then called his son and medical power of attorney to let him know of the event. He further stated that the fall occurred shortly after the unexpected death of his wife, who had been his point of contact for the facility. He has now identified his son as his medical power of attorney. The resident stated that he is now recovered and anticipates that he will be released from care by the orthopedic surgeon at his next visit in the coming weeks. An interview was conducted with the Director of Nursing (DON/Staff # 79), on 6/26/2025 at 11:30 A. M. The DON stated that she recalled events relating to the resident's fall. She states that the resident was being monitored for a shearing injury, even though he is completely mobile using rails and could turn himself from side to side independently. The DON reported that the resident often refused to offload pressure and preferred to sit in his wheelchair, so a low air mattress was applied to his bed. The DON stated that when he fell, nursing staff reported the injury and an electronic order from the provider was processed for a mobile x-ray. She states that the family was notified, but she did not remember which family member was called. She further stated that the process is to start at the top of the resident's contact list with the most important contact and continue down the list until someone is reached. The DON reported that the resident initially declined to go to the hospital for an X-ray and preferred that a mobile X-ray be done. The DON reported that she was in close contact with the resident following the fall, and she did not feel it was necessary to seek more urgent care pending imaging results, as the resident's pain was not reported to be higher than his baseline. The DON reported that the mobile x-ray company did not respond timely and staff called to check on the x-ray service's arrival and she followed up when she was notified that the service had not arrived to request service. Staff # 79 stated that the patient was sent to the hospital prior to receiving the imaging results. She reported that the resident has frequent hospitalizations related to his recurrent urinary tract infections and issues with a clogged suprapubic catheter. She states that the delay from 1/9/25 injury to 1/12/ hospitalization did meet her expectations due to her knowledge of the resident and her assessment that he did not complain of extra pain, so her decision not to send the resident out for imaging in an acute care setting made sense. The DON did not mention the change in mental status that was reported in the progress notes. A telephone interview was conducted on 6/26/25 at 12:19 P.M. with the resident’s son who confirmed that he received no notification of his father's injury by the facility. He reported that his father notified his aunt (father's sister) to report the event 2-3 days after the fall who contacted him to let him know of the injury, and that the resident remained in pain. He stated that his father told him the technician who took the X-ray at the facility told the father 'okay, this is broken' and later his father was transferred to the hospital. The son stated that following the hospitalization, he came to the facility to talk with the facility staff to discuss what happened. He stated that he spoke with 2 nurses (did not have names) and was advised that they would have the Assistant Director of Nursing (ADON) contact him, but he did not receive any follow-up calls. He reports he received no notification of a recent hospital visit relating to the need to address a clogged catheter that occurred on 6/12/2025. He stated that these instances 'gave him pause' and he contacted attorneys, but based on conversation with them and subsequent conversation with his father, he confirmed that the resident feels safe in the facility and has elected to remain in the facility at this time. A review of the Accidents and Supervision policy, last reviewed on 4/22/2024, revealed that it is the policy of the facility that the resident environment will remain free of accident hazards as is possible. The policy further states that each resident will receive adequate supervision and assistive devices to prevent accidents. The policy indicates that supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents, which is defined by type and frequency and based on the individual resident’s assessed needs and identified hazards in the resident's environment. A review of the Fall Risk Assessment policy, last reviewed on 4/22/2024, indicated that it is the policy of the facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. The policy indicated that risk assessments will be completed upon admission, quarterly, or when a significant change is identified. A review of the Incidents and Accidents Policy last reviewed 3/16/2024 indicated that it is the policy of the facility to utilize “Risk Management” in the resident’s electronic health record (PCC) to report, investigate and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Compliance guidelines within the policy indicate that incident/accident reports are part of the facility’s performance improvement process and are confidential quality assurance information -Regarding Resident #21 Resident #21 was admitted to the facility on [DATE] with diagnoses that included epilepsy, type two diabetes mellitus with diabetic polyneuropathy, and hemiplegia and hemiparesis affecting left non-dominant side. Review of the physician orders revealed an order, dated August 3, 2023, which ordered a weekly skin check and Braden scale to be completed on every Thursday. This order was discontinued on February 11, 2024. Further review of orders revealed an order, dated February 15, 2024, which ordered weekly skin checks every Thursday, and this order was active until discontinued on April 14, 2024. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS also revealed that the resident had one sided impairment in a lower extremity, and required substantial or maximal assistance with rolling left and right. The MDS indicated that the resident was also frequently incontinent of bladder and always incontinent of bowel. The MDS revealed that the resident was at risk of developing pressure ulcers, and did not have any pressure ulcers at the time of assessment. Review of the charted skin assessments revealed skin assessments completed on the following dates: February 1, 2024 February 14, 2024 March 21, 2024 April 11, 2024 There was no evidence found that skin assessments were completed between February 2, 2024 to February 13, 2024. There was no evidence found that skin assessments were completed between February 15, 2024 to March 20, 2024. There was no evidence found that skin assessments were completed between March 22, 2024 to April 10, 2024. Based on this review, weekly skin assessments were not completed as ordered by the physician. Additionally, a review of the nursing progress notes from these time periods revealed no evidence that a full skin assessment was completed during the described time periods. Interview was conducted on June 26, 2025 at 12:57PM with a Certified Nursing Assistant (CNA/Staff #88), who stated that nurses complete the skin checks for residents, though CNAs would also alert nurses if they see any skin issues while conducting showers. Interview was conducted on June 26, 2025 at 1:15PM with a Licensed Practical Nurse (LPN/Staff #73), who stated that nurses should complete weekly skin checks on residents, which are often scheduled on a resident’s shower day. The LPN stated that these skin checks should be documented in the Electronic Health Record (EHR) under Assessments. The LPN explained that the purpose of the skin checks is to make sure the resident is not having skin breakdown. The LPN stated that the risk of not completing a skin check as ordered would be that the resident may have developed wounds or their wounds would have worsened. Interview was conducted on June 27, 2025 at 10:39AM with the Director of Nursing (DON/Staff #79), who stated that nurses should conduct weekly skin checks. The DON stated that the wound nurse will also do a skin check when checking wounds, and that CNAs will also do skin checks on shower days. The DON stated that head-to-toe assessments and admission skin assessments should be documented in the EHR. When asked about Resident #21’s skin checks, the DON confirmed she was aware that there were periods of time that the skin checks were not completed, and she stated that it was one nurse that missed them. The DON explained that the process at that time was to have one nurse complete all of the skin checks, but the process had since been changed, and now the floor nurses complete their own skin checks. Review of the facility policy titled, Pressure Injury Prevention and Management, revealed that licensed nurses should conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury, and findings should be documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to provide and environment free from accident hazards for one resident (#21) and failed to ensure adequate supervision to ensure one resident (#105) did not elope. The deficient practice could result in residents being injured, abused, or lost. -Regarding Resident #105-Resident (#105) was admitted on [DATE] and re-entered on September 8, 2024, with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, repeated falls, adjustment disorder, and type II diabetes. The care plan dated September 30, 2022 revealed that the resident is at risk for injuries from falls related history of falls, weakness, decreased balance, medications, Lymphangioleiomyomatosis (LALM), and Marijuana use. Interventions included to provide cueing, supervision, and assistance as indicated.The Elopement Risk Evaluation dated September 8, 2024 revealed that the resident was not a risk for elopement. The fall assessment dated [DATE] revealed the resident has fallen one to two times within the last six months and was a moderate risk for falling.The order summary included an order dated September 11, 2024 for a change of condition, date of fall was September 10, 2024 that included a hematoma, neuro-checks started. Every shift for three days monitor for new injuries, mood changes, ambulation changes, cognition changes, and/or other changes off baseline. The MDS dated [DATE] included a brief interview for mental status score of 13 indicating the resident was cognitively intact. It included one fall since admission or prior assessment with an injury. It also revealed that the resident was able to use electric wheelchair independently. Review of the order summary revealed: -orders for outside physical therapy appointments included an order for transportation. -there was no start date for the order, may not go out on leave of absence or pass unless with family member and coordinated with the Social Services Assistant (SSA), Director of Nursing (DON), or the Assistant Director of Nursing (ADON). All appointments must be scheduled for transport with the unit secretary.A nurse note dated October 15, 2024 revealed that the resident was brought back to the facility via a gurney from the hospital. According to the day nurse report, the resident went out and was found passed out. The resident was then transported to the hospital. A physician note dated October 16, 2024 revealed that the resident left for an appointment yesterday and was later found in her chair on 19th Avenue with an altered mental status (AMS). Paraphernalia was later found in her room. She was brought to the hospital and observed. Review of the Medication Administration Record (MAR) dated October 16, 2024 revealed that the resident was being monitored for a change of condition (COC) every shift for three days after returning from the hospital.A nurse note dated October 16, 2024 included that the resident is back in the facility after a brief time in the hospital emergency room due to falling asleep at the train rail. The resident was waiting for the train to take her to therapy outside of the facility, when according to the resident, she was enjoying the sun and closing her eyes in her electric wheelchair. A pedestrian called 911 and they took her to the hospital for evaluation. The Director of Nursing (DON), Social Services Assistant (SSA) and Executive Director (ED) went to speak with the resident. The Assistant Director of Nursing (ADON) had spoken t the resident last week about not following transportation directions. The resident usually sets up her own transportation, but lately has been cancelling rides home or not catching the train and coming back to the facility late. The DON, SSA, and ED spoke to the resident about passes being tweaked. The resident is to take transportation set up by the facility from this point forward, and all passes out of the facility besides medical transport need to be accompanied by a family member for safety. The resident agreed to this. The Social Services note dated October 16, 2024 revealed that the ADON, ED, and SSA met with the resident on October 16, 2024 to discuss the risks and complications of leaving the facility on her own. The resident declines insurance transportation and prefers to set up her own. This implies that the resident takes public transportation and there have been several occasions where the resident leaves and does not come back within the hours it would take for her to come back. The resident cancels her transportation and goes elsewhere for hours without informing the facility. On October 15, 2024, the resident was found with AMS at the Metro Rail Station and paramedics were called and she was taken to the emergency room. On October 16, 2024, the SSSA and a certified nursing assistant (CNA) had to go to the hospital to pick up the resident's motorized wheelchair. The DON, ED, and SSA explained the risks, complications, and liability to the resident at length and in detail. The resident agreed with everything. She understands that if she is to go to a medical appointment, she will need to go with medical transportation, and if she wishes to go elsewhere, she will need a family member to go with her. There have other times when the resident leaves during heat advisory days and takes her motorized wheelchair to shopping centers that are miles away. A skin wound treatment note dated October 17, 2024 revealed that the resident was observed by other staff at the building sitting outside of the facility gates on the main road slumped over in her wheelchair. A large fluid filled blister was identified to the resident's upper right leg. The physician was notified and received orders to clean with alcohol, aspirate with needle and cover with island dressing. Serous fluid was aspirated from the blister. The resident tolerated the procedure well with no complaint of discomfort during the procedure. The SSA progress note dated October 17, 2024 revealed that the hospital records stated that the resident was positive for THS at the hospital emergency room. During the morning meeting, staff were informed that the resident had left to an appointment alone in her motorized wheelchair. At around 2:45 p.m., the DON and the ADON were informed by the Maintenance Director that the resident was passed out on the sidewalk of 19th Avenue. The DON, ADON, and nurse went to evaluate the resident. She was passed out and appeared to be under the effects of a substance. She stated that she did not recall meeting with the ED, DON, and SSA on October 16, 2024. The resident had a permanent smirk on her face and could not fully open her eyes. She was unable to operate the electric wheelchair. The ADON had to maneuver the electric wheelchair, operating the joystick while slowly and safely wheeling the resident back to the facility. The DON contacted the physician and he ordered a drug testing panel. The DON, ADON, and the SSA met with the resident on October 17, 2024 once the resident was in bed and alert. They discussed the dangers, risks, complications, and liabilities regarding the resident's habitual leaving the facility on her own with the excuse of going to a medical appointment and she is out of the facility for several hours and staff is unaware of her whereabouts. When the resident was found today, she had several shopping bags from different stores. At this time, the resident will not be able to use her motorized wheelchair. She is a danger to herself. The elopement screening dated October 17, 2024 revealed that the resident was a high risk for elopement with a score of 14. The care plan dated October 17, 2024 revealed that the resident is an elopement risk as evidenced by leaving the community unattended after being instructed not to, impaired safety awareness, Marijuana use.The care plan dated October 17, 2024 revealed that the resident has a substance abuse problem related to Marijuana use as evidenced by positive testing and AMS. Interventions included to remain nonjudgmental. Be alert to changes in behavior. Report changes to the nurse/physician. Review definition of drug dependence and categories of symptoms (patterns of use, impairment caused by use, tolerance to substance). An interview was conducted on June 25, 2025 at 9:00 a.m. with the (DON/staff #79), who stated that the brief interview for mental status score (BIMS), fall risk assessment, and the elopement risk assessment is used to determine if it is safe for a resident to leave the long-term care facility on the second floor and go out independently. She stated that if a resident wants to go out of the building and leave the property, a physician order is needed. The resident had orders to go to appointments once or twice a week, which included medical transport, but the resident refused the transport and would would take the train. The resident would come back late, hours after her appointment, and would be high. She stated that they tried to counsel the resident about taking the medical transportation because it was too hot outside. She stated that the second time, the resident was out by the rail line, she and staff ran out there and the resident was high and she kept wheeling to the left towards the traffic and we had to wheel her in manually. She stated that the resident was sent out to the hospital both times she was found by the train tracks and tested positive for Marijuana. An interview was conducted on June 25, 2025 at 12:11 p.m. with the Unit Coordinator/Social Services Assistant (#23), who stated that she schedules the outside appointments for the residents which includes transportation. She stated that the transportation driver comes up to the second floor to pick up the resident for his/her appointment and she goes to get the resident. If a resident refuses transportation and wants to go to an outside appointment on his/her own, they are allowed to go if they are capable. She stated that she discusses with the management team to see if a resident can go to appointments on their own: DON, ADON, nurses, and the SSA Director. The team decides if the resident can leave the facility alone, and it depends if the resident is alert and oriented, and a fall risk. She stated that if she sets up transportation with the appointment, and the resident refuses the transportation, she notifies the family to see if family can come and pick the resident up and take the resident to the appointment. She redirects the resident and would also see if she could reschedule the appointment if family can't come. If the resident continues to try and leave, she reports it to the DON and the ADON. If the resident leaves it is considered an elopement. Only long-term residents are allowed to go downstairs to the first floor, and the concierge is expected to stop the long-term resident from leaving the building and call the long-term care unit to let staff know that a resident is trying to leave. She stated that she is not required to keep the appointment forms for the residents, so she doesn't have a record of resident (#105) going to outside appointments on October 15 and 17, 2024. She reviewed the resident's clinical record and stated that she couldn't find any documentation showing that the resident attended outside medical appointments on the above dates, but there were orders for the appointments. She remembered one time when the resident refused the transportation and wanted to go by herself. She told the resident that they would have to reschedule and the resident insisted she could go in her motor scooter, but finally agreed to stay here. She stated that the resident was allowed to go downstairs by herself and would just leave. She would go to the store and back, Fry's Grocery Store in her scooter. She is aware that residents need an order/pass from the physician to leave the building and believes that the SSA takes care of it. It was her understanding that the resident was allowed to leave the building. She was not aware of the resident being found in her wheelchair by the light rail. She stated that the risk to being left outside is a heat stroke. An interview was conducted on June 25, 2025 at 1:08 p.m. with the (SSA/staff #65), who stated that resident can go downstairs after they are assessed for falls and would include a resident in a wheelchair because the resident could still be a risk. The brief interview for mental status score (BIMS) of 13 or higher would be required for cognition. She would also look at the resident's diagnoses and a history of drug use. A resident with a history of drug use would not be safe to go downstairs alone because family, friends, a boyfriend could bring drugs, and the resident could leave the building to go drug seeking. The front desk monitors who is going downstairs, and would notify her if a resident is trying to leave who should not leave. She goes out to redirect the resident. Transportation is set up for all residents going out to outside appointments and if the resident refuses the transportation and wants to go by her/himself, the interdisciplinary team would have to determine if it was safe: drug use, get lost, cognition. fall risk and the psychosocial, such as is the family okay would all need to be evaluated. Then she stated that the staff on the first floor would address any concerns, but are considered independent of the long-term care unit. The facility policy, Elopement states that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. -Resident #21 Resident #21 was admitted to the facility on [DATE] with diagnoses that included epilepsy, repeated falls, and hemiplegia and hemiparesis affecting left non-dominant side. Review of the care plan revealed a problem focus, initiated on June 30, 2023, which revealed that Resident #21 was at risk for injuries from falls. Interventions in place included ensuring the call light was in reach and providing cueing/supervision as indicated. