Based on observation interview, record review, manufacturer's manual review and facility policy review, the facility failed to ensure oxygen (O2) orders were in place for one of three sampled residents (Resident (R)32). In addition, maintain O2 concentrators filters free of dust and nasal cannulas were placed in bags while not in use for two of three sample residents (R32 and R33).This deficient practice had the potential to allow an increased chance of unnecessary respiratory treatment and infection. Findings include:Review of the facility's policy titled Medication Orders, revised 04/25/25 revealed, Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Recording Orders. 3. Oxygen orders- When recording orders for oxygen, specify the rate of flow, route, and rationale.Review of the undated user manual for the concentrator page 23, revealed Cleaning the Cabinet Filter: Caution: DO NOT operate the concentrator without the filter installed. 1. Remove the filter and clean at least once a week depending on environmental conditions.Review of the facility's policy titled Oxygen Administration revised 04/25/25 revealed, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the Procedure. 22. Store oxygen tubing in a bag while not in use.1. Review of R32's undated Administration Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 06/22/17 and indicated a diagnosis of respiratory disorders and congestive heart failure.During an observation on 07/21/25 at 10:50 AM, R32 was wearing a nasal canula and the oxygen tubing was connected to the concentrator which indicated two liters per minute (L/min). During the same observation, the cabinet filter was noted to have a visible layer of dust on it.Review of the physicians' orders under the Orders tab in the EMR revealed no order for oxygen.During an observation on 03/22/25 at 2:25 PM, the cabinet filter had a visible layer of dust on it. The nasal canula was placed on top of the concentrator.During an interview on 07/23/25 at 10:04 AM, Registered Nurse (RN)1 was asked to look at the oxygen concentrator. RN1 stated, I guess this filter is dirty. RN1 stated the filter should be cleaned but was unsure who would clean the filters. RN1 was asked about whether the nasal canula should be left to open air. RN1 stated, It should be bagged.During an interview on 07/23/25 at 10:15 AM, the Director of Nursing (DON) was asked about the dusty filter and nasal canula in the open air. The DON stated, The filters should be cleaned as needed by the Durable Medical Equipment Specialist (DMES) and the nasal canula should be bagged when not in use.During an interview on 07/23/25 at 10:17 AM, the DMES stated the filter should be maintained monthly and changed out as needed.During an interview on 07/23/25 at 12:00 PM, the DON was asked about R32's oxygen order. The DON confirmed there was no oxygen order. It must have been missed when the resident came back from the hospital in June.2. Review of R33's undated Administration Record located in the EMR under the Profile tab, revealed an admission date of 09/07/24 and indicated a diagnosis of acute respiratory failure with hypoxia.Review of the physicians' orders under the Orders tab in the EMR, revealed on 05/11/25 Oxygen at 1-2 L/min Via Nasal Canula prn [as needed] to keep Sats [oxygen saturation in the blood] at or above 90%.Observation on 07/21/25 at 11:03 AM, revealed no filter on the cabinet of the concentrator and the nasal canula was placed on top pf the concentrator to open air.During an observation on 07/22/24 at 2:30 PM, no filter on the cabinet of the concentrator and the nasal canula was placed on top pf the concentrator to open air.During an observation on 07/23/25 at 9:56 AM, R33 was wearing a nasal canula and the concentrator was set on two L/min and there was no filter on the cabinet.During an interview on 10:10 AM, RN1 was asked about the filter. RN1 looked and stated, There should be a filter on the machine. I did not realize some machines did not have internal filters.During an interview on 07/23/25 at 10:15 AM, the DON was asked to look at R33's concentrator. The DON stated, It should have a filter to prevent anything from entering the machine.During an interview on 07/23/25 at 10;17 AM, the DMES was asked about the filter and stated, All concentrators should have a clean filter.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that meet the needs of one of ten residents (Resident [R]5) observed for medication pass when Omeprazole (used to treat heartburn and indigestion) was administered after meal instead of before meal as ordered for R5.These failures could lead to decreased medication effectiveness and potential adverse health outcomes for R5.Findings:On 07/24/2025, at 08:51 AM, a medication administration observation to R5 was conducted with Registered Nurse (RN) 1. RN 1 administered medications to R5 including 1 tablet of Omeprazole 20 mg.Review of R5's physician's order dated 07/10/2025 indicated an order for Omeprazole Oral Tablet Delayed Release 20 milligram to give one tablet by mouth in the morning for GERD (Gastroesophageal Reflux Disease) to Administer 30-60 minutes prior to meals.In an interview on 07/24/2025, at 10:29 AM, R5 stated that he had eaten breakfast at 7 AM before R1 administer the medication. In an interview on 07/24/2025, at 10:31 AM, RN1 acknowledged that Omeprazole should be given before R5 had his breakfast.Review of facility policy titled, Administering Medications with revision date of 04/25/2025 indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement an effective infection control program in accordance with internal policies and procedures, nationally recognized infection control guidelines and regulations when:a. Glucometers (a device used to check the blood sugar) were not cleaned and disinfected after use.b. Staff did not perform hand hygiene before putting on gloves. Failure to implement infection prevention practices may contribute to cross contamination of infection that can jeopardize the health and safety of residents and staff. Findings:In an observation on 07/23/2025, at 11:04 AM, Licensed Practical Nurse (LPN) 1 entered the room of R7. LPN1 don on gloves without performing hand hygiene and proceed to check R7's blood sugar. After checking the blood sugar, LPN stored the glucometer in the black casing and did not clean and disinfect the equipment.In another observation on 07/23/2025 at 12:08 PM, LPN1 don on gloves without performing hand hygiene and checked R40's blood sugar. LPN1 then placed the glucometer back in the black casing and did not clean and disinfect the equipment. In an interview on 07/23/2025 at 12:25, LPN1 acknowledged the findings and stated, Sorry I missed it. LPN1 also confirmed glucometer brand as [NAME] and facility was using Micro-kill disinfectant wipes and Sani-Cloth wipes to clean the glucometer.Review of [NAME] Quintet AC Blood Glucose Meter Owner's Manual 89115-0055-01 under Cleaning and Disinfecting Procedures indicated, Indirect transmission of Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) during the delivery of healthcare services has been increasingly reported. Persons using blood glucose monitoring systems have been identified as one risk group due to sharing of lancets, lancing devices, and blood glucose meters. The cleaning procedure is to remove dust, blood and body fluid from the surface and should be performed whenever the meter is visibly dirty. The disinfecting procedure is necessary to kill pathogens such as HIV, HBV and HCV on the device. NOTE: the cleaning procedure can only remove visible contaminates from surfaces. Only the disinfecting procedure can eliminate non-visible pathogens. The meter MUST be cleaned and disinfected after use on each patient. Review of facility policy titled Hand Hygiene Policy dated 08/28/24 indicated, 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.According to Center for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Setting guidelines retrieved from https://www.cdc.gov/handhygiene/providers, on 08/28/25, Hand Hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel), or surgical hand antisepsis. Under Glove Use indicated, Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 12 sampled residents (R42) was provided assistance in formulating an advance healthcare directive when they expressed a desire to create one. This failure put the resident at risk for not having their wishes for treatment known and had the potential for the resident's decision regarding his healthcare and treatment options not being honored. Findings: Review of the electronic medical record (EMR) revealed R42 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 06/19/24, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R42 had no cognitive impairment. Review of the advance healthcare directive acknowledgment form signed by R42 upon admission indicated that R42 wished to complete a healthcare power of attorney. Review of the EMR failed to show a copy of R42's advance healthcare directive. On 09/26/24 at 10:57 AM, an interview was conducted with Social Worker (SW) 1. SW 1 acknowledged that when R42 was admitted in June 2024, R42 expressed a wish to complete a healthcare power of attorney. SW 1 stated when residents express a desire to develop an advance healthcare directive, the procedure was to assist the resident as soon as possible. SW 1 explained that they typically provide the resident with copies of the forms to review in advance and invite a notary to complete the paperwork. When asked if this process was completed, SW 1 stated that it was not. SW 1 verified that R42 was capable of making healthcare decisions. On 09/26/24 at 11:44 AM, an interview was conducted with R42 in her room. R42 stated that she remembered the facility staff asking her when she came to the facility in June if she wanted to formulate an advance healthcare directive. R42 stated she wished to designate a family member as her healthcare power of attorney. However, no one followed up, so I forgot about it. According to the facility's policy titled Residents' Rights Regarding Treatment and Advance Directives (undated), 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 an advance directive .On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one of three residents (R31) reviewed for hospitalization, or their representatives in writing and send a copy of the notice to the ombudsman of the reason for the transfer. This had the potential for the resident and/or their representative to be unaware of their rights and posed the risk of the ombudsman not being aware of the circumstances should appeals be filed by the resident or their representative regarding the transfer/discharge. Findings: Review of the electronic medical record (EMR) revealed R31 was initially admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 03/02/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R31 had no cognitive impairment. Review of a physician's order dated 02/17/24 revealed an order to send R31 to the acute care hospital for evaluation and treatment. Review of the Progress Notes revealed a Health Status Note dated 02/17/24, indicating R31 was admitted to the acute care hospital for cellulitis (bacterial skin infection). Review of the EMR failed to show documentation that R31 and/or his representative was provided with a written notice of transfer, nor a copy of the notice was sent to the Office of the Long-Term Care Ombudsman. On 09/25/24 at 01:41 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 verified R31 was transferred and admitted to the hospital on [DATE]. LPN 1 stated she could not find any documentation of a written notice of transfer provided to R31 and/or his representative. LPN 1 mentioned that she would need to check with the medical records department. On 09/25/24 at 02:52 PM, an interview was conducted with the Director of Nursing (DON). The DON verified the above findings and stated that R31 and/or his representative was not provided a written notice of transfer when he was transferred and admitted to the hospital on [DATE], but should have been. On 09/27/24 at 01:58 PM, an interview was conducted with Social Worker (SW) 1. SW 1 stated they send emails to the ombudsman at the end of the month to notify them of admissions, transfers, and discharges. When asked if they send a copy of the notice of transfer/discharge to the ombudsman, SW 1 stated no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (R31), reviewed for hospitalization, and/or their representative were provided with written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital. This failure had the potential for R31 or their representative to be unaware of their right to request a bed-hold and their right to return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period. Findings: Review of the electronic medical record (EMR) revealed R31 was initially admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 03/02/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R31 had no cognitive impairment. Review of a physician's order dated 02/17/24 revealed an order to send R31 to the acute care hospital for evaluation and treatment. Review of the Progress Notes revealed a Health Status Note dated 02/17/24, indicating R31 was admitted to the acute care hospital for cellulitis (bacterial skin infection). Review of the EMR failed to show documentation R31 and/or his representative was provided information regarding the facility's bed-hold policy at the time of transfer to the acute care hospital. On 09/25/24 at 01:41 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 verified R31 was transferred and admitted to the hospital on [DATE]. LPN 1 stated she could not find any documentation R31 was provided information regarding the facility's bed-hold policy at the time of transfer. On 09/25/24 at 02:52 PM, an interview was conducted with the Director of Nursing (DON). The DON verified the above findings and stated that R31 and/or his representative was not provided written information regarding the facility's bed-hold policy when R31 was transferred and admitted to the hospital on [DATE], but should have been. According to the facility's policy titled Bed-hold and Returns revised 04/11/24, Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy . Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. the rights and limitations of the resident regarding bed-holds; b. the reserve bed payment policy as indicated by the state plan (Medicaid residents); c. the facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and d. the details of the transfer (per the notice of transfer).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment for two of 12 sampled residents (R23 and R29) accurately reflected the residents' status. *R29's weight loss and anticoagulant use were coded incorrectly. *R23's active diagnosis of depression was not coded in the MDS. These failures had the potential for the residents to not receive an individualized plan of care based on their specific care needs. Findings: For R29: Review of the electronic medical record (EMR) revealed R29 was admitted to the facility on [DATE] with diagnoses including hypertension and coronary artery disease. Review of the MDS with assessment reference date of 07/26/24 revealed Section K, which addresses weight loss of 5% or more in the last month or 10% or more in the last 6 months, was marked as Yes, indicating R29 was not on a physician-prescribed weight loss regimen. However, a review of R29's weights showed that R29 did not experience a weight loss of 5% in the last month or 10% in the last 6 months. Further review of the MDS revealed that R29 was coded as taking an anticoagulant medication with an indication noted. However. Review of the Medication Administration Record for July 2024 failed to show any evidence that R29 was receiving an anticoagulant. On 09/27/24 at 12:00 PM, a telephone interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator reviewed the medical record and verified the above findings. The MDS Coordinator stated R29's MDS was coded inaccurately for both weight loss and anticoagulant use. Resident 23 R23 was admitted with diagnoses including hypertension, muscle weakness, and pneumonia. Review of R23's physicians order dated 03/14/24, indicated R23 was receiving Prozac (antidepressant) for Depression, AEB [as evidence by] self isolation. Review of R23's Quarterly MDS assessment dated [DATE], under Section I Active Diagnoses indicated the diagnosis of Depression was coded NO. In an interview on 09/26/24, at 02:17 PM, RN1 confirmed that R23 was receiving Prozac. RN1 also stated, R23 was admitted with Prozac for withdrawn behavior prior to him coming to nursing home. In an interview on 09/27/24, at 12:13 PM, MDS Coordinator stated,(R23) is getting antidepressant. MDS Coordinator explained the diagnosis of depression should be coded as yes. He added, It is incorrect, it should be coded yes for diagnosis. According to MDS 3.0 Resident Assessment Instrument (RAI) Manual, under Section I defined Active Diagnoses as Physician-documented diagnoses in the last 60 days that have a direct relationship to the resident ' s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.

Based on interview and record review, the facility did not ensure that the resident's drug regimen was free from unnecessary drugs when Midodrine HCL (used to treat low blood pressure) was administered outside the parameters for one of one sampled resident (Resident [R] 41). This failure resulted R41 receiving unnecessary medication that could negatively affect his health and well-being. Findings: R41 was admitted with diagnoses including Parkinson's Disease (chronic and progressive movement disorder), muscle weakness, and orthostatic hypotension (low blood pressure [BP] that happens when standing after sitting or lying down). Review of R41's physician order, dated 07/29/24, indicated an order for Midodrine HCl 10 milligram 1 tablet three times a day for Orthostatic Hypotension to Hold for Systolic Blood Pressure (SBP) less than 110. SBP is the measure of pressure within the arteries while the heart beats. Review of R41's August 2024 Medication Administration Record (MAR), indicated a Midodrine HCl Oral Tablet 10 MG was administered outside the parameters on the following dates: 08/01/24 at 2PM for SBP of 122 08/05/24 at 2PM for SBP of 135 08/09/24 at 6AM for SBP of 148 08/15/24 at 6AM for SBP of 140 08/15/24 at 10PM for SBP of 157 08/17/24 at 2PM for SBP of 142 In an interview with Registered Nurse (RN)1 and review of R41's August 2024 MAR on 09/25/24, at 02:46 PM, RN1 verified that R41 was given a dose of Midodrine outside the parameters. RN1 stated, If there's a check that means it was given out of parameters. Review of facility's policy titled, Administering Oral Medication with revised date of 04/11/24, indicated, 6. Check the label on the medication and confirm the medication name and dose in the MAR .8. Check the medication dose. Recheck to confirm the proper dose .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the as needed order for psychotropic medications (drugs that affect brain activities with mental processes and behavior) for one of six residents (R) reviewed for unnecessary medications (R45) had the documented rationale from the physician for the appropriateness of extending the medication beyond 14 days. This failure had the potential for R45 to experience adverse effects or receive unnecessary psychotropic medications. Findings: Review of the electronic medical records (EMR) showed R45 was admitted to the facility on [DATE], and was receiving hospice services. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 08/28/24, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating R45 had severe cognitive impairment. Review of the Order Summary Report showed the following physician's orders dated 09/09/24: - LORazepam [antianxiety medication] oral concentrate Oral Concentrate 2 MG/ML (Lorazepam) Give 0.25 ml orally every 1 hours [sic] as needed for Anxiety AEB [as evidenced by] increased HR [heart rate] for 90 Days Give 0.5 mg= 0.25 ml. end of life care - LORazepam [sic] Oral Concentrate 2 MG/ML (Lorazepam) Give 0.5 ml orally every 1 hours [sic] as needed for severe Anxiety AEB increased HR and SOB for 90 Days Give 1 mg=0.5 ml. end of life care Review of R45's medical record failed to show the physician or prescribing practitioner documented a rationale for the appropriateness of extending the as needed order for lorazepam beyond 14 days. On 09/26/24 at 11:51 AM, an interview and concurrent medical record review was conducted with Registered Nurse (RN) 1. RN 1 reviewed R45's medical record and could not find a documented rationale from R45's physician of the rationale for the appropriateness of extending the as needed orders for lorazepam beyond 14 days. On 09/27/24 at 12:42 PM, the Director of Nursing (DON) was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate was below 5%. The medication error rate was 12%. Three medication administration errors were identified out of 25 opportunities during medication administration observation on 09/26/24 as follows: *RN 2 administered a medication to Resident (R) 20 that was ordered to be administered before a meal, but instead, it was administered after R20 had already eaten breakfast. *RN 2 administered two different eye drops to R20 without allowing the required 3-5 minute wait between drops, as outlined in their policy and standard of practice. These failures could lead to decreased medication effectiveness and potential adverse health outcomes for R20. Findings: On 09/26/24 at 08:43 AM, a medication pass observation to R20 was conducted with Registered Nurse (RN) 2. RN 2 was observed preparing medications for R20 which included calcium acetate (medication used to lower high phosphate levels in patients with kidney disease) 667 milligrams (mg) 3 capsules, brimonidine (eye drops used to treat glaucoma or high eye pressure) 0.2%, and dorzolamide (eye drops used to treat glaucoma or high eye pressure) 2%. On 09/26/24 at 0850 AM, RN 2 administered the oral medications to R20, which R20 swallowed without difficulty. On 09/26 24 at 08:53 AM, RN 2 administered one drop of brimonidine to both eyes and then immediately applied one drop of dorzolamide to both eyes without waiting 3 to 5 minutes between eye drops. After completing the medication pass to R20, RN 2 was interviewed. RN 2 verified that she administered the eyedrops without allowing time in between for absorption. RN 2 stated that she always administered the eyedrops this way and added they were scheduled at the same time. When asked if she needed to wait between drops, she responded, it does not say that in the order. Review of R20's physician's orders and Medication Administration Record for September 2024 revealed an order dated 08/12/24 for calcium acetate oral tablet 667 mg, give 3 tablets by mouth before meals. The medication label had a sticker that stated take with food. On 09/26/24 at 09:36 AM, an interview was conducted with R20 in his room. R20 stated when RN 2 administered his medications, he had already eaten breakfast. On 09/26/24 at 09:41 AM, a follow up interview was conducted with RN 2. RN 2 stated when administering the medications, she follows the physician's order. RN 2 verified she did not administer the calcium acetate before meals as ordered by the physician. RN 2 stated she knew R20 had eaten breakfast when she gave the medications. On 09/26/24 at 01:59 PM, a telephone interview and concurrent medical record review was conducted with the Consultant Pharmacist. The Consultant Pharmacist stated for calcium acetate where the bottle instructions state to give it with food but the doctor's order says to administer it before meals, the Consultant Pharmacist stated that they have to follow the physician's order. The Consultant Pharmacist stated I'm looking at the medications right now, I don't see any indication that this resident had a stomach irritation concern. The Consultant Pharmacist was also asked about the administration of two different eyedrops, to which she stated there should be a 3 to 5 minute wait between them. The Consultant Pharmacist noted that this is part of the pharmacy's standard of care policy. According to the facility's policy titled Medication Administration Eye Drops dated 05/16, While the eye is closed, use one finger to compress the tear duct in the inner [NAME] (inner canthus) of the eye for 1-2 minutes. This reduces systemic absorption of the medication. Alternatively, the resident may keep his/her eyes closed for approximately three minutes .If another drop of the same or different medication is prescribed for administration in the same eye at the same time, wait 3 to 5 minutes for optimal absorption then repeat procedure above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the hospital failed to ensure a Registered Dietitian (RD) or qualified nutrition professional provided frequent oversight of food and nutrition services which resulted in deficient practices related to the competency of foodservice staff for the safe storage of refrigerated foods and ensuring sanitary condition of walk-in refrigerator (Refer to F812). These failures had the potential to lead to foodborne illness in a highly susceptible population of 45 residents who received food from the facility kitchen. Findings: In an interview on 09/24/24 at 10:00 AM, Acting Dietary Manager (ADM) explained that she assumed the position of Dietary Manager four months ago and the previous Dietary Manager (DM) is now assigned at the Assisted Living. ADM added, she is in the process of completing the required training for Dietary Manager certification (also known as CDM). The Dietary Manger Consultant stated that she is responsible to oversee (ADM) while she's in training. During initial tour of the kitchen on 09/24/24 at 10:04 AM, the following was observed: 1. Inconsistent labelling of food items such as: a. Bread cubes for Puree Bread labeled with use-by date of six (6) days after preparation, Cut-pineapple and open canned oranges labeled with use-by date of six (6) days after preparation or opening, Cut-peaches and honeydew labeled with use-by date of five (5) days after preparation, Canned cherries labeled with use-by date of three (3) months after opening. b. Raw sausages and meat patties covered with plastic wrap kept in a sheet pan was not labelled with prepare date and use by date. During concurrent interview, ADM stated, The cook prepared the sausage yesterday [09/23/24]. The practice is to write a date when it was prepared and used by date. c. At the bottom rack inside the walk-in refrigerator, a [NAME] Sweet and Sour Sauce was labeled that read, OP 8/14/24 and Use by 9/14/24. During concurrent interview, ADM stated, OP means open date. It's outdated. 2. The lower portion of the storage rack had a large amount of thick gray, black, whitish powder-like substance. In addition, the following items were also covered with thick gray, black, whitish powder-like substance. i. Grey Poupon Dijon Mustard 48 oz with opened date of 06/20/24. bottle covered with thick gray, brown whitish powder-like substance. ii. 1-gallon Kens Balsamic Vinaigrette iii. 4 gallons of [NAME] Honey Mustard iv.1-gallon of Teriyaki Marinate sauce with opened date 04/1/24 During concurrent interview at 1010 AM, the DMC stated, It's a mold referring to the thick gray, black, whitish powder-like substance. In an interview on 09/24/24, at 10:22 AM, ADM stated that cleaning of the kitchen including walk-in refrigerator is the responsibility of everyone. ADM explained that she is in the process of creating a schedule for each dietary staff to complete specific task such as cleaning the walk-in refrigerator. In an interview on 09/25/24, 01:31 PM, Registered Dietician (RD) stated that she was made aware of the presence of molds and it is not acceptable especially it's in the fridge. The RD also stated that it is an educational opportunity. We (facility) already provided an in-service to all staff. In an interview on 09/27/24, at 01:58 PM, the Administrator stated (ADM) is not the Manager. She doesn't have CDM (Certified Dietary Manager) cert (certification) yet. The Dietary Manager in the assisted living does the oversight. The DM who was also present during the interview explained that she was also providing oversight to ADM. The DM added, I manage the assisted living. Honestly, I am not here every day, but I speak to (ADM) at least twice a week. I rely much to her. The Administrator further stated, the facility hired DMC to help on mentorship of ADM, Unfortunately, she did not provide the appropriate leadership. Review of facility policy titled, Registered Dietician dated 03/27/24, under Primary Responsibility indicated, The Registered Dietician oversees the dietary supervisor and makes recommendations to the Administrator and Director of Food and Nutrition Services orally and through monthly reports. Specific responsibilities included, 2. Develop managerial and planning skills of supervisory staff, e.g. [example], purchasing procedures, specifications, inventories and records, completing Competency Checklist for dietary supervisor . Review of the facility Dietary Manager job description, dated 09/2022, indicated an essential function of Dietary Manager including 1. Maintain kitchen sanitation in compliance with applicable rules and regulations. 