**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, the State Agency's (SA) complaint portal, and review of the facility's policy and procedures, the facility failed to ensure a resident (#40) received medications according to physician's orders. The deficient practice could result in resident experiencing unnecessary pain.Findings include: Resident #40 was admitted to the facility on [DATE] with diagnoses that included Dementia, fusion of the spine in the cervical region, and a fracture of the humerus in the right arm. The care plan, initiated on August 9, 2023, indicated Resident #40 was on pain medication therapy related to chronic pain syndrome. Interventions included administering analgesic medications as ordered by the physician and to observe for side effects and effectiveness of the medications.A physician's order, dated September 18, 2023, revealed an order for Dilaudid (Hydro-morphine HCI) Oral Tablet 2 MG (milligrams). The order indicated that .5 mg tablet was to be given every 4 hours as needed for pain 4-10.Review of the Narcotic Count Sheet for Hydro-morphine HCL 2 mg tablet starting October 9, 2023. The documentation revealed that Licensed Practical Nurse (LPN/Staff #120) logged out doses on the following days and times:- October 18 at 7:00 P.M. and 11:00 P.M.- October 19 at 7:00 P.M., and 11:00 P.M.- October 25 at 7:00 P.M. and 11:00 P.M. - October 26 at 3:00 A.M., 7:00 A.M., and 7:00 P.M.- October 27 at 11:00 P.M., 3:00 A.M., and 7:00 A.M.Review of the October 2023 Medication Administration Record (MAR), provided by the facility, indicated that Dilaudid Oral Tablet 2 MG was not administered on October 18, 19, 24, and 25 by Staff #120.Review of the staff schedule reveals that the night shift is from 6:00 P.M. to 6:00 A.M.Review of the facility's 5-day report submitted to the SA regarding Resident #40 revealed that Resident #40 was complaining of pain on October 27, 2023 at 10:15 A.M., however the nurse working that shift was unable to administer pain medication due to the narcotic count sheet indicating the medication was last given at 7:00 A.M. The same report revealed that the medication cart keys was handed to the day shift nurse at 6:40 A.M. which was prior to the 7:00 A.M. medication log out time indicated on the Narcotic Count Sheet. The same 5-day report included a statement from the day shift nurse, LPN/Staff #121. The statement revealed that Resident #40 was medicated with Dilaudid at 11:16 A.M.A telephone interview was attempted on August 15, 2025 at 9:41 A.M. with Staff #121, however the phone number was not in service.An interview was conducted with Staff #67 on August 15, 2025 at 12:31 P.M. Staff #67 shared that when a resident is discharged without their narcotic medications, the medication gets destroyed by a nurse manager. She indicated that the documentation of the destruction is documented via the pharmacy website when her and the ADON destroys it. When asked what happened with Resident #40's Dilaudid medication, Staff #67 explained that Staff #120 signed the medication out on the Controlled Substance Count sheet but did not document the administration on the MAR. She said it was reasonable that Staff #120 did administer the medication but did not document it or it was signed off on the sheet and not given to the resident and possibly stolen. When asked if it was reasonable for the documentation to take place in one area and not the other area 8 times by the same staff in a short time frame, Staff #67 indicated that it was not reasonable and there was a possibility that the medication was diverted. She shared that possible diversion would be a risk to residents because they would not be getting their pain medications and they would be in pain. She also shared that documenting medication administration on the Narcotic Count Sheet and not the MAR did not meet her expectations.Review of the policy titled, Administration of Medications, indicates the policy was last reviewed on September 16, 2024. The policy states that The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms.Review of a second policy titled, Abuse, indicates the policy was last reviewed on May 6, 2025. The policy states that Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent. It also provides examples of misappropriation which included Missing prescription medications or diversion of a resident's medication(s), including but not limited to, controlled substances for staff use or personal gain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** BBased on clinical record review, interviews, the State Agency's (SA) complaint portal, and review of the facility's policies and procedures, the facility failed to ensure 4 out of 4 residents' (#47, #48, #52, and #53) medications were not misappropriated by nursing staff. The deficient practice resulted in the facility not keeping an accurate record of controlled substances. Findings include:Related to Resident #47-Resident #47 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of the right femur, generalized muscle weakness, stage 3 kidney disease and cognitive communication deficit.Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #47 had a Brief Interview for Mental Status (BIMS) and scored a 12 which indicated he had moderate cognitive impairment. The same MDS also indicated the resident was taking opioids as part of his medication regimen.The care plan, revised on May 24, 2024, revealed Resident #47 was on a PRN (Pro Re Nata or as needed) pain medication therapy related to multiple fractures, osteosarcoma and chondrosarcoma. Interventions included administering analgesic medications as ordered by the physician and to observe and monitor for possible side effects.A physician's order, dated April 23, 2024, indicated Resident #47 was to take Fentanyl patch 72-hour 75 MCG (micrograms)/HR (hour). Instructions stated to apply 1 patch, transdermally, every 72 hours for chronic pain and remove per schedule. The clinical record indicated this order was discontinued on April 29, 2024 due to a dosage increase.A new physician's order, dated April 29, 2024, indicated Resident #47 was to take Fentanyl patch 72-hour 100 MCG/hour. Instructions stated to apply 1 patch, transdermally, every 72 hours for chronic pain and remove per schedule.An entry, on Resident #47's Progress Note, dated May 4, 2024 at 5:58 P.M., was created by Registered Nurse (RN/Staff #61). The note indicated that Fentanyl patch was applied, changed and noted on the MAR.A second Progress Note entry was dated May 5, 2024 at 9:58 P.M. and was created by Staff #120. The entry noted that Fentanyl patch was applied and changed and noted on the MAR.An entry, on Resident #47's Progress Note, dated May 6, 2024 stated that the Nurse Practitioner (NP) and the resident's wife were notified about the missing Fentanyl patch, and the investigation is ongoing per DON (Director of Nursing). The entry was created by RN/Staff #51.Review of the May 2024 MAR revealed Staff #120 documented on May 4 at 7:28 AM that she had removed the Fentanyl Patch 100 mcg and at 7:29 A.M. she had applied a new patch. There was no documentation that reflected staff #61 had removed or applied the Fentanyl 100 mcg patch on May 4, 2024 as indicated on the Progress Note.Review of a complaint submitted to the SA complaint portal on May 10, 2024 at 8:08 A.M. indicated there was a possible drug diversion of Resident #47's Fentanyl by Staff #120. The facility's 5-day investigation included a controlled substance record for Fentanyl 75 mcg patch. The same record had an entry, dated May 4, recorded by Staff #120. The entry indicated at 7:00 A.M. a patch was taken and there was 1 patch remaining. There was a note written stating wrong pt (patient). The entry was signed by Staff #120 and the 2nd signature was illegible. The same 5-day investigation report indicated the 2nd signature was not able to be identified. The investigation report also included a Controlled Substance Record sheet for another resident who was in the facility at the time of this alleged incident. The record indicated the resident had an order for Fentanyl 75 mcg patch. However, the same record did not have documentation that the medication patch was given to the resident on May 4, 2024 or May 5, 2024.An interview was conducted on August 14, 2025 at 11:16 A.M. with Registered Nurse (RN/Staff #51), telephonically. Staff #51 shared that he had noticed a patch of Fentanyl 75 mcg missing and had reported it to his interim supervisor.An interview was conducted on August 14, 2025 at 12:00 P.M. with LPN/Staff #108. Staff #108 shared that when a resident is discharged and their narcotic medications are left at the facility, they continue the narcotic count and it is documented on the controlled substance count sheet. He continued to explain that the process is continued until the medication is destroyed by the ADON and the DON. He shared that he had never destroyed medications but he understood the process of destroying medications was needing to be done by two nurses.An interview was conducted on August 15, 2025 with LPN/Staff #97 at 11:17 A.M. Staff #97 explained the process for managing controlled substances as continuing to keep the medication in the lockbox until the DON and the ADON collect it. They then take it somewhere to destroy the medication. She shared that they still continue to include the medication in their narcotic count every shift until it is removed to keep track of how many medications they have on hand. She added that the risk of not doing so would be the medication being given to the wrong patient and the facility not keeping an accurate count of how many medications they have on hand. She also added that there was also a risk of medication being stolen.Related to Resident #48Resident #48 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes without complications, Alzheimer's Disease, and Osteoarthritis.A review of the Discharge MDS, dated [DATE] revealed Resident #48 had a BIMS of 02 which indicated she had severe cognitive impairment.The physician's orders, dated May 3, 2024, indicated the order for Ozempic 2 mg subcutaneous solution Pen-injector 8 mg/3ml (milliliter) was created by Staff #120 at 8:58 P.M. The entry on the order details indicated the order was prescriber written. The same order was discontinued by Staff #120 on May 6, 2024 and there was no reason given for the discontinuation.Review of the hospital discharge medication orders received by the facility did not reveal an order for Ozempic.The May 2024 MAR revealed that on May 3, 2024 Staff #120 documented Ozempic not being administered at 9:00 P.M. due to vitals outside of parameters of administration.A secondary review of the Ozempic order did not reveal parameters with the order.An interview was conducted on August 14, 2025 at 10:34 A.M. with Physician (Staff/#123). Staff #123 indicated that he was not a provider at the facility however, there were Physicians from his medical group who served the facility. He also indicated that Nurses are not permitted to put in orders without his approval.Review of the facility's 5-day investigation report, submitted to the SA, on May 10, 2024 at 10:52 A.M. indicated that on May 5, 2024 the DON was notified by a nurse that Resident #48's Ozempic was missing. During the investigation, it was discovered that a second resident, Resident #53, had medication orders put in, which was later determined to have not been authorized by the provider. The same report also included a written statement from Staff #120 where she indicated that she had put in an order for Ozempic to be refilled for the wrong resident. The same statement also indicated that Staff #120 had put in an order for Mounjaro to be refilled for the wrong resident as well.Related to Resident #53-Resident #53 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, type 2 diabetes without complications, and generalized muscle weakness.A physician's order for Mounjaro Subcutaneous Pen-Injector 2.5 MG/0.5ML, dated May 3, 2024, was created by Staff #120 at 8:59 P.M. The communication method, identified on the Order Audit Report, indicated that the prescriber wrote the order. The prescriber was identified as Staff #123 The same Order Audit Report indicated the order was discontinued on May 6, 2024 at 4:17 P.M. by Staff #120 and the discontinue reason listed was wrong patient.Review of the hospital discharge medication list received by the facility did not reveal an order for Mounjaro.Review of the May 2024 MAR for resident #53 had an entry for May 4, 2024. The entry was signed by Staff #120 and noted that the vitals (were) outside of parameters of administration.The facility submitted a complaint to the AZBON (Arizona Board of Nursing) on May 10, 2024 at 12:35 P.M. The complaint listed Staff #120 as the Nurse in question. The complaint to the AZBON listed the resident as Resident #53. Included in the complaint to the AZBON was the Proof of Delivery by Cheetah courier with a tracking number of 202391710. This indicated the Mounjaro was delivered to the facility on May 6, 2024 at 3:48 P.M.Related to Resident #52-Resident #52 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, pleural effusion, pneumonia, and acute respiratory failure.The care plan, initiated on March 26, 2023, indicated Resident #52 was admitted to Hospice services due to his terminal prognosis with the goal of his dignity and autonomy being maintained at the highest level. Interventions included observing the resident closely for signs of pain and to administer pain medications as ordered.Review of the physician's orders indicated Resident #52 was admitted to Hospice services on March 26, 2023. Additional review of the physician's order revealed an order for Morphine Sulfate Oral Solution 100 MG/5ML with instructions to give 0.25 ML by mouth every hour as needed for Hospice Pain management 4-10.Review of the October 2023 MAR revealed an entry on October 27, 2023 created by Staff #120. The entry had a code of 10 which indicated, Other/See Progress Notes. Review of the progress notes revealed no documentation on October 27, 2023 by Staff #120.A review of the 5-day investigation report, submitted to the SA on November 2, 2023 at 11:56 A.M. included a statement from LPN/Staff #124. The statement was written on November 2, 2023 and indicated that on October 26 Staff #124 took report and counted narcotics with off-going Staff #120 however, during this time the two bottles of liquid morphine was not counted. The same investigation report included a second statement from LPN/Staff #121 on October 28, 2023 at 12:02 P.M. The statement shared that Staff #121 received shift report from Staff #120 and while doing count, Staff #121 noticed both bottles of morphine for Resident #52 was off. Staff #121 indicated, in her written statement, that she brought it to the attention of Staff #120 and they both did a corrected count.A telephone interview was attempted on August 15, 2025 at 9:41 A.M. with Staff #121, however the phone number was not in service.The 5-day report, submitted to the SA, by the facility indicated Staff #120 was suspended on May 6, 2024 and terminated on May 10, 2024. The report also indicated the staff member was reported to the AZBON. An interview was conducted on August 14, 2025 at 12:00 P.M. with LPN/Staff #108. Staff #108 explained that residents who are taking controlled substances have their medications stored in the narcotic box which is located in each medication cart. He also explained that the medications are considered double locked because the narcotic box is locked and is stored within the locked medication box with only the on-duty nurse having the key to the cart and narcotic box. Staff #108 confirmed that liquid morphine is kept within the locked narcotic box inside of the medication cart. He explained that during shift change, both of the incoming and outgoing Nurses will either visually inspect or pour out the medication to get an accurate count of what is in the bottle. If the amount of medication does not match what is recorded on the count sheet, the Assistant Director of Nursing (ADON) or the Director of Nursing (DON) will be notified and they will review the issue and do an investigation. When asked about the process for ordering medications for residents, Staff #108 shared that the Doctor will put in orders or tell the Nurse to put in the orders for the residents and then the Nurse will fax the order to the pharmacy. He explained that nurses are not able to order medications without a physician's authorization. The risk to the residents would vary depending on the medication itself. He explained that the risks could be nothing all the way to a lethal overdose.An interview was conducted with LPN/Staff #97 on August 15, 2025 at 11:17 A.M. Staff #97 explained that controlled substances are stored in a lock box in the medication cart. The Nurse on duty is the only person with the key however, there was a master key in case a Nurse accidently gets locked out of the medication cart. Staff #97 indicated that the master key was held by nurse management. Staff #97 explained that Nurses are able to order medications by calling the Doctor or the Nurse Practitioner (NP) to consult with them. She indicated that the Doctor or NP has to approve the orders for medications and that Nurses are not able to order medications without a Physician's authorization.An interview was conducted with ADON/Staff #67 on August 15, 2025 at 12:31 P.M. Staff #67 shared that her expectations for tracking the controlled medications during shift overlap is for both the outgoing nurse and the incoming nurse do the medication count together and that count is then documented on the controlled sheet which is in front of the narcotic book. She also explained her expectations for ordering new medications. She shared that for all narcotic medications, the nurse needs to have a written order. For all other medications, orders are entered into the Electronic Health Record (EHR) and then it automatically is sent to the pharmacy. She shared that both Nurses and Physician's are able to put in the orders, however, she expected that if a Nurse puts in the order, they are to also document, in the EHR, the phone call with the Physician and that they verified the order with the Physician. Staff # 67 recalled the incident with Resident #48 and shared that her and the interim DON, at the time, noticed there were several medication orders coming in at night time which was not the norm. She recalled that the interim DON had spoken with the Physician to verify if he approved the medication order and the physician confirmed that he did not approve the medication order for Ozempic and Mounjaro. Staff #67 indicated that when Staff #120 did not document the phone orders on the progress note and putting in the orders without a Physician's approval, she was not meeting Staff #67's expectations. She also shared that the risk to the resident if they were administered the medications without the Physician's oversight, the resident could have a negative reaction to the medications. Regarding Resident #53's Mounjaro, Staff #67 was asked about the entry dated May 4, 2024 on the MAR. After reviewing the MAR, she stated that it was documented, by Staff #120, that the medication was not administered due to vitals being outside of parameters. Staff #67 shared that the medication did not have parameters so that (documentation) did not make sense. She also reviewed the October 2023 MAR for Resident #48 and shared that the documentation by Staff #120 was the same for Ozempic, vitals being outside of parameters as the reason for not giving Resident #48 the medication, did not make sense due to the medication not having parameters. Related to Resident #52, Staff #67 was asked to review of Morphine narcotic count sheet. She reviewed the records and shared that it looked like there were two separate bottles of morphine. It looked like Staff #120 opened the 2nd bottle before the 1st bottle of morphine was zeroed out. Somehow, we jumped from 29.75 ML to 23 or 25 ML on the narcotic count sheet. She shared that the jump in numbers told her there was some missing medication and it also told her that either someone was stealing the medication or they administered it and forgot to document the administration. However, due to the large amount that went missing, 4.25 ML or 6.25 ML, the chances that 17 to 25 doses of Morphine being administered and not documented was highly unlikely. Related to Resident #47, Staff #67 explained that the resident had an order for Fentanyl 75 mcg in April of 2024, however the dosage was increased to 100 mcg on May 1, 2024. Staff #67 confirmed that the Fentanyl patches would be tracked using the Narcotic Count Sheets. She also explained that the patch was replaced every 72 hours where the Nurse would remove the patch at 8:59 A.M. and then put on a new patch at 9:00 A.M. which was outside of Staff #120's scheduled working hours as her shift ended at 7:00 A.M. Review of a policy titled, Storage and Expiration Dating of Medications and Biologicals, indicated it last revised on August 1, 2024. The policy refers to controlled substances storage and explains that the facility should store Schedule II-V Controlled Substances, in a separate compartment within the locked medication carts and should have a different key or access device. It states that controlled medications must be counted with another designated staff member when there is an exchange of keys. It also noted that the facility should ensure all controlled substances are stored in a manner that maintains their integrity and security.Review of a second policy titled, Abuse, indicates the policy was last reviewed on May 6, 2025. The policy states that Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent. It also provides examples of misappropriation which included Missing prescription medications or diversion of a resident's medication(s), including but not limited to, controlled substances for staff use or personal gain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that two residents (#222 and #223) and/or the resident's representative received an accurate and complete Advanced Beneficiary Notice (ABN) when Medicare services terminated. The deficient practice could result in residents not knowing of their potential liability for payment. Findings include: Resident #222 was admitted on [DATE] with diagnosis including urinary tract infection, difficulty walking, muscle weakness, arteritis, hypothyroidism, hyperlipidemia, repeated falls, neuromuscular dysfunction of the bladder, and protein-calorie malnutrition. A review of the admission MDS (minimum data set) dated January 7, 2024 revealed a BIMS (brief interview of mental status) score of 00, suggesting severe cognitive impairment. A review of the advanced beneficiary notification for resident #222 revealed the estimated cost for ongoing care effective on February 2, 2024 would be $345.00 a day. The form further revealed that both option 1 and option 3 had been selected in the area that indicated to check one box only. The directions on the form stated to select only one option. Option 1 noted that the care as listed above, outlining the $345.00 a day fee, was wanted, and option 3 noted that the resident does not want the care as listed above. Option 1 and option 3 are in conflict with one another. ____________________________ Resident #223 was admitted on [DATE] with diagnosis including knee pain, patella fracture, depression, glaucoma, irregular heartbeat, obesity, osteoarthritis, breast cancer and spinal stenosis. A review of the 5-day MDS (minimum data set) dated November 29, 2023 revealed a BIMS (brief interview of mental status) score of 15, suggesting that the resident was cognitively intact. A review of the advanced beneficiary form for resident #223 revealed that the estimated cost, to the resident, beginning December 05, 2024 would be $345.00 a day. The 'options-section' of the form denoting that only one box should be checked revealed that no boxes were checked, leaving ambiguity as to whether resident #223 was opting to continue or not continue with services past December 05, 2023. _____________________________ An interview was conducted on July 16, 2024 at 3:13 P.M. with staff #112 (Social Services Director). Staff #112 stated that she believed the advanced beneficiary notification (ABN) was always required for each resident when they are running out of Medicare days of service. Staff #112 stated that only one box should be checked for those sections explicitly stating check one box and that this section is required to be completed. Staff #112 reviewed the ABN for resident #223 and stated that a check-box should have been selected, but had not. Staff #112 reviewed the ABN for resident #222 and stated that only one box should have been checked not 2, as observed on the form. Staff #112 stated that the risk would include, that if the form was incorrectly completed, it would make the form invalid. Staff #112 stated that these forms were completed inaccurately and that she takes full responsibility for the errors. Staff #112 stated that going forward one person will be completing the form, another person will audit it for accuracy and it will be documented in point click care (PCC). An interview was conducted on July 16, 2024 at 3:27 P.M. with staff #110 (administrator). Staff #110 stated that her expectation is that the ABN is given timely and accurately. She stated that the ABN is completed by social services. Staff #110 reviewed the ABN documentation for resident #223 and resident #222 and stated that these should have been completed accurately, but the options section of the ABN was not accurately completed for either resident. Staff #110 stated that the risk could include reimbursement being impacted as well as an impact on resident rights. A review of the policy entitled Resident Rights with a review date of September 25, 2023 revealed that the resident has the right to request, refuse and or discontinue treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that initial and ongoing weights were conducted for one resident (Resident #36). The deficient practice could result in a change of condition not being assessed and monitored. Findings include: Resident #36 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, Parkinson's disease and chronic respiratory disease. Review of the clinical record revealed that the resident weighed 187 pounds on February 9, 2024. Review of the nutritional assessment dated [DATE] revealed that the resident was malnourished. The care plan dated February 22, 2024 revealed that the resident was at risk for weight fluctuation related to dysphagia and anoxic brain injury. Interventions included eternal feeding as ordered and weight as per the facility policy. The minimum data set (MDS) dated [DATE] included a staff assessment for mental status score of 2 indicating the resident had moderate cognitive impairment. The clinical record revealed that the resident weighed 168.6 pounds on June 4, 2024 and 167.4 pounds on July 2, 2024. An interview was conducted on July 17, 2024 at 10:07 a.m. with a Registered Dietician (staff #66), who stated that a nutritional assessment is done when residents are admitted and all residents are supposed to be weighed. He stated that resident #36 was not weighed when he was admitted to the facility and the weight documented in the clinical record was taken from the weight documented in the hospital transfer records. He also stated that the resident should have been weighed monthly as per the facility policy in order to assess and monitor weight loss, fluctuations, fluid shifts, and if a weight change has occurred, so the root cause can be determined. He stated that there is a risk of developing malnutrition and/or congestive heart failure (CHF) fluid retention not being recognized if weights are not being monitored. An interview conducted on July 17, 2024 at 11:15 a.m. with the Director of Nursing (DON/staff #59), who stated that the facility policy states that all residents are supposed to be weighed weekly for the first four weeks and then monthly. The reason for weighing the resident is to check for significant weight loss or gain. She stated that when the resident was admitted , the certified nursing assistant (CNA) should take the resident's initial weight and should not use the recorded weight from the hospital records because the weight may not be accurate. She stated that they just recently talked about weighing hospice patients, and all residents should be weighed. The facility addendum to the Lippincott procedure revised August 21, 2023 states that measuring a patient's weight is part of a routine admission to a health care facility. An accurate record of the patient's weight is essential for calculating dosages of drugs, fluid maintenance, anesthetics, and contrast agents; calculating tidal volume in patients requiring mechanical ventilation; assessing the patient's nutritional status; and determining the patient's height-weight ratio, body surface area, and body mass index (BMI). The facility policy, Weights and Heights reviewed August 23, 2023 states that all residents are weighed within 24 hours of admission and weekly for 4 weeks and as needed thereafter or more as determined by the RAR committee and/or physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#6) received assistance with bathing. The deficient practice could result in poor hygiene and skin infections. Findings include: Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included a anxiety, depression, unspecified protein-calorie malnutrition, and a personal history of venous thrombosis and embolism. The care plan for activities of daily living (ADLs) dated March 25, 2024 revealed that the resident has an ADL self-care performance deficit related to weakness and decreased mobility due to acute kidney failure (AKF), pressure ulcer (PU), seizures (s/z) and depressive disorder (d/o). Interventions included that the resident requires assistance by staff with bathing/showering as necessary. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident was cognitively intact. It also revealed that the resident was dependent on assistance with showers/bathing. Review of the shower/bathing task sheet revealed that the resident was schedule to bath on Monday and Thursday evenings. Review of the shower/bathing task sheet dated April 2024 revealed: -Thursday, April 4, 2024, bathing was completed. -Thursday, April 11, 2024, bathing was refused. -Thursday, April 25, 2024, activity did not occur. Review of the skin care alert form revealed the following directions: Complete this form [NAME]. While assisting the resident with self-care (bathing, toileting. dressing, Etc.), document the presence of any areas of concern or changes in skin, including: redness, bruising, surgical wounds, drainage. rashes, blisters, etc. Use side two to document detail and indicate current strategies to prevent pressure ulcer/injuries. Review of the skin care alert forms from April 2024 through June 2024 revealed one form dated April 15, 2024 with the documention of a bed bath being completed. Review of the shower/bathing task sheet dated May 2024 revealed: -Friday, May 3, 2024, activity did not occur. -Monday, May 6, 2024, bathing was completed. -Thursday, May 9, 2024, activity did not occur. -Monday, May 13, 2024, activity did not occur. -Monday, May 20, 2024, activity did not occur. -Thursday, May 23, 2024, activity did not occur. Review of the shower/bathing task sheet dated June 2024 revealed: -Friday, June 14, 2024, activity did not occur. -Monday, June 17, 2024, bathing was completed. -Thursday, June 20, 2024, bathing was completed. -Monday, June 24, 2024, bathing was completed. -Thursday, June 27, 2024, bathing was completed. Review of the shower task sheet dated July 2024 revealed bathing only one time during the week of July 4, 2024. No bathing was documented on the task sheet from July 5, 2024 through July 15, 2024 and no refusals were documented. During an interview conducted on July 16, 2024 at 12:23 p.m. with the Director of Nursing (DON/staff #59), she stated that skin care alert form is being used for the paper shower form and acknowleded that there is nothing on the form to indicate a shower, hair washing, or nail care was done. The form states that it can be used for shower, toileting, dressing, etc. She acknowledged that staff are not identifying which task is being done. During a second interview conducted on July 17, 2024 at 11:12 a.m. with the (DON/staff #59), she stated that there is a shower schedule for the residents and each resident is scheduled for showers twice a week. It is her expectation that if a resident is not showering, the certified nursing assistant (CNA) should offer a couple of times and report the refusal to the nurse. The nurse should talk to the resident. The nurse could document the refusal on the skin care alert form ask the resident to sign it. She stated that there is a risk of poor hygiene and skin breakdown if a resident is not bathing. The facility policy, Activities of Daily Living (ADLs) revised February 12, 2024 states that the resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs will be reported to the nurse.