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS also revealed that the resident had one sided impairment in a lower extremity, and required substantial or maximal assistance with rolling left and right. The MDS indicated that the resident was independent to move from lying in bed to sitting on the side of the bed, and he required partial or moderate assistance to transfer from chair to bed. Review of the nursing progress notes revealed a nurse's note, dated February 13, 2024, which indicated that Resident #21 was alert and oriented x2, had some confusion, and could not always verbalize his needs. Review of the nursing progress notes revealed a note dated February 14, 2024, which indicated that Resident #21 was found on the floor around 12:10AM. The note revealed that a new alternating pressure pad was in place at the time of the fall, and that no fitted sheet was in place at the time of the fall. The note indicated that Resident #21 explained that his bed was uncomfortable and that he had slid down the bed. The note revealed that the resident was placed back in bed after applying a fitted sheet to the mattress and assessing the resident. Further review of the nursing progress notes revealed an IDT meeting note, dated February 18, 2024, which reviewed that Resident #21 had experienced a fall on February 14, 2024. The note indicated that the resident was uncomfortable in bed and slipped on the flat sheet covering the mattress topper. The note revealed that following the event, the care plan was updated to include a fitted sheet on the bed to reduce fall risk during transfer or when lying in bed. Interview was conducted on June 26, 2025 at 12:57PM with a Certified Nursing Assistant (CNA/Staff #88), who stated that if a resident is a fall risk, interventions are put in place such as a low bed, a fall mattress on the floor by the bed, call light within reach, and checking on them often. The CNA also stated that all residents should have full linens on their beds. Interview was conducted on June 26, 2025 at 1:15PM with a Licensed Practical Nurse (LPN/Staff #73), who stated that staff attempt to prevent falls to the best of their ability, using interventions such as frequent checks, a low bed, call light within reach, and the use of a fall mattress if they had fallen before. The LPN also stated that all residents have standard linens on their beds, which are made by the shower aids. Interview was conducted on June 27, 2025 at 10:02AM with Resident #21, who confirmed that he had experienced a fall while at the facility, and confirmed that he had slid out of bed. The resident declined providing any further detail. Observation revealed that Resident #21 was in bed with his call light within reach at the time of interview. Interview was conducted on June 27, 2025 at 10:39AM with the Director of Nursing (DON/Staff #79), who stated that interventions in place to help residents from slipping out of bed included keeping the bed in the lowest position and the use of a fall mattress if indicated. When asked about Resident #21’s fall, the DON recalled that Resident #21 would roll himself in bed. The DON stated that the resident had a low air-loss mattress in place, and when he rolled, he slid down the side of the bed. The DON also confirmed that at the time, the resident had a flat sheet in place but no fitted sheet on the bed. The DON explained that following the fall, a new air mattress was purchased, which had foam around the edges, assisting in fall prevention. The DON also stated that the care plan was updated to specifically address the need of a fitted sheet on the bed. Review of the facility policy titled, Accidents and Supervision, revealed that the resident environment should remain as free of accident hazards as possible.

Based on personnel file review, interviews, and policy review, the facility failed to complete a yearly performance review for 1 of 2 sampled Certified Nursing Assistants (CNA/Staff #12). The deficient practice could result in insufficient and inadequate care for residents.Findings include: Review of the personnel file for a CNA (Staff #12), revealed a hire date of July 13, 2023, for hourly employment. Review of the file did not reveal a yearly performance review had been completed or any evidence of that a performance review had been conducted for the year of 2024 or 2025. An interview had been conducted on June 26, 2025 at 2:59PM with the Director of Nursing (DON/Staff #79) where Staff #79 stated that the facility implemented a broad spectrum pay assessment for CNA's that is reviewed alongside county requirements to update pay amount accordingly. Staff #79 stated that the facility does not complete one on one reviews with staff to discuss their overall performance. Staff #79 stated that the extent of a performance review is relied on formal complaints regarding a staff's work ethics, areas that may have been discussed as a trend, infection control practices utilizing infection control mapping, and review of physical documentation; and that review will dictate what trainings are planned for staff. Staff #79 did state that the risk of not implementing a performance review procedure can result with staff losing the opportunity for improvement. Staff #79 did state, that although there is currently no structure to the performance review process, that the facility is currently implementing a procedure for the completion of one on one reviews that will be to discuss the overall performance of a CNA, and to appropriately provide trainings utilizing the performance review results. A review of title 42 CFR S483.35 (e) (7) revealed that a facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. Review of the facility's employee handbook revealed that performance evaluations should be an ongoing discussion of feedback between supervisors and employees. The handbook also revealed that evaluations are established on an annual, documented basis, as a standard to formalize an interactive conversation about the performance of an employee. The handbook also revealed that the performance reviews do not always result into a pay raise, however, a performance review should be completed. The handbook also stated that the performance evaluation will require the signature of the employee who is undergoing a performance review. A review of a facility policy titled ‘Performance Evaluations' had been provided by the facility on June 27, 2025, which revealed that a performance evaluation will be completed annually, and to occur during the same time as the employee's compensation review.

Based on observation, staff interviews, and policy review, the facility failed to ensure that medications were dated when opened. The deficient practice could result in reduced drug effectiveness and adverse reactions.Findings include:During a medication observation conducted on 6/25/2025 at 09:40 A.M., one 50 mL, multi-dose vial of 1% lidocaine was observed in the medication refrigerator with no opened-on date.An interview with Licensed Vocational Nurse (LVN), (Staff # 63) was conducted on 6/25/2025 at 09:10 A.M., who reported that medications should be labeled when opened, and if not needed to refrigerate, may be kept until the manufacturer's expiration date. The LVN stated that medications should be stored in a locked cart or in the medication storage room at all times and stated that the risk to the resident could be to use expired medicine.An interview with Licensed Vocational Nurse (LVN), (Staff # 41), was conducted on 6/25/2025 at 8:45 A. M. who stated that blister-packed medications should always be placed back into the cart when the cart is not attended by a nurse and that the medication cart should be locked. The LVN stated that this is for patient privacy as well as to decrease the risk of medications being removed by other staff or residents. Staff # 41 stated that the impact of leaving medications on the medication cart would be that someone may take medications that are not prescribed and cause them harm.An interview with the Assistant Director of Nursing (Staff # 81), was conducted on 6/26/2025 at 09:17 A. M., who stated that all liquids, insulins, and over-the-counter (OTC) medications should have an open date. The ADON stated that twenty-eight days after they are opened, they are discarded. Staff # 81 stated that non-refrigerated liquids and OTCs are okay to use until the manufacturer's expiration date. The ADON reported that medications received in bubble packs at reordered when 5 days are left on the card, which minimizes waste and potential risk of administering expired medications. The ADON stated that an opened but unlabeled vial in the medication storage room does not meet expectations and that the risk is that the medicine may not be effective for treating the patient. Staff #81 reported that controlled substances are double locked, whether they are in the medication cart or in the medication storage. Unsecured medications on the unit do not meet expectations, and the impact to the resident is that patient information could be shared inadvertently or someone could take the medications. The ADON confirmed that controlled substances are double locked, whether they are in the medication cart or in the medication storage. Unsecured medications on the unit do not meet her expectations, and the impact to the resident is that patient information could be shared inadvertently or someone could take the medications. An interview was conducted with the Director of Nursing (DON) (Staff # 79) on 6/26/2025 at 09:57, who reported that all medications are bubble-packed when received. Staff # 79 reported that opened medication vials are good for twenty-eight days and that opened and unlabeled medications would not meet expectations. The DON identified the risk as that if medication is not labeled, staff don't know when to discard it.Review of the Medication Monitoring policy reviewed 1/5/2025 revealed that Medications shall be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications.Review of the Medication Storage policy review 1/5/2025 revealed that the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with policy and procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policies and procedures, the facility failed to ensure the clinical record for one resident (#4) contained the required notification/documentation to the receiving provider. The deficient practice could result in the receiving provider not being informed of the resident's status. Findings include: Resident #4 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis affecting left non-dominant side and right dominant side, anxiety disorder, quadriplegia, psychoactive substance dependence., adjustment disorder with anxiety, retention of urine, history of transient ischemic attack, and cerebral infarction. Review of the clinical record revealed the resident was discharged to the hospital on March 30, 2023. Further review of the clinical record revealed no evidence that the receiving provider had been notified of the resident's status/condition and reason for transfer. Review of the clinical record revealed no evidence that a discharge summary had been completed. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had an unplanned discharge to an acute care provider. An interview was conducted on September 7, 2023 at 09:12 AM with the Director of Nursing (DON/staff #5), who stated that the discharge summary was completed on paper prior to August 2023. He reviewed the clinical record and stated that there was not evidence that a discharge summary had been completed, or of notification to the receiving provider. Review of the facility policy titled, Transfer and Discharge (including AMA - Against Medical Advice), revealed that transfer to another provider, for any reason, the following information must be provided to the receiving provider: -Contact information of the practitioner who was responsible for the care of the resident -All information necessary to meet the resident's needs including resident status, reason for transfer. Obtain physician's orders for emergency transfer, contact provider of the hospital, ensure necessary information is provided as part of the facility's transfer form. Document assessment findings and other relevant information regarding the transfer in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure that one resident's (#33) care planned interventions were reassessed for effectiveness and revised as needed. Resident #22 was admitted on [DATE] with diagnoses that included major depressive disorder and claustrophobia. A physician order dated December 22, 2022 directed for the resident's behavior to be monitored every shift in relation to the medication Sertraline for depression as evidenced by flat affect and self-isolation. It also indicated to monitor anti-depressant side effects every shift. Review of the admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. The assessment did not indicate that the resident was receiving psychological therapy. Review of a care plan initiated on January 5, 2023 revealed that the resident uses antidepressant medication. The interventions indicated to observe for/document/report to physician as needed ongoing signs/symptoms of depression that are unaltered by antidepressant medications. A care plan with a focus on the resident's mood problem was initiated on January 5, 2023. The interventions indicated for the resident to have behavioral health consults as needed, and to allow resident adequate time to talk, and encourage him to express his feelings. A psych re-evaluation note dated January 30, 2023 documented that resident displays partial response to treatment, though symptoms remain unstable as evidenced by irritability, frustration, anxiety, demanding, and verbally aggressive with staff. Resident is having a difficult time adjusting to new environment. Resident was noted as grieving previous life and autonomy. Under the plan portion of the notes, it indicated that resident will be monitored and evaluated for response and side effects in 3-4 weeks or as needed. A quarterly PHQ-9 (Patient Health Questionnaire-9) assessment dated [DATE] revealed a score of 3 indicating that the resident has minimal depression. A social service note dated July 27,2023 revealed that resident continues to have difficulty adjusting to being in long term facility. The note indicated that social services will request continued psych consult. A physician order dated August 20, 2023 prescribed Sertraline HCI oral tablet and directed to give 150 milligrams by mouth one time a day for depression as evidenced by verbalization of sadness. Review of a physician note dated August 23, 2023 indicated under the review of systems portion that resident's psych was stable and at baseline. It also noted under plan, the resident be on Sertraline, followed by in-house psychiatry. Review of a physician note dated August 30, 2023 indicated under the review of systems portion that resident's psych was stable and at baseline. The plan portion of the note, indicated Sertraline, followed by in-house psychiatry. During an interview with resident #33 conducted on September 5, 2023 at 9:09 am, he stated that his depression is worse. Resident #33 said he told the facility how he feels but no one has addressed his depression. Hospice was addressing it but he was being dropped from hospice so he is worried that the situation will get worse. A Pre-admission Screening and Resident Review (PASRR) Level I Screening assessment dated [DATE] revealed that the resident has major depression and that referral for LL determination for MI (mental illness) only was needed. Further review of the resident's clinical record did not reveal any indication that resident #33 received psych follow-up, psych consult, or that he was followed by in-house psychiatry. Additionally, there was no mention that resident was referred for behavioral health consult as needed and as indicated on his care plan. Review of the August 2023 Medication Administration Record (MAR) revealed that the resident received medications as ordered. Review of the August 2023 Treatment Administration Record (TAR) indicated that resident received treatments as ordered. Review of the September 2023 MAR revealed that the resident received medications as ordered. Review of the September 2023 TAR indicated that the resident received treatments as ordered. An interview with the Social Services Director (SSD/staff #56) was conducted on September 7, 2023. Staff #56 stated that she does psych referrals but that case managers also does them. She said she was familiar with resident #33, and that the resident was unhappy where he is at and has a hard time adjusting to his current situation of being at the facility while his wife is at home. Staff #56 stated that the resident has had a change in psych provider since July 27, 2023 so she would have to check if he has been receiving continued psych consult. She also indicated that the facility had a change in psych providers around that time. Due to this she is unsure of whether resident #33 was being seen or not. Staff #56 indicated that according to resident #33, he is not depressed. She noted that resident #33 has been improving in the last two months. Initially, the resident was very guarded, defensive, easy to anger, and would find any excuse to get mad-he gets mad when he is not addressed by his title Doctor. Additionally, staff #56 noted that during an IDT (interdisciplinary team) meeting, it was brought up that resident #33 is verbally abusive. She said that she relayed to the previous Director of Nursing (DON) her recommendation that resident receive continued psych consult. This was also relayed to the previous psychiatrist. Staff #56 stated that psych is not an in-house service and that they come whenever there are enough residents that they need to see. She said psych is normally in the long-term care floor every once or twice a week. Staff #56 stated that resident #33 was for sure not