2. Supervise dietary staff .23. Staff must ensure that their department is maintained in a clean and safe manner by assuring that all necessary equipment and supplies are maintained .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to ensure food safety standards when 1) there was lack of consistent labeling of preparation date and use-by date for foods capable of foodborne illness 2) storage of food items outside the shelf life and 3) food storage practices that may promote cross contamination as evidence by presence of molds in the walk-in refrigerator. Failure to provide a food production environment that is safe and sanitary may result in foodborne illness, cross contamination of food and equipment and use of expired ingredients that may affect flavor and/or texture of food. Foodborne illness and cross contamination may result in gastrointestinal distress and in severe instances may result in death. The use of expired ingredients may result in a food product that is unpalatable, resulting in decreased meal intake. This had the potential to affect 45 residents who received meals from the facility. Findings: 1a.During initial tour of the kitchen on 09/24/24 at 10:04 AM, the following food items were labelled as follows: i. Bread cubes for Puree Bread with prepare date of 9/21/24 and use by within six (6) days on 9/27/24 ii.Peaches with prepare date of 9/22/24, and use by within five (5) days on 9/27/24. iii.Honeydew with prepare date of 9/19/24, and use by within five (5) days on 9/24/24. iii.Cherries with prepare date of 9/2/24, use by within three (3) months on 12/2/24. iii.Orange with prepare date of 9/20/24 and use by within six (6) days on 9/26/24. iv. Pineapple with prepare date of 9/20/24 and use by within six (6) days 9/26/24. 1b. At 10:07 AM, further observation inside the walk-in refrigerator, there was a sheet pan containing raw sausages and meat patties covered with plastic wrap with no prepare date and use by date. During concurrent interview, Acting Dietary Manager (ADM) stated, The cook prepared the sausage yesterday [09/23/24]. The practice is to write a date when it was prepared and used by date. 2. At the bottom rack inside the walk-in refrigerator, a [NAME] Sweet and Sour Sauce was labeled that read, OP 8/14/24 and Use by 9/14/24. During concurrent interview, ADM stated, OP means open date. It's outdated. 3. The lower portion of the storage rack had a large amount of thick gray, black, whitish powder-like substance. The following items were also covered with thick gray, black, whitish powder-like substance. i.Grey Poupon Dijon Mustard 48 oz with opened date of 06/20/24. bottle covered with thick gray, brown whitish powder-like substance. ii.1-gallon Kens Balsamic Vinaigrette iii. 4 gallons of [NAME] Honey Mustard iv.1-gallon of Teriyaki Marinate sauce with opened date 04/1/24 During concurrent interview at 1010 AM, the Dietary Manager Consultant (DMC) stated, It's a mold referring to the thick gray, black, whitish powder-like substance. During an interview on 09/24/24, at 10:22 AM, ADM stated that cleaning of the kitchen including walk-in refrigerator is the responsibility of everyone. ADM explained that she is in the process of creating a schedule for each dietary staff to complete specific task such as cleaning the walk-in refrigerator. During an interview on 09/25/24, 01:31 PM, Registered Dietician (RD) stated that she was made aware of the presence of molds and it is not acceptable especially it's in the fridge. Review of the facility policy titled, Food Storage dated 07/11/24 indicated, Procedure: All products should be inspected for safety and quality and be dated upon receipt and when prepared. Use Use-By date on all food stored in refrigerators and use dates according to the timetable in the Dry, Refrigerated and Freezer Storage Charts .Any expired or outdated food products should be discarded . Under Raw Meat indicated, Hamburger and fresh chicken should be cooked within one to two days of purchase Other fresh meats should be cooked or frozen within three to four days of purchase depending on the type of meat. For Fresh Fruits, Fresh fruit should be checked and sorted for ripeness . Most fruits should be used within 3 to 5 days . Review of the facility policy titled, Cleaning Schedules dated 08/21/18 indicated, Policy, The Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services and other clinically qualified nutrition professional . According to USDA Food Code, 2022, Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate and drafts of unfiltered air can be sources of microbial contamination for stored food. Shoes carry contamination onto the floors of food preparation and storage areas. Even trace amounts of refuse or wastes in rooms used as toilets or for dressing, storing garbage or implements, or housing machinery can become sources of food contamination. Moist conditions in storage areas promote microbial growth. Furthermore, The possibility of product contamination increases whenever food is exposed. Changing the container(s) for machine vended time/temperature control for safety food allows microbes that may be present an opportunity to contaminate the food. Pathogens could be present on the hands of the individual packaging the food, the equipment used, or the exterior of the original packaging. In addition, time/temperature control for safety foods are vended in a hermetically sealed state to ensure product safety. Once the original seal is broken, the food is vulnerable to contamination .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer assistance to formulate an advance directive to one of 12 sampled residents (R38). This failure placed R38 at risk of not having his wishes for treatment known and had the potential for the resident's decision regarding his healthcare and treatment options not being honored. Findings: Review of the electronic medical record (EMR) showed R38 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 08/07/23, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R38 had no cognitive impairment. Review of the Advanced Directive Statement dated 08/01/23, showed R38 wished to complete/designate a Health Care Power of Attorney. A copy of an advance directive was not located in R38's medical record. On 09/12/23 at 11:52 AM, an interview was conducted with R38. R38 stated he remembered signing the form upon admission that he wished to formulate an advance directive. R38 stated he thought he had one already before coming to the facility, but if he did not have one yet, he would like to designate a family member as his healthcare Power of Attorney. R38 stated no one from the facility has followed up with him nor offered him assistance in formulating an advance directive since he signed the form. On 09/12/23 at 12:15 PM, an interview was conducted with the Social Worker (SW). The SW verified the above findings and stated she had not followed up with R38 nor provided assistance in formulating an advance directive since the resident filled out the Advance Directive Statement on 08/01/23. On 09/12/23 at 12:29 PM, an interview was conducted with the Social Services Director (SSD). The SSD stated upon admission, they asked the resident or the representative to fill out the Advance Directive Statement. If the resident did not have an advance directive, .we ask if they want to complete one .If they say I wish to have one, what we would do is we get the form, not right there and then .it varies 'coz the Notary is not here all the time .we give them the paperwork to read and they will review it. The SSD verified R38 was not provided the advance directive form nor was provided assistance in formulating an advance directive. According to the facility's policy titled Advance Directives revised 07/21/22, 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 or 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. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives .The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision .Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to complete a thorough investigation for one (Resident (R) 23) reviewed for a facility reported incident of neglect, out of a survey sample of 12 residents. There was no evidence the facility interviewed other current residents regarding the allegation of potential neglect associated with a staff member (Certified Nursing Assistant (CNA) 109). The timeline of the report of the incident does not match the statement from the perpetrator CNA 109. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation, dated 03/22, revealed .When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Interview the involved resident, if possible, and document all responses. If the resident is cognitively impaired, interview the resident several times to compare response. If there is no discernible response from the resident, interview the resident's family to see how the resident would react to the incident. Interview all witnesses, roommates, residents in adjoining rooms, and staff members in the area. All statements should be signed and dated by the person making the statement. Document the entire investigation chronologically. Review of a Facility Related Incident (FRI) submitted by the facility and received by the State Agency (SA) on 08/18/23 revealed R23 had visible hair loss. The timeline of the event starts with a text from 08/08/23 from CNA 109 which stated, On Tuesday, August 8th around 8:00 or 9:00 PM, R23 wanted to go to the restroom. I was getting R23 ready to put her on the lift with the help of CNA 30 when I noticed the resident's hair was short. I stated to CNA 30 that she must have gotten a hair cut and no one passed on the information. That morning, I put R23's hair in a bun. The report did not contain any other documentation of interviews with CNA 109 who is the alleged perpetrator. Later in the day, the Director of Nursing (DON) at the time, brought to the surveyor three interviews, one dated 08/17/23 and two dated 08/19/23 that contained interviews with CNA109. No other residents were interviewed. The FRI states Provide all steps taken immediately to ensure resident(s) are protected. Immediate assessment of the alleged victim and provision of medical treatment as necessary; R23 was interviewed by Social Services. Evaluation of whether the alleged victim feels safe and if she does not feel safe, taking immediate steps to protect the resident; R23 does not indicate any safety fears from other residents and staff. If the alleged perpetrator is facility staff, removal of the alleged perpetrator's access to the victim and other residents and assurance that ongoing safety and protection provided for the alleged victim and other residents. This was not answered. Interview on 09/12/23 at 11:06 AM with Licensed Practical Nurse (LPN) 78 revealed, I was not working the day of the incident. R23 always wore her hair in a braid down her back and it was to her waist. Now her hair is mid-back. Interview with the DON on 09/12/23 at 11:23 AM, who was the DON at the time of the incident, The resident had her hair trimmed. The staff thought the beautician had cut her hair. R23 is not capable of cutting her own hair. There was no consent for the resident's hair to be cut. The resident has had no change in her baseline and no fear has been noticed. We concluded that CNA 109 was the only person with the resident on night shift for an extended period of time and must have cut the residents hair. When the DON was asked how much hair was cut, he stated maybe two inches. When the DON was asked for dated and signed statements from CNA 109, he could not find any statements in the file other than the printed text message from CNA 109's phone. Review of the medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis that included Alzheimer's and chronic kidney disease. Review of the quarterly Minimum Data Set with and Assessment Reference Date of 03/18/23 indicated a Brief Interview for Mental Status (BIMS) of four out of 15 which indicated severe cognitive impairment. An attempted interview on 09/12/23 at 3:17 PM with R23 revealed that the resident was sitting in the commons area coloring. When asked how she was today, said she was fine. That was the extent of our conversation. Interview with CNA 109 on 09/13/23 at 7:59 AM revealed, I did not cut the residents hair. I work the night shift and when I put the resident to bed, her hair was fine. In the morning I brushed her hair and put it in a bun. When I returned the next night, her hair had been braided and was shorter. I did not cut her hair. An attempt was made to contact R23's guardian on 09/13/23 at 9:01 AM; however, there was no answer and after leaving a brief message, there was no return call from the guardian. Interview on 09/14/23 at 2:29 PM with the Administrator revealed, We looked at video footage of the hallway where the resident resides. On the 6th of August, R23's hair was fine. On the morning of August 7th, her hair had been cut. The CNA in question was the only person in her room from the footage. The resident's hair was braided in the video.