Based on observation, a staff interview, and the facility policy and procedures, the facility failed to ensure that the daily staff posting included the correct information. Findings include: On July 14, 2024 at approximately 9:00 a.m. the daily staff posting was observed hanging on the wall just to the left of the reception desk. The information observed on the posting was: -July 12, 2024 -census 60 -number of each type of staff for each shift -the total hours scheduled for each type of staff for each shift -the actual hours worked was not completed During this time the Director of Nursing (DON/staff #59) approached and removed the daily staff posting dated July 12, 2024 and stated that she was just about to the change it. Review of the facility documentation revealed that the census was 58 on July 14, 2024. An interview was conducted on July 17, 2024 at 11:30 a.m. with the (DON/staff #59), who stated that the Central Supply Director/staffing coordinator (staff #95) is responsible for completing daily staff posting and works Monday through Friday. She stated that staff #95 prepares the daily staff postings for the weekend and the weekend receptionist is supposed to switch them out. She stated that the posting is for visitors and residents to see how many staff are available in the building. The facility policy, Facility Staffing Posting revised December 13, 2023 states that the facility needs to post nurse staffing information in a prominent place where it is accessible to residents and visitors. The data should be clear, readable, up to date and current. When listing the total number of staff and actual hours worked, the facility is required to reflect staff absences on each shift that occur due to callouts or illness. The nurse staffing data needs to be posted on a daily basis at the beginning of each shift. The required information that needs to be posted includes: I. Facility name 2. Current date 3. Resident census 4. Total number of staff and actual hours worked per shift for: a. Registered Nurses b. Licensed Nurses c. Certified Nurse Aides

Based on employee record review, staff interviews, and the facility policy and procedures, the facility failed to ensure that one staff (#110) was free of tuberculosis (TB) prior to working in the facility. The deficient practice could result in residents being infected with tuberculosis. Findings include: Staff # was hired as the Administrator (staff #110) for the facility on January 8, 2024, During an interview conducted on July 16, 2024 at 1:56 p.m. with the accounting clerk/human resources personnel (staff #73), she stated that (staff #110) did not provide a current TB test for herself. She stated that the Executive Director is probably supposed to have a TB test prior to working in the building. She stated that the reason for testing is to prevent the risk of TB spreading throughout the building. An interview conducted on July 17, 2024 at approximately 9:50 a.m. with the (staff #110), who stated that she did not have a tuberculosis test prior to working in the facility. She stated that she was tested yesterday, July 16, 2024, and the test results had not been read. An interview was conducted on July 17, 2024 at 11:19 a.m. with the Director of Nursing (DON. /staff #59), who stated that when a person is hired, he/she is required to show a test result for TB is negative prior to working in the facility. She stated that the administrator (staff #110) walks the floors of the building and should do daily. She doesn't interact directly with residents, but follows up with residents as needed. She stated that staff #110 can come into contact with residents when she is walking the halls. The facility policy, Tuberculosis - Testing and Screening revised June 28, 2024 states that the facility will evaluate each associate and volunteer for tuberculosis in accordance with current CDC guidelines, unless more stringent guidance is provided by local or state regulation. New associates or volunteers who have been made a conditional offer shall be screened for presence of infection through the following measures; pre-placement risk assessment and symptom evaluation and the facility should also perform skin test for M. Tuberculosis using the Mantoux TST skin test.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate and comfortable temperature levels was provided to meet the needs of 14 residents (#4, #5, #8, #11, #20, #25, #34, #35, #41, #42, #43, #48, #56, and #167). The deficient practice could result in the resident's room not having a homelike and comfortable environment. The facility census was 58 and the sample was 14. Findings include: On the morning of July 15, 2024, between the hours of 6:45 a.m. to 7:00 a.m., surveyors experienced a notable difference in temperature perceived and felt when entering the facility. The temperature felt uncomfortably warm. During an interview with the Assistant Maintenance Technician (staff #33) conducted on July 15, 2024 at approximately 6:45 a.m., staff #33 mentioned that the generator did not kick in properly during the power outage yesterday evening. This resulted in the cooling tower (chiller) not activating to cool down the temperature in the facility. Staff #33 stated that the chiller is in the process of kicking in but will take approximately 4 hours to cool down the facility. An observation of the residents' areas was conducted on July 15, 2024 starting at approximately 7:15 a.m. There was no evidence that rooms were being tested for ambient temperature by the staff. This was despite the residents' areas being noticeably and feeling warm/uncomfortable. Regarding Resident #4: -Resident #4 was admitted to the facility on [DATE] with diagnoses that included fracture of the lower end of the right femur, pain in right knee, chronic kidney disease, and osteoarthritis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was cognitively intact. The assessment also revealed that the resident was dependent for transfers. The MDS indicated that the resident uses a walker as a mobility device. During an interview conducted with the resident on July 15, 2024 at 8:23 a.m., the resident stated that last night they had no power and that she was uncomfortable. An observation was conducted of the resident's room on July 15, 2024 at 8:23 a.m. There was a notable warm temperature in the room. Regarding Resident #5: -Resident #5 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer of sacral region, osteoporosis, hypertension, and gastro-esophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has modified independence pertaining to decisions regarding tasks of daily life. The assessment also indicated that the resident required substantial assistance for chair to bed transfers, and sit to stand activities. The MDS also noted that the resident uses a wheelchair as a mobility device. During an interview conducted on June 15, 2024 at 8:19 a.m., the resident responded Si when asked if it was warm in their room. An observation was conducted of the resident's room on June 15, 2024 at 8:19 a.m. The temperature registered 80.7? Fahrenheit. The room felt noticeably warm. During a walk-through inspection conducted with the Maintenance Director (staff #32) conducted on July 15, 2024 at 9:30 a.m., the temperature was taken with a thermometer and registered 76.6 Fahrenheit. Regarding Resident #8: - Resident #8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, chronic obstructive pulmonary disease, angina pectoris, and peripheral vascular disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has modified independence when it came to decisions regarding tasks of daily life. The MDS also indicated that the resident is dependent on assistance with regards to most transfers. The MDS also noted that the resident uses a wheelchair for mobility. During an observation of the resident's room on July 15, 2024 at 8:17 a.m., the temperature taken with the thermometer registered 81.2? Fahrenheit. Physical inspection of the air conditioner (AC) thermostat located in the room revealed that the controls do not work regardless of the setting. The room felt uncomfortably warm. An interview with the resident was conducted on July 15, 2024 at 8:17 a.m. Resident #8 confirmed that it is hot in the room. During a walk-through inspection conducted with the Maintenance Director (staff #32) conducted on July 15, 2024 at 9:29 a.m., to check the temperature in the residents' area, resident #8's room temperature registered 81.1 degrees Fahrenheit. Regarding Resident #11: -Resident #11 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included paroxysmal atrial fibrillation, antherosclerotic heart disease, dementia, and paralytic syndrome. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The MDS assessment also indicated that the resident is dependent on assistance for transfers. An observation of the resident's room was conducted on July 15, 2024 at 8:26 a.m. During the observation, the room felt hot. The temperature taken with a thermometer registered 81.1 Fahrenheit. During an interview with resident #11 conducted on July 15, 2024 at 8:26 a.m., the resident said that hell yeah, it's hot referring to his room. In a follow-up observation conducted on July 15, 2024 at 9:33 a.m., it was noted that the temperature in the room was finally comfortable. The temperature taken with the thermometer registered 76 Fahrenheit. Regarding Resident #20: -Resident #20 was initially admitted to the facility on [DATE] on readmitted on [DATE] with diagnoses that included quadriplegia, chronic obstructive pulmonary disease, heart failure, esophagitis, schizophrenia, and bipolar disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. The assessment noted that the resident is dependent on assistance for transfers. The MDS also indicated that the resident utilizes a wheelchair as a mobility device. An observation conducted on July 15, 2024 at 8:12 a.m. revealed that the room was uncomfortably hot. The temperature taken with a thermometer registered 83.5 Fahrenheit. In an interview with resident #20 conducted on July 15, 2024 at 8:12 a.m., the resident stated that they did not have AC (air conditioner) in their room since Friday. The resident said that on Friday, July 12, the AC was fixed just before supper. However, it stopped working through the night Friday into Saturday. The resident noted that maintenance looked at it yesterday and it was still not working. During a walk-through inspection conducted with the Maintenance Director (staff #32) conducted on July 15, 2024 at 9:29 a.m., the room was still felt uncomfortably hot. The temperature was taken with a thermometer and it registered at 82.4 Fahrenheit. Regarding Resident #25: -Resident #25 was admitted to the facility on [DATE] with diagnoses that included anemia, heart failure, diabetes, and depression. Review of the Significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that he is cognitively intact. The assessment also indicated that the resident is dependent on assistance for all transfers. The MDS noted that the resident uses a wheelchair as a mobility device. A CNA (Certified Nursing Assistant/staff #9) was observed entering resident #35's room on July 15, 2024 at 8:35 a.m. Resident #35 was heard asking the CNA to turn on his air conditioner (AC). Staff #9 informed the resident that they did not think that the AC was working. The CNA told resident #35 that the thermostat was set at 74 Fahrenheit and stated that the AC had not been working but that they would report it to the Maintenance Director. Staff #9 noted that that AC was also not working in room [ROOM NUMBER] this morning and that it they reported it to the Maintenance Director when he was up on the second floor. An interview with a CNA (Certified Nursing Assistant/staff #9) was conducted on July 15, 2024 at approximately 8:38 a.m. Staff #9 said that the process is that they would document in a book at the nurse's station when things are not working. The CNA noted that they are going to document the issue right now. During an interview with resident #25 conducted on July 15, 2024 at approximately 8:40 a.m., resident #35 stated that he was hot last night and told a CNA last night. The resident was informed by that CNA that the air was not working and that there was nothing she could do about it. The resident said that they were told there was a fan. However, they did not see one. Resident #25 stated that they did not sleep well because they were hot. They said that they woke up at 3:00 a.m. and it was still hot. The resident noted that they were offered water through the night and cold cloth. An observation of the resident's room was conducted on July 15, 2024 at 8:55 a.m. The temperature was taken using a thermometer and registered 82.4 Fahrenheit. The wall-mounted thermostat was set at 74 Fahrenheit and the reading of the actual room temperature was displayed 84 Fahrenheit. Regarding Resident #34: -Resident #34 was admitted to the facility on [DATE] with diagnoses that included dementia, hypertension, and type 2 diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident is cognitively intact. The MDS also indicated that the resident utilizes a walker as a mobility device. An observation of the resident's room was conducted on July 15, 2024 at 8:24 a.m. During the observation, the room was noticeably hot. A look at the wall mounted thermostat located in the room revealed the temperature to be 84 Fahrenheit. A thermometer was used to take the room temperature and it registered 83.0 Fahrenheit. A walk-through inspection was conducted with the Maintenance Director (staff #32) on July 15, 2024 at on July 15, 2024 at 9:33 a.m., the temperature was taken using a thermometer and it registered 74.3 Fahrenheit. Regarding Resident #35: -Resident #35 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included systolic heart failure, dysphagia, Takotsubo syndrome, dementia, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident makes independent decision regarding tasks of daily life. The assessment indicated that the resident requires substantial/maximum assistance for most transfers. The MDS also noted that the resident utilizes a wheelchair as a mobility device. An observation of the resident's room was conducted on July 15, 2024 at 8:20 a.m. The room was observed to have the AC on. However, it was only blowing room temperature air. The temperature was taken using a thermometer and it registered 81.8 Fahrenheit. An interview with resident #35 conducted on July 15, 2024 at 8:20 a.m., the resident stated that the is very warm. During a walk-through inspection conducted with the Maintenance Director (staff #32) conducted on July 15, 2024 at 9:31 a.m., the temperature was taken with a thermometer and it registered 79.5 Fahrenheit. Regarding Resident #41: -Resident #41 was admitted to the facility on [DATE] with diagnoses that included acute embolism, atherosclerotic heart disease, hypertension, depression, and obstructive and reflux uropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. The MDS also indicated that the resident is dependent on assistance for transfers. The assessment also noted that the resident uses a wheelchair as a mobility device. An observation of the resident's room was conducted on July 15, 2024 at 8:20 a.m. During the observation, it was noted that the AC was on but was only blowing room temperature air. The temperature was taken using a thermometer and it registered 81.8 Fahrenheit. During an interview with resident #41 conducted on July 15, 2024 at 8:20 a.m., the resident stated that it was warm in the room. A walk-through inspection was conducted with the Maintenance Director (staff #32) on July 15, 2024 at 9:31 a.m. During the inspection, the temperature was taken with a thermometer and it registered 79.5 Fahrenheit. Regarding Resident #42: -Resident #42 was admitted to the facility on [DATE] with diagnoses that included heart failure, hypertension, diabetes, paraplegia, and seizure disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. The MDS indicated that the resident requires partial/moderate assistance for some transfers. An observation of the resident's room was conducted on July 15, 2024 at 8:11 a.m. During the observation the resident's room felt uncomfortably warm. The temperature was taken using a thermometer and the inner wall by the resident's restroom registered 87.1 Fahrenheit while the wall by the window registered 83.3 Fahrenheit. Regarding Resident #43: -Resident #43 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes, chronic kidney disease, anxiety disorder, depression, and gastro-esophageal reflux disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The assessment indicated that the resident is dependent on assistance for all transfers. The MDS also noted that the resident uses a wheelchair as a mobility device. An observation of the resident's room was conducted on July 15, 2024 at 8:09 a.m. During the observation, the resident's room was noted to be pretty warm. The temperature was taken with a thermometer and it registered 82.6 Fahrenheit. An interview with resident #43 was conducted on July 15, 2024 at 8:19 a.m. Resident #43 stated that the during dinner last night, a storm hit town and a power outage ensued as they finished dinner. Due to the fire outage, the elevator was not functional, fire doors closed, and after awhile the emergency lights came on. However, the elevators remained non-functional. The resident noted that they were unable to get back to their room upstairs so they were instead placed in room downstairs until the power came back on. Resident #43 noted that the power came back on between 10:30 p.m. to midnight. The resident said that when they got upstairs, it was so hot and the doors were closed so it was really hot in their room. The resident noted stated that there was no air conditioning, no fan in the room and it was so uncomfortable due to the heat. When they woke up in the morning, it was really hot and uncomfortable. They noted that it was so hot in their room that even the CNA (Certified Nursing Assistant) was sweating and wiping herself with paper towels as she was helping them. The resident noted that they almost could not breathe because it was so hot. The resident explained that they came back downstairs to grab breakfast and to cool down. Resident #43 said that last night, what the staff did to assist with the heat was to give him cold water and just not put blankets on him. The resident explained that in their case, the room have to be kept at 73 Fahrenheit otherwise they are uncomfortable. Resident #43 noted that last night the heat is too bad and it was so bad that even with oxygen and the CPAP (continuous positive airway pressure) machine, they still could not breathe right. The resident mentioned that this was the longest that they had to go without AC. However, they mentioned that this happens every summer. Resident #43 noted that since the beginning of this summer, the air in the hallway has not worked and that was the reason why there was a fan on in the hallway even before the power outage. A walk-through inspection was conducted with the Maintenance Director (staff #32) on July 15, 2024 at 9:38 a.m. The temperature was taken with a thermometer and it registered 81.0 Fahrenheit. Regarding Resident #48: -Resident #48 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included seizures, narcolepsy without cataplexy, dysphagia, aphasia, depression, meningitis, diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has severely impaired cognitive skills for daily decision making. The MDS also indicated that the resident is dependent on assistance for all transfers. An observation of the resident's room was conducted on July 15, 2024 at 8:17 a.m. During the observation, it was noted that the AC (air conditioner) in the resident's room was not working. Physical inspection of the thermostat was unremarkable. However, the controls do not work regardless of the setting. In an interview with resident #48 conducted on July 15, 2024 at 8:17 a.m., the resident noted that the AC does not work. Resident #48 confirmed that it is hot in the room. A walk-through inspection was conducted with the Maintenance Director (staff #32) on July 15, 2024 at 9:29 a.m. During the inspection, the temperature was taken with a thermometer and registered 81.1 Fahrenheit. Regarding Resident #56: -Resident #56 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, epileptic seizures, gastric ulcer, bipolar disorder, and gastro-esophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident is cognitively intact. The MDS noted that the resident utilizes a wheelchair as a mobility device. An observation of the resident's room was conducted on July 15, 2024 at 8:24 a.m. The wall mounted thermostat displayed the room temperature at 84? Fahrenheit. The temperature was taken using a thermometer and registered 83.0 Fahrenheit. A walk-through inspection was conducted with the Maintenance Director (staff #32) on July 15, 2024 at 9:32 a.m. The temperature was taken using a thermometer and it registered 74.3 Fahrenheit. Regarding Resident #167: -Resident #167 was admitted to the facility on [DATE] with diagnoses that included pulmonary embolism, gastrointestinal hemorrhage, multiple sclerosis, polycystic ovarian syndrome, type 2 diabetes, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. The MDS noted that the resident utilizes a walker as a mobility device. An observation of the resident's room was conducted on July 15, 2024 at 8:10 a.m. The temperature was taken with a thermometer and registered 79 Fahrenheit. During an interview with the resident conducted on July 15, 2024 at 8:10 a.m., the resident stated that they did not have a functioning air conditioning the first week that they were here. The resident said that they told the facility but they did not fix the issue until last week Monday or Tuesday. Resident #167 noted that there was a power outage last night and it was very hot and humid. The resident noted that the power did not come back on until 11:30 p.m. The resident said that they woke up from the noise and looked at their watch and that was how they knew when the power came back on. The resident noted that the nurse had checked on them and opened the window for them. A follow-up interview was conducted with a CNA (Certified Nursing Assistant/staff #9) on July 15, 2024 at 9:22 a.m. The CNA noted that they are supposed to move the resident when it is hot and the air is not working. On July 15. 2024 at 9:22 a.m., it was observed that the staff were transferring residents from the second floor to the first floor. An interview with the Maintenance Director (staff #32) was conducted on July 15, 2024 at 9:41 a.m. Staff #32 stated that they were notified at 6:15 p.m. of the power outage. They then called the Assistant Maintenance Technician (staff #33) and got ready to go out to the facility. Staff #32 noted that they arrived at the facility at approximately 6:45 p.m. They noted that the facility was dark, and the staff was panicking. They both started troubleshooting, checked the electrical room, and checked the breakers. It appeared that the main breaker for the building was popped, so they kicked it on. They turned the generator on manually at around 7:40-8:00 p.m. Staff #32 noted that it took about an hour to troubleshoot. They did not get the chillers working again since it took too much voltage. However, there was enough power for oxygen, air mattress, CPAP (Continuous Positive Airway). The staff #32 noted that downstairs it was 75 degrees and upstairs it was 78 degrees. The Maintenance Director noted that chiller temperatures have to be 80 and 90 always a 10-degree difference. When they got arrived in the facility in the morning, they did not know that the circular pumps went off. They had to go though each unit at 7:00 a.m. to reset all the AC (air conditioner) units. The Maintenance Director said that staff #33 had bypassed the circular pumps because they turned the alarm and did not share this with staff #32. Had the alarm been on, they would have known there was an issue with the circular pumps. An interview with a Registered Nurse (RN/staff #69) was conducted on July 15, 2024 at 10:10 a.m. Staff #69 stated that the electricity went out last night around 6:15-6:20 p.m. The RN indicated that they checked and instructed staff that residents on O2 (oxygen) had to be put on the O2 tank. Staff #69 indicated that they are familiar with which residents are on O2. The RN stated that the first priority is to get the residents on O2 then checked each room to make sure that everyone was fine. They explained to residents that there was a storm and electricity is out and staff made sure that everyone had ice water. Staff #69 noted that by the time they notified maintenance, one of the nurses had already contacted the ED (Executive Director/staff #110) and the DON (Director of Nursing/#59). Maintenance arrive approximately 15-20 minutes later. The generator came on bout 15-20 minutes later. The RN noted that the O2 concentrators can be ran by the generator but no CPAP/BiPAP (Continuous Positive Airway/Bilevel Positive Airway Pressure) and they have to use the red plugs. The beds would not be working since it requires too much electricity. Staff #69 said that there were two residents that they had to put back on the air mattress after they were able to put everyone that needed on to be on O2. The RN indicated that vital-need equipment were not automatically plugged into the red outlets and that staff had to physically switch out the needed equipment to the red outlets and plug them in. Staff #69 said that one of the residents from the second floor got stuck downstairs until around 11:30 p.m., when the electricity came back. They made sure that the resident had water and that there was a CNA (Certified Nursing Assistant) assigned to that resident. They checked on that resident to make sure that the resident was okay. Staff #69 noted that the alarm did not go off last night regarding the generator. The generator did not kick in. The light went on and off and the doors shut. The RN went to each of the residents' room and informed them that they were there and that the electricity will comb back. Staff #69 said that by the time they left at around 8:30 p.m., it was not hot. However, when they returned on shift at around 7:10 a.m., it was hot. The NOC shift did not talk to them since they were assigned to the first floor. Therefore, they were not aware of anyone taking the temperature in the residents' rooms at night. Staff #69 said that if the resident's room is warm, they are supposed to move the resident to another location and report the issue to maintenance as soon as possible. However, since the facility had no electricity the elevator was not working, so they could not move the residents. The RN said that if you have to check the temperature then it is too late since it is too hot. Elderly people, they do not feel the change quick, you have to recognize if the climate is not okay. When there is an issue staff can call or use the TELS system to submit a work order. For the power outage, the phone call was appropriate response. They got the residents ice. They assumed that the generator would kick in. However, it did not kick in right away. During an interview with the Assistant Maintenance Technician (staff #33) conducted on July 15, 2024 at 10:48 a.m., staff #33 stated that they were called in when the power went out to get the generator started. They stated that the Maintenance Director called them at approximately 6:15-6:30 p.m. They arrived at the facility around 6:47 p.m. The Assistant Maintenance Technician noted that when they arrived at the facility, the building was dark and they had to get the generator key and got it going. The generator finally kicked in at about 7:06 p.m. Staff #33 noted that they do weekly test on the generator and run it weekly for 3 hours, take temperature readings, etc. to ensure that it is working. The Assistant Maintenance Technician said that last week, they came by and looked at the generator to see if they were going to disconnect it while they were going to do some work. Staff #33 said that there is no alarm system for the generator. However, for the boilers, when the gas runs low and runs out, an alarm goes off, and it shuts off the pumps to include the one for the chiller which they did not know. The alarm for the boiler went off and you have to go and switch off the alarm, and places on standby, causing the chiller and boiler to automatically shut off. Staff #33 stated that it takes 2-3 hours to get going for the chiller to actually start cooling and get the air conditioner working. The Assistant Maintenance Technician said that this morning, they realized that the AC was not cooling, this was around 5:00 a.m. Last night, they reset the AC before he left at 2:15 a.m. Staff #33 noted that they checked the temperatures in the rooms before leaving and it was averaging 73-78 Fahrenheit upstairs and 72 Fahrenheit downstairs. The Assistant Maintenance Technician stated that it takes time to cool off the rooms. The windows upstairs were open because the staff were trying to keep the residents cool. Staff #33 admitted that they did not document any of the room temperature taken last night. They also noted that each time the pumps go into standby mode, they had to go into each room and reset the AC. The Assistant Maintenance Technician said that when they arrived in the facility this morning and came into the kitchen, they noticed and felt that it was hot. They went upstairs to check the rooms but did not take the temperature. Staff #33 said that it was hot and the residents were sleeping. They commented that the residents could have been moved from the second floor to the first floor where it was cooler. They indicated that the process when it is hot in the facility is to use portable coolers, and noted that there are only 3 portable coolers and they are all being used upstairs. Staff #33 admitted that the elevator was not working in the [NAME] last night when the power outage ended. They stated that they would have moved the residents if it was hot. They noted that they were not sure what the temperature is when residents have to be moved. Staff #33 noted that they used extension cords for red plugs in the hallways since they were not in all rooms. They said that the only things plugged into the red outlet were oxygen and things needed for the resident's health and safety. Staff #33 said that there were no fans in the rooms. They admitted that they are supposed to try and make sure the residents are comfortable as much as possible with the limited resources and old system. They noted that climate control is for the residents' comfort. They indicated that they called the Maintenance Director (staff #32) at approximately 6:12 a.m. and was told that he was on his way and they will all figure it out. Staff #33 recalled that last year, when it last happened last summer, the facility brought all the residents downstairs to the dining rooms. Back then the electricity was out for 2 hours but it was long enough to feel the heat. Staff #33 stated that they saw the Maintenance Director around 7:00 a.m., and both of them went around the rooms. They both agreed that the rooms were hot but did not take temperatures of the residents' rooms. They noted it was hot based on ambient air. Staff #33 stated that it was around 8:00 a.m. when temperatures were taken and it averaged 83? Fahrenheit upstairs and 78 Fahrenheit downstairs. The Assistant Maintenance Technician indicated that they were concerned about the residents being in hot rooms since they are weak and have conditions. Staff #33 noted that neither the Administrator (staff #110) nor the DON (staff #59) asked them about temperatures. They indicated that they were with the Maintenance Director (staff #32) were outside working on the chiller when the DON approached the Maintenance Director to have a conversation but did not know what was discussed. Staff #33 noted that they are trained for fire but admitted there is not an emergency elevator or a plan on how to evacuate residents from the second floor that are not ambulatory. The Assistant Maintenance Technician admitted that they have not done disaster drills. It is a concern how to get residents out and there are a few who are very heavy set. It is the second time the electricity had gone out and they noted that they do not have a standard practice to follow. An interview with a Registered Nurse (RN/staff #50) was conducted on July 17, 2024 at 8:29 a.m. Staff #50 stated that when they arrived on shift the day after the power outage, the none of the residents complained. However, staff #50 said that the rooms felt hot to him. The RN stated that they had not experience a power outage that resulted in the facility being hot. Staff #50 noted that the protocol when a resident's room is hot is for them to move the resident to a cooler room. The RN said that there are guns (thermometer) on the cart that are used to check room temperature. However, it was unknown whether the temperature for the rooms were taken. An interview with the Administrator (staff #110) was conducted on July 17, 2024 at 1:09 p.m. Staff #110 stated that a comfortable environment for residents is part of homelike environment. Residents should have areas to rest, congregate, have a sense of peace, and lack of chaos. The Administrator stated that the impact on residence if the facility is not comfortable with regards to temperature is that it could influence sleep hygiene, quality of sleep, and rest. It could influence maintaining proper hydration. Could for disturbing for one's ability to rest comfortably. Staff #110 said that high temperature can imp

Based on observations, staff interviews, and policy, the facility failed to ensure multiple food items were stored at safe temperatures in accordance with professional standards. This deficient practice could result in placing residents at risk for food-borne illnesses. The facility census was 58. Findings include: During an initial observation of the kitchen, conducted at 8:25 a.m. on July 14, 2024 with staff #15. In the walk-in refrigerator, the thermometers both inside and out registered a temperature displaying 45 degrees Fahrenheit (F). Inside the refrigerator were various food items including milk, eggs, yogurt, meat, cheese, and dressings. Staff #15 stated the temperatures are recorded on the log twice daily, morning and evening. Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 14, 2024 was recorded at 36F. The evening temperature was recorded at 40F. The log includes a critical limit (CL) for temperature at 40F on the high end, and revealed that in the event of a temperature not within the required range, to notify the Director of food services or maintenance immediately. During a kitchen observation conducted on July 15, 2024 at 10:12 a.m. of the same walk-in refrigerator, the external thermometer and internal thermometer registered a temperature displaying 42F. Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 15, 2024 was recorded at 37F. The evening temperature was recorded at 40F. During a kitchen observation conducted on July 16, 2024 at 9:30 a.m. of the same walk-in refrigerator, the external thermometer registered a temperature displaying 50F. The internal thermometer registered a temperature displaying 44F. A second observation was made on July 16, 2024 at 11:50 a.m. The external thermometer again showed a temperature displaying 50F, and the internal thermometer displayed a temperature of 44F. Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 15, 2024 was recorded at 38F. The evening temperature had not been recorded yet. An interview was conducted on July 16, 2024 at 12:35 p.m. with a cook (kitchen staff #40). The cook stated that most of the foods served for meals are stored in the walk-in refrigerator, including prep stuff for the next day, thawing meat, dairy and milk, as well as cottage cheese. The cook also stated that left overs are also stored in the same walk-in. The cook stated that temps in the walk-in need to be 39F or below, and that temperatures are recorded using the outside thermometer twice daily in the monthly log. An interview was conducted on July 16, 2024 at 12:44 p.m. with the Registered Dietician and Kitchen Manager (RD/kitchen staff #66). The RD stated that temperatures need to be under 40F in the walk-in or it puts the food at risk of causing food-borne illness such a botulism. The RD stated that all refrigerated items used in the facility are stored in that walk-in, including dairy, cheese, eggs and leftovers. The RD further stated that he was aware of a door being replaced on the freezer for a temperature issue, but was not sure about the walk-in. During this interview the RD removed two random containers of food product from the walk-in refrigerator and took the temperature of them. A single serving yogurt container, and a jar of Mayonnaise. The temperature of both items was measured by the RD at 45F. An interview was conducted with the Maintenance director (Facility/staff #32) on July 16, at 1:25 p.m. The Maintenance director stated that there was a mistake with what the temperature was set at in the walk-in refrigerator. He stated that the walk-in was accidently set to 40F by mistake when it was being worked on, roughly one month ago. He further stated that the outside thermometer on the walk-in was broken, and does not register temperatures correctly. However, the facility logs showed multiple entries for the month of July with temperatures ranging from 32F and 40F. An interview was conducted with the Executive director (ED/staff #110) on July 17, at 11:50 a.m. The ED stated they were aware of the food issue and it was being corrected. The ED further stated that her expectation is that food is stored safely, an that thermometers will be calibrated correctly going forward. Review of the facility policy titled 'Food Safety' revised April 26, 2023 and reviewed May 1, 2024 revealed that it is the policy of the facility to ensure food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. It further revealed that the danger zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F allow the rapid growth of pathogenic microorganisms that can cause foodborne illness.

Based on record review and staff interview the facility failed to ensure the emergency and standby power systems were functioning properly. Failure to implement an emergency and standby power systems plan during an emergency could lead to harm of the patients and/or staff. Findings include: Based on record review and staff interview on July 17-18, 2024, the facility failed to ensure the emergency generator was adequate for the facility needs during an emergency. The facility has had a rental generator since March 2, 2020. On July 14, 2024 the facility experienced a power failure and the temporary generator failed to turn on leaving the facility totally without power. Medical equipment, the elevator and facility walk-in refrigerator and freezer were none functioning during the total outage. The following are staff interviews: Monday, July 15, 2024, at approximately 0941 hours an interview was conducted with staff # 32, Maintenance Director. Staff #32 stated that he was notified at 1815 hours on July 14, 2024, that the power was out. Staff #32 stated that he responded to the facility arriving at 1845 hours. Staff # 32 further stated that the facility was dark and the staff were panicking. Staff # 32 stated that he began troubleshooting and found that the main breaker for the facility had popped and that he reset it. Staff #32 further stated that it took approximately one hour to troubleshoot and that the generator was manually started between 1945 and 2000 hours. Staff # 32 stated that the chillers were not active as they drew too much voltage. Staff # 32 stated that When he arrived at the facility on July 15, 2024, he was unaware that the circular pumps were off. Staff # 32 stated that he later learned that staff #33 had bypassed the circular pumps because he had turned the alarm had been turned off. Staff# 32 stated that had the alarm been on he would have known there was an issue with the circular pumps. Staff #32 stated that at 0700 hours on July 15, 2024, they had to go through the facility and reset all of the AC units. Monday, July 15, 2024, at approximately 1010 hours an interview was conducted with staff # 69, RN unit nurse. Staff # 69 stated that the electricity went out between 1820 and 1830 hours on July 14, 2024. The residents that were on oxygen concentrators had to be switched to O2 tanks due to the electricity being out. Staff #69 stated that the alarm did not go off last night regarding the generator. Staff # 69 further stated that with the electricity being out he knew that the doors needed to be watched to prevent any elopement. Staff # 69 stated that if the resident rooms are hot they should begin moving residents immediately however, if the electricity is out the elevators would not work so they would not be able to move the residents. Staff # 69 stated that he was assuming the generator would kick in right away, but that it did not, and this is why they called maintenance. Monday, July 15, 2024, at approximately 1048 hours, Staff # 33 was interviewed. Stated that the power had gone out the previous night, July 14, 2024. Staff # 33 stated that he received a telephone call from Staff # 32, Maintenance Director sometime around 1810-1815 hours on July 14, 2024, and asked him to respond to the facility. Staff # 33 stated that he arrived at the facility around 1847 hours and saw that the facility was all dark. Staff # 33 stated that the generator had not kicked on right away and estimated that the generator got going between 1906 and 1910 hours. Staff # 33 further stated that when the power goes off, the gas shuts off for safety reasons and this turns the pumps off to include the chiller system. Staff # 33 stated that he and staff # 32 were in the boiler room around 0500 hours on July 15, 2024, and realized the air conditioning was not cooling. Staff #33 stated that he noticed the heat when he came in at 0500 hours on July 15, 2024, and noticed the kitchen was hot and rechecked the rooms. Stated that he noticed the rooms were hot but did not re-temp them at that time. Stated that he thought the residents should be moved to a place that was more comfortable. The west elevator was working last night when the lights came back. The north elevator was not working. Stated that no discussion of moving residents last night. Stated that residents could have been moved last night. Stated that some units were still functional, but because of auxiliary pump the residual water was allowing for a few units to work. Stated that he did not know at what temp residents should be moved. Stated that extension cords were running into the rooms. All red plugs are in the hallway. There are no red plugs in the rooms. Staff # 33 stated that there is no standard practice to handle a power outage. Stated that in all the time that he has been there, there have been no mock disaster drills. Stated that he had brought concerns up to staff #32 regarding what they would do, especially with the heavier residents. The findings were confirmed by staff #32 and #110 during the exit conference conducted on July 18, 2024. The first day the facility was on a temporary generator was March 2, 2020 per the rental contract the facility provided. The life safety code portion of this survey started July 17, 2024. 1598 days is the distance between the two dates. Which is 4 years, 4 months and 15 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and the facility's documentation and policies, the facility failed to ensure a safe and comfortable environment for residents: Findings include: Regarding safe environment: During the initial walk-through observation of the facility conducted on July 14, 2024 at 10:11 a.m., the following was observed: - Doorway frame missing in room [ROOM NUMBER], light brown paint is peeling, exposing the green pain underneath. It felt rough to the touch. - Corner handrail by room [ROOM NUMBER] was rough with gouges and the edges felt sharp enough to scratch/tear skin during an unintended contact. - Numerous doorframes on the second-floor hallway had paint peeling and has gouges that were sharp to the touch. - Numerous handrails on the second floor was rough with gouges that are rough/sharp to the touch. - Second floor nurse's station corner had a nail sticking out on the bottom corner. That same bottom corner had gouges that were rough to the touch. - Corner handrail on the second floor by the stairway had 4 screws sticking out. Additionally, the handrail had gouges and was sharp/rough to the touch In a follow-up wall-through conducted on July 17, 2024 at 8:53 a.m., the following was observed: - Numerous handrails on the second floor was rough with gouges that are rough/sharp to the touch. - Numerous doorframes on the second-floor hallway had paint peeling and has gouges that were sharp to the touch. This included shower doorframe. - Corner handrail by room [ROOM NUMBER] was rough with gouges and the edges felt sharp enough to scratch/tear skin during an unintended contact. - Corner rail by soiled utility on the second floor had a metal brace that was slightly sticking out. - Second floor nurse's station corner still had a nail sticking out on the bottom corner. That same bottom corner had gouges that were rough to the touch. - Below the handrail next to linen room on the second floor by room [ROOM NUMBER] had a metal brace on the wall corner that is slightly sticking out. That same corner has pieces of the wall corner with severe gouges that is rough/sharp to the touch. - Corner entry to wall to room [ROOM NUMBER] had a metal brace that was coming off the wall and the wall corner had severe gouges that was rough/sharp to the touch. - Inside entry wall right hand side in room [ROOM NUMBER] has long deep gouges on the lower wall above the baseboard. - Corner handrail on the second floor by the stairway no longer had the 4 screws sticking out. However, the handrail had gouges and was sharp/rough to the touch. An interview with a Registered Nurse (RN/staff #50) was conducted on July 17, 2024 at 8:29 a.m. Staff #50 stated the process for submitting work orders is that they can either use the book, the app, or call the emergency number for maintenance for whoever is on call. When asked about the overall status of the hallways/residents' living area, the RN noted that the place could use a lot of TLC (tender loving care). Staff #50 noted that to their knowledge maintenance had never asked staff or residents' input regarding what needs to be done. The RN indicated that like the staff, the residents have just come to accept the overall appearance/status of the facility. However, it would be nice to make the area more presentable, a little bit more modern. An interview with the Maintenance Director (staff #32) was conducted on July 17, 2024 at 9:34 a.m. Staff #32 noted that works orders are submitted by residents by informing the nurses and/or staff who in turn submit work orders via TELS system. The Maintenance Director noted that the turn around time for work orders depends on the required work. Usually the priority are those work orders related to call lights, O2 (oxygen) tanks or anything related to resident safety. For work orders tagged as priority, maintenance resolves them no more than 24-hours. Other work orders such as painting, normally takes 2-3 days to close out. Staff #32 stated that there are no current plans for updates to halls or rooms per corporate. The Maintenance Director indicated that they conduct walk-throughs on Mondays and take care of the issues. A walk-through with the Maintenance Director (staff #32) was conducted on July 17, 2024 at approximately 9:56 a.m. to look at the identified observations above. Below are staff #32's comments: - room [ROOM NUMBER]'s long deep gouges on the lower wall above the baseboard-noted that it is not very homelike - handrail by room [ROOM NUMBER] with a metal brace on the wall corner - indicated that it was not noticed before but is a concern since it is metal - shower doorframe on second floor - noted that it is a concern since there are metal components - room [ROOM NUMBER] - indicated that it is a concern since the metal brace came off as we were inspecting it - nail sticking out at nurse's station was no longer there, a photo from the entrance day and earlier in the morning sticking out was shown to staff #32 - he noted that it is a concern since someone could get hurt with it. A follow-up interview was conducted with the Maintenance Director (staff #32) on July 17, 2024 at approximately 10:15 a.m. Staff #32 stated that in their opinion, the facility is livable, but some of the identified harm during our walk-through puts it at 75% homelike. Whether they gets all the things fixed, it is a routine and it will get messed up again. The Maintenance Director said that it is hard to maintain but it is livable and that if residents were asked, the residents would say it is okay. Staff #32 said that during their walk-through, they identify what can damage residents and staff, prioritize it and fix it. However, if nobody says anything, and they are not aware, they it cannot be fixed. The Maintenance Director said that it is important for the facility to be safe and comfortable so residents and their families are happy and to make it better for the residents. An interview with the Administrator (staff #110) was conducted on July 17, 2024 at 1:09 p.m. Staff #110 stated that the expectation is that the living area for resident are clean, free of obstruction and without significant odors. The facility is to be clean and safe from hazards. Staff #110 stated that repairs should be maintained to have a homelike environment such as paint and upkeep. The Administrator stated that this is important since this is the home for people living here and they deserve a good quality of life. It has to be safe so that residents are not put at risk for accidents or injuries. Staff #110 stated that the impact if the facility is not homelike and safe is that residents might feel discomfort, might reduce the homelike environment feel until things were repaired, it could provide a risk for some type of injury i.e. if legs extend beyond the wheelchair there could be a risk of injury. Review of the open work order report generated on July 15, 2024 did not reveal any work order pertaining to any of the issues identified during the walk-through observations. Review of the facility policy titled Preventive Maintenance Program revised January 11, 2023 and reviewed January 22, 2024 indicated that the facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. The facility policy titled Work Request System revised May 14, 2019 and reviewed January 15, 2024 indicated that the work order request system was designed to provide an established and effective means of requesting, coordinating, and completing maintenance of a corrective nature. A facility policy titled Resident Rights issued June 8, 2020 and reviewed September 25, 2023 indicated that resident has a right to safe, clean, comfortable, and homelike environment.