currently being followed-up by the new psych provider. Resident #33 did not transfer to the new provider. Staff #56 stated that if he was receiving services in January, she is not sure why he was not transferred when the facility switched providers. She stated that maybe his info was not relayed to the new person in July. Staff #56 noted that it would have been the previous DON's responsibility to ensure the resident's information flowed to enable the transfer/continuity of care to happen. She indicated that the previous DON cut her off with certain processes so she is not sure if the new psych provider has a roster of residents who needs to be seen. An interview was conducted on September 8, 2023 at 11:49 am with a Certified Nursing Assistant (CNA/staff #52), who stated that whenever she notices something is off or the resident express sadness she informs the nurse immediately so they can follow-up on the resident. She indicated that she is familiar with resident #33 and that he was nice and pleasant. Staff #52 noted that resident #33 sometimes gets a little agitated but nothing major. She noted that she is not aware of any mood or emotional concerns regarding this resident. However, she stated that the resident told her today that he was depressed so she informed the nurse. Staff #52 indicated that the intervention for mood/emotional concern is that CNAs must inform the nurse about concerns so they can follow-up. When asked if she was trained in behavioral health, she replied that she was not a behavior technician. As a CNA she assists residents with ADLs (activities of daily living). An interview was conducted on September 8, 2023 at 11:23 am with a Licensed Practical Nurse (LPN/staff #7), who stated that she checks for emotional patterns like depression, anxiety, loneliness, and would monitor these symptoms during Med Pass. Staff #7 indicated that she is somewhat familiar with resident #33 since she has taken care of him a few times. She said that the resident does not present any concerning mood or emotional behavior. However, she did note that the resident expresses agitation when things do not go his way or if the food he receives is not what he ordered. Staff #7 stated that each time she administers his medications, the resident does inform him that he is depressed which has been an ongoing problem. She also said that as an intervention, she relays the information to the physician and she monitors and documents the resident's behavior on the MAR. Staff #7 stated that the resident is on medication for depression but she does not know which one off the top of her head. When asked if there are non-pharmacological interventions attempted, she indicated that she had not done any. Staff #7 said that she is not aware if resident #33 is monitored by Psych but indicated that he would benefit from it. During an interview with the Director of Nursing (DON/staff #5) conducted on September 8, 2023 at 11:57 am, he stated that residents with mood/emotional concerns should be monitored every shift. If any alterations are noted, then the physician should be notified, and interventions should be followed-up. When asked who tracks/audit residents recommended for psych consult, staff #5 indicated that it is either the DON or the Assistant Director of Nursing (ADON). The DON or ADON contacts the psych provider, who then conducts and evaluation on the resident, and provides recommendations for interventions. According to staff #5, if a resident has concerns and needs a psych consult, an order for psych eval is placed, and that is how they track who needs it. He stated that no one keeps a log of who needs psych evals/follow-ups/treatments. Staff #5 noted that he is familiar with resident #33, who he described as pleasant and does not cause anything of concern. When asked if he was aware that per a psych note dated January 30, 2023 that resident #33 was supposed to be monitored and reevaluated in 3-4 weeks or as needed, and if it was accomplished, the DON sated that there is an order for psych consult sent by the Social Services Director on September 7, 2023 but no follow-up has been completed prior to this survey. When asked about the Social Services Director's (SSD) note dated July 27, 2023 which indicated that the SSD will request continued psych consult for the resident and if it was accomplished, staff #5 sated that the resident has not been seen by psych since January and that he would follow-up right away. Review of the facility policy titled Comprehensive Care Plans revised July 18, 2023 indicated that the facility implements a comprehensive person-centered care plan for each resident to meet their needs which include mental and psychological needs as identified in the resident's comprehensive care plan. Additionally, the policy noted that alternative interventions will be added/revised, as needed. Review of the facility policy titled Abuse, Neglect and Exploitation revised August 8, 2023 stated that the facility will implement policies and procedures that achieves identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#201) was provided services consistent with professional standards of practice. The deficient practice could result in unmanaged pain for residents. Findings included: Resident #201 was admitted on [DATE], diagnoses that included joint replacement aftercare, diabetes mellitus, chronic obstructive pulmonary disease, fibromyalgia, anxiety disorder, depression, and dorsalgia. Review of the care plan revealed no evidence of a focus for pain management. Review of physician orders revealed the following orders: -Gabapentin oral capsule 300mg four times a day for neuropathy -Diclonfenac Sodium External Gel 1% tropical. Apply to affected area topically every 8 hours as needed for pain. -Oxycodone HCL Oral Tablet 5mg tablet every 4 hours as needed for pain 6-10 -Doppler ultrasound to right lower leg due to increased pain and swelling. -Regarding Administration outside of pain level parameters: Review of the August 2023 MAR, revealed that the Oxycodone had been administered outside of parameters for a pain level of 5 on 4 occasions. Review of the September 2023 Medication Administration Record (MAR) revealed that Oxycodone HCL Oral Tablet 5mg, give 1 tablet by mouth every 4 hours as needed for pain 6-10, was administered for a pain level of 5 on 6 occasions. Continued review of the clinical record revealed no evidence that the provider was notified regarding the oxycodone being administered for a pain level outside of parameters (5) during the months of August 2023 - September 2023. -Regarding Administration of Oxycodone with less than 4 hours between doses: Review of the August and September 2023 MARs revealed that the oxycodone had been administered less than 4 hours between doses on 5 occasions. Further review of the August 2023 MAR, revealed that the Oxycodone was administered on August 28, 2023 at 5:30 AM, 8:31 AM and 10:30 AM. Further review of the September 2023 MAR revealed that on September 6, 2023 the oxycodone was administered at 5:20 PM and again at 8:42 PM. There was less than 4 hours between administration times. Review of the clinical record revealed no evidence that the provider had been notified that the oxycodone was administered less than 4 hours between doses on all 5 occasions. An interview was conducted on September 7, 2023 at 02:24 PM with a Licensed Practical Nurse (LPN/staff #33), who stated that the process for pain management/medication administration included assessing the resident's pain level, and location and document in the clinical record. He also stated that it is the facility policy to follow physician orders as directed, including any parameters. He further stated that that anytime a medication is administrated outside of the ordered parameters, the provider should be notified, and it should be documented in the progress notes. The LPN stated that the nurse should document that the provider was notified, why the medication was administered outside of parameters. He also stated that it is the facility policy to administer medications within the time-frame ordered by the provider. He further stated he would not expect oxycodone to be administered less than four hours apart. He stated that if this occurred, the nurse should notify the provider and get a one-time order, and document in progress notes. The LPN stated that when a resident is on opioids he would expect that it would be included in the care plan. He reviewed the clinical record and stated that in August 2023 and September 2023 MARs there were multiple occasions that oxycodone had been administered for a pain level of 5, which was outside of the ordered parameters, and also several times that the medication had been administered with less than 4 hours between doses. He also stated that the risk could result in over sedation, and constipation. An interview was conducted on September 7, 2023 with the Director of Nursing (DON/staff #5), who stated the facility process for pain management should be included in the care plan. He also stated that the facility policy is to follow physician orders as written, including parameters and time frames. He further stated that when a medication is ordered to be administered every 4 hours, that is should not be administered less than 4 hours apart, unless there is a onetime order. He stated that if this occurs there should be documentation in the clinical record of physician notification and orders. The DON reviewed the August 2023 and September 2023 MARs and stated that oxycodone had been administered outside of parameters on multiple occasions, and that oxycodone had also been administered less than the ordered 4 hours apart on multiple occasions. He stated that he was not concerned about the medication being administered less than 4 hours between doses, because for oxycodone can be administered every hour with an order for hospice residents. The DON reviewed the clinical record revealed and stated that there was no evidence that the physician was notified regarding the administration of the oxycodone outside of parameters and less than 4 hours between doses during August or September 2023. He also reviewed the care plan and stated that there is no care plan for pain management but is documented as Pressure ulcer -- but would suffice for pain management. He also stated that the provider should have been notified regarding the pain level of 5, and requested that the order/parameters be changed. Review of the facility policy titled, Physician/Practitioner Orders, revealed that Review of the facility policy titled, Medication Administration, revealed that medications are administered as ordered by the physician and in accordance with professional standards of practice. Identify resident by photo in the Medication Administration Record (MAR), review MAR to identify medication to be administered. Verify resident name. Review of the facility policy titled, Medication Errors, revealed that it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. A medication error means the observed or identified preparation or administration of medications which is not in accordance with the prescriber's order, or accepted professional standards and principles which apply to professionals providing services. To prevent medication errors and ensure safe medication administration, nurses should verify the right medication, dose, route, and time of administration, right resident and right medication. Review of the facility policy titled, Documentation in the Medical Record, revealed that each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy reviews, the facility failed to ensure that services were provided to treat and follow-up a resident's (#33) diagnosed mental health condition. The census was 49. The deficient practice could result in residents not receiving individualized person-centered care and treatment, in order to reach their highest practicable well-being. Findings include: Resident #22 was admitted on [DATE] with diagnoses that included major depressive disorder and claustrophobia. A physician order dated December 22, 2022 directed for the resident's behavior to be monitored every shift in relation to the medication Sertraline for depression as evidenced by flat affect and self-isolation. It also indicated to monitor anti-depressant side effects every shift. Review of the admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. The assessment did not indicate that the resident was receiving psychological therapy. Review of a care plan initiated on January 5, 2023 revealed that the resident uses antidepressant medication. The interventions indicated to observe for/document/report to physician as needed ongoing signs/symptoms of depression that are unaltered by antidepressant medications. A care plan with a focus on the resident's mood problem was initiated on January 5, 2023. The interventions indicated for the resident to have behavioral health consults as needed, and to allow resident adequate time to talk, and encourage him to express his feelings. A psych re-evaluation notes dated January 30. 2023 documented that resident displays partial response to treatment, though symptoms remain unstable as evidenced by irritability, frustration, anxiety, demanding, and verbally aggressive with staff. Resident is having a difficult time adjusting to new environment. Resident was noted as grieving previous life and autonomy. Under the plan portion of the notes, it indicated that resident will be monitored and evaluated for response and side effects in 3-4 weeks or as needed. A quarterly PHQ-9 (Patient Health Questionnaire-9) assessment dated [DATE] revealed a score of 3 indicating that the resident has minimal depression. A social service note dated July 27,2023 revealed that resident continues to have difficulty adjusting to being in long term facility. The note indicated that social services will request continued psych consult. A physician order dated August 20, 2023 prescribed Sertraline HCI oral tablet and directed to give 150 milligrams by mouth one time a day for depression as evidenced by verbalization of sadness. Review of a physician note dated August 23, 2023 indicated under the review of systems portion that resident's psych was stable and at baseline. It also noted under plan, the resident be on Sertraline, followed by in-house psychiatry. Review of a physician note dated August 30, 2023 indicated under the review of systems portion that resident's psych was stable and at baseline. The plan portion of the note, indicated Sertraline, followed by in-house psychiatry. During an interview with resident #33 conducted on September 5, 2023 at 9:09 am, he stated that his depression is worse. Resident #33 said he told the facility how he feels but no one has addressed his depression. Hospice was addressing it but he was being dropped from hospice so he is worried that the situation will get worse. A Pre-admission Screening and Resident Review (PASRR) Level I Screening assessment dated [DATE] revealed that the resident has major depression and that referral for LL determination for MI (mental illness) only was needed. Further review of the resident's clinical record did not reveal any indication that resident #33 received psych follow-up, psych consult, or that he was followed by in-house psychiatry which were services that were identified as needed by the resident. Review of the August 2023 Medication Administration Record (MAR) revealed that the resident received medications as ordered. Review of the August 2023 Treatment Administration Record (TAR) indicated that resident received treatments as ordered. Review of the September 2023 MAR revealed that the resident received medications as ordered. Review of the September 2023 TAR indicated that the resident received treatments as ordered. An interview with the Social Services Director (SSD/staff #56) was conducted on September 7, 2023. Staff #56 stated that she does psych referrals but that case managers also does them. She said she was familiar with resident #33, and that the resident was unhappy where he is at and has a hard time adjusting to his current situation of being at the facility while his wife is at home. Staff #56 stated that the resident has had a change in psych provider since July 27, 2023 so she would have to check if he has been receiving continued psych consult. She also indicated that the facility had a change in psych providers around that time. Due to this she is unsure of whether resident #33 was being seen or not. Staff #56 indicated that according to resident #33, he is not depressed. She noted that resident #33 has been improving in the last two months. Initially, the resident was very guarded, defensive, easy to anger, and would find any excuse to get mad-he gets mad when he is not addressed by his title Doctor. Additionally, staff #56 noted that during an IDT (interdisciplinary team) meeting, it was brought up that resident #33 is verbally abusive. She said that she relayed to the previous Director of Nursing (DON) her recommendation that resident receive continued psych consult. This was also relayed to the previous psychiatrist. Staff #56 stated that psych is not an in-house service and that they come whenever there are enough residents that they need to see. She said psych is normally in the long-term care floor every once or twice a week. Staff #56 stated that resident #33 was for sure not currently being followed-up by the new psych provider. Resident #33 did not transfer to the new provider. Staff #56 stated that if he was receiving services in January, she is not sure why he was not transferred when the facility switched providers. She stated that maybe his info was not relayed to the new person in July. Staff #56 noted that it would have been the previous DON's responsibility to ensure the resident's information flowed to enable the transfer/continuity of care to happen. She indicated that the previous DON cut her off with certain processes so she is not sure if the new psych provider has a roster of residents who needs to be seen. An interview was conducted on September 8, 2023 at 11:49 am with a Certified Nursing Assistant (CNA/staff #52), who stated that whenever she notices something is off or the resident express sadness she informs the nurse immediately so they can follow-up on the resident. She indicated that she is familiar with resident #33 and that he was nice and pleasant. Staff #52 noted that resident #33 sometimes gets a little agitated but nothing major. She noted that she is not aware of any mood or emotional concerns regarding this resident. However, she stated that the resident told her today that he was depressed so she informed the nurse. Staff #52 indicated that the intervention for mood/emotional concern is that CNAs must inform the nurse about concerns so they can follow-up. When asked if she was trained in behavioral health, she replied that she was not a behavior technician. As a CNA she assists residents with ADLs (activities of daily living). An interview was conducted on September 8, 2023 at 11:23 am with a Licensed Practical Nurse (LPN/staff #7), who stated that she checks for emotional patterns like depression, anxiety, loneliness, and would monitor these symptoms during Med Pass. Staff #7 indicated that she is somewhat familiar with resident #33 since she has taken care of him a few times. She said that the resident does not present any concerning mood or emotional behavior. However, she did note that the resident expresses agitation when things do not go his way or if the food he receives is not what he ordered. Staff #7 stated that each time she administers his medications, the resident does inform him that he is depressed which has been an ongoing problem. She also said that as an intervention, she relays the information to the physician and she monitors and documents the resident's behavior on the MAR. Staff #7 stated that the resident is on medication for depression but she does not know which one off the top of her head. When asked if there are non-pharmacological interventions attempted, she indicated that she had not done any. Staff #7 said that she is not aware if resident #33 is monitored by Psych but indicated that he would benefit from it. During an interview with the Director of Nursing (DON/staff #5) conducted on September 8, 2023 at 11:57 am, he stated that residents with