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility policies and procedures, the facility failed to provide documentation of one resident's (Resident 40) discharge summary at the time of transfer to a hospital. The deficient practice could result in receiving facilities not having the necessary information for continuing care of residents. Findings include: Review of the facility policy and procedure titled Discharge Planning Process revised 7/21/22 included a Discharge Summary will include a recapitulation of the resident's stay including but not limited to: -Diagnoses --Course of Illness --Treatments or therapies --Pertinent Labs --Radiology -All Consultations -A final summary to include resident's discharge status, that will be made available to authorized persons but consent of the resident or the resident's representative. Resident 40 (R) admitted on [DATE], readmitted on [DATE] had diagnoses that included end stage renal disease, gastro-esophageal reflux disease without esophagitis, essential (primary) hypertension, encephalopathy, and moderate protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) dated [DATE] showed R40 had a BIMS (Brief Interview for Mental Status) score of 9 indicating the resident had moderately impaired cognition. R40 required extensive two-person assistance with bed mobility, dressing, toilet use, and personal hygiene. R40 was totally dependent on two-person assistance for transfers and locomotion. R40 was frequently incontinent of urine and always incontinent of bowel. R40 had one (1) stage 1 pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence) and one (1) unstageable pressure ulcer (an ulcer with a wound bed covered by slough and or eschar [a dry, dark scab or falling away of dead skin]) Review of another Conversation note dated 8/4/23 at 11:53 AM included that R40 was transferred by EMS (emergency medical services) to the emergency room at 7:09 AM. Review of the Nursing Home to Hospital Transfer Form with a completion date of 9/14/2023 included that R40 was transferred on 8/4/23 for further evaluation and treatment of wound. The form included that the resident was alert, oriented, follows instructions and the SBAR Acute Change in Condition Note was included. Review of the record revealed no documentation the receiving provider received the Medical Doctor 12 (MD) contact information, resident representative information including contact information, advance directive information, instructions or precautions, comprehensive care plan goals, and copy of the resident's discharge summary. Review of the record did not reveal a SBAR Acute Change in Condition Note During an interview conducted on 9/14/23 with the Director of Nursing (DON) and ADON, the DON stated there was no documentation of a transfer summary or information that was provided to the receiving facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R28 was admitted on [DATE] with diagnoses that included spinal stenosis (narrowing of the spine which puts pressure on the spinal cord & nerves & can cause pain), lumbar region without neurogenic claudication (when nerves get pinched within the center of the lumbar spine, causing intermittent leg pain), chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and obstructive sleep apnea. Review of the record revealed another provider order dated 4/12/23 included to apply oxygen, 1-5 L (liters) via NC (nasal cannula) as needed to keep O2 (oxygen) saturation greater than 90% as needed for low oxygen saturation. Review of a Quarterly Minimum Data Set (MDS) dated [DATE] included that R28 had a Brief Interview for Mental Status (BIMS) score of 15 indicating he was cognitively intact and the resident was on oxygen therapy while a resident of the facility. Review of the record revealed no documentation of a care plan for oxygen administration and monitoring to keep saturations greater than 90%. During an interview conducted on 9/14/23 with the Director of Nursing (DON) and ADON99, ADON99 stated oxygen administration is care planned for based on a provider order. When asked if there should have been a care plan for the oxygen order to keep sats greater than 90%, both state, yes. Cross reference F695 Based on observation, interview, and record review, the facility failed to develop comprehensive plans of care to reflect the individual care needs of two of 12 sampled residents (R38 and R28). * The facility failed to develop a comprehensive care plan to address R38's dialysis (a treatment to rid the body of toxins when the kidneys no longer function) and care of his dialysis access site. * The facility failed to develop a comprehensive care plan for R28, who was receiving oxygen therapy. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: 1. On 09/11/23 at 10:10 AM, an observation and interview was conducted with R38 in his room. R38 was observed sitting on his wheelchair. R38 stated he was waiting for his transport to dialysis. When asked where his dialysis access site was, R38 stated he had a fistula (arterio-venous fistula, access is created by surgically connecting an artery and a vein) on the left upper arm. Review of the electronic medical record (EMR) showed R38 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 08/07/23, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R38 had no cognitive impairment. Review of the physician's order dated 08/17/23, revealed R38 was to receive dialysis every Monday, Wednesday, and Friday at a dialysis center. Fistula site at the left upper extremity was to be monitored for bruit (a sound or murmur heard in auscultation) and thrill (the vibration felt over the arterio-venous fistula when blood flows through the narrow space) every shift. Review of the plan of care failed to show a care plan problem was developed to address R38's dialysis and care of his access site (fistula). On 09/13/23 at 11:18 AM, an interview and concurrent medical record review was conducted with Licensed Practical Nurse (LPN) 29. LPN 29 stated R38's dialysis access site was a fistula on his left upper arm. LPN 29 stated she monitored for bruit by .listening and for thrill, she .feels the vibration. LPN 29 stated dialysis access site should be monitored every shift on non-dialysis days, and before going and upon return from dialysis. When asked to show documentation of the assessment or monitoring of R38's fistula, LPN 29 was not able to find one and stated normally it should be in the TAR [Treatment Administration Record]. LPN also verified there was no care plan developed to address R38's dialysis and care of the dialysis access site. On 09/14/23 at 01:41 PM, an interview was conducted with the Director of Nursing (DON). The DON was informed and acknowledged the above findings. The DON stated the dialysis access site should be monitored every shift and as needed, and pre and post dialysis. The DON stated a care plan should have been developed to address dialysis and care of the access site. According to the facility's policy titled Care Planning - Interdisciplinary Team revised 07/21/22, A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS) .The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team. Cross reference to F698.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the comprehensive plan of care for one of 12 sampled residents (R7) was revised to reflect current needs and interventions. R7 sustained an unwitnessed fall in the bathroom on 07/24/23. R7's care plan was not revised to reflect the post fall interventions to apply grab bar covers to optimize grip and to consider support bar options in the bathroom. This failure posed the risk of not providing R7 with individualized person-centered care. Findings: Review of the electronic medical record (EMR) showed R7 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 06/07/23, showed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R7 had no cognitive impairment. R7 was independent and did not require staff assistance for transfers and locomotion on unit. Review of the Fall Charting dated 07/24/23, showed R7 was found lying supine with head facing the wall and feet/legs by the commode. Wheelchair was in front of commode with one wheel locked and the other one unlocked. Resident was heard saying help. No skin tears or bruising noted at this time. Resident was using poor safety awareness. Review of Progress Notes dated 07/29/23, showed IDT (interdisciplinary team) - Interventions to decrease risk of future incidents: Consider another support bar in bathroom. Review of the Post Fall IDT Meeting dated 07/31/23, showed interventions implemented post fall included Will order grab bar cover to optimize grip and will explore additional [sic] grab baroptions [sic]. Review of the plan of care failed to show documentation the care plan was revised to reflect the post fall interventions to apply grab bar cover and to consider another support bar in the bathroom. On 09/13/23 at 12:07 PM, an observation, interview, and concurrent medical record review was conducted with Licensed Practical Nurse (LPN) 29. LPN 29 verified the above findings. LPN 29 went into R7's room and observed R7 inside the bathroom sitting on his wheelchair. LPN 29 verified there were no grip covers on the bathroom grab bars per the post fall intervention. LPN 29 verified R7 used the toilet and was independent with transfers. LPN 29 verified the care plan was not revised to reflect the post fall interventions of applying a grab bar cover to optimize grip and to consider another support bar in the bathroom. According to the facility's policy titled Care Planning - Interdisciplinary Team revised 07/21/22, A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS) .The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. According to the facility's policy titled Fall Prevention Program revised 05/05/23, Each resident's risk factors and environmental hazards will be evaluated when developing the Resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed .When any resident experiences a fall, the facility will .Review the resident's care plan and update as indicated. Cross reference to F689.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident with a pressure injury received necessary monitoring and treatments to promote healing for one of three residents (R40) sampled for closed record review. R40 did not receive thorough weekly wound monitoring, a pressure reducing chair cushion, or changes in wound care after documented changes in wound drainage. R40's sacral wound increased 317% in area, developed malodorous drainage and increased pain requiring transfer to a hospital on 8/4/23. Findings include: Review of the electronic Health Record (e-HR) R40 admitted on [DATE], readmitted on [DATE], had diagnoses that included end stage renal disease, hypertension, and moderate protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) dated [DATE] showed R40 had a BIMS (Brief Interview for Mental Status) score of 9 indicating the resident had moderately impaired cognition. R40 required extensive two-person assistance with bed mobility, dressing, toilet use, and personal hygiene. R40 was totally dependent on two-person assistance for transfers and locomotion. R40 was frequently incontinent of urine and always incontinent of bowel. R40 had one (1) stage 1 pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence) and one (1) unstageable pressure ulcer (an ulcer with a wound bed covered by slough and or eschar [a dry, dark scab or falling away of dead skin]) Review of a Skin Only Evaluation note dated 7/7/23 at 5:41 PM included R40 had a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough) pressure ulcer on the coccyx (a triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum). Review of the e-HR revealed a provider order dated 7/7/23 for sacral wound care. The order included to cleanse with soap and water daily and as needed (PRN) with every episode of incontinence, apply EPC (Extra Protective Cream) barrier cream (skin protectant that helps treat and prevent rash associated with diaper use or continued exposure to feces, urine or both. Protects skin from minor irritation associated with diaper dermatitis and exposure to feces and urine and helps seal out wetness) and cover with a border foam in the evening. Review of the e-HR revealed wound evaluations and communication notes dated: -7/7/23 at 10:21 PM Wound Evaluation, no documentation of an assessment of the periwound (tissue surrounding a wound). -7/7/23 at 10:51 PM Communication Note entered by Registered Nurse 65 (RN) included I also marked her (R40) pressure ulcer to her coccyx as a deep tissue injury, but I'm not sure if that is correct. -7/11/23 at 5:17 AM, no measurements documented. -7/19/23 at 9:06 AM, no documentation of an assessment of the periwound. -7/27/23 at 9:32 AM, no documentation of an assessment of the periwound. -8/1/23 at 5:51 AM, no documentation of an assessment of the periwound. -8/4/23 at 6:57 AM, area increase 317%, length increase 114%, width increase 87%, no documentation of an assessment of the periwound. Review of the e-HR revealed no documentation of wound measurements completed for ten (10) days from 7/8/23 to 7/18/23. Review of the care plan initiated on 7/10/23 for a documented pressure ulcer included a goal that the wound would show signs of improvement. Interventions for this goal included to keep the skin clean and well lubricated and monitor bony prominences for redness. Review of the e-HR revealed a provider order dated 7/19/23 for treatment of an unstageable sacral wound. The order included to cleanse with soap and water daily and PRN (as needed) with every episode of incontinence and to place matrix (a dressing developed to maintain a moist microenvironment that is conducive to granulation tissue formation, epithelialization, and rapid wound healing) and cover with border foam in the evening for wound care. Review of a Skin/Wound note dated 7/20/23 and 7/22/23 both included that the sacral wound was now 90% slough (pus) to the wound bed with a small amount of serous (thin; watery; like serum) drainage. Review of a care plan initiated on 7/24/23 for potential/actual impairment to skin integrity .DTI to sacrum on admission included a goal that the resident would maintain or develop clean and intact skin. The