Based on employee record review, staff interviews, and the facility policy and procedures, the facility failed to implement and maintain an effective training program for annual training: abuse, resident rights, infection control, dementia training, and emergency preparedness for multiple staff (#50, #26, #43, #54, #38, #59, #32 and #110). The deficient practice could impact the safety, rights, and care provided to residents. Findings include: Review of the employee records for a registered nurse (RN/staff #50) revealed that abuse training was completed on June 15, 2022, completed resident rights on February 27, 2023, infection control training on June 15, 2022, and there was no documentation for emergency preparedness. -Review of the employee records for (RN/staff #26) revealed that abuse training was completed on October 6, 2022, resident rights completed on March 31, 2023, infection control completed on January 27, 2023, and emergency preparedness was competed on January 27, 2023. -Review of the employee record for Licensed practical nurse (LPN/staff #43) revealed that abuse training was completed March 9, 2022, resident rights completed on May 25, 2022, infection control completed May 31, 2022, and there was no documentation for emergency preparedness. -Review of the employee record for (LPN/staff #54) revealed that abuse training was completed on January 2, 2023, resident rights was completed on January 2, 2023, infection control was completed on February 20, 2023, dementia care January 3, 2023, and there was no documentation for emergency preparedness. -Review of the employee record for a Certified nursing assistant (CNA/staff #38) revealed that abuse training completed on October 18, 2022, resident rights October 18, 2022, infection control June 20, 2022, dementia training completed on October 18, 2022, and emergency preparedness was not attempted. -Review of the employee records for The Director of nursing (DON/staff #59) revealed that abuse training was completed on June 29, 2022, resident rights training was not attempted, infection control was not completed, emergency preparedness was not attempted. -Review of the employee records for the Maintenance Director (staff #32) revealed that abuse training, resident rights, infection prevention, and dementia care were not attempted. -Review of the employee records for Administrator (staff #110) revealed no documentation for abuse training, resident rights was not attempted, infection control was not attempted, and emergency preparedness not attempted. An interview was conducted on July 16, 2024 at 1:56 p.m. with the human resources accounting clerk (staff #73), who stated the corporate office usually sends an email when training needs to be done. She stated that all staff, including the Administrator, are required to complete emergency preparedness, resident rights, abuse, infection control, and dementia training annually and the training are due based on the the staff's date of hire. An interview was conducted on July 16, 2024 at 3:33 p.m. with (staff #110), who stated that all the staff are required to complete the training annually, but not all the staff had completed emergency preparedness. She stated that they have printed up most of the current training for the ten employees. An interview was conducted on July 17, 2024 at 11:19 a.m. with (DON/staff #59), who stated that she has a policy on required annual training for staff: infection control, abuse, resident rights, dementia, emergency preparedness. She stated that the training due date is based on the date of hire and everyone, including the Administrator, are supposed to complete the training. The facility policy, Yearly Required Training: states that a facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. Each associate will be provided the following core educational content annually through the learning management software that will be part of a curriculum titled Annual General Requirements Curriculum. Each associate will need to complete the courses individually by the due date provided in the course assignment page. Core education includes: infection prevention and control, emergency preparedness, resident rights, abuse, but did not include dementia care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure a residents' care was not neglected. Neglected care could result in increased morbidity for residents. Findings include: Resident #48 was admitted on [DATE] with diagnoses of depression, anxiety disorder, generalized muscle weakness and difficulty in walking. A 5 day Minimum Data Set (MDS) dated [DATE] included that this resident was cognitively intact and needed partial/moderate assistance with toileting hygiene. A care plan dated 5/16/23 included that this resident requires Activities of Daily Living (ADL) assistance and therapy services needed to maintain or attain highest level of function. Interventions include to assist with mobility and ADL's as needed. However, a complaint/Incident Investigation Report dated 2/1/24 included that a resident is stating that on Saturday, January 20, at approximately 9:00 PM, a Certified Nursing Assistant (CNA) came into the room to provider patient care, but was refusing to change her brief. The resident stated that the Aide was trying to force her to stand up and when patient expressed that she couldn't do it, the CNA threw the brief at the patient and told her to change it herself. A 5 day facility investigation included an interview with a Licensed Practical Nurse (LPN/#105) dated 1/26/24 at 7:07 AM, which included, Upon entering residents room, to administer evening medications, the resident was upset and kept asking me why does that CNA hate me. She was very loud and just kept repeating that she could not stand and that they don't believe me when I tell them I can not stand for long and they insist that I stand for them to change my brief. She just kept repeating that and that she had been in the hospital and was bleeding inside and that is why she is weak. I explained to her that no one hates her and that I would talk to them. She was still upset so I informed her that the CNA would be told not to come back in her room and that I would change her brief and assist her with whatever she needed. This 5 day facility investigation also included an interview that was conducted on 1/22/24 with the Director of Nursing (DON/staff #16) .(resident #48) stated that she had the call light on to ask to have her diaper changed because she was wet. (resident #48) stated that when the CNA did come in to provide care, the CNA kept demanding her to stand saying, You're able to stand. I've seen you stand before. Resident #48 said that she kept trying to tell the CNA that her legs were bothering her and she couldn't stand. She further stated that the CNA then threw a diaper at her and said to change herself before walking out of the room. After speaking with resident #48, I met with the roommate. The roommate states that she watched the CNA throw the brief at the patient. This writer asked if the CNA could have been trying to toss the brief onto the bed to gather their supplies in one area, and the roommate denied this as a possibility An interview was conducted on February 7, 2023 at 1:23 P.M. with resident #27 who said that about a month ago, her roommate (resident #11) was complaining about the aid not changing her. She said that the aid just handed a brief to her and said you can change herself. An interview was conducted on February 7, 2023 at 1:55 P.M. with a Certified Nursing Assistant (CNA/staff #55) who said that when checking if a resident needs a brief change, she would ask them if they need help and to check them every 2 hours to see if they need assistance with transferring or hygiene. She said that it is abuse if a resident asks for assistance with brief care and staff refuse. An interview was conducted on February 7, 2023 at 2:00 P.M. with a Registered Nurse (RN/staff #32) who said that if a resident asks for help, staff have to help them. This nurse said that refusing to help a resident is 100% abuse. An interview was conducted on February 7, 2023 at 2:09 P.M. with the Executive Director (staff #6) who said that our staff should be responding to residents' requests for help, and checking on them if they have a need for assistance. She said that staff should respond with promptness and assist residents according to their ability, need and care plan. She said that it is not her expectation that the staff would refuse to assist the resident as it would be neglect of care. A policy titled Abuse - Identification of Types dated 7/18/23 revealed that abuse includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This policy included that in these cases, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident's representative (#4) was able to exercise her rights regarding decisions about the resident's care. This deficient practice could result in resident's or their representatives not being able to make their own healthcare decisions. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, Diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment. Review of the facility's investigation report revealed that on December 24, at approximately 12:00 p.m. the Resident's daughter approached the nursing station expressing that there was a large bruiser to her mother's face that was not present during her visit the day prior. Review of progress notes revealed a nurse's note that detailed the daughter of the resident visiting on Sunday December 24, 2023 and had requested the nurse send the resident to the hospital related to the hematoma that was discovered. However, review of progress notes further revealed that on December 25, 2023 the daughter was again present at the facility and upset with the facility staff because the resident was still in the facility. A progress note dated December 25, 2023 at 1:18 p.m. detailed the staff called 911 and had the resident sent with emergency services to the hospital. The note further reveals the daughter followed the resident to the hospital. An interview was conducted with a Licensed Practical Nurse (LPN/staff #91) on January 3, 2024 at 4:00 p.m. The LPN stated that the daughter of the resident had requested her mother be sent to the hospital but for some reason the nurse didn't do it. The LPN further stated that she was the one who sent the resident to the hospital, and it was on December 25, 2023 after noon. An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 p.m. The DON stated that there was a delay in communication among the staff and a delay in action with regards to this injury when it was discovered. The DON also stated that she can't speak to why they didn't send her out, and further stated that we have done in-services on whether the residents have rights to be sent out and how our opinions don't matter. The DON concluded that her expectation is that the staff would follow facility policy. A review of facility policy titled 'Area of Focus, Resident rights' Reviewed November 27, 2023 revealed that the facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#4) was free from neglect by staff. The deficient practice could result in further incidents of neglect of the residents. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, diabetes, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. An anticoagulant care plan created on December 14, 2023 revealed that the resident was on anticoagulant therapy. The goal was to not experience uncontrolled bleeding through the next review period, with noted interventions that staff will observe and report adverse reactions of anticoagulant therapy such as lethargy, sudden changes in mental status, blurred vision, significant or sudden changes in vital signs, and bruising. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment. A review of progress notes revealed that during direct care two staff members had identified a medium sized hematoma on the right side of the resident's forehead, and that no report was given to the writer from day shift of any incidents that had occurred that day. An interview was conducted with a Licensed Practical Nurse (LPN/staff #91) on January 3, 2024 at 4:00 PM. The LPN stated that at the beginning of the shift on the morning of December 25, 2023, it was reported that the resident had a hematoma on the right side of her face. The LPN also stated that nobody did neuros because nobody knew when it happened. An interview with a Certified Nursing Assistant (CNA/staff #13) was conducted on January 4, 2024 at 9:15 AM. The CNA stated that the resident was normally very pleasant but confused, and not aggressive. The CNA stated that during rounds at the end of the shift, approximately 6:00 p.m. on Saturday December 23, 2023 no bruising was seen on resident #4. An interview was conducted with a Registered Nurse (RN/staff #82) on January 4, 2024 at 9:55 AM. The RN stated that when she got the report of the hematoma, she notified the doctor and started a neurological assessment. The RN also stated that the resident was on three separate blood thinners. However, a review of the clinical record revealed no change of condition assessment and no neurological assessment. An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 PM. The DON stated that there was a delay in communication among the staff and a delay in action with regards to this injury when it was discovered. The DON further stated that no neurological assessment was done for this incident. The DON also stated that her expectation of her staff is to follow the facility policies and that there should have been no delay in treatment. A review of facility policy titled 'Preventing, Reporting, and Investigating Abuse' revised July 2022 revealed that Neglect is a failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an injury of unknown origin was reported to the Administrator, and state agency within 24 hours. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, Diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment. Review of the facility's investigation report revealed that on December 24, at approximately 12:00 PM, the Resident's daughter approached the nursing station expressing that there was a large bruiser to her mother's face that was not present during her visit the day prior. Review of State agency documentation revealed the report for this incident was received by the agency on December 27, 2023 at 10:30 AM. An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 PM. The DON stated that there was a delay in communication among the staff and a delay in action with regards to this injury when it was discovered. The DON further stated that the facility had 24 hours to report an injury of unknown origin. A review of facility policy titled 'Abuse - Protection of residents' reviewed July 18, 2023 revealed that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, or not later than 24 hours of the events that caused the allegation do not involve abuse to the Administrator and to other officials including the State survey agency in accordance with State law through established procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#4) was assessed according to professional standards. The deficient practice could result in a delay of clinically necessary treatment. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, diabetes, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. An anticoagulant care plan created on December 14, 2023 revealed that the resident was on anticoagulant therapy. The goal was to not experience uncontrolled bleeding through the next review period, with noted interventions that staff will observe and report adverse reactions of anticoagulant therapy such as lethargy, sudden changes in mental status, blurred vision, significant or sudden changes in vital signs, and bruising. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment. A review of progress notes revealed that during direct care two staff members had identified a medium sized hematoma on the right side of the resident's forehead, and that no report was given to the writer from day shift of any incidents that had occurred that day. An interview was conducted with a Licensed Practical Nurse (LPN/staff #91) on January 3, 2024 at 4:00 PM. The LPN stated that at the beginning of the shift on the morning of December 25, 2023, it was reported that the resident had a hematoma on the right side of her face. The LPN also stated that nobody did neuros because nobody knew when it happened. An interview with a Certified Nursing Assistant (CNA/staff #13) was conducted on January 4, 2024 at 9:15 AM. The CNA stated that the resident was normally very pleasant but confused, and not aggressive. The CNA stated that during rounds at the end of the shift, approximately 6:00 p.m. on Saturday December 23, 2023 no bruising was seen on resident #4. An interview was conducted with a Registered Nurse (RN/staff #82) on January 4, 2024 at 9:55 AM. The RN stated that when she got the report of the hematoma, she notified the doctor and started a neurological assessment. However, a review of the clinical record revealed no change of condition assessment and no neurological assessment. An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 PM. The DON stated that no neurological assessment was done for this incident. The DON also stated that her expectation of her staff is to follow the facility policies and that there should have been no delay in treatment. Review of facility policy titled 'Abuse, Neglect, and Exploitation' reviewed July 18, 2023 revealed Neglect of goods or services may occur when staff are aware, or should be aware of resident's care needs, based on assessment and care planning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#10) was free from physical abuse by staff. The deficient practice could result in further incidents of staff to resident abuse. Findings include: -Resident #10 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's disease, weakness, aphasia, Bipolar disorder, depression, and anxiety. A behavioral care plan revised February 6, 2023 revealed the resident was at risk for mobility performance deficit related to Alzheimer's dementia. The goal was to maintain a current level of functional mobility through the next review period, and a noted intervention that staff are to assist her turn and reposition in bed as necessary. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had significant cognitive impairment. A review of the facilities reported incident reports detailed an altercation between a Certified Nursing Assistant (CNA/staff #50), and resident #10 as witnessed by another CNA (CNA/staff #16), stating that when CNA #16 entered the room she witnessed CNA #50 push the patient into the wall, and was yelling at her. When asked what she was doing, CNA #50 stated you weren't here and didn't hear what she called me. She called me an asshole. However, a review of the clinical record revealed a progress note detailing the incident dated December 4, 2023 revealed no mention of the previously reported incident, and only noted that the resident stated she didn't remember the incident. An interview was conducted with a resident (#77) on December 6, 2023 3:20 p.m. The resident stated that CNA #50 has always had an attitude, and can be very rude. An interview with a CNA (CNA/staff #1) was conducted on December 6, 2023 at 4:25 p.m. The CNA stated that CNA #50 was having a lot of problems working the floor, needed a lot of help, and stated she feels CNA #50 was overwhelmed. An interview with a CNA (CNA/staff #16) was conducted on December 6, 2023 at 4:37 p.m. The CNA stated that the witnessed statement provided above was accurate. She stated that when she went to answer the call light, she entered the room to see CNA #50 behind the patient with her hands on her back and was pushing her into the window, and then CNA #50 stated it was because the resident had called her a name. CNA #16 then stated she reported the incident to the nurse and then to the Director of Nursing. An interview with the Director of Nursing (DON/staff #80) was conducted on December, 2023 at 5:05 p.m. The DON stated that CNA #16 had reported the incident appropriately, and that CNA #50 was suspended immediately. The DON also confirmed she is the abuse coordinator and that it was reported timely per state guidelines. She stated her expectation is that her residents are not abused and that any suspicion of abuse is reported timely. A review of facility policy titled 'Abuse: Protection of residents' reviewed July 18, 2023 revealed that the facility will ensure that all residents are protected from physical and psychosocial harm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of facility policy and the Lippincott procedure, the facility failed to ensure assistance with eating was provided for 2 out of 3 sampled residents (#12 and #14). The deficient practice could result in residents having inadequate nutritional status and weight loss. Findings include: -Resident #12 admitted on [DATE] with diagnoses of nontraumatic intracranial hemorrhage, dysphagia following cerebral infarction and acute respiratory failure with hypoxia. The admission/readmission collection tool dated March 7, 2023 revealed the resident had no chewing or swallowing issued evident at this time. A physician orders dated March 7, 2023 included for the following: -Regular diet, puree texture, thin consistency diet, condiments with 1:1 supervision for small bites and sips; -Enteral feeding at 80 ml (milliliters)/hour x 24 hours via pump and to flush with [no specified amount] mL water every [no specified time] hours; and, -Speech Therapy evaluation and treatment as indicated, one time only for 7 days. The Cognitive/BIMS (brief interview for mental status) note dated March 8, 2023 revealed the resident was aphasic and cannot answer all questions The Weight Summary revealed that on March 8, 2023 the resident had a weight of 193.0 lbs. (pounds). An ADL (activities of daily living) care plan dated March 8, 2023 revealed the resident had performance deficit related to limited mobility, shortness of breath and recent CVA (cerebrovascular accident). The goal was that the resident to improve her current level of function in ADLs. Interventions included the resident was totally dependent on staff for eating and required assistance by staff to eat. A care plan dated March 8, 2023 revealed the resident at was risk for weight fluctuation related to intracerebral hemorrhage, CVA and dysphagia. Goal was to maintain the resident's current weight. Interventions included assistance with meals as needed. A physician order dated March 8, 2023 revealed an order to hold enteral feeding beginning 03/10/23. The skin/wound note dated March 8, 2023 included the resident had right-sided weakness, difficulty verbalizing needs, was working with speech therapy and was on puree diet with enteral feeding orders on hold. The skilled note dated March 9, 2023 revealed the resident was alert and oriented but was unable to make needs known. An encounter note dated March 12, 2023 revealed the resident was alert and oriented x 2. The Weight Summary included that on March 13, 2023 the resident's weight was 199.3 lbs. The physician order dated March 14, 2023 included an enteral feed order for formula at 60 mL/hr. for 12 hours via pump and to flush with 45 ml water every 1-hour times 20 hours per day. The Nutrition/Dietary progress note dated March 14, 2023 revealed the resident had a 6-pound weight gain that week; and that, speech therapy felt the resident would consume more if tube feeding were off more. Per the documentation, the resident was encouraged to increase her intake by mouth. The admission MDS (Minimum Data Set) assessment dated [DATE] revealed that the resident was rarely/never understood, had modified independence with some difficulty in new situations only for cognitive skills for daily decision making; and, required extensive assistance for most ADLs including eating. A nutrition/dietary note dated March 21, 2023 included the resident had 5 lbs. weight loss this week following a 6 lbs. weight gain the week prior. Further, the documentation included the resident was tolerating tube feeding at night and may consider tube feeding back to 20 hours per day. The weight recorded for March 27, 2023 was 197.2 lbs. Review of the March 8 through 31, 2023 MAR (Medication Administration Record) revealed enteral feeding was provided as ordered. Despite documentation that the resident required assistance with eating, the CNA (certified nursing assistant) documentation from March 8 through April 10, 2023 revealed multiple dates with no documentation to indicate whether or not the resident received assistance with eating. It also revealed multiple dates that identified the resident was independent and/or required setup help only with eating. There was no evidence found in the clinical record of a reason why the resident was not provided with assistance with eating on dates not marked in the CNA documentation. -Resident #14 admitted on [DATE] with diagnoses of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease and unspecified protein-calorie malnutrition. The weight record dated March 4, 2023 was 103.6 lbs. An ADL care plan dated March 5, 2023 revealed the resident had self-care performance deficit related to disease process, limited range of motion and pain. The goal was that the resident will maintain her current level of function. Interventions included total dependence on 1 staff for eating. The alert note dated March 5, 2023 included that the resident no longer tolerated tube feeding; and that, G-tube (gastrostomy tube) feeding was stopped per family's request. The skin/wound note dated March 6, 2023 revealed the resident was suffering from malnutrition and PEG (percutaneous endoscopic gastrostomy) was placed on February 13. Per the documentation the resident was more alert so the NP (nurse practitioner) ordered oral diet and to hold tube feeding. A Health Status Note dated March 6, 2023 included the resident had been seen by the NP and an order to discontinue tube feeding was received. Per the documentation, the resident had mechanical soft diet with thin liquid; and that, the resident was doing pretty well eating by mouth. A health status note dated March 8, 2023 revealed the resident was eating better and was more alert than before. The skilled note dated March 10, 2023 revealed the resident was alert, able to make needs known and required one-person assistance with ADL cares, mobility and transfers. The admission MDS assessment dated [DATE] revealed the resident had severe cognitive impairment; required extensive assistance for ADLs, including eating; and, received nutritional approaches such as feeding tube and a mechanically altered diet while she was a resident at the facility. The health status note dated March 13, 2023 included the resident will no longer be under hospice; and that, the resident would be under skilled nursing. A physician order dated March 14, 2023 included for regular diet puree texture, thin consistency. The nutrition/dietary note dated March 20, 2023 revealed the resident was on regular puree diet and was on daily nutritional shake. The skilled note dated March 21, 2023 revealed the resident was alert with increased confusion and required one-person assistance with cares and transfers. The weight record dated March 22, 2023 was 98.4 lbs. which was 5.01% weight loss since admission. The nutrition/dietary note dated March 22, 2023 included that NP was informed of the resident's weight loss; and that, resident's family declined hospice. The skilled note dated March 26, 2023 included that resident was alert with good appetite. According to the documentation, resident pulled out her PEG tube. The nutrition/dietary note dated March 28, 2023 revealed the resident had a 2 lbs. weight loss this week, PEG tube was pilled out and was on daily nutritional shakes. It also included that increased oral intake was encouraged. The CNA documentation for March 2023 revealed multiple dates with no documentation to indicate whether or not the resident received assistance with eating; there were multiple dates that documented the resident as independent and/or required setup help only with eating. There was no evidence found in the clinical record of a reason why the resident was not provided with assistance with eating on dates not marked in the CNA documentation. The weight record on April 3, 2023 was 94.8 lbs. which was 8.49% weight loss since admission in March 4, 2023. The health status note dated April 6, 2023 revealed that weight loss was noted and that the resident had variable oral intake. An interview was conducted on April 20, 2023 at 12:03 p.m. with a CNA (staff #99) who stated that she would look at the [NAME] (resident information sheet) which would tell her whether or not a resident requires assistance with eating. The CNA stated that nurses may also tell the CNAs; and that, every resident care plan is documented in the electronic record so the CNAs have access to them. She stated that in the area where she works 3 out of the 12 residents require assistance with feeding; and, if once resident needed assistance with eating, staff would always assist residents with eating. The CNA if a resident did not want to eat she would document the resident refused the meal. Further, the CNA said that the expectation was that the CNAs would document accurately after every shift whether or not resident ate or refused. She stated that residents who need assistance to eat but do not receive it would be at risk for weight loss, skin breakdown and an overall decline. An interview was conducted on April 20, 2023 at 1:02 p.m. with a licensed practical nurse (LPN/staff #62) who stated that she ensures residents receive assistance with meals by making sure the CNAs know who needs help. The LPN said that if she notices a resident was left unattended, she would find out who their CNA was and ask why. She stated that if the CNA was busy, she would assist the resident herself. Further, she stated that she ensures that the CNA documentation is done; however, she does not really review it. The LPN stated if a resident had not been eating she would review the CNA documentation. She stated that the cues that would suggest the resident had not received assistance would include an untouched tray, weight loss, a change in vital signs and/or skin condition. In an interview with the Assistant Director of Nursing (ADON/staff #128) conducted on April 20, 2023 at 1:56 p.m., the ADON stated that speech therapy would assess residents and if they needed assistance with eating it would be care-planned. She stated that there was also an option for restorative services; however, if a resident just needed assistance with eating they would not go to restorative dining. She stated that if a resident was receiving long-term care services they would have a CNA assigned to them for feeding. She stated the CNA would document the amount of assistance required, the amount of assistance provided and the amount of food eaten per meal. The ADON said that if the resident refused their meal, the CNA would be expected to document that the resident refused; and that, her expectation was that CNAs would document accurately after every shift. She stated that a resident who required assistance with eating, but did not receive it, would be at risk for a decline in weight and possible dehydration. She stated that it would not meet her expectations for residents not to receive needed assistance. The Lippincott procedures - Feeding, Long-Term Care reference, reviewed August 22, 2022 included that various disabilities and conditions may prevent a resident from self-feeding, including cognitive deficits, neuromuscular disease, cancer, obstructive lung disease and traumatic injury. A resident who cannot self-feed is susceptible to malnutrition. The resident may also experience pain, nausea, depression, and anorexia as a result of the condition or its treatment. The facility policy on Activities of Daily Living (ADLs) policy included that the resident will receive assistance as needed to complete activities of daily living. Any change in the ability to perform ADLs will be documented and reported to the licensed nurse. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices.