mood/emotional concerns should be monitored every shift. If any alterations are noted, then the physician should be notified, and interventions should be followed-up. When asked who tracks/audit residents recommended for psych consult, staff #5 indicated that it is either the DON or the Assistant Director of Nursing (ADON). The DON or ADON contacts the psych provider, who then conducts and evaluation on the resident, and provides recommendations for interventions. According to staff #5, if a resident has concerns and needs a psych consult, an order for psych eval is placed, and that is how they track who needs it. He stated that no one keeps a log of who needs psych evals/follow-ups/treatments. Staff #5 noted that he is familiar with resident #33, who he described as pleasant and does not cause anything of concern. When asked if he was aware that per a psych note dated January 30, 2023 that resident #33 was supposed to be monitored and reevaluated in 3-4 weeks or as needed, and if it was accomplished, the DON sated that there is an order for psych consult sent by the Social Services Director on September 7, 2023 but no follow-up has been completed prior to this survey. When asked about the Social Services Director's (SSD) note dated July 27, 2023 which indicated that the SSD will request continued psych consult for the resident and if it was accomplished, staff #5 sated that the resident has not been seen by psych since January and that he would follow-up right away. Review of the facility policy titled Comprehensive Care Plans revised July 18, 2023 indicated that the facility implements a comprehensive person-centered care plan for each resident to meet their needs which include mental and psychological needs as identified in the resident's comprehensive care plan. Additionally, the policy noted that alternative interventions will be added/revised, as needed. Review of the facility policy titled Abuse, Neglect and Exploitation revised August 8, 2023 stated that the facility will implement policies and procedures that achieves identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident's (#11) drug regimen was being monitored and the PRN (as needed) psychotropic medications had a limited duration. The facility census is 49. The deficient practice could result in residents receiving psychotropic medications that may not be necessary. Findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included anxiety, depression, and dementia. The [quarterly] Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 11 indicating the resident had a moderate cognitive impairment. A review of resident #11's Care Plan, initiated on 12/13/2022, revealed the resident was at risk for behavior issues such as screaming/yelling, throwing objects, restlessness. Interventions included administering medications as ordered and monitoring/documenting for side effects and effectiveness of medications, report ongoing symptoms of depression to medical provider (revised on 06/16/2023). A review of resident #11's physician orders indicated the resident was to take the following medications: -buspirone HCI (anti-depressant) -Divalproex Sodium (mood stabilizer) -Divalproex Sodium (mood stabilizer -Duloxetine HCI (anti-depressant) -Escitalopram Oxalate (Anti-depressant) -oxycodone (opioid) A review of the September 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed there was no indication of: -Behavior monitoring (self-injurious behavior, screaming, throwing objects, and restlessness) being performed as a result of the resident taking psychotropic medications. -Opioid PRN medication (oxycodone) having a limited duration. Review of the Medication Regimen Review (MRR) dated 08/16/2023 stated Psychotropic medication reminder: Continue to monitor and document behaviors for the psychoactive medications buspirone, duloxetine, escitalopram, trazodone, and divalproex for dementia with agitation to ensure the safety, effectiveness and appropriateness. An interview was conducted on 09/06/2023 at 1:10 PM with Certified Nursing Assistant (CNA # 41). CNA #41 stated she had been working at the facility for 1 ½ years and she was familiar with resident #11. CNA #41 shared that resident #11 had behaviors when her husband was not visiting. CNA #41 stated she would attempt to redirect the resident when there was an outburst and she knew how to redirect the resident because she knew the resident well. The CNA would then inform the floor nurse of the resident's behaviors for them to monitor and her expectation was the RN would document the behaviors in the resident's chart. CNA #41 indicated she did not know where behavior monitoring information was accessible to her during her shift. In an interview with Registered Nurse (RN #45) on 09/07/2023 at 8:45 AM it was revealed that she would expect that symptom/behavior monitoring as well as medication effectiveness would be on the TAR. RN #45 reviewed resident #11's TAR and acknowledged there was no medication monitoring and symptom/behavior monitoring on the chart. She stated the resident was recently discharged and re-admitted to the facility and the monitoring was not put back onto the chart. When asked who is responsible to add or make changes to the TAR, she stated that any nurse is able to do it. When asked about resident #11's oxycodone PRN end date, RN #45 stated she was not sure why there was no end date in place. An interview was conducted with the Director of Nursing (DON #5) on 09/07/2023 at 11:14 AM. DON acknowledged that resident #11 had current orders for several psychotropic medications and there was no monitoring for symptoms, side effects, or effectiveness on the resident's TAR. He stated his expectation was for RNs to ensure monitoring was on the TAR and if it wasn't it would be brought to his attention right away so it could be added in. When asked about the policy regarding the duration of PRN medications that are psychotropics, he stated that the use of those medications was limited to 14 days unless indicated for extended use by a physician. Upon review of the resident's orders for PRN medications, he indicated that he was not sure why there was no end date in place. Review of a facility policy titled, Psychotropic Medication, dated 07/18/2023, indicated, PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. The policy also indicated the effectiveness of the medications must be demonstrated by monitoring and documentation of the resident's response to the medication(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, facility documentation and policy and procedures, the facility failed to maintain infection prevention and control during catheter care for one resident (#26). The deficient practice could result in transmission of infection. Findings include: Resident #26 was admitted on [DATE] with diagnoses that included dementia, traumatic brain injury, and (BPH) benign prostatic hyperplasia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The assessment also included the presence of a indwelling catheter. Review of a care plan initiated on September 16, 2022, revealed an area of focus that included potential for urinary tract infections related to indwelling catheter with interventions that included catheter care with soap and water every shift and as needed, and to flush catheter as ordered. Review of orders revealed the following: -Irrigate foley catheter with 60cc of normal saline every shift, dated March 24, 2023. -Enhanced barrier precautions: foley required - gloves, gowns, mask, face shield/goggles during maintenance, dated August 30, 2023. -Change indwelling catheter, 18 french 10 ml (milliliter), Foley bag as needed for dislodgement, leakage, clogged, dated August 3, 2023. Catheter care observation was conducted on September 6, 2023 at 9:59 AM with a Certified Nursing Assistant, (CNA/staff #41), the following was observed: -Enhanced barrier precautions notice posted outside the resident's room. -The CNA sanitized her hands, donned a gown, gloves, mask, and goggles. -She entered the resident's room and stated that she was there to conduct catheter care. -The CNA raised and positioned the bed using the remote. -Without changing gloves, she proceeded to remove the resident's the brief, then removed a wipe from the package, and proceeded to wipe from top to bottom starting at the glans penis, turning the wipe with each time. Then cleansed around scrotum, turned the resident and cleansed anal area with a clean wipe from front to back, turning the wipe. -The CNA applied zinc barrier to buttocks. -The CNA then removed one glove, and reapplied the brief (with the hand that had no glove), removed the other glove, and replaced the gown. -She then placed on clean gloves and removed the dirty linen, brief, and replaced the blanket. -She lowered the bed using the remote with the same gloves. An interview was conducted with the CNA (staff #41) on September 7, 2023 at 08:55 AM, who stated that it is the facility policy to change gloves prior to starting catheter care, and after positioning the resident/bed. She stated that she knew that she did not change the gloves during catheter care after positioning the resident, and prior to beginning the catheter care. She stated that the risk of using contaminated gloves for catheter care could result in cross contamination, and possible infection. An interview was conducted on September 7, 2023 at 09:05 AM with the Wound Care and Infection Preventionist (staff #30), who stated that for catheter care she expected the CNA to donn gloves, gown, mask, goggles prior to entering the resident's room. She then stated that the CNA should sanitize the bed side table, get supplies ready and explain the procedure to the resident. She stated that she expected the CNA to discard gloves after positioning the resident, sanitize hands, and donn a clean pair of gloves, then start the catheter care. She further stated that the risk of not changing gloves prior to starting catheter care, and after positioning the resident, could result in cross-contamination, infection and possible urinary tract infections. An interview was conducted on September 7, 2023 at 09:12 AM with the Director of Nursing (DON/staff #5), who stated that that catheter care is completed by CNAs every shift and as needed. He also stated that it was his expectation that a clean pair of gloves would be donned prior to starting catheter care, and after positioning the resident. He further stated that catheter care needs to be as clean as possible. He also stated that the CNA should donn a clean pair of gloves to prep for the treatment, and reposition the resident, would donn a 2nd pair of clean gloves prior to starting catheter care, and would donn a 3rd set of clean gloves to reposition the resident after catheter care. The DON stated that the risk of using contaminated gloves during catheter care could result in transmission of infection. Review of a facility policy titled, Catheter Care, revealed that it is the facility policy to ensure that resident's with indwelling catheters receive appropriate catheter care. Assist the resident to a lying position, perform hand hygiene, then don gloves. Review of a facility policy titled, Infection Prevention and Control Program, revealed that all staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and review of policies, the facility failed to ensure one resident (#4), was free from significant medication errors, related to the resident receiving medications ordered for another resident. The deficient practice could result in complications and adverse medication side effects. Findings include: Resident #4 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis affecting left non-dominant side and right dominant side, anxiety disorder, quadriplegia, psychoactive substance dependence., adjustment disorder with anxiety, retention of urine. Review of the clinical record revealed no evidence of an investigation regarding medication administration dated March 30, 2023. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. Review of a care plan, initiated April 18, 2023, revealed a focus that included: -Has communication problem related to soft voice, usually understood. Review of nursing progress note dated March 29, 2023 at 3:29 PM revealed the resident can make needs known, but can be very difficult to understand. Review of the Medication Administration Record dated March 2023 revealed the following orders that were current on March 30, 2023: -Miconazole Nitrate External Powder 2%, apply to neck, chest topically every day shift for fungal rash. -Senna Oral Tablet 8.6 milligram (mg) give 1 tablet by mouth one time a day for bowel care -Morphine 10mg/ml (milliliter), 0.25mg (2.5mg) every 1 PRN PO/SL pain or trouble breathing every 1 hours as needed for pain/trouble breathing Review of nursing note dated March 30, 2023 at 1:29 AM, late entry, revealed that the medications administered: Lipitor 40mg, Neurontin 600mg, Keppra 750mg, Lopressor 50 mg, ranolazine ER 500mg, Flomax 0.4 mg, Tylenol 650 mg, Lantus 55 units. Further review of nursing progress notes date March 30, 2023 at 1:32 AM, late entry, revealed having a hard time seeing pulling medications in a dim lit hallway by exit sign as time is 1:00 AM and attempting to complete an 8:00 PM medication pass. Knocked on door announced my presence and turned on light, approached the patient bed and called name on medication cards as patient had no armband on and patient responded yes. This writer named the medications given to patient. Upon completing returned to medication cart and realized this was not the correct patient. Vital signs taken: blood pressure 139/67; Pulse 60; respirations 16; glucose 99. Immediately provided orange juice with two packs of added sugar. Called hospice nurse and gave a report. Hospice nurse returned call and stated to send patient to hospital and call 911. 911 called, stayed with the resident until paramedics arrived. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed an unplanned discharge with return anticipated, to an acute hospital. Review of hospital history and physician dated March 30, 2023 at 4:41PM revealed the resident was brought in for evaluation after mistakenly being given atorvastatin 20 mg, Tylenol 650mg, Neurontin 600mg, Keppra 750mg, Lopressor 50mg, ranolazine 500mg, Flomax 0.4mg, and Lantus 55 units at the care facility at approximately 1:00 AM. The note also revealed that per the nurse, the patient was given another patients medication at the care facility. The history stated that on presentation to the emergency room, laboratory data showed evidence of sepsis due to urinary tract infection and hypoglycemia, hypotension and that the resident was administered 2 liters of intravenous fluid bolus and started on pressor due to refractory hypotension. The note continued stating that the patient appeared obtunded and sleepy, not able to answer any questions, admitted for critical care. Review of the facility complaint filed with the Arizona State Board of Nursing on April 7, 2023 at 12:07 PM revealed the description of the incident as medications administered to the wrong resident, the nurse failed to change the screen in the medical record to the resident she administered the medication. The complaint further stated that the electronic medical record has the residents' pictures as an identification, however, the nurse was looking at the wrong screen, and someone else's picture. Review of the facility medication error incident report revealed that a registry nurse administered the wrong medications. The report listed poor lighting as a predisposing environmental factor. Review of hospital records dated April 2, 2023 at 14:00, revealed an assessment/plan of treatment related to medication overdose that occurred at the long-term care. An interview was conducted on September 07, 2023 at 07:59 AM with the Administrator (staff #2), who stated that there was an adverse effect on March 30, 2023, that was reported to the nursing board, but it was not investigated any further than that. She stated that she would have expected that the previous administrator would have completed a self-report to the state, in addition to the nursing board, because of the adverse effect. She also stated that she was informed of the incident when she started as Administrator at the facility. She stated that the medication error occurred on March 30, 2023 when a registry nurse did not do the 5 rights prior to medication administration. She further stated that the resident was sent to the emergency room for treatment. The Administrator stated that the agency nurse was reported to the Arizona State Board of Nursing, and did not return to the facility. An interview was conducted on September 7, 2023 at 08:59 AM with a Licensed Practical Nurse (LPN/staff #33), who stated that there are pictures of all resident on the electronic medical record (EMR) to assist with resident identification during medication administration. He stated that when he administers medications he identifies the resident with the picture on the electronic medical record (EMR) and the identification bracelets. He stated that the facility policy for medication administration includes to follow the 5 rights (right: time, resident, dose, medication, route). He also stated that at night he would turn on the overbed light to identify the resident. An interview was conducted on September 7, 2023 at 09:09 AM with an LPN (staff #45), who stated that prior to medication administration she would check the EMR photo, the name on the room door, wrist tag, and also ask the resident his/her name. She also stated that the risk of administering medications to the wrong resident could result in harm or death. An interview was conducted on September 7, 2023 at 09:12 AM with Director of Nursing (DON/staff #5), who stated that when she administers medications the resident is identified by a wrist tag and the EMR photo. He also stated that he is aware of another resident receiving the wrong medication and was told the resident was sent to the hospital. He further stated that the resident was administered another patient's medication, and sent to hospital. He reviewed the clinical record and stated that there was no evidence that an investigation or self-report had been completed, expect for the medication error form. He also stated that he would have expected a full investigation that included interviews with residents and staff. Review of the facility policy titled, Medication Errors, revealed that it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. A medication error means the observed or identified preparation or administration of medications which is not in accordance with the prescriber's order, or accepted professional standards and principles which apply to professionals providing services. A Significant medication error means one which cause the resident discomfort or jeopardizes his/her health and safety. The facility shall ensure medications will be administered as follows according to physician's orders, and in accordance with accepted standards and principles which apply to professionals providing services. To prevent medication errors and ensure safe medication administration, nurses should verify the right medication, dose, route, and time of administration, right resident and right medication. Review of the facility policy titled, Incidents and Accidents, revealed it is the policy of this facility for staff to report, investigate and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. An incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. Incidents that risk to the level of abuse or neglect, will be managed and reported according to the facility's abuse prevention policy. Incidents/Accidents that require an incident/accident report include medication or treatment errors. Review of the facility policy titled, Medication Administration, revealed that medications are administered as ordered by the physician and in accordance with professional standards of practice. Identify resident by photo in the Medication Administration Record (MAR), review MAR to identify medication to be administered. Verify resident name. Review of the facility policy titled, Abuse, neglect and Exploitation, revealed that it is the policy of the facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will have written procedures that include reporting of all alleged violations to the state agency and to all other required agencies within specific timeframes. Taking all necessary actions as a result of the investigation that include analyzing the occurrence to determine why abuse, neglect occurred, training staff, identification of staff on changes made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to provide one resident (#194) and the resident's representative a written notice of transfer/discharge for transfers to the hospital. The sample size was 2 residents. The deficient practice could result in residents and representatives not being provided a written notice of transfers or being informed of their discharge transfer rights, and advocacy information. Findings include: Resident #194 was readmitted to the facility on [DATE], discharged to the hospital on June 10, 2022 and readmitted on [DATE], and discharged on June 29, 2022 and readmitted on [DATE]. Diagnoses included an internal left hip prosthesis infection, Methicillin Resistant Staphylococcus Aureus (MRSA) infection, bacteremia infection of the left hip, and dislocation of the left hip prosthesis. A progress note dated June 10, 2022 at 1:30 PM stated the representative for resident #194 was called and notified that the resident was sent to the hospital. Review of a nursing progress note dated June 10, 2022 at 1:36 PM revealed resident #194 was refusing all cares and assessments. Further, the note stated the resident was noted to have increased pain after a fall, agitation, confusion, and a urinary tract infection (UTI). The note stated that the Nurse Practitioner (NP) was notified and gave orders to transfer the resident to the emergency room for further evaluation. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed that resident #194 had an unplanned discharge to an acute hospital. However, there was no evidence that the resident or the resident's representative was notified of the transfer to the hospital in writing. The notice would notify the resident and the representative of the resident transfer and discharge rights. Review of a progress note dated June 29, 2022 at 12:10 PM revealed resident #194 had complained of pain and was not able to engage in therapy. The NP was notified and orders were given for an x-ray to the left hip. Review of the discharge MDS assessment dated [DATE] revealed resident #194 had an unplanned discharge to an acute hospital. However, there was no evidence that the resident or the resident's representative was notified of the transfer to the hospital in writing. The notice would notify the resident and the representative of the resident transfer and discharge rights. An interview was conducted with a Licensed Practical Nurse (LPN/staff #13) on July 27, 2022 at 10:18 AM. The LPN stated that when a resident has a change in condition then she will complete a head to toe assessment. Further, she stated that if she thinks the resident needs to be sent to the hospital then she will call the medical provider and ask for an order to send the resident. Additionally, she stated the resident's representative will be notified and she will explain to them that the resident was sent out of the facility. The LPN stated that she is unaware of any other paperwork that needs to be completed. She stated that after the resident is sent out, she will let the Director of Nursing (DON) know what happened. The LPN stated that the DON or the Assistant Director of Nursing (ADON) may complete further documentation related to transferring the residents to the hospital. An interview was conducted with the DON (staff #2) on July 28, 2022 at 1:02 PM. The DON stated that when a resident requires a transfer she would expect the nurses to let the resident know why they need to be transferred and to notify the resident's emergency contact and the medical provider. She stated that there should be documentation in the resident's medical record about the discharge. Further, the DON stated that the facility does not complete a notice of transfer or discharge for anyone in the facility and that the facility only completes a transfer note in the resident's chart. The DON stated that there is no assessment completed related to the discharge. The DON also stated that she was unaware of the requirement and did not know what information was required in the contents of the notice. The facility policy titled Transfer and Discharge Notice stated the purpose is to assure proper notice of transfer and discharge. When the resident is to be transferred to another institutional setting or discharged to a non-institutional setting, social services shall assure that the notice of transfer and discharge has been given to the resident, family, and surrogate. Social service staff shall document that the notice of transfer/discharge has been sent to the resident, family, and surrogate. Social services shall document the resident's acceptance of the new setting when possible. In reference to record keeping, the notice of transfer and discharge shall be maintained in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to provide evidence of a Level 1 PASRR (Preadmission Screening and Resident Review) screening for one sampled resident (#4). The deficient practice could result in residents not receiving services needed. Findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, psychotic disorders with hallucinations due to known psychological conditions, other recurrent depressive disorders, anxiety disorder, and adjustment disorder with mixed anxiety and depressed mood. Review of the clinical file did not reveal a PASRR Level I. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status score of 12 indicating the resident had moderate impaired cognition. The active diagnoses included anxiety disorder, depression, psychotic disorder, an unspecified mental disorder due to known psychological conditions, and adjustment disorder with mixed anxiety and depressed mood. The assessment also revealed the resident had received an antidepressant medication for 7 days during the lookback period. During an interview conducted on July 28, 2022 at 10:15 a.m. with the Social Services Coordinator (staff #38), she reviewed the clinical record and stated that she did not see a PASRR Level I. Then, she went down to medical records and could not find any documentation that a PASRR Level I had been completed. She stated that the facility had recently identified a problem with the PASRRs not being completed and she was currently in the process of reviewing all the residents' records to ensure it was done. She said that she had not reviewed the resident's clinical record yet. She stated that based on the resident's diagnoses and because the resident was taking Mirtazapine and had a psych consult in June 2022, a level I should have been completed and submitted to state authority for a level II PASRR evaluation. Staff #38 stated the purpose of a level II is to screen for services that may not be provided and see if the resident is appropriate for the facility. She said that she would submit a level II immediately. The facility's policy, Preadmission Screening and Resident Review Reports (PASRR), stated that the purpose is to provide screening for mental illness/mental retardation prior to admission. An initial PASRR shall be completed prior to admission of all individuals on MediCal and all residents with mental illness or mental retardation. Residents who initially apply to a nursing facility directly following a discharge from an acute care stare are exempt if they are certified by a physician prior to admission to require a nursing facility stay of less than 30 days and they require care at the nursing facility for the same condition for which they were hospitalized . If a referral for a Level II is indicated, the resident must not be admitted to a MediCal certified nursing facility until the Level II portion of the evaluation process has been completed by an independent evaluator. All documentation shall be maintained in the resident's medical record.

Based on observation, staff interviews, facility documentation, and policy reviews, the facility failed to ensure the dishwasher sanitation was consistently monitored. The deficient practice could increase the risk of foodborne illness. Findings include: During the initial kitchen observation conducted on July 25, 2022 at 12:45 p.m. with the Executive Chef/Certified Dietary Manager (staff #47), staff were observed to be using the dishwasher to clean metal serving dishes. The completed dishes were being stacked on wire shelving to air dry. Staff #47 stated the dishwasher was a low temperature chemical machine. He referred to the dishwasher temperature log and stated that the chemical level was last tested at 50 ppm (parts per million), which was within the required range. The last documentation was July 25, 2022 breakfast. The log was blank for lunch temperature and ppm check. For observation purposes, he tested the chemical level multiple times and was unable to get any chemical reading, the test strip did not change color, he stated the dishwasher was not showing correct sanitation levels. Staff #47 stated the water had just been refilled and the machine required 5-6 cycles to prime. After re-running the machine multiple times and changing test strips, he stated the dishwasher was not measuring any sanitation level and that all dishes washed since the last time the sanitizer tested in the correct range would need to be re-washed. Staff #47 stated the dishwasher would be shut down and he would call for service. He stated the risk if the dishwasher was not dispensing the sanitizer at the appropriate level during the dishwashing process, was a potential for contamination and then resident illness. A follow up kitchen visit was conducted on July 25, 2022 at 12:57 p.m. with staff #47. He stated the lunchtime testing of the dishwasher should have been done before staff began washing the items used for lunch preparation/service. An interview was conducted on July 27, 2022 at 12:32 p.m. with the Executive Director (staff #74). She stated that she expected the kitchen equipment to be operable and would expect staff to call maintenance if outside services were needed. She stated she expected staff to adhere to the protocol for monitoring equipment. Staff #74 stated the dishwasher monitoring should have been done before staff started washing the dishes used for the lunch meal. She stated if the dishwasher was not cleaning/sanitizing dishes as required, it was unsanitary and there was a risk for food borne illness. Review of the dishwashing procedure included the concentration of the sanitary solution during the rinse cycle is 50-100 ppm with chlorine sanitizer on low temperature dish machines. Wash and rinse temperatures must be observed and logged during the dishwashing period 3 times a day. PPM noted on a cold temperature dish machine three times a day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, staff interviews, and review of facility policy, the facility failed to ensure advance directive information was accurate for two residents (#18 and #32). The sample size was 2 residents. The deficient practice could result in the resident's wishes not being honored. Findings include: -Resident #18 was admitted to the facility on [DATE] and readmitted for the current stay on February 27, 2022 with diagnoses that included anorexia, adult failure to thrive, pneumonia and hypoxemia. At the top of the electronic medical record the resident was documented to be a full code (wanted cardiopulmonary resuscitation). Review of the physician's orders did not reveal an order for the resident's code status. Review of the resident's active care plan revealed a care plan dated [DATE] that stated the resident had chosen to be a full code. Review of the nursing progress note dated [DATE] included: Spoke with the resident regarding the resident healthcare directives which indicated the resident was a DNR (Do Not Resuscitate). The note also revealed the resident was alert and oriented time 3 (person, place, and time) and would like the code status changed to full code. Review of the medical record revealed an Advance Directives/Medical Treatment Decisions form dated February 27, 2022 signed by the resident. The area for choosing to formulate an Advance Directive was not marked and no areas of Advance Directive decisions were check marked on the form. The area to check the resident chose not to formulate an Advance Directive at the time/I want efforts made to prolong my life and want life-sustaining treatment to be provided; did not have a check mark. The form had full code handwritten on the top right-hand side of the form. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included that the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact. An interview was conducted on [DATE] at 10:24 a.m. with a registry Licensed Practical Nurse (LPN/staff #46). She stated that refers to her nurse report sheet and that the resident was a DNR, so she would not resuscitate the resident if the resident was to code. She stated that she knows the residents code status from the report sheet that she was provided. She stated that it was important that the code status on the report form match the code status chosen by the resident or representative. She then looked up the resident in the electronic record and noted that the resident was marked a full code in the electronic system. The LPN stated that she would need to go to the chart to clarify the resident's status. On review of the resident's chart she stated the resident was a full code. She stated that if the code status was not accurate in all areas, there was a risk that the staff might start CPR (cardiopulmonary resuscitation) when the resident did not want it, or not start CPR when the resident wanted it. She stated if the resident's code status changed, the code status should be updated in all the areas that the code status is listed. She stated, with this resident, there was a risk that staff would not have attempted the life saving measures that the resident wanted. An interview was conducted on [DATE] at 10:53 a.m. with the Director of Nursing (DON/staff #2). She stated that staff would know the resident's code status by looking at the chart and by looking in the electronic medical record. She stated the facility uses a lot of registry and that all registry staff had access to the electronic medical record and were all CPR certified. She stated that the night nurse gave the registry nurse the wrong form and stated the facility no longer uses the report sheet provided to the registry nurse because the sheet did not always get updated. The DON stated that if the registry nurse was provided a report form, the information on the form should be correct for each resident. On review of the form provided to the registry nurse, she stated that the form showed resident #18 as a DNR, but that it was incorrect as the resident is a full code. The DON stated there is a risk that the staff might not follow the resident choice if the report form did not match what the resident wanted. The DON stated that she expected staff to go to the resident's chart/electronic record in the case of an emergency/resident code situation. -Resident #32 was admitted to the facility on [DATE] with diagnoses that included right ankle and foot acute osteomyelitis, cellulitis of the right lower limb, and type 2 diabetes mellitus with foot ulcer and hyperglycemia. On review of the resident's electronic record on [DATE] there was no code status listed on the resident's information banner. Review of the resident's physical chart on [DATE] revealed an advanced directives section in which the top page was an orange Prehospital Medical Care Directive (Do not Resuscitate) form that was signed by the resident on [DATE]. Also included in the section was a two-page white/yellow form for advance directives medical treatment decision which revealed the resident chose to formulate and issue advance directives of medical durable power of attorney, living will, DNR, and organ donation which was signed by the resident on [DATE]. Review of a Social Service note dated [DATE] included the resident code status as DNR. Review of a quarterly MDS assessment dated [DATE] included the resident had a BIMS score of 15, which indicated the resident's cognition was intact. On [DATE] at 10:18 a.m., further review of the resident's record/advance directive tab revealed a pink POLST (Provider Orders for Life-Sustaining Treatment) form dated [DATE] that was located beneath the other forms in the section which indicated to attempt CPR (cardiopulmonary resuscitation) and give full treatment which was signed by the physician and the resident. Review of a Social Service note dated [DATE] included POLST completed, code status Full code. Review of the clinical record did not reveal a care plan related to the resident's advance directives/code status. On review of the resident's electronic record later on [DATE] it was noted that the resident now had an order, dated [DATE], for a full code status. An interview was conducted on [DATE] at 10:33 a.m. with a registry LPN (staff #45). He stated that he would look on the electronic medication list or profile to find the resident's code status. He stated that the code status for resident #32 was not in the electronic system where he would usually find it so he would have to check the chart for the information. On review of the chart, the nurse stated that the resident was a DNR and if the resident was to code, he would not do CPR. He stated he would go off of the most current choice that the resident made and that the most current form should be on the top of the section in the chart. After review of the POLST form behind the DNR forms that indicated that the resident wanted to be a full code, the LPN stated the most current form was not on top. The LPN stated he would not have followed the resident's wishes and would have performed CPR if the resident had coded. An interview was conducted on [DATE] at 10:53 a.m. with the DON (staff #2). She stated the code status for resident #32 should have been listed in the electronic record and that now the record shows the resident is a full code. On review of the physical chart, she stated the resident was a DNR but that no witness had signed it. When the DON reviewed the POLST form, she stated that the most current and accurate code status decision should be on top in the medical record and it was not. She stated that there is a risk that staff would not have followed this resident's choice in the case of an emergency situation/code. Review of the facility policy for Advance Directives included: Advance directives will be respected in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he/she chooses to do so. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The plan of care for each resident will be consistent with his/her documented treatment preferences and/or advance directive. The resident has the right to refuse treatment, A resident will not be treated against his/her own wishes. Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessments and care plan. The DON or designee will notify the Attending Physician of advance directives for that appropriate orders can be documented in the resident's medical record and plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #39 was admitted to the facility on [DATE] with diagnoses that included a lumbar vertebra fracture, encephalopathy, Parkinson's disease, and lupus. Review of the admission Minimal Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. An interview was conducted on July 25, 2022 at 1:25 PM with resident #39. The resident stated that sometimes he does not get his ordered medications. The resident stated that he is ordered a lot of medications and has a very detailed regimen that he has gotten used to. The resident stated that he was not able to name the medications specifically however when he asked nursing staff about the medications they never told him specifically what was going on. Resident #39 stated that staff give him a general answer that the nurses are working on getting the medications from the pharmacy. Further, he explained that it is easy for him to tell when medications are missing because multiple times throughout the day there are three capsules missing at a time. The resident stated that he knows they have been missing on multiple occasions. Review of physician orders dated July 11, 2022 revealed Droxidopa 100 milligrams (mg) 2 capsules by mouth three times a day for orthostatic hypotension with meals; and Rytary Extended Release (ER) 36.25-145 mg 3 capsules by mouth four times a day for Parkinson Disease. Regarding Droxidopa Review of the Medication Administration Record (MAR) for July 2022 revealed Droxidopa was scheduled three times per day at 9:00 AM, 1:00 PM, and 6:00 PM. The following dates and times indicated see nurses note: July 14, 2022 at 1:00 PM and 6:00 PM July 15, 2022 at 9:00 AM 1:00 PM July 16, 2022 at 1:00 PM and 6:00 PM July 18, 2022 at 9:00 AM, 1:00 PM, and 6:00 PM July 25, 2022 at 9:00 AM, 1:00 PM, and 6:00 PM Review of the nursing progress notes revealed no notes documented for the administration at 1:00 PM and 6:00 PM on July 14, 2022 or for scheduled times at 9:00 AM and 1:00 PM on July 15, 2022. Review of the clinical record revealed no evidence the medical provider was notified. A progress note regarding Droxidopa dated July 16, 2022 at 12:33 PM stated prior authorization was needed, however there was no documentation the medical provider was notified. An administration progress note dated July 18, 2022 at 7:34 PM revealed the medication was on order from the pharmacy. Review of the clinical record revealed no evidence the medical provider was notified. An administration progress note dated July 25, 2022 at 11:57 AM stated Droxidopa was not available and was reordered. A progress note dated July 25, 2022 at 5:25 PM stated the facility was waiting for the medication from the pharmacy. However, there was no evidence the medical provider was notified the resident had not received the medication as ordered. Regarding Rytary Review of the MAR for July 2022 revealed Rytary was scheduled three times per day at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. The following dates and times indicated see nurses note: July 15, 2021 at 8:00 PM July 18, 2022 at 8:00 AM and 12:00 PM July 25, 2022 at 8:00 AM, 12:00 PM, and 4:00 PM July 26, 2022 at 8:00 PM A progress note dated July 15, 2022 at 8:57 PM stated Rytary was on order from the pharmacy. However, there was no documentation the medical provider was notified the resident did not receive the medication. A progress note dated July 18, 2022 at 7:28 PM stated Rytary was on order from the pharmacy. There was no documentation the medical provider was notified the resident did not receive the medication. Review the care plan initiated on July 20, 2022 stated the resident has Parkinson's disease. The goal was that the resident would remain free of further signs/symptoms, discomfort or complications related to Parkinson's disease. Interventions included administering medications as ordered. Review of the progress note dated July 25, 2022 at 9:40 AM stated Rytary was not available and the prescription was faxed to the pharmacy. Review of the administration progress notes dated July 25, 2022 at 10:06 AM regarding Rytary stated awaiting from pharmacy. A progress note dated July 25, 2022 at 11:53 AM stated the nurse had spoken to the pharmacy and the medication will be sent out July 26, 2022. However, there was no documentation the medical provider was notified the resident did not receive the medication. A progress note dated July 25, 2022 at 11:57 AM stated the medication was not available and was reordered. A progress note dated July 25, 2022 at 4:13 PM stated the medication was not available. An interview was conducted on July 27, 2022 at 10:18 AM with an LPN (staff #13). The LPN stated for a newly admitted resident, usually their medications have already been ordered from the pharmacy so when the resident gets to the facility the medications are already there for them. She stated that if the nurse is unable to locate the medications, the nurse will contact the pharmacy. The LPN stated there had been some issues getting resident #39's medications from the pharmacy. She stated that when she called the pharmacy on July 25, 2022, the pharmacy told her they were out of Rytary. She further stated she was out of the medication at the facility so the resident did not receive the medication. The LPN stated if a resident does not receive medications as ordered, the nurses will notify the medical provider. The LPN stated that she does not chart in the resident's record if she notified the medical provider, she deletes her messages, and she is unable to provide evidence that notification occurred. She stated she knows that every time the medication was unable to be administered to the resident there should be documentation the physician was notified. The LPN stated that she believes the resident has a right to receive their prescribed medications. An interview was conducted on July 27, 2022 at 1:46 PM with the DON (staff #2). The DON stated when a resident is going to be newly admitted , they order their prescribed medications through the pharmacy so that once the resident arrives the medications should be at the facility. She explained that if the orders are in the resident medical record by 8:00 PM then the medication should be on the last run for the day. She stated that if the orders are put in the resident record after 8:00 PM then the medications should be in by mid-morning. The DON stated that she expects the staff to refill the resident medications when there are approximately 7 pills left to avoid the resident running out of medications. The DON stated that she is not aware of any concern related to residents not getting their medications. Further, the DON stated that if the resident is completely out of their medications then she expects the nurse to call the pharmacy and get some answers. The DON stated that sometimes the pharmacy can do a stat run and get the medication to the facility even faster than normal. She stated that if there are difficulties that continue then the nursing staff should notify her so she can assist them. The DON stated whenever a resident does not get their prescribed medications they should notify the medical provider. The DON stated that she was unsure if the nurses document in the resident's record if the physician is notified when a resident does not get their medications but she thought they should. The DON stated she reviewed the record and there were multiple days where the resident did not receive their prescribed medications. The facility policy titled administering medications stated medications shall be administered in a safe and timely manner, and as prescribed. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Medications must be administered in accordance with the orders, including any required time frame. Based on clinical record reviews, staff and resident interviews, and review of facility policy, the facility failed to ensure two residents (#17 & #39) received medications according to professional standards of practice. The sample size was 5 residents. The deficient practice could result in residents experiencing negative impact from not receiving ordered medications. Findings include: -Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteoporosis, paraplegia, atherosclerotic heart disease, and epilepsy. The care plan initiated on March 28, 2021 revealed the resident had the potential for injuries from seizures related to seizure disorder. The goal was that the resident would remain free from injury related to seizure activity. Interventions included giving the seizure medication as ordered. Review of the care plan revised on June 14, 2021 revealed the resident had the potential for alteration in comfort related to neuropathy, for adverse effects from the use of an antidepressant medication. Interventions included administering medications as ordered. Review of the Medication Administration Record (MAR) for July 2022 revealed no evidence medications scheduled to be administered at 9:00 a.m. on July 20, 2022 were administered to the resident, the areas were blank. The medications included: -Acetaminophen for pain management; -Apixaban for Deep Vein Thrombosis prophylaxis; -Cholecalciferol (Vitamin D), cyanocobalamin (Vitamin B12), fish oil, and magnesium oxide (supplements); -Gabapentin for neuropathy; -Levetiracetam for seizures; and -Sertraline for depression. Review of the clinical record did not reveal any nursing progress note or physician communication related to the medications scheduled for administration on July 20, 2022 at 9:00 a.m. An interview was conducted on July 27, 2022 at 11:46 a.m. with a Licensed Practical Nurse (LPN/staff #6). He stated that a check mark in the administration box on the MAR would mean a medication was administered. He stated if the area for documenting medication administration was left blank on the MAR, there was no way to show the scheduled medications were administered. The LPN stated if ordered medications were not given, the risk to the resident would depend on what the medication was being used for, but that there was a risk of adverse effects to the resident. An interview was conducted on July 27, 2022 at 12:28 p.m. with the Director of Nursing (DON/staff #2). She stated she expected staff to follow physician's orders as written. She stated that if the area for documenting medication administration was left blank on the MAR, she would have no way to show that the medication had been administered as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility document, and review of policies and procedures, the facility failed to ensure one resident (#94) consistently received the necessary services to maintain good hygiene. The sample size was 2 residents. The deficient practice could result in skin breakdown, odors and negative psychosocial impact. Findings include: Resident #94 was most recently admitted to the facility on [DATE] with diagnoses that included difficulty walking, muscle weakness, and major depression. Review of the May 2022 Activities of Daily Living (ADL) cares revealed: -No evidence that personal hygiene care was provided on May 31, 2020; -No evidence that toileting care was provided: on day shift May 27, 28, 30, and 31; on evening shift May 25, 26, 30, or 31; or on night shift May 26-31. -Area for bathing included (specify bathing days); There were no specific days identified, the time period area had two rows for PRN (as needed) bathing, and there was no documentation that the resident received any bathing. Review of a Certified Nursing Assistant (CNA) body worksheet dated May 28, 2020 revealed the resident had a bed bath. However, there was no evidence revealed a second shower/bath was offered that week. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident's cognition was intact. The assessment also revealed the resident received extensive assistance with toileting and hygiene, and help in part of bathing. The resident was coded as frequently incontinent of both bowel and bladder. Review of the resident's care plan revealed a focus dated May 25, 2020 that the resident required extensive to total staff care with ADL Self Cares related to atrial fibrillation, history of COVID, history of cardiac arrest, cardiomyopathy, and incontinence of bowel and bladder. Review of the June 2022 ADL cares revealed: -No evidence that personal hygiene care was provided on June 22 and 27; -No evidence that toileting care was provided: on day shift June 4, 7-14, 16-22, 27, and 30; on evening shift June 2-4, 10, 14, 16, 18-19, 22, 26-27, or 29; or on night shift June 2-17, 19-22, 24-28, or 30. -Area for bathing included (specify bathing days); There were no specific days identified, the time period area had two rows for PRN bathing, and there was no evidence the resident received any bathing. Review of the CNA body worksheets for June of 2022 revealed: -For the week ending June 6, 2020, the resident was bathed on June 1 and June 4, 2020; -For the week ending June 13, 2020, the resident was offered a bath on June 11, 2020; the resident refused that shower/bed bath want it tomorrow. However, there was no evidence that staff offered bathing a second time that week or that the resident received bathing that week. -For the week ending June 20, 2020, the resident was bathed on June 18, 2020. However, there was no evidence staff offered bathing a second time that week. -For the week ending June 27, 2020, there was evidence for bathing for June 22 and 25. Review of the July 2022 ADL cares revealed: -No evidence that personal hygiene care was provided on July 2-3, 7, 25-26, 28, 30 or 31; -No evidence that toileting care was provided: on day shift July 1-12, 16, 23, 25-26, or 28-31; on evening shift July 1-3, 5-7, 9, 11, 14-15, 18, 20-22, 24-26, 28, or 30-31; or on night shift July 2-6, 10-26, or 28-31. -Area for bathing included (specify bathing days); There were no specific days identified, the time period area had two rows for PRN bathing, and there was no evidence the resident received any bathing. Review of the CNA body worksheets for July of 2022 revealed: -For the week ending July 4, the resident was bathed on July 2, 2020. However, there was no evidence staff offered bathing a second time that week. -For the week ending July 11, the resident was bathed on July 9, 2020. However, there was no evidence staff offered bathing a second time that week. -For the week ending July 18, the resident was bathed on July 13, 2020. However, there was no evidence staff offered bathing a second time that week. -For the week ending July 25, there was no evidence the resident was bathed/showered. -For the week ending August 1, the resident was bathed on July 30, 2020. However, there was no evidence staff offered bathing a second time that week. An interview was conducted on July 27, 2022 at 11:32 a.m. with a CNA (staff #35). She stated that incontinence care should be provided two times or more on an eight-hour shift. Staff #35 stated the care provided would be documented in the resident's electronic medical record. She stated that there was no other place to find the documentation. She stated that if the information was not documented in the record, it would be considered to have not been done. She stated if the resident did not receive incontinence care they could develop an odor and be at risk for infection or skin breakdown. She stated it would also result in a dignity issue for the resident. She stated that the facility gets complaints that incontinence care had not been provided. The CNA stated that sometimes, when she arrives for her shift, it appears that the resident did not receive the incontinence care that they should have related to signs of excessive urine, pad sopping wet, brown ring on pad, odor and sometimes the resident's skin was reddened. She stated this did not happen very often, maybe two residents every few days/in a week. She stated that if the care area was blank, or coded with an 8, she would have to assume the care was not done. The CNA stated that bathing/showers are done on a schedule and that each resident is supposed to get two showers a week. She stated that she was able to complete her scheduled showers. She stated that she did a shower sheet with every shower and placed the sheet in the shower book. She stated the nurse needed to sign the shower sheet. She stated the electronic system did not give a choice of resident refusal, so if the resident refused she would code them as an 8 and mark the refusal on the shower sheet. She stated if the showers were marked as 8 or left blank and there was no shower sheet, the facility would not be able to show that the bathing/shower was offered/or given. An interview was conducted on July 27, 2022 at 11:46 a.m. with a Licensed Practical Nurse (LPN/staff #6). He stated when a CNA provides care (including hygiene, shower/bath, incontinence care), the CNA is supposed to document the care in the resident's electronic record. He stated that he did not believe there was any other way to show that the care was given. He stated that hygiene/toileting care should be provided each shift and showers twice a week. He stated that the CNA would do a shower sheet on the resident's scheduled shower day and the nurse would sign off on the shower. He stated there was no way to see that the shower was offered and given/refused if there was no documentation and/or shower sheet. The LPN stated the nurse may document refusals in the progress notes, but not always. The LPN stated if the resident did not receive incontinence care there was a risk for skin breakdown/ailments/rashes, resident odor, and the resident may mentally feel bad about it. An interview was conducted on July 27, 2022 at 12:28 p.m. with the Director of Nursing (DON/staff #2). She stated that she expects staff to provide showers twice, sometimes three times, a week. She stated that staff needed to provide incontinence/perineal care every time they change a resident, 3-4 times in an 8-hour shift if the resident was incontinent. The DON stated the staff would document the care provided in the tasks section of the electronic medical record. She stated if staff did not document, there was no way to show that the care was given. She stated that the risk of not receiving required incontinence care was infection and skin breakdown. She stated she expects a shower sheet to be filled out which would indicate the type of bathing received (bed/shower) or the documentation that the resident refused. She stated that a nurse is required to sign off on the shower sheet. The DON stated if the bathing was not documented, the facility would be unable to show that a shower was offered/given. The DON stated if a resident was not showered/provided hygiene care, the resident would be more prone to infection, skin breakdown, dry skin, and could have resulting mental effects. Review of a facility forms, dated April 2021 (previously revised September 2015) and April 2022, titled SNF (Skilled Nursing Facility) Shower Schedule revealed residents were scheduled for two showers a week by room number. Review of a facility policy for Incontinence Care included: It is the policy of this facility to promote skin hygiene, minimize risk of infection, and facilitate skin integrity by providing incontinence care as needed to residents. Review of a facility policy for Shower/tub bath included: The purposes of this procedure are to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. Review of a facility policy for Perineal Care included: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Review the resident's care plan to assess any special needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and facility policy and procedures, the facility failed to provide incontinence care on a regular basis for one resident (#145) and failed to provide appropriate care/services to maintain or improve continence for one resident #146. The sample size was 3 residents. The deficient practice could impact the dignity and independence along with the skin integrity of residents. Findings include: -Resident #145 was admitted to the facility on [DATE] with diagnoses that included a displaced mid-cervical fracture of the left femur, chronic lymphocytic Leukemia of B-cell, and chronic kidney disease, stage 3. The admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment. The assessment also included the resident was totally dependent on one-person physical assistance for toilet use. Review of the care plan dated September 16, 2020 revealed the resident had an Activities of Daily Living (ADL) Self Care Deficit related to Sequela of the Left Hip FX, Chronic Non-traumatic Subdural Hematoma, decreased mobility, decreased balance, and weakness. The intervention for toileting/incontinence care stated one-person assistance. Review of the ADL task sheet for July 2020 revealed the resident did not receive assistance with incontinence care on one or more shifts from July 21, 2020 through July 26, 2020, July 28, 2020, July 30 and July 31 2020. -Resident #146 was admitted to the facility on [DATE] with diagnoses that included Rhabdomyolysis, morbid obesity, and major depression. The resident was discharged on April 8, 2021. Review of the care plan dated March 23, 2021 for bladder incontinence related to impaired mobility included the interventions to check and change the resident every 2 hours and as required for incontinence and bladder retraining: encourage/assist the resident to void every two hours. The admission MDS assessment