intervention for this goal included monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs or symptoms of infection, maceration etc. to MD, and Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of a Conversation (facility's method of communication with the Medical Doctor) note dated 7/29/23 at 6:23 pm, entered by RN65, included I think there needs to be a discussion with (R40) on what she is wanting for her future care. PT will have to chime in here, but I don't think she has been able to work with them in the 3 weeks she's been here because she is always in pain. She dreads dialysis and I try to have a discussion with her that she is able to refuse but she doesn't. However, the last few times she has come back she is nearly in tears. We make her as comfortable as possible before she goes, but I don't think she can tolerate sitting in one spot for the 6-7 hours that she is away. Any input is greatly appreciated. Review of a Skin/Wound note dated 7/29/23 at 8:00 PM included that the sacral wound still had 100% slough in the wound bed with a small amount of drainage and foul odor noted. The note included that R40 complained of pain to sacral wound. Review of the record revealed no new orders written on 7/31/23 to address concerns with pain, dialysis, or wound care. Review of a Wound evaluation dated 8/1/23 at 5:51 AM included that the wound had decreased in area by 33%, length by 33%, and had increased in width by 2%. The evaluation again indicated that wound progress had stalled. Review of a Skin/wound note dated 8/2/23 at 5:34 PM included that the sacral wound was unstageable, had no drainage, but still had an odor. A late entry to the note included that there was now an area to the left of the wound that was necrotic and foul smelling. Review of a Skin/wound note dated 8/2/23 at 8:00 PM included that the sacral wound now had a moderate amount of foul smelling brown drainage with pain. Review of a Progress Note dated 8/2/23 included that MD12 was asked to see the resident (R40) due to a wound in the sacral area and that the provider examined her (R40) sacral area. The note included that the sacral area with an unstageable pressure injury that was also affected by moisture associated skin disease. Necrotic tissue partially removed. The note included a plan for surgical debridement partial of the wound noted at this time. Minimal odor. Reports of heavy drainage noted. Recommend that we maximize her nutrition, maintain support surface, speak with dialysis for offloading (and/or cushions), and turning schedule. Review of the e-HR revealed a provider order dated 8/2/23 that included for R40 to have an offloading cushion needed for lifetime. Review of the e-HR revealed no documenation of an implementation of the an offloading cushion. Review of a Skin/wound note dated 8/3/23 at 9:50 AM included that the Unstageable wound to sacrum was changed by night nurse. At this time dressing was saturated with brown odorous drainage. Sacrum has a bony prominence with slough, discoloration, and necrotic tissue noted to the peri area of her wound. Calcium alginate applied to wound bed and covered with a foam dressing. Review of a Skin/wound note dated 8/3/23 at 8:00 pm included that sacral wound again had a foul odor and pain at the site. Review of a Skin/wound note dated 8/4/23 at 3:30 AM included that a moderate amount (of) foul smelling brown drainage from sacral wound, area of necrotic tissue has increased from this writer's last assessment (8/3/23 at 8:07 PM) to 90% of wound bed, wound has doubled in size, necrotic tissue is boggy, dressing change per MD order, resident crying with any movement Message sent to MD via online messaging. Review of a Wound evaluation dated 8/4/23 at 6:57 AM included that the wound had increased in area by 317%, length 114%, and width 87%. The evaluation included that the progress was now deteriorating. Review of Conversation note dated 8/4/23 at 4:14 am included that the Pain is in her (R40) sacral area at the wound site. It has become worse over the last 2 days. She cries with any movement. Giving the PRN Tylenol but doesn't seem to be effective. The wound has had changes since yesterday. The wound is 90% necrotic and boggy. There is a horrible foul-smelling odor that can be smelled when entering the room. The drainage has increased significantly over the last 2 days and has gone from being serous to a tannish brown. Review of another Skin/wound note dated 8/4/23 at 7:59 AM, entered by LPN/WN95, included that the Resident is so uncomfortable/crying and tries to reposition herself even after staff turns her. PRN Tylenol was given this AM by night nurse. Unstageable wound to sacrum dressing was saturated with brown odorous drainage. Sacrum has a bony prominence, necrotic, very odorous, discolored, and necrotic tissue noted to the peri area of her wound. Calcium alginate applied to wound bed and covered with a foam dressing. Review of another Conversation note dated 8/4/23 at 11:53 AM included that R40 was transferred by EMS (emergency medical services) to the emergency room at 7:09 AM. During an interview conducted on 9/12/23 with Certified Nursing Assistant (CNA) 44, CNA44 stated that R40 was repositioned every two hours but was always in pain. CNA44 stated that they would try to reposition or offer comfort and if those interventions did not work they would tell the nurse. CNA44 stated they remember R40 being in pain from the admission until she left. During an interview conducted on 9/12/23 with RN107, RN107 stated that R40 interventions for the pressure injury included a specialty mattress and off-loading devices. RN107 stated they did not recall if the provider was notified after non-pharmaceutical and pharmaceutical interventions had been offered to R40, but RN107 stated that if a notification to the provider was made it would be documented in the e-MR. During an interview conducted on 9/13/23 with Licensed Practical Nruse/Wound Nurse (LPN/WN) 95 and Assistant Director of Nursing (ADON), LPN/WN95 stated that when R40 was admitted , they were working one day a week as a wound nurse and the other days on the floor. LPN/WN95 stated that they would complete wound assessments on Tuesdays and R40's Medical Doctor (MD) 12 would review the information and pictures in the eMR. LPN/WN95 stated that she does measurements and document what the wound looks like. LPN/WN95 stated that the wound assessments in the system that are incomplete are still open until she can get back to them and add information. LPN/WN95 stated that some of the information might be missing because it was almost two months ago. LPN/WN95 stated that she did not have an order for the Calcium alginate dressing applied to R40 on 8/3/23, but she stated that it was appropriate because of the increased dressing. LPN/WN95 stated she does not remember calling MD12 on 8/3/23 when the wound change in appearance with increased drainage. LPN/WN95 stated that on admission, R40 had a lot of pain and the Tylenol was effective up to a point. LPN/WN95 stated that R40's pain was a red flag for her and the increased pain started on 8/2/23 after the wound had opened up. LPN/WN95 stated R40 did really want to turn because she was in so much pain. LPN/WN95 stated that the odor, eschar and pain had increase starting on 8/2/23. LPN/WN95 stated that the resident's wound progressively got worse and that the increasing pain contributed to that worsening. During an interview conducted on 9/13/23 via phone with MD12, MD12 stated that the pressure ulcers were discussed with the resident and family prior to admission. MD12 stated that because the resident had to travel to dialysis and spend hours laying on hard surfaces, that R40 would have been better at another facility with inhouse dialysis or closer to an outpatient dialysis facility. MD12 stated that the traveling to dialysis was most likely the cause of the wound worsening. MD12 stated that the he did a little bit of debridement and it was clear that was a deep tissue issue and the drainage started to increase. MD12 stated that the resident had around the clock Tylenol ordered for pain management and it was effective. MD12 stated he did not recall any issue with pain not being managed with the ordered interventions and that he performed a debridement at the bedside and the resident did not have any pain with the procedure. MD12 stated that the difference between a Matrix dressing and Calcium alginate dressing is that the Calcium alginate is for wounds with larger amounts of drainage. MD12 stated that he minimizes the formulary, so the facility does not have a lot of wound care products. MD12 stated that when a wound has necrotic tissue debridement is the treatment. MD12 stated that he did not recall the wound having an odor and he was notified on 8/4/23 about the change in the wound and that is why he sent R40 to the hospital. Review of the e-HR did not reveal any specific interventions to address off-loading or pain management on dialysis days. The record did not include specific concerns with transportation to and from dialysis. During an interview conducted on 9/14/23 with the Director of Nursing (DON) and ADON, ADON stated that on admission, all residents have a head to toe assessment. ADON stated that resident's admitted with a wound have the wound documented with measurements and photographs of the would uploaded into the e-HR. ADON stated that the provider looks at the assessment in the system and orders treatments based on the assessment. ADON stated the assessment should be completed within 24 hours of admission, weekly, and if there are any changes in condition. ADON stated all treatments need provider orders and should be care planned for. ADON stated the previous DON (RN108) was the oversight for all wound assessments prior to 9/11/23 when the current DON started. DON stated that the wound nurse, LPN95, has had written assessments that are not uploaded into e-HR but she does not know what information is on those assessments. DON was asked what the risk would be for a nurse providing wound care with a change in the wound without a provider order, DON stated, it would be practicing outside of the scope and is a risk to the patient. Review of the facility's policy and procedure titled Pressure Injury Prevention and Management revised 7/21/22, included that Assessment of Pressure Injury Risk .Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly and after any newly identified pressure injury. Findings will be documented in the medical record .Assessments of pressure injuries will be performed by a licensed nurse and documented in Point Click Care (PCC, [eMR]) .Evidenced-Based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injure present .interventions could include, but are not limited to .Provide appropriate, pressure-redistributing, support surfaces .Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present treatment decisions will be based on characteristics of the wound, including the stage, size, amount of exudate, and presence of pain, infection or non-viable tissue .Charting wounds will include progress/decline or stability of wound. Cross Reference F697

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure one of 12 sampled residents (R7) was free from accident hazards. The facility failed to ensure the post fall interventions were in place for R7, who sustained a fall on 7/24/23, creating a risk for further falls and injuries. Findings: Review of the electronic medical record (EMR) showed R7 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 06/07/23, showed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R7 had no cognitive impairment. R7 was independent and did not require staff assistance for transfers and locomotion on unit. Review of the Fall Charting dated 07/24/23, showed R7 was found lying supine with head facing the wall and feet/legs by the commode. Wheelchair was in front of commode with one wheel locked and the other one unlocked. Resident was heard saying help. No skin tears or bruising noted at this time. Resident was using poor safety awareness. Review of Progress Notes dated 07/29/23, showed IDT (interdisciplinary) - Interventions to decrease risk of future incidents: Consider another support bar in bathroom. Review of the Post Fall IDT Meeting dated 07/31/23, showed interventions implemented post fall included Will order grab bar cover to optimize grip and will explore additional [sic] grab baroptions [sic]. Review of the plan of care failed to show documentation the care plan was revised to reflect the post fall intervention to apply grab bar cover and to consider another support bar in the bathroom. Cross reference to F657. On 09/12/23 at 11:11 AM, an interview was conducted with Certified Nursing Assistant (CNA) 94. CNA 94 stated R7 was independent with activities of daily living and .he goes to the bathroom by himself. On 09/13/23 at 10:37 AM, an interview was conducted with R7 in his room. R7 was observed sitting on his wheelchair. R7 stated he used the bathroom for toileting independently and used the grab bars when transferring himself from wheelchair to toilet. R7 was observed with contracture (shortening of the tendons and muscles causing the joints to become stiff and unable to fully function) to both hands. On 09/13/23 at 12:07 PM, an observation, interview, and concurrent medical record review was conducted with Licensed Practical Nurse (LPN) 29. LPN 29 verified the above findings. LPN 29 went into R7's room and observed R7 inside the bathroom sitting on his wheelchair. LPN 29 verified there were no grip covers on the bathroom grab bars per the post fall intervention. LPN 29 verified R7 used the toilet and was independent with transfers. On 09/13/23 at 12:29 PM, an interview and concurrent medical record review was conducted with Physical Therapy Assistant (PTA) 5. PTA 5 stated he was familiar with R7 and agreed that grab bar cover should be in place and R7 .would benefit on one. According to the facility's policy titled Fall Prevention Program revised 05/05/23, Each resident's risk factors and environmental hazards will be evaluated when developing the Resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed .When any resident