Based on observations, staff interviews, and policy review, the facility failed to maintain an environment for residents that was free of pervasive odors. The deficient practice could result in residents not having a homelike environment. Findings include: During a facility observation conducted on March 13, 2023 at 09:11 AM, a strong urine odor was noted in the vicinity of resident #38's room. It was noted again at 12:10 PM, and 3:27 PM the same day. On March 14, 2023 the same strong urine odor was noted outside resident #38's room at 9:23 AM, 12:04 PM, and 2:38 PM the same day. An interview was conducted on March 13, 2023 with the Resident #38 at 12:15 PM. The resident stated that the room always smells of urine and that it comes from her bathroom which is regularly cleaned but the smell remains. She stated that the smell is of urine and stated that it always smells that way. An interview was conducted on March 15, 2023 at 11:53 AM with a Certified Nursing Assistant (CNA/staff #67), who stated that she has noticed a urine odor this morning but that typically it doesn't smell. She then stated that her nose was clogged and didn't really notice the smell but would get housekeeping. She stated that housekeeping is who they would contact for odors. An interview was conducted on March 15 at 2:00 PM with the Administrator (staff #125) who stated that he was not aware of the odor in the hallway or the resident's bathroom. He stated he would have housekeeping check the room again and that they try to keep the building free of odors. Review of the facility policy titled, Resident Belongings and Home Like Environment' issued January 26, 2023 defines a homelike environment should include the resident's opinion of the living environment. It further states that It is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record review, resident interview, staff interviews, observation, and review of facility policy and procedure, the facility failed to ensure nail care was provided for one resident (#18). The deficient practice could result in residents not receiving necessary care and services to maintain good grooming and personal hygiene Findings include: Resident #18 was admitted on [DATE] with diagnosis that included cerebrovascular disease, type 2 diabetes, long term use of insulin, polyneuropathy, neuralgia, neuritis and other symptoms and signs involving the circulatory system. The MDS (minimum data set) dated December 29, 2022 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact. The MDS further did not reveal psychosis or behaviors. Review of the care plan goal dated February 11, 2023 included that resident #18 has an ADL (activities of daily living) self-care deficit due to left-sided hemiparesis. The noted intervention included that staff will continue to assist and encourage the resident in participation. It further noted that the resident requires assistance with personal hygiene. A review of the progress notes from February 12, 2023 through March 10, 2023 did not reveal any notation of nail care need or treatment. A review of the skin care alert forms dated February 20, 2023 through March 9, 2023 revealed no documentation of skin or nail concerns. An observation on March 9, 2023 at 9:33 a.m. revealed the thumb nail, of resident #18, to be yellowing and long (1/2 inch) above the nail bed. The other nails on both hands were jagged, appearing rough, uneven and splitting. During an interview with resident #18 on March 9, 2023 at 9:33 a.m. the resident stated that he had asked to have his nails trimmed and staff stated that they don't have time. During a wound care observation on March 10, 2023 at 10:34 a.m. with a Registered Nurse (RN/staff #126) and the Nurse Practitioner (NP/staff #127), the resident stated that his fingernails still needed to be cut. The NP stated that he would bring it up to the Certified Nursing Assistants (CNA). However, an observation of resident #18 on March 13, 2023 at 10:11 a.m. revealed that the fingernails had still not been trimmed. An interview was conducted on March 13, 2023 at 10:21 a.m. with staff #71, a CNA. Staff # 71 stated that the need for nail care is observed at all times, but more specifically during shower time. She stated that if a resident is not diabetic then a CNA can conduct the nail care. If a patient is diabetic then then the CNA would alert the nurse, who would then see the patient and document it. However, there is no documentation of nail care need or treatment evident in the medical record for resident #18. An interview was conducted with staff #80, an RN, on March 13, 2023 at 11:48 a.m. Staff # 80 stated that generally CNA's identify nail care concerns and either conduct the nail care if the resident is not diabetic or alert the nurse if the resident is diabetic. If it is a more complex case, the RN stated that the DON would be alerted. The RN stated that turn around for nail care is less than a week. The RN stated that if a resident refuses nail care, it would be documented in the progress notes. An interview conducted on March 13, 2023 with the director of nursing (DON/staff #4). The DON stated that the expectations are that nails are clipped and well-maintained. She stated that refusals for nail care are documented, documentation for the need of nail care should be found in progress notes or the skin care alert forms. She stated the risk of not conducting nail care include the potential for the nails to tear or infection. The nail care policy dated August 25, 2021 and reviewed August 22, 2022, included the following: Any concerns with skin or nails identified during the completion of nail care should be reported to the nurse who will document and report to the practitioner as needed. Additionally, the policy revealed that fingernails are to be clean and trimmed to avoid injury and infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and review of policy, the facility failed to ensure one resident (#60) received care and services in accordance with physician's orders, professional standards of practice and his person-centered care plan. The sample size was 23. The deficient practice could increase the risk for complications and/or rehospitalization. Findings include: Resident #60 readmitted to the facility on [DATE] with diagnoses including urinary tract infection, acute respiratory failure with hypoxia and heart failure. A physician's order dated 02/24/23 included monitoring for edema every shift for congestive heart failure (CHF). A physician's order dated 02/25/23 revealed for furosemide (diuretic) 20 milligrams (mg); give one tablet a day for fluid retention for 14 days. The Admission/readmission Collection Tool dated 02/26/23 included the resident's most recent weight at 298.2 pounds (lbs). A physician's order dated 02/26/23 included weight every night shift for CHF before breakfast. Report 3 lb weight gain in a day or 5 lb weight gain in a week to MD. Review of the Weight Summary dated 02/28/23 revealed the resident weighed 302.4 lbs. Review of the February 2023 MAR revealed furosemide was administered per orders. A congestive heart failure care plan initiated 03/02/23 related to weight fluctuations associated with diuretic medications had a goal to have no complications related to peripheral edema. Interventions included to observe and report any signs or symptoms of CHF, including dependent edema of the legs and feet, shortness of breath upon exertion and weight gain. The March 2023 Medication Administration Record (MAR) revealed that on 03/03 the resident had 1+ edema on day shift and 4+ edema on the night shift. On 03/04 the resident had 4+ edema on both the day and the night shifts. However, review of the clinical record did not indicate that the provider had been notified. Review of the March 2023 MAR, the resident received daily weights from 03/02 to 03/04. However, according to the Weight Summary, the resident's weight was not recorded again until 03/05/23. An orders administration note dated 03/05/23 at 5:33 a.m. included Cardiac/CHF Protocol - Weight every night shift for CHF, before breakfast. Report 3 lb weight gain in a day or 5 lb weight gain in a week to MD. 317.4 lbs. However, further review of the clinical record did not include documented evidence that the provider had been notified of the 14.8 lb gain within the 5 day period. Review of the Weight Summary dated 03/06/23 revealed the resident's weight was documented at 317.2 lbs. However, the clinical record gave no indication that the provider had been notified. On 03/07/23 at 11:39 a.m. a health status note indicated that the resident's right lower leg had increased edema, the weight gain was noted and new orders for furosemide 40 mg twice daily for 3 days were obtained. A skilled note dated 03/08/23 at 4:00 a.m. included that weight gain was noted with the resident's weight at 320.6 lbs that morning. The note indicated that the provider had been made aware. On 03/14/23 at 2:04 p.m. an interview was conducted with a Registered Nurse (RN/staff #39). He stated that the resident should be weighed daily per orders. He stated that it would be kind of like a medication error not to weigh the resident. He stated that the Certified Nursing Assistants weigh the residents, then they report to the nurse. He stated that the nurses should have been aware of the changes in the resident's weights and that it should have been reported to the physician. An interview was conducted on 03/14/23 at 2:19 p.m. with the Director of Nursing (DON/staff #4). She stated that her expectation was that the physician's orders would be followed. She stated that a resident with CHF could go into CHF exacerbation and have complications related to his diagnosis. The Heart Failure, Long-Term Care policy/procedure, revised January 9, 2023 included that treatment in the older adult should focus on reducing symptoms, reducing hospitalizations and preventing acute exacerbations. Monitoring includes daily and/or weekly weight and monitoring extremities for peripheral edema and other signs and symptoms of fluid overload. The Change in Status, Identifying and Communicating, Long-Term Care policy/procedure, reviewed 08/19/2022, included that in the long-term care setting, any change from baseline in a resident's status must be identified and addressed. A resident is more likely to return to baseline status and avoid complications when a condition is recognized early so that it can be treated. When a nurse recognizes a potentially life-threatening condition or significant change in a resident's status, the nurse must communicate with other health care providers to meet the resident's needs. The care plan should address the resident's risk factors, allow for rapid identification of a change in status, and define baseline assessment findings. A nursing assistant who notices [changes in a resident's condition] should immediately report them to a nurse. The nurse, in turn, must communicate a resident's change in status, including assessment findings, to the practitioner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, clinical record review, and review of facility policy, the facility failed to ensure one resident (#4) received appropriate catheter care and services in accordance with professional standards. Two residents were reviewed for urinary catheter/Urinary Tract Infection (UTI). The deficient practice could result in complications with indwelling urinary catheters, including infection. Findings include: Resident #4 admitted to the facility on [DATE] with diagnoses including displaced comminuted fracture of shaft of humerus, right arm, subsequent encounter for routine healing, acute kidney failure with tubular necrosis and a UTI. An indwelling Foley catheter care plan dated 02/21/23 related to obstructive uropathy had a goal for no complications related to indwelling catheter use. Interventions included catheter care every shift. A skilled nursing note dated 02/26/23 at 10:36 a.m. included that the resident's Foley catheter was intact and patent and draining yellow urine. The skilled nursing note dated 02/27/23 at 11:16 a.m. revealed that the resident's urine was positive for klebsiella pneumoniae greater than 1000,000. The note indicated that the results were sent to the provider. A physician's order dated 02/27/23 included cephalexin (antibiotic) 500 milligrams (mg); give one capsule every 6 hours for UTI for 5 days. The 5-day admission Minimum Data Set assessment dated [DATE] revealed the resident scored 15 on the brief interview for mental status, indicating intact cognition. She required extensive 1-2 person physical assistance for most activities of daily living and she had an indwelling urinary catheter. Review of the February 28, 2023 MAR revealed the medication was administered as ordered. The March 2023 MAR revealed the resident was provided antibiotic medication as ordered, with the exception of 03/04 at 6:00 a.m. when no documentation was provided to indicate whether or not the resident had received the medication. On 03/05/23 at 10:23 a.m. a skilled nursing note included that the resident's Foley was intact and draining yellow [urine]. A physician's order dated 03/07/23 included for a urinalysis and culture and sensitivity for elevated blood sugars. Review of the MAR indicated the order was completed by night shift on that date. On 03/09/23 at 1:24 p.m. an interview was conducted with resident #4. She stated that she thinks she has UTIs due to improper cleaning of her catheter. The resident gave permission for observation of catheter care. An observation of her urinary catheter bag revealed a small amount of very cloudy/turbid urine. An observation of the resident's catheter bag was conducted on 03/10/23 at 10:50 a.m. The urine in the resident's bag was noted to be dark orange with turbidity. On 03/10/23 at 10:51 a.m. an observation of catheter care was conducted with a Certified Nursing Assistant (CNA/staff #47). The CNA was not observed to perform hand hygiene. She donned clean gloves. The resident's brief was opened for the procedure. The CNA used wipes to clean inside the resident's upper thighs, moving to the labia and finally cleaning the insertion site of the tube. She did not use clean wipes during the process. Once at the insertion site, she held the catheter tubing with one hand and cleaned the tubing with the hand holding the wipes. She was observed to use approximately 4-6 passes up and down the tube to clean. During this process, the CNA identified a medium bowel movement in the resident's brief. She had the resident turn to her side and proceeded to clean the resident's anus and buttocks and removed the soiled brief. The CNA doffed her soiled gloves then applied clean ones without performing hand hygiene. She applied a clean brief to the resident, pulled up the bedding and gathered the trash. On 03/10/23 at approximately 11:00 a.m. an interview was conducted with CNA staff #47. She stated that another CNA had trained her on how to do catheter care. She stated that this was the way she had been taught and the way she does catheter care each time. An interview was conducted on 03/10/23 at 11:07 a.m. with a Licensed Practical Nurse (LPN/staff #62). She stated that her process for providing catheter care began with washing her hands and applying clean gloves. She stated that she was taught to use soap and water for the procedure. She stated that she would clean the upper thighs and ensure there was no stool in the resident's brief. She stated that using a clean cloth, she would separate the resident's labia and using a down and out motion she would clean the area. She stated that using a clean cloth, she would clean the insertion site and the tube using a downward motion only. She stated that if an upward motion was used, it could introduce bacteria into the resident's urethra. She stated that the resident would absolutely be at a higher risk for UTI. She stated that utilizing an inappropriate technique for catheter care could additionally place the resident at risk for pain, antibiotic use and rehospitalization. On 03/10/2023 at 1:57 p.m. a Lab report included the results of the culture and sensitivity. According to the documentation, the resident's urine was positive for klebsiella pneumoniae of greater than 100,000 colony forming units per milliliter. An infection note dated 03/11/23 at 7:39 a.m. included that the results of the culture and sensitivity were reported to the provider. An interview was conducted on 03/14/23 at 10:20 a.m. with the Director of Nursing (DON/staff #4). She stated that either nurses or CNAs may complete catheter care. She stated that the CNA will provide peri care prior to catheter care. She stated that either wipes or perineal cleansing spray with wipes would be appropriate, according to preference. She stated that her expectation of the process would include hand hygiene, changing the resident's brief, washing hands with soap and water and donning clean gloves. She stated the performance of catheter care included cleaning the labia, holding the resident with one hand and cleaning with the other. She stated that the expectation is to begin at the dirty area and clean away from the body. She stated that the process should be repeated until there is no visible soiling. She stated that when the process is completed, the individual providing care should take off their soiled gloves and wash their hands. She stated that it would not meet her expectations for the caregiver to clean the catheter tubing in an up and down motion. The Indwelling Urinary Catheter (Foley) Management policy, reviewed 08/22/2022, included that the facility will ensure that residents admitted with a urinary catheter, or determined to need a urinary catheter for a medical indication will have the following areas addressed, including insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure medication was obtained and available to meet the needs of one resident (#43). The sample size was 5. The deficient practice may result in residents not receiving medications necessary to treat their medical conditions. Findings include: Resident #43 readmitted to the facility on [DATE] with diagnoses including atherosclerosis of coronary artery bypass graft(s) without angina pectoris, type 2 diabetes mellitus with diabetic neuropathy and hyperlipidemia. A history of nonrheumatic aortic valve disorder care plan dated 02/01/23 related to a history of myocardial infarction had a goal for the resident to verbalize less difficulty breathing. Interventions included to give medications as ordered. Review of a physician's order dated 02/08/23 included rosuvastatin calcium (HMG-CoA reductase inhibitor) 40 milligrams (mg) at bedtime for hyperlipidemia. The admission Minimum Data Set assessment dated [DATE] revealed the resident scored 3 on the Brief Interview for Mental Status, indicating severe cognitive impairment. He required extensive 2-person physical assistance for most activities of daily living. Review of the February 8 - 28, 2023 Medication Administration Record (MAR) revealed 17 out of 21 opportunities for medication administration included the codes 9 or 10 in the space provided for nursing documentation. Per the Chart Codes key located on the last page of the MAR, code 9 meant the resident was sleeping. Code 10 was an indication of Other/See Progress Note. A review of the resident's progress notes revealed documentation including: medication ordered, medication not available, awaiting pharmacy and on order. According to the MAR, rosuvastatin calcium was administered on 4 out of 21 days in the month: 02/22, 02/23, 02/24 and 02/26. On 03/13/23 at 8:58 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #45). He stated that the pharmacy will deliver once per shift or 3 times a day. He stated that if he put an order in now, he would typically get the medication that same day or evening. He stated that if the medication did not arrive, the facility has an automated medication dispensing machine (OMNICEL) and usually anything they need will be there. He stated that if a resident's medication was not available in his cart, he would check to make sure it had been ordered, check the bottom of the medication cart where overflow medications are kept, then he would get the medication from the OMNICEL. He stated that if the pharmacy reported that the medication was not available, he would call the provider and ask for an alternate medication. He stated that unless there was a crazy backorder, there would be no reason for the medication not to be available. An interview was conducted on 03/14/23 at 10:10 a.m. with the Director of Nursing (DON/staff #4). She stated that if the residents' medications were not delivered right away, she would expect nurses to get it from the OMNICEL. She stated that usually medications are delivered within 12 hours. She stated that it did not meet her expectations for resident #43 not to have received his medication. She stated that the nurses should have called the doctor, pharmacy, and/or should have notified her. The Pharmacy Services and Procedures Manual, revised 01/01/22, included that facility staff should monitor pharmacy communications to address or correct all orders that require clarification before the next scheduled medication delivery, when possible. Facility staff should notify the physician/prescriber of any identified discrepancies in electronically prescribed orders received from the pharmacy and orders entered into the resident's medical record for resolution. The Administration of Medications policy, revised 02/13/23, included the facility will ensure medications are administered safely and appropriately per physician orders to address residents' diagnoses, signs and symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and policy, the facility failed to ensure that medications were stored safely and secured in the medication cart. The deficient practice could increase the risk for unsecured medications, including/and/or schedule II - V medications, to be unsecured. Findings include: Prior to a medication administration observation conducted on 03/13/23 at 8:31 a.m. a medication cart was identified on the [NAME] hallway near room [ROOM NUMBER]. A medication cup containing approximately 8 pills was noted on top of the cart. The medication cart was unlocked. The computer on top of the cart had been left open and a resident's private health care information was visible. There were no residents identified in the hallway. The nurse returned to the cart within approximately 3 minutes. An interview was conducted on 03/13/23 at 8:58 a.m. with a Licensed Practical Nurse (LPN/staff #45). He stated that the earlier situation was not normal. He stated that typically, he does keep his cart locked. He stated that he was supposed to lock his cart with the medications inside and lock the screen on his computer before he stepped away. He stated that he knew the protocol. He stated that he left the cart because a Hospice nurse called him urgently stating her resident was having pain. On 03/14/23 at 9:08 a.m. an interview was conducted with the Director of Nursing (DON/staff #4). She stated that when a nurse is called urgently for assistance, the nurse should ask the aide to let the resident know that they will be there in a minute. She stated that it would not meet her expectations for nurses to leave medications on top of the cart, leave the cart unlocked and/or leave the screen to their computers open and visible. She stated that doing so would not meet expectations for resident safety and/or could be a HIPAA violation. She stated that the nurses have all been trained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure that three residents (#17, #67, #275 ) and/or the resident's representative received the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when Medicare services terminated. The sample size was 3. The deficient practice could result in residents not being informed of their potential liability for payment. Findings include: Resident #17 was admitted [DATE] with diagnosis including congestive heart failure, metabolic encephalopathy, chronic kidney disease-stage 4, unspecified dementia, and type 2 diabetes mellitus. The resident was discharged to home with home health services on March 6, 2023. However, review of the clinical record for resident #17 did not reveal the resident and/or the resident's representative had been provided the SNFABN. Resident #67 was admitted [DATE] with diagnosis including intracapsular fracture of the left femur, severe protein-calorie malnutrition, and pressure ulcer of the sacral region-stage 1. The resident remained in the facility. However, review of the clinical record for resident #67 did not reveal the resident and/or the resident's representative had been provided the SNFABN. Resident #275 was admitted [DATE] with diagnosis including cellulitis of buttock, cutaneous abscess of buttock, and type 2 diabetes mellitus. The resident was discharged home on October 11, 2022. However, review of the clinical record for resident #275 did not reveal the resident and/or the resident's representative had been provided the SNFABN. An interview was conducted on March 10, 2023 at 8:32 a.m. with the Social Services Director, staff #93. She stated that all residents should be given an ABN (advanced beneficiary notice) in conjunction with the NOMNC (notice of Medicare non-coverage). She stated she is working with the business office to streamline the process and ensure that all applicable residents receive the appropriate notifications. She stated that residents #17, #67 and #275 did not receive an ABN. An interview was conducted on March 10, 2023 at 8:51 a.m. with the Business Office Manager, staff #57. The business office manager stated that her understanding is that every resident should receive an ABN along with a NOMNC when Medicare Part A services terminate, but is aware that this has not been happening. An interview was conducted on March 10, 2023 at 1:34 p.m. with the facility administrator, staff #125. The administrator stated that he thought the ABN's were being completed, but found out they had not been when they were requested during the survey. He is stated that his expectation is for each resident, as applicable, to have a signed ABN and NOMNC in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record reviews, and policy, the facility failed to ensure the medication error rate was not 5% or greater by failing to administer a medication as ordered for two of three sampled residents (#26 and #48). The medication error rate was 10.71%. The deficient practice could result in additional medication errors. Findings include: -Resident #26 readmitted to the facility on [DATE] with diagnoses which included primary hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease and major depressive disorder, single episode. A physician's order dated 12/04/22 included duloxetine HCl (antidepressant) capsule delayed release sprinkle 60 milligrams (mg); give one capsule once daily for depression as evidenced by verbalizing sadness. On 03/13/23 at approximately 8:56 a.m. an observation of medication administration was conducted with a Licensed Practical Nurse (LPN/staff #45). Per review of the resident's duloxetine medication card, the dose per capsule was identified as 20 mg. Per observation, staff #45 popped two capsules into the medication cup for administration. Staff #45 administered the medication to the resident and documented that the dose was given as ordered. An interview was conducted on 03/14/23 at 8:58 a.m. with an LPN (staff #41). She reviewed resident #26's medication card containing duloxetine HCl 20 mg. She read the order from the card which stated to give 60 mg or 3 capsules per day. She stated that she had not passed medications to resident #26 yet. Per her review, she stated that she could see that 8 capsules were missing from the card; two correct doses of 60 mg and one dose of 40 mg. -Resident #48 was readmitted to the facility on [DATE] with diagnoses including respiratory failure, atrial fibrillation and type 2 diabetes mellitus without complications. Review of a physician's order dated 01/20/23 included: -Folic acid (supplement) 1 mg; give 1 tablet daily for supplement. -Vitamin D (supplement) 25 micrograms (mcg) (1000 Units); give one tablet daily for supplement. On 03/14/23 at 8:08 a.m. an observation of medication administration was performed with an LPN (staff #41). During the observation, it was noted that in lieu of folic acid 1 mg, staff #41 obtained the folic acid from a bottle which was identified as 400 mcg and to place it into the medication cup. Later in the observation, staff #41 was noted to pull 50 mcg/2,000 Units of Vitamin D3 instead of 25 mcg/1,000 Units of Vitamin D and place it into the medication cup. Staff #41 administered the medications and supplements to the resident. An interview was conducted on 03/14/23 at 8:58 a.m. with LPN/staff #41. She reviewed the bottles of supplements and verbalized that she had given the wrong doses of each. She stated that she had not noticed the difference before and would go to Central Supply to get the correct supplements for the resident. On 03/14/23 at 9:08 a.m. an interview was conducted with the Director of Nursing (DON/staff #4). She stated that her expectation was for medications to be administered as ordered by the physician. The Administration of Medications policy, revised 02/13/23, included that the facility must ensure that its medication error rates are not 5 percent or greater and that residents are free of any significant medication errors. Staff who are responsible for medication administration will adhere to the 10 rights of medication administration, including the right drug. Every drug administered must have an order from the provider. Compare the order with the medication administration record (MAR) for accuracy. Compare the label on the drug to the information on the MAR three times: before removing the container from the drawer, as the drug is removed from the container, and at the bedside before administering it to the resident. The right dose should be ensured by checking the MAR and the doctor's order before medicating. If there is any doubt about the dose on the MAR or if there is a question on the drug, stop and verify all information before administering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that advance directives were consistent in the clinical record for one resident (#185). The sample size was 2. The deficient practice could result in residents receiving services which are not in accordance with their wishes. Finding include: Resident #185 was admitted to the facility on [DATE] with diagnoses that included a left femur fracture, anemia and heart failure. Review of the face sheet revealed the resident was a DNR (Do Not Resuscitate). Review of the Advance Directive signed 2/1/22 by the resident/responsible party and facility representative/title revealed the resident wishes to be a Full Code. The care plan initiated on 2/9/22 revealed the resident has an Advance Directive and is a Full Code. The goal was that the resident's Advance Directive will be honored. Interventions included the resident has decided to remain a Full Code. A physician order dated 2/24/22 stated the resident was a DNR. An interview was conducted with a Licensed Practical Nurse (LPN/staff #3) on 03/03/22 at 1:26 PM. Staff #3 stated that she believes resident #185 was admitted as a Full Code, but changed it to a DNR later and the new Advance Directive form was not completed. An interview was conducted with the Director of Nursing (DON/staff #14) on 03/03/22 at 2:24 PM. The DON stated that it is her expectation that a resident's Advance Directive be consistent. The DON added that while she is ultimately responsible, the unit manager is tasked with reviewing and keeping the Advanced Directives correct. In an interview conducted with the unit manager (staff #59) on 03/03/22 at 2:26 PM, she stated that a resident's code status is addressed upon admission. Staff #59 stated that if the admitting nurse forgets to address an advanced directive or obtain the correct documentation, the change or omission should be caught by her. She stated if not caught, this is a problem which could cause the nurse to be confused and result in the resident not having their advance directive followed. During an interview conducted with the resident on 03/03/22 at 2:44 PM, the resident stated the code status was full code when admitted . The resident also stated that after discussing code status with a family member, both agreed to change the code status to DNR. Review of the facility policy titled Advanced Directives and Advance Care Planning (revised 10/20/21) stated the ability of a person to control decisions about medical care and daily routines has been identified as one of the key elements of quality care at the end of life. If the resident has an advance directive, the resident's physician is made aware of such, and the appropriate orders are incorporated into the resident's plan of care. Residents may revise an advance directive either orally or in writing. The policy stated the physician must give an order for any changes in the advance directives and a notation is made on the care plan or the care plan will be adjusted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policies and procedures, the facility failed to ensure the care plan was revised to include wounds for one resident (#45). The sample size was 23. The deficient practice could result in comprehensive care plans not being updated to include wounds for multiple residents. Findings include: Resident #45 admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, cognitive communication deficit, need for assistance with personal care, and pressure ulcer of sacral region. Review of a nurse progress note dated January 7, 2022 included a foam dressing to the coccyx was in place. Review of the Physical Therapy evaluation dated January 8, 2022 revealed the resident had skin tears, wounds to the bilateral lower extremities and arms, and that the number of wounds was 5. Review of a nurse progress note dated January 10, 2022 revealed zinc oxide was applied to the buttocks to prevent skin breakdown. Review of a nurse progress note dated January 11, 2022 revealed the resident's right heel had peeled dead skin and that skin prep was applied to build a shield. The note also revealed Zinc oxide was applied to the groin for redness. Review of the care plan initiated on January 11, 2022 did not include any actual breaks in skin integrity or goals for healing, and the interventions did not address the treatments reflected in the progress notes. A nurse progress note dated January 12, 2022 stated to monitor for signs and symptoms of infection to the sacral ulcer every shift for decubitus; redness noted, no signs and symptoms of infection. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was at risk for developing pressure ulcers/injury and revealed the assessment for pressure ulcers and other ulcers, wounds and skin problems was not completed. Review of the Admission/readmission Collection Tool signed January 21, 2022 (resident admission date was January 6, 2022) revealed the resident's skin was not intact. The tool stated the resident's skin had friction and shearing, the left front knee had 4 small intact scabs, there was redness to the right heel, and the sacrum had blanchable redness. The Weekly Skin Integrity Data Collection form signed January 21, 2022 included the left front knee had 4 small intact scabs, the sacrum had blanchable redness, and the right heel had an open wound. A physician order dated January 21, 2022 stated to cleanse and apply Mepilex to the resident's bilateral heels. Review of a Braden Scale for predicting pressure sore risk and risk factors, dated January 27, 2022, included the resident had an existing pressure ulcer. Review of a pressure ulcer Care Area Assessment (CAA) signed February 2, 2022 (associated with the admission MDS dated [DATE]) included that per assessment, the resident had blanchable redness to sacrum and redness to bilateral heels. The resident was at risk for developing pressure ulcers/injury due to incontinence, impaired mobility. Review of a nurse progress note dated February 6, 2022 revealed treatment was applied to the bilateral heels and the right heel measured 4 centimeters (cm) x 4 cm and the left heel measured 2 cm x 2 cm, and there were ulcers on the bony prominence to the outer left foot area. A Weekly Skin Integrity Data Collection form signed February 13, 2022 revealed the right heel had an open wound and there was blanchable redness to the sacrum. However, review of the care plan did not reveal the care plan had been revised/updated to include the breaks in the resident skin integrity/documented wounds, or an update to goals or interventions from January 12 through February 27, 2022. An interview was conducted on March 7, 2022 at 12:41 p.m. with a Registered Nurse (RN/staff #128), who stated a resident's wounds should be included on the care plan with goals and interventions. An interview was conducted on March 7, 2022 at 1:49 p.m. with the Director of Nursing (DON/staff #14), who stated that identified wounds should be included on the resident's care plan. An interview was conducted on March 8, 2022 at 11:53 a.m. with a RN Care Manager (staff #26), who stated that she does some of the revisions/updates to the care plans. The RN stated the comprehensive care plan goals should be individualized and measurable and the interventions should be individualized. She stated the altered skin integrity should be on the care plan and the care plan should be updated for acquired alterations in the skin integrity. The RN stated it is important for the care plan to be current and accurate as residents are constantly changing and the staff uses the care plan to know how to take care of the residents. Review of a facility policy for Comprehensive Care Plans and Revisions dated March 2, 2022 revealed the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan. Ensure the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs. The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. The policy also revealed that when changes occur, the facility should review and update the plan of care to reflect the changes to care delivery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, the Facility Assessment, facility documentation, and policy review, the facility failed to ensure one resident (#278) received consistent assistance with Activities of Daily Living (ADL). The sample size was 5. The deficient practice could result in residents not receiving assistance needed for ADL care. Findings include: Resident #278 was admitted on [DATE] with diagnoses of encounter for surgical aftercare following surgery on the circulatory system, muscle weakness and need for assistance with personal care. This resident was discharged from the facility on September 24, 2021. Review of the Care Plan initiated on September 14, 2021 revealed the resident needed ADL assistance and therapy services to maintain or attain the resident's highest level of function. The goal was that the resident wished to attain their prior level of function. Interventions included assisting the resident with mobility and ADLs as needed. Review of the ADL Task record for September 2021 revealed that for September 12 through 24, 2021, the resident received assistance for toilet use 0 times on September 12, 14 and 18, 1 time on September 13, 15, 16, and 17, and 2 times on September 19, 20, 21, 22, 23 and 24. Continued review of the ADL Task record for September 2021 revealed that for September 12 through 24, 2021, the resident received assistance with personal hygiene 0 times on September 12 and 14, 1 time on September 13, 15, 16, 18, 21 and 24, 2 times on September 17, 19 and 20, 3 times on September 22, and 4 times on September 23. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed this resident required extensive assistance with toileting, transfer, and bed mobility; and required supervision with personal hygiene. The assessment included the resident was occasionally incontinent of urine and bowel. An interview conducted on March 3, 2022 at 11:17 AM with a Registered Nurse (staff #127), who said that the facility was low on CNAs in September 2021 and still is. He said that the staff were having trouble changing people as needed and that it feels like it never stops. This staff said that staff let management know but nothing ever changes. An interview was conducted on March 3, 2022 at 11:32 AM with a Licensed Practical Nurse (LPN/staff #64), who said that she has worked at the facility for years. This staff said that she did not think that the facility ever had enough CNAs. She said that they had trouble getting their tasks done in 2021 and now there are not enough staff to get the residents changed. The LPN stated they do not have enough staff and are having trouble getting the residents up. An interview was conducted on March 3, 2022 at 1:09 PM with a Restorative Nurse Assistant/Certified Nursing Assistant (RNA/CNA/staff #120), who said that sometimes it is pretty tough. She said that she will sometimes help the CNAs because they need the help. She said sometimes the residents keep them in the room for an hour and there will be other residents call lights going off. She said that sometimes there are not enough CNAs on the floor in the evening and staff call off. She said that if that happens then she will help with CNA duties and then try to get back to helping with RNA duties but she cannot always get back to them. She said that she was at the facility this last year and that there have always been problems with staffing. An interview was conducted on March 8, 2022 at 9:43 AM with a CNA (staff #122), who said that some of the duties of a CNA include changing residents, answering call lights, taking lunch orders, helping residents out of bed, serving lunch orders, and getting the residents what they ask for. She said that she tries to get everything done. The CNA stated that she did not want to say that there was not enough staff to get required tasks done, but it is a no. She said that they have a hard time. Staff #122 said there are a lot of showers that need to be given but they do not have enough staff to get them all done. She said that she would say that the staffing was the same in 2021. An interview was conducted on March 8, 2022 at 3:01 PM with a CNA (staff #32), who said that she charts toilet use multiple times a shift. The CNA stated this included when she assists the resident and when she does not assist the resident with bowel care. She said that if there was nothing charted at all, that meant that nothing got charted because the staff just did not chart. She said that the facility did not have enough staff to get CNA tasks done. She said that it feels like she is working against the odds. She said that tasks may not be charted because the staff were overwhelmed. An interview was conducted with the Director of Nursing (DON/staff #14) on March 8, 2022 at 3:59 PM, who said that the CNAs provide the ADL care and document care they provide every shift. She said they are supposed to chart the care that they provide. The DON said that it is her expectation that the residents receive ADL care to meet their needs. A review of the facility assessment tool initiated on June 13, 2019 and reviewed 02/22/22 reflected an average daily census of 75 residents. Pertinent facts or descriptions of the resident population that must be considered when determining staffing and resource needs included daily review of schedules, utilization of the [NAME], and be based on resident needs and requests. According to the facility assessment the required number of direct care staff hours per patient day (HPPD) included 2.25 hours for Certified Nursing Assistants (CNAs), 0.76 hours for Licensed Practical Nurses (LPNs), and 0.79 hours for Registered Nurses (RNs). In addition, 0.12 hours were assigned for Restorative CNAs (RCNAs). The total number of HPPD was 3.81. Review of the facility daily staffing forms and facility documentation from September 12 through 18, 2021 revealed the census ranged from 88 to 93 residents, with an average census of 91. Per review of the nursing staff punch detail, CNA hours were less than the required 2.25 PPD for 7 out of 7 days and the combined RN and LPN hours were less than the requirement of 1.55 PPD for 7 out of 7 days. Further review of the documentation revealed that for 7 out of 7 days the total combined hours for all direct care nursing staff was less than 3.81 HPPD. A facility policy titled Activities of Daily Living (ADLs) revealed that the resident will receive assistance as needed to complete ADLs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one of three sampled residents (#128) received adequate supervision and assistive devices to prevent accidents. The deficient practice could result in increased resident injuries. Findings include: Resident #128 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, weakness, and cachexia. Review of the resident's care plan initiated on June 3, 2020 revealed the resident was at risk for fall. The goal was that the resident would not sustain serious injury requiring hospitalization. The interventions included for floor mats next to the bed. A review of the significant change in status Minimum Data Set assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The assessment included the resident had one fall since the prior assessment and sustained a major injury. The assessment also included the resident was receiving hospice care. Review of a quarterly MDS assessment dated [DATE] revealed the resident had one fall since the prior assessment with no injury. Review of nursing event progress notes dated October 27, 2020 revealed the resident had fallen out of the chair and was noted to have a contusion to the right cheek/eye with an abrasion above it. The resident was able to perform Activities of Daily Living (ADL) per baseline, was alert and oriented times 1 per baseline, and pupils were equal, round, reactive to light, and accommodating. The Interdisciplinary Team (IDT) reviewed the incident and included the intervention to assist the resident back to bed after meals. Review of the resident's fall care plan revealed that an intervention was added on October 27, 2020 to assist the resident back to bed after meals. Review of a fall risk evaluation dated October 27, 2020 revealed a score of 18/category 10 or above and included the resident had 1-2 falls in 90 days. Review of a quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making and needed extensive assistance with bed mobility and transfers. The assessment included the resident had one fall since the prior assessment and sustained an injury that was not major. Review of a nurse progress note dated January 19, 2021 revealed the resident had fallen in the room and was found lying on the left side of the floor next to the bed. Nonskid socks were in place, the call light was not on, the resident was not soiled, and was in no apparent distress. Assessed for injury, noted bruising to left eyebrow and left deltoid, noted bump to forehead, and skin tear to left forearm. The resident was able to perform ADLs, grips and pulls with bilateral upper extremities. No facial grimacing with movement. Assisted by 3 staff into bed, 72-hour neurological checks initiated, ensured fall mats in place, frequent checks being made by staff, monitored for any increased pain, and notified family, Director of Nursing (DON), unit manager, and Medical Doctor (MD). Review of a Palliative Care nurse note dated January 20, 2021 revealed teaching was provided to the caregiver on safety and keeping the fall mats in place. The noted stated that, per facility nurse, the resident fell from bed yesterday resulting in a bruise to the eyebrow and left shoulder. The note also stated that the fall mats were under the bed. Review of a nurse progress note dated January 22, 2021 revealed the resident was found in the day room at 10:00 a.m. on the floor on the right side in front of the wheelchair. The resident was assessed to have a laceration above the right eyebrow and on the outside corner of right eye below the eyelid. The wounds were cleaned and dressed. The physician, family, hospice nurse, Assistant Director of Nursing (ADON), and Unit Manager were notified and that the hospice nurse was ordering a Geri chair. Review of a Palliative Care IDT note dated January 27, 2021 revealed the fall mats were not in place when the resident fell out of bed on January 19, 2021. The note included the resident had a fall out of the wheelchair when placed into the T.V. room instead of being returned to bed resulting in a large bump above the right eye and a gash below the right eye per phone conversation with the facility nurse. The note included the resident had falls on January 19, 2021 and January 22 2021. An interview was conducted on March 3, 2022 at 9:49 a.m. with a Registered Nurse (RN/staff #127) who was caring for the resident at the time of the falls on October 27, 2020 and January 19, 2021. Regarding the fall on January 19, 2021, The RN stated that he would have documented the floor mat was in place in his progress note if the mat had been in place at the time of the fall. He stated he believed the portion of the note that included ensured floor mats were in place was post fall. He stated that anytime the resident was in bed, the mats should have been in place because the resident would fall. He stated that he assumed the information in the hospice note was correct if the hospice staff documented that the floor mats were not in place at the time of the fall and that the resident fell from bed. He stated that the fall mats may have potentially decreased the injury to the resident. Regarding the fall on January 22, 2021, the RN stated the resident should not have been in the day room and should have been placed in bed following breakfast as care planned. He stated that keeping the resident up after a meal and placing the resident in the day room put the resident at a further risk for a fall. An interview was conducted on March 3, 2022 at 11:18 a.m. with a Licensed Practical Nurse (LPN/staff #64). On review of the IDT palliative care note from January 27, 2021, she stated that she thought that hospice had called and that she was unable to find the resident's nurse so she answered the questions with the information that she knew at the time. She stated the care planned interventions of fall mats in place should have been followed and that it was important to have fall mats in place for this resident related to the resident's history of falls from the bed. The LPN stated that the resident should have been placed in bed immediately after eating the meal as care planned and that the resident should not have been left up and placed in the day room. She stated that 10:00 a.m. would be late for putting the resident to bed after breakfast and that the resident should not have been left alone. The LPN stated that she would not have expected the resident to be in the dayroom at that time, she stated that she would have kept her visible in hallway until the resident could be put to bed. A phone interview was conducted on March 3, 2022 at 1:09 p.m. with an LPN (staff #30) who wrote the note regarding the fall on January 22, 2021. She stated that if a resident was known to be at risk for falls, staff would put the resident to bed within 15 minutes of finishing their meal. She stated that the resident would be placed in the entrance of the day room or at the nurses' station until the nurse found a Certified Nursing Assistant (CNA) to put the resident to bed. She stated that a resident should not still be up at 1000 a.m. if they are supposed to be put to bed after the meal because breakfast was delivered approximately 7:30 a.m. to 8:00 a.m. The LPN stated the residents are up for about an hour and then assisted to bed and given care. She stated that a resident with a falls risk would be one of the first ones to be assisted back to bed. On review of the nurse progress note from January 22, 2021, she stated that she remembered the resident and the fall. She stated that the resident was care planned to be put into bed immediately after the meal. The LPN stated that she told the CNA to put the resident into bed and the CNA did not do as instructed and instead put the resident into the day room. She stated that the resident was visible to staff in the area. The LPN stated that if the CNA had put the resident to bed as instructed the resident would not have fallen. An interview was conducted on March 3, 2022 at 1:31 p.m. with a CNA (staff #121) who documented on this resident on January 22, 2021 during the shift in which the resident fell. He stated that the residents would lose their balance and fall from the wheelchair. He stated that staff had to be careful and recognize if a resident was trying to get up. The CNA stated that he did not think that resident #128 was his resident and did not remember the nurse telling him to put the resident to bed right after breakfast. He stated that he had a lot of residents and that falls happen all of the time. An interview was conducted on March 7, 2022 at 1:49 p.m. with the DON (staff #14). She stated that upon admission, a resident is assessed for fall risk and whether the resident has a history of falling. She stated if the resident is determined to be at risk for falls, interventions would be put in place. She stated if a resident had a fall the nurse would assesses the resident, document, and based on what the resident was trying to do at the time of the fall would initiate an intervention, and would notify nurse management to review the incident and intervention. The DON stated there would be an IDT note and the care plan and [NAME] would be updated to include interventions. She stated that when investigating a fall, they would usually ask what devices were in place, what did the resident do, what was the resident trying to do, the resident position, was the resident soiled, and the call light placement. The DON stated if the fall mats were not in place when the resident was in bed then staff did not follow protocol. She stated she was unable to determine from the progress note on January 19, 2021 if the fall mats were in place or not. The DON stated this resident should have been placed in the bed as care planned following the breakfast meal. She stated she was unable to determine from the clinical note on January 22, 2021 the relation of the fall to the breakfast meal. The DON stated she expects staff to follow the interventions and care plan and if staff did not, there was risk for additional falls and injury/harm to residents. Review of a facility policy on Incident and Reportable Event Management dated July 19, 2021 revealed some residents have a heightened vulnerability to hazards in the resident environment and can result in life threatening injuries. An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents. The facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents, which included, implementing interventions to reduce hazard(s) and risk(s). To help reduce the risk of an event, all residents receive assistance and supervisions as addressed in their care plan. Review of a facility policy on Fall Management reviewed August 2, 2021 included the purpose is to promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators. The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, and review of policies and procedures, the facility failed to provide bowel care as needed for one sampled resident (#45). The deficient practice could result in residents having constipation. Findings include: Resident #45 admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, oropharyngeal phase dysphagia, cognitive communication deficit, and difficulty in walking. Review of the physician orders dated January 6, 2022 revealed the following: -May use facility standing orders/protocols; -Milk of Magnesia suspension 400 milligrams (mg)/5 milliliters (ml) (magnesium hydroxide) give 30 ml by mouth as needed for constipation-no bowel movement (BM) on previous 9 shifts; -bisacodyl suppository 10 mg insert 1 suppository rectally as needed for constipation daily; -Fleet enema 7-19 grams (gm)/118 ml (sodium phosphates) insert one application rectally as needed for constipation if no results from suppository; -Docusate Sodium Tablet 100 mg by mouth every 12 hours for a diagnosis of constipation. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was able to make himself understood and was able to understand others. The assessment did not include an assessment of the resident's cognitive patterns. The resident was coded as extensive assistance with toileting, and always incontinent of bowel. Review of the bowel movement documentation revealed the resident had a BM recorded on January 30, 2022 at 9:59 p.m. and that the next recorded bowel movement was on February 4, 2022 at 1:59 p.m., which was over 3 days/9 shifts. A BM was recorded for the resident on February 8, 2022 at 11:25 a.m. and the next recorded bowel movement was on February 14, 2022 at 9:57 p.m., which was over 3 days/9 shifts. A BM was recorded for the resident on February 20, 2022 at 1:59 p.m. and the next recorded bowel movement was on February 26, 2022, which was over 3 days/9 shifts. Review of the Medication Administration Record did not reveal as needed (PRN) medication for constipation was administered to the resident. A review of the clinical record did not reveal any progress notes related to the BMs over 3 days/9 shifts. Review of the physician's orders revealed an order dated February 22, 2022 for Senna 8.6 mg (laxative) tablet; give 2 tablets by mouth at bedtime for constipation. Constipation, or the risk for, was not addressed on the care plan. An interview was conducted with the resident on February 28, 2022 at 1:44 p.m. The resident stated that he was impacted and that staff was working on it. During the interview the resident yelled out complaining of pain and requested assistance with constipation multiple times, and was observed to be rocking in the bed with his knees pulled up. An interview was conducted on March 3, 2022 at 11:33 a.m. with a Licensed Practical Nurse (LPN/staff #64). She stated that every time resident #45 is changed the Certified Nursing Assistant (CNA) would tell the nurse if the resident had a BM or not. The LPN stated if the CNA did not chart a BM in three days the nurse would get an alert and would administer the PRN medication. She stated that if the resident had no BM for three days and there was no PRN administration documented, either the PRN use was not documented by the nurse or the nurse was not aware that the resident had not had a BM in three days. The LPN stated that if she receives a BM alert on her shift, she would medication the resident and chart the medication administration. Staff #64 stated that there was no way, other than MAR/progress notes, to show the resident received treatment of no BM over three days. An interview was conducted on March 7, 2022 at 1:49 p.m. with the Director of Nursing (DON/staff #14). She stated that interventions would be put in place if after three days (9 shifts) a resident did not have a BM. The DON stated that the resident should have a care plan if there was a history of consistent constipation to address the resident needs/concerns. The DON stated that if a resident went 3 days/9 shifts without a BM there should be documentation of PRN medication use per protocol and that if the resident was not treated there was a risk for bowel obstruction. Review of the facility policy for Bowel Protocol reviewed July 19, 2021 revealed the purpose is to provide effective interventions for signs and symptoms of constipation. Nursing staff shall document the resident's bowel movements each shift and the evening shift nurse will assess the bowel movement data daily and respond accordingly to the protocol and/or physician's orders. The policy stated if no bowel movement is recorded for two days, assess for signs and symptoms of constipation. If the resident is alert and oriented, ask about any unrecorded bowel movements. Assess for constipation if no bowel movement is recorded for 3 days. In the absence of acute abdominal symptoms, administer a PRN laxative or enema as ordered by the physician. After 4 days with no bowel movement or inadequate response to previous interventions, contact the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure one sampled resident (#45) diagnosed with dementia received the appropriate treatment and services. The deficient practice could result in residents with dementia not obtaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #45 admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, dementia without behavioral disturbance, history of a transient ischemic attack and cerebral infarction. Review of the physician's progress notes for January 7, 11, 15, and 19, 2022 included a diagnosis of dementia. Review of the baseline care plan signed January 11, 2022 did not address the resident's diagnosis of dementia. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed no assessment of cognitive patterns, mood, or behavior for this resident. Diagnoses included Non-Alzheimer's dementia and cognitive communication deficit, there were no psychiatric/mood disorders marked. Review of the associated Psychotropic Drug Use Care Area Assessment (CAA) revealed the resident received antipsychotic medication for dementia. The assessment included the resident would receive psychiatric services as needed. Review of the physician's orders dated January 19, 2022 revealed for: -Quetiapine Fumarate/Seroquel (antipsychotic) tablet 25 milligrams (mg) give one tablet by mouth two times a day for dementia with behavioral disturbance As Evidenced By (AEB) agitation; -Document number of episodes of agitation every shift for dementia with behavioral disturbance AEB agitation. A physician's progress note dated January 19, 2022 included the diagnosis of dementia. However, the note did not include the addition of behavior disturbance, agitation, or treatment with antipsychotic medication. Review of a psychoactive medication informed consent for Seroquel dated January 19, 2022 revealed the resident was on the medication at admission and the proposed course of the medication was prolonged treatment. The consent also revealed the medication was prescribed for Dementia with behavioral disturbances AEB agitation, and the expected benefits to the resident is to decrease agitation. Review of the care plan initiated on January 19, 2022 revealed the resident uses the psychotropic medication Seroquel related to dementia with behavioral disturbances AEB agitation. The interventions included observing for effectiveness each shift; discussing with physician, family regarding ongoing need for use of medication, review behaviors/interventions and alternate therapies attempted and their effectiveness. However, the care plan did not include individualized care planning to address the resident's diagnosis of dementia for characteristics and interventions. Review of the clinical record did not reveal non-medication interventions and alternative therapies were attempted. Review of the January 2022 Medication Administration Record (MAR) revealed Seroquel was administered as ordered. The number of episodes of agitation were done as ordered and was present in 8 of 25 shifts for one to 4 times during the shifts from January 19, 2022 through January 31, 2022. Review of an Admission/readmission Collection Tool signed January 21, 2022 revealed the resident had impaired cognition, was able to make himself understood, was alert, and oriented to himself (not place, time, or situation). The assessment included no exhibited mood or behaviors and had an order for an antipsychotic medication, Quetiapine 25 mg twice daily. However, the resident was admitted to the facility on [DATE]. A nurse behavioral note dated January 23, 2022 revealed the resident was observed to be hallucinating, talking to a family member who the resident said was lying next to the resident moving their feet. The note stated the resident was heard having a conversation with the family member several times that morning. The note also revealed the roommate stated that the resident was talking to someone all night and no one was there. Review of the clinical record did not reveal further assessment into the potential cause for the resident's hallucination and did not reveal monitoring for hallucinations on the MAR. Review of the physician's progress notes for January 25, 2022 did not include any information related to the resident's behavioral disturbances related to dementia/psychiatric medication treatment, or document the recent hallucination. A nurse behavior note dated January 30, 2022 included staff was unable to obtain a urine specimen due to confusion causing combativeness. Review of the clinical record did not reveal any changes to the behaviors monitored for this resident. A Roster Report from the consultant pharmacist revealed the resident was reviewed on February 2, 2022. There was no documentation and no recommendations related to the psychotropic medications received by the resident. Review of a monthly summary dated February 3, 2022 included under mood/behavior of: easily upset, frequently hostile, and interferes with or rejects care. A nurse behavior note dated February 3, 2022 revealed staff was unable to obtain a urinalysis as the resident became verbally abusive. Review of the clinical record did not reveal any changes to the behaviors monitored for this resident. Review of the February 2022 MAR revealed Seroquel was administered as ordered. The MAR included the number of episodes of agitation was present on 16 of 56 shifts for 1 to 3 times during the shifts. A review of the March 2022 MAR revealed Seroquel was administered as ordered and the resident had no episodes of agitation through March 2, 2022. Review of the MARs from January 2022 to March 2022, and the clinical documentation did not reveal documentation of non-drug interventions or effectiveness of medication treatment. Review of the care plan initiated on March 1, 2022 revealed the resident was at risk for change in mood or behavior due to medical condition Dementia. The goal was the resident would allow staff to assist with basic care needs. The interventions included consulting with the resident on preferences regarding customary routine, and medications as ordered. However, the care plan did not include any identification of specific characteristics or interventions for this resident related to dementia diagnosis/cognitive status. Review of a monthly summary dated March 3, 2022 included under mood/behavior of: expresses according to situation. An interview was conducted on March 3, 2022 at 11:33 a.m. with a Licensed Practical Nurse (LPN/staff #64). She stated that she received training on dementia care from the facility. She stated that resident #45 exhibited dementia by sometimes being repetitive and sometimes becoming agitated with cursing. The LPN stated that sometimes an antipsychotic is used without a psychotic diagnosis, that she was not sure if dementia was a psychotic diagnosis, but that agitation could be a psychotic behavior. The LPN stated that when treating a resident with dementia with an antipsychotic medication, staff would need to document the behavior being displayed and notify the physician. She stated that sometimes nursing would try non-medication interventions with a resident. An interview was conducted on March 7, 2022 at 2:25 p.m. with the Director of Nursing (DON/staff #14). She stated usually the diagnosis of dementia would be included in the History and Physical and the admission Nursing Collection Tool. She stated that if the nurses noted that the resident had dementia and had additional needs, the concern would be brought up in grand rounds and would be further assessed with the provider. The DON stated that the facility did not do routine assessments of residents with a dementia diagnosis to determine manifestations, characteristics/behaviors, and specific interventions for the resident. She stated the care plan should include dementia and, based on the MDS/CAA assessment, should contain goals and interventions to meet the resident's needs. The DON stated that the facility tries not to use psychotropic medications for residents with a diagnosis of dementia but that the medication may be used based on the plan of care and the physician's orders. The DON stated the consultant pharmacist told the facility that dementia with behaviors was an appropriate diagnosis for antipsychotic use. The DON stated that she would say that agitation was not an appropriate diagnosis for antipsychotic use. She stated that the resident would be monitored for behaviors each shift which would be documented in the MAR and the provider would be notified of increased behaviors. An interview was conducted on March 8, 2022 at 10:05 a.m. with the Social Services (staff #17). She stated it was important to assess all areas of the MDS and complete the assessment to obtain a clear picture of the resident and their needs. She stated that if the resident had an alteration in an area, a CAA would usually trigger and would prompt further assessment into the area and lead to the development of the care plan. She stated that if a section of the MDS was dashed/not assessed any related CAAs would not be triggered. Staff #17 stated that the care plan should be specific to the resident and the goals should be measurable so staff would know what the resident needs and how to take care of them. Staff #17 stated that if the resident's needs were not on the care plan there was a risk the resident might not reach their highest level of potential. On Review of the resident's MDS, she stated that sections for cognition, mood, and behavior were not completed. An interview was conducted on March 8, 2022 at 1:04 p.m. with a Certified Nursing Assistant (CNA/staff # 7). She stated that the resident had memory issues which makes the resident frustrated and then the resident yells because the resident thinks staff are not listening. She stated that the resident accepted care from staff. She stated that the resident had agitation at times but she did not think the resident would harm himself or others. An interview was conducted on March 8, 2022 at approximately 2:00 p.m. with the DON (staff #14), who stated the resident had not received a psychiatric assessment yet. Review of the black box warning related to Seroquel that was included with the physician order revealed for increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel is not approved for the treatment of patients with dementia-related psychosis. Review of a facility policy for Behavioral Health Management revised August 2, 2021 revealed the purpose is to promote resident safety, attain highest practicable mental/psychosocial well-being and reduce behavior related events. Providing behavioral health care and services is an integral part of the person-centered environment. This involves an interdisciplinary approach to care, with qualified staff that demonstrate the competencies and skills necessary to provide appropriate services to the resident. Individualized approaches to care are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's behavioral health needs. The facility will provide services to a resident to address the assessed problem related to mental disorder or psychosocial adjustment difficulty. The facility will provide medically related social services for highest practicable well-being as necessary for each resident. The facility will identify the need for medically-related social services and ensure that these services are provided. Complete the nursing assessment and social services assessment upon admission/readmission, quarterly, and as needed with change of condition. Monitor the resident closely for expressions or indications of distress; Assess and plan care for concerns identified in the resident assessment; Accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record; Share concerns with the IDT to determine underlying causes, including differential diagnosis; Ensure appropriate follow-up assessment, if needed; and Discuss potential modifications to the care plan. Initiate Behavior Monitoring, Behavior Management Care Plan, and [NAME] as indicated by assessment findings, resident/responsible party conversations, and observations. The facility must provide necessary behavioral health care and services which include ensuring the necessary care and services are person-centered and reflect the resident's goals for care; Ensuring direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being; Providing an environment and atmosphere that is conducive to Providing meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community; and Ensuring that pharmacological interventions are only used when nonpharmacological interventions are ineffective or when clinically indicated. Review of a facility policy for Psychotropic Medication Use revised November 28, 2016 revealed the facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors. Facility should take a holistic approach to behavior management that involves a thorough assessment of underlying causes of behaviors and individualized person-centered non-drug and pharmaceutical interventions. Facility staff should provide the resident with a supportive environment promoting comfort, recognizing individual needs and preferences. Staff should become familiar with the cultural, medical, and psychological information about the resident to identify potential environmental and other triggers to prevent or reduce behavioral symptoms and/or distress, types and the consequences of behaviors exhibited by the resident and interventions that may be indicated for a specific behavior type. Facility staff should focus on an understanding of behaviors as a form of resident communication or distress. Residents who exhibit new or worsening behavioral or psychological symptoms of dementia will be evaluated by a health care professional and the care team to identify contributing factors such as treatable medical conditions, physical problems, emotional stressors, psychiatric or psychological factors, social issues, or environmental factors. Facility should involve the resident or the resident's representative(s) in the discussion of potential non-drug and medication interventions to address the management of behaviors and the involvement should be documented in the resident's medical record. Psychotropic medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use. Antipsychotic medication used to treat Behavioral or Psychological Symptoms of Dementia must be clinically indicated, be supported by adequate rationale for use, and may not be used for a behavior with an unidentified cause. Where physician/prescriber orders a psychotropic medication for a resident, the facility should ensure that physician/prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacologic medication is necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of policies and procedures and the National Institute of Mental Health, the facility failed to ensure there was adequate indication for the use of an antipsychotic medication for one resident (#45). The sample size was 5. The deficient practice could result in residents receiving antipsychotic medications unnecessarily. Findings include: Resident #45 admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, dementia without behavioral disturbance, history of a transient ischemic attack and cerebral infarction. Review of the physician's orders dated January 6, 2022 revealed for Quetiapine Fumarate/Seroquel (antipsychotic) tablet 25 milligram (mg) give one tablet by mouth two times a day for anxiety as evidenced by (AEB) crying; and document the number of hours of anxiety as evidenced by (AEB) crying. Review of the Psychoactive Medication Informed Consent for Seroquel dated January 7, 2022 revealed an illegible single word entry under The following non-drug approaches have proven to be ineffective; and under expected benefits to resident help (?) treatment. The reason the medication was prescribed was listed as anxiety AEB crying. The proposed course of the medication was for prolonged treatment. Review of the physician's progress notes for January 7, 11, 15, and 19, 2022 did not reveal psychiatric diagnoses, psychotropic drug use, or psychiatric concerns. The progress notes included a diagnosis of dementia. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed no assessment of cognitive patterns, mood, or behavior. Diagnoses included Non-Alzheimer's dementia and cognitive communication deficit, there were not psychiatric/mood disorders marked. The assessment revealed the resident received 6 days of an antipsychotic medication during the 7-day lookback period, that the medication was routine, that a gradual dose reduction had not been attempted or contraindicated, and that a complete drug regimen review did not identify potential clinically significant medication issues. Review of the associated Psychotropic Drug Use Care Area Assessment (CAA) revealed the resident received antipsychotic medication for dementia and any changes in mental status would be reported to the nurse and provider for intervention. The assessment included the resident would receive psychiatric services as needed and the medication would be at the lowest dose possible for maintenance. Treatable/reversible reasons for use of a psychotropic drug included a check mark by medical conditions, such as heart disease, diabetes, or respiratory disease. Review of the physician's orders dated January 19, 2022 revealed: -Quetiapine Fumarate/Seroquel tablet 25 mg give one tablet by mouth two times a day for dementia with behavioral disturbance AEB agitation; -Antipsychotic medication, Seroquel, monitor every shift document (+) if side effects present and write progress note, (-) side effects not present; -Document number of episodes of agitation every shift for dementia with behavioral disturbance AEB agitation. Continued review of the orders revealed a Seroquel black box warning that mortality was increased in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel is not approved for the treatment of patients with dementia-related psychosis. The physician's progress note dated January 19, 2022 did not address the behavioral disturbance/agitation or the antipsychotic medication use related to dementia. Review of a second Psychoactive Medication Informed Consent for Seroquel dated January 19, 2022 revealed on the medication at admission written under The following non-drug approaches have proven to be ineffective. The reason the medication was prescribed was listed as Dementia with behavioral disturbances AEB agitation, and under expected benefits decrease agitation. The proposed course of the medication was for prolonged treatment. Review of the resident's care plan dated January 19, 2022 revealed the resident uses the psychotropic medication Seroquel related to dementia with behavioral disturbances AEB agitation. The goals included the resident would be/remain free of psychotropic drug related complications, and would reduce the use of psychotropic medication. The interventions included to administer the psychotropic medication as ordered, observe for side effects and effectiveness each shift; consult with the pharmacy and MD (Medical Doctor) to consider dosage reduction when clinically appropriate, at least quarterly; discuss with MD, family regarding ongoing need for use of medication, review behaviors/interventions and alternate therapies attempted and their effectiveness; educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of Seroquel; Observe for and report as needed (PRN) any adverse reactions of psychotropic medications. However, review of the clinical record did not reveal effectiveness of medication, non-medication interventions and alternative therapies attempted. Review of the January 2022 Medication Administration Record (MAR) revealed: -Quetiapine was administered as ordered from January 7 through January 31, 2022. -Side effect monitoring for Quetiapine/Seroquel was started on January 19, 2022 with no side effects documented. -Document number of hours of anxiety as evidenced by AEB crying was done from January 7 through 19, 2022 as ordered and documented as present on 2 of 25 shifts with the number 6 on the night shift January 13 and 15, 2022. -Document number of episodes of agitation was done from January 19, 2022 through January 31, 2022 as ordered and documented as present 8 of 25 shifts for one to 4 times during the shifts. An Abnormal Involuntary Movement Scale (AIMS) assessment dated [DATE] did not reveal any abnormal movements. Review of an Admission/readmission Collection Tool signed January 21, 2022 revealed the resident had no exhibited mood or behaviors and had an order for an antipsychotic medication, Quetiapine 25 mg twice daily. However, the resident admitted on [DATE]. Review of a nurse behavioral note dated January 23, 2022 revealed the resident was observed to be hallucinating. The resident was talking to a family member who the resident stated was lying next to the resident and the family member was moving their feet. The resident was heard having a conversation with the family several times that morning. The resident's roommate stated that the resident was awake and talking to someone all night and no one was there. Review of the clinical record did not reveal further assessment into the potential cause for the resident's hallucination and did not reveal monitoring for hallucinations on the MAR. Review of the physician's progress notes for January 25, 2022 did not reveal psychiatric diagnoses, psychotropic drug use, or psychiatric concerns. The note did not include any information related to the resident's documented hallucination. Review of the clinical record did not reveal any changes to the behaviors monitored for this resident. Review of a Roster Report from the consultant pharmacist revealed the resident was reviewed on February 2, 2022. There was no documentation and no recommendations related to the psychotropic medications received by the resident. Review of a monthly summary dated February 3, 2022 included mood/behavior of easily upset, frequently hostile, and interferes with or rejects care. Review of the February 2022 MAR revealed: -The Quetiapine was administered as ordered. -Side effect monitoring for Quetiapine/Seroquel as ordered with no side effects documented. -Document number of episodes of agitation was done as ordered and documented as present on 16 of 56 shifts for 1 to 3 times during the shifts. Review of the March 2022 MAR with documentation through March 2, 2022 revealed: -The Quetiapine was administered as ordered. -Side effect monitoring for Quetiapine/Seroquel as ordered with no side effects documented. -Document number of episodes of agitation was done as ordered and no agitation was documented to be present. Review of a monthly summary dated March 3, 2022 included mood/behavior of expresses according to situation. Review of the clinical record did not reveal any changes to the behaviors monitored for this resident. An interview was conducted on March 3, 2022 at 11:33 a.m. with a Licensed Practical Nurse (LPN/staff #64). She stated that the order for a psychotropic medication needed to have a diagnosis and a behavior that were appropriate for the medication being used. The LPN stated that she was not sure if dementia was a psychotic diagnosis but that agitation could be a psychotic behavior. She stated that when treating a resident with dementia with an antipsychotic medication, staff would need to document the behavior being displayed and notify the physician. The LPN stated that the nurse did not make the decision regarding psychotropic use on a resident, the doctor does. She stated that sometimes nursing would try non-medication interventions with a resident. An interview was conducted on March 7, 2022 at 2:25 p.m. with the Director of Nursing (DON/staff #14). She stated that an antipsychotic medication should be used if the provider determines it is needed for the resident. She stated it is important to have an appropriate diagnosis and behavior for the psychotropic medication use. The DON stated that the consultant pharmacist told the facility that dementia with behaviors was an appropriate diagnosis for antipsychotic use. The DON stated that she would say that agitation was not an appropriate behavior for antipsychotic use. She stated that the resident would be monitored for behaviors and adverse side effects each shift which would be documented in the MAR, and the provider would be notified of increased behaviors and/or adverse side effects. An interview was conducted on March 8, 2022 at 1:04 p.m. with a Certified Nursing Assistant (CNA/staff #7). She stated that the resident has memory issues which makes the resident frustrated and then the resident yells because the resident thinks staff are not listening. She stated that the resident did not report hearing voices or seeing something/someone present when the person/item was not in the room with them. She stated the resident had agitation at times. An interview was conducted on March 8, 2022 at 1:16 p.m. with the District Pharmacy Clinical Manager (staff #133). He stated that it was permissible to use an antipsychotic medication for the diagnosis of dementia with behavioral disturbance. He stated the resident would be monitored on admission for behaviors, but depending on the situation the resident may/may not exhibit behaviors right away. He stated that a specific target behavior would be desired for antipsychotic use but was not always available on admission. Staff #133 stated that antipsychotic use is resident specific and that it did not require a psychotic diagnosis or behavior for use. He stated that agitation, as a behavior, was appropriate for the use of Seroquel and was often the behavior used when a resident was admitted to the facility with an antipsychotic medication in place. Staff #133 stated that this resident was still in the investigative phase and the facility would monitor for behaviors, and if the resident exhibited hallucinations or behaviors the behavior monitoring would usually be expanded. Staff #133 stated that dementia with behavioral disturbances as evidenced by agitation was not an on label use for Seroquel, but that there was no on label medication for use with agitation with dementia. He stated that the presence of the resident's name on the Roster Report from the consultant pharmacist meant the medication review was done on the resident and, if there were no recommendations made regarding the antipsychotic medication, there were no irregularities identified. Staff #133 stated that a risk versus benefit review would be done on a quarterly basis or if the resident was exhibiting active side effects. He stated that he heard the resident was exhibiting hallucination, which would be an appropriate reason for the antipsychotic use, and would be added to the behavior monitoring and care plan at the time of the quarterly review. An interview was conducted on March 8, 2022 at approximately 2:00 p.m. with the DON (staff #14). She stated that the resident had not received a psychiatric assessment yet. Review of a facility policy for Psychotropic Medication Use revised November 28, 2016 revealed stated a psychotropic drug is any medication that affects brain activities associated with mental processes and behavior. Comply with all applicable law relating to the use of psychopharmacologic medications. Do not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors. Take a holistic approach to behavior management that involves a thorough assessment of underlying causes of behaviors and individualized person-centered non-drug and pharmaceutical interventions. Provide the resident with a supportive environment promoting comfort, recognizing individual needs and preferences. Become familiar with the cultural, medical, and psychological information about the resident to identify potential environmental and other triggers to prevent or reduce behavioral symptoms and/or distress, types and the consequences of behaviors exhibited by the resident and interventions that may be indicated for a specific behavior type. Focus on an understanding of behaviors as a form of resident communication or distress. Residents who exhibit new or worsening behavioral or psychological symptoms of dementia will be evaluated by a health care professional and the care team to identify contributing factors to include treatable medical conditions, physical problems, emotional stressors, psychiatric or psychological factors, social issues, or environmental factors. Involve the resident or the resident's representative(s) in the discussion of potential non-drug and medication interventions to address the management of behaviors, and the involvement should be documented in the resident's medical record. Psychotropic medications may be used to address behaviors only when non-drug approaches and interventions were attempted prior to their use. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. Antipsychotic medication used to treat Behavioral or Psychological Symptoms of Dementia must be clinically indicated, be supported by adequate rationale for use, and may not be used for a behavior with an unidentified cause. When a physician/prescriber orders a psychotropic medication for a resident, the facility should ensure that the physician/prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacologic medication is necessary. Review of the National Institute of Mental Health stated the word psychosis is used to describe conditions that affect the mind, where there has been some loss of contact with reality. When someone becomes ill in this way, it is called a psychotic episode. During a period of psychosis, a person's thoughts and perceptions are disturbed, and the individual may have difficulty understanding what is real and what is not. Symptoms of psychosis include delusions (false beliefs) and hallucinations (seeing or hearing things that others do not see or hear). Other symptoms include incoherent or nonsense speech and behavior that is inappropriate for the situation. A person in a psychotic episode also may experience depression, anxiety, sleep problems, social withdrawal, lack of motivation, and difficulty functioning overall. Someone experiencing any of the symptoms on this list should consult a mental health professional. There is no one specific cause of psychosis. Psychosis may be a symptom of a mental illness, such as schizophrenia or bipolar disorder. However, a person may experience psychosis and never be diagnosed with schizophrenia or any other mental disorder. There are other causes, such as sleep deprivation, general medical conditions, certain prescription medications, and the misuse of alcohol or other drugs, such as marijuana. A mental illness, such as schizophrenia, is typically diagnosed by excluding all of these other causes of psychosis. To receive a thorough assessment and accurate diagnosis, visit a qualified healthcare professional (such as a psychologist, psychiatrist, or social worker).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #4 was admitted to the facility November 13, 2021 with diagnoses of acute embolism and thrombosis of vein, and acute respiratory failure with hypoxia. A review of the care plan initiated on November 16, 2021 revealed the resident was at risk for change in mood or behavior due to medical condition. The goals included the resident desired to be consulted with decisions related to care and desired to participate in care in order to improve current functional status. Interventions included consulting with the resident on preferences regarding customary routine Review of the clinical record revealed an admission MDS assessment dated [DATE] that had dashes entered for every question in Sections C (cognitive patterns) and D (mood) indicating that no information was entered. An interview was conducted on March 8, 2022 at 2:42 PM with an MDS nurse (staff #24), who said that in the RAI manual dashes indicate that a question is incomplete, not done or unable to find information. The MDS nurse stated that she would expect to see Sections C and D completed. She said that Section C and Section D are delegated to a different department. She said that it is Social Services who completes these sections and that Social Services does not have an assistant. Staff #24 stated the MDS nurse signs off on all assessments and checks them for accuracy. She said that staffing issues have caused it to be a struggle to try and stay caught up. An interview was conducted on March 8, 2022 at 3:59 PM with the Director of Nursing (DON/staff #14), who said that the MDS is in place to comprehensively assess the residents and that it is like a 7 day look back. She said that the assessment generates a CAA (Care Area Assessment) and that a comprehensive care plan for the resident is developed from the CAA. The DON stated that she would expect the staff to follow the RAI manual. The DON stated that it does not meet her expectation that Sections C and D were not completed. The facility policy titled Resident Assessment Instrument (RAI) and Care Plan revealed the RAI was designed to assist facility staff in gathering definitive information regarding the resident's life history, needs, strengths, preferences, and goals. Observing and interviewing the resident, family, and staff from all disciplines are required to develop an individualized person-centered care plan that provides a path for the resident achieving or maintaining their highest practicable level of well-being. The Care Area Triggers are derived from the information coded on the MDS that identify residents who have or are at risk for developing specific functional problems that require further assessment. The policy stated the information identified using the MDS and the Care Area Assessment process is used to develop an individualized person-centered care plan that includes the resident's voice, the resident's goals while residing in the facility and for discharge, that assist the resident to attain and/or maintain their highest practicable level of well-being. The policy also revealed a written explanation must be included in the resident's medical record if participation of the resident and their representative is determined not to be practicable for the development of the resident's care plan. The RAI Version 3.0 Manual stated a dash (- ) indicates no information and that CMS (the Centers for Medicare & Medicaid) expects dash use to be a rare occurrence. This manual included that the facility should attempt to conduct the BIMS (Brief Interview for Mental Status/Section C) with all residents and that most residents are able to attempt the BIMS. The manual also stated to attempt to conduct the mood interview (Section D) with all residents and that most residents who are capable of communicating can answer questions about how they feel. -Resident #34 admitted to the facility on [DATE] with diagnoses that included paraplegia, incomplete, personal history of traumatic brain injury, and major depressive disorder. Review of the annual MDS assessment dated [DATE] revealed the assessment areas for cognitive patterns (section C) and mood (section D) contained only dashes which meant the areas were not assessed for the MDS. Based on clinical record reviews, staff interviews, review of facility policy and procedure, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessments were complete for 3 residents (#45, #34, and #4). The sample size was 23. The deficient practice could result in incomplete resident assessments impacting residents' plan of care. Findings include: -Resident #45 admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, cognitive communication deficit, dementia, and pressure ulcer of sacral region. Review of the admission MDS assessment dated [DATE] revealed the assessment areas for cognitive patterns (section C); mood (section D); behavior (section E); and unhealed pressure ulcers/injuries, including current number of unhealed pressure ulcers/injuries at each stage (section M) only contained dashes which meant the areas were not assessed for the MDS. An interview was conducted on March 7, 2022 at 1:49 p.m. with the Director of Nursing (DON/staff #14). She stated that she expected the MDS assessments to be accurate, complete, and for staff to follow regulatory requirements. The DON stated that the cognition and mood sections were required parts of the MDS and should be completed. An interview was conducted on March 7, 2022 at 3:14 p.m. with a Registered Nurse/MDS coordinator (RN/staff #24). She stated that she would refer to the RAI manual for directions when completing the MDS. She stated that the expectation is that the MDS would be filled out completely and per regulatory requirements. She stated that when she dashed a section it meant the section was not completed because she did not have the information, could not find the information, or the assessment was not completed timely and as a result the area was not assessed for the purposes of the MDS. On review of the MDS for resident #45, the RN stated that sections C, D, and M were not complete on the MDS. The RN stated that it is important for the MDS assessment to be complete and accurate as it drives the Care Area Assessments (CAA) and the care plan, and an inaccurate MDS assessment would cause inaccurate communication in multiple areas. The RN stated that she was aware that sections C and D were being dashed on the MDS and the DON had been made aware. An interview was conducted on March 8, 2022 at 10:05 a.m. with Social Services staff (staff #17). She stated that she was responsible for completing sections C, D, E, and Q on the MDS and that it was important to assess those areas and complete the assessments. She stated it was important because the assessment needed to give a clear picture of who the resident is and what they needed, and would tell the facility staff how to take care of the resident appropriately by communicating the assessed areas to staff. Staff #17 stated that if the resident had an alteration in an assessed section it would usually trigger a CAA which would ask for specifics related to the area. Staff #17 stated that once the assessment is complete the information would go into the care plan, but that if an MDS assessment section was not completed any associated CAAs would not trigger. On review of the admission MDS assessment for resident #45, she stated that section C and D had not been completed and should have been. She stated that the assessments were not completed because she did not have enough time to complete all of the required assessments in the building and that she was trying to get support from other staff. Staff #17 stated that all reviewed MDSs that were not complete for section C, D, E, and Q were not completed for the same reason. Review of the RAI manual, Version 1.17.1, dated October 2019 included: -SECTION E: BEHAVIOR Intent: The items in this section identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. These behaviors may place the resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs, preferences or illness. Behaviors include those that are potentially harmful to the resident himself or herself. The emphasis is identifying behaviors, which does not necessarily imply a medical diagnosis. Identification of the frequency and the impact of behavioral symptoms on the resident and on others is critical to distinguish behaviors that constitute problems from those that are not problematic. Once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact. -SECTION M: SKIN CONDITIONS Intent: The items in this section document the risk, presence, appearance, and change of pressure ulcers/injuries. A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program. Pressure ulcers/injuries and other wounds or lesions affect quality of life for residents because they may limit activity, may be painful, and may require time-consuming treatments and dressing changes. Without a full body skin assessment, a pressure ulcer/injury can be missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #58 admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris, major depressive disorder, single episode, unspecified, and unspecified dementia without behavioral disturbance. The quarterly MDS assessment dated [DATE] revealed the assessment areas for cognitive patterns (section C) and mood (section D) contained only dashes which meant the areas were not assessed for the MDS. The facility policy titled Resident Assessment Instrument (RAI) and Care Plan included that the procedures for the Resident Assessment and Care Planning as set forth in the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument User's Manual 3.0 are required when completing the MDS and Care Area Assessment. This document revealed that the MDS uses assessment patient observation, staff, family and patient interviews to form the foundation of the comprehensive assessment and MDS assessments are completed at a minimum upon admission, quarterly, annually, and with a significant change in patient status. Review of the RAI manual, Version 1.17.1, dated October 2019 included: -Section C: the intent of this section is that the items in this section are intended to determine the resident's attention, orientation and ability to register and recall new information and that these items are crucial factors in many care planning decisions. This manual included that the facility should attempt to conduct the interview with all residents and that this interview is conducted during the look-back period of the Assessment Reference Date (ARD) and is not contingent upon item B0700, Makes Self Understood -Section D: the intent of this section is that the items in this section address mood distress, a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity and that it is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable. This manual included that the facility should attempt to conduct the interview with all residents and this interview is conducted during the look-back period of the Assessment Reference Date (ARD) and is not contingent upon item B0700, Makes Self Understood. Based on clinical record review, staff interviews, review of facility policies and procedures and the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate and complete for 3 residents (#10, #30, and #58). The sample size was 23. The deficient practice could result in residents' MDS assessments not being accurate and complete. Findings include: -Resident #10 admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment, major depression, anxiety disorder, bipolar disorder, and schizophrenia. Review of a Significant Change in Status MDS assessment dated [DATE] and a quarterly MDS assessment dated [DATE] revealed under section C/Cognitive Patterns that the Brief Interview for Mental Status (BIMS) should be conducted. However, the BIMS interview and the Staff Assessment for Mental Status contained only dashes which means the areas were not assessed. The assessment, under section D/Mood, indicated that the mood interview should be conducted. However, the Mood Interview and Staff Assessment of Resident Mood contained only dashes. -Resident #30 admitted to the facility on [DATE] with diagnoses that included cerebral infarction, major depressive disorder, and cognition communication deficit. Review of a quarterly MDS assessment dated [DATE] revealed, under section C, that the BIMS should be conducted. However, the BIMS interview and the Staff Assessment for Mental Status contained only dashes which means the areas were not assessed. The assessment, under section D, indicated that the mood interview should be conducted. However, the Mood Interview and Staff Assessment of Resident Mood contained only dashes. Review of a quarterly MDS assessment dated [DATE] revealed, under section C, that the BIMS and the Staff Assessment for Mental Status should be conducted. However, the BIMS interview and the Staff Assessment for Mental Status contained only dashes which meant the areas were not assessed. The assessment, under section D, indicated that the mood interview should be conducted. However, the Mood Interview and Staff Assessment of Resident Mood contained only dashes. An interview was conducted on March 7, 2022 at 1:49 p.m. with the Director of Nursing (DON/staff #14). She stated that she expected the MDS assessments to be accurate, complete, and staff to follow regulatory requirements. She stated that the cognition and mood sections were required parts of the MDS assessment and should be completed. An interview was conducted on March 7, 2022 at 3:03 p.m. with Social Services staff (staff #17). On review of the November 18, 2021 MDS assessment for resident #10, she stated that sections C and D had not been completed. An interview was conducted on March 7, 2022 at 3:14 p.m. with a Registered Nurse/MDS coordinator (RN/staff #24). She stated that she would refer to the RAI manual for directions for filling out the MDS assessment. She stated that the expectation is that the MDS assessment would be filled out completely and per regulatory requirements. She stated that when she dashed a section it meant the section was not completed because she did not have the information, could not find the information, or the assessment was not completed timely and as a result the area was not assessed for the purposes of the MDS assessment. On review of the December 15, 2021 MDS assessment for resident #30, she stated that sections C and D were not complete on the MDS assessment. She stated that it was important for the MDS assessment to be complete and accurate as it drives the Care Area Assessments (CAA) and the care plan and an inaccurate MDS assessment would cause inaccurate communication in multiple areas. She stated that she was aware that sections C and D were being dashed on the MDS assessments and the DON had been made aware. An interview was conducted on March 8, 2022 at 10:05 a.m. with Social Services staff (staff #17). She stated that she was responsible for completing sections C and D on the MDS assessments and that it was important to assess those areas and complete the assessments. She stated it was important because the assessment needed to give a clear picture of who the resident is and what they needed and would tell the facility staff how to take care of the resident appropriately by communicating the assessed areas to staff. She stated that if the resident had an alteration in an assessed section it would usually trigger a CAA which would ask for specifics related to the area. Staff #17 stated that once the assessment was completed the information would go into the care plan, but that if an MDS assessment section was not completed any associated CAAs would not trigger. On review of the last two assessments for resident #30, she noted that section C and D were not completed and should have been. Staff #17 stated that assessments were not completed because she did not have enough time to complete all of the required assessments in the building and that she was trying to get support from other staff. She stated that all reviewed MDS assessments that were not complete for section C & D were not completed for the same reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure the accurate completion of a Pre-admission Screening and Resident Reviews (PASRR), and failed to complete/update a PASRR when the resident's stay exceeded 30 days for one sampled resident (#10). The deficient practice could result in failure to refer a qualifying resident to level 2 services. Findings include: Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major Depressive Disorder, Bipolar Disorder, Anxiety Disorder, and Schizophrenia. The resident's primary diagnosis was listed as chronic respiratory failure with hypoxia. Review of a PASRR Level 1 (version 04/2020) dated May 18, 2021 revealed the PASRR Level 1 review type to be pre-admission. The form was marked no for the question: Does the individual have any of the following Serious Mental Illnesses, which included the options of Schizophrenia, Major Depression, and Bipolar Disorder. The form was marked no for the question: Does the individual have any of the following mental disorders, which included Anxiety Disorder. The Referral Determination stated no referral necessary for any Level 2. However, the resident did have diagnoses of Serious Mental Illness and Mental Disorder. Review of a PASRR Level 1 (version 03/2006) dated August 06, 2021 revealed for an exemption for Convalescent care (admission from the hospital after receiving acute inpatient care, requires Nursing Facility (NF) services for same condition and physician has certified before admission to the NF that individual requires 30 days or less NF services. The section titled Identification of Potential Mental Illness documented that the resident had no primary diagnosis of serious mental illness, and no level of impairment limiting life activities within the past 3 to 6 months, and no recent treatment within the past two years. The Referral Action was no referral necessary for any Level 2. Review of the clinical record did not reveal the completion/update of a PASRR Level 1 when the resident stayed in the facility over thirty days following readmission on [DATE]. An interview was conducted on March 7, 2022 at 3:03 p.m. with the Social Services Director (staff #17). She stated that the facility receives a Level 1 PASRR screening from the hospital when the resident is admitted and that the PASRR was expected to be accurate. She stated that facility staff would look over diagnoses when reviewing the new admission. She stated that if she noticed the resident had a qualifying diagnosis, she would initiate a level two for that resident. She stated that the PASRRs for resident #10 were not accurate as the resident had qualifying diagnoses that were not included, and that the resident should have been referred for a level two. She stated that when a resident is discharged to the hospital from the facility, a new PASRR would be completed when the resident returned. Another interview was conducted on March 8, 2022 at 10:05 a.m. with the Social Services Director (staff #17). She stated that she had reviewed the resident's medical records and that no level two referral had been sent for resident #10. She stated the risk of an inaccurate PASRR screening was that a resident may not receive appropriate services for their psychiatric diagnosis. An interview was conducted on March 8, 2022 at 10:59 a.m. with the Director of Nursing (DON/staff #14). She stated that the PASRR was done on admission and that the facility usually receives the screening from the hospital. She stated that the screening documentation was based on the resident's mental illness and developmental disability. She stated that social services should review the PASRR for accuracy and if the screening was not accurate/was on the wrong form, should update it with current form/accurate information. She stated the PASRR would not be considered accurate if it did not include the resident's diagnosis specific to the form. She stated if the resident had Schizophrenia, Major Depression, and Bipolar Disorder the resident should have been referred for a level two determination. She stated an inaccurate/incomplete screening puts the resident at risk for unmet psychosocial, psychiatric, and mental needs. Review of a facility policy titled Pre-admission Screening (PASRR) last reviewed August 7, 2021 revealed PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASRR requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability, be offered the most appropriate setting for their needs, and receive the services they need in those settings. Ensure a Level 1 PASRR screening has been completed on all potential admissions prior to admission. A negative Level 1 screen permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual disability arises later. A positive Level 1 screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASRR Level 2, which must be conducted prior to admission to a nursing facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #130 was admitted to the facility on [DATE] with diagnoses that included hydrocephalus, unspecified, heart failure, unspecified, and primary hypertension. A physician order dated 02/18/22 included for Metoprolol Tartrate 100 mg. Give 1 tablet by mouth two times a day for hypertension. Review of the Medication Administration Record (MAR) for February 2022 revealed the medication was administered twice daily per the physician order from 02/18/22 through 02/28/22. Another physician order dated 02/28/22 revealed for Metoprolol Tartrate 100 mg. Give 1 tablet by mouth two times a day for hypertension, hold for systolic blood pressure less than 95 and/or heart rate less than 55. Review of the MAR for March 2022 revealed Metoprolol Tartrate was administered as ordered. However, review of the baseline care plan did not include antihypertensive medication use. An interview was conducted on 03/08/22 at 1:02 p.m. with the DON (staff #14). She stated that her expectation is that high risk medications, including antihypertensives, be included in the resident's care plan. The DON stated that not including Metoprolol Tartrate in the care plan did not meet her expectations. Review of the facility policy titled Care Planning - Baseline, Comprehensive, and Routine Updates revealed completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission. The baseline care plan must include the minimum health care information necessary to properly care for each resident immediately upon admission and a summary must be presented to the resident or their representative that includes the initial goals of the resident, a summary of the resident's medications and dietary instructions, services, and treatments to be administered by the facility, and any updates. Based on clinical record reviews, staff interviews, and review of policy, the facility failed to ensure dementia and psychotropic drug use was included in one resident's (#45) baseline care plan; and failed to ensure antihypertensive medication use was included in one resident's (#130) baseline care plan. The sample size was 23. The deficient practice could result in residents' needs not being identified and interventions not being in place to address those needs. Findings include: -Resident #45 admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, dysphagia, cognitive communication deficit, and dementia. Review of the physician's orders dated January 6, 2022 revealed for: -Quetiapine Fumarate/Seroquel (antipsychotic) tablet 25 milligram (mg) give one tablet by mouth two times a day for anxiety as evidenced by (AEB) crying; -Document number of hours of anxiety AEB crying. The provider's progress note dated January 7, 2022, included a diagnosis of dementia. The baseline care plan signed January 11, 2022 did not address the resident's diagnosis of dementia or antipsychotic medication use. In addition, no evidence was revealed the baseline care plan was developed within 48 hours of admission as the only date was the date the nurse signed. An interview was conducted on March 7, 2022 at 1:49 p.m. with the Director of Nursing (DON/staff #14). She stated if nurses note that the resident had dementia and had additional needs they would bring it up in grand rounds and the needs would be further assessed with the provider. She stated that dementia should be included on the baseline care plan. Another interview was conducted on March 7, 2022 at 2:25 p.m. with the DON (staff #14). She stated that an antipsychotic medication should be used for a resident if it was determined to be needed by the provider. She stated it was important to have an appropriate diagnosis/behavior for use of the medication and that the resident would be monitored each shift for behaviors and side effects. She stated if staff suspect side effects or noted an escalation in behaviors they would let the provider know. The DON stated she would expect the baseline care plan to include psychotropic medication use. An interview was conducted on March 8, 2022 at 11:53 a.m. with a Registered Nurse/Care Manager (RN/staff #26). She stated that the floor nurse admitting the resident would initiate the baseline care plan. She stated that the baseline care plan establishes what the resident's admitting diagnoses are and is used as a guide for caring for the resident until the comprehensive care plan is completed. The RN stated that dementia and psychotropic drug use should be included on the baseline care plan and that it is important for the care plan to be current and accurate as it is used to inform staff how to take care of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Regarding surgical incision monitoring: Resident #387 admitted to the facility on [DATE] with diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing; muscle weakness (generalized); and need for assistance with personal care. Review of the clinical record revealed a physician order dated 02/18/22 to monitor the left lower extremity surgical incision for signs and symptoms of infection every shift. The care plan initiated on 2/18/22 revealed the resident had actual impairment to skin integrity of the left lower extremity related to surgical wound. The goal was for the resident to maintain or develop clean and intact skin, and to monitor for signs and symptoms of infection. Interventions included wound treatments and weekly skin checks, as ordered. The resident's weekly skin assessment dated [DATE] revealed that weekly skin assessment was performed with no significant findings. Review of the admission Minimum Data Set assessment dated [DATE] revealed the resident required one-person assistance with eating and personal hygiene, and two or more-person assistance with bed mobility, transfers, locomotion on the unit, dressing, and toilet use. Review of the Treatment Administration Record (TAR) revealed no evidence that the surgical incision was monitored for 4 shifts: Day shift 2/19/22, Day shift 2/24/22, Day shift 2/25/22, and Day shift 2/26/22. An interview was conducted with a Certified Nursing Assistant (CNA/staff #33) on 03/02/22 at 02:42 PM. The CNA stated her role includes assisting residents with whatever basic skin needs they have, repositioning residents to prevent pressure injuries and ensure skin integrity. The CNA stated the CNAs can check bandages and will report anything concerning to the nurse. The CNA also stated that if they see anything on a resident's skin during a shower, they would mark it on the shower sheets. An interview was conducted on 03/02/22 at 02:55 PM with a Licensed Practical Nurse (LPN/staff #28). Staff #28 stated the floor nurses are responsible for evaluating wounds, changing dressings, and following up with the wound nurse as needed. The LPN stated the wound nurse is able to perform assessments and decide if physician evaluation is needed. The LPN stated that for a resident with a surgical wound, the duty of the floor nurse is to monitor the wound daily and notify the physician of any concerns. Staff #28 stated the wound observations need to be documented in the electronic record system and that if the nurse cannot perform a wound observation, they have to document why they were not able to do so. The LPN stated that if there is no documentation in the treatment or medication admiration record for wound observations or treatments, that means the nurse either did not observe the wound or they did not document that they did the observation. The LPN stated that management would contact the nurse to do the observation and document if any care was performed. An interview was conducted on 03/08/2022 at 03:59 PM with the Director of Nursing (DON/staff #14). The DON stated that it is her expectation that nurses follow physician orders and document any medications or treatments they perform for surgical wound care in the MAR and TAR. The DON stated the nurse on the floor is in charge of making sure the treatments get done. She stated the management staff conducted random audits to ensure treatments are being performed. The DON stated a surgical wound not being monitored for 4 shifts does not meet her expectations for nursing care. A facility policy titled, Wound Management, Long-term Care, revealed that when assessing a resident's skin, a strong wound care team is required to evaluate and ensure that protocols have the ability to address any risk factors for worsening of patient condition. Specific interventions included continuous skin assessment, consistent monitoring and intervention to prevent worsening of injuries. Regarding wound assessment and treatment: Resident #278 was admitted on [DATE] with diagnoses of encounter for surgical aftercare following surgery on the circulatory system, muscle weakness and need for assistance with personal care. This resident was discharged on September 24, 2021. A hospital departure document faxed September 9, 2021 revealed this resident had multiple bullae with some ruptured and weeping edema from bilateral lower extremities (BLE) and median sternotomy and chest tube dressings. An Admission/readmission Collection Tool dated September 12, 2021 stated this resident had weeping wounds to both lower extremities, a surgical site to the abdomen, and was status post mitral valve replacement to the chest. A Care Plan dated September 14, 2021 revealed the resident has a break in skin integrity. Interventions included weekly skin checks and treatment as ordered. Review of physician orders dated September 14, 2021 stated to cleanse and apply dressing to the chest and abdominal surgical site; and to cleanse the BLE areas with normal saline, apply kerlix and ace bandage three times a week on the day shift on Monday, Thursday, and Saturday and as needed for BLE edema. A review of the Treatment Administration Record for September 2021 revealed the treatment was provided to the BLE but did not reveal evidence that the treatment to the chest and abdominal surgical sites was done. Continued review of the clinical record including Weekly Skin Integrity Data Collection dated September 14 and 21, 2021 did not reveal evidence of an assessment of the wounds or that a Wound Observation Tool had been completed. A 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had surgical wound care and application of nonsurgical dressings during the lookback period. An interview conducted on March 2, 2022 at 10:49 AM with the Director of Nursing (DON/staff #14), who said that residents' skin is assessed upon admission and documented in the Initial admission in the skin integrity section. She said that once the admitting nurse conducts the head to toe skin assessment, the nurse will inform the wound nurse if the resident has a wound. The DON stated the physician would be notified and an intervention would be put into place. She said that if the wound nurse is present on admission, she will conduct the head to toe skin assessment otherwise the wound nurse will see the resident the next day and document her findings. This DON reviewed the resident's chart and said that on the admission Assessment she saw that the resident had weeping leg wounds and surgical wounds. The DON stated there is an order for the leg wounds but did not see anything in the documentation regarding the chest wound assessment. A follow up interview with the DON (staff #14) was conducted on March 8, 2022 at 3:59 PM, who said that when staff find a wound they should report it to the wound nurse, DON, or wound designee. She said that she would expect the staff to document the length/width/depth, wound bed, wound edge, drainage, smell, and staging if the type of wound required staging. The DON stated that her expectations for wound assessment would be that once the wound has been assessed that staff would complete a wound monitoring tool and weekly skin assessment. She said that the Wound Observation Tool is where the measurements are documented. The DON stated that the assessments of these wounds did not meet expectations. A facility policy titled Documentation and Assessment of Wounds revealed that the purpose of this policy was to guide the associates and licensed nurse in the assessment of wounds to include pressure ulcer/injuries, venous, arterial, diabetic, dehisced surgical wounds, and other (not otherwise specified). This document included that a wound assessment/documentation is required to occur at a minimum 'weekly' and that documentation is located in the EHR- progress notes, (WOT) Wound Observation Tool, and/or Skin Integrity Data Collection Tools. Based on clinical record reviews, staff and resident interviews, and review of policies and procedures, the facility failed to ensure communication was provided to hospice for one sampled resident (#128) regarding a change in condition; failed to ensure one of three sampled resident (#387) received surgical incision monitoring according to physician's orders; and failed to ensure wound assessment and treatment were conducted for two of three sampled resident (#278). The deficient practice could result in reduced quality of care for residents. Findings include: Regarding communication with Hospice: Resident #128 admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, cachexia, and weakness. Review of the resident's care plan initiated on February 25, 2020 revealed the resident had a terminal prognosis. The interventions included to work cooperatively with the hospice team to provide the resident's spiritual, emotional, intellectual, physical, and social needs. A quarterly MDS assessment dated [DATE] revealed the resident was receiving hospice services at the facility. Review of a nurse progress note dated October 27, 2020 revealed the resident had fallen out of the chair and had a contusion to the right cheek/eye with an abrasion above it. The note stated that notifications were made to the family, Medical Doctor (MD), and the on-call nurse. However, the note did not include that hospice was notified of the fall. Review of a quarterly MDS assessment dated [DATE] revealed the resident was receiving hospice services at the facility. Review of a nurse progress note dated January 19, 2021 revealed the resident had fallen in the room and had bruising to the left eyebrow and left deltoid, a bump to the forehead, and a skin tear to the left forearm. The note stated that notifications were made to the family, DON, unit manager, and the MD. However, the note did not include that hospice was notified of the fall. Review of a Palliative care note dated January 20, 2021 revealed that per the facility LPN, the resident fell yesterday and had a bruise to the eyebrow and shoulder. The Palliative Care Registered Nurse (RN) documented attempts had been made to reach the facility 6 times yesterday, was placed on hold and sent to voice mail that hung up. The note included the Palliative Care RN was notified of the fall by the resident family member, not the facility. The note included the Palliative RN spoke today to the facility LPN, and that the LPN stated that he forgot to call hospice and that he did not have the hospice phone number. The Palliative RN offered the number but the LPN declined and stated that the number was in a staff member's office. An interview was conducted on March 3, 2022 at 9:49 a.m. with a RN (staff #127). He stated there was no documentation in the clinical record to show that hospice was notified at time of the falls on October 27, 2020 and January 19, 2021, and that hospice should have been notified. The LPN stated that facility protocol would be for the nurse caring for the resident to call hospice if a resident had a change of condition, injury, or fall. An interview was conducted on March 3, 2022 at 11:18 a.m. with an LPN (staff #64). She stated that if a resident is on hospice, the facility would notify hospice of any fall the resident had at the time the fall happened. The LPN stated that this was facility protocol for communication with hospice. An interview was conducted on March 7, 2022 at 1:49 p.m. with the DON (staff #14). She stated that the facility would notify the provider, hospice, and family of any accidents or changes in a resident's condition. The DON reviewed the clinical documentation for the resident's fall on January 19, 2022 and stated that there was no documentation that the facility notified hospice of the fall. Review of a facility policy for Hospice Coordination of Care reviewed May 7, 2021 revealed the care of the resident receiving hospice services must reflect ongoing communication and collaboration between the nursing home and the hospice staff. The designated IDT member facilitates communication between the facility and hospice and includes the resident's representative in decision making. A communication process is established between the facility and hospice to ensure the needs of the resident are addressed and met 24 hours a day and that the communication is documented to reflect concerns and responses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #42 admitted to the facility on [DATE] with diagnoses that included paraplegia, unspecified, mild protein-calorie malnutrition, and type 2 diabetes mellitus. Review of the admission MDS assessment dated [DATE] revealed the resident had a stage 4 pressure ulcer (PU) that was present upon admission. Review of the care plan dated 05/01/19 revealed the resident had a potential for impairment to skin integrity related to impaired mobility due to spinal cord injury, prior stage 4 PU to the sacrum, diabetes mellitus, and limited mobility. The goal was the resident will remain clean and free of skin breakdown. Interventions included pressure relieving/reducing cushion and heel pillows to protect the skin while the resident is up in the chair. A skin/wound note dated 02/13/20 revealed the wound to the resident's sacrum had been resolved. A physician order dated 06/24/20 included for turning and repositioning every 2 hours every shift, with instruction to wake the resident up if needed. Regarding the PU to the coccyx: An alert progress note dated 04/11/21 at 11:52 a.m. revealed that at 11:00 a.m. as a CNA was turning the resident to the side, the CNA saw an opening on the resident's coccyx. The note stated that the wound was in the same area where the old wound was and measured 5 cm x 7 cm x 1 cm. The note stated the wound was cleansed with normal saline and a foam dressing was applied over the wound. The note stated notifications were made. A Weekly Skin Integrity Data Collection dated 04/12/21 revealed that the resident's skin was not intact and that the finding was not new. A description of the site included that a dressing was in place to the coccyx. However, no complete assessment of the wound was completed. A Skin/Wound note dated 04/16/21 at 11:52 a.m. revealed the wound team assessed the re-injury to the previous stage 4 coccyx wound. Per the note, the wound had shallow skin destruction on scarred tissue on the coccyx. The wound was described as pearly pink in color, with attached even edges, and a moist wound base. The surrounding skin was described as macerated, and that moisture was likely a key factor in reinjury. The note stated the treatment was updated, the resident and staff were encouraged to reposition frequently, and provide meticulous hygiene. The note stated an air mattress and Roho cushion were in place. However, the documentation did not reveal evidence that a complete assessment had been performed. Review of the resident's care plan did not reveal an update or revision had been initiated to include the changing status of the resident's skin. A Weekly Skin Integrity Data Collection dated 04/19/21 revealed there was an open area to the resident's coccyx, a treatment was in place, and there was redness to the surrounding area. The significant change in status MDS assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. The assessment also revealed the resident required extensive 2-person assistance for most activities of daily living, and had a stage 4 PU that was not present upon admission/reentry. A Wound Observation Tool dated 04/22/21 at 11:49 a.m. revealed the resident had an acquired stage 4 PU to the coccyx that had been observed on 04/12/21. The assessment included that the overall impression of the visible tissue was that it was improving, beefy red granulation tissue was present, there was a scant amount of serous drainage, and the wound measured 0.8 cm x 0.5 cm x 0.3 cm. The additional comments stated the resident had a re-injured prior stage 4 pressure injury (PI) that was superficially eroded and macerated. No signs or symptoms of infection or pain were noted. Current treatment/plan included collagen/silver alginate. A Skin/Wound note dated 04/29/21 at 8:41 a.m. revealed improvement to the coccyx wound continued, the dimensions were smaller, and the resident was compliant with repositioning. The Wound Observation Tool dated 04/29/21 at 8:44 a.m. revealed the acquired stage 4 PU was improving, had beefy red granulation tissue, no drainage, and measured 0.2 x 0.2 cm x 0.2 cm. A Wound Observation Tool dated 05/06/21 at 1:18 p.m. stated the acquired stage 4 PU had healed/resolved. Epithelial tissue was present, and there was no drainage. A Skin/Wound note dated 05/18/21 at 3:46 p.m. revealed the recently resurfaced stage 4 PI to the resident's coccyx was re-injured. The note stated the wound was very small and round with minor depth. The surrounding skin was described as moist and macerated. The note stated that treatment had been reinstated, microclimate management options reviewed, and that the physician and dietary had been notified. However, a thorough wound assessment, including wound measurements, was not completed. Review of the Weekly Skin Integrity Data Collection dated 05/24/21 through 07/05/21 revealed weekly skin observations and treatments to the sacrum was provided. However, a complete assessment of the wound was not done from 05/18/21, when the reinjury was identified, through 07/07/21. A Wound Observation Tool dated 07/08/21 at 2:01 p.m. revealed the previous acquired wound to the coccyx had reopened. The wound was classified as a stage 2 PU. The wound bed was described as pink epithelial tissue and beefy red granulation tissue, with a scant amount of serosanguinous drainage. The wound measured 0.9 cm x 1.0 cm x 0.1 cm. Additional comments stated the previous wound had re-opened, that no signs or symptoms of infection or pain were observed, and the current treatment plan included collagen/silver alginate. A Skin/Wound note dated 07/08/21 at 2:11 p.m. revealed the previous wound to the resident's coccyx had