dated [DATE] included a BIMS with a score of 15 indicating the resident was cognitively intact. The assessment also stated the resident required extensive assistance of one-person for toilet use. Review of the ADL task sheet for March 2021 revealed the resident did not receive assistance with incontinence care or bladder training every two hours on: -March 25, 2021 -March 26, 2021 -March 27, 2021 -March 28, 2021 -March 30, 2021 -March 31, 2021 -April 3, 2021 -April 4, 2021 -April 5, 2021 During an interview conducted on July 26, 2022 at 1:13 p.m. with the Social Services Coordinator (staff #38), she stated that the certified nursing assistants (CNAs) should be documenting any assistance with Activities of Daily Living (ADLs) they provided for the resident on the task sheets. Staff #38 stated that is the only place where the CNAs document. On July 26, 2022 at 1:32 p.m., an interview was conducted with a CNA (staff #35), who said that she documents ADL care on the task sheets every shift. During the interview, she reviewed the task sheets and stated that she documents under the toileting task when she assists the resident with using the toilet or using a bedpan. Staff #35 stated that when she changes a resident's brief, she documents under the hygiene task. She reviewed the hygiene task and observed that it included brushing teeth, hair and washing face and hands, but did not include changing the resident's brief and stated that was what she was trained to do. An interview was conducted on July 26, 2022 at 2:34 p.m. with a licensed vocational nurse (LVN/staff #13). She said that it is her expectation that the CNAs check the resident every two hours for incontinence and it should be documented on the task sheet. During the interview she reviewed the task sheets and stated there are 3 CNA shifts and all 3 shifts should be documenting incontinence care on the task sheet. She also stated that the code (8) on the task sheet means the activity, toileting, did not occur, but the resident was changed. She was not able to explain how or where the CNA would document that the resident's brief was changed or incontinence care was provided. On July 27, 2022 at 10:49 a.m., an interview was conducted with the Director of Nursing (DON/staff #2), who stated that she expects the CNAs to check the residents every two hours for incontinence care. The DON stated if they are not independent it would be as needed. She stated if there is a toilet training plan, CNAs would follow the plan, which includes how often to check/assist the resident. She said the CNAs document incontinence care on the toileting task sheet one time per shift and this includes anything to do with incontinence care, including toileting and changing briefs. The DON reviewed the toileting task sheets for both residents and stated that the code 8 means that incontinence care was not provided during the shift. She also stated that there are three CNA shifts and each shift should be documenting the care. The DON stated that if the CNA left it blank, she would say the care did not occur. She stated that the nurses on shift will be responsible for monitoring the task sheets from this point forward. The facility's policy, Incontinence Care, stated it is the policy of this facility to promote skin hygiene, minimize risk of infection, and facilitate skin integrity by providing incontinence care as needed to residents. Document according to facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one resident (#18) was administered medications according to the parameters as ordered by the physician. The sample size was 5 residents. The deficient practice could result in residents receiving unnecessary drugs. Findings include: Resident #18 most recently admitted to the facility on [DATE] with diagnoses that included pneumonia and hypoxia. Review of the physician's orders revealed: -An order dated February 28, 2022 for Apixaban (anticoagulant) 5 milligram (mg) tablet via Gastrostomy (G) Tube two times a day for Atrial-fibrillation. Hold for Pulse Rate (PR) under 60. -An order dated February 28, 2022 for Metoprolol Tartrate (Beta Blocker) 100 mg tablet two times a day via G-tube for hypertension. Hold for Systolic Blood Pressure (SBP) under 100, PR under 60. Review of the current care plan revealed: -A focus most recently revised on March 11, 2022 that stated the resident was at risk for adverse effects from anticoagulation therapy with an intervention to give the medication as ordered. -A focus most recently revised on March 11, 2022 that stated the resident had altered cardiovascular status related to, including, atrial fibrillation and hypertension with an intervention to administered medications as ordered. Continued review of the physician's orders revealed: -An order dated May 16, 2022 for Amiodarone Hydrochloride (HCl) (antiarrhythmic) 200 mg tablet via Percutaneous Endoscopic Gastrostomy (PEG) Tube one time a day for atrial fibrillation. Hold for pulse under 60. -An order dated May 21, 2022 for Metoprolol Tartrate 50 mg tablet two times a day via PEG-tube for hypertension. Hold for SBP under 110. Review of the May 2022 Medication Administration Record (MAR) revealed: -Metoprolol Tartrate 100 mg tablet was administered below parameters on 5 occasions: at 4:00 a.m. on May 6, 12, and 17 for an SBP of 99; at 4:00 p.m. on May 3 for an SBP of 96 and May 4 for an SBP of 95. -Metoprolol Tartrate 50 mg was administered below parameters on two occasions: at 4:00 p.m. on May 27 and at 4:00 a.m. on May 28 for an SBP of 96. Review of the June 2022 MAR revealed: -Metoprolol Tartrate 50 mg was administered below parameters on five occasions: at 4:00 p.m. on June 4 for an SBP of 104, June 5 for an SBP of 109, June 7 for an SBP of 90, June 23 for an SBP of 98, and June 27 for an SBP of 108. Review of the July 2022 MAR revealed: -Apixaban 5 mg and Amiodarone HCl 200 mg were administered below parameters on one occasion on July 19 for a pulse of 52. -Metoprolol Tartrate 50 mg was administered below parameters on seven occasions: at 4:00 a.m. on July 5 for an SBP of 100 and July 15 for an SBP of 104; at 4:00 p.m. on July 7 for an SBP of 96, July 14 for an SBP of 96, July 19 for an SBP of 98, July 20 for an SBP of 105, and July 27 for an SBP of 108. An interview was conducted on July 27, 2022 at 11:46 a.m. with a Licensed Practical Nurse (LPN/staff #6). He stated that nurses are expected to follow the physician's orders as written, including all parameters. He stated a medication given below the blood pressure parameters could cause a further decrease in the blood pressure, unconsciousness, even death. An interview was conducted on July 27, 2022 at 12:28 p.m. with the Director of Nursing (DON/staff #2). She stated that she expected the staff to follow the physician's orders as written, including parameters for medications. She stated that she expected the nurses to hold the medication if the resident values are below the ordered parameters, or the parameter indicated to hold the medication, unless the nurse called the physician and the physician told the nurse to give the medication. She stated there should be a progress note of the physician's instruction. The DON stated the resident was at risk for extremely low blood pressure and could experience adverse effects as a result of not holding a medication as prescribed. The facility policy titled administering medications stated medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. The individual administering the medication must check to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. The following information must be checked/verified for each resident prior to administering medications: Allergies to medications; and Vital signs, if necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure lab results for one sampled resident (#94) were obtained and reported as ordered by the physician related to diabetic management. The deficient practice could result in uncontrolled blood sugar changes with adverse effects to the resident. Findings include: Resident #94 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (DM) and long-term use of insulin. Review of the resident's care plans revealed a focus initiated on May 14, 2020 that the resident had DM with a goal that the resident would have no complications related to diabetes and be free of hypo or hyperglycemia. The interventions included: diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness, and fasting serum blood sugar as ordered by doctor. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The assessment included diagnoses of diabetes mellitus and insulin use during the lookback period. The physician order dated May 24, 2020 included Insulin Lispro Solution, inject as per sliding scale before meals and at bedtime for DM. Instructions included if blood sugar was 351 to 600 give 10 units and notify the MD. Review of the May 2020 Medication Administration Record (MAR) revealed: -The blood sugar result for 6:30 a.m. was marked N/A with a reason code of 7 (sleeping) on one occasion. -The blood sugar result for 6:30 a.m. was marked N/A with no reason code on one occasion. -There was no documentation that the MD was notified of blood sugar results over 351 on 2 occasions. Review of the June 2020 MAR revealed: -The blood sugar result for 6:30 a.m. was marked N/A with a reason code of 7 (sleeping) on 5 occasions. -The blood sugar result for 6:30 a.m. was marked N/A with no reason code on 3 occasions. -There was no documentation that the MD was notified of blood sugar results over 351 on 14 occasions. Review of the July 2020 MAR revealed: -The blood sugar result for 6:30 a.m. was marked N/A with a reason code of 7 (sleeping) on 6 occasions. -The blood sugar result for 6:30 a.m. was marked N/A with no reason code on three occasions. -There was no documentation that the MD was notified of blood sugar results over 351 on 12 occasions. Review of Nurse Progress notes for the resident's stay did not reveal documentation of communication to the physician when blood sugars were not obtained and when blood sugars were 351-600. An interview was conducted on July 27, 2022 at 11:46 a.m. with a Licensed Practical Nurse (LPN/staff #6). He stated that a resident sleeping would not be a valid reason to not obtain a blood sugar as ordered unless the resident was care planned that they did not want to be woken up for medicine/blood sugar checks. He stated not doing the ordered blood sugar check would result in a risk for hyper/hypo glycemia and associated adverse effects. The LPN stated the resident should have been woken up for the blood sugar as ordered. The LPN also stated if the resident actively refused the blood sugar the refusal should be documented and the physician notified. An interview was conducted on July 27, 2022 at 12:28 p.m. with the Director of Nursing (DON/staff #2). She stated that she expected staff to follow the physician's orders as written. The DON stated that she expected routine blood sugars to be done as ordered by the physician and stated that sleeping was not a valid reason not to do the ordered blood sugar check. She stated the resident would be at risk for hypo/hyperglycemia and further hyperglycemia when the resident ate their meal and did not have the necessary insulin coverage. The DON stated without a blood sugar check, the nurse would not know the correct amount of insulin to give. A second interview was conducted on July 28, 2022 at 12:44 p.m. with the DON (staff #2). She stated if the order directed to notify the physician if the blood sugar was over a certain value, the nurse must notify the physician as ordered so that the physician could give direction. She stated the communication should be documented in the nurses' notes/progress notes and should include that the staff called the physician as ordered and what the physician response was. The DON stated there was a risk of continued high blood sugars and the risk of a diabetic coma or other diabetic complications if the physician was not called as ordered. Review of a facility policy for Administering Medications included: Medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: The date and time the medication was administered; the dosage; the route of administration; the injection site; any complaints of symptoms for which the drug was administered; any results achieved and when those results were observed; and the signature and title of the person administering the drug. Review of a facility policy for Diabetes, Nursing Care of Resident With included: Hypoglycemia is usually slow to onset. Hyperglycemia usually has a rapid onset. Assessment and determination of the resident's nutritional needs will be performed by the IDT (Interdisciplinary Team) in coordination with appropriate individuals. Review of an unnamed policy included: The resident's attending physician, or healthcare practitioner will be notified of the results of diagnostic tests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on concerns identified during the survey, the Facility Assessment, staff interviews, and policy review, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure a plan of action was developed and implemented that corrected identified quality care concerns related to infection control surveillance and antibiotic stewardship. The deficient practice could result in other quality concerns not being corrected. Findings include: During the survey concerns were identified regarding infection control surveillance which included tracking and monitoring the use of antibiotics, education, antibiotic stewardship, monitoring infections, and identifying infection trends in the facility. Review of the facility's assessment dated [DATE] revealed the facility is a 60-bed licensed skilled nursing unit. The average daily census for the facility was 44 - 45 residents. The assessment stated that they admit a variety of different residents and that they may have a variety of infectious diseases which may include skin and soft tissue infections, respiratory infections, urinary tract infections, infections with Multi-Drug Resistant Organisms (MDRO), MRSA (Methicillin-resistant Staphylococcus aureus), Clostridioides Difficile, Septicemia, Influenza, Covid-19, and scabies. Additionally, the assessment stated that the facility evaluates all components of the Infection Prevention and Control Program through the process of ongoing outcome and process surveillance with reporting to the QAPI Committee. An interview was conducted on July 26, 2022 at 12:41 PM with the Infection Preventionist (IP/staff #34). The IP stated that she had just begun her position as IP for the facility in the past few weeks. Further, she stated that she was having difficulty locating infection control surveillance for the facility from January 2022 to June 2022. The nurse explained that there is minimal surveillance that was conducted in February of 2022, however she suspected that the month of February 2022 was not complete. The IP stated the antibiotic stewardship program is a part of the surveillance and monitoring of infection control. Further, she explained QA meetings should include information on antibiotic stewardship and infection control surveillance. She stated that she has attempted to locate documentation of any information brought to the QA committee or monthly reports, however she has not found any information at this point for antibiotic stewardship for reviewing antibiotics. Additionally, the IP stated currently there is no system in place for monitoring antibiotics and is not aware of any provider involvement with antibiotic stewardship. An interview was conducted on July 26, 2022 at 2:25 PM with the Director of Nursing (DON/staff #2). The DON stated the facility does not have a system in place for monitoring infections except COVID-19. She explained that the interdisciplinary team meets to discuss residents that have infections and are on antibiotics. Further, she stated the IP completes logs for tracking infection control. The DON stated the infection control monitoring logs had not been updated since March 2022 and January and February 2022 were not completed. The DON stated that monitoring infections is important for the safety of the residents and to prevent any outbreaks. Additionally, she stated that not conducting thorough monitoring of infections could put residents and staff at risk. The DON stated that the pharmacy does not provide any antibiotic review sheet. However, the DON explained that the IDT (interdisciplinary team) discusses any residents that are on any antibiotics and if there is a true need. The DON stated this is not documented anywhere that she is aware of. An interview was conducted with the Executive Director (ED/staff #4) on July 28, 2022 at 8:58 AM. The ED stated the QAPI committee meets quarterly and monthly with the subcommittee. Further, she explained that in the monthly meeting they discuss and review their action plans. The ED stated that the last quarterly QA meeting was on April 26, 2022. She stated that a portion of the meeting they discussed antibiotic stewardship program and then reviewed antibiotics with the medical director as well. Additionally, she stated the team initiates action plans based on their findings and then reviews the current ones. The ED stated that the team is set to meet again on July 30, 2022. The ED explained that the IP nurse is new to the position for approximately 2 weeks and is reviewing the infection control surveillance and is expected to report to the QA committee at that meeting. The ED explained that the current antibiotic stewardship program included the medical director reviewing a list of all the residents on antibiotics for appropriateness. The ED stated that she was unable to provide further documentation to support antibiotics being reviewed with the physician or the criteria in which the infections were analyzed. Another interview was conducted with the ED (staff #4) on July 28, 2022 at 3:35 PM. The ED stated that the QA committees' purpose is to identify items of concern and put action plans in place in the attempt to correct them to be compliant. The ED stated even though there is little evidence that the surveillance was being done from January 2022 through June 2022, the QA committee did not create an action plan because nosocomial rates would have triggered them to look for IP concerns, but they did not trigger. The ED explained that the QA committee used to report on nosocomial infections however in recent meetings they have not. She explained that the QA committee had not created any action plan to address infection control surveillance at any time in the last year because up until the end of 2021 infection control surveillance was being done. She explained that the former IP had resigned from the position and that the facility had hired a new IP in the past 3 weeks. Further, she stated that there had been a large staffing issue that had caused the facility to experience a lot of spiraling and being in survival mode. The ED stated that she had chosen resident care and had fallen behind on paperwork. The ED declined to share QA notes. The ED stated that the QAPI did not put an action plan in place for IP surveillance and on-going monitoring of the infections in the facility. The facility policy titled Quality Assurance and Performance Improvement (QAPI) Plan stated this facility shall develop, implement, and maintain a comprehensive data driven facility-wide QAPI Plan that focuses on indicators of the outcomes of care and quality of life. The objectives of the QAPI Plan are to provide a means to identify and resolve present and potential negative outcomes related to resident care and services. Sources of information may include, but are not limited to incident reports, communication with residents and staff members, infection control reports, return to hospital reports and general observations. The owner and/or governing board (body) of the facility shall be ultimately responsible for the QAPI Program. The Administrator is responsible for assuring this facility's QAPI Program complies with federal, state, and local regulatory agency requirements. The Committee identifies and prioritizes problems and opportunities that reflect organizational process, functions and services provided to residents based on performance indicator data and resident and staff input and other information.