experiences a fall, the facility will .Review the resident's care plan and update as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that one resident's pain from an unstageable pressure ulcer was managed according to the standards of practice and the resident's goal and preferences for 1 of 3 closed record sampled residents (Resident 40). Findings include: Review of the electronic health record (e-HR) revealed R40 admitted on [DATE], readmitted on [DATE] had diagnoses that included end stage renal disease, hypertension, and moderate protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) dated [DATE] showed R40 had a BIMS (Brief Interview for Mental Status) score of 9 indicating the resident had moderately impaired cognition. Review of the e-HR revealed the following provider orders entered on 7/7/23: -Vital and Pain evaluation every day and night shift. -Pain level documentation 0-10 every day and night shift for assessment of pain. -Acetaminophen (Tylenol) tablet, 650 mg (milligram), give 1 tablet by mouth every 4 hours as needed for general discomfort. Review of a care plan initiated on 7/24/23 for acute/chronic pain related to emotional distress, crying out/moaning during treatments or care included a goal that the resident would verbalize adequate relief of pain or the ability to cope with incomplete relieved pain. The interventions for this goal included Anticipate the resident's need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment, and Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Review of a Conversation note (facility's method of communication with the Medical Doctor) dated 7/29/23 at 6:23 PM, entered by Registered Nurse (RN) 65, included I think there needs to be a discussion with (R40) on what she is wanting for her future care. PT will have to chime in here, but I don't think she has been able to work with them in the 3 weeks she's been here because she is always in pain. She dreads dialysis and I try to have a discussion with her that she is able to refuse but she doesn't. However, the last few times she has come back she is nearly in tears. We make her as comfortable as possible before she goes, but I don't think she can tolerate sitting in one spot for the 6-7 hours that she is away. Any input is greatly appreciated. Review of a Skin/Wound note dated 7/29/23 at 8:00 PM included that R40 complained of pain to sacral wound. Review of the Medication Administration Record (MAR) for July 2023 revealed that R40 was not medicated for pain on 7/29/23 at 8:00 PM. There is no documentation of the pain level at 8:00 PM, alternatives provided for comfort, or notification to the provider. Review of a Conversation note dated 7/31/23 at 10:37 AM, entered by Medical Doctor (MD) 12 , included a response to the note dated 7/29/23 at 6:23 PM . The note by MD12 stated where is the pain and discomfort? Review of the record from 7/7 to 8/1/23 revealed multiple pain evaluations that included R40 vocalized complaints of sacral pain with pain scores ranging from 0-6 on a scale of 0-10, ten being the worst. The evaluations included that non-medication interventions did not provide relieve relief. Review of a Vitals and Pain Only Evaluation dated 8/2/23 at 6:43 PM included that R40 had vocal complaints of sacral pain with a score of 5/out of 10 . The evaluation included that pain occurs multiple times a day and non-medication interventions did not provide relieve. Review of a Skin/wound note dated 8/2/23 at 8:00 PM included that the sacral wound now had a moderate amount of foul smelling brown drainage with pain. Review of a Skin/wound note dated 8/3/23 at 8:00 PM included that sacral wound again had a foul odor and pain at the site. Review of a Skin/wound note dated 8/4/23 at 3:30 AM included that that the resident was crying with any movement. Review of the MAR for August 2023 included that R40 was medicated for a pain level of 6/10 on 8/4/23 at 3:37 AM. Review of the record revealed that the Acetaminophen provided for pain was ineffective. Review of Conversation note dated 8/4/23 at 4:14 am included that the Pain is in her (R40) sacral area at the wound site. It has become worse over the last 2 days. She cries with any movement. Giving the PRN Tylenol but doesn't seem to be effective. Review of another Skin/wound note dated 8/4/23 at 7:59 AM, entered by LPN/WN95, included that the Resident is so uncomfortable/crying and tries to reposition herself even after staff turns her. PRN Tylenol was given this AM by night nurse. Review of another Conversation note dated 8/4/23 at 11:53 AM included that R40 was transferred by EMS (emergency medical services) to the emergency room at 7:09 AM. Review of the record revealed no documentation of the provider addressing R40's pain or any new orders for pain management from 8/4/23 from 3:37 AM to 7:09 AM. During an interview conducted on 9/12/23 with Certified Nursing Assistant (CNA) 44, CNA44 stated that R40 was repositioned every two hours but was always in pain. CNA44 stated that they would try to reposition or offer comfort and if those interventions did not work they would tell the nurse. CNA44 stated they remember R40 being in pain from the admission until she left. During an interview conducted on 9/13/23 with Licensed Practical Nurse/Wound Nurse (LPN/WN) 95 and Assistant Director of Nursing (ADON), LPN/WN95 stated that when R40 was admitted she had a lot of pain and the Tylenol was effective up to a point. LPN/WN95 stated that R40's pain was a red flag for her and the increased pain started on 8/2/23 after the wound had opened up. LPN/WN95 stated R40 did really want to turn because she was in so much pain. LPN/WN95 stated that the odor, eschar and pain had increase starting on 8/2/23. LPN/WN95 stated that the resident's wound progressively got worse and that the increasing pain contributed to that worsening. LPN/WN95 stated she does not remember calling the provider for medication for pain and stated there is no documentation that she called the provider. During an interview conducted on 9/14/23 with the Director of Nursing (DON) and ADON, DON stated that the expectation is for nursing to contact the provider if a resident's pain is not being managed. DON stated that all communication with the provider should be documented and if the staff have not heard back from the provider within 30-40 minutes, the staff should page again. DON stated that if a resident is crying or in visible pain, the provider should be called and continued to be called until the pain is addressed. DON stated for cognitively impaired residents, the face scale should be used to assess pain. DON stated that general discomfort would be between a 1-3 or 4 pain level on a scale of 0 to 10. When asked if there was documentation of the provider being notified of the ineffective pain management for R40, DON stated, no, there is no documentation. Review of the facility's policy and procedure titled Pain Management revised 5/5/23, included the facility will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences .the facility will recognize when the resident is experiencing pain and identify circumstances when pain can be anticipated. Evaluate the resident for pain and cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain). Manage or pain prevention, consistent with a comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals .staff will observe for nonverbal indicators which may indicate the presence of pain .facial expressions (e.g. grimacing, frowning, fright, or clenching of the jaw) and behaviors such as resisting care. Cross Reference F686

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that trauma survivors receive trauma-informed, culturally competent care accounting for residents' experiences and preferences to avoid triggers leading to re-traumatization for one resident (Resident (R) R19) of 12 residents in the sample. Findings include: Review of R19's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed that R19 was admitted to the facility on [DATE] with an admitting diagnosis of toxic encephalopathy, infective endocarditis, post-traumatic stress disorder (PTSD) chronic. Review of R19's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/07/23 located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 07 out of 15, which is indicative of severe cognitive impairment. Review of R19's Care Plan located in the EMR under the Care Plan tab revealed that there was no care plan for PTSD and triggers had not been identified. A trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening. A trauma-informed assessment had not been completed by the facility upon admission. This assessment would have identified the physical and emotional safety of the resident and identified triggers to prevent re-traumatization of the resident. Interview on 09/14/23 at 9:41 AM with Social Worker 10 revealed, The facility did not complete a Trauma Informed Care Assessment on R19. He is currently going to Tribal Behavior Health per his request. He is being seen by a Psychiatrist and Case Manager. Tribal Health does give the facility hand-written notes for R19's visits. We receive no other communication and we do not know if PTSD is discussed. R19 is a very cultural and spiritual person and does not want to take medications for mental health. Review of the consultation reports from 01/18/23 through 09/05/23 from Tribal Behavior Health, does not address R23's PTSD. Interview on 09/14/23 at 9:26 AM with the MDS Coordinator 113 revealed, A Care Plan should have been completed for PTSD. I try to make a care plan for every diagnosis when a resident is admitted . I do not know why it was not completed. I lumped everything together under Mood and Behaviors. When asked what R19's triggers were for PTSD, MDS Coordinator 113 could not answer. Interview on 09/14/23 at 9:58 AM with Registered Nurse (RN) 27 revealed, I did not know that R19 had PTSD. I have never seen him agitated. Interview on 09/14/23 at 10:02 AM with Certified Nursing Assistant (CNA) 109 revealed, A nurse told me that R19 had PTSD, but I do not know his triggers. Interview on 09/14/23 at 11:10 AM with the Director of Nursing (DON) revealed, The care plan should have been completed. We need to know what R19's triggers are. During an interview with the Administrator on 09/14/23 at 2:53 PM, revealed Expectations are that upon admission to the facility, the base line care plan should have stated the history of the residents trauma. The facility did not have a policy regarding caring for residents with PTSD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Consultant Pharmacist's medication recommendation was addressed for one of five residents (R38) reviewed for unnecessary medications. The facility failed to ensure the Consultant Pharmacist's recommendation for R38 was acted upon by the physician. This failure had the potential for R38 to receive unnecessary medications. Findings: Review of the electronic medical record (EMR) showed R38 was admitted to the facility on [DATE]. Review of the Consultant Pharmacist's Medication Regimen Review dated 08/01/23, showed a note to R38's attending physician to Please write an analgesic order clarification to include specific parameters for the following orders: Acetaminophen 500mg po [per orem, by mouth] Q6hrs PRN [as needed] pain . suggest clarify Acetaminophen 500mg [sic] to PRN pain 1-3 Review of the Active Orders as of 09/12/23, showed acetaminophen oral tablet 500 mg (milligrams), give 500 mg by mouth every 6 hours as needed for pain. The physician's order was not clarified to include the specific parameter recommended by the Consultant Pharmacist. Review of the Medication Administration Record for September 2023 showed R38 was administered the acetaminophen tablet on 09/11/23 at 10:00 AM for a pain level of 5 (on a pain scale of 0 to 10 with 0 = no pain to 10 = severe pain). On 09/13/23 at 01:47 PM, an interview and concurrent medical record review was conducted with the Registered Nurse (RN) Supervisor. The RN Supervisor verified the above findings and stated the recommendation of the Consultant Pharmacist was not acted upon since it was recommended on 08/01/23. On 09/14/23 at 01:41 PM, an interview was conducted with the Director of Nursing (DON). The DON was notified and acknowledged the above findings. When asked what the facility's process was in ensuring the Consultant Pharmacist's recommendations were acted upon in a timely manner, the DON stated .after I receive them, I delegate to whom I want to follow up with the provider . I like it to have it done within a week. The facility was unable to provide a policy specific to Drug Regimen Review during the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 12 sampled residents (R25) was free from significant medication errors. R25 was not administered the extended-release medications according to the physician's order. The medications were crushed and dissolved in water and were administered via GT (gastrostomy tube, a tube inserted through the abdomen into the stomach used to administer nutritional formula and medications). This failure could cause in rapid release and absorption of the medications that could result in a potentially life-threatening fatal dose. Findings: On 09/13/23 at 08:17 AM, an interview was conducted with Registered Nurse (RN) 127. RN 127 was approached by the surveyor about medication pass observation. RN 127 stated there was only one resident (R25) in the facility with GT. RN 127 stated she had administered R25's medications scheduled to be administered at 08:00 and 09:00 AM .just now. RN 127 stated she administered the medications via GT. RN 127 stated she crushed the pills and dissolved completely in water and administered via GT. Review of the electronic medical record (EMR) showed R25 was admitted to the facility on [DATE]. Review of the physician's orders dated 02/28/23, revealed the following: - Morphine Sulfate (narcotic pain medication) ER tablet Extended Release 15 mg, give 1 tablet by mouth two time a day for pain, swallow whole do not chew or crush. - Potassium Chloride (supplement) ER Tablet Extended Release 20 MEQ (milliequivalent), give 20 mEq by mouth one time a day for Hypokalemia. Review of