reopened. The wound was described as 50% granulation vs 50% epithelial tissue. The note also revealed the TAR orders had been updated. A Plan of Care note dated 07/14/21 at 11:52 a.m. revealed the wound to the coccyx had reopened and was being treated. The note stated that the wound NP would assess the wound that week and that wound care continued. Review of the clinical record revealed wound assessments were provided on 07/15/22 and 07/22/22 with no significant changes. Review of the July 2021 TAR revealed treatments/dressing changes were provided per physician orders. Further review of the TAR revealed turning and repositioning was performed every 2 hours, with the exception of 07/18 and 07/29 on the day shifts, when there was no documentation to indicate whether or not turning had been performed. A Wound Observation Tool dated 08/01/21 revealed a complete wound assessment. The wound measured 0.5 cm x 0.5 cm x 0.1 cm and the wound bed was described as pink epithelial tissue. A Skin/Wound note dated 08/01/21 at 4:38 p.m. revealed the small wounds to the coccyx remained unchanged in appearance and size. Treatment was updated to include Venelex (wound barrier) to the area daily and as needed. No drainage was present. A Nutrition/Dietary note dated 08/03/21 at 11:34 a.m. revealed wound care was noted, and the resident had own protein supplements and snacks in the room. The potential for impairment to skin integrity care plan was updated on 08/12/21 to include treatments as ordered. A Skin/Wound note dated 08/13/21 at 1:02 p.m. revealed the wound to the coccyx had declined in size and appearance with 10% of slough present and no drainage. Per the note, the provider was present. However, a thorough wound assessment, including wound measurement, was not performed from 08/02/22 through 08/20/22. A Skin/Wound note dated 08/20/21 at 2:37 p.m. revealed the wound had decreased in the amount of slough, the measurements and treatments remained the same, and the wound NP would follow up the following day. However, review of the clinical record did not include wound NP notes for the following day. A Wound Observation Tool dated 08/25/21 at 12:47 p.m. revealed the acquired stage 2 PU remained unchanged, had epithelial tissue, no drainage, and measured 1.5 cm x 1.5 cm x 0.2 cm. Additional comments included the previous wound reopened, small open areas below at 0.3 cm x 0.3 cm x 0 cm. No signs or symptoms of infection or pain present. Current treatment included triamcinolone (steroid/anti-inflammatory) & Venelex daily and as-needed. Review of the August 2021 TAR revealed treatments were provided in accordance with the physician orders. Per the TAR, repositioning was performed every 2 hours. A Skin/Wound note dated 09/03/21 at 6:31 a.m. revealed the wound to the coccyx had increased in measurements. The wound was described to have non-granulation tissue present with yellow tissue apparent as well. The wound NP was present and ordered an update on the treatment. The note also revealed the resident voiced a lot of anxiety related to the wound and decline. A Wound Observation Tool dated 09/03/21 at 6:35 a.m. revealed the stage 2 PU had worsened. The wound had epithelial tissue present, a scant amount of serosanguinous drainage, measured 2.5 cm x 2.5 cm x 0.5 cm. No signs/symptoms of infection or pain present. The current treatment included cleansing the area well, packing iodoform ribbon into the wound with a 1 cm tail hanging, covering with a foam dressing, every other day and as needed. On 09/07/21, the potential for impairment to skin integrity care plan was updated to include turning and repositioning as needed and as tolerated to prevent skin breakdown, and Swing Master exerciser for 15-30 minutes as needed. However, a thorough wound assessment was not conducted again until 09/17/21. A Wound Observation Tool dated 09/17/21 at 8:12 a.m. stated the stage 2 PU to the coccyx was improving. The visible tissue was described as epithelial/pink, with a scant amount of serosanguinous drainage. The wound measured at 2.0 cm x 2.0 cm x 0.3 cm. The treatment remained unchanged. Per the clinical record, a thorough wound assessment was conducted on 09/29/21. The September 2021 TAR revealed treatments/dressing changes were provided as ordered. Per the TAR, turning and repositioning was performed daily, with the exception of 09/24 when there was no evidence to indicate whether or not turning had been provided. There was no evidence to indicate that the Swing Master had been utilized. Review of the clinical documentation revealed that treatments/dressing changes were performed from 10/08/21 through 11/24/21. Wound assessments were performed on 10/08, 10/19, 10/27, and 11/05 through 11/24. Review of the Wound Observation Tool dated 12/03/21 revealed the acquired PU to the coccyx was now classified as a stage 3. The tool revealed epithelial tissue was present, there was no drainage, pain, signs or symptoms of infection, and the wound measured 1.5 cm x 1.5 cm x 0.3 cm. Treatments were updated to include Anasept wound gel (antimicrobial), pack wound, cover with foam dressing 3x week and as needed. The Wound Observation Tool dated 12/10/21 revealed the stage 3 PU was assessed and measured 1.5 cm x 1.5 cm x 0.3 cm. Treatment orders were updated to include application of fungal powder, packing the wound with 2x2 gauze, and covering with gauze. Per the clinical documentation, wound assessments were conducted on 12/22/21 and 12/28/21. The December 2021 TAR revealed treatments and turning/repositioning were provided as ordered. Review of the physician orders revealed the order to turn and/or reposition the resident was discontinued on 01/06/22. Per review of the Wound Observation Tools, the wound was not assessed again until 01/15/22, and was assessed again on 1/26/22 stating the wound was unchanged. Review of the January 2022 TAR revealed treatments were provided as ordered and that turning/repositioning was done through 01/06/22. Further review of the wound assessments did not reveal a wound assessment until 02/15/21 which stated the wound was unchanged and measured 1.5 cm x 1.5 cm x 0.3 cm. Review of the Wound Observation Tool dated 02/28/22 revealed the stage 3 ulcer was unchanged and measured 1.5 cm x 1.5 cm x 0.3 cm, had epithelial tissue, no drainage, no pain, and no signs or symptoms of infection. An interview was conducted with the resident on 02/28/22 at 12:02 p.m. The resident stated that at night, staff only turned her twice and that the staff stated it is because they do not have enough staff to turn her more frequently. The resident stated that she thinks the wound on the coccyx is getting better. On 03/03/22 at 11:26 a.m., an observation of wound care was conducted with a Registered Nurse (RN/staff #128). The wound measured 1.3 cm x 1.5 cm x 0.3 cm. The stage 3 PU was described as pink/granulation tissue, with a small amount of serosanguinous drainage, so signs or symptoms of infection or pain, no odor, and no tunneling or undermining. On 03/07/22 at 10:57 a.m., an interview was conducted with the resident. The resident stated that she had been admitted to the facility with a pressure ulcer, that it had gotten better for a while, but that it came back. The resident stated that she has had the wound on the coccyx for a long time. The resident stated that the CNAs put the Swing Master on at about 7:30 p.m., then they turn/reposition her at about 8:30 p.m. The resident stated that she is repositioned around midnight and then again around 3 or 4 in the morning. The resident stated that the day shift staff will reposition her and put the Swing Master on again at about 9:00 a.m. The resident stated that she does not always receive repositioning when she needs it. The resident stated that her neck and shoulders hurt quite a bit because she lays in the same position for hours. The resident stated that she would like to get up and sit in the wheelchair, but that it is broken. An interview was conducted on 03/08/22 at 3:15 p.m. with the DON (staff #14). She stated that the goal is for the resident to be repositioned every 2 hours and as needed. She stated that repositioning should be documented per protocol and nursing judgment. She stated that they say if it is not documented, it did not happen. The DON stated that when a wound has been identified, a wound assessment should be completed right away, or within 24 hours. The DON stated that the nurse manager or she has also been designated to assess wounds if the wound nurse was not available. The DON stated that a complete assessment would include a wound measurement, staging, description of the wound bed, drainage, odor, signs or symptoms of infection, and the surrounding tissue; and should also include interventions and treatments provided. She stated that pressure ulcers should be assessed at least weekly. The DON stated that it would not meet her expectations for a lapse in assessment of 2 weeks or more. She stated that it would not meet her expectations if a thorough assessment had not been conducted. The DON stated that weekly wound assessments were intended to monitor for potential complications, further breakdown, and infections. She stated that the wound care did not meet her expectations. The facility policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management stated the intent is to provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the National Pressure Injury Advisory Panel (NPIAP) and Wound, Ostomy, Continent Nurses Society (WOCN). Based on the comprehensive assessment of a resident, the facility must ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure ulcers from developing. A skin assessment/inspection should be performed weekly by a licensed nurse. Measures to maintain and improve the resident's tissue tolerance to pressure are implemented in the plan of care. Upon admission and throughout the stay, at a minimum, a pressure redistribution surface should be in use with turning and repositioning as needed with ADL care/assistance, incontinence care if needed to include skin barriers application as needed, and preventative wheelchair cushion if indicated, etc. When skin breakdown occurs, it requires attention and a change in the plan of care to appropriately treat the resident. Based on clinical record review, observations, staff and resident interviews, and review of policies and procedures, the facility failed to ensure two of two sampled residents (#42 and #45) received care, consistent with professional standards of practice, to prevent and promote the healing of pressure ulcers. The deficient practice could result in wound complications and further pressure ulcer formation for residents. Findings include: -Resident #45 admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, cognitive communication deficit, need for assistance with personal care and pressure ulcer of sacral region, unspecified stage. Review of the physician orders revealed an order dated January 6, 2022 to monitor for signs and symptoms of infection to sacral ulcer every shift for decubitus. A Braden Scale for Predicting Pressure Sore Risk and Risk Factors dated January 6, 2022, revealed the resident was at high risk with a score of 14 and included a potential problem for friction and shear as the resident moves feebly or required minimum assist. During a move, skin probably slides to some extent against sheets, the chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. Risk factors included decreased or impaired bed/chair mobility; urinary or bowel incontinence; history of pressure ulcers; and lean muscle mass. Review of a nursing progress note dated January 7, 2022 revealed the resident had a foam dressing to the coccyx in place. Review of the Admission/readmission Collection Tool revealed the resident's weight and vital signs were obtained on January 7, 2022. The tool also revealed the resident had friction/shearing of the skin, the left front knee had 4 small scabs intact, the right heel had redness with heel pillows in place, there was blanchable redness to the sacrum, and the left foot/third toe had a small scab that was intact. The tool was signed by a Registered Nurse (RN) on January 21, 2022 including the section for Skin Condition. Review of a nursing progress note dated January 10, 2022 revealed use of zinc oxide to buttocks to prevent skin breakdown. However, review of the clinical record did not reveal an order for the zinc oxide use. Review of a nursing progress note dated January 11, 2022 revealed heel pillows were in place during bed hours, the right heel had peeled dead skin, skin prep was applied to build a shield, and heel elevated on pillows. The note also revealed Zinc was applied to the groin for redness and the coccyx had no open areas. The note also revealed the resident was alert and oriented with confusion and forgetfulness. Review of the care plan initiated on January 11, 2022 revealed the resident was at risk for break in skin integrity. The goal was that the resident would maintain intact skin with no skin breaks. The interventions included to clean and dry skin after each incontinent episode, pressure reducing mattress, and weekly skin checks. Review of the physician orders dated January 12, 2022 included heel pillows while in bed. Review of a nursing progress note dated January 12, 2022 revealed redness was noted to the sacral area with no signs/symptoms of infection. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was at risk of developing pressure ulcers and had a pressure reducing device for the bed. The assessment did not include whether the resident had one or more unhealed pressure ulcer(s) at Stage 1 or higher; or if the resident had any other ulcers, wounds and skin problems. The assessment also revealed the resident had an indwelling urinary catheter, was always incontinent of bowel, and needed extensive assistance of one person for toilet use. Additional review of the clinical record did not reveal a weekly skin assessment had been conducted a week after admission. Review of a Weekly Skin Integrity Data Collection sheet dated January 21, 2022 revealed the resident had an open area/wound to the right heel that was new. The documentation also revealed the Nurse Practitioner (NP) was notified of the heel wound, Mepilex was placed on both heels, and that resident had heel pillows on. The sites and descriptions included an open right heel wound. Further review of the clinical record did not reveal an assessment of the right heel. The physician orders dated January 21, 2022 stated to cleanse and apply Mepilex to the bilateral heels every 3 days on the night shift and as needed (PRN). Review of the Treatment Administration Record (TAR) for January 2022 did not reveal that staff monitored for signs and symptoms of infection to sacral ulcer on January 26, 2022 on the night shift. The area was left blank. Review of a Weekly Skin Integrity Data Collection dated January 30, 2022 revealed documentation that the resident's skin was intact. However, the previous Weekly Skin Integrity Data Collection form indicated that the resident had impaired skin and review of the clinical record did not include healing of the identified open area. Review of the TAR for January 2022 revealed a code 10, which means other/see progress note, for the treatment to the bilateral heels on January 30, 2022. However, review of the progress notes for January 30, 2022 only contained the order and no further documentation regarding the treatment. Review of Weekly Skin Integrity Data Collections dated February 4, 2022 revealed the resident had an open area/wound which was not new and that there were no new findings. The site and descriptions included a healing right heel wound with heel pillows in place and blanchable redness to the sacrum. However, review of the clinical record did not reveal further assessment of the right heel. Review of a nursing progress note dated February 6, 2022 revealed the resident had wound care to the bilateral heels and that the order needed to be updated. The note stated the wounds were cleansed and Medihoney was applied to the wound beds. The note also revealed the right heel wound measured 4 centimeters (cm) by 4 cm, the ulcer to the left heel measured 2 cm by 2 cm, and that there were ulcers on the bony prominence to the outer left foot area. A review of the Wound Observation Tool for February 6, 2022 revealed the resident had a facility acquired stage 3 pressure ulcer to the right heel that was improving. The tool also revealed there was no drainage, no pain, no infection; tissue with red beefy skin and slight areas of dark red, and measured 2.0 cm x 2.4 cm x 0.1 cm. The tool stated the measurements of 4 cm x 4 cm by the floor nurse on February 6, 2022 indicated the wound measurements had improved. Bilateral heel pillows, long bed, and current treatment order completed. Review of another Wound Observation Tool dated February 6, 2022 revealed the resident had a facility acquired unstageable pressure ulcer to the left outer heel that had slough/eschar, epithelial tissue, scant amount of serosanguineous drainage, no pain, no infection, and measured 1.5 cm x 2.5 cm x 0.1 cm. The comments included the left heel wound was measured by the floor nurse on February 6, 2022 and measured 2 cm x 2 cm. Treatment orders in place, heel pillow in place. Review of the Weekly Skin Integrity Data Collection dated February 13, 2022 revealed the resident had an open wound to the right heel, blanchable redness to the sacrum, and that there were no new findings. The Weekly Skin Integrity Data Collection dated February 17, 2022 only stated the skin was not intact and there were no findings. Review of the February 2022 TAR revealed a code of 10 on February 20, 2022 for the treatment to the bilateral heels. However, review of the progress note revealed the order and no further documentation regarding the treatment. The care plan initiated on February 28, 2022 and revised on March 3, 2022 revealed the resident has pressure ulcers to the bilateral heels or the potential for pressure ulcer development related to the history of ulcers. The goal was that the pressure ulcer will show signs of healing and remain free of infection. Interventions included administering treatments as ordered, following the facility policies/protocols for the prevention/treatment of skin breakdown, educating the resident/family/caregivers as to causes of skin breakdown including transfer/positioning requirements and the importance of frequent repositioning, and if the resident refuses treatment, confer with the resident, IDT (Interdisciplinary Team), and family to determine why and try alternative methods to gain compliance and document the alternative methods. Review of a Weekly Skin Integrity Data Collection dated March 1, 2022 revealed the resident's left heel had an unstageable pressure injury, the left lateral foot had a stage 3 pressure injury, the right heel had a stage 3 pressure injury, and there were no signs or symptoms of infection to the wounds. Review of the physician orders for March 1, 2022 revealed the following: -Right heel wound - cleanse, apply foam dressing 3 times a week every Monday, Thursday, and Saturday and as needed; -Left heel and ankle - Cleanse with normal saline, cover wounds with silver foam, wrap in Kerlix/Ace bandage 3 times a week every Monday, Thursday, and Saturday; -Bilateral Heel pillows - on at all times when in bed; -Long bed. Review of nursing progress notes dated March 4, 2022 revealed the NP was updated on the wound assessments. Continue with current treatment and may change to a Low Air Loss mattress. Review of the Wound Observation Tools dated March 4, 2022 revealed the resident had a facility acquired stage 3 pressure ulcer to the left outer ankle. The tool also revealed granulation tissue was present, no drainage, pain, or signs of infection, and that the ulcer measured 2 cm x 1.6 cm x 0 depth. The documentation included treatment orders obtained, heel pillows, and a new order for LAL mattress. An observation of the resident was conducted on February 28, 2022 at 1:23 p.m. The resident had heel pillows to bilateral feet and both feet were wrapped. The resident stated that his feet were chewed up. The resident was observed to have slid down in bed and to be repeatedly pressing his feet against the footboard of the bed. An observation was conducted of the resident in bed on March 2, 2022 at 1:38 p.m. The footboard was gone from the bed and no heel protectors were observed in place at the time of the observation. The left foot was wrapped and appeared to have a dressing beneath the wrapping. An interview was conducted on March 2, 2022 at 1:44 p.m. with a Licensed Practical Nurse (LPN/staff #64). She stated the resident had been seen by the wound nurse yesterday, March 1, 2022, and that the foot board had been removed because the resident was getting some sores on his foot which the wound nurse thought was from the resident pressing heels/feet into the footboard. She stated the facility was looking into a longer bed for the resident. Another interview was conducted with the LPN (staff #64) on March 3, 2022 at 11:33 a.m. The LPN stated the resident has open areas to the heels and that it was determined that the bed was too short and the resident needed a longer bed. She stated a longer bed was provided for the resident yesterday, March 2, 2022. The LPN stated the resident's bed may also need an extension as the resident moves a lot in bed and tends to slide down. She stated the resident had increased restlessness related to spouse being hospitalized 5-6 days ago and as a result she had observed the resident press his feet into the footboard and lay his feet on top of the footboard. She stated up to then, the spouse would alert staff to move the resident up in bed if needed. The LPN stated that the resident was non-compliant with repositioning and the staff had to frequently reposition/re-apply the resident's heel protectors. The LPN also stated the resident had redness to the sacral area and that staff was applying barrier cream to the area. During an interview conducted with the LPN (staff #64) on March 7, 2022 at 11:38 a.m., the LPN stated the resident's foot dressing had been changed that morning due to the dressings being soiled/displaced. She stated that the resident moves his legs/feet a lot causing the dressings to roll up/come loose. The LPN stated the wounds looked a little better, like they were starting to heal. A wound observation was conducted on March 7, 2022 at 11:40 a.m. with a Registered Nurse (RN/staff #128). The resident was observed lying supine in a long bed, on a specialty mattress, with heel protectors in place and legs elevated on a pillow with his heels/feet a distance from the footboard. The RN was observed to provide the ordered treatment to the wounds. -Right heel: wound bed dark red, round, with partial skin loss. The RN identified the wound as a stage three pressure ulcer that measured 2 cm x 1.5 cm x 0.1 cm. -Left heel: observed open area to outer edge of heel with normal appearance to surrounding tissue. The RN stated the wound was an unstageable pressure with slough that prevented visualization of the wound bed that measured 2.5 cm x 1.5 cm. -Left outer foot: observed round open area to lateral malleolus with dark red base and active dripping of serosanguineous drainage and redness to surrounding skin. The RN stated the stage 3 pressure ulcer had a beefy red wound bed and measured 2 cm x 1.6 cm x 0.1 cm. The resident was observed to be getting angry during the wound care. An interview was conducted with the RN (staff #128) on March 7, 2022 at 12:41 p.m., who stated weekly skin assessments are conducted for each resident and documented in the electronic clinical record. He stated the Certified Nursing Assistant (CNA) observes the resident's skin during showers and will notify the nurse of any skin issue. The RN stated a description of new open areas is documented in the Weekly Skin Integrity Data Collection and the nurse would notify the wound nurse. He stated a pressure ulcer would be documented on the weekly skin assessment as other. He stated the wound nurse would assess a pressure ulcer weekly and document the assessment which should include all regulatory required information. He stated that the NP does rounds and documents notes on wounds as well. On review of the clinical record for resident #45, he stated that he did not find any wound notes from the NP. The RN stated that if a wound was not assessed as required the wound could get worse and/or infected. An interview was conducted on March 7, 2022 at 1:49 p.m. with the Director of Nursing (DON/staff #14). She stated that a skin assessment is done at the time of a resident's admission and documented on the admission tool. The DON stated if wounds were identified a treatment would be put in place and the wound nurse would be notified. The DON stated a skin check was done on a weekly basis and as needed and that the CNAs would notify the nurse of altered skin integrity. She stated the nurse would notify the wound nurse, DON, and Assistant Director of Nursing (ADON) if there was an open area. She stated if the wound was a pressure wound or in a pressure area, the DON or wound nurse would further assess the wound, the family

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #4 was admitted to the facility November 13, 2021 with diagnoses of unspecified rotator cuff tear or rupture of left shoulder and muscle weakness. Review of the clinical record revealed a physician order dated November 13, 2021 for physical therapy (PT) to evaluate and treat, and an order dated November 15, 2021 for skilled PT five times a week. Review of the PT discharge summary revealed the resident was discharged from PT on December 2, 2021 and that a restorative program had been established. A Rehabilitation/Restorative Care Referral Form dated December 3, 2021 included a physical therapy recommendation that the resident receive heel slides supine (left side active assisted range of motion, right active range of motion), ankle pumps active range of motion, lateral rolling with maintaining side posture, and glute squeeze assisted range of motion and quad set 1 x 10 each, 3 times a week for 8 weeks. The form also stated this was a functional maintenance program and no physician order was needed. However, a review of the Task Documentation Survey Report for December 2021 and January 2022 revealed this resident received RNA services 1 time in December 2021 and 3 times in January 2022. A Care Plan initiated on December 8, 2021 revealed this resident had an Activities of Daily Living (ADL) self-care performance deficit related to Activity Intolerance. Interventions included NURSING REHAB/RESTORATIVE: Bed Mobility Program #1 heel slides supine (left side active assisted range of motion, right active range of motion), ankle pumps active range of motion, lateral rolling with maintaining side posture, and glute squeeze assisted range of motion and quad set 1 x 10 each prn (as needed) for restorative. Review of the Task Documentation Survey Report for February 2022 revealed this resident did not receive any RNA services in February 2022. An interview was conducted on March 3, 2022 at 11:45 AM with the Assistant Director of Rehabilitation (staff #73), who said that long term residents receive rehab if they have a physician's order. She said that residents receive RNA services when they are finished with rehab. An interview conducted on March 3, 2022 at 1:09 PM with a Restorative Nursing Assistant (RNA/staff #120), who stated that she receives orders from the therapy department. The RN stated that when a resident is on their last day of therapy the therapist will have her accompany them and teach her to perform the care for the resident. She said that this resident is on RNA services. Staff #120 said that the resident will refuse because he is in pain and that sometimes she forgets to document the refusals. The RNA stated that she helps the Certified Nursing Assistants on the floor because they need help and that she will try to get back to do restorative services with the residents who need it but she is not always able to do so. An interview was conducted on March 8, 2022 at 2:20 PM with this resident who said that RNA has been seeing him but not steadily and not often. He said that it should be 3 times a week but often it is just once a week. The resident stated that he did not see RNA for almost 3 weeks at one time during his stay, however he had seen her 2 times the week of the survey. He said that the RNA services helped him because he is in less pain and is less stiff when he receives services. The resident said that he thinks that the RNA services are good for him and that he gets as much as he can. He said that he tells the RNA services no once in a while but that if the staff come back later that day it would be ok. An interview was conducted with the Director of Nursing (DON/staff #14) on March 8, 2022 at 3:59 PM, who said that her expectations for Restorative Nursing Care was that the Certified Nursing Assistants provide the ADL care and then document the care that they provide. She reviewed the resident Task Documentation Survey Reports and said that she sees the gaps. The DON said that it is her expectation that the residents receive care to meet their needs. A facility policy titled Restorative Nursing stated the facility is responsible for providing maintenance and restorative programs as indicated by the resident's comprehensive assessment to achieve and maintain the highest practicable outcome. To promote the resident's optimum function, a restorative program may be developed by proactively identifying, care planning and monitoring of a resident's assessments and indicators. Restorative programs may be initiated by nursing and/or therapy. Nursing Assistants must be trained in the techniques that promote resident involvement in restorative activities. The policy also stated the trained Certified Nursing Assistant will document provided techniques per the restorative care plan in the medical record. Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure three residents (#56, #11, and #4) with limited range of motion and mobility consistently received restorative nursing services to maintain or improve range of motion and mobility. The sample size was 5. The deficient practice could result in residents experiencing a decrease in range of motion and mobility. Findings include: -Resident #56 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, muscle weakness (generalized), and difficulty in walking, not elsewhere classified. Review of the Rehabilitation/Restorative Care Referral form dated 12/29/21 from OT (occupational therapy) revealed a Level 1 functional maintenance program (no physician order needed) for 3 times a week for 8 weeks. The referral included for transfer, active ROM (range of motion), and eating services and included instructions/precautions, set up required, and equipment. Review of the care plan revised on 12/30/21 revealed the resident has an ADL (activities of daily living) self-care performance related to Parkinson Disease. The goal was that the resident will maintain the current level of function in ADL's. Interventions included for nursing rehab/restorative services. A review of the Nursing Rehab/Restorative task report for January 2022 revealed the transfer program occurred on an as-needed (PRN) basis on 01/06, 01/12, and 01/31. The documentation also revealed restorative services for eating did not occur for 20 meals. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive 1-person physical assistance for most ADLs. The assessment also revealed restorative services were performed 1 out of 7 days in the look-back period for training and skill practice in transfers. Review of the Rehabilitation/Restorative Care Referral form dated 01/27/22 revealed for transfer, active ROM, and eating services on Monday, Wednesday, and Saturday. Per the February 2022 Nursing Rehab/Restorative task report, the resident only received transfer services on one occasion. The documentation did not include whether restorative services were provided for eating. Review of the March 2022 Nursing Rehab/Restorative task report revealed no evidence restorative transfer services were provided on Wednesday, 03/02/22. -Resident #11 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage 3 unspecified, scoliosis, unspecified, and primary generalized osteoarthritis. Review of a physician order dated 11/08/21 included for physical therapy/occupational therapy (PT/OT) evaluation. A Rehabilitation Services Multidisciplinary Screening Tool dated 11/08/21 revealed a restorative plan had been initiated. The tool stated the resident was not appropriate for Skilled Therapy Intervention at that time as the resident refused because she did not like exercise. Review of a Rehabilitation/Restorative Care Referral form dated 11/08/21 from OT revealed a Level 1 functional maintenance program which included transfer, splint/brace (palmar guard) assistance, and ambulation 3 times per week for 8 weeks. The care plan initiated on 11/08/21 revealed the resident has an ADL self-care performance deficit related to activity intolerance. The goal was that the resident will maintain current level of function. Interventions included nursing rehabilitation/restorative services. The admission MDS assessment dated [DATE] revealed the resident required extensive 2-person physical assistance for most ADLs, received 0 days of restorative services, and splint or brace assistance was provided for 1 out of 7 days of the lookback period. Review of the Nursing Rehab/Restorative task report for November 2021 revealed the resident refused transfer and ambulation on 11/25/21 and was only provided transfer and ambulation services on 11/27/21. The report also revealed splint/brace services were provided on 11/9, 11/14, 11/27, 11/28, and 11/30 and the resident refused on 11/24, 11/25, and 11/26. The December 2021 Nursing Rehab/Restorative task report only revealed the resident was provided transfer and ambulation services on 12/11 and refused on 12/2 and 12/16. The report also revealed no evidence from 12/19 - 12/31, that the resident was provided splint/brace services 3 times a week or that the resident refused. The report only stated the resident was provided services on 12/19 and 12/22 during that time frame. On 03/07/22 at 3:47 p.m. an interview was conducted with the Director of Nursing (DON/staff #14). She reviewed the Restorative documentation and stated that the numbers in the columns indicated the amount of time spent with the resident. RR meant the resident refused, and blanks or NA meant the activity did not occur. An interview was conducted with a Restorative Certified Nursing Assistant (RNA/staff #120) on 03/08/22 at 11:17 a.m. She stated that she tries to provide services to each of her residents, even when they are short-staffed. The RN stated that if there was no documentation, she might have been busy on the floor as a CNA on those dates. She stated that she documents NA in some instances because she did not know what else to put and she had asked another RNA to work with the resident on those dates. The RNA stated blanks meant the resident did not have restorative services that day, or did not receive restorative services that day. On 03/08/22 at 3:12 p.m., an interview was conducted with the DON (staff #14). She stated that the risks for not providing restorative services could result in decreased functioning or mobility. The DON stated her expectation is that the residents receive the restorative services per the referral, unless they refuse. The DON reviewed the restorative services documentation for both residents and stated that it did not meet her expectations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, facility documentation, and policy review, the facility failed to ensure there was sufficient nursing staff to meet the needs of the residents. The deficient practice could result in residents' needs not being met. The census was 99. Findings include: Review of the facility assessment tool reviewed 02/22/22 reflected an average daily census of 75 residents. Pertinent facts or descriptions of the resident population that must be considered when determining staffing and resource needs included daily review of schedules, utilization of the [NAME], and be based on resident needs and requests. According to the facility assessment the required number of direct care staff hours per patient day (HPPD) included 2.25 hours for Certified Nursing Assistants (CNAs), 0.76 hours for Licensed Practical Nurses (LPNs), and 0.79 hours for Registered Nurses (RNs). In addition, 0.12 hours were assigned for Restorative CNAs (RCNAs). The total number of HPPD was 3.81. Review of the daily staffing forms and facility documentation from February 1-28, 2022 revealed the census ranged from 87 to 100 residents, with an average census of 94. However, per review of the nursing staff punch detail, CNA hours were less than the required 2.25 PPD for 18 out of 28 days and the combined RN and LPN hours were less than the requirement of 1.55 PPD for 16 out of 28 days. Further review revealed that for 17 out of 28 days the total combined hours for all direct care nursing staff was less than 3.81 HPPD. During the entrance conference conducted on 02/28/22 with the facility Administrator (staff #134) and the DON (staff #14), it was confirmed that the facility census was 99, that the facility did not utilize agency staff, and that the facility had staffing challenges but not staffing shortages. A Review of the Resident Council minutes included that on 12/14/21 the residents discussed concerns regarding the amount of time it took for their call lights to be answered. Per the note, the administrator and DON discussed staffing and the census. In addition, the residents complained that their food was always served cold. The minutes indicated that the administrator would follow up with plate warmers. The Resident Council minutes dated 01/11/22 revealed that the plate warmers would be coming in on 01/17/22. The Resident Council minutes dated 02/15/22 revealed that the residents stated that call lights were taking too long to be answered, and not just on one shift. In addition, the residents complained that the food on their trays was cold and that their coffee was cold too. The Resident Council minutes dated 03/08/22 included complaints related to long waits for call lights to be answered on the night shifts. On 02/28/22 and 03/01/22, during the resident screening process, several residents stated they were concerned about the lack of nursing staff available to meet their needs. One resident stated that at night they only turn her twice. She stated that she was told that it was because they did not have enough staff to reposition her more frequently. She stated that as a result, she feels a lot of pain in her shoulders and neck and her pressure ulcers were not healing. Another resident said that she had to wait for 3 hours for staff to come assist her on the evening shift. She stated that her window was open and it was freezing in her room. She said her calendar blew off the wall. She stated that she eventually called her family member and told them. Then, she said, the staff finally came and closed the window. One resident stated that the facility did not have enough staff to provide care without him having to wait for a long time. He stated that the issue occurs on various days/shifts. He stated that he calls for incontinence care and it could be up to 6 hours before he receives the care. He stated that it usually takes close to an hour to get the care. He stated that his skin gets a little sore. Another resident stated there was usually only one nurse on the entire floor. He stated that he has waited up to 5 hours for staff to assist him to the toilet in the mornings. He stated that as a result, he urinated all over the floor. Multiple residents stated that their meals were usually delivered late, especially breakfast, and that the meals were still warm only some of the time. Another resident stated that it takes 30 minutes or longer for staff to come answer her call light to provide incontinence care. She stated that sometimes the staff come in, turn off the light, and then do not come back because they have forgotten about her. Another resident stated that she has not been able to get the help she needs to get out of bed in the morning because it takes 2 staff to utilize the Hoyer lift. She stated that she has been told that there are not enough staff to get her up. She stated that as a result, she has not received assistance to get out of bed for several weeks. On 03/02/22 at 1:12 p.m., an interview was conducted with a Physical Therapy Assistant (staff #23). She stated that the second floor is short-staffed a lot so that a lot of residents are not able to get out of bed because there is not enough staff to help them. She stated that there are 2 CNA/restorative staff, but because the unit is usually short-staffed, the residents do not receive services because restorative is on the floor working as CNAs. She stated that even if the second-floor residents have physical therapy/occupational therapy, a lot of time there is not enough staff to get residents out of bed and get them ready to go therapy. An interview was conducted on 03/02/22 at 2:10 p.m. with a Registered Nurse (RN/staff #127). He stated that they are always short-staffed and that it has been horrible. He stated that he will stay late to help the evening nurse to pass medications, but that when he is not working the residents tell him that sometimes it is almost midnight before they get their medications. He stated that often, there is only one nurse on the floor passing medications to 50 or more residents. He stated that the nurses and the CNAs are burned out and that he feels it could be dangerous to the residents. An interview was conducted on 03/03/22 11:32 AM with a Licensed Practical Nurse (LPN/staff #64), who said that she has worked at the facility for years. This staff said that she did not think that the facility ever had enough CNAs. She said there are not enough staff to get the residents changed. The LPN stated they do not have enough staff and are having trouble getting the resident up. An interview was conducted on 03/03/22 at 11:45 AM with the Assistant Director of Rehabilitation (staff #73), who said that they have 6 residents admitting a day and they only have one Physical Therapist. She said that she has 20 residents a day and does not know how she can do a good job. An interview was conducted on 03/03/22 at 1:09 PM with a Restorative Nurse Assistant/Certified Nursing Assistant (RNA/CNA/staff #120), who said that sometimes it is pretty tough. She said that she will sometimes help the CNAs because they need the help. She said sometimes the residents keep them in the room for an hour and there will be other residents call lights going off. She said that sometimes there are not enough CNAs on the floor in the evening and staff call off. She said that if that happens then she will help with CNA duties and then try to get back to helping with RNA duties but she cannot always get back to them. On 03/07/22 at 11:12 a.m., an interview was conducted with a CNA (staff #7). She stated that the residents frequently tell her that their food is cold. She stated that there are a lot of trays to pass, about 60. She stated that they try so hard to hurry up. She stated that she thinks that may be why the food is so cold. She stated that the staff is not allowed to warm up the residents' food in the microwave because on two occasions, the food got too hot and the residents were burned. An interview was conducted on 03/08/22 at 9:30 a.m. with the staffing coordinator (staff #91). She stated that they all work 12 hour shifts and that there was a PPD that she had to follow to determine the number of staff necessary to meet the residents' needs. She stated that if the acuity is high, they would staff higher than the PPD. She stated that she would explain that to the administrator and DON and that usually they would say OK, because they need to take care of the residents. She stated that she and the central supply staff were both CNAs and that they help on the floor when needed. Usually, she said, she will go to the floor in the mornings and help the staff catch up if they have fallen behind. Staff #91 stated that no adjustments were made for the weekends. Staff #91 stated she handles call-offs by having someone on-call to come in, or she will come in. She stated that she had included herself in the time sheets provided as one of the CNAs. She stated that staff, usually CNAs, will come to her with concerns about lack of staffing; but, the residents' families talk to the managers. Staff #91 stated that staffing comes up in the CNA and all staff meetings. She stated that she hears all of the concerns regarding staffing, but that staff need to go to the managers