Based on observations, staff interviews, facility documentation, and policy and procedure review, the facility failed to consistently implement an ongoing system of surveillance for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, and failed to handle potentially soiled linens using safe and sanitary techniques. The deficient practice could result in trends not being identified and the spread of infection. Findings include: Regarding surveillance Review of the Infection Surveillance Monitoring binder revealed line listing and mapping of infections was last completed December 2021. January 2022 to June 2022 had no completed listing or mapping/evaluation of infections. An interview was conducted on July 26, 2022 at 12:41 PM with the Infection Preventionist (IP/staff #34). She stated infection surveillance is completed with a form called Surveillance Data Collection Form, is initiated by the nurses, and is color coded with blue for respiratory infections, pink for soft tissue including skin, soft tissue, or wound infections, lavender for gastrointestinal infections, and green for other infections. She stated she is able to identify infections or new antibiotics in the mornings because there is documentation on Point Click Care's (PCC's) dashboard. She further stated there is mapping documentation for COVID-19 but she was not able to locate any other line listing/mapping/monitoring of any other infections from April 2022 to June 2022. She stated January 2022 to March 2022 has limited information but was not completed. She further stated she took the role of IP approximately 2 weeks ago and is not aware of who was responsible prior to this. An interview was conducted on July 26, 2022 at 2:26 PM with the Director of Nursing (DON/staff #2). She stated staff #34 is the current IP and the prior IP is no longer employed at the facility. She stated she was responsible for IP during the time of transition between IPs, and the current IP is the 3rd IP for 2022. She stated the facility currently does not have a system in place for monitoring infections except for COVID-19. She stated the infection control monitoring has not been updated since March 2022 and January 2022 to February 2022 were not completed. She stated she was not aware the infection control books were not completed and she is not aware of any communication or meetings where this information was communicated. The DON stated she does not attend the facility Quality Assurance Performance Improvement (QAPI) meeting and has been the DON since February 2022. She further stated monitoring infections is important for the safety of the residents and to prevent an outbreak as it puts residents and staff at risk if they are not monitored. An interview was conducted on July 28, 2022 at 8:58 AM with the Executive Director (ED/staff #4). She stated the QAPI meeting is held quarterly and there is a subcommittee meeting held monthly, which includes the medical director. She stated the monthly meeting is to discuss and review their action plans. She stated she was not aware the infection surveillance monitoring book was not completed from January 2022 to June 2022. The ED stated the current IP is the 3rd IP employed with the facility during 2022. She stated the current IP is new to the position. She stated it is her expectation infections are monitored and reviewed for trends and the information to be reviewed in QAPI. The facility's Infection Control Policy revised October 2018 stated the facility shall track the prevalence of infections by maintaining a monthly tracking log to gather, document, and list surveillance data that may include resident identifiers, onset of date, infection related diagnoses, site of infection, culture/organism data, antibiotic treatment, type of infection and isolation implementation. The policy further stated monthly surveillance data shall be analyzed and summarized to identify the number of residents who developed infections and will be maintained for at least 12 months and reviewed at least quarterly by the QAPI committee. Regarding linens An observation of the laundry room was conducted on July 27, 2022. A Laundry Aide (staff #20) was observed removing clothing from a blue laundry bin located next to a washing machine and placing the clothing into the washer. Staff #20 was not wearing any personal protective equipment (PPE), including no mask, gloves, gown, face shield, hair bonnet or shoe covers. An interview was conducted on July 27, 2022 at 12:21 PM with the Director of Housekeeping and Laundry (staff #51). He stated his department has no problem obtaining PPE and has PPE in storage as well. He stated laundry is placed in the dirty staging area, placed in the blue bin designated for dirty laundry and placed into the washing machine, dryer, placed in the white bins designated for clean laundry, separated and folded on the clean side of the laundry room and distributed appropriately. He stated employees are expected to wear gowns, gloves, face shield, hair bonnet, and shoe covers when handling dirty linen. An interview was conducted on July 27, 2022 at 12:34 PM with the Laundry Aide (staff #20). She stated the blue bin next to the washer is considered a dirty laundry bin. Staff #20 stated the clothes placed into the washer were in the blue bin and would be considered contaminated. She stated the clothes that were put in the washing machine were donated clothes from facility residents and came from the residents' rooms. She further stated when she works with contaminated/dirty clothes, a gown, mask, gloves, and face shield are required. She stated a mask is required to wear at all times. Staff #20 was observed removing her mask from her left pants pocket during the interview and donning the face mask and stated she takes it off sometimes because it gets hot in the laundry room. She further stated it is important to wear PPE to prevent cross contamination of dirty and clean laundry. Another interview was conducted on July 27, 2022 at 12:38 PM with staff #51. He stated staff #20 was placing dirty clothing into the washing machine. He stated staff #20 was not wearing any PPE and should have been wearing a gown, gloves, and a face mask while removing clothes from the dirty bin. He further stated it is important for PPE to be worn between dirty and clean linen to prevent contamination of clean items. Staff #51 stated leaning against the blue bin with personal clothing does not protect staff members' clothes from contaminating clean clothes when folding clean clothes. The facility's Housekeeping and Laundry Services Safety Procedures Policy dated 11/01/2010, stated staff should assume all human blood and body fluids should be considered potentially infectious. In addition to body fluids, all instruments, surfaces, and materials that have the potential to be contaminated with blood or other infectious materials should be treated as if they are infectious. The policy further stated staff should wear disposable gloves when handling soiled laundry and must also wear a protective gown, goggles, and/or mask as appropriate if splattering or soiling is likely.

Based on staff interviews, facility documentation, and policy and procedure review, the facility failed to develop and implement a facility-wide system to monitor the use of antibiotics. The deficient practice could result in the facility not ensuring residents who require an antibiotic are prescribed the appropriate antibiotic and could result in adverse effects from unnecessary or inappropriate antibiotic use. Findings include: Review of the Infection Surveillance Monitoring binder revealed line listing and mapping of infections was last completed December 2021. January 2022 to June 2022 had no completed listing or mapping/evaluation of infections. In an interview conducted with the Infection Preventionist (IP/staff #34) on July 26, 2022 at 12:41 PM, she stated infection surveillance is completed with a form called Surveillance Data Collection Form, is initiated by the nurses, and is color coded with blue for respiratory infections, pink for soft tissue including skin, soft tissue, or wound infections, lavender for gastrointestinal infections, and green for other infections. She stated she is able to identify infections or new antibiotics in the mornings because there is documentation on Point Click Care's (PCC's) dashboard. She stated there is mapping documentation for COVID-19 but she was not able to locate any other line listing/mapping/monitoring of any other infections from April 2022 to June 2022. She stated January 2022 to March 2022 has limited information but is not completed. She further stated she took the role of IP approximately 2 weeks ago and is not aware of who was responsible prior to this. The IP stated there is currently no system in place for monitoring antibiotics and she is not part of an antibiotic stewardship committee and is not aware of the provider's involvement with antibiotic stewardship. She further stated an antibiotic stewardship program is part of the surveillance monitoring, Quality Assurance meetings, in-servicing staff of Urinary Tract Infections, and promoting hygiene and fluids. An interview was conducted on July 26, 2022 at 2:26 PM with the Director of Nursing (DON/staff #2). She stated she has been the DON since February 2022. She stated staff #34 is the current IP and the prior IP is no longer employed at the facility. She stated she was responsible for IP during the period of time of transition between IPs and the current IP is the 3rd IP for 2022. She stated the facility currently does not have a system in place for monitoring infections except for COVID-19. She stated the infection control monitoring has not been updated since March 2022, and January 2022 to February 2022 were not completed. She stated she was not aware the infection control books were not completed. The DON stated she is not aware of any communication or meetings where this information is communicated and she does not attend the facility Quality Assurance Performance Improvement (QAPI) meeting. She further stated monitoring infections is important for the safety of the residents and to prevent an outbreak as it puts residents and staff at risk if they are not monitored. The DON stated she is not aware of an antibiotic stewardship program for the facility. She further stated the pharmacy does not provide a list of antibiotics to the facility, it is not discussed in QAPI and she is not part of the antimicrobial stewardship committee. She stated monitoring infections is important for the safety of the residents. An interview was conducted on July 28, 2022 at 8:58 AM with the Executive Director (ED/staff #4). She stated the QAPI meeting is held quarterly and there is a subcommittee meeting held monthly, which includes the medical director. She stated the monthly meeting is to discuss and review their action plans. She further stated part of the meeting is the antibiotic stewardship program. The ED stated the antibiotics are reviewed with the medical director and they initiate action plans based on their findings and review. She stated the medical director obtains the list of all antibiotics and reviews for appropriateness and makes changes as appropriate and this continues to be reviewed in QAPI as well. The ED was not able to reveal documentation of antibiotic listings or documentation of review. She stated there was no further documentation to support antibiotics are reviewed with the physician. The facility Antimicrobial Stewardship Program policy dated 2016 stated the members of the antimicrobial stewardship committee should include at a minimum the Medical Director, DON, IP and pharmacist or the facility's consultant pharmacist. It further stated the committee should meet at least quarterly to review data collected, facility trends, analyze performance and develop action plans for antimicrobial use improvement. Essential data should include antimicrobial orders and utilization, clinical documentation supporting resident condition and assessment, supplemental information from infection surveillance logs, microbiology testing, other tests used to confirm infection such as imaging, trends in infections by unit and facility-wide, and trends by prescriber.

Based on personnel file reviews, staff interviews, facility document, and facility policy and procedures, the facility failed to provide evidence that 3 out of 10 staff (#16, #34, and #19) were provided training on abuse, neglect, exploitation, misappropriation of resident property and dementia management. The deficient practice could result in staff not knowing how to protect residents from abuse and residents with dementia not receiving the services and care needed. Findings include: -Staff #16 was hired on June 24, 2022 as a registered nurse (RN). Review of staff #16's personnel file revealed no evidence that staff #16 completed training during orientation, which included training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management. -Staff #34 was hired on April 19, 2022 as a licensed practical nurse (LPN). Review of staff #34's personnel file revealed no evidence that staff #34 completed training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management. -Staff #19 was hired as a certified nursing assistant (CNA) on May 1, 2022. Review of staff #19's personnel file did not reveal that any training had been completed, which included training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management. During review of the personnel files on July 27, 2022 at 7:49 a.m. with the Human Resource Assistant (staff #52), she stated that orientation training is supposed to be completed within 10 days of staff being hired and training includes abuse and dementia. She also said that the Director of Human Resources is responsible for ensuring staff training is completed, but the facility did not have a director for a long time. An interview was conducted on July 27, 2022 at 9:00 a.m. with the Director of Human Resources (staff #51), who stated orientation training includes abuse, neglect, exploitation, misappropriation of resident property training, but she does not know if it includes dementia management training. She stated that when staff do not receive training, there is a risk that employees would not know what to do to take care of residents. The facility's New Hire Orientation checklist included abuse and dementia training. The facility's policy, Abuse Prevention Training and Reporting, stated all employees will be trained on recognizing possible signs and symptoms of alleged abuse, and the procedure for reporting alleged abuse. Copies of all training will be maintained in the employee file.