the Medication Administration Record for September 2023 showed the morphine sulfate ER tablet was scheduled to be administered at 08:00 AM and 08:00 PM daily; and the potassium chloride tablet was scheduled to be administered at 09:00 AM daily. Both medications were signed as administered by RN 127 on 09/13/23. Review of the bubble pack for the morphine sulfate ER 15 mg tablet revealed the following boxed warning: May cause drowsiness. May cause dizziness. Do not chew or crush. Review of the bubble pack for R25's potassium chloride ER 20 mg tablet revealed a sticker warning Do not chew or crush. Review of the Progress Notes revealed a Health Status Note entry dated 09/13/23 at 09:00 AM, showing R25's attending physician was .notified and made aware of morphine Sulfate tablet 15mg administrated [sic] per PEG tube. Verbal order to monitor VS [vital signs] Qhalf hour for 2 hours, Q1hour for 2 hours, and then Q2hrs for 2hours. Resident alert and awake. Resp even and unlabored. On 09/13/23 at 01:21 PM, a follow-up interview and concurrent medical record review was conducted with RN 127. RN 127 verified the above findings and stated the morphine sulfate and potassium chloride tablets were both extended-release tablets and should not be crushed or dissolved. RN 127 stated she notified R25's physician regarding the medication error and was now monitoring R25 for adverse effects from the medications. RN 127 stated this was her first time administering medications to R25 as she just started her employment in the facility last week. RN 127 stated the reason why she administered the medications via GT was that R25 .did not eat his breakfast this morning. When asked what could be the potential outcome when an extended release medication such as morphine sulfate was crushed and dissolved and administered via GT, RN 127 stated it could cause respiratory distress, lethargy . it could decrease pulse. According to www.accessdata.fda.gov, serious, life-threatening, or fatal respiratory depression may occur with use of morphine sulfate. Morphine sulfate extended-release tablets are to be swallowed whole. Crushing, chewing, or dissolving an extended-release morphine sulfate tablet can cause rapid release and absorption of a potentially fatal dose of morphine. According to www.accessdata.fda.gov, potassium chloride extended-release tablets are intended to slow the release of potassium so that the likelihood of a high localized concentration of potassium chloride within the gastrointestinal tract is reduced. Potassium chloride tablets are to be swallowed whole without crushing. Chewing or sucking the tablets. According to the facility's policy titled Medication Administration revised 07/21/22, Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time .Administer medication as ordered in accordance with manufacturer specifications .Crush medications as ordered. Do not crush medications with do not crush instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and review of facility policy and procedure, the facility failed to ensure infection control practices were maintained during observation of medication administration for one of three residents (Resident 34). The deficient practice puts residents at risk for illness from infection. Findings include: Review of the facility policy and procedure titled Infection Prevention/Control: Infection Surveillance revised 7/19/23 included Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices to reduce infections and prevent the spread of infections. Review of the facility policy and procedure titled Medication Administration revised 7/21/22 included Medications are administered by licensed nurses, or other staff legally authorized in this state, as ordered by the physician and in accordance with professional standards of practice, to prevent contamination or infection .Remove medication from source, taking care not to touch medication with bare hand. Resident 34 (R) was readmitted on [DATE] with diagnoses that include hypertension, type 2 diabetes, open wound to the right lower leg and dependence on renal dialysis. Review of the record revealed a provider orders dated 8/25/23 that included to give Fluconazole Oral Tablet 200 MG (Fluconazole) Give 200 mg orally one time a day every Mon, Wed, Fri for fungal infection. The record included another order to give Refresh Plus Ophthalmic Solution (Carboxymethylcellulose Sodium (Ophth)) Instill 1 drop in both eyes four times a day for dryness. During an observation conducted on 913/23 at 8:26 AM of medication administration to R34, Licensed Practical Nurse 29 (LPN) removed a Fluconazole and placed it into a plastic medication cup. LPN29 then removed a single dose ampule of Refresh Plus Ophthalmic Solution and placed it into the cup with the Fluconazole pill. CMS surveyor asked to see the ophthalmic solution to document it as part of the observation process. LPN29 removed the ophthalmic solution and handed it to this CMS survyor. The CMS surveyor examined and documented the ophthalmic solution, then handed it back to LPN29. LPN29 then placed the ophthalmic solution back into the plastic cup with the Fluconazole pill. LPN29 picked up the plastic cup and was observed walking into R34's room. LPN29 removed the ophthalmic solution, gave the resident the cup, and the resident ingested the medication. During an interview conducted on 09/13/23 8:43 AM with LPN29, LPN29 stated that she performs hand hygiene before and after medication administration. She stated that she dons gloves before administering the medications and doffs them afterwards. When asked if the outside of the eye drop container was sterile, she stated, no. When asked why she put the container in the cup with the medication she said, she did not know why she did it. When asked if the practice of putting it in cup with the medication follows infection control practices, she said, no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 28 was admitted on [DATE] with diagnoses that included spinal stenosis (narrowing of the spine which puts pressure on the spinal cord & nerves & can cause pain), lumbar region without neurogenic claudication (when nerves get pinched within the center of the lumbar spine, causing intermittent leg pain), chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and obstructive sleep apnea. Review of the record revealed a provider order dated 4/12/23 included to use CPAP (continuous positive airway pressure) at 8 cm (centimeters) of pressure one time a day for sleep apnea, apply prior to sleep. If resident refuses please inform provider and write a progress note. Review of the record revealed another provider order dated 4/12/23 included to apply oxygen, 1-5 L (liters) via NC (nasal cannula) as needed to keep O2 (oxygen) saturation greater than 90% as needed for low oxygen saturation. Review of a care plan revised 8/16/23 for bi pap at night for sleep included a goal that R28 will be free from signs and symptoms of respiratory infections. Interventions for this goal included oxygen via mask at 2 liters at night with CPAP. Review of record for 9/3, 9/4, and 9/5/23 revealed that the CPAP was not functioning properly and R28 was placed on 4l/NC (liters per nasal cannula) each night. Review of the record did not reveal documentation of an oxygen level below 90% on 9/3, 9/4, 9/5/23. The record did not reveal an order to apply oxygen at 4l/NC overnight for a CPAP not functioning properly. Review of a Health Status note dated 9/10/23 at 10:30 PM included that R28 was Placed on oxygen at 3l/NC pending verification that CPAP is working correctly, MD aware. Review of the record did not reveal documentation of an oxygen level below 90% on 9/10/23. The record did not reveal an order to apply oxygen at 3l/NC overnight for a CPAP not functioning properly. During an interview conducted on 9/14/23 with the Director of Nursing (DON) and ADON99, ADON99 stated oxygen administration is care planned for based on a provider order. ADON99 stated that she was under the impression that leadership was aware of the issues with R28's CPAP and that a respiratory therapist would be coming to assess the unit. ADON99 that the staff need to have an order to provider oxygen to a resident. When ADON99 and DON were asked if there was an order for the staff to apply oxygen at night on 9/3, 9/4, 9/5/23 and 9/10/23, both stated, no, there was no order for the oxygen. Cross reference F656 Based on observation, interview, and record review, the facility failed to provide safe respiratory care to meet the needs of two of 12 sampled residents (R16 and R28). * The facility failed to ensure the licensed nurses documented the administration of supplemental oxygen to R16 according to the physician's order. In addition, the facility failed to notify R16's physician when he was refusing to wear his CPAP (continuous positive airway pressure, is a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure) according to the physician's order. * The facility failed to ensure R28 was administered oxygen in accordance with the physician's order. These failures posed the risk of the residents not being provided the appropriate respiratory care and treatment. Findings: 1. On 09/12/23 at 08:47 AM, an observation and concurrent interview was conducted with R16 in his room. R16 was observed receiving oxygen at 2 liters per minute via a nasal cannula (a small, flexible tube that contains two open prongs for oxygen delivery intended to sit just inside the nostril). R16 stated he received oxygen continuously during the day. When asked how long has he been receiving oxygen continuously during the day, R16 stated .ever since it's been months. Review of the electronic medical record (EMR) revealed R16 was admitted to the facility on [DATE]. Review of the History and Physical examination dated 06/07/23, revealed R16's diagnoses included congestive heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs) and obstructive sleep apnea (a disorder in which a person frequently stops breathing during sleep). Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 08/08/23, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R16 had no cognitive impairment. Review of the Order Summary Report revealed physician's orders dated: - 05/01/23, for oxygen at 0.5 to 3 liters via nasal cannula PRN (as needed) for SOB (shortness of breath)/low oxygen level. - CPAP at 9 cm (centimeter) of pressure every night shift for sleep apnea. Apply prior to sleep. If resident refuses please inform provider and write a progress note. a. Review of the Medication Administration Record and Treatment Administration Record for September 2023 revealed R16's oxygen saturation monitored every shift ranged from 90 to 98%. There was no documentation R16 was administered oxygen as ordered by the physician. Review of the Progress Notes revealed nursing entries showing R16 was administered oxygen. For example, on 09/02/23 at 07:40 AM, R16's oxygen saturation was 94% on oxygen via nasal cannula; on 09/04/23 at 07:11 AM, R16's oxygen saturation was 95% on oxygen via nasal cannula; and on 09/05/23 at 07:27 AM, R16's oxygen saturation was 94% on oxygen via nasal cannula. On 09/12/23 at 11:37 AM, an interview and concurrent medical record review was conducted with Registered Nurse (RN) 107. RN 107 verified the above findings and stated R16 received oxygen at 2 liters per minute continuously during the day. RN 107 stated oxygen administration should have been documented every time it was administered to the resident. b. Review of the Medication Administration Record and Treatment Administration Record for August and September 2023, revealed R16 had been refusing to wear the CPAP at bedtime. For example, for the month of August 2023, R16 used the CPAP five out of 31 days. From 09/01/23 to 09/11/23, R16 used the CPAP once for 4 hours on 09/06/23. There was no documentation the physician was notified when R16 refused the CPAP. Review of the Progress Notes revealed the following nursing entries dated: - 09/06/23 at 11:00 PM, showing RESIDENT CALLED FOR ASSISTANCE WITH CPAP HEAD PIECE .WENT INTO RESIDENT'S ROOM AT THIS TIME. RESIDENT STATED HIS CPAP NOSE/FACE PIECE WAS NOT ON CORRECTLY. Another entry on the same date at 11:15 PM revealed LPN WENT INTO RESIDENT'S [sic] AGAIN TOASSIST [sic] HIM. ONCE IN RESIDENT'S ROOM, HE STATED THAT HE WAS NOT GETTING ANY AIR FROM CPAP NOSE/FACE PIECE. - 09/07/23 at 01:38 AM, showing R16 called the licensed nurse that he did not want the CPAP because it was not on correctly. On 09/13/23 at 11:29 AM, an interview and concurrent medical record review was conducted with Licensed Practical Nurse (LPN) 29. LPN 29 reviewed the medical record and was unable to show documentation R16's physician was notified about the resident's refusal to wear the CPAP. When asked what the reason was for R16's refusal to wear the CPAP, LPN 16 stated .he just did not want it .he just didn't like it. On 09/13/23 at 12:11 PM, an interview was conducted with R16 in his room. R16 stated he had been refusing the CPAP because it was .too loose the air goes everywhere, it doesn't go to the nose. R16 stated he had been telling the licensed nurses about this and to check .if the measurement had changed .if it fits perfectly I'm going to wear it, that's what I told them. R16 stated he wanted to wear the CPAP and .I slept well when I used it. According to the facility's policy titled Oxygen Administration revised 07/21/22, After completing the oxygen set up or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for p.r.n. administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure. the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. According to the facility's policy titled CPAP/BIPAP Support revised 07/21/22, notify the physician if the resident refuses the procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 12 sampled residents (R38), who required dialysis (a treatment to rid the body of toxins when the kidneys no longer function), received care and services consistent with professional standards of practice. The facility failed to assess and document care of R38's dialysis access site. This failure posed the risk of not detecting problems such as bleeding or other