with their big concerns. Staff #91 stated that if there was something going on every day, where staff would come to her asking what was going on with the staffing, of course they would have to do something to fix it. She stated she does not use agency staff. She stated that she is connected to an agency, but they do not have staff either. Staff #91 stated that it was so hard to get staff because they get paid so much more to travel. She said it was like this at every facility. Staff #91 stated that when the DON goes into QAPI (Quality Assurance & Performance Improvement) meetings, she brings up the staffing concerns, but that she, herself, does not go to the meetings. Staff #91 stated that the risks associated with insufficient staffing would mean that they were not meeting the needs of the residents. An interview was conducted on March 8, 2022 at 9:43 AM with a CNA (staff #122), who said that some of the duties of a CNA include changing residents, answering call lights, taking lunch orders, helping residents out of bed, serving lunch orders, and getting the residents what they ask for. She said that she tries to get everything done. The CNA stated that she did not want to say that there was not enough staff to get required tasks done, but it is a no. She said that they have a hard time. Staff #122 said there are a lot of showers that need to be given but they do not have enough staff to get them all done. An interview was conducted on 03/08/22 at 2:42 PM with an MDS (Minimum Data Set) Nurse (staff #24), who said that all of the nurses in the MDS department are called to work on the floor and that it has been a struggle to try and stay caught up. She said that she is usually called during the weekends and that she is not comfortable performing the duties of a nurse as she had not previously worked as a floor nurse in long term care. At 9:59 a.m. on 03/08/22, an interview was conducted with the DON (staff #14). She stated that the PPD is used to determine the number of staff needed in-house, and that in Grand Round (morning rounds) residents' needs are identified and discussed. Based on that discussion, she said she may add more staff or switch staff around to meet the residents' needs. She stated that the PPD was based upon the census of the building, and that they also looked at the census on the units. She stated that she would consider the skilled unit to have a higher need, but that it fluctuates. The DON said that if they have more residents that require Hoyer transfers, then they would need more staff upstairs in Long-Term Care. The DON stated that the staffing coordinator handles all the call-ins, they did not use an agency, and that they did not really need them. She stated that the last time the agency was utilized was a few months ago. The DON said that a lot of staff work overtime if needed, and that the managers will also come and work the floor if there are call-offs and are needed. The DON stated that if there are workload concerns, staff bring those concerns to her during nurses' meetings. She stated that she has not had nursing complaints of staffing concerns. She stated that the CNAs would say something to her if they needed more help. She said that when residents complain, she tries to listen and tries to explain who is actually on the floor, and how they do their staffing in the building. She explains that staff may not be available during shift change, etc. She stated that families complain that they need more staff. The DON stated they look into the complaints and try to offer solutions right away. She said that staffing is brought up in every QAPI meeting and discussed each month. The DON stated that she has not identified trends in short staffing, and that they are able to handle their caseloads. She reviewed the numbers of staff required according to the PPD/resident acuity and stated that she did not realize that. The DON stated she had no idea they were short-staffed. On 03/08/22 at 12:20 p.m., the facility administrator (staff #134) stated he would like to provide more staffing information. He indicated that the PPD numbers demonstrated in the documentation were based upon staffing for a 24-hour period. He defined the 24-hour staffing period as 6:00 a.m. to 5:59 a.m. the following morning. He illustrated his calculations using punch detail from 02/18/22 as an example of meeting the direct care nursing HPPD. Review of the documentation revealed that on that date, the census was 95. According to his calculations, the total hours worked on that date by all direct care nursing staff was 305.88. He divided 305.88 by 95 to determine that 3.21 was the HPPD on that date. However, 3.21 did not meet the required resident need of 3.81 as stated in the facility assessment. An interview was conducted on 03/08/22 at 4:01 p.m. with the administrator (staff #134) and the DON (staff #14). Staff #134 stated that staffing issues have been ongoing since the spring of last year. He stated that the last time they had reached out to an agency was January 2022. He stated that they are also trying to focus on retention. He stated that the Quality Assessment and Assurance (QAA) committee meets monthly. Staff #134 stated that they have invited the staffing coordinator, but she has not come on a regular basis. He stated that every month, the staff bring up staffing issues. The administrator stated that staffing concerns are also brought to his attention via concern cards and through the staff bulletin board. The facility policy titled Staffing stated the facility maintains adequate staff on each shift to meet the residents' needs, posts daily staffing data and furnishes staffing information to the state as specified in the Federal regulations. The policy stated the facility utilizes the Facility Assessment as the foundation to determine staffing levels necessary to ensure that the residents' needs are met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #49 was admitted to the facility on [DATE] with diagnoses that included gangrene, not elsewhere classified, type 2 diabetes mellitus, and primary hypertension. Review of physician orders dated 12/04/21 included for Carvedilol 6.25 mg. Give 1 tablet by mouth two times a day for hypertension hold for SBP of less than 110 or a heart rate (HR) of less than 60. The 5-day Minimum Data Set assessment dated [DATE] revealed the resident scored 4 on the Brief Interview for Mental Status, indicating severely impaired cognition. In addition, the resident required extensive 2-person physical assistance for most activities of daily living. Another physician order, dated 12/20/21 revealed for Furosemide (diuretic) 40 mg. Give 1 tablet by mouth one time a day every Mon, Wed, Fri for congestive heart failure (CHF). Hold for SBP of less than 120. However, per the December 2021 MAR, Carvedilol was administered to the resident on more than 5 occasions when the SBP was less than 110, including on 12/09 for a BP of 100/60, 12/21 for a BP of 90/55, 12/26 for a BP of 98/62, and 12/28 for a BP of 100/58. In addition, Furosemide was administered to the resident on three occasions when the SBP was less than 120, including: 12/22 for a BP of 112/60, 12/24 for a BP of 107/74, and 12/29 for a BP of 86/54. A congestive heart failure care plan related to diuretic medication as evidenced by weight fluctuations dated 01/03/22 had a goal to verbalize less difficulty breathing. Interventions included to give cardiac medications as ordered. The January 2022 MAR revealed Carvedilol was administered more than 10 times when the resident's SBP was less than 110 including on 01/05 for a BP of 91/63, 01/10 for a BP of 101/66, and 01/26 for a BP of 91/55. Per the MAR, Furosemide was administered on 5 occasions when the resident's SBP was less than 120 including on 01/12 for a BP of 109/78, 01/19 for a BP of 112/79, and 01/31 for a BP of 110/76. Review of the February 2022 MAR included Carvedilol being administered more than 10 times when the resident's SBP was less than 110 including on 02/10 for a BP of 97/70, 02/21 for a BP of 94/58, and 02/25 for a BP of 94/64. Furosemide was administered on three occasions when the resident's SBP was less than 120 including on 02/09 for a BP of 102/64. On 03/02/22 at 1:55 p.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #64). She stated that her process of administering antihypertensive medications begins with checking the resident's blood pressure. She stated that sometimes the parameters on the medication are for blood pressure and sometimes for pulse. The LPN stated that if the medication is given outside of the parameters, she would consider it a medication error. She stated that she would notify the provider and document the conversation in the clinical record. The LPN stated that the risks of giving these medications outside of the ordered parameters might include the possibility of stopping the heart beat and losing the resident. Staff #64 reviewed the resident's MARs and stated that whether or not the medication should have been held would have depended on the resident's heart rate. The LPN stated that if the resident's BP was 101/60 but the heart rate was 99, she would give the medication because the order says or. She stated that she would not know for sure whether or not the administrations were errors until she saw the resident's heart rate. -Resident #130 was admitted to the facility on [DATE] with diagnoses that included hydrocephalus, unspecified, heart failure, unspecified, and primary hypertension. Review of the physician's orders dated 02/28/22 included for Metoprolol Tartrate 100 mg. Give 1 tablet by mouth two times a day for hypertension, hold for SBP less than 95 and/or HR less than 55. Review of the March 2022 MAR revealed the resident received Metoprolol Tartrate on 03/04 for a HR of 50, less than the ordered parameter of 55. Review of the resident's progress notes did not reveal that the physician had been notified. An interview was conducted on 03/02/22 at 2:10 p.m. with a Registered Nurse (RN/staff #127). He stated that if the resident's SBP or HR was less than the ordered parameter he would hold the medication. He reviewed the resident's MAR and stated that the medication should have been held and the physician called. He stated that the expectation would be to document the administration in the progress notes and to let the on-coming nurse know of the error. On 03/08/22 at 01:02 p.m., an interview was conducted with the DON (staff #14). She stated that her expectation is that medications will be given as ordered by the physician. The DON stated that if there is a medication error, nursing must report it to the resident, the physician, and the DON. She stated they must follow the physician's orders. The DON stated the risks of administering antihypertensive medications when the resident's vitals are below the ordered parameters might include adverse reactions such as hypotension, cardiac issues, and risk for further complications. She stated that the administration of those medications did not meet her expectations. The facility policy titled Administration of Medications stated all medications are administered safely and appropriately per physician order to address the residents' diagnoses and signs and symptoms. Based on clinical record reviews, staff interviews, and review of policies and procedures, the facility failed to ensure medications were administered as ordered to three residents (#45, #49, and #130). The sample size was 5. The deficient practice could result in residents receiving medications that are not necessary. Findings include: -Resident #45 admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, type 2 diabetes mellitus, and hypertension. Review of the physician's orders dated January 6, 2022 revealed for; -Lisinopril give 2.5 milligram (mg) by mouth one time a day for hypertension, hold for Systolic Blood Pressure (SBP) less than 110. -Metoprolol Tartrate tablet 50 mg give one tablet by mouth two times a day for hypertension, hold for SBP less than 110. -Terazosin hydrochloride capsule 10 mg give one capsule by mouth at bedtime for hypertension, hold for SBP less than 110. -Humalog solution 100 units/milliliter (ml) subcutaneously before meals and at bedtime for diabetes. Inject as per sliding scale: if 0-199 = zero units and call Medical Doctor (MD) if less than 60; 200-249 = 2 units; 250-299 = 4 units; 300-349 = 6 units; 350-399 = 8 units; 400+ =10 units and call MD if times two. -The Humalog order was rewritten January 8 and 14, 2022 with no change to the above medication or directions. Review of a care plan for Diabetes mellitus dated January 10, 2022 included a goal that the resident would have no complications related to diabetes. The interventions included blood sugar checks as ordered and medication as ordered. The care plan did not address hypertension or hypertension medications. Review of the January 2022 Medication Administration Record (MAR) revealed scheduled at 9:00 a.m.: -Lisinopril 2.5 mg, hold for SBP less than 110: On January 8, 2022 was coded as a 7 hold/see progress notes with a blood pressure of 194/74; on January 13 and 16, 2022 the Blood Pressure (BP) documentation was an X and the medication was marked as 3 vitals outside of parameters of administration. -Metoprolol Tartrate tablet 50 mg hold for SBP less than 110: On January 8, 2022 was coded as a 7hold/see progress notes with a blood pressure of 194/74; on January 10 and 15, 2022 was administered when the SBP was under 110; on January 13 and 16, 2022 the BP documentation was an X and the medication was marked as 3 vitals outside of parameters of administration; on January 15, 2022 the medication was not documented as given and marked as 3/vitals outside of parameters of administration when the SBP was greater than 110; and there was no documentation on the MAR of a second blood pressure value for the medication that was ordered two time a day to determine if the medication was administered necessarily. -Terazosin Hydrochloride capsule 10 mg, hold for SBP less than 110 scheduled at 8:00 p.m.: On January 17, 2022 the medication was not documented as given and marked as 3/vitals outside of parameters with no blood pressure documented in the administration time frame; and there was no documentation on the MAR of a blood pressure value for the medication to determine if the medication was administered necessarily. -Humalog solution 100 unit/ml, inject per sliding scale. No documentation of blood sugar value or insulin administration for 6:00 a.m. on January 7 and 27, 2022 as the MAR was left blank; or for January 11, 2022 6:00 a.m., there was no blood sugar value as it was documented as NA and 10/see progress notes. Review of the January 2022 Weights and Vitals Summary revealed: -No blood pressure value found for 0900 a.m. administration period for Lisinopril on January 13 or 16, 2022. -There were 20 days without a blood pressure value within the administration time period for the 8:00 p.m. medication use Metoprolol and Terazosin. -No blood sugar information for 6:00 a.m. on January 7, 11, or 27, 2022. Review of the January 2022 progress notes revealed: Regarding Lisinopril order; -January 8 and 16, 2022 listed the order, but no further administration documentation. Regarding Metoprolol order: -January 8, 2022 listed the order, but no further administration documentation. Regarding Humalog order; -January 11, 2022 at 8:32 a.m. documentation that the resident was already eating. Review of the February 2022 MAR revealed: -Lisinopril was marked NA for the blood pressure value on February 18, 2022 and the medication was marked as administered. -Metoprolol was marked as administered at 8:00 a.m. on February 18, 2022 with no blood pressure value documented; and there was no documentation on the MAR of a second blood pressure value for the medication that was ordered two times a day to determine if the medication was administered necessarily. -Terazosin, there was no documentation on the MAR of a blood pressure value for the medication to determine if the medication was administered necessarily. -Humalog solution 100 unit/ml, inject per sliding scale. No documentation of blood sugar value or insulin administration for 6:00 a.m. on February 5, 2022, as the MAR was left blank; and the medication was marked as 3/vitals outside of parameters of administration on February 27, 2022 for the 9:00 p.m. administration time when the blood sugar was documented as 236 which would require insulin coverage. Review of the February 2022 Weights and Vitals Summary revealed: -No blood pressure value on February 18, 2022 for the 9:00 a.m. administration time period for Lisinopril, or the 8:00 a.m. administration time period for Metoprolol. -There were 27 days without a blood pressure value within the administration time period for the 8:00 p.m. medication use of Metoprolol and Terazosin. -No blood sugar information for 6:00 a.m. on February 5, 2022. Review of the March 2022 MAR revealed: -Metoprolol, there was no documentation on the MAR of a second blood pressure value for the medication that was ordered two times a day to determine if the medication was administered necessarily. -Terazosin, there was no documentation on the MAR of a blood pressure value for the medication to determine if the medication was administered necessarily. Review of the March Weights and Vitals Summary revealed: -There were 2 days without a blood pressure value within the administration time period for the 8:00 p.m. medication use of Metoprolol and Terazosin. An interview was conducted on March 3, 2022 at 11:33 a.m. with a Licensed Practical Nurse (LPN/staff #64). She stated if a medication was ordered with parameters, she would know that the parameter was met by obtaining the applicable value (i.e., blood pressure) prior to administering the medication. The LPN stated that the parameter value would be documented on the MAR and that if the parameter was not met, she would not give the medication. She stated that she would follow the sliding scale for insulin if ordered and that the MAR documentation would show the blood sugar value and the amount of insulin given. She stated that she did not know what NA would mean when coded on the MAR in place of the ordered parameter value or blood sugar. The LPN stated that if a medication with parameters was ordered two times a day, there should be documentation of the required value for each time the medication was administered. She stated that the single blood pressure documented on the MAR for Metoprolol for resident #45 would be the day shift value and that she would not be able to show what the evening blood pressure was. She stated that if the medication was given the MAR would show a check mark for the administration and if the medication was held there would be a number in place of the check mark that would tell if it was held. On review of the MAR for the resident, the LPN stated the Terazosin did not include the blood pressure value for the evening dose and that she would not be able to show that the resident met parameters. She stated that the value may also be found in the vital signs section or the record. She stated if the nurse gave the medication without first checking for the ordered parameter value, there would be a risk for a dangerous decrease in blood pressure. She stated that protocol was not followed on this resident. An interview was conducted on March 8, 2022 at 2:26 p.m. with the Director of Nursing (DON/staff #14). She stated that she expected the MAR to be complete and staff to follow physician's orders, including parameters. She stated that if parameters for medication use were ordered there should be documentation of the parameter value at the time of the medication administration and/or holding of the medication. She stated if there was not a value for the parameter, the staff would not be able to show if the parameter was or was not met. The DON stated that there should not be blank administration areas on the MAR as the staff would not be able to show that the medication was administered/parameter obtained. The DON stated that the blood sugar value should not be marked NA and the parameter value should not be documented as an X. The DON stated there was a risk for medical harm, complications with blood pressure or blood sugar with resident #45 if staff did not follow orders/parameters.

Based on review of facility documentation, staff and resident interviews, observation, and review of facility policies and procedures, the facility failed to provide each resident with food and drink that was at an appetizing temperature. The deficient practice could lead to issues with nutrition and impact resident quality of life. Findings include: During the initial portion of the survey on February 28, 2022 and March 1, 2022, multiple complaints were received from residents related to food served at the facility. Twelve residents stated food was served to them cold and that the staff response to the cold food was that staff had specific orders not to warm anything up for the residents; yes, they know; and there is no microwave for resident use. One resident stated staff were in and out of the room very quickly when delivering the meal and did not answer the call light during that time so the resident could tell staff the food was cold. One resident stated that meal times are getting later and later. Two residents stated they were not offered anything else when they told staff the food was cold. Review of the Resident Council notes revealed the following: -December 14, 2021- Food is cold. Staff will follow up on plate warmer. -January 17, 2022- Plate warmer coming in. -February 15, 2022- French dip sauce cold, should be warm. Hall trays, food and coffee are cold. Review of the facility's comment and concern forms revealed: -January 6, 2022 - resident with complaints of cold food and coffee. -January 20, 2022 - resident with complaints of cold food. The facility responses included taking the temperature of food trays in resident halls and reviewing kitchen logs. Review of facility's Quality Assurance and Performance Improvement Plan (QAPI) dated January 2022 for Cold Food-Food temperature at low ranges revealed there were concerns stated during resident council that coffee and food items were served cold on meal trays at various times for breakfast, lunch and dinner. Systemic changes included: Education for kitchen/lobby staff on properly measuring the temperature of food and beverages and on properly measuring temperature on warming devices and food prior to leaving kitchen; Temperature checks audit randomly twice a week; In-service staff about plate warmer, encouraging to increase time at meal tray pass, splitting meal trays to two separate carts when being delivered. The QAPI documentation also included the plate warmer was fixed and replaced on January 24, 2022. An evaluation of a test tray was conducted on March 2, 2022 at 12:40 p.m. The cart containing the test tray arrived at the resident unit at 12:48 p.m. Tray delivery was started at 12:51 p.m. Temperatures were obtained of the test tray using a facility thermometer with a Certified Nursing Assistant (CNA/staff # 7). The readings were as follows: Fish 126 degrees Fahrenheit (F), rice 138.7 degrees F, vegetables 125.1 degrees F. The tray was taken directly to the conference room for tasting. The food was warm to taste and the plate felt warm to touch. Additional interviews were conducted with 4 residents on March 2, 2022 regarding the lunch meal on March 2, 2022. Three of the residents stated that their meal was lukewarm, and one resident stated that their food was cold. An interview was conducted on March 2, 2022 at 2:25 p.m. with a CNA (staff #124), who stated the residents complain that meals are cold, more at dinnertime. She stated the residents do not complain to her at every meal. She stated that she can offer the resident something else or another plate but that the residents do not take the offer. She stated that she brought the concerns to the attention of the Director of Nursing (DON/staff #14) and the Dietician (staff #136) and they said OK. The CNA stated the time it takes to deliver the meals would depend on resident acuity. The CNA stated that the staff is able to serve food warmer in the dining room, but that most of the residents eat in their room. An interview was conducted on March 2, 2022 at 2:37 p.m. with another CNA (staff #38). She stated that the residents complain their meals are cold and there are more complaints at breakfast time. The CNA stated that she receives complaints a few times/meals a week from multiple residents. She stated that she would offer the resident something else. She stated that she had notified the Dietician of the concerns and that he stated he would speak to the kitchen. The CNA stated the pass the meal trays pretty promptly and that the concerns have gotten better. She stated that staff was not allowed to warm up food in the microwave for the residents. An interview was conducted on March 2, 2022 at 2:43 p.m. with the DON (staff #14). She stated that she had been made aware of residents' complaints of cold food. She stated that the administrator had addressed related concerns/grievances with the residents. She stated that the Kitchen Manager (staff #16) was doing follow up and that the facility had a new plate warmer. She stated that she believed the concern was in QAPI and that related in-services had been completed with staff. On March 2, 2022 at 3:19 p.m., an interview was conducted with the Dietician (staff #136). He stated he was aware of resident complaints regarding cold food and the facility was using plate warmers and heated waxed bases. He stated that the staff tries to get the meals passed quickly. Staff #136 stated residents were encouraged to go to the dining room for meals. He stated that they have long halls and that it is hard to keep the food warm until the end of the hall has been served. He stated the facility moved from two to three carts upstairs in an attempt to pass the meal sooner after plating. He stated that staff were supposed to offer an alternative or a fresh tray if they received complaints that the resident's food was cold. Staff #136 stated that the company did not really want staff to reheat/microwave food related to burn risk. In an interview conducted on March 3, 2022 at 9:09 a.m. with a cook/kitchen staff (staff #12), he stated that cold food delivery was a concern in the facility. He stated that a new plate warmer was obtained and the tray line rotated. He stated that staff comes to the kitchen for a new resident tray approximately one time a day. Staff #12 stated this happens most often for rooms served from the upstairs third cart. He stated that they use the smart therm to warm the wax bases prior to stacking for plating, and that they stay warm for 50 minutes. An interview was conducted on March 3, 2022 at 9:30 a.m. with the Kitchen Manager (staff #16). She stated that resident concerns regarding cold food started at the beginning of January 2022 in resident care conferences and Resident Council meetings. She stated that the facility was trying to figure out, through speaking with residents, which area/meal was of concern. She stated that staff had completed random temperature measurements of trays right before delivery and the food temperatures were ok. She stated that she would like to see the foods in high 150's F and that some foods had lower temperatures than that. Staff #16 stated they identified the plate dispenser heating unit was not working and replaced it, and that they also use heated wax bases under the plate. She stated the combination should be keeping meals up to temperature until delivery to the resident. Staff #16 stated that she still gets complaints of cold food here and there so they began to look at the meal service as a whole. She stated at the beginning of February they changed some of the meal times around and implemented two carts per hall upstairs and on the large hall of the first floor so that food could be delivered closer to plating time. Staff #16 stated they hired a new part time server to help with tray delivery and pick up, two weeks ago. An interview was conducted on March 7, 2022 at 11:12 a.m. with a CNA (staff #7). She stated that the residents tell her that their food is cold. She stated that there are a lot of trays to pass, about 60. She said they try so hard to hurry up. She stated that she thinks that may be why the food is so cold. The CNA stated that they are not allowed to warm food in the microwave because, on two occasions, the food had gotten too hot and the residents were burned. Review of a facility policy titled Quality of Food dated 1/1/2014 revealed an objective that the participant will be able to recognize the importance of quality food and what factors may affect the quality of food. Food is the highlight of a resident's stay. Food quality is a team effort. The policy stated several factors affect the quality of food including having service temperatures that are appropriate. Palatability temperature of hot food should be >/= to 120 degrees Fahrenheit for delivery. Review of a facility policy titled Presentation of the Meal revised 12/16/21 revealed each meal provided to the residents is served attractively, accurately, efficiently and at the appropriate temperature.

Based on observations, interviews, and policy review, the facility failed to ensure that infection prevention protocols were implemented in the processing of laundry. The deficient practice could result in contamination of clean linen. Findings include: During an observation conducted of the laundry facilities on 03/03/22 at 12:04 PM, a laundry assistant (staff #52) was observed on the dirty side of the laundry facility, sorting bags of dirty laundry. Blue bags and clear bags were observed in the laundry cart. Staff #52 was donned in a yellow gown and was wearing gloves. The gown was observed to be tied at the neck and not the waist, and was falling off her shoulders. When asked about what different the colors of laundry bags indicated, staff #52 stated that blue was general laundry, and yellow was isolation laundry. Staff #52 stated the yellow bags of laundry had to be washed separately from the regular laundry in the blue bags, and that she had not seen any yellow laundry bags recently. At 12:06 PM, staff #52 was observed pulling up the top of the gown over her shoulders while wearing her soiled gloves. As she pulled the gown up, her hair brushed up against the now contaminated part of the top of her gown. At 12:13 PM, staff #52 found a resident's broach attached to a sheet in the dirty laundry. She removed the broach using her soiled gloves, crossed from the dirty side of the laundry facility to the clean side of the laundry facility while wearing the dirty personal protective equipment (PPE), and placed the dirty broach onto the clean laundry folding table. She then walked back to the dirty side of the laundry facility to continue sorting through the soiled linens. Staff #52 sorting of laundry included a soiled brief and washcloth with stool, wrapped in a bed sheet contaminating her gloves further. Once done sorting linens, staff #52 pulled the arms of her gown over her contaminated glove, removed her gloves, then removed her gown over her head. Staff #52 then stated that the yellow laundry gowns are washed at the end of their 8-hour shift, so that they are cleaned before their next use. Then, without washing her hands, staff #52 proceeded with the observation of the laundry facility. Staff #52 was observed touching wet clean laundry in the washer, dried clean laundry in the drier, laundry on the clothes donation rack, personal laundry for the hall racks of north downstairs, and south downstairs, and personal laundry on the racks for 90-day hold. At 12:27 PM, staff #52 started to fold clean white laundry with her unwashed hands. On 03/03/22 at 01:09 PM, an interview was conducted with the laundry & housekeeping supervisor (staff #42), who stated there are three different kinds of laundry disposal bags. Staff #42 stated blue is for regular laundry, yellow is for isolation precautions laundry, and red is for biohazard blood laundry; and that each form of laundry is meant to be washed separately from one another to prevent cross contamination. Staff #42 stated currently they were out of the yellow bags, and for the time being housekeeping had been placing blue bags into the isolation laundry receptacles. Staff #42 stated that when collecting the laundry, housekeeping had been tying up the blue bags and placing a clear trash bag over the top to indicate that the laundry was from residents on isolation precautions. Observations were conducted of two different residents' rooms on contact isolation precautions on 03/03/22 at 01:37 PM and 01:50 PM. The laundry bins were observed with a blue liner to place dirty laundry in. An interview was conducted on 03/08/22 at 03:37 PM with the Director of Laundry and Housekeeping (staff #16), who stated laundry staff that collect and launder laundry must wear the required appropriate PPE for each. Staff #16 stated staff should remove PPE and wash their hands prior to going to the clean side of the laundry room. Regarding staff #52 breaks in infection control, staff #16 stated that staff #52's actions did not meet her expectations of laundry processing. A facility policy titled, Laundry Services, revealed that nursing and laundry associates will follow all policies and procedures regarding the handling, storage, processing, and transporting of laundry. Associates will follow infection prevention and control guidelines. Bags containing contaminated laundry must be clearly identified with labels, color-coding, or other methods so that healthcare workers can handle these items safely, regardless of whether the laundry is transported within the facility or destined for transport to an off-site laundry service. The facility must have hand hygiene products and appropriate PPE available for associates to use while sorting and handling contaminated linens. In the laundry, dirty linen should be moved from the dirtiest to the cleanest. In the laundry, handwashing facilities and protective barriers (e.g., gowns, gloves, and masks) shall be made available to personnel who sort laundry. Staff should wear gowns and tear-resistant reusable rubber gloves while sorting soiled linens. Face mask and eye protection shall be used when there is a potential for splashing blood or other infectious materials in the eyes. Laundry personnel shall wash their hands and remove protective barriers before going into the clean linen area.

Based on observations, staff interviews, policy review, and the Centers for Medicare & Medicaid Services (CMS) and Center for Disease Control (CDC) guidelines, the facility failed to ensure infection control protocols were maintained during COVID-19 testing. The deficient practice could lead to the spread of infection. Findings include: During an interview conducted with the Infection Preventionist (IP/staff #60) on 03/03/22 at 8:52 AM, a Licensed Practical Nurse (LPN/staff #3) was observed to enter the L shaped office and remove testing supplies from the testing cart. The LPN was observed to place the testing supplies on the counter next to the microwave and begin the self-testing process. The LPN was not observed to perform hand hygiene, don gloves, or sanitize the counter next to the microwave before self-testing for COVID-19. Immediately following this observation, the IP was asked what their testing for COVID-19 process was. The IP stated that she would demonstrate their COVID-19 testing process. The IP moved the completed test card for staff #3 to the COVID-19 testing cart middle shelf. The IP then performed hand hygiene, and donned a face shield and gloves before performing the COVID-19 test on staff #3 using new testing supplies. The test card was placed on the middle shelf of the cart with the time and date. Staff #3 asked the IP if she should go or stay in the vicinity to which the IP answered stay in the vicinity. At 9:00 AM, the admissions director (staff #58), donned in an N95 mask, was observed to enter the office and walk to the cart with the supplies for testing. The IP informed staff #58 that she would be performing the COVID-19 testing. Staff #58 appeared shocked and asked if staff #60 was doing the testing now. At 9:01 AM, a Certified Occupational Therapy Assistant (COTA/staff #20) wearing an N95 mask was observed to enter the office, retrieve testing supplies from the cart, and begin to self-test himself at the bench next to the microwave. Staff #20 was not observed to perform hand hygiene. The IP then tells staff #20 to come over and the IP completes the test. The IP places the test on the middle shelf of the cart, with the other COVID-19 tests. At this point staff #3 and staff #58 who each were wearing an N95 mask, were positioned face to face but were not observed to follow social distancing guidance. Staff #20 was positioned north of the microwave with his unclean hand touching the area where the used COVID-19 tests were. At 9:04 AM, a Registered Occupational Therapist (staff #19) donned in an N95 mask entered the office and proceeded to reach for the COVID-19 test supplies. The IP informs staff #19 that she is performing the COVID-19 tests and for staff #19 to wait for her. Staff #19 places her documents and cellphone on the same part of the counter where the used COVID-19 tests had been and staff #20's hands were. The IP proceeds to test staff #19 for COVID-19 at the testing cart. At 9:06 AM after being tested, staff #19 goes to stand directly next to staff #20 to chat without observing social distancing guidance. Staff #19 picks up her documents and holds them in her hands as she is chatting with staff #20. Staff #19's cell phone rang and she picked up the phone from the counter to answer it. At 9:07 AM, a Registered Physical Therapist (staff #74) wearing an N95 mask entered the office and placed her laptop where the COVID-19 tests, staff #19's documents and cellphone just were. Staff #74 fills out her COVID-19 test with a pen and the IP proceeds to test staff #74. At 9:08 AM, the IP informs staff #3 that she can leave and staff #3 leaves the room. At 9:09 AM, staff #74, staff #19, and staff #20's COVID-19 tests were observed sitting on top of each other on the middle shelf of the COVID-19 test cart. At 9:14 AM, the IP stated staff #58 was done with the 15-minute dwell time. At 9:16 AM, the IP stated staff #20 was done with their 15-minute dwell time. At 9:17 AM, an LPN (staff #115) enters the office and is instructed by the IP to monitor the staff for COVID-19 testing dwell time in the day room. Staff #115 takes the testing cart and the remaining staff with her as she exits the office. An interview was conducted on 03/03/22 at 9:20 AM with the IP who stated that usually she provides testing for COVID-19 in the day room and not her office. The IP stated that the process is that she tests the staff, and that the staff do not self-test. She also stated that she could not perform this function due to the State being in the building and there being no one else to take over her position. The IP stated staff #115 was asked to cover for her while she conducted the rest of the IP interview, but that staff #115 already had a main role she had to complete. The IP also stated that staff had previously been trained to perform COVID-19 self-testing, but the facility prefers for her to perform the test when possible. An interview was conducted on 03/08/2022 at 03:59 PM with the Director of Nursing (staff #14). The DON stated that it is her expectation that staff socially distance during testing. She stated that COVID-19 testing can be performed either in the day room or in the IP office on the Monday and Thursday scheduled testing days. Staff #14 stated that sometimes the testing can be a bit hectic when they have students present as well. The DON stated her expectation is that bleach wipes be used before and after each person has been tested and that the 3-minute dwell time for the wipes be observed. Regarding the observations, the DON stated that the description did not meet her expectations of how COVID-19 testing should be performed. A facility policy titled, Coronavirus (COVID-19) (SARS-CoV-2), revealed that the facility is to follow the core principles of COVID-19 Infection Prevention as defined by CMS and CDC to mitigate COVID -19 entry into the facility. The policy stated this includes hand hygiene, cleaning and disinfecting of high frequency touched surfaces, social distancing at least six feet between persons, and resident and staff testing conducted as per the Code of Federal Regulations. The policy also stated the long-term care facility must conduct testing in a manner that is consistent with current standards of practice for conducting COVID -19 tests. Review of the CMS Interim Final Rule related to testing requirements revealed collecting and handling specimens correctly and safely is imperative to ensure the accuracy of test results and prevent any unnecessary exposures. The specimen should be collected and, if necessary, stored in accordance with the manufacturer's instructions for use for the test and CDC guidelines. During specimen collection, facilities must maintain proper infection control and use recommended PPE, which includes an N95 or higher-level respirator, eye protection, gloves, and a gown when collecting specimens. The CDC Hand Hygiene guidance for Healthcare Personnel (HCP) in Healthcare Settings revealed HCP should use an alcohol-based rub or wash with soap and water immediately before performing an aseptic task or handling invasive devices, and after contact with body fluids or contaminated surfaces.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interview, facility document, and policy review, the facility failed to ensure their policy was implemented, by failing to ensure 4 residents (#378, #381, #387, and #388) and/or their representatives were educated regarding the benefits and potential side effects associated with the COVID-19 vaccine and offered the vaccine. The deficient practice could result in residents not being aware of the risks and benefits, and potential side effects of COVID-19 vaccines and not being offered the COVID-19 vaccine. Findings include: -Resident #378 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease and dementia. Review of the clinical record revealed no evidence the resident was educated regarding the benefits and risks, and potential side effects of the COVID-19 vaccine or that the resident was offered the COVID-19 vaccine. -Resident #381 was admitted to the facility on [DATE] with diagnoses that included infection and inflammatory reaction due to internal right hip prosthesis and muscle weakness. Review of the clinical record revealed no evidence the resident was educated regarding the benefits and risks, and potential side effects of the COVID-19 vaccine or that the resident was offered the COVID-19 vaccine. -Resident #387 was admitted to the facility on [DATE] with diagnoses that included fracture of the unspecified part of the neck of the left femur, subsequent encounter for closed fracture with routine healing and muscle weakness. Review of the clinical record revealed no evidence the resident was educated regarding the benefits and risks, and potential side effects of the COVID-19 vaccine or that the resident was offered the COVID-19 vaccine. -Resident #388 was admitted to the facility on [DATE] with diagnoses that included heart failure and hypertension. Review of the clinical record revealed no evidence the resident was educated regarding the benefits and risks, and potential side effects of the COVID-19 vaccine or that the resident was offered the COVID-19 vaccine. An interview was conducted on 03/03/22 at 09:56 AM with the Infection Preventionist (IP/staff #60). The IP stated that upon admission, residents are educated on and offered flu and pneumonia vaccines. The IP stated that however, residents are not educated on or offered COVID-19 vaccines upon admission. Staff #60 stated that the onus is on the resident to notify the staff that they are requesting the COVID-19 vaccine. The IP stated that at that time, if the resident requests, she would arrange for the resident to receive the vaccine. She stated vaccine clinics for COVID-19 are held on an as needed basis depending on demand. A review of the facility's admission packet obtained on entrance and reviewed on 03/03/22 revealed that there was no COVID-19 vaccine consent form. A facility policy titled, Covid-19 Vaccination Program Policy for Residents, revealed the facility will ensure residents are offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized. The policy stated the facility will educate residents or resident representatives regarding the benefits and potential side effects associated with the COVID-19 vaccine and offer the vaccine unless it is medically contraindicated, or the resident has already been immunized.