complications that would require immediate notification of the physician. Findings: On 09/11/23 at 10:10 AM, an observation and interview was conducted with R38 in his room. R38 was observed sitting on his wheelchair. R38 stated he was waiting for his transport to dialysis. When asked where his dialysis access site was, R38 stated he had a fistula (arterio-venous fistula, access is created by surgically connecting an artery and a vein) on the left upper arm. Review of the electronic medical record (EMR) showed R38 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 08/07/23, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R38 had no cognitive impairment. Review of the physician's order dated 08/17/23, showed R38 was to receive dialysis every Monday, Wednesday, and Friday at a dialysis center. Fistula site at the left upper extremity was to be monitored for bruit (a sound or murmur heard in auscultation) and thrill (the vibration felt over the arterio-venous fistula when blood flows through the narrow space) every shift. Review of the EMR failed to show documentation R38's fistula at the left upper extremity was assessed for bruit and thrill every shift according to the physician's order. Review of the plan of care failed to show a care plan problem was developed to address R38's dialysis and care of his access site (fistula). Cross reference to F656, example #1. On 09/13/23 at 11:18 AM, an interview and concurrent medical record review was conducted with Licensed Practical Nurse (LPN) 29. LPN 29 stated R38's dialysis access site was a fistula on his left upper arm. LPN 29 stated she monitored for bruit by .listening and for thrill, she .feels the vibration. LPN 29 stated dialysis access site should be monitored every shift on non dialysis days, and before going and upon return from dialysis. When asked to show documentation of the assessment or monitoring of R38's fistula, LPN 29 was not able to find one and stated normally it should be in the TAR [Treatment Administration Record]. LPN also verified there was no care plan developed to address R38's dialysis and care of the dialysis access site. On 09/14/23 at 01:41 PM, an interview was conducted with the Director of Nursing (DON). The DON was informed and acknowledged the above findings. The DON stated the dialysis access site should be monitored every shift and as needed, and pre and post dialysis. The DON stated a care plan should have been developed to address dialysis and care of the access site. According to the facility's policy titled Hemodialysis Access Care revised 07/21/22, care of arterio-venous fistula includes Check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to educate and offer influenza and pneumococcal vaccines the residents were eligible to receive in accordance with the current Centers for Disease Control and Prevention (CDC) guidelines to 3 of 5 residents (R28, R14, and R15) reviewed for immunizations. This failure posed the risk of the residents contracting influenza or pneumonia and its associated complications. Findings: On 09/14/23 at 11:48 AM, an interview and concurrent review of the facility's immunization program was conducted with the Registered Nurse (RN) Supervisor. The RN Supervisor stated the facility followed the current CDC guidelines for vaccinations, including pneumococcal vaccines. For R28: Review of the Electronic Medical Record (EMR) showed R28 was admitted to the facility on [DATE], was [AGE] years old, with diagnoses including diabetes and chronic respiratory failure with hypoxia. Review of the Immunization tab of the EMR showed R28 historically received the influenza vaccine on 02/04/22, and PCV 13 on 06/08/15. Review of R38's Health Summary from the acute care hospital dated 02/10/23, revealed under Health Maintenance Reminders, R38 was due to receive the influenza vaccine. Per the CDC guidelines for Pneumococcal vaccines, R38 was eligible to receive the PCV 20 or PPSV 23. Further review of the medical record failed to show documentation R38 was educated and offered the influenza and pneumococcal vaccines that he was eligible to receive. For R14: Review of the EMR showed R14 was admitted to the facility on [DATE]. R14 was [AGE] years old. Review of the Immunization tab of the EMR revealed R14 received PPSV 23 on 08/03/21. Per the CDC guidelines, R14 was eligible to receive PCV 15 or PCV 20 a year after receiving the PPSV 23 vaccine. The medical record failed to show documentation R14 or her representative was educated and offered the pneumococcal vaccine that she was eligible to receive. For R15: Review of the EMR showed R15 was admitted to the facility on [DATE]. R15 was [AGE] years old, with diagnoses including diabetes and chronic kidney disease. Review of the Immunization tab of the EMR revealed R15 historically received PCV 13 on 08/31/15. Per the CDC guidelines, R15 was eligible to receive PCV 15 or PCV 20 a year after receiving the PCV 13 vaccine. The medical record failed to show documentation R15 or his representative was educated and offered the pneumococcal vaccine that he was eligible to receive. The RN Supervisor verified the above findings. The CDC's Pneumococcal Vaccine Recommendations found at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html, last reviewed 02/13/23, revealed there are 2 types of pneumococcal vaccines available in the United States: - Pneumococcal conjugate vaccines (PCV13, PCV15, and PCV20) - Pneumococcal polysaccharide vaccine (PPSV23) For Adults 65 Years or Older: CDC recommends pneumococcal vaccination for all adults 65 years or older. For adults 65 years or older who have only received PPSV23, CDC recommends you: - Give 1 dose of PCV15 or PCV20. - The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. - Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults 65 years or older who have only received PCV13, CDC recommends you either: - Give 1 dose of PCV20 at least 1 year after PCV13. or - Give 1 dose of PPSV23 at least 1 year after PCV13. According to the facility's policy titled Pneumococcal Vaccine (Series) revised 07/19/23, Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization .The individual receiving the immunization, or the resident representative, will be provided with a copy of CDC's current vaccine information statement relative to that vaccine . For adults 65 years or older who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and want to receive PCVI3 and PPSSV23: Administer 1 dose of PCV 13 first then give 1 dose of PPSV23 at least 1 year later. (Anyone who received any doses of PPSV23 before age [AGE] should receive 1 final dose of the vaccine at age [AGE] or older. Administer this last dose at least 5 years after the prior PPSV23 dose. If the resident already received PPSV23, give the dose of PCV 13 at least 1 year after they received the most recent dose). According to the facility's policy titled Influenza Vaccine revised August 2016, Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized . Prior to the vaccination, the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. (See current vaccine information statements at http://www.cdc.gov/vaccines/hcp/vis/index.html for educational materials.) Provision of such education shall be documented in the resident's/employee's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure one (Resident (R) 3) of four residents reviewed for falls had adequate supervision and failed to ensure five of the resident's eight falls were thoroughly investigated. Findings include: Review of the facility policy, Accidents and Supervision revised 06/28/22, revealed, The facility should make a reasonable effort to identify the hazards and risk factors for each resident .This information is to be documented and communicated across all disciplines .Communicating the interventions to all relevant staff .Providing training as needed .Documenting interventions .Ensuring that the interventions are put into action .Supervision is an interventions and means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Review of R3's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 02/10/23 with medical diagnoses that included dementia, weakness, and repeated falls. Review of R3's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an assessment reference date (ARD) of 05/15/23, revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15, indicating moderate cognitive impairment. R3 required extensive assistance with all activities of daily living (ADL). Review of R3's current Care Plan located in the EMR under the Care Plan tab revealed R3 fell on [DATE], 03/03/23, 03/14/23, 04/18/23, 04/27/23, 05/05/23, 05/19/23 and 06/23/23. All of the falls, except the fall on 02/14/23, were unwitnessed and all falls except 03/03/23 (laceration to left eye) were without injury. Interventions included Continue interventions on the at-risk plan (initiated 02/16/23) .Encourage participate [sic] in PT (physical therapy) and OT (occupational therapy) services as ordered (initiated 04/28/23) .Encourage resident to participation [sic] in activities in common area (initiated 06/23/23) .Place personal items within reach (initiated 03/05/23 .Provide activities that promote exercise and strength building .Prove 1:1 activities if bedbound (initiated 02/16/23) .VST Alert system (motion sensor alarm) to assist in identifying times resident requires assistance without calling and further identify risk factors (initiated 04/28/23) .The resident is encouraged to eat meals out of room, dining or common area, if refused monitor while in room (initiated 07/19/23). 1. Review of R3's Post Fall Evaluation found under the Assessments tab, dated 03/14/23 revealed R3 had a fall at 6:30 AM. The Fall Details Note revealed R3 was attempting to transfer and the wheelchair footrests were in the way. There was no conclusion or interventions listed. 2. Review of R3's Post Fall Evaluation found under the Assessments tab, dated 04/18/23 revealed R3 had a fall at 6:04 PM. The fall occurred in R3's room. The Fall Details Note revealed R3 was attempting to ambulate without assistance. There was no conclusion or interventions listed. 3. Review of R3's Post Fall Evaluation found under the Assessments tab, dated 04/27/23 revealed R3 had a fall at 11:55 PM. The Fall Details Note revealed Resident found sitting on floor next to bed. States he was too close to the edge of his bed and slid OOB (out of bed). There was no conclusion or interventions listed. 4. Review of R3's Post Fall Evaluation found under the Assessments tab, dated 05/05/23 revealed R3 had a fall at 2:05 PM. The Fall Details Note revealed Resident reports he was eating lunch in his room when he accidentally knocked over his water. He attempted to bend down to pick up the cup which had resulted in him sliding out of his chair landing on his butt. There was no conclusion or interventions listed. Review of the Progress Note found under the Progress Note tab, dated 05/05/23, revealed .An intervention for fall prevention includes eating meals in the dining area for additional monitoring. Resident refused. This intervention was not on the Care Plan until 07/19/23 and staff were unaware of the intervention until staff training began on 07/19/23. 5. Review of R3's Post Fall Evaluation found under the Assessments tab, dated 06/23/23 revealed R3 had a fall at 7:00 PM. The Reason for fall revealed Self-transfer. There was no conclusion or interventions listed. During an interview with the Certified Nurse Aide/Unit Clerk (CNA/UC) on 07/18/23 at 4:00 PM, revealed she knew R3 should be monitored frequently, wear non-skid socks, and be encouraged to use his call light. She said she was not aware of any other fall interventions. She said she would use the [NAME] to review any other changes or interventions for the resident. During an interview with the Director of Nursing (DON) on 07/19/23 at 10:48 AM revealed all staff should be educated on fall interventions as soon as possible to avoid further falls. He said that the intervention to ensure R3 was encouraged to eat outside of his room was documented on 05/05/23 in a progress note, but not documented on the care plan or on the [NAME] until 07/19/23. He said there was no documentation revealing staff had been educated on the fall intervention for R3. DON confirmed R3 had three more falls, in his room after the fall on 05/05/23. He said the CNA/UC should have been aware of all fall interventions for R3. During an interview with MDS Coordinator (MDSC) and the DON, on 07/19/23 at 11:00 AM, the MDSC stated she was responsible for updating the care plan and would update after every fall. She stated there should be an intervention listed on the care plan for every fall. Upon review of the care plan MDSC and the DON confirmed there were falls that were listed but not all the falls had an intervention. Both agreed that if education had been provided staff would be more aware of the interventions which could have potentially reduced the falls. The DON and the MDSC said they would complete education immediately to ensure all staff were aware of the interventions for R3. Both agreed there should be education after any new interventions were implemented for a resident. During an interview with CNA2 on 07/19/23 at 11:40 AM she said she would receive report from the nurses during shift change if there were any changes. She said she would report any changes to the nurse. CNA2 said she would use the [NAME] if she needed more information. She said she would try to keep R3 out of his room and encourage activities and eat outside of his room. She stated if R3 refused, she would notify the nurse and ask what she should do next. She stated no one had ever told her to keep him out of his room at mealtime but said it made sense since she knew his falls happened in his room and many around mealtime. During an interview with the Administrator and the DON on 07/19/23 at 1:21 PM, the Administrator and the DON said the everything on the Accidents policy should be implemented and all falls should be reviewed in the Quality Assurance Performance Improvement (QAPI) monthly. The DON said they had not been reviewing falls monthly. The Administrator said they would begin reviewing